Move On is a graduation project which is focused on redesigning the HandsOn game, a therapeutic game for arm-hand rehabilitation which is developed at Roessingh Research and Development (RRD). The HandOn game is a ‘mixed reality’, i.e. a video game played by interacting with physical objects. It trains grasping and horizontal reaching movements in a rehabilitation context. The game is mostly used by adults aged 50+ with hemiparesis, weakness at one side of the body, due to stroke. Design Assignment: The goal of the HandsOn redesign is to include training vertical reaching movement and motivate stroke patients in starting, enduring and repeating the game.Design method: The Persuasive Design Method is used to structure the redesign process (Siriaraya, n.d.). First the “transfer effect’ is determined, being the therapeutic effect to be aimed for by the game. Second, the “user real world” is analyzed involving the user, its motives and values and its context. Thirdly, in the game design phase the persuasive game will be iteratively designed with the aim to increase an experience of a game world in the player. Subsequently, this game world experience is designed in such a way that it facilitated realization of the transfer effect (phase 1). Finally, an ‘evaluation’ is conducted on whether the game design causes the ‘transfer effect’.Transfer effect: To determine the transfer effect regular arm and hand therapy exercises are analyzed, therapists are interviewed and a literature study is conducted. It can be concluded that arm and hand rehabilitation exercises can be decomposed in various elements. Every rehabilitant needs a unique combination of these elements, which a therapist is able to estimate. -An optimal rehabilitation effect can be reached through tailoring the game for the abilities of the player. Long term motivation, for about three months, can be reached by: -Communicating to the rehabilitant what he has reached within therapy through progress feedback -Showing the relevance of exercises by real life simulation Motivation during play can be reached by: -A challenging, but not too challenging, task -Multi-sensory feedback -A clear start and end of the task, to work towards to User real world: The user real world, i.e. the user-experienced rehabilitation context, is analyzed through interviews with rehabilitants, which confirmed the motivational factors exposed in the research for the transfer effect. The greatest wish of all rehabilitants is to live independently again. This inspired a game theme focused on daily life tasks that rehabilitants were used to do at home. Game design: An effective, motivating game for arm and hand rehabilitation broadly exists of three steps: 1. Tailoring trough game settings, 2. game play which includes moving physical objects and 3. Reflection through progress feedback. Based on these steps, three design directions were developed: gamifying daily chores, a game revolving around tea and a game about chores in- and outside the house. These design directions were evaluated with healthcare professionals, and two were chosen to elaborate into concepts. In the ‘Tea Time’concept, the player runs a teahouse and should serve orders, physical objects, to his customer, being coasters placed on a table. In the ‘Joblocks’concept, the player simulates different chores in- and outside the house with the use of ambiguous objects. Both concepts are evaluated on their therapeutic and motivational effect and feasibility. Tea Time was choosen, since it is indicated to be most feasable. A prototype of Tea Time was created for testing. Evaluation: The prototype’s game experience and motivation towards therapy were tested by four rehabalilitants. They played the game three times in three weeks and filled in questionnaires and were interviewed about motivation and game experience. Two therapists reviewed the prototype for points of improvement. It can be concluded that the game creates motivation towards arm and hand rehabilitation. Game experience stayed almost the same over three weeks, which indicates players can play the game for weeks without getting bored. Game experience itself was ranked neutral. Game experience can be increased by more accurately tailoring the game’s challenge for the individual rehabilitant. Recommendations are made for an improved game, which has main focus on better tailoring physical challenge by: -objects that vary in shape and weight -more placement possibilities of coasters -more variety in time limit And better tailoring cognitive challenge by: -Multisensory cues for playing -Possibility to reduce sensory stimuli -Adding an easier level It is expected that the new recommended prototype will meet the therapeutic requirements and motivates and challenges rehabilitants.

This master thesis report is the result of a six-month-long graduation project for the Design for Interaction master at TU Delft. The report describes the development of the design guidelines to attune the TAS program to the Netherlands. The main goals that guided the project were three: identify which aspects of a healthy habit program (TAS program) can be adapted to the Netherlands; understand how to design for it by creating a set of design guidelines; and how to apply the guidelines to attune the program to the Netherlands.. Healthy habit programs targeted to teenagers are crucial since it is the period in which bodies develop and finish forming. The early understanding of healthy habits is key to helping teenagers to acquire lasting healthy behaviors and classrooms provide a great context that supports the knowledge building experience. The TAS program was evaluated in 103 Spanish classrooms, in different autonomous regions, and proved to increase healthy behaviors among teenagers, such as improving nutritional habits (increase of fruit and vegetable intake and decrease of fried food) or increasing physical activity. Therefore, the opportunity to adapt a successful healthy habit program to another European country was identified. The research phase of the project consisted mainly of sensitizing activities and literature research to get to know the context and domain of the project; and interviews with Dutch and Spanish parents and teenagers to understand the reality and daily life habits by comparison. The opportunity to design a set of guidelines based on the research outcomes was identified, a set of 10 guidelines grouped in four groups: medium, content, communication and engagement. The guidelines were applied to one of the workshops of the TAS program with the aim of evaluating the effectiveness of the guidelines and the workshop itself. The concept was evaluated with Spanish and Dutch secondary teachers and Dutch experts in the field of health programs in order to assess the validity of the concept and identify to what extent the implemented changes were culture specific. The project was approached from a cultural framework, in which socio-cultural dimensions served as a way to find a direction for the project but also as a tool to compare and identify cultural variables between Spain and the Netherlands.

Weight stigma is defined as the negative attitudes and beliefs that are manifested by stereotypes, rejection and prejudice towards individuals because they are overweight. Weight stigmas have a negative impact on the mental health of people with excess weight. They internalize the weight stigmas and therefore blame themselves and feel less worthy. This can cause their physical health to deteriorate and can lead to weight gain. One of the most harmful types of weight-related stigmatization is the interpersonal stigmatization within the direct social environment. The central aim of this research has been to explore solutions to reduce weight-related stigmatization within the direct social environment of people with obesity. To narrow down the scope, the project was focused on stigmatized women who show interest in body positivity and fat acceptance. This thesis refers to these women as ‘fat’ instead of ‘obese’ in order to respect their cultural values. The research was divided into a theoretical background study, a qualitative user research and an explorative study with methods including interviews, quick prototyping and user tests. The insights gained throughout the project come together into an overview of the most stigmatizing beliefs: (1) Fat people eat too much and exercise too little; (2) Becoming fat due to an unhealthy lifestyle is your own fault; (3) Losing weight is a matter of self-discipline; and (4) Slim people are healthier, happier and more successful. According to this research, the stereotypes and prejudices manifested in these stigmatizing beliefs are the result of misunderstandings and lack of knowledge. Therefore, the overview is complemented with facts and myths about weight that unravel the beliefs. Based on this overview, an interactive platform for fat women was designed: Big Fat Nonsense (in Dutch: Dikke Onzin). This platform consists out of a website (www.dikkeonzin.org), a podcast, a discussion template and social media channels. The design is based on the finding that stigmatized women often cope with internalized stigma. They first need to be empowered in order to stand up for themselves. By reading facts and myths about weight, answering the reflective questions on the website and listening to stories via the podcast, they gain the confidence to start a discussion with a stigmatizer in their direct social environment. A discussion template can be downloaded on the website to structure their conversation about stigmatizing beliefs. By answering the questions on the discussion template, the users are forced to set agreements on the desired weight-related communication within their relationship. In order to reach the target group, the design is promoted via social media channels and ambassadors. Finally, the design of Big Fat Nonsense has been evaluated with the target group and their close relationships. The design succeeded to provoke nuanced and in-depth conversations. However, to fully validate the effect of the design, it should be evaluated by measuring the amount of stigmatization before and after usage.

The aim of this graduation project is to increase physical exercise of employees with low socio economic status (SES) by engaging them in a health intervention. Individuals with low SES often negatively influence their health by having an unhealthy lifestyle. This lifestyle causes the individual problems and non-communicable diseases (NCD), which causes a shorter life expectancy and being ill makes it harder to participate in work activity. The client for this project is DZB Leiden, a re-integration company of the municipality of Leiden. DZB is there for everyone who wants to work but has difficulty keeping up with the current work practice. The people turning to DZB often experience a work disability and have a low socio-economic status. DZB also recognizes an unhealthy lifestyle among their employees. A healthier life will contribute to the well-being of the employee and will decrease employee absenteeism. Thus, not only looking from an employment perspective, but considering improvement of quality of life of their employees, DZB is determined to give a contribution to their employees’ health. To increase the physical activity of the employees, a persuasive game was designed to be played at DZB. Persuasive game design is a tool to motivate people to perform certain behaviours in a game experienced world, which can be beneficial to them in the real world. The physical activity experienced during the game can motivate people to perform the desired behaviour in the real life. In order to design a game based health intervention that will be accepted by the employees, an extensive field study was conducted. By taking a human-centered approach and co-designing with the employees a deeper understanding of the target group was created, including their view on health, motivations, barriers and needs. The findings from the field study were translated to 10 points of attention to be considered for creating the health intervention. Also, a framework for design was developed, including three motivational elements: humour, fellowship and discovery. By applying the 10 attention points and design framework, the final game ‘Sailors in Motion’ was developed. Sailors in Motion is a game where boats are hidden and searched for throughout the building of DZB in a scavenger hunt with treasure maps. Making and following these maps stimulates the player to walk around at DZB. The game is all about discovering new places in the building, which is done together with colleagues. Additionally, the game includes joyful elements. During the journey, health messages can be found, meant to educate the player about the benefits of physical activity. Finally the game was evaluated with the employees. The aim of this evaluation was to figure out whether the game stimulated to walk and triggered to increase physical activity in the employees’ daily life. The evaluation showed that the game does put people in motion and creates a immersive experience for the player. However, since the game was evaluated in a short time, the effect of the game on someone’s health awareness was difficult to measure. It is recommended to play the game more often and spread the activities over multiple weeks to provoke behaviour change. Also, the game could be part of a larger health program where employees set goals and get support to reach them. The game serves as a starting point where people can easily engage in to experience the benefits of physical activity on their mood and body. This experience can motivate them with setting personal health goals and eventually changing their behaviour. The deliverable of this project is not only the tangible game, but also a variety of insights about the employees of DZB. The company could use the framework for design as well as the 10 point of attention during future development of health related initiatives at DZB.

This graduation project is related to macular degeneration. Macular degeneration affects the macula, a central pit on the retina which is responsible for the highest visual acuity due to the densely packed cone photoreceptors. Symptoms of macular degeneration can vary in the early stage from blurred vision to abnormal dark adaptation (Jager et al., 2008) however in late stage macular degeneration symptoms can be much more invasive including partial and complete loss of the central vision. In order to cope with the loss of central vision patients could prescribe to what is called eccentric viewing. Eccentric viewing is a technique where the peripheral vision is used to see. Using eccentric viewing as a method to cope with macular degeneration requires, for optimal results, practice. This can be done through training. This project was originally aimed at designing a training method for eccentric viewing with the use of motivating game elements. By speaking to experts from Visio and Bartimeus as well as patients throughout the research phase it became apparent that eccentric viewing was not deemed necessary. Instead other problems were addressed which had a higher priority in solving. These problems include the lack of provided information after the official diagnosis, the attitude of the ophthalmologist during the diagnosis and the perceived gap between the diagnosis and the Low-Vision clinics. By creating a patient journey and examining the different problems that occur during that journey a choice was made to focus on a combination of the lack of information after the diagnosis and the gap between the diagnosis and the Low-Vision clinics. Six different topics of information were defined which play part in the lack of information. These six topics are: information about the condition, information about aids, make it easier, information about peer support, training / revalidation support and information about involved instances. Together these six topics cover most of the aspects surrounding macular degeneration. To convey this information to the target group a web-based medium is used. Due to the special target group guidelines have been defined which help in designing a website for visually impaired people. This has resulted in a framework where the necessary information can be placed in. Because of time restrictions one of the six topics which was defined was further developed. That topic is ‘Make it easier’. It resulted in a collection of tips from “experienced” macular degeneration patients on making Activities of Daily Living (ADL) easier to perform. In total 20 different tips were gathered through a brainstorm session, an online survey and telephone contact with Bartimeus. These tips were spread over three different themes: cooking, grocery shopping and public transport. Each tip was accompanied by an image, a descriptive text and a spoken quote. Finally an evaluation test has been conducted with two participants to verify whether the proposed design succeeded. The results from the evaluation show the potential success of the design but are not conclusive. Therefore further testing needs to be done with more participants over a longer period of time.

Taming Esortra is a persuasive game for people diagnosed with osteoarthritis. The two most important symptoms of osteoarthritis are pain and joint stiffness; making it hard and painful for patients to exercise. However, exercise is important and can actually stop the osteoarthritis from getting worse. Taming Esortra uses narrative game-elements and self-monitoring to help patients gain control over their disease. It does this by helping them gain insight in the burden of osteoarthritis and see how they can decrease that burden through exercise.

This study centers around the development of a crafting tool within the CardioVitaal cardiac rehabilitation (CR) program, aimed at transforming physical activities into personally fulfilling experiences for patients post-rehabilitation. The design vision emphasizes leveraging health crafting theory to empower patients to discern what brings them joy in exercise. Through literature reviews, expert interviews, collaborative sessions with cardiac patients, and iterative design processes, a digital crafting application was designed. This app serves as a digital companion, offering personalized activity recommendations, action planning flows, and reflection prompts to support patients in sustaining physical activities beyond the confines of the CR program.

Asthma is a chronic disease and is characterized by inflammations of the airways. Since there is no cure available yet, asthma treatment is aimed at asthma control, to minimize patients’ symptom experiences and to prevent patients of having exacerbations (lung attacks). A key driver in this, is the extent to which patients adhere to their prescribed medication treatment, also called ‘medication adherence’. It has been found that one third of Dutch asthma patients show poor adherence to their treatment. The client of this project, the pharmaceutical company AstraZeneca, has developed a smart inhaler in combination with an application. This technology makes it possible to measure medication adherence and present the adherence data to patients and healthcare providers. However, if the motivation of patients remains low to take their medication as prescribed, such interventions will likely not succeed because patients may ignore the reminders sent. Therefore, the aim of this graduation project is to develop a proof of concept for a self-management eHealth intervention that motivates patients to adhere to their medication treatment. This thesis describes the development of Ademgenoot, an asthma self-management application connected to a smart inhaler. Ademgenoot uses narrative game-elements to motivate asthma patients to adhere to their prescribed medication treatment. In this, Ademgenoot focuses on the positive outcomes of taking the daily maintenance medication. Moreover, the application gives the patients the opportunity to try-out the daily intake of the medication, by offering them a six weeks challenge linked to a personal goal. During this period Ademgenoot visualizes the process of the medication intake in a playful way to make the effect of the medication visible and to prevent disengagement. At the end of the challenge, patients should have gained insights on the effect of the intake of the daily medication and their improved symptom control within their daily lives. The design process from investigating the user’s needs and values to various idea directions towards the final design will be discussed. In addition, this thesis includes the different research that was conducted to gain a better understanding behind patients’ motives to not follow their treatment, the conducted research on the difficult step of motivating people to change their behaviour and the different user tests that were set up. A WhatsApp prototype was built to test the concept of Ademgenoot in practice. Patients received screens responding to their medication use for a couple of days via WhatsApp. The end user test delivered the proof of principle that the concept of Ademgenoot has the ability to motivate patients to adhere to their prescribed treatment. In addition, participants expressed to be enthusiastic about the concept and stated that they would like to use the application in their daily life. A positive side-effect appeared to be that some participants mentioned that it would help in the creation of a habit. Follow-up studies are recommended on finding additional ways to track the development of the patients’ daily wellbeing within the application. This and other recommendations are presented in the final part of this thesis.

This graduation project aims to contribute to an emotionally-safe, i.e. comfortable and trauma-free, hospitalization experience for children. Hospitalization can be emotionally threatening and traumatizing for children. Children have to undergo multiple medical examinations, in a setting that is unfamiliar to them. Resilience is needed to cope with the challenges that come with the hospitalization. A positive emotional state can help children manage fear, stress and anxiety. In this graduation project, the narrative interactive game-play intervention Hideaway was created to foster resilience and empower children during their short (3-7 days) stay in the hospital, building on the previously developed Hospital Hero app©. In order to create a valuable design intervention, an iterative research and design process was followed. A literature study and a context mapping study were performed to gain insight into the emotional experience of children (4 to 14 years old) and contributory contextual factors. Data was collected using observations, conversations with (former) patients, parents and healthcare professionals, and interviews with experts specialized in psychological impact of hospitalization in children. Using activity booklets, hospitalized children were asked about their social contacts, emotions and desires. Make-and-say sessions with children and co-creation sessions with children were held to further determine the core intervention strategy. From the research, multiple challenges that negatively influence children’s mental state were identified: accumulation of medical procedures, unfamiliar daily routine/environment, not being able to play. This is strengthened by lack of peer-interactions and restricted mobility (i.e. contact isolation, being bedbound). To help children cope with these challenges, an interactive storytelling-based game was designed, integrating peer-contact, social play and child-friendly coping tips. Hideaway invites children to work together in a collaborative digital game of ‘hide-and-seek’, thereby creating connection between peers in and outside the hospital, letting children explore and escape the hospital room, and empowering children. A prototype of Hideaway was evaluated with children and healthcare professionals, showing a promising potential to evoke a positive emotional state in children and with that fostering resilience and empowerment. Research and design recommendations have been made to provide a bridge to future implementation of Hideaway. The eHealth solution Hideaway facilitates playful peer-interactions and has the potential to stand in for missed daily peer-interplay. Hideaway provides a valuable addition to the Hospital Hero app©, expanding outpatient care support with hospitalization support, and could be applicable to other settings (e.g. pediatric rehabilitation).

The possibilities of applying game elements for positive behavior change in non-game contexts (i.e. gamification) seem limitless, ranging from politics to treatment of mental illness. However, the number of applied gamification studies is still limited. Our research (part of CRISP G-Motiv) aimed to contribute to the knowledge about designing and applying game elements for teamwork. First, we defined four basic design components that constitute a ‘gameful’ experience (i.e. feeling as if playing a game): goals, rules, objects, and freedom. Next, we explored the application of game elements in two lab- and two field experiments. In the lab, we developed a multiplayer computer game to examine the effect of different rules on interdependent behavior and we developed a physical game with coins to investigate the effect of different rule-sets on output in group-brainstorm meetings. In the field, we implemented and investigated the effect of gamified interventions to improve the cohesion within the operating teams of a strip-galvanizing factory and at a consultancy firm, we developed and tested a game with coins to change the attitude of participants of ‘red team’ meetings. The results of these studies showed that in teamwork, game elements seem mainly valuable for raising attention and changing goal-driven behaviors and experiences. In order to design and research a gamification that positively influences teamwork it is important to consider: 1) the above-mentioned four basic design components and 2) to what extent they pervade in the emotions, attention, and behavior of team members. @en