Participatory Design of Fall Prevention Exergames using Multiple

Enabling Technologies

Christos Goumopoulos

, Michail Chartomatsidis

and Georgios Koumanakos

Information and Communication Systems Engineering Department, University of the Aegean, Greece

Depia Automations, Thessaloniki, Greece

Frontida Zois, Patras, Greece

Keywords: Exergames, Fall Prevention, Human Centered Design, Focus Group, Kinect Sensor, Virtual Reality, Smart

Floor, Design Guidelines, Elderly.

Abstract: Exergames provide significant health benefits for older people. In particular, reinforcing strength and balance

through exercises is an effective measure to prevent falls. In addition, cognitive improvements and mental

benefits for the elderly can be achieved through physical activity tasks. In this paper a new exergame platform

is introduced that combines hardware and intelligent software to create adaptable gaming experiences to

improve physical and cognitive functions of older people. The platform integrates different enabling

technologies (motion recognition sensor, virtual reality and smart floor) to provide the user with a wider

variety of interactions and exercises. The design and development of the exergames is based on the principles

of human centered and participatory design as this approach is particularly suitable for the development of

technological solutions targeted towards the elderly. In this context, the main methods applied are the

development of prototypes and use of qualitative research methods such as participatory development with

the help of a focus group using interviews, questionnaires and end user observation. Representative exergames

were presented in the form of high and low fidelity prototypes for feedback to both end users and healthcare

experts. The data collected from a focus group workshop have been analyzed in order to provide the main

guidelines and to record aspects that require attention in the design and implementation of the exergames.

1 INTRODUCTION

In 2050 the world population of the elderly (aged 65

and over) is estimated to be 1.5 billion (United

Nations, 2020). While long living is an important

accomplishment of the present societies, the cost of

ineffective aging is significant both individually and

socially. Interventions that can support effective

aging are therefore of great importance to improve the

quality of life and well-being of older people.

On the other hand, even normal aging has a

detrimental effect on the body and the mind

associated also with the increased risk of falling

(Melzer et al., 2004). Falls have significant

consequences for the elderly, as the feeling of fear

develops strongly, resulting in a negative impact on

their behavior, causing in general the avoidance of

activities. Moreover, according to studies, 5-20% of

falls have serious consequences, such as head

injuries, fractures and in extreme cases immobility or

even death (Sterling et al., 2001). The large increase

of elderly falling cases makes research targeting their

prevention an important public health priority.

Studies have shown that systems directed at

improving the physical condition of the elderly lead

to a reduction of up to 50% in the risk of falling

(Gillespie et al., 2012).

Recently the development of systems that support

exercising in the form of games (exergames) has been

observed. These systems have been proven to be safe

for the elderly and help improve both cognitive and

physical functions to a greater extent than traditional

ways of practice, mainly due to the motivation they

provide to users (e.g. entertainment, challenges in the

form of different difficulty levels, scoreboards etc.)

(Skjæret et al., 2016). The critical question, however,

is whether these systems are easy for the general

public to use. Research has shown that although

existing systems help significantly to reduce the risk

of falling, it is, still, difficult to use them by people

who are unfamiliar with this technology, such as the

elderly (Nyman et al., 2012). Moreover, the lack of a

simple interface often makes their adoption difficult.

Goumopoulos, C., Chartomatsidis, M. and Koumanakos, G.

Participatory Design of Fall Prevention Exergames using Multiple Enabling Technologies.

DOI: 10.5220/0011044100003188

In Proceedings of the 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2022), pages 70-80

ISBN: 978-989-758-566-1; ISSN: 2184-4984

Most systems have been developed using sensors

that are provided by commercial gaming machines

such as Nintendo Wii, and Microsoft Kinect Xbox.

However, the games that have been designed are not

adapted for the elderly as there is often difficulty both

in using and in understanding them, so the presence

of a third more experienced person is always required

to guide the users (Valenzuela et al., 2018). It is

understood that such a situation prevents older people

from using this technology while creating a feeling of

fear and lack of confidence.

In addition, with the recent emergence of virtual

reality technology, a new way of practice is emerging

in a more realistic environment (Xu et al., 2020). In

addition to the physical condition, studies have shown

that using this technology can bring improvements on

cognitive skills. On the other hand, even this practice

is aimed mainly at young people familiar with the

technology. Furthermore, its usage becomes even

more difficult as it requires the use of one or two

additional remote controls.

With technology rapidly evolving, advanced

systems tend to become accessible by all citizens. It

is therefore important to determine not only the

effectiveness of games in terms of physical and

cognitive improvement but also to identify the most

appropriate technologies to be applied in order to

ensure the safety of older people in different

situations. The development of a platform that

combines new technologies and provides solutions to

fill gaps and shortcomings in existing systems is

therefore necessary.

In this paper, a new exergame platform,

developed in the context of the GAME2AWE project

(https://game2awe.aegean.gr/), is introduced that

combines hardware and intelligent software to create

adaptable gaming experiences to improve physical

and cognitive functions of older people.

GAME2AWE aims to develop a platform for game-

based exercise applications suitable for the elderly by

integrating innovative features that combined are not

provided by existing systems, to the best of our

knowledge. The objectives of GAME2AWE are

served by the following research and development

activities:

• Design of games suitable for the elderly following

a human centered design approach regarding

game mechanics specification by involving all

relevant stakeholders (elderly, caregivers,

medical experts, system and game engineers) in

all phases of system development.

• Combining multiple technologies for the

development of the GAME2AWE platform in

order to support multimodal interactions (voice,

gestures, movement and touch) which can

facilitate the implementation of game scenarios in

a way that motivates and enhances users’

autonomy while making the platform easy to use.

• Design and construction of a robotic tile as a

component for the assembly of a smart floor

which will serve as an autonomous computing

platform for the deployment of games that train

motor and cognitive functions.

• Integration of measures in the game mechanics

that have been proven to predict the risk of falling,

such as the Choice Step Reaction Time (Lord and

Fitzpatrick, 2001), providing the potential for

using the platform as a diagnostic tool.

• Application of machine learning algorithms to

analyze the data collected by the platform in order

to: a) define more effective exercise programs by

adapting the difficulty level to the profile of each

user; b) train a model to classify users at cognitive

and motor levels according to their performance.

• Evaluation of the game platform in three

dimensions (motor, cognitive and technological)

by applying a randomized controlled trial and

using valid relevant scales.

For the development of the exergames a first

inventory of potential games in the form of scenarios

and key features was assembled based on relevant

studies (Sato et al., 2015; Shaw et al., 2015; Skjæret

et al., 2016; Xu et al., 2020) and our own relevant

experiences (Kostaki and Goumopoulos, 2016;

Chartomatsidis and Goumopoulos, 2019).

Subsequently, in order to meet the above-mentioned

objectives, representative scenarios were selected

from two main themes “Life on a Farm” and “Fun

Park Tour”, and were presented for feedback to both

end users and healthcare experts within a focus group.

The data collected from the focus group workshop

were analyzed in order to provide the main guidelines

and to record aspects that require attention in the

design and implementation of the exergames.

The rest of the paper is organized as follows.

Section 2 explores the topic of physical activity.

Recommendations proposed for physical activity by

organizations and relevant literature with a focus on

fall prevention are reported. Sections 3 and 4 discuss

the methodology that frames the development of the

platform and the participatory design of the

exergames. Finally, the conclusions are given.

Participatory Design of Fall Prevention Exergames using Multiple Enabling Technologies

2 PHYSICAL EXERCISE

RECOMMENDATIONS FOR

ΤΗΕ ELDERLY

The World Health Organization (WHO) and other

associations have made recommendations for

physical activity referring to adults over 65 years of

age according to which elderly people should perform

150 minutes of moderate aerobic activity weekly, or

alternatively 75 minutes of intense aerobic activity

(American College of Sports Medicine, 2013). A

combination of moderate and intense exercise during

the week is an alternative option. For example,

moderate physical activity may include activities

such as walking at a regular and quicker pace,

housework, woodworking, cutting the grass and

dancing. Intense physical activity, on the other hand,

includes jogging and running, construction work,

farming, swimming and cycling.

Aerobic activities are also recommended to take

place in sessions of ten minutes at the minimum and

to combine exercises for strengthening muscle power

two or more times a week. The WHO highlights

physical activities that enhance the balance for

seniors with low mobility capacity. Performing these

exercises thrice each week can lead up to 30%

reduction of the falling risk (World Health

Organization, 2008). If the recommendations on

exercising cannot be reached, because of health

problems, the elderly adults should aim to be as

energetic as possible in a safe manner that improves

their physical condition. In addition, exercising five

hours a week, corresponding to moderate aerobic

activity of 300 minutes, or intense aerobic activity of

150 minutes, renders greater health benefits such as

reduced risk of harmful weight and chronic diseases.

GAME2AWE aims to offer physical activity

opportunities to older people who experience

physical and cognitive impairment due to aging. The

most frequent expected impairment will be associated

with muscle weakness due to elderliness, which can

lead to falls and other health problems. In this context,

it is important to categorize the games and the

exercises involved according to the needs and

physical abilities of each user.

The review of relevant literature has shown that

strengthening and balance exercises are suitable for

reducing the risk of falling (World Health

Organization, 2008; Tucker et al., 2011; Kiselev et

al., 2015). In this direction, the identification of

suitable exercises to be used in the exergame platform

is important. Physiotherapists suggest stepping

exercises as appropriate, because they have found that

performance in such exercises can be a good predictor

of falls. It also turns out that a recurring exercise

program with stepping exercises can improve the

balance in the elderly. Stepping exercise requires

significant physical activity, which is useful for

improving physical health. Stepping or walking

exercises are also recommended by bodies such as

WHO, the European Health Directorate and the US

Department of Health and Human Services.

Some of the exercises included in the exergames

of the GAME2AWE platform are: ‘walking in

standing or sitting position’, ‘weight shifting in

standing or sitting position’, ‘standing on one leg’,

‘foot stretching’; ‘flank stretching’, ‘weight shifting

to both sides in standing position’, ‘weight shifting

forwards and backwards in standing position’, ‘leg

lifting’ and ‘from chair sitting to standing position’.

3 METHODOLOGY

Our approach is based on the activity theory of aging,

according to which an active lifestyle leads to greater

health both physically and mentally and better quality

of life (Lemon et al., 1972). In contrast, a sedentary

lifestyle leads to health deterioration and

unsuccessful aging (Brown et al., 2008). Against this

background, exergaming is a promising approach to

reinforce the strength and balance of older people, as

exergames can improve both cognitive and motor

capabilities.

3.1 Technologies

One of the most well-known technologies used in

exergames is the Microsoft Kinect motion sensor

(Zhang, 2012), which allows the user to interact with

the computer through the use of gestures, movements

and voice commands. In particular, Kinect 2.0 is an

interactive motion detection device consisting of an

infrared (IR) projector, an IR camera, an RGB camera

and a multidimensional microphone. It also supports

voice input and recognition. Kinect can detect in real

time a human body (or multiple bodies) and locate its

skeletal structure, in terms of a 25-joint skeletal

model, when an individual is in sight. Thus, users do

not need to wear sensors since system interactions can

be realized through diverse movements and gestures.

Kinect streamlines interactions and enables more

natural communications, making it easier for the user

to engage with the game.

The integration of Kinect in exergames and its

positive contribution regarding the improvement of

strength, endurance and balance of the elderly has

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

been reported in several studies (Sato et al., 2015;

Skjæret et al., 2016). The low cost of the equipment

makes it accessible to the elderly and allows even for

daily exercise at home.

Figure 1 illustrates an example exergame foreseen

in the GAME2AWE platform using the Kinect

motion sensor. In this scenario, the players’ mission

is to collect olives from an olive tree land in the digital

space of a series of games called “Life on a Farm”.

The mechanics of the game incorporate movements

which were selected as appropriate exercises for fall

prevention while at the same time serving a specific

goal in the gameplay. For example, side steps are used

for selecting a tree to harvest. A rowing movement is

used for spreading the olive collection sheet, while

arms lifting is used for harvesting crops. In more

advanced levels of the game more demanding

movements are required for harvesting, such as flank

stretching with arm lifting and standing on one leg

with arm lifting.

Figure 1: An example game using Kinect sensor in the “Life

on a Farm” theme of the GAME2AWE platform.

Virtual reality (VR) technology presents a three-

dimensional virtual world in which a person can

move and interact with objects around her, giving the

user the feeling that she is actually in the virtual

world. From a technical point of view, VR systems

are built on three concepts: Interaction, Imagination

and Immersion (Sheridan, 2000). Interaction refers to

the ability of shaping the virtual world according to

the user's actions and the user's ability to interact with

objects in the virtual world. Imagination is the ability

to perceive the virtual world and its components as

real. Immersion is the degree to which we can

perceive our presence in a non-real world as natural.

Utilizing VR technology can greatly benefit the

elderly in terms of cognitive stimulation. VR creates

an interactive and immersive environment that gives

users the impression of joining a virtual world. This

technology allows the elderly to visit various places,

immersed in a virtual setting that would normally be

quite dangerous or too far away or impossible to

occur due to health problems (Xu et al., 2020). Figure

2 illustrates an example VR game that is foreseen in

the GAME2AWE platform to train cognitive skills

such as visual perception, concentration and problem

solving. This game belongs to a series of games

within a common theme called “Fun Park Tour”. It

refers to a virtual tour in a park where the user can

choose to play games that have a fun character while

at the same time it is required to perform movements

that are relevant to fall prevention.

Figure 2: An example VR game in the “Fun Park Tour”

theme of the GAME2AWE platform.

Although VR is a technology with several design

challenges, when used in exercise games (Shaw et al.,

2015), it has been shown to provide a safe and

appropriate environment that can be adapted to the

needs of each user. The use of this technology has a

positive effect on the elderly with chronic diseases

such as dementia, improving both their physical and

cognitive status (Eisapour et al., 2018). Apart from

cases of dementia, VR has been applied to other

diseases such as musculoskeletal and post-cerebral

rehabilitation (Gervasi et al., 2010). Researchers have

used VR-based commercial exergames that aim to

enhance various physical functions in the elderly,

such as balance and strength. The effectiveness of VR

technology in reducing the risk of falling, for

example, has been explored at a preliminary level (de

Melo et al., 2018).

Moreover, although systems incorporating VR

have proven to be effective in improving the motor

and cognitive condition of older people, an obstacle

often encountered is the need to have one or two

additional remote controllers which may not be

acceptable by older people. GAME2AWE proposes a

combination of camera motion recognition

technology (Kinect sensor) and VR aiming at

removing additional sensors from the user thus

providing greater freedom of movement.

Augmented reality (AR) varies from VR as it

involves the introduction of virtual entities into the

real environment, instead of the creation of a

completely virtual space. It usually includes an

indirect representation of the real environment, with

Participatory Design of Fall Prevention Exergames using Multiple Enabling Technologies

virtual features and information, thus enhancing the

user's sense of reality. Mixed reality (MR) is

described as a wide intersection between VR and AR,

which integrates 3-D holograms into the real

environment. These forms of technology include

applications aimed at cognitive practice, which

includes decision-making and learning in a virtual

environment (Aruanno and Garzotto, 2019).

Another way of exercising that is explored is

through the use of an interactive mat or floor (Heller

et al., 2014). The smart floor offers the ability to

create an integrated system with autonomous power

without the use of additional equipment such as

computers or power supply. The information is

transferred by the user to the floor through pressure

which is measured from embedded sensors on the

floor. In GAME2AWE platform, the smart floor has

a modular structure (puzzle format) making it easy to

assemble and adapt it to any space (Figure 3).

Figure 3: Smart floor module model in the GAME2AWE

platform.

Technologies that do not require the use of a

complex user interaction environment such as the

proposed smart floor are more suitable for the elderly

to improve their physical and cognitive functions.

The smart floor will be used as a large touch screen

to project motion patterns that users individually or in

groups should follow in the scenario of a game. For

example, in the dancing game, foreseen in the

GAME2AWE platform, there are predefined shapes

(arrows) on each tile of the smart floor. The smart

floor displays one of these shapes and the user is

asked to step on the tile with the corresponding shape

within a timeframe.

Another objective served by the smart floor is the

integration of the Choice Step Reaction Time (CSRT)

metric in the games as a predictor of falling risk.

Participants are asked to take quick steps in response

to the corresponding visual stimuli presented

randomly on the tiles and return back to their original

position. CSRT is measured in milliseconds and may

be broken down into three components: a) reaction

time, i.e., the time from the presentation of the

stimulus to the lifting of the foot; b) motion time, i.e.,

the time from the lifting of the foot to the contact of

the foot on the lightened tile; c) total response time,

i.e., the sum of reaction and motion time. According

to the study of Lord and Fitzpatrick (2001), elderly

who are prone to fall have significantly increased

CSRT times (1322±331 msec) compared to elderly

people who are not prone to fall (1168±203 msec).

3.2 Architecture

GAME2AWE proposes an innovative combination of

motion detection technology, VR and smart floor thus

providing the user with a greater variety of

interactions and exercises. The architecture of the

GAME2AWE platform is illustrated in Figure 4. The

Device Layer is the first level of the platform

architecture, where external devices communicate

with the system. The information collected by the

devices is forwarded to the Data Layer where it is

modeled using machine learning algorithms. The

information is then classified by the Analysis Layer

for the purpose of accepting or rejecting an

action/movement. In case of acceptance, information

is perceived by the user through Game Mechanics.

The game mechanisms inform the system about the

progress of the user in the gameplay in order to make

the corresponding adaptation of the game parameters.

The Adaptation Layer defines how to communicate

from a set of services to and from the Interaction

Layer. Finally, the Interaction Layer provides the user

interfaces.

The Adaptation Layer (AL) is an important

module of the architecture that provides the system

intelligence to create adaptable gaming experiences.

The AL is responsible for adjusting the parameters

and elements of each game. A key topic in the design

of the AL is to provide the ability to adapt the

elements that are related to the difficulty level of the

game. The games in the platform contain a variety of

parameters that can be used for the adaptation

process. For example, in the olive harvest game

(Figure 1) such parameters include the number of

trees, the crop type, color, and the growing frequency.

The input data that the AL will use to make decisions

on the configuration of the gameplay parameters will

be derived both from the data of the current game

round as well as from the corresponding performance

data from previous game sessions, which will be

retrieved from the data repository. This data will be

processed and given as input to machine learning

models. The result will be a set of parameters that will

regulate the adaptable elements of the game.

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

Figure 4: GAME2AWE platform architecture.

The use of machine learning models is justified

by the fact that the parameters to adjust for each game

will usually be more than one, and the degree of

variation for each of them would be different in each

step, which means that it would be extremely difficult

to rely is simple conditional statements in order to

build the decision logic.

3.3 Development and Evaluation

Human centered design according to ISO 13407

(International Organization for Standardization,

1999) for interactive applications is followed for the

development of the exergame applications. The

design is based on an iterative process where face-to-

face meetings take place at the initial stage between

the application development team, the elderly and

health specialists (physiotherapists, orthopedics,

psychologists) who are invited to identify possible

interaction activities and the basic mechanisms

related to the interventional goals of each game. A

focus group is created to help refine the

characteristics of each game and the body movements

that will be used to empower the elderly during the

game. By capturing the initial plan of the application,

a quick prototype of the game concept is

implemented, which is given to users for evaluation.

The development team responsible for analyzing user

assessments and for confirming the suitability of the

prototype usage, takes an active role at this stage. This

is followed by a redesign phase with improved game

rules and interactions prior to the final development

of the prototype.

The evaluation of the platform includes three

dimensions: motor, cognitive and technological. A

total of 60 users are foreseen and their participation is

based on age (≥65 years) and health criteria

(possibility of independent movement, absence of

serious health problems). The methodology includes

a control group and an intervention group using a

randomized controlled trial. For all users,

measurements of motor and cognitive functions will

be recorded before and after the use of GAME2AWE

exergames. The intervention group will use the

GAME2AWE platform 1-2 times a week until each

participant completes 24 sessions. Valid relevant

tests/scales will be used for the motor axis such as: 30

Second Sit to Stand Test (30SST), Berg Balance

Scale (BBS), Choice Stepping Reaction Time

(CSRT), Functional Reach Test (FRT) and Time Up

and Go (TUG). The Mini-Mental State Examination

(MMSE) and Montreal Cognitive Assessment

(MoCA) scales will be used for the cognitive axis. For

the technological acceptance of the platform by users,

parameters such as Perceived Usefulness, Perceived

Ease of Use and Output Quality (Technology

Acceptance Model 3) are evaluated. The Physical

Activity Enjoyment Scale (PACES) will be used to

assess user satisfaction. Qualitative research will be

carried out through semi-structured interviews with

the users participating in the pilot study. This research

will also identify subjectively the measure of quality

of life improvement. The following functions will be

examined by experts to assess the improvement

brought by the use of the GAME2AWE platform:

walking, muscle strengthening, balance, space-time

orientation, attention, concentration, memory and

observation.

During the use of the platform, the system collects

and stores encrypted performance data such as game

scores, interaction time with the game screens, game

usage frequency, games successfully completed,

number of errors, etc. The platform relies on

pseudonymisation to store users and connect them to

the corresponding information collected from them.

The stored data is used by machine learning

algorithms to define more effective exercise

programs to reinforce balance and strength in order to

prevent falls and improve cognitive abilities. In

addition, the discovery of patterns in stored data will

be exploited to classify older people at diagnostic

levels in order to complement traditional diagnostic

tools.

The research data to be collected during the

evaluation of the game platform will comply with the

requirements of the legislation on the protection of

Participatory Design of Fall Prevention Exergames using Multiple Enabling Technologies

personal data and in particular with the General Data

Protection Regulation. The participation of users in

the research will require their written consent in

accordance with ethics and ethical rules in scientific

research.

4 DESIGNING EXERGAMES

WITH A FOCUS GROUP

4.1 General Observations

There are many important questions that need to be

answered in order to create an exergaming technology

that is suitable for the elderly. Motivating people to

physical activity is not always an easy task and this

can be particularly true for older people. Studies have

shown that exergames by their nature motivate the

elderly to exercise as long as they provide enjoyment

at the same time as exercising.

The social interaction that can occur when playing

games in groups is also an important incentive that

enhances the eagerness for using exergames and

should be taken into account in the design of games.

Even the choice of the appropriate music and more

generally the sound stimuli provided by the

application to enhance the exercise experience can be

a positive incentive for the continuation of exercises.

In principle, the different needs and expectations

of older people must be understood, while taking into

account their different characteristics. Contact with

end users is important to meet these needs. A key

element is therefore the involvement of the elderly in

the process of developing applications following a

human centered design approach. The involvement of

health and care experts is also very important for

example in selecting appropriate exercises and

integrating them into games. Under this approach

tools that can help are, for example, interviews and

focus groups (Dwivedi et al., 2012).

4.2 Focus Group Workshop

A qualitative research was carried out using a focus

group (FG) that is considered vital in the human

centered design process adopted for the exergames

development. The research was carried out through a

coordinated group discussion based on the

perceptions and experiences of the participants. It was

thought that a group discussion would encourage

participants to share experiences in order to draw

useful conclusions. Basic rules were followed which

argue that a FG workshop should last one to two

hours and have 6-12 participants. Questions should be

asked in such a way that participants can express their

views and are not limited to ‘yes’ or ‘no’ answers

(Bruseberg and McDonagh, 2002).

The FG workshop took place in September 2021

in the facilities of a daily care center for elderly and

lasted 2 hours. Participants after being informed of

the objectives of the meeting validated their voluntary

participation by accepting the terms and signing the

relevant consent document. The FG sample consisted

of all the main stakeholders planned to be involved in

the design of the game platform (i.e., elderly, care

givers, health specialists and system engineers). The

FG workshop was conducted with eleven participants

(N=11) which were categorized into two primary

roles: elderly as end users and domain experts. Table

1 contains basic demographic features of the FG.

Table 1: Basic demographics of the Focus Group.

Characteristic Experts End Users

N5 6

(

±stdev

)

37.2 ±7.91 68.5 ±11.64

Gender

(

male/female

)

2/3 1/5

Education years

≥16

9.66 ±4.27

Technology familiarity* 4 2.16 ±1.72

*Technology familiarity (e.g. frequency of internet usage

and computing devices) was assessed with relevant

questionnaire items in a scale of 0 to 4.

In this context, a brief introduction was provided

by the scientific coordinator of the study on the

objectives of the meeting and the technologies to be

used. Then game concepts and scenarios were

presented in two stages and at each stage a group

discussion was held which was structured in order to

collect appropriate information that will contribute to

the better design of the exergames. Prototypes from a

previous study (Chartomatsidis and Goumopoulos,

2019) were also demonstrated. As the end users had

not any previous experience with exergames,

launching the discussion through the presentation of

relevant applications was deemed necessary to

prepare the ground for the discussion. By using

brainstorming and observation techniques as well as

an informal interview with the members of the FG,

helped to capture experiences and opinions, as design

and operational issues of the exergames were

discussed more thoroughly.

Representative scenarios from two game themes

(“Life on a Farm” and “Fun Park Tour”) were

presented to the end users and healthcare experts for

feedback. The objectives of the discussion in the FG

can be summarized as follows:

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

• Involvement of stakeholders (end users, experts)

in the process of developing the exergames;

• Discussion on game themes;

• Evaluation of game scenarios/designs;

• Clarity of game goals;

• User interface simplicity;

• Multiplayer support;

• Feedback on prototypes to create friendly games

for the target user group;

• Assessment of suitability and safety of exercises

and movements incorporated in the game flow.

A discussion guide was used, but at the same time

an attempt was made to make the conversation as

open as possible. The discussion concerned the game

scenarios/prototypes presented. The discussion guide

included questions organized in categories as follows:

General questions

Is this the first time you've seen games that use

the technologies presented?

If so, what have you used in the past?

In what context?

In general, have you ever played computer

games?

If so, on which platform?

Usefulness of applications/games developed

using the technologies presented

Motivation to exercising?

Improvement on:

• Physical condition

• Cognitive skills

• Mood

• Self-confidence

• Socialization

Could you think of incentives that can help older

people to use such applications?

Could you think of some obstacles refraining

older people from using such applications?

What other services/functionality could be

integrated into the platform to better support end

users with respect to exercising?

General understanding of the subject of the

game, its gameplay and its elements

How does it work?

How are the points earned?

What do the different levels of difficulty mean

and how are they displayed on the screen?

What do you think of combining physical

exercises with cognitive challenges during the game?

Music and sounds in the game?

What do you think of the idea of a series of games,

where new games will be accessed with a small cost?

The climate was positive and the interactive

conversation was very efficient as a climate of trust

and intimacy was established which allowed all

participants to give responses, make suggestions for

improvement and even develop a dialogue between

them without the need for the intervention of the

researchers.

4.3 Data Analysis

Analyzing the data collected in the context of a

qualitative research is very important, as the

conclusions drawn will essentially help to better

design the exergames.

Therefore, the data collected from the FG

workshop, including recordings, handwritten notes

and the reactions during the presentations, were

analyzed. By recording gestures, facial expressions,

tone change, and voice intensity, it was possible to

grasp any enjoyment, difficulty or contrast to game

elements. Such information is equally important for

drawing useful conclusions. For example, when end

users wanted to indicate new themes in games they

spoke calmly and comprehensively, while in points

that did not agree with the structure of the user

interface, the volume of their voice increased, which

testified to their opposition. There was also an attempt

to decode and isolate words or expressions used by

the FG members, such as difficulty, flexibility,

pleasant, obscure, etc.

The main findings of the group discussion held

during the FG workshop are summarized below. The

findings are based on the comments of the

participants and the observation of their reactions

during the presentation of the game scenarios and

prototypes.

After the presentation of the first set of games

(theme “Life on a Farm”) it took some time before

end users made their observations. It turned out that

it was not clear to them from the presentation how

these games work in practice. When it was explained

that the avatar seen on the screen follows the moves

made by the player, participants appeared to be more

aware of how the games work and provided more

feedback. The game theme was positively

commented as it concerned an environment familiar

to most end users.

The participants seem to have liked the game

“harvesting olive trees”. However, there were some

concerns about how the crops would appear on the

trees and how they could organize their harvest.

There were positive comments regarding the

combination of colors and how the scenery generally

looked in the game scenarios. One end user

commented that it would be better for the buttons to

Participatory Design of Fall Prevention Exergames using Multiple Enabling Technologies

appear with more shade around their outline to

indicate clearly that this is an interaction button.

As it was conveyed that the games will be

enriched with musical themes, participants wondered

about the genre of music and the sounds that will be

used in the games. Participants were informed that the

goal is to include sounds that are natural to the

environment. It was suggested that music should be

rhythmic to give the right tone for physical activities.

Most participants expressed concerns about the

familiarity of older people with the use of technology

and the use of related applications. In particular, for

the game applications and for the first sessions of the

intervention, they suggested that clear instructions

should be given for the execution of the movements

using an avatar-guide or a video. They also suggested

using a permanent “Show me the move” button that

could be used at any time by the end users when they

need help. A relative view that was expressed

indicated that such game applications could also be

used as an incentive to familiarize older people with

the technology in general.

With respect to the distinct game difficulty levels

and the required movements, participants agreed that

in-game exercise programs should have a variation

from very simple for the weakest participants and

gradually evolve for the most competent. There was

a difficulty in understanding this function at first.

There was a concern that they might be forced into

activities that are difficult and that will not be able to

cope with them. The explanation given that the game

will automatically adjust the difficulty of the game

according to the player’s abilities and that the player

will be able to adjust the choice of difficulty helped

to better understand this platform functionality.

Experts alike end users suggested multiplayer

support, preferably in a collaborative form rather than

competitive. Given that such games could be used in

daily care centers for elderly, a physiotherapist could

work with groups of 3-4 people at the same time, an

option that provides opportunities to enhance elderly

socialization beyond other factors, i.e., motor and

cognitive functions.

The end users in their majority agreed that most

of the movements that are requested in the exergames

shown to them seem feasible albeit some may be

more challenging (e.g. ‘standing on one leg with arm

lifting’), that the exercises seem realistic relatively to

the flow of the games, that these games could be used

for the intended purpose, and that they have

understood most of the information on the screens of

the prototypes presented.

The exercises integrated in the game scenarios

were assessed for suitability by experts in orthopedics

and physiotherapy with positive feedback. According

to their evaluation the exercises selected support the

kinetic dimension of the program and can help the

elderly to reinforce their balance and strength and as

a consequence to prevent osteopenia and to reduce

vulnerabilities and fall risk.

The experts also expressed their concern about the

suitability of the games for people with low mobility.

The approach that can be followed in this respect is to

integrate into the exergames more movements in the

sitting position. From a technical point of view, this

requires training of motion recognition algorithms for

both standing and sitting positions.

Finally, the idea of accessing additional games at

a small cost was discussed. This approach was

thought to have a positive effect on continuing the

exercises for a longer period of time as one can get

tired of playing the same game all the time. Although

participants agreed that the idea is useful they showed

reluctance to pay the cost themselves and wondered

whether their insurance fund could cover it.

4.4 Aspects of Attention

Older people have some characteristics that need to

be taken into account when developing technological

systems for them. These characteristics can be

summarized as follows:

• Impairment of cognitive functions such as

memory weakening and reduced ability to learn

new things.

• Impairment of sensory functions, such as

reduced visual and hearing acuity.

• Intensity of health problems with older age.

• Mobility deterioration.

• Different needs and requirements depending on

their lifestyle and cultural, social and economic

background.

• Need to use auxiliary equipment, for example

using a walker device when standing and

walking.

• Little or no familiarity with technology and

therefore a lack of trust in technology systems.

Trust improves when successful interaction with

specially designed systems happens.

• Difficulty in retaining and recalling much

information, suggesting that it is important to

take into account memory-related issues.

• Response difficulty to more than one task

simultaneously.

The overall analysis of the data collected during

the FG workshop raises some key issues that should

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

be taken into account in the implementation of the

games. These elements are summarized in Table 2.

Table 2: Aspects requiring attention in the

design/implementation of games.

ect Desi

n Guideline

Game theme

Daily life activities: excursions in

nature, vacation, swimming, fishing, life

on a farm, gardening, sports, dancing,

puzzle games, home tasks, shopping at

the su

ermarket.

People

diversity

The game should take into account the

diversity of people (gender, age,

educational attainment, social/cultural

ack

roun

)

, e.

. in the avatar selection

Dual activity

Exercises combining physical

movements and cognitive skills training

Instructions

What is expected by the player, why the

player has to do the exercise and what is

the benefit that will arise?

How will the player carry out various

activities, challen

es and exercises?

Feedback

Whether movements are done correctly

Positive and motivating

User

interface

Easy and intuitive menu

Easy navigation

Clearly visible objects

Limited number of information and

elements

Motivation

Enjoyment

Clear objectives that can be achieve

Progress

Allow progress in the game to enhance

the player’s self-effectiveness and self-

estee

Multiple

levels

Different levels of difficulty, where

additional challenges can be added to

her levels

Social

interaction

Multiplayer games or use of games in

daily care centers for elderly people

Music and

sounds

Appropriate music: rhythmic music,

classical music, no music, natural

sounds

(

air, birds, water flowin

Adaptation

of difficulty

Adjust the rate of difficulty change in

the game according to the user’s profile

and

erformance

Usage

statistics

Ability to store user’s progress and

results for later analysis

5 CONCLUSIONS

Physical activity is important for the elderly to

preserve good health and quality of life. In order to

encourage the elderly to be more physically active,

they should be provided with easy to use applications

that will actually motivate them to perform helpful

exercises for long periods. In GAME2AWE, the goal

is to create friendly exergames for the elderly using

multiple enabling technologies. The research

hypothesis to explore by the end of the project is that

by using this platform to exercise physical and

cognitive functions systematically, the risk of falling

can be reduced and relevant functional indexes would

be improved. Such results can have a positive impact

on reducing the related social and financial burdens.

In this paper the methodology that frames the

development of the platform was outlined and the

participatory design of the exergames was explored

thoroughly. Qualitative research methods were

applied in order to be able to understand end users and

the challenges to motivate older people into adopting

exergames involving physical activity. The analysis

of the data collected raised important issues related to

the development of exergames for the elderly and

were listed as a set of design instructions to be

followed in the development of the platform.

ACKNOWLEDGEMENTS

This research has been co‐financed by the European

Regional Development Fund of the European Union

and Greek national funds through the Operational

Program Competitiveness, Entrepreneurship and

Innovation, under the call RESEARCH – CREATE –

INNOVATE (project code: T2EDK-04785)

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