33 Design of the persuasive game ‘Ademgenoot’ 2 already motivated to self-manage their condition, feel more necessity in doing so and actively monitor their symptoms and behaviour. In addition, engagement with such self-monitoring programs can be challenged, as they often require people to enter their symptoms or asthma control manually (21,24-26). Serious games are designed to motivate and engage users for non-entertainment goals, utilizing game elements and game mechanisms. Consequently, they are increasingly used as strategies within behaviour change interventions to overcome the challenges of disengagement. Although serious games are often applied to facilitate educational purposes, they have also proven effective in motivating users to adopt specific attitudes and health behaviours such as medication- and therapy adherence or adopting a healthy lifestyle (27). Notably, serious games have demonstrated effectiveness in improving medication adherence among cancer patients, promoting physical activity in people with diabetes and addressing several mental disorders (27-29). To understand the underlying mechanisms through which serious games promote beneficial health outcomes, the Persuasive Game Design Model was developed (30,31). According to the model, the skills, attitudes, and beliefs developed within the game world can be transferred to the real world. The Persuasive Game Design Model offers, at the same time, a comprehensive step-by-step framework to standardize and guide the development of serious games. This framework entails (1) defining the transfer effect, including the type of effect and the type of change (e.g., reinforcing, altering or forming new behaviours or attitudes) (2) investigating the users’ context, (3) identifying, developing and testing game components (e.g., challenges, game levels, and virtual rewards) and game mechanics (e.g., collaboration and competition), and (4) evaluating the effectiveness of the game in achieving the intended transfer effect (31). Given the potential of serious game to engage individuals and change behaviours, serious games could prove to be an effective way of motivating people to adhere to their maintenance inhaler. When designing a persuasive game interconnected to an EDM, it is important to actively involve all stakeholders, to ensure alignment with stakeholder and end-user needs and preferences (22,32). In recent years, a participatory design methodology has emerged as a valuable approach to include end-users and other stakeholders in the development of eHealth. This approach emphasizes several key processes, including at least two iterative cycles of testing and feedback, involving end-users at all stages of the process, and incorporating input from other stakeholders such as clinicians and smart inhaler developers (33). The objective of this study was to apply a participatory design approach to design a persuasive game aimed at improving medication adherence among people with asthma by leveraging the potential of smart inhalers and incorporating behaviour change and persuasive game design strategies. This paper describes the development cycle, design requirements and assessment of the final prototype on usability, usefulness, and perceived impact on improving medication adherence.
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