© 2018 by KARTHIKA JAYAPRAKASH

karthikapriyaj@gmail.com​  |  Tel: 704-780-0013

AIR- HEROES

SPRING 2018

Enabling continuity of care for children with chronic health conditions like Asthma.

UX Design, Storytelling, Gamification

 

THE PROJECT IN BRIEF

THE PROJECT IN BRIEF

The Problem

POOR ASTHMA MANAGEMENT & A LACK OF CONTINUITY OF CARE NEGATIVELY AFFECTS THE HEALTH OF PEDIATRIC PATIENTS
 
Asthma is a chronic disease that can be controlled by proper management without affecting quality of life. Poorly managed Asthma can lead to increased Asthma exacerbations, hospitalizations and long term consequences like deterioration in lung health. Children from low socio-economic backgrounds with chronic health conditions like Asthma are more adversely impacted than their counterparts because of a lack of continuity of care, self advocacy and education. Current tools used to gather lung function data are neither  commonly available nor easy to use.
POOR ASTHMA MANAGEMENT & A LACK OF CONTINUITY OF CARE NEGATIVELY AFFECTS THE HEALTH OF PEDIATRIC PATIENTS
 
Asthma is a chronic disease that can be controlled by proper management without affecting quality of life. Poorly managed Asthma can lead to increased Asthma exacerbations, hospitalizations and long term consequences like deterioration in lung health. Children from low socio-economic backgrounds with chronic health conditions like Asthma are more adversely impacted than their counterparts because of a lack of continuity of care, self advocacy and education. Current tools used to gather lung function data are neither  commonly available nor easy to use.

The Users

The Users

Our primary users are children between the ages of 7-12 who suffer from Asthma and come from low socio- economic backgrounds.
Our secondary users are the parents, caregivers and healthcare providers of these children.  
Our primary users are children between the ages of 7-12 who suffer from Asthma and come from low socio- economic backgrounds.
Our secondary users are the parents, caregivers and healthcare providers of these children.  

The Solution

The Solution

Our solution is an Android mobile application that uses gamification to engage the young user. Our approach is to educate our users and encourage behavior change as they use the app. 

To aid in continuity of care, we gamify the process of recording lung function metrics and incentivize daily usage. Lung function data is recorded on a daily basis, and, notifications are used to alert parents if poor lung function is detected.

Our solution is an Android mobile application that uses gamification to engage the young user. Our approach is to educate our users and encourage behavior change as they use the app. 

To aid in continuity of care, we gamify the process of recording lung function metrics and incentivize daily usage. Lung function data is recorded on a daily basis, and, notifications are used to alert parents if poor lung function is detected.

My Role

My Role

Team: Karthika Jayaprakash, Jim Helm, Jon Duong, Hannah Alequin
Team: Karthika Jayaprakash, Jim Helm, Jon Duong, Hannah Alequin
I was the design lead on this project, I created the narrative, graphics and wireframes for the Air- Heroes app and conducted user tests. The other members of my team worked on the implementation of the app on the Android platform.  
Tools: Balsamiq, Adobe Illustrator, Android Studio
I was the design lead on this project, I created the narrative, graphics and wireframes for the Air- Heroes app and conducted user tests. The other members of my team worked on the implementation of the app on the Android platform.  
Tools: Balsamiq, Adobe Illustrator, Android Studio

RESEARCH

Given project time constraints the user research was primarily based on Literature Reviews and evaluation of currently available Asthma applications.
Survey of currently available solutions:
The Asthma Action Plan(AAP) is a CDC recommended handwritten tool used by doctors to educate parents and children on how to manage and control Asthma. The AAP helps them recognize and treat symptoms, identify triggers and understand the treatment/medication to be used based on the severity of the symptoms.
There is evidence of the potential of digital intervention, using web and mobile applications, to help promote better health practices. Most Asthma related applications currently available on the market however are targeted at adult users. They do not make use of the potential of mobile phone sensors to track Asthma related health parameters.
There is an unmet need for apps created for children that teach Asthma Management and aid in continuity of care by regularly collecting health metrics. Since the AAP is a paper document, its accessibility is reduced, a mobile solution could overcome this limitation as smartphone adoption is over 85% in this demographic.
 
Users:
African American children are disproportionately affected by Asthma as are children of Puerto Rican origin. Children from impoverished backgrounds visit the ER over the norm. Environmental factors that are more prevalent in low-income areas such as pollution and the presence of mold and mildew in residences increase the likelihood of children developing Asthma. Children from single-parent households are also at increased risk of Asthma exacerbations, as are children in families with multiple children. Children, especially those from a lower socio-economic background will need solutions that are created specifically keeping their needs in mind. Medical adherence, trigger identification and avoidance, recognition and treatment of symptoms, increased patient self advocacy and continuity of care will improve patient health.
As smartphones have a very high penetration rate in this demographic and as Android OS smartphones are available at very affordable prices, an Android mobile application would be ideal.
Children from low income families, multiple children households and single parent families have poorer health outcomes due to economic and time stress. As parents play an important role in managing their child's Asthma the solution must take their needs into account.
Lung Function Data:
One promising use of sensors is the use of microphones in smartphones to track lung function. We conducted user tests on 4 participants in their 20's to evaluate the usability of the 'Ma ma' technique versus the Spirometer technique to gather lung function data. The 'Ma ma' technique was selected based on the simplicity of use keeping in mind the age of our users. 

RESEARCH

Given project time constraints the user research was primarily based on Literature Reviews and evaluation of currently available Asthma applications.
Survey of currently available solutions:
The Asthma Action Plan(AAP) is a CDC recommended handwritten tool used by doctors to educate parents and children on how to manage and control Asthma. The AAP helps them recognize and treat symptoms, identify triggers and understand the treatment/medication to be used based on the severity of the symptoms.
There is evidence of the potential of digital intervention, using web and mobile applications, to help promote better health practices. Most Asthma related applications currently available on the market however are targeted at adult users. They do not make use of the potential of mobile phone sensors to track Asthma related health parameters.
There is an unmet need for apps created for children that teach Asthma Management and aid in continuity of care by regularly collecting health metrics. Since the AAP is a paper document, its accessibility is reduced, a mobile solution could overcome this limitation as smartphone adoption is over 85% in this demographic.
 
Users:
African American children are disproportionately affected by Asthma as are children of Puerto Rican origin. Children from impoverished backgrounds visit the ER over the norm. Environmental factors that are more prevalent in low-income areas such as pollution and the presence of mold and mildew in residences increase the likelihood of children developing Asthma. Children from single-parent households are also at increased risk of Asthma exacerbations, as are children in families with multiple children. Children, especially those from a lower socio-economic background will need solutions that are created specifically keeping their needs in mind. Medical adherence, trigger identification and avoidance, recognition and treatment of symptoms, increased patient self advocacy and continuity of care will improve patient health.
As smartphones have a very high penetration rate in this demographic and as Android OS smartphones are available at very affordable prices, an Android mobile application would be ideal.
Children from low income families, multiple children households and single parent families have poorer health outcomes due to economic and time stress. As parents play an important role in managing their child's Asthma the solution must take their needs into account.
Lung Function Data:
One promising use of sensors is the use of microphones in smartphones to track lung function. We conducted user tests on 4 participants in their 20's to evaluate the usability of the 'Ma ma' technique versus the Spirometer technique to gather lung function data. The 'Ma ma' technique was selected based on the simplicity of use keeping in mind the age of our users. 
 
 

ANALYSIS

ANALYSIS

The goal of our project was to create a solution to help improve the health outcomes of children who suffer from Asthma and

come from a low socio-economic background.

The following requirements were identified after the Literature review-
  1. The solution should increase patient engagement, facilitate continuity of care and enable self advocacy.
  2. The solution should educate patients about triggers, symptoms and treatments.
  3. The solution would need to be affordable, portable and easily accessible in multiple contexts. as, children could spend time at child care centers, homes of neighbors and relatives, public spaces like parks, libraries etc. besides their primary homes and schools.
  4. The solution should consider how to assist parents in the care of their child's Asthma, as parental involvement is a huge factor in improving health outcomes,
  5. Children with chronic health conditions may suffer from low self esteem, the solution should address this aspect.
Implementation Decisions-
As smartphones have a very high penetration rate in this demographic and as Android OS smartphones are available at very affordable prices, we chose to create an Android mobile application. We would use sensors commonly available in low-cost phones (microphones, accelerometer), and the application would not require much processing power or be very large so that it would work on low-cost phones which may not have adequate memory.
Using insights from the Literature review, I constructed 4 child personas to help inform our design decisions.
The goal of our project was to create a solution to help improve the health outcomes of children who suffer from Asthma and

come from a low socio-economic background.

The following requirements were identified after the Literature review-
  1. The solution should increase patient engagement, facilitate continuity of care and enable self advocacy.
  2. The solution should educate patients about triggers, symptoms and treatments.
  3. The solution would need to be affordable, portable and easily accessible in multiple contexts. as, children could spend time at child care centers, homes of neighbors and relatives, public spaces like parks, libraries etc. besides their primary homes and schools.
  4. The solution should consider how to assist parents in the care of their child's Asthma, as parental involvement is a huge factor in improving health outcomes,
  5. Children with chronic health conditions may suffer from low self esteem, the solution should address this aspect.
Implementation Decisions-
As smartphones have a very high penetration rate in this demographic and as Android OS smartphones are available at very affordable prices, we chose to create an Android mobile application. We would use sensors commonly available in low-cost phones (microphones, accelerometer), and the application would not require much processing power or be very large so that it would work on low-cost phones which may not have adequate memory.
Using insights from the Literature review, I constructed 4 child personas to help inform our design decisions.

Personas

Personas

Ideation

Ideation

 

DESIGN

DESIGN

I led a brainstorming exercise which resulted in over 40 ideas. These were in two categories, one had to do with the features and the structure of the application and the other with the theme or concept of the application.
I led a brainstorming exercise which resulted in over 40 ideas. These were in two categories, one had to do with the features and the structure of the application and the other with the theme or concept of the application.
The following was the broad structure of the game we arrived at post-brainstorming.
  1. The application would include a game to engage and entertain children
  2. The child would need to submit lung function data once daily to gain access to the game
  3. The process of gathering Lung Function data would be gamified and a narrative would be created
  4. Game time would be limited but extra game time could be gained by taking a quiz on Asthma facts
  5. Additionally, a daily bonus would incentivize regular play
The best of the concept ideas were shortlisted, and I created the following 3 more detailed concepts using elements from the shortlist.
The concepts were evaluated by team members and the project mentor and the Air Heroes concept was selected based on its potential to appeal to a wider age group and the use of lung function data submission to allow access to game play.

Narrative

Narrative

STORYBOARD
I created the storyboard below to present our narrative.
In our ideation sessions we had come up with a lot of ideas using 'air power' and 'lung power' to fill canisters that would power a jetpack that the child would use to play games. I came up with the idea of creating the jetpack in the shape of human lungs. Since the jetpack would power their adventures in the game, this could serve to subtly emphasize to the child that 'strong lungs' would take them far.
 
WIREFRAMING NARRATIVE
The 'Ma-Ma' technique of gathering Lung function requires the child to first hold the phone in the normal speaking posture, take a deep breath and hold it. Next, the child has to say the syllable 'Ma' as many times as possible until they run out of breath. To make this process seem natural, fit the space adventurer concept of the game and motivate the child to submit lung function data I modified the narrative. In the new narrative, the alien gifts the child a jet pack called the Lung 'Ma'chine that is powered by the word 'Ma'. I also decided to use our personas as avatars that children could pick in the game so that they could better identify with the character in the game and improve engagement.

App Flow Diagram

App Flow Diagram

The following was our initial plan for the flow of the app. The daily bonus screen would be presented once every 24 hours. The first time in a day the app was opened, the narrative would be played and the lung function data screen would be presented. Once lung function data was submitted the child would earn a powered- up 'lung machine' which could be used to play the game for a certain duration. Once the lung machine ran out of power the child could earn more play time by taking a quiz on Asthma facts. The home screen would allow access to the lung function, game and quiz components and in addition have settings and shop buttons.
The following was our initial plan for the flow of the app. The daily bonus screen would be presented once every 24 hours. The first time in a day the app was opened, the narrative would be played and the lung function data screen would be presented. Once lung function data was submitted the child would earn a powered- up 'lung machine' which could be used to play the game for a certain duration. Once the lung machine ran out of power the child could earn more play time by taking a quiz on Asthma facts. The home screen would allow access to the lung function, game and quiz components and in addition have settings and shop buttons.

Lung Function Data

I created these wireframes were created for the Lung Function data collection component of the app. Due to project time constraints we retained the audio and implementation of the 'Ma-Ma' technique while providing a new GUI. 
The 'Ma-Ma' technique uses Microsoft Cognitive Services to translate the voice data and denotes each 'Ma' utterance as a word. The number of 'Ma' syllables uttered are then counted. This process is started once the child clicks the stop button in wireframe 3 below. Wireframe 4 was created to let the child know that the system was processing data for the 10-15 seconds it took to calculate this.   

Game Design

Our mandate for the game design was to make it educational and model ideal behavior. The player is introduced to 2-3 triggers at the beginning of each level and is asked to avoid them as they weaken the players 'lung machine' on contact. The player's avatars are powered by the 'lung machines'. Triggers fall in a top-down direction on the screen and the players have to tilt the phone to avoid the triggers. The lung machine loses a little charge every time they hit a trigger. Rescue inhalers that also drop down at intervals, can be used to power-up/strengthen the Lung Machine.
Players collect coins during game play that could be used to purchase more playtime, customize avatars etc.

Home Screen & Daily Bonus

The following are the final wire frames for the home screen and the Daily Bonus screens. Based on user tests, a 'story' button was added to the home screen to allow kids to replay the narrative if they wanted.

Quiz

Given project time constraints, the quiz component was designed text based. The player is presented with a series of 3 questions. The Lung Ma-chine gets proportionally charged based on the number of questions they answer correctly. The player is given an option to retake the quiz to improve their score and fully charge the Lung Ma-chine. In future iterations we plan to use some pictorial quizzes as well as, a play audio option for our younger users. We also plan to reduce the amount of text on the screens based on user feedback.

EVALUATION

User Testing

 
PARTICIPANTS: 
Our target primary user group was children with Asthma between the ages of 7 to 12. I conducted user tests of the app on 6 participants, 4 children aged between 6 - 10 years and 2 adults in their twenties. None of the children had Asthma, one 9 year old had some experience with inhalers used to treat allergy symptoms. One adult had Asthma.
 
PROCEDURE: 
 Once consent was obtained from parents, the children were asked if they would like to try a smartphone app. We then observed them as they used the app. A short interview was conducted post-task.

The main goal of the user tests was to evaluate the usability of the lung function data gathering component. The benchmark task was for the users to use the application to submit their lung function metrics. For this, they would have to identify the “Charge Lung Ma-chine” button from the home screen menu and follow the instructions. The children were handed the app, no instructions were given unless specifically requested by the child.

PERFORMANCE METRICS: 

  • Effectiveness

    • Task completion rate - number of participants who completed the task without assistance

    • Error rate - number of participants who submitted their lung function metrics correctly

  • Ease of use

    • Difficulty of completing the task

      • verbal response: How easy or difficult was it to charge the Lung Ma-chine? 

      • verbal response: Did you understand the instructions to charge the Lung Ma-chine

  • Satisfaction​​

    • Willingness to use the Air Heroes app

      • verbal response: Would you like to use this app again? 

 

 FINDINGS: WHAT WORKED

- Both adults and all children except our 6 year old completed the task without assistance.

- All children also reported that they would like to use the app again, especially if the game were implemented.

- All children reported that it was easy to charge the Lung Ma-chine and that they understood instructions easily. (In observations though we noted that the 6 yr. old required help to read instructions and that 3 children did not follow instructions as intended)

- Two children asked if they could try the Recharge Lung Ma-chine component as they wanted to improve their scores.

- Most child users reported that they liked the story introduction to the “Charge Lung Ma-chine” activity. A couple of them wondered if they could have a longer story. This could be an additional component to increase the enjoyability of the app.

- Findability was good amongst most users. The participants were easily able to navigate to different parts of the app from the home screen

- The children were very excited about the game, but were disappointed that it was not fully implemented at the time of user testing. They quickly figured out how to turn the phone to make the avatar move which was the only part that was implemented.

FINDINGS: WHAT DIDN'T WORK

While evaluating the usability of the Lung Function Data component, we observed that

- Some users failed to hold the phone to their ears when instructed.

This led us to consider experimenting further with either a visual cue(a child holding a phone to their ear) or an audio prompt(using the phone’s speakers to convey the instruction).

- All users found the wait time while the results were calibrated a little too long. Some child participants started to click different parts of the screen thinking the app had stopped responding

We plan to mitigate this in future iterations by showing an animated count meter or animated in-process icon

- Users especially children did not follow instructions about holding their breath in until the second tone and then saying as many ma’s as they could before they ran out of breath. Most took in a quick breath and exhaled before the second tone.

- Some users even took in multiple breaths while saying “ma-ma” multiple times.

- Users also had different ways of articulating “ma- ma”, some were mumbled, others spoke them too fast.

The implication this has on our application is that we need to conduct more elaborate user tests while fine-tuning the usability of the audio instructions for the “ma-ma”  component. One aspect would be to use a less robotic, child friendly voice and secondly to consider the way the “ma-ma” is enunciated in the audio, giving the syllable more stress and spacing the syllables out more giving the users a clearer idea of how to speak the word. We could also create a video that shows the child the correct technique of submitting lung function data.

- Our 6 year old user required help reading the menu. Since our target user group comprises of children from low socio-economic backgrounds, literacy levels could be low, as a result we should add audio instructions for the lung component for future iterations.

 

Our intention for Air Heroes was to create an entertaining yet educational application with a wide reach to help children manage Asthma and provide much needed continuity of care to those from the disadvantaged communities. From our preliminary user testing we saw that children were excited about the narrative and enjoyed the gamified process of submitting lung function data. This shows that healthcare applications of this type that parlay the ubiquity of smartphones have great potential in improving continuity of care.

On the flip side we discovered that our method of instruction could have been vastly improved. Due to project time constraints we used the audio instructions of the original 'Ma-Ma' implementation. Our participants found the audio to be 'like a robot', they also did not accurately follow the instructions. For future iterations, we would need to redesign the instructional mechanism of the lung function data component if possible as a participatory design exercise with children of this age group.

Additionally, we would need to evaluate the application through a longitudinal study and with children who have Asthma.  

We would also have to study further how to account for children who take multiple breaths during the process. We would also need to study further how the rapid or slow enunciation of the 'Ma's' would impact the accuracy of the lung function data.

Finally, in this iteration we did not design the parental notifications or the screens where data could be presented to health professionals. There is much work to be done on that aspect that will elevate the value of this app.

REFLECTION