47 Design of the persuasive game ‘Ademgenoot’ 2 two participants mentioned that relying on reliever use as a benchmark was not appropriate, as they rarely used their reliever medication despite feeling breathless and experiencing symptom flare-ups. They suggested the possibility of reporting on their level of asthma control regardless of reliever use, and the user could be rewarded with a fish in the water for doing so. Evaluation of the concept with two patient advocates showed similar findings. The patient advocates found Ademgenoot easy to use and particularly valuable for individuals recently diagnosed with asthma and children, owing to its playful and fun approach. The combination of game elements and medication usage statistics was especially appreciated, as they expected that this would motivate people to be adherent. However, the patient advocates emphasized the importance of evaluating the inhaler behaviour and asthma control with a healthcare professional during regular consultations as improvement may be less when medication is not properly adjusted. They considered the weekly reports to be helpful in reflecting together on medication use, asthma control and trigger events. Furthermore, they emphasized that the report on symptoms or control should reflect how one feels, as one might be medication adherent yet still experience significant discomfort. Finally, both patient advocates suggested that Ademgenoot could also be beneficial for individuals with limited health literacy due to its prominent visual component. Discussion This paper demonstrates that a participatory user-centred design approach, combined with involvement from healthcare professionals, behaviour change experts and persuasive game design experts, can result in an engaging, fun persuasive game that has the potential to motivate people with mild asthma to be adherent to their maintenance medication. We identified reasons for non-adherence and user needs, identified behaviour change strategies (phase 1) and translated these into design and serious game requirements (phase 2). Several iterations were performed in which prototypes were evaluated with end-users, which led to the final persuasive game Ademgenoot (phase 3 and 4). Final evaluation showed that Ademgenoot has the potential to motivate people to adhere to their maintenance inhaler, promote longterm behaviour change and is feasible in clinical practice. A key finding during the define phase (phase 1) was that people’s non-adherence was often due to their perception of asthma as an episodic rather than chronic condition. This perception stems from the intermittent periods of symptom worsening and has been previously reported in qualitative research studies on reasons for nonadherence (45). Furthermore, non-adherence was influenced by the delayed perceived effect of maintenance medication, and a lack of comprehension regarding the distinction between maintenance and reliever inhaler. Consistent with our findings, multiple studies have reported perceived lack of efficacy and suboptimal knowledge of reliever and maintenance medications as drivers for non-adherence (45–48).
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