Feasibility of a Mobile Exergame for Patients with Heart Failure

Abstract

Background:

Physical activity is beneficial and recommended to improve outcomes for patients with heart failure (HF). Exergaming combines gaming technology with physical activity. Therefore, we developed a mobile exergame in a co-design process, the exergame would engage participants in physical activity anywhere and anytime. This study aims to assess the feasibility of a newly developed mobile exergame, heart farming, for patients with HF.

Methods:

A total of 14 participants with HF used the exergame on their smartphones for one month (9 Swedish and 5 Spanish participants; 9 males, mean 72 years, range 61–82 years). Participants were provided an introduction to the exergame, and follow-up was carried out regularly by telephone. Participants were advised to increase the daily walking duration by 10 minutes a day, based on the number of meters walked in the 6-minute walk test (6MWT). Areas of feasibility identified were acceptability, demand, implementation, and practicality, which were examined during telephone follow-ups and interviews, and data downloaded from the exergame.

Results:

Participants found the farming theme appealing, and coaching encouraged them to perform the exergame on a regular basis (acceptability). Based on the 6MWT, the personal goal for daily walking was set (mean of 704 meters, range 250–900 meters). Participants reported that daily goals and tasks were manageable. The exergame was perceived as appropriate to decrease sedentary time, and participants reported improved physical health (demand). The exergame was perceived as easy to learn and use, and adjustable to individual needs (implementation). Exergaming while walking and conversing with others was described as less convenient (practicality).

Conclusion:

Participants with HF valued personalized support and the exergame’s farming theme was appealing. The goal to increase walking by 10 minutes a day was seen as a realistic way to reduce sedentary behavior. When introducing the exergame, it is essential to emphasize the importance of proper lighting, so meters walked are accurately recorded.

Introduction

Exergaming is an approach used to increase physical activity that combines gaming technology with physical activity.¹ Exergaming has become increasingly popular in recent years, particularly among individuals who are seeking a more engaging and enjoyable way to stay active.¹ For patients with heart failure (HF), regular physical activity is an important component of their recovery and overall health management.² Although the WHO recently strongly recommended that safe and appropriate facilities are needed to promote physical activity,³ there is insufficient capacity in existing physical activity programs for older persons with chronic diseases, as many programs cannot even meet the current demand.⁴ Exergaming offers a potential alternative that is both enjoyable and safe for cardiac patients.⁵ Several studies have explored the potential benefits of exergaming for cardiac patients, including improvements in aerobic capacity, strength, and balance.^6–8 Moreover, exergaming has been shown to be an effective tool for increasing adherence to exercise programs among cardiac patients, which is critical for long-term success.^6–8 The HF-Wii study, which included 605 participants with HF where the intervention group received access to a Nintendo Wii console at home, did not show a significant increase in exercise capacity.⁹ In interview studies where participants in the intervention group played the Wii exergame, participants reported that exergaming was an enjoyable activity.^10,11 However, they also conveyed a preference for physical activities tailored to their capacity. In addition, participants wanted the flexibility of engaging in exergaming outdoors rather than solely in front of a screen. They also highlighted the importance of incorporating total body movement into the exergame sessions and expressed a keen interest in playing collaboratively with others.^10,11 Building on insights gained from this study, a new exergame was developed for mobile phones (Heart Farming). The mobile exergame allows patients with HF the flexibility to engage in physical activity at any time and place, making it a convenient and accessible alternative to exergaming in front of a screen. Mobile exergaming has been shown to have potential benefits, including the promotion of a healthy lifestyle, particularly among sedentary individuals.^12–14

After developing a mobile exergame with the aim of reducing physical inactivity in patients with HF, a feasibility study was performed as part of a multi-center randomized controlled study, the Heart-eXg study (clinicaltrial.gov Identifier: NCT05641662). Feasibility studies investigate whether a novel technology will work in real-life settings and identify its crucial components.¹⁵ According to Bowen et al. (2009)¹⁴ there are eight areas of feasibility to consider: acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited efficacy. This feasibility study aimed to assess the feasibility of a mobile exergame for patients with HF, regarding four areas of feasibility: acceptability, demand, implementation, and practicality (see definitions Table 1).¹⁶ The areas of adaptation, integration, expansion, and limited efficacy were not taken into consideration in this study, as the focus here is on the feasibility of the exergame, not the evaluation of the effects of the exergame intervention.

Table 1.

Description of Methods for Data Collection and Data Analyses

Area of focus for feasibility	Aspects of feasibility	Methods for data collection	Methods for data analyses
Implementation
To what extent can the mobile exergame be successfully delivered to the intended participants?	Success or failure of execution	Data from interviews with participants about their perceptions of success or failure in implementing the mobile exergame	Directed deductive content analyses
	Number of resources needed for implementation	Time required to introduce and support participants in the use of mobile exergaming	Time estimated by the research team
Demand
To what extent is the mobile exergame likely to be used?	Expressed interest in or intention to use	Data from descriptive field notes and interviews, with the participants’ expressions of interest or intention to use	Directed deductive content analyses
	Actual use of the mobile exergame	Data on how participants used the mobile exergame (logged in the application)	Descriptive statistics (frequencies)
Practicality
To what extent can the mobile exergame be conducted with the intended participants?	The ability of participants to engage in mobile exergame activities	Data from descriptive field notes and interviews with the participants about their ability to carry out mobile exergame activities	Directed deductive content analyses
Acceptability
To what extent is the mobile exergame deemed to be suitable, satisfying, or attractive to participants?	Perceived satisfaction and appropriateness of mobile exergaming as a product	Data from descriptive field notes and interviews with the participants about the appropriateness of the mobile exergame	Directed deductive content analysis

Materials and Methods

Participants and recruitment

As the planned RCT study will include participants from both Sweden and Spain, these countries were selected for the feasibility study. Inclusion criteria were having HF and interest in participating in a study to decrease sedentary time. Potential participants received information from the research team verbally or by e-mail and were contacted two weeks later by telephone to inquire about their interest in participating and to provide further information about the study.

Mobile exergame

Heart Farming is a mobile exergame developed for the purpose of this study (Fig. 1). The primary objective of this mobile exergame is to motivate participants with HF to walk 10 extra minutes a day. The number of meters individual participants needed to walk to complete a 10-minute daily walk was based on a six-minute walk test (6MWT)¹⁶ which was conducted before the participants started playing the exergame.

FIG. 1.

Screenshot of heart farming, showing a farm and fields planted with seeds.

The concept behind the exergame, Heart Farming, is to engage participants in taking care of a virtual farm. Participants need to walk in real life to accomplish the activities in the exergame, such as buying fields, planting seeds, watering crops, harvesting crops, and selling crops to neighbors. Additional features include collecting animals and sending crops to other players who use the game. Participants are also able to play in autoplay mode, wherein the exergame automatically collects a randomized harvest while participants walk in real life. The exergame uses augmented reality technology that uses the smartphone camera to detect and track the participant’s movement in the real world, both indoors and outdoors. Participants receive a daily reminder on their mobile phone to take care of their farm if they have not opened the exergame app.

Procedure

In the feasibility study, participants were asked to use the exergame for one month. The participants were given access to the mobile exergame at no cost. Members of the research team installed the exergame on the participants’ smartphones, and the participants were then given an introduction and instructions for the exergame both orally and in written form. The Swedish participants received the installation and introduction to the exergame in their homes. The number of meters individual participants needed to walk to reach the 10-minute goal was based on the latest 6MWT done in the clinic. The Spanish participants received the introduction at the hospital, and the goal for all participants in this group was to walk 500 meters in the exergame every day, as recent 6MWT scores were not available. For one participant in Spain, the number of meters was lowered to 250 meters, as this participant was considered too frail to walk 500 meters a day. Exergame instructions were also available on paper. Other members of the participant’s household were also able to access the exergame.

After participants were familiarised with the mobile exergame, participants were called on day two and day four, and then once per week for four weeks, to assess their experiences of exergaming and to provide motivation.

Data collection

Quantitative and qualitative data were collected using the feasibility areas,¹⁷ of Implementation, which examines experiences when the exergame is delivered to the participants and the required resources; Demand, which examines the actual use of the game; Practicality, which examines whether the mobile exergame can be delivered to the participants; and Acceptability, which examines the participants’ opinions of the game (Table 1).

Qualitative data were collected from individual interviews. Individual semi-structured interviews were conducted after the study period by MA and NS. The interviews were conducted face-to-face (n = 11) or by telephone (n = 3), with an interview guide developed for this study. An example of an interview question is: “Describe your perception and experiences from playing the mobile exergame Heart Farming” followed by probing questions. All interviews were audiotaped and lasted between 15 and 45 minutes (median 21 minutes).

Quantitative data were collected to describe the participant characteristics. Time requirements were calculated for the introduction session and the telephone follow-ups. In addition, the exergame collects statistics about the participant’s actual use of the mobile exergame (walking distance with the exergame).

Analyses

Qualitative data from the interviews were analyzed using directed deductive content analysis (Table 1). This method is used when starting with predetermined concepts that describe the examined phenomenon.¹⁸ MA and NS transcribed the interviews verbatim. xx translated the Spanish interviews into English. The transcripts were read several times by MA to get a sense of the whole. The deductive analysis used the feasibility areas of acceptability, demand, implementation, and Practicality as predetermined concepts for coding the text. In the next step of the coding process, text describing the feasibility areas was highlighted and used to create subcategories. Throughout the analyses, there was a back-and-forth movement between the transcriptions, the predetermined feasibility areas, and aspects of feasibility and coding. To ensure the trustworthiness of the analyses, the categories and subcategories were discussed by LK, MA, NS, and TJ throughout the analyses. To ensure the trustworthiness of the interpretation of the Spanish interviews, NS assessed the categories and subcategories to ensure the Spanish interviews were accurately interpreted in English.

Quantitative data were obtained from the actual use of the exergame app and from the participants’ statistics (meters walked per day with the exergame).

Ethics

This study was conducted in line with the Declaration of Helsinki, and the project received ethical approval from the Regional Ethical Review Board in Linköping (Dnr2021-03314) and the Ethical Committee of Clinical Research (Comitè d’Ètica d’Investigació Clínica de la Fundació Unió Catalana d’Hospitals, number CEIC22/91). Participants received written and verbal information about the aim of the study before giving written informed consent to participate.

Results

Fourteen participants with HF (9 in Sweden and 5 in Spain) participated in the feasibility study, with a mean age of 72 years (range 61–82 years). All participants owned a smartphone, but six were not compatible with the mobile exergame since the devices did not support augmented reality, which was required to play the exergame (Table 2). These participants borrowed a suitable smartphone for the duration of the study. One participant’s spouse was also introduced to the exergame, and the spouse’s daily goal was based on the participant’s 6MWT. We present the findings in each of the four feasibility areas.

Table 2.

Participant Characteristics

Participant number	Age	Sex	Marital status	Education	Borrowed smartphone	Experience with exergaming	Exergamed with others	Daily exergame goal in meters
SwF01	74	Male	Married	College or university education	No	No	No	417^a
SwF02	81	Male	Single	Secondary school	Yes	No	No	855^a
SwF03	75	Male	Married	College or university education	No	No	No	700^a
SwF04	82	Male	Married	College or university education	No	No	No	775^a
SwF05	65	Male	Married	Secondary school	Yes	Yes	No	750^a
SwF06	70	Female	Married	Secondary school	No	No	No	900^a
SwF07	66	Female	Widow	College or University education	No	Yes	No	733^a
SwF08	73	Male	Married	Secondary school	No	No	Yes	667^a
SwF09	63	Male	Living with partner	Secondary school	No	Yes	No	510^a
SpF01	79	Female	Single	Primary school	No	No	No	250
SpF02	61	Male	Single	Primary school	Yes	Yes	No	500
SpF03	75	Female	Married	Primary school	Yes	No	No	500
SpF04	78	Female	Widow	Primary school	Yes	No	No	500
SpF05	64	Male	Single	Secondary school	Yes	No	No	500

Based on a previous 6-minute walk test.

Sw, Sweden; Sp, Spain.

Implementation

The feasibility area of implementation describes aspects that are vital for the exergame to be successfully delivered to the participants.¹⁷

Success or failure in the execution of exergaming

Some participants did not recall receiving reminders, while others felt that reminders were unnecessary, as they had already established routines in exergaming. The participants who received the installation and introduction to the exergame at home reported that this was convenient since it was an environment where they would use the exergame. The participants who received the installation and introduction at the hospital were satisfied with the set-up. They valued the supportive and pressure-free nature of telephone follow-ups, as they provided reassurance with the promise of available help. The timing of the follow-ups, which were frequent at first and then tapered off, aided in habit formation.

If I had any questions, it was nice to have someone who cared about how things were going/…/Yes, above all it was good for these 4 weeks so that it became a habit, otherwise it is easy to stop. Now you don’t do that. (SwF07)

Number of resources needed for implementation

The time that participants participated in the feasibility study in one month was estimated to be 6–7 hours, where the introduction was 30–60 minutes, the duration of exergaming per day was 10 minutes, and each telephone follow-up was 5–10 minutes. In Sweden, two research team members initially conducted the familiarization step by installing the exergame on participants’ smartphones, or the borrowed smartphones, and then provided the introduction. After an evaluation, it was decided that this could be conducted by one person to save time and resources. Therefore, in Spain, the installation and introduction were done by one research team member.

Impact of familiarity with digital technology

Participants who were familiar with digital technology (e.g., computers) found the exergame intuitive and self-explanatory. On the contrary, participants who had less experience with technology appreciated having a written manual, although they perceived it as more beneficial for novice gameplay than for advanced gameplay. Many participants felt that the initial instructions were brief and suggested adding additional sessions, either in a group setting or through recorded videos that allow for repeated viewing and a more comprehensive understanding of the exergame.

Demand

The feasibility area of demand concerns whether mobile exergaming is likely to be used by the participants.¹⁷

Expressed interest or intention to use

Participants generally enjoyed exergaming, as it was perceived as a gateway to increased regular physical activity since walks became a daily routine. The daily walks were performed at the same time every day, often during the morning, and the mobile exergame was seen as an extra encouragement to decrease the participants’ sedentary time.

Some participants were motivated by a sense of obligation to the study team, while others were genuinely enthusiastic about the exergame and its features; some participants found motivation in the exergame’s reward system and progression to higher levels, while others were driven by the desire to improve their physical fitness. The use of the mobile exergame reduced perceived barriers to physical activity. Interestingly, the exergame sometimes spurred participants to exceed their planned walking duration, as it was relatively easy to achieve the goal within the exergame. Participants generally found the daily goals and tasks manageable and liked the option to play both indoors and outdoors. Many participants reported experiencing notable improvements in their physical fitness, citing increased walking distances, increased strength, and greater motivation to adopt healthier eating habits and lose weight during the study. In addition, participants noted improved psychological well-being, feeling more energetic and experiencing an overall increase in their happiness.

I had a cardiac arrest and was depressed for a year or so, and had a very hard time getting started and doing things. This (Heart Farming) got me going/…/this made me walk, and it made it easier for me/…/When we went on a short vacation, I was able to walk in a different way than I would have been able to do without this app. (SwF01)

Actual use

Participants aimed to increase their daily physical activity by 10 minutes, achieving an average walking distance of 704 meters, with individual ranges spanning from 250 to 900 meters (Table 2). The data collected from the mobile exergame revealed diverse participation patterns (Fig. 2). Most of the participants consistently met their daily goals. Seven (SwF01, SwF02, SwF04, SwF06, SwF07, SpF01, SpF02, and SpF03) consistently met the prescribed 10-minute walking target. Notably, participant SwF06 met the prescribed walking distance goal but often exceeded the 10-minute walking goal. Three participants (SwF05, SwF09 and SpF04) had irregular participation; while they mostly met their daily goals, they occasionally surpassed or missed them. One participant (SpF04) walked double the daily goal after missing a day of walking with the exergame. One participant (SwF08) discontinued exergaming after ten days, while one participant (SwF03) never started exergaming. Unfortunately, we lost data on exergaming from one participant (SpF05) due to challenges connecting the smartphone to the internet. This participant indicated during the telephone follow-ups that he walked every day with the exergame.

FIG. 2.

Exergaming behavior (number of meters walked) of participants with heart failure over 30 days (see the number of meters for daily goals in Table 2).

Practicality

The feasibility area of practicality describes whether the mobile exergame, Heart Farming, can be carried out by the participants given their existing resources and circumstances.¹⁷

The ability to conduct mobile exergame activities

Participants did not express difficulties exergaming, although adequate lighting was crucial for the mobile exergame’s camera to accurately record walking distances. The exergame had difficulty recording meters walked in dimly lit areas indoors or under tree shadows, which could result in participants feeling discouraged if they walked more than what was recorded. When exergaming for a longer period, the smartphones could get overheated, which rapidly drained the battery. If the participants only walked their 10-minute goal each day, this was not a problem.

Participants were given a transparent pouch so that they could wear the smartphone around the neck, and while all participants tried to use the pouch, the majority opted to hold the smartphone in their hands. Participants that exergamed together with others reported that when they focused both on the gameplay and conversation with others, their walking rhythm was disrupted.

It has stopped and then I have had to start it up again. …But it has also meant that I have certainly gone much further than I would have done (laughter) …So I have certainly done almost double that I think (laughter). (SwF02)

Acceptability

The feasibility area of acceptability concerns the participants’ perceptions of the mobile exergame as suitable, satisfying, or attractive.¹⁷

Perceived satisfaction

Participants found the graphics in the exergame to be clear and easily visible on the screen. While some participants reported that the exergame’s sounds and vibrations were irritating and opted to turn them off, others viewed these features as helpful indicators of gameplay activity that prevented the need to constantly check the smartphone screen. Generally, participants enjoyed the farming theme of the exergame, particularly activities like buying seeds, planting, watering, and harvesting crops. They also enjoyed storing and selling their harvest. The feature of collecting animals was popular; however, some participants expressed a desire for more interactive functions for the animals, such as feeding and providing water.

It was enjoyable, and there was a sense of realism in it. The items you cultivated were satisfying. Moreover, receiving rewards like horses and puppies added to the excitement. It felt like a reward for the effort put into walking. (laughter). (SwF01)

Some participants used the auto-planning function to achieve their goals without being interrupted during walking, while others developed strategies to gain more rewards. Participants reported that accomplishing self-set goals in the exergame and progressing to higher levels was rewarding. Only one participant explored the option to exergame with others, though they often did not walk simultaneously but compared their progress afterward.

Perceived appropriateness

While many participants were unfamiliar with exergaming, they generally found it enjoyable. Some viewed the game’s design as youthful, but they recognized its effectiveness in promoting walking. The farming theme resonated well with many, though opinions varied among the participants. Some felt it was best suited for those with farming backgrounds, while others believed it diverged from the realities of actual farming.

It felt childish, silly for a 73-year-old/…/maybe it didn’t feel very natural either. I didn’t like the game/…/it wasn’t for me (as a former farmer). (SwF08)

Discussion

In this study, we set out to explore the feasibility of a new mobile exergame designed to decrease sedentary time in participants with chronic HF. We assessed the feasibility areas of implementation, demand, acceptability, and practicality.¹⁷

For the successful implementation of a mobile exergame intervention in participants with HF, a good familiarisation step is necessary. Our findings show that participants valued the personalized support, finding the Heart Farming exergame both engaging and easy to use. After familiarisation, participants were able to use the exergame independently. Previous research on exergaming in older adults suggests that it can take time for them to learn exergaming and it is therefore recommended that healthcare professionals oversee the setup and introduction of exergaming.^{10,11,19–22} In our study, participants appreciated receiving written instructions but also expressed interest in receiving video-recorded guidance. Thus, for the ongoing RCT study (clinicaltrials.gov: NCT05641662), we have developed instructional videos for the exergame. Participants in our feasibility study reported that they appreciated the option to play both indoors and outdoors. The ability to exergame outdoors was seen as an important feature in the mobile exergame. In a study that included a commercial exergame that was connected to a TV screen, the inability to be active outdoors was seen as a barrier to exergaming.^10,23 The feasibility study identified an implementation challenge: not all participants owned smartphones that were compatible with the mobile exergame. Consequently, the research team estimated that around 25% of the participants might need to borrow a smartphone during the future RCT study. As the exergame is run with augmented reality, it can track participants’ activities both indoors and outdoors and walk back and forth over short distances, which is the case when walking indoors or outdoors in the backyard. Using an alternative technology such as GPS (which would make basically all mobile phones usable) would not make it possible to track users under these conditions. Future exergame development should assess other technologies to assess the number of metres walked, as well as the option to combine technologies, so that the exergame can be used on older mobile phones that do not support augmented reality. Furthermore, future exergame development could include additional devices, such as activity trackers, which can be connected to the mobile exergame to assess the number of meters walked so that users do not need to hold their mobile phone in their hands while exergaming.

Participants appreciated receiving rewards for their game achievements and enjoyed tracking their progress. Studies on older adults similarly highlight the motivational benefits of observing improvements in exergame play.^{10,11,19,22,24–31} One issue highlighted in the study was the ability of the smartphone camera to accurately record walking distances. For instance, shadows could prevent accurate readings. This issue had the potential to decrease motivation among participants. Several mobile phones available on the market have sensors that allow accurate tracking in dark conditions, but such technologies are not commonplace. Therefore, it is important to provide participants with instructions on the importance of adequate lighting for the smartphone camera to ensure that distances are accurately recorded during gameplay. This issue has been incorporated into the familiarisation step and in the instructions, both in written form and through the instructional videos.

Participants who would prefer to exergame with others found it difficult to find peers to play with. Previous research on exergaming and older adults identified the importance of enabling older adults to engage in exergaming either collaboratively or competitively.^32,33 Research on exergaming as a competitive activity for older adults has shown the value of enabling participants to exergame together.^34–36 Future research in mobile exergaming should explore collaborative or competitive exergaming in more depth using Heart Farming.

Conclusions

This feasibility study aimed to assess the feasibility of a mobile exergame for patients with HF, regarding four areas of feasibility: acceptability, demand, implementation, and practicality. Participants generally found the daily goals and tasks manageable and appreciated the option to play both indoors and outdoors (acceptability). The exergame was perceived as an appropriate way to decrease sedentary time and was reported to improve physical health (demand). The mobile exergame was perceived as easy to learn, easy to use, and adjustable to individual needs (implementation). The exergame did not always record the number of meters walked, which could cause participants to feel discouraged when they had walked farther than what was recorded. Exergaming while walking and conversing with others was described as less convenient (practicality).

Footnotes

Authors’ Contributions

The authors of the manuscript have contributed to the conception of the work. They have reviewed it critically for important intellectual content. They have given final approval of the version to be published. They have agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The Kamprad Foundation (grant 20210074); The Medical Research Council of Southeast Sweden (grant FORSS-940933); The Swedish Heart and Lung Foundation (grant 20200190), and The Swedish National Science Council (grant 2020-01109).

References

Graves

, Ridgers

, Atkinson

, Stratton

. The effect of active gaming on children’s heart rate, perceived exertion and enjoyment. Journal of Science and Medicine in Sport, 2010; 13(2):210–213.

McDonagh

, Metra

, Adamo

, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 2021:ehab368.

Organization

. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. 2013.

Clark

, Mundy

, Catto

, MacIntyre

. Participation in community-based exercise maintenance programs after completion of hospital-based cardiac rehabilitation: A mixed-method study. J Cardiopulm Rehabil Prev, 2011; 31(1):42–46.

Taylor

, McCormick

, Shawis

, et al. Activity-promoting gaming systems in exercise and rehabilitation. J Rehabil Res Dev, 2011; 48(10):1171–1186.

García-Bravo

, Cuesta-Gómez

, Campuzano-Ruiz

, et al. Virtual reality and video games in cardiac rehabilitation programs. A systematic review. Disabil Rehabil, 2021; 43(4):448–457.

Ruivo

. Exergames and cardiac rehabilitation: A review. J Cardiopulm Rehabil Prev, 2014; 34(1):2–20.

Skjæret

, Nawaz

, Morat

, et al. Exercise and rehabilitation delivered through exergames in older adults: An integrative review of technologies, safety and efficacy. Int J Med Inform, 2016; 85(1):1–16.

Jaarsma

, Klompstra

, Ben Gal

, et al. Effects of exergaming on exercise capacity in patients with heart failure: Results of an international multicentre randomized controlled trial. Eur J Heart Fail, 2021; 23(1):114–124.

10.

Klompstra

, Jaarsma

, Mårtensson

, Strömberg

. Exergaming through the eyes of patients with heart failure: A qualitative content analysis study. Games Health J, 2017; 6(3):152–158.

11.

Cacciata

, Stromberg

, Klompstra

, et al. Facilitators and challenges to exergaming: Perspectives of patients with heart failure. J Cardiovasc Nurs, 2022; 37(3):281–288.

12.

Peng

, Crouse

, Lin

J-H

. Using active video games for physical activity promotion: A systematic review of the current state of research. Health Educ Behav, 2013; 40(2):171–192.

13.

, Theng

. Mobile exergaming for health: A systematic review of recent studies. Health Education Journal, 2015; 74(6):732–743.

14.

Mullins

, Khoury

. Mobile exergaming: A review of current research and future directions. Journal of Physical Activity and Health, 2016; 13(12):1435–1443.

15.

Craig

, Diepe

, Macintyre

. Medical Research Council (MRC) Developing and Evaluating Complex Interventions. MRC: London; 2006.

16.

Guyatt

, Sullivan

, Thompson

, et al. The 6-minute walk: A new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J, 1985; 132(8):919–923.

17.

Bowen

, Kreuter

, Spring

, et al. How we design feasibility studies. Am J Prev Med, 2009; 36(5):452–457.

18.

Hsieh

H-F

, Shannon

. Three approaches to qualitative content analysis. Qual Health Res, 2005; 15(9):1277–1288.

19.

Agmon

, Perry

, Phelan

, et al. A pilot study of Wii Fit exergames to improve balance in older adults. J Geriatr Phys Ther, 2011; 34(4):161–167.

20.

Brown

EVD

, Dudgeon

, Gutman

, et al. Understanding upper extremity home programs and the use of gaming technology for persons after stroke. Disabil Health J, 2015; 8(4):507–513.

21.

Koh

JSG

, Hill

A-M

, Hill

, et al. Evaluating a novel multifactorial falls prevention activity programme for community-dwelling older people after stroke: A mixed-method feasibility study. Clin Interv Aging, 2020; 15:1099–1112.

22.

Meekes

, Stanmore

. Motivational determinants of exergame participation for older people in assisted living facilities: Mixed-methods study. J Med Internet Res, 2017; 19(7):e6841.

23.

Cacciata

, Stromberg

, Klompstra

, et al. Facilitators and challenges to exergaming: Perspectives of patients with heart failure. J Cardiovasc Nurs, 2021.

24.

Forsberg

, Nilsagård

, Boström

. Perceptions of using videogames in rehabilitation: A dual perspective of people with multiple sclerosis and physiotherapists. Disabil Rehabil, 2015; 37(4):338–344.

25.

De Vries

, Van Dieën

, Van Den Abeele

, Verschueren

. Understanding motivations and player experiences of older adults in virtual reality training. Games Health J, 2018; 7(6):369–376.

26.

Howes

, Wilson

, Pedlow

, et al. Older adults’ experience of active computer gaming for falls prevention exercise: A mixed methods study. Ppr, 2021; 42(2):173–183.

27.

Millington

. Exergaming in retirement centres and the integration of media and physical literacies. J Aging Stud, 2015; 35:160–168.

28.

Rogers

, Shamley

, Amosun

. Older Adults’ Experience of an exergaming intervention to improve balance and prevent falls: A nested explanatory qualitative study. Applied Sciences, 2021; 11(24):11678.

29.

Tabak

, de Vette

, van Dijk

, Vollenbroek-Hutten

. A game-based, physical activity coaching application for older adults: Design approach and user experience in daily life. Games Health J, 2020; 9(3):215–226.

30.

Valenzuela

, Razee

, Schoene

, et al. An interactive home-based cognitive-motor step training program to reduce fall risk in older adults: Qualitative descriptive study of older adults’ experiences and requirements. JMIR Aging, 2018; 1(2):e11975.

31.

Swinnen

, de Bruin

, Dumoulin

, et al. The VITAAL stepping exergame prototype for older adults with major neurocognitive disorder: A usability study. Front Aging Neurosci, 2021; 13:701319.

32.

, Erdt

, Chen

, et al. The social effects of exergames on older adults: Systematic review and metric analysis. J Med Internet Res, 2018; 20(6):e10486.

33.

Jaarsma

, Klompstra

, Strömberg

, et al.; HF‐Wii study team. Exploring factors related to non‐adherence to exergaming in patients with chronic heart failure. ESC Heart Fail, 2021; 8(6):4644–4651.

34.

, Li

, Chia

, et al. Exergaming as a community program for older adults: The effects of social interaction and competitive information. J Aging Phys Act, 2021; 29(3):466–474.

35.

Júnior

, Biduski

, Bellei

, et al. A bowling exergame to improve functional capacity in older adults: Co-design, development, and testing to compare the progress of playing alone versus playing with peers. JMIR Serious Games, 2021; 9(1):e23423.

36.

Askenäs

, Aidemark

, Jaarsma

, et al. Co-design to self-organizing exergaming-a study of stimulating physical activity for elderly people with a chronic health condition. International Conferences on Internet Technologies & Society; 2019;2019.