QR HUG: A Study on the Development of a Game to Manage a Shelter Using QR Codes

Background

In recent years in Japan, there exist serious problems caused by frequent disasters such as earthquakes and torrential rains. One of these problems is the management of a shelter. There is a gaming approach to understand such problem situation, such as protracted shelter life and the worsening health of the evacuees, and to consider alternatives to respond well to the future crisis situation. This approach is called HUG (HUG stands for Hinanjo Unei Game in Japanese, this means Shelter Management Game) game. HUG game is a gaming simulation that game players learn the management of shelter with various events, and players are required to have appropriate correspondence to events that occur frequently. The target group of this game is mainly, people engaged in health care support activities on an event of a disaster and the administrative staff. However, the game also would be playable by anyone. In this game, players decide how to deal with difficulties while considering them that the difficulties might occur one after another. Incidentally, there is a problem in this game. This game is supposed to experience the shelter launch and management of the day (or the next day) of disaster occurred, and evacuees’ information is clearly indicated as a card. However, the actual shelter operation lasts several months, and new problems may occur or converge on the contrary as time passes. The initial decision might seem to be correct decision making at that time, but this decision might be not always effective in the future. For more effective training, players should know how decision making on the first day of the shelter management affects over time. At present HUG, there is no way to learn about it. Also, this periodical constraint makes HUG game is not helpful for specialists such as medical, health care, and nutrition. Because these problems occur as time passes and so they cannot play the game while utilizing their knowledge. Furthermore, among evacuees, some people cannot communicate due to various reasons or cannot grasp themselves abnormal conditions. In this research, we propose a new HUG game using QR codes (QR HUG) in order to reflect the problem of such a shelter. Through this improvement, we aim to add function in the game that specialists can make the experience using their knowledge. Furthermore, we also aim to make players aware of their decision making will influence in the future, and to make them understand that the cooperation with other specialists and administrative staff at the disaster is important. Also, we will discuss the result of implementing this new game.

Features and Problems of a Shelter in Japan

Here, we describe the characteristics of a shelter in Japan and the problems in them. Shelter in this research is a temporary refuge facility that is set up immediately after the disaster, and the disaster victims who have lost their homes (or are difficult to live in the house for some reasons), will live for a while until moving to a new house.

As shelter is set up immediately after a large-scale disaster, a tent is used worldwide commonly (Davis, Thompson, & Krimgold, 2015). A series of earthquakes in Turkey, 1999, and the L’Aquila earthquake in Italy, 2009, tents were mainly used (Alexander, 2010; Nakabayashi, 2000). However, in Japan, the Cabinet Office’s guideline for the operation of the evacuation centers has indicated that “facilities are less affected by the anticipated disasters, in a relatively easy location to transport disaster relief goods.” (Cabinet office of Japan (Disaster Prevention Division), 2016) The guideline means that the victims who lost their home or were difficult to live in there due to the dangers, they are forced to live in a shelter. Facilities designated as evacuation centers are mainly public schools. Public schools are public facilities, they can accommodate relatively large personnel and meet the conditions indicated in the above guidelines, so they are often designated as a shelter. In the Great East Japan Earthquake, 2011, and the heavy rain event of July 2018, the victims who lost their homes lived in public schools designated as a shelter in the area. The operation phases of evacuation centers would be roughly divided into two stages. The first is the phase immediately after the disaster. In this phase, those are required to establish evacuation centers, to accept evacuees, to establish of accommodation systems, and to secure urgent drinking water and food. Moreover, regional administrative staff leads initiatives to tackle these issues. The period experienced by players in HUG games is roughly the same as this phase. Meanwhile, in the phase after a few weeks of the disaster, the quality of shelter life should be improved. The quality of life means nutrition management, improvement of the living environment, hygiene management, relaxation of stress and so on. Specialists such as medical, health care, and nutrition make an assessment in this phase. Their decision is essential to clarify what kind of support and supplies are needed for there. On the other hand, in the Cabinet Office’s guideline, local inhabitants should be the entity that operates the evacuation center. They have to cooperate with local administrative staff, facility managers, i.e., school teachers and local voluntary health care organization. However, to respond immediately by the administrative staff or to manage proactively by the residents are difficult. This difficulty was apparent in the actual past earthquake case, such as Iwate Prefectural Otsuchi High School case. Due to the death or missing of the senior administrative staff, The teachers of high school corresponded more than 24 hours just after the disaster. Also, in the next phase, voluntary management by residents was judged by the other administrative staff to be difficult. This staff was required to play the core of the operation.

What is life in a shelter? It is shown briefly in Figures 1 and 2. Figure 1 is a picture of a shelterset in a gymnasium of a public school, which was taken one week after the Great East Japan Earthquake in 2011. There were no partitions to secure living space, and each the bedding placed on the floor is only the individual space of the evacuees. The aisle was set up, but not widely, especially elderlies located near to the entrance was often exposed to drafts. Since they had to excrete frequently, and worried about making footsteps in the midnight, they located near to the entrance. Further, the hygienic environment of the toilet was extremely degraded at the time, so evacuees hesitated to use the toilet. Moreover, the distribution situation of water and food was not quantitatively and qualitatively stable. Although in an emergency, the shelter is never comfortable.

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Figure 1.

A state of shelter for 1 week after the Great East Japan Earthquake in 2011 (Photo Courtesy of NIKKEI, Inc.).

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Figure 2.

A state of shelter for 1 month after the Kumamoto earthquake in 2016 (Photo Courtesy of NIKKEI, Inc.).

Figure 2 is a picture of the evacuation center about one month after the occurrence of the Kumamoto earthquake in 2016. Unlike Figure 1, the living space was partitioned, and the individual space was also wider than that in Figure 1. However, we cannot make a comparison simply in each case of Figures 1 and 2. Because of the scale of the earthquake and the number of days elapsed after the disaster was different, there was a difference in the shelter environment in each case. Furthermore, the shelter of Kumamoto earthquake was operated by taking advantage of the lessons learned in the Great East Japan Earthquake in 2011. In fact, in either situation, the victims are forced to live in a difficult life.

In this chapter, as features of shelter, we introduced situations of facilities, administrators and the environment. In addition, we describe problems emerging in there with the actual case.

Health Care Activities on a Disaster and Gaming

In this section we consider the significance of experiencing and learning evacuation center management through gaming based on the characteristics of Japanese shelter. Various difficulties will be encountered in the management of shelter, and people who manage it have to deal with such risks. In terms of opportunities to learn risk management of health, it is difficult to conduct evaluation experiments for such risk management in a real situation (Ichikawa, 2018). On the other hand, through simulation and gaming, participants could experience (in a virtual world) crises situations that are difficult to experience in the real world (Crookall, 2004). In terms of educational effects, using a game-like user interface is expected to improve the performance of group collaboration (Jung, Schneider, & Valacich, 2010). Various activities including such educational gaming that considers disaster prevention in Japan, including HUG, are being conducted (Toyoda, 2018; Yamori, Yoshikawa, & Ajiro, 2005; Zoda & Oyama, 2013). As mentioned in the previous chapter, shelter management should be done mainly by local inhabitants. But in reality, there is an actual situation where facility managers and administrative staff are forced to take the lead, regardless of each phase. In that sense, an experience shelter management through gaming is important for stakeholders such as public health nurses, nutritionists, nurses, and local residents. These stakeholders do not participate basically in the launch of the shelter. They cannot experience the difficulties, and the normal HUG game is very useful in this aspect. However, except for local residents, such specialists cannot make the gaming experience that using their specialized knowledge, such as shelter assessment, diagnosis of evacuees, and so on. Their expertise is particularly necessary during the period when they assess the shelter. The gaming experience should also correspond to such a reality. Furthermore, local residents cannot know what and how to rely on specialists if they manage shelter independently. Through QR HUG gaming experience, we expect players to know the difficulty of shelter launch and management, risk management at the time of the disaster, the importance of establishing a cooperative structure between stakeholders in peacetime, and the ability to cope with ever-changing situations. Unlike conventional HUG game, QR HUG can express the change of situation using QR code. This improvement can be expected to strengthen more the ability to respond to changes. Furthermore, when experts such as public health nurses, dietician nurses and so on play the games, gimmick that can be judged by their vocational knowledge makes the gaming more advance. The explanation about the HUG game and the QR HUG will be given in the next chapter.

Introduction of HUG Games and Development of QR HUG

First, we explain the HUG game. In explaining the HUG game, we referred to the HUG game explanation page (http://www.pref.shizuoka.jp/bousai/e-quakes/manabu/hinanjyo-hug/about.html) in Shizuoka prefecture, Japan. Outline of the HUG game is that players act as a shelter administrator. they should set cards resembling evacuee adequately on a plane figure that resembles a gymnasium and a classroom in a school as a shelter, and they also respond to various events occurring in evacuation centers. Players face various events such as checking the state of evacuees, considering a room to house them, securing a living space such as a place to make meal and arrangement of a temporary toilet, responding to a VIP inspection and press coverage. Through these experiences, players could discuss themselves freely and learn the launch and management of a shelter. The player group is recommended less than six persons, except for the reader.

Required Goods

The necessary items include cards that describe evacuee’s information. Sheets are also included that resemble various facilities and rooms in the school and will serve as a place for arranging evacuees (Figure 3). There are two kinds of cards. The first card is evacuee cards, listed various information about evacuees, such as age, gender, living area, household composition (almost all evacuees belong to some household) and the circumstances they possess. This type of card occupies most of the 250 pieces of a set. the other card is a situation granting card, that contains a variety of events. These events occur in shelters, such as the arrival of aid supplies and the consultation from evacuee. Situation granting cards occupy the remainder of the 250 pieces of a set. Two types of cards are numbered from 1 to 250, regardless of the distinction of type.

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Figure 3.

Image and size comparison of HUG card and sheet (image is gymnasium).

There are three types of sheets. The first two are a gymnasium where most evacuees will be located, and several classes room where it is supposed to locate evacuees who need consideration. Also, the other one is a sheet that represents the entire site of the school, which is mainly used to stick tags the state of each facility such as some toilet that cannot be used. As a point to be aware of, the size of the gymnasium or classroom’s sheets corresponds to the size of the card, and the size of the card means the individual space of an evacuee. And so, the players should be avoided to arrange like a bundle even though it is just cards. They are also necessary to secure a passage after securing the space for evacuees. In addition, they should prepare sticky notes and writing utensils for ongoing notes and debriefing comments.

QR HUG Features

Now we explain QR HUG. The characteristic of QR HUG is that the evacuee card is given a QR code to give players additional information. If the player scans this QR code with a dedicated application, additional text information that is not printed on the card is displayed on the app (Figure 4). Further, this information is modifiable by changing the dictionary data (this is a repository to display corresponding information when the QR code is scanned) in the app. The dictionary data itself can also be downloaded by scanning a particular QR code. Further, the character string scanned from the QR code printed on the card becomes a keyword in the dictionary data. This means that the app can display various text adapted to the training situation from the same QR code, by changing the dictionary data. By implementing such specifications, it is possible to match the text to be displayed to each specialist and to change the text content depending on the training situation easily. The reason for this design is to simulate an assessment of shelter. Specialists are required to use their knowledge to grasp and detect the situation and issues of shelters. As the training for the specialists, there is an assessment method to talks with people and get the required information. However, such dialog training takes more time and human resources. On the other hand, the method of providing listed evacuees’ health information is too simple compared with the actual operation. With this issue, we realized that the simulated dialog assessment experience in controlling costs, by printing a QR code on the evacuee card in HUG game and letting players scan it. This scanning operation should be done as a new phase after all cards have been placed in HUG game. The phase is set as one day or several days or several weeks after the shelter was launched. This setting enables training tailored to the situation that specialists should make an assessment of actual shelter. Moreover, in the scanning survey, the text displayed should be various and suggestive. The issue of evacuees is diverse, and the specialist should trust to other experts (including administrative staff) if he/she cannot cope. In a disaster, each specialist will make interviews to identify issues and decide which sector is appropriate to delegate to the non-specialty problems. Through collaborative work in training, we want players to understand what they should do. By adding an action to scan this hidden information, HUG game offers a better aspect.

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Figure 4.

An excerpt of the QR HUG app’s manual.

There are other possibilities for improvement. For example, changing the placement of evacuees. There is a good or bad environment in the large facilities such as the gymnasium, depending on the position of the door and the window. If an evacuee who does not have a good condition is staying in a place with a bad environment in the facility, his/her physical condition might become worse. In the case of a cold or infectious disease such as infectious gastroenteritis, this evacuee should be moved. This series of assessment can be expressed with QR HUG, as the phase in which players make a relocation. The relocation phase should be after the scanning cards phase. During this phase, players scan the QR code, diagnose evacuees state from the suggestive text and consider the need to relocate evacuees. At the same time, players should understand that evacuees’ simply first-in placement makes harmful effect. Moreover, new improvements would be considered for the flow of the existing HUG game. As the option of the game, players are provided the role of diagnosing an evacuee in one of the phases of the existing HUG game. The main purpose of this option is to add a new element to the determination of urgency in the existing HUG game. There is a lot of events which the situation that is brought by the granting cards but some of the events have (either explicitly or not) less urgency. This purpose is to let the player decide the priority of a matter. To check the health condition of evacuees is certainly important. However, the burden of the checker would become large in the launch phase. For such difficulty, player groups should consider the situation carefully (e.g., give up the diagnosis, etc.).

In those ways, by printing a QR code to the card and using a special application, we expect a new HUG game. But, not limited to HUG game, the use of the QR code makes it possible to change the situation of training dynamically. For example, when specialists train jointly, a situation grant is made to utilize the expert knowledge of the public health nurse in the first phase. In another phase, another situation is given to utilize the nutritionist’s knowledge. We also realized the possibility of this kind of multi-layered training by using a QR code. This advanced training will make it possible to share each expert knowledge on disaster prevention among experts.

In the next chapter, we will introduce a game example. This new HUG game has added the phase of scanning cards and relocation.

Implementation of Games

In October 2018, as part of the Public Lecture “Disaster Nursing Education Course for Nursing Teachers / Leaders” in Hyogo Prefectural University, evacuation center simulation exercises using HUG games and QR HUG was carried out (number of participants: 44). The purpose of this exercise was to understand what kind of actions should be provided to evacuation centers from the viewpoint of nursing / healthcare persons, while experiencing the operation of shelter using the gaming method. The lecture is practically 6 hours on Saturday, and the participation in this exercise required the participants to pay the fee (6,000 yen). Participants were mainly from professionals involved in nursing and public health. All participants were grouped as a team composed of several people. Each group contained various experts. After playing the conventional HUG game and assigned the evacuees, players scanned the QR code with the application and discussed the management of the shelter and the relocation. Participants played actively in the game, despite struggling with the difficulty of shelter management seriously, as they have to make decisions while considering the alternatives (Figure 5).

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Figure 5.

State of the day. After placing the evacuees, Players scan the QR code using the application.

After all the lesson were finished, we conducted a survey, and all 44 participants responded. This time, we aimed to collect the effects of QR HUG using a descriptive questionnaire. There are eight question items. The reason for using the descriptive type was that we wanted to get specific comments from participants. In addition, some of the participants had involved in relief and nursing activities in actual disasters. We also wanted to collect their opinions based on their expertise. On the other hand, we had considered that to collect a sample size which meets the statistical hypothesis test would be difficult. Although the lecture would be very meaningful, it made a burden to the participants’ financial and time. In the first place, we had acknowledged the number of participants and judged this size was not sufficient. Therefore, we did not ask questions using the Likert scale.

Table 1 summarizes the sentences of the questions and questionnaire results for participants.

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Table 1.

Summary of the question.

Age: under30s=2.3%, 30s=25%,40s=34.1%,50s=31.8%,60s=6.8%	Yes(%)	No(%)	Not sure(%)
Q1. Have you been involved in health care support activities on a disaster?	27.3	72.7	0
Q3. Have you taken health care-related training?	68.2	29.5	2.3
Q4. Have you experienced HUG game before?	27.3	72.7	0
Q6. Do you consider that there were meaningful outcomes through an experience of HUG game with your professional viewpoint?	97.7	2.3	0
Q7. Do you consider that there were meaningful outcomes through an experience of new HUG game using QR code with your professional viewpoint?	93.2	4.5	2.3

As a question not listed in the table, we also asked by the comment description method, without Q5. Those questions are what kind of support activities on actual disasters each participant had done (question Q2), what is the meaningful aspects of the HUG game (question Q6) and QR HUG (question Q7) with the point of specialist’s view (question Q6 and Q7 contain alternatives and comments.), and what is the points of improvement (question Q8). Question Q5 is the one choice question that asked them about their age group. The majority of participants were in the age of 30s to 50s. There is 27.3% of the participants who actually had experience in supporting activities such as nursing and public health in past disasters. In addition, 68.2% of them participated in disaster-related training in the past. From the questionnaire, it turned out that many of the participants were responsible for as health care or nursing staff at the time of disaster. The percentage of respondents who judged that the experience of HUG game and QR HUG was meaningful from their vocational point of view was over 90%.

Here we showed some of the answers from the descriptive type questions. These comments are edited to be easy to understand respecting the original sentence and meaning. The respond from the question of what is the meaningful aspects of the QR HUG from the point of specialists view is “People who clearly need support were aggregated and supported at an early stage. However, if I did not quickly notice that a person who looks as if there is no problem but have hidden dangerousness, I would be impossible to keep his lives. “or” As time passed, various symptoms came out, so I felt I should deal with that part. I also understood that I had to give the part (authors note: this “part” means the problem which she cannot deal with) to the administrative sector. “Furthermore, a comment based on a professional point of view, especially from the nurse is “I was troubled though I have a nurse’s point of view, and it was good to be able to discuss with the other sectors. “or” As a support nurse on a disaster, I should be working with doctors, administrative staff, and other medical professionals.”

On the other hand, the comment from question of what is the points of improvement are, “It is good if there is information that can be read by the QR code, such as a past illness history, a disease condition or a symptom (this is relatively easy to judge, like temperature and blood pressure).” Another comment is “It is good if there is a version of the game content that matched the level of students involved in public health.” Also, “I want a contrivance that not only evacuees appeal their difficulty, but also possible environments that can be imagined.”

Discussion

According to a review of existing studies, there are many different approaches to experiential learning on disaster preparedness in nursing education. Each approach has each method of data collection and instruments. Many approaches have used simulations in different ways and focused on the principles of emergency preparedness (preparedness, response, recovery, and mitigation) (Jose & Dufrene, 2014). Our approach also includes simulation and reproduces the response required for specialists who are involved in shelter management. From the above, our approach is consistent with the features listed in the existing research. About the method of the questionnaire, we particularly focused on the specific comments and suggestions from the specialists. On the other hand, in a study that conducted HUG as regional disaster training, participants were asked to indicate the usefulness of HUG (Morimoto, Yoshioka, & Iwai, 2017). They surveyed 66 participants using the Likert scale and received responses from 64 out of 66 participants. We considered that 44 participants were small to be collected as a sample. Based on the existing research, we might be better to create questions using the Likert scale.

Next, we consider whether the three goals of this study were fulfilled. First, we consider the functions in the game that specialists can play using their knowledge. As QR HUG, we implemented the method of printing a QR code on the existing HUG game card and scanning it with a dedicated app. Along with the implementation of the function, we proposed an extension of the existing HUG game and a new training possibility. We made specialists and administrative staff experience QR HUG, and more than 90% of the participants evaluated this game as meaningful. On the other hand, according to the comments of participants, one of the participants was confused because she used an unfamiliar system for the first time. Another participant commented it is difficult to introduce QR HUG to the education of students without the provision of printed matter and app. It is necessary to make an explanation video when the system is made available widely to the public. Or, we would stop HUG-based composition such as using hundreds of cards and large sheets, and we would think of another way. In addition, there was a criticism that it was rare that the name of the disease would be completely clear in a shelter, and the text of scanned had to be devised. Considering the professional knowledge, the text should be more ambiguous.

Second, we argue that the game is about making specialists aware of their decision-making effects in the future. The comments on QR HUG we introduced in the previous chapter were conscious of the passage of time. Such an answer was not in Q6.’s comment (many of the comments in question Q6 mentioned about the importance of prompt and appropriate judgment). This comment is the effect of introducing QR HUG and a new phase. From the above, we can say that this goal has been fulfilled.

Moreover, we discuss making each specialist and administrative staff understand the importance of collaboration between each other. In the previous chapter, there was a comment that this person wants to utilize their skills to work with stakeholders.

In addition, the comment that the participant learned how to cooperate is “I thought that it is important to do the precedence ranking/grouping from various demands and to connect with other organizations (the response will be done by a team).” Based on these comments, it can be said that the goal has been achieved. On the other hand, there was a demand to learn to collaborate other than diagnosis and relocation. It is our new assignment to provide an opportunity to learn more meaningful collaborative work. This assignment is related to our first goal.

Also, we did not integrate QR HUG with the phase that exists in the conventional HUG game and did not conduct training as like content scanned by QR changes dynamically. We will conduct such training in the future.

Conclusion

In this article, first, we define the research goals. Second, we introduce characteristics and problems of shelters set up in a disaster in Japan and explain the significance of experiencing shelter management in gaming. In addition, we introduce a HUG game that experiences shelter management and indicates the problems in the game. Based on that point, we develop a new HUG game called QR HUG and suggest a new game by extending previous HUG game. We also implement QR HUG which specialists engaged in health care activities on a disaster. QR HUG received a high evaluation from them. From the evaluations and comments of the participants, it can be said that three research goals have been achieved. On the other hand, as an improvement point, it was pointed out from them that displayed text should be more ambiguous and the necessity for a game to learn collaboration in shelter management. Based on these points, we will improve the QR HUG in the future.