A Study on the Effect of Gamification on Alleviation Anxiety Levels of the Elderly in China

Abstract

As the problem of aging becomes increasingly serious, anxiety symptom has seriously affected the mental health of the elderly as a ubiquitous phenomenon in the elderly of China. Recently, a lot of researches show that gamification plays a positive role in relieving negative moods. This paper sorts out the gamification design strategies for the elderly to relieve anxieties and develops a collage game for the elderly according to this strategy: background, text and picture materials are used to make different subject patterns of collage and create own collage works. This game is used to verify the influence of gamification intervention means on the anxieties of the elderly as an intervention of control experiment. In this experiment, 42 participants were divided into two groups. The experiment group used gamification intervention, while the control group did not; STAI scale and galvanic skin were used to measure the change in the anxiety level of participants. According to the results, collage game for the elderly can relieve the anxiety state of the elderly, and most of the participants were free from usage pressure and relieved their anxieties during the game. Gamification seems to be a promising way to relieve the anxieties of the elderly. In the future work, it is necessary to make long-term experiments with a large sample size, so as to verify the influence of gamification intervention means on the reduction of anxieties, explore the influence of demography factor on the reduction of anxieties and sort out more targeted gamification intervention means.

1 Introduction

In recent years, aging has gradually become an important social issue, and the realization of active aging has become an important problem to be solved around the world. Literature shows that, according to the national survey of the National Bureau of statistics, by the end of 2018, China’s elderly population (aged 60 and over) has reached 249 million, accounting for 17.9% of the total population; the elderly population aged 65 and over 167 million, accounting for 11.9% of the total population [1]. The sudden peak of aging is more likely to cause various psychological problems of the elderly, such as anxiety and depression. According to the World Health Organization (WHO), more than 20% of adults aged 60 and over suffer from mental or neurological disorders (excluding headache), while anxiety affects 3.8% of the elderly population, and material use problems affect about 1% of the population [2]. The trend of serious psychological problems will become an obstacle in the family life and social life of the elderly, and also a challenge for the international community to achieve the goal of active aging.

Gamification is defined as the application of game elements to non-game environment, which can attract users’ attention and improve users’ enthusiasm. In recent years, gamification related research has been applied in many fields. A large number of studies have shown that play and gamification play a positive role in calming emotions and reducing stress, especially for children. For example, Elke et al. [3] introduced ‘mindlight’, a neurofeedback video game to prevent anxiety disorders in children, and recruited 136 subjects to conduct a randomized controlled experiment. The results showed that children’s anxiety was significantly reduced after the experiment. Knox et al. [4] recruited 24 children and adolescents who received anxiety treatment to carry out a control experiment to verify whether biofeedback based play can help reduce the anxiety and depression of children and adolescents. The research proved that biofeedback assisted relaxation training in the form of video games can effectively reduce the anxiety of children and adolescents. Barbara et al. [5] described a 2D jump ‘n’ run game ‘mindspace’ developed for 7–12-year-old children with anxiety disorder. The game combines cognitive behavior technology and aims to let children understand their own anxiety problems, complete tasks to obtain incentives, and specifically relax these children’s patients. In addition, there are also a lot of researches that should apply gamification to stress management. For example, Corinna et al. [6] designed a stress management system with the idea of gamification, which can be used to avatar, agent, complete routine tasks, experience value, virtual currency, badge and other gamification elements to help users manage stress. Alluhaidan and Plachkinova [7] designed a program to reduce the pressure of patients with congestive heart failure (CHF), which integrates meditation breathing. When patients breathe, they can see the interactive images of the lungs. So that the patients can understand their physical condition, improve their participation and reduce anxiety. Mercer [8] designed a game using elements such as natural scenes and animals. Users need to find the specified small animals in the forest within a certain period of time. Through the experiment of questionnaire and blood pressure measurement, the effect of the game on reducing pressure was verified.

In the past, most of the research on game or gamification for the elderly focused on physiological training or cognitive ability. Yu-Hsiang Lin et al. [9] developed a serious game for training the cognitive and physiological functions of the elderly by using sensors and microcontrollers. The elderly can sit in a chair and use modular sensing tools to play rhythm games. They can train the cognitive functions of the elderly through physical activities and serious games, such as reaction speed, short-term memory and working memory. Wlkeogh j et al. [10] used Nintendo Wii video sports fitness game to intervene the elderly in the nursing home for eight weeks. The analysis results showed that the biceps flexion and extension endurance, physical activity level and life quality of the intervention group were significantly improved. Participants also expressed their sense of achievement from the game and believed that the game provided them with a way to social In addition, research on the willingness and motivation of the elderly to play games can help designers design games for the elderly more specifically. Ingmar Wagner and Michael Minge [11] invited 18 pairs of elderly people to play a dice game. They compared their subjective enjoyment and use motivation by providing different social conditions for the elderly. Through repeated scale measurement, it is found that social game elements enhance the elderly’s positive mood and willingness to maintain the game, and social contact is an important element of interaction between the elderly and technology.

From the review research on game and gamification, it can be found that there are few researches focusing on the mental health and emotions of the elderly, while game and gamification have shown their advantages in the field of emotions, which seems to be a promising means of intervention in mental health of the elderly. This study aims at alleviating the anxiety of the elderly, and proves the influence of the game design on alleviating the anxiety of the elderly through the control experiment. We hope to design an effective, accepted and widely used game based intervention method to alleviate the anxiety of the elderly.

2 Materials and Methods

2.1 Game Design

In the early research on gamification, the widely accepted point of view is that the game elements are applied to non-game systems to improve user experience and participation. Among them, game design principles, methods, game framework, game mechanism and specific interface design are all game elements [12]. Some research believe that gaming experience depends on game design elements, which should be able to interact to stimulate players’ emotional input [13]. Therefore, before the game design, the physical, psychological conditions and preferences of the elderly should be consider to find the design elements that can alleviate the anxiety of the elderly.

After entering middle age, all physiological functions will be decline gradually, but after entering old age, this change will be more obvious. The specific physiological characteristics of the elderly are as follows:

• vision: decreased vision; decreased color perception; decreased spatial perception; decreased dark adaptation and light adaptation.

• touch: with the growth of age, the skin, muscle and nervous system will also lost all hint of youth, so it will cause the tactile response of the elderly to be slow, and the use of touch-screen electronic products will be more difficult than that of the young.

• responsiveness: poor tolerance of stimulation; slower responsiveness.

• memory: learning ability is weakened; short-term memory, near event memory.

Health problems and changes in social roles [14] may cause psychological changes in the elderly. Due to aging and even diseases, the ability of self-care of the elderly has declined. Nowadays, with the rapid development of science and technology, people’s life style changes rapidly, and the life of the elderly is more vulnerable to impact. Therefore, the psychological status of the elderly also has several characteristics different from that of the young:

• emotional dependence needs: feeling uneasy and lost; increasing dependence on family members, and possibly on some entertainment activities.

• social support needs: strong expression desire; more pursuit of content in entertainment activities; desire to reflect their own value.

• nostalgia: nostalgia is a kind of complex that most old people have. Nostalgia can remind the aged people of what they did when they were young, and produce a sense of self-identity or good feeling for their past experience. Nostalgia therapy has also been widely used in the intervention of anxiety and depression in the elderly [15, 16], and achieved good results.

• conservative: unwilling to take risks; value accuracy and avoid mistakes.

In addition, different kinds of games will have different effects on emotional relief, and different types of games also correspond to different types of people. Game elements related to emotional relief include:

• attention diversion: when playing games, people need to focus on the current game tasks or the world outlook of the game, which can temporarily separate people from the real world, avoid things that cause anxiety and bad emotions, and play a role in alleviating anxiety.

• weakening stimulating elements: slow rhythm; weakening winning and losing judgment; cooperation mechanism; soft music, etc.

• relaxing elements: some studies have shown that elements related to nature, pictures, etc. can relieve people’s pressure to a certain extent [17]; in addition, some studies have proved that nostalgia can alleviate the anxiety of the elderly, and some nostalgic pictures or playing methods can be appropriately used to evoke their old memories.

Based on the physical and psychological characteristics of the elderly and the game elements to ease anxiety, the game design principles suitable for the elderly are extracted (Fig. 1) for application in future design. The principle consists of three dimensions: game planning, interactive design and visual design.

Fig. 1.

The design strategy for the elderly

According to the above design principles, flash is used to develop a puzzle game to alleviate the anxiety of the elderly. The game provides picture materials, background materials and text materials. Players can choose the materials they want and drag them to the drawing board area. Through basic operations such as zooming in, zooming out and rotating, they can freely assemble and assemble a picture.

In order to enhance the fun of the game, a wealth of picture materials are provided. Since this experiment is aimed at the elderly in China, the preferences of the elderly in China will be taken into account in terms of material and language. The game material can be divided into three categories: common material, background material and text material. Common materials correspond to different themes, which may be animals, plants, figures, patterns and other illustrations. Background material includes scenery, color block and other materials. Some Chinese poems are used as text materials, which can be matched with other picture materials. For avoid causing tension and anxiety, the slow-paced playing method is adopted, and there is no clear judgment on the winning and losing, and there is no time limit. The elderly can play the game leisurely and relaxed (Fig. 2).

Fig. 2.

The homepage

There are three modes in the game: Chinese style, nature and family portrait, with different kinds of materials built in. In addition to the core playing method, the game also has some additional functions. In the process of puzzle, users can save the progress at any time. After completing the puzzle, they can also share the work to the social platform, which is helpful to strengthen the social communication, satisfy the expression desire, reflect the self-worth of the elderly, and has a positive effect on improving their self-identity and reducing their anxiety (Figs. 3 and 4).

Fig. 3.

Chinese style mode

Fig. 4.

Example of Chinese style

2.2 Participants

42 elderly participants were recruited in this experiment, including 18 males and 24 females, aged 60–78 years, with an average age of 67.79 years. The participants were included in the following conditions: clear consciousness, smooth communication; normal vision, no eye disease; independent action, no serious disease affecting action.

2.3 Procedure

First, the participants who met the criteria were randomly divided into experimental group and control group. There were 23 participants in the experimental group, including 10 males and 13 females, aged 60–76 years, with an average age of 67.52 years. There were 19 participants in the control group, including 8 males and 11 females, aged 62–78 years, with an average age of 68.11 years. They all signed the consent before the experiment and filled in the pre-STAI. The control group did not use game intervention to keep the participants calm for seven minutes. The experiment group was intervened by playing the puzzle game. In the process, the researchers conducted process guidance, but only when the participants had difficulty in playing. The time limit of the game was seven minutes. Participants in each experimental group need to complete the same task flow:

• 1. Start the game.

• 2. View the introduction pictures and enter the game homepage.

• 3. Click the entrance of game mode, enter the puzzle game operation page, view the styles of material, exit and go back to the homepage.

• 4. View the styles of three modes for puzzle game respectively, choose one style for the game.

• 5. Click the mode entrance, enter the operation page of the puzzle game.

• 6. Choose the picture material, drag it to the area of painting board, click the function button for operation, adjust the material.

• 7. Drag other materials, adjust and combine them in the area of painting board.

• 8. Click to save after completing the puzzle game.

• 9. Click sharing button to share the painting to the social media software (the step is up to the option of the participants).

• 10. Go back to the homepage of the game, click the entrance of my painting album, enter painting album.

• 11. View the paintings browsed and saved.

• 12. End the game.

Before starting the task, the researcher will help the subjects to wear the skin electric sensor and record the skin electric signal. After that, the subjects need to fill in the STAI again and accept the interview. All participants will be asked about two aspects: (1) recent living conditions and the causes of anxiety; (2) experience of playing video games. In addition, the subjects in the experimental group were asked about their feelings and difficulties in playing the puzzle game.

2.4 Measurement Indexes

The independent variable of the experiment is intervention means based on games and the dependent variable is the anxiety level of the tested. Among them, the relevant assessment for the anxiety level of the tested is mainly divided into two aspects. The first one is to rely on the subjective assessment questionnaire STAI to assess the anxiety level of the participants. The second one is to test the physiological index-skin electricity SC/GSR of the tested as the objective index. With the combination of the subjective and objective indexes, it will be able to assess the anxiety level of the participants more comprehensively.

• Subjective indexes

STAI is used to measure the anxiety level of the participants. The scale is the self-assessment type and divided into two sub-scales, including 40 description items in total: S-AI includes 20 items. S-AI describes the temporary unhappy mood experience, such as worry, tension, fear, nervousness and so on which are accompanied with hyper function of autonomic nervous system, so it can be used to measure the temporary anxiety level of the tested and it is also able to induce the experience of situation anxiety. T-AI includes 21–40 items. T-AI describes the anxiety tendency which is relatively stable and becomes different in different individuals. T-AI can be used to identify the frequent anxiety level of the tested within the specific time duration, moreover, it is also able to assess the effectiveness of psychological consultation and treatment.

• Objective indexes

In the experiment, the skin electricity of the tested is measured. In terms of skin electricity, it refers to a kind of emotional physiological index being able to reflect the emotional changes of the participants, so it is used as the mutual evidence with anxiety inventory. The hardware equipment for measuring the physiological index include: one unit of Psytech-10 multichannel physiological instrument, PC, skin electric sensor, BioTrace+acquisition and observation of piezoelectricity signal used in software.

3 Results

3.1 Baseline Data Analysis

The S-AI sub-score and T-AI sub-score of the participants in the experimental group are compared with that in the control group before the experiment for carrying out T test of independent samples. The STAI total score and T-AI total score in the two groups are not significantly different before the experiment (P > 0.05). STAI total score in the experimental group is compared with the control group before experiment for carrying out T test of independent samples. The result shows that there is no significant difference between STAI total scores in the two groups before experiment (P > 0.05) (Table 1).

Table 1. Comparison of STAI scores between experimental group and control group before experiment

¹

Therefore, it shows that there is no significant difference between the initial anxiety levels in the experimental and control groups before experiment. Moreover, the baseline data of S-AI sub-score, T-AI sub-score are in line with that of the STAI total score. They can be further used to carry out comparison analysis with the score changes of anxiety scales after experiment (Table 2).

Table 2. Comparison of SC/GSR data between experimental group and control group before experiment

²

The skin electricity SC/GSR score in the experimental group is compared with that in the control group before experiment for carrying out T test of independent samples. There is no significant difference between the initial skin electricity SC/GSR values of the tested ones in the two groups before experiment (P > 0.05). Therefore, it shows that there is no significant difference between the initial skin electricity levels in the experimental and control groups before experiment. Moreover, the baseline data of SC/GSR is in line with each other. The comparison analysis of the changes of skin electricity SC/GSR data after experiment can be carried out, which is of great significance.

3.2 The Change of Anxiety Level in the Control Group

In the control group, S-AI sub-score, T-AI sub-score before experiment are compared with those after experiment for carrying out T test. The results show that there is no significant difference between S-AI sub-score, T-AI sub-score before and after experiment (P > 0.05). In the control group, the STAI total score before experiment is compared with after experiment for carrying out matching T test. The results show that there is no significant difference between STAI total score before and after experiment (P > 0.05). It is obvious that there are no significant differences for S-AI sub-value, T-AI sub-value and STAI total score in the control group before and after the experiment and there are no obvious changes for these values after the experiment. When the intervention means based on games is not carried out, there is no obvious change for the anxiety level of the aged people measured by STAI (Tables 3 and 4).

Table 3. Comparison of STAI scores before and after the experiment in the control group

³

Table 4. Comparison of SC/GSR data between control group and control group before experiment

⁴

The initial skin electricity SC/GSR value of the 19 tested ones in the control group before the experiment is compared with that after the experiment for carrying out matching T test. There are no significant differences for skin electricity SC/GSR values before and after the experiment (P > 0.05). It is obvious that there are no significant differences for skin electricity SC/GSR values before and after the experiment in the control group and there are no obvious changes for the values before and after the experiment. When the intervention means based on games is not carried out, there is no obvious change for the anxiety level of the aged people showed by physiological index skin electricity signal, which is consistent with the previous measurement results measured by STAI.

3.3 The Change of Anxiety Level in the Experiment Group

In the experimental group, the S-AI sub-score experiment is compared with that after the experiment for carrying out matching T test. There are significant differences for S-AI sub-score before and after the experiment (P < 0.01). After the experiment, the S-AI sub-score is reduced obviously. The T-AI sub-value in the experimental group before experiment is compared with that after the experiment for carrying out matching T test. There are differences for T-AI sub-value before and after the experiment (0.01 < P < 0.05). After the experiment, the T-AI sub-score is reduced, but the extent is not obvious. The STAI total score in the experimental group before experiment is compared with that after the experiment for carrying out matching T test. There are obvious differences for STAI total score before and after the experiment (P < 0.01). After the experiment, the STAI total score is reduced obviously (Table 5).

Table 5. Comparison of STAI scores of experimental group before and after the experiment

⁵

In the experiment group, after the tested ones finish the puzzle game designed for aged people as the intervention means based on games, the anxiety level of aged people measured by STAI decreases, which indicates that such puzzle game can alleviate the anxiety level of the tested ones, but what is noteworthy is that the S-AI-immediate anxiety level of the tested ones is obviously alleviated while its alleviating effect on the T-AI-anxiety feelings in recent period is not so obvious (Table 6).

Table 6. Comparison of SC/GSR data of the experimental group before and after the experiment

⁶

The skin electricity SC/GSR in the experimental group before experiment is compared with that after the experiment for carrying out matching T test. There are significant differences for skin electricity SC/GSR before and after the experiment (P < 0.01). After the experiment, the skin electricity SC/GSR is reduced obviously.

In the experiment group, after the tested ones finish the puzzle game designed for aged people as the intervention means based on games, the anxiety level of aged people measured by physiological index skin electricity signal decreases, which is in line with the measurement results of STAI. The results indicate that the experimental intervention stuff-puzzle game for the aged people can alleviate the anxiety of the tested ones.

4 Discussion and Conclusion

It is found out in the research that intervention means based on games can reduce the anxiety of the aged people to some extent. The matching T test is carried out for STAI total score, S-AI sub-value, T-AI sub-value, skin electricity SC/GSR value before and after the experiment in the experimental group, then it is found out that those in the experimental group show reduction of anxiety level in both aspects of STAI and physiological index-skin electricity signal. Moreover, those in the experimental group are compared with those in the control group receiving no intervention means based on games and showing no difference in anxiety level. The result reveals that the aged people in the experimental group receiving intervention means based on games in the subject have lower anxiety level with relatively positive effectiveness.

The intervention stuff in the experiment for the aged people is the video game made in accordance with design strategies based on games for reducing the anxiety of aged people proposed in the previous content. The game is featured with low stimulation, slow rhythm, weak winning and losing judgment, few restrictions, simple functional structure and so on. It is expected that the aged people can play games with relaxing mood, no pressure, no learning difficulties. It is known in the interview after experiment that most of the aged people engaged in the experiment have the habit to play video devices and have higher level of acceptance for video games. The tested ones also show the acceptance attitude for the game and just a small part of the tested ones show that they feel pressure in operation. Some of the participants ones propose suggestions for improvement of the game, such as increasing music used to calm emotions, increasing coordination mechanism which is more specific. All the suggestions will be iterated in the future research.

Additionally, the limitations of the research include the limited number of participants ones, so there is certain restriction for the analysis results, which just represents the reduction of anxiety for the participants ones in the experiment. What is noteworthy is that the S-AI of the tested ones drops obviously and the T-AI of the tested ones drops not obviously in accordance with the changes of the relevant values in the STAI before and after the experiment in the experimental group. It is revealed that the intervention means and ways based on games can obviously alleviate the situation anxiety of the tested ones while their alleviating effect for T-AI anxiety is not obvious, it is possibly caused by the short-term experiment period in the research and only one time of intervention is carried out. Further subsequent research must be carried out for more in-depth exploration. In the future, the long-term and continuous intervention based on games with certain frequency should be carried out to observe whether its effect on reducing T-AI anxiety will be more obvious or not. In the subsequent research, the performance of the participants ones with large sample volume can be mined deeply and the effect of the demographic factors on the means based on games used to alleviate the anxiety level of aged people can be explored. It also further explores the category of aged people that intervention means based on games is suitable for, which helps to carry out further intervention for the anxiety of aged people in accordance with their traits. Moreover, more experimental research can be carried out in accordance with the design strategies based on games extracted in the paper for alleviating the anxiety of aged people, then the variables can be controlled to explore the differences of different design factors based on games for alleviating the anxiety of aged people, which lays a good foundation for subsequent application and designing of intervention means based on games.

To sum up, it is preliminarily shown by the research that intervention means based on games has certain effect on alleviating the anxiety level of aged people. The puzzle game made in accordance with the design strategies of the research can alleviate the anxiety level of the tested ones to some extent. Hopefully, it is possibly the non-drug method used to intervene the anxiety of the elderly.