Gamification Concepts to Promote and Maintain Therapy Adherence in Children with Growth Hormone Deficiency†
Round 1
Reviewer 1 Report
Thank you for asking me to review the paper on “Gamification concepts to promote and maintain therapy adherence in children with growth hormone deficiency”. This is an important study as growth hormone deficiency has negative impact on physical and mental health. I have the following recommendations:
1. The authors mentioned about the success of gamification in obesity. It is important to highlight the role of depression in growth hormone deficiency and obesity while gamification promotes weight loss. Please add the following statements in line 169:
minutes/day) was observed [ 32 169 ]. Similarly, gamification-based smartphone application may help in weight loss in obese adolescents (Reference: PMID: 29854386). Depression is commonly associated with growth hormone deficiency (Reference: PMID 14767091) and obesity (Reference: PMID: 28401646). Gamification can reduce cognitive bias which are commonly found in depression (Reference: PMID: 30040771). The success of these games highlights …
2. This is a review article. For Table 1 and 2, the authors took tables from other articles published by other authors. I am concerned about the copyright issues. I recommend the authors to remove those tables and describe the results in the manuscript.
Author Response
Reviewer #1:
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1. The authors mentioned about the success of gamification in obesity. It is important to highlight the role of depression in growth hormone deficiency and obesity while gamification promotes weight loss. Please add the following statements in line 169:
minutes/day) was observed [ 32 169 ]. Similarly, gamification-based smartphone application may help in weight loss in obese adolescents (Reference: PMID: 29854386). Depression is commonly associated with growth hormone deficiency (Reference: PMID 14767091 19845844) and obesity (Reference: PMID: 28401646). Gamification can reduce cognitive bias which are commonly found in depression (Reference: PMID: 30040771). The success of these games highlights …
AUTHORS' ANSWER: We have added the reviewer's recommended statement and the new references it cites. Thank you for helping us improve the quality of our article.
2. This is a review article. For Table 1 and 2, the authors took tables from other articles published by other authors. I am concerned about the copyright issues. I recommend the authors to remove those tables and describe the results in the manuscript.
AUTHORS' ANSWER: Table 1 is reproduced from an open access journal (free to use, permission automatically granted as long as source is acknowledged), and we have cited the reference per MDPI's format: "reproduced with permission from [40]". Table 2 has been removed and the results it was presenting (from reference [45]) have been described in the text of the manuscript.
Reviewer 2 Report
This paper proposes the implementation of gamification within Growth Hormone (GH) therapy to improve children's adherence to the therapy. Frameworks for the successful application of gamification are introduced and discussed, and example applications from other domains are utilized to support some of the specific game elements proposed in this field. Overall, this is a well-written and well-organized paper which explores the challenge of successful GH therapy from several angles and proposes solutions to each challenge. However, there are three major challenges which, if addressed, would vastly improve the clarity and technical soundness of the proposed concepts.
The first is that the role of children in GH therapy could be more clearly addressed. From the understanding of this reader, injections/treatment are administered regularly by parents/medical professionals and "adherence" refers to a child's agreement to/acceptance of each treatment. In other words, "adherence" in this context may be somewhat different than in, say, physical activity and obesity prevention, where a child controls the therapy through physical action. It would be helpful to clarify in the work whether this assumption is true or not with a more in-depth discussion of the roles of various parties in GH therapy.
The second is that, in the final paragraph of the overview of gamification strategies for health, it is mentioned that "all the involved human, personal and psychological factors of the target population must be considered (e.g. age group, demographics, health literacy, clinical status)" but strategies for addressing some of these attributes are not sufficiently described. This is a very important point, as it has direct implications in game design. Clinical status and health literacy, for example, may vary quite a bit from case to case; how can a game's interface in GH therapy address this variability?
The final, and perhaps the most important challenge, is that of domain transferability. Examples in the domains of diabetes management and physical activity are given, but it should not be assumed that the strategies applied in these domains will transfer to the domain of GH therapy without (potentially significant) differences in the way game elements are presented. To address this, some discussion about how strategies such as the "virtual pet" might be implemented specifically in GH therapy, with details of how self-efficacy could be achieved for children given their role in this therapy, could be included in the work.
Having addressed these challenges, the paper would make a strong argument for the exploration of gamification in GH therapy.
Author Response
Reviewer #2:
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1. There are three major challenges which, if addressed, would vastly improve the clarity of the proposed concepts. The first is that the role of children in GH therapy could be more clearly addressed. From the understanding of this reader, injections/ treatment are administered regularly by parents/medical professionals and "adherence" refers to a child's agreement to/acceptance of each treatment. In other words, "adherence" in this context may be somewhat different than in, say, physical activity and obesity prevention, where a child controls the therapy through physical action. It would be helpful to clarify in the work whether this assumption is true or not with a more in-depth discussion of the roles of various parties in GH therapy.
AUTHORS' ANSWER: Thank you for helping us improve the quality of our article. We have cited a new reference [46] and added the following text:
"Current adherence to paediatric GH therapy is suboptimal. In children, both parents (administering injections) and the child play a role. Reasons for poor adherence include forgetting to take/administer the injection or refill the prescription, being away from home, exhaustion from long-term injections (the child's pain can be equally non-pleasant for parents administering the injection), and drug shortage and inaccessibility to the pharmacy. The barriers to adherence remain the same among adolescents, namely forgetting to take the injection, painful injections, concern about long-term complications, and exhaustion from long-term injections [46]. Gamification can help make the experience of administering injections more pleasant and less painful for both the child and her/his parents, and ensure better long-term compliance, e.g., by raising a virtual pet to keep the patient motivated and engaged."
46. Mohseni S, Heydari Z, Qorbani M, Radfar M. Adherence to growth hormone therapy in children and its potential barriers. J Pediatr Endocrinol Metab. 2018 Jan 26;31(1):13-20. doi: 10.1515/jpem-2017-0157
2. The second is that, in the final paragraph of the overview of gamification strategies for health, it is mentioned that "all the involved human, personal and psychological factors of the target population must be considered (e.g. age group, demographics, health literacy, clinical status)" but strategies for addressing some of these attributes are not sufficiently described. This is a very important point, as it has direct implications in game design. Clinical status and health literacy, for example, may vary quite a bit from case to case; how can a game's interface in GH therapy address this variability?
AUTHORS' ANSWER: We have cited a new reference [47] and added the following text:
"Games aimed at improving paediatric GH therapy adherence should carefully address the health literacy levels and needs of different children and their parents. Game designers are encouraged to observe the principles of clear health communication in their game materials (textual and audio-visual) [47], and to work with a representative sample of target users (children and their parents) in an iterative fashion to test (and refine) features of the games repeatedly, as necessary, early in the design and development process, to help avoid late-stage failures."
47. Doak LG, Doak CC (Editors). Principles for Clear Health Communication (2nd Edition). Pfizer, 2004. Available at https://www.pfizer.com/files/health/PfizerPrinciples.pdf
3. The final, and perhaps the most important challenge, is that of domain transferability. Examples in the domains of diabetes management and physical activity are given, but it should not be assumed that the strategies applied in these domains will transfer to the domain of GH therapy without (potentially significant) differences in the way game elements are presented. To address this, some discussion about how strategies such as the "virtual pet" might be implemented specifically in GH therapy, with details of how self-efficacy could be achieved for children given their role in this therapy, could be included in the work.
AUTHORS' ANSWER: We have added the following text:
"Applying the ‘virtual pet’ approach to GH therapy, the authors are currently developing and testing a game app in which a virtual coach helps guide the child through the app and educate them on why GH therapy is necessary. The child is given ownership of the app and responsibility to care for a virtual pet that needs their help and attention to grow. The app aims to establish a daily play moment to help distract (from pain), relax and reward the child for injecting (or what the game refers to as ‘stamping’). Within the app the child can select the room where they want to stamp and where stamping will fit in their end of day routine. This helps the child to feel more in control of what will happen, when and where. Once a routine is established, it is proposed that this will help to normalise injections and make it easier for the child (and his parents) to comply. As part of a mini-game, the child is first encouraged to complete a breathing exercise by blowing into the microphone of the smartphone to push the virtual pet on a swing. The parent ‘stamps’ the child when the child inhales and the app records the sound of the injection and time taken to complete administration. If it is taking too long to administer this may be an indication that the parent needs further support from their healthcare professional. Upon the moment of injection, the virtual pet flies off the swing and the child must move the phone to collect rings and gain points. After the mini game has finished, the in-game virtual coach praises the child for stamping and asks for feedback on how the stamp went, e.g., the child’s mood, wet or dry injection, and presence of bruising. In another mini-game, the child is encouraged to stamp the virtual pet. This can take place before or after the child’s own GH injection. The child selects the stamp and injects when the pet inhales. This exercise reinforces the need for daily injections and the importance of breathing when stamping. It is hoped that the child will form a bond with their virtual pet and will feel accountable if they do not take care of it by completing their daily injections. Over time, as the child maintains treatment, the virtual pet will grow and level up to unlock more functionality within the app. Points earned in the game can be used to buy items for the pet or to decorate rooms in its virtual house. Each level-up unlocks new activities and ways to interact with the pet to keep the child engaged. The app can also be used to capture vital information on growth, adherence, adverse events, etc. Data are stored in a secure database and, with parental consent, may be used to provide healthcare professionals with a better insight on adherence so that they can direct therapy accordingly."
Round 2
Reviewer 1 Report
I recommend publication.
Reviewer 2 Report
All of my concerns have been adequately addressed. Revised version is recommended for publication.
