49 Design of the persuasive game ‘Ademgenoot’ 2 Use of narrative to complement behaviour change The internalization of motivation is further facilitated by a narrative with the protagonist (Brad). Narratives have been successfully employed in serious games to complement behaviour change theories and have shown to effectively support behaviour change (52). Through immersion and the creation of affection for the narrative protagonist, people can mentally envision the health benefits related to the desired behaviour and apply them in the real life. Furthermore, narratives can provide intriguing incentives for people who, having affection for the protagonist, feel obliged to finish the story and act on feeling of relatedness to the protagonist (53). As such, our protagonist Brad may foster internalization of external motivation to complete the game and adopt the behaviour promoted in the game. Furthermore, a narrative can serve as an analogy of a real-world setting, enhancing a possibly boring and unstimulating context, and inspiring players by adding a narrative overlay (54). Ongoing feedback on behaviour to change behaviour Ademgenoot utilizes EDM logging to offer direct and continuous feedback on inhaler usage. Feedback delivered through digital technologies, in order to facilitate behaviour change’, has been promising to disrupt and change undesired habits or automatic behaviour (55). Effective feedback depends on factors such as timing, delivery, modality, and content (55). Generally, continuous, real-time feedback delivered visually, enabling reflection-in-action (i.e., in the moment), is the most effective. Ademgenoot offers continuous real-time visual feedback on inhaler usage and perceived asthma control, which is an improvement over the current reflectionon-action-based (i.e., afterwards) practice during regular consultations. Future developments should explore how best to provide feedback on perceived asthma control, for example, by incorporating asthma questionnaires such as the Asthma Control Questionnaire (ACQ). Moreover, integration of automatic monitoring of environmental triggers (e.g., pollen data) or peak flow data could provide a more comprehensive self-management tool (56). Strengths and limitations Our paper takes a distinctive approach by utilizing participatory user-centered design with service design techniques, behaviour change principles, and persuasive game theory. This approach involves creating personas and multiple prototype iterations. By actively involving end-users, key design requirements were identified, increasing the chances of the intervention being accepted and adopted. Furthermore, by integrating theoretical frameworks, we promote understanding of mechanisms explaining motivational effects (57). As such, our study contributes to the knowledge base of persuasive game design as an effective method for changing health-related behaviour. Another strength of our study is that besides the end-users, multiple other stakeholders were involved, including healthcare professionals, patient advocates and developers of smart inhalers. Their involvement ensured the accuracy, feasibility,
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