Use the flair "Developer" for posts. See our guidelines for promo code distribution. Self promotion can only be done on a Saturday. All posts will be checked by the mods, and excessive self promotion will lead to temporary bans and post removals. AppAdvice - Daily iOS apps gone free. Chaos Rings 3 or MH: Stories is an incredible port of a really fun and lighthearted RPG. Chaos Rings 3 is a real gem. Good point with the iOS update issue. Most of the great original iOS games that SE made are gone now.
I hate how disposable gaming is on iOS. Even Android has become a better gaming platform at this point. CR3 is a full fledge Jrpg with a story. Both worth the price tag defends on what genre you prefer. Thought it was really awesome put around hours to it. I downloaded the MH demo and played for almost 2 hours Cmon guys don't downvote him for just having a different opinion he even complimented the quality is great. I'm enjoying MHS a lot too but this is the type of game you will love or hate.
Not everyone enjoys turn-based combat, cartoonish graphics, childish storyline, etc Thanks kind stranger! I was enjoying a lot, thought I would buy once the demo ended. Do the sidequests become more diverse? I thought the same at first but after playing a bit more, I found the combat felt very rewarding. MH Stories all the way. Lots of Missions and Contents. The art isn't good like before too anime-ish for me But it's worth it. The story is not too dark, but the plots are still interesting.
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Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.
Pain is a common and significant burden to children and adolescents with cancer.
This pain may result from cancer, the various cancer treatment methods, or associated procedures, and is known to lower quality of life compared to healthy children [ 1 - 6 ]. Adolescents with cancer aged years reported that pain was the most distressing symptom of the cancer experience [ 7 , 8 ]. Poorly managed pain has been shown to be additionally problematic as it results in anxiety and distress related to subsequent treatment and negative long-term psychological effects [ 9 , 10 ].
Proper assessment is the essential first step to effectively manage pain experienced by children and adolescents with cancer. Following pain assessment, pain management strategies can be developed, refined, and evaluated to provide the best possible pain relief for adolescents. Still, several barriers prevent appropriate pain assessment for adolescents.
In addition, existing tools have methodological problems and do not allow for longitudinal assessments in everyday settings [ 12 , 13 ]. Self-report in the form of paper-based approaches has been the most commonly used pain assessment modality [ 14 ]. However, patient recall of past experiences involves active reconstruction of events, which can lead to inaccuracies and biases in the reporting of the event [ 14 ].
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Finally, patients resort to hoarding back filling or completing paper-based pain diaries in longitudinal assessment diaries just prior to returning them to the research center, which reduces the accuracy of collected data [ 15 ]. Real-time data capture using electronically-based pain assessments represent a superior method for capturing patient pain data.
Wireless mobile devices such as smartphones can: Recent studies in pediatric [ 16 , 17 ] and adult [ 18 , 19 ] populations have used Internet and mobile device modalities to effectively track and manage health conditions. Adolescents have adopted mobile technology into their everyday lives in a much quicker and more engaging way than other generations. Mobile technology is known to serve five major functions for adolescents - entertainment, information, communication, organization, and support. Of these functions, entertainment and information represent the most frequent uses of technology by adolescents [ 21 ].
Capitalizing on the popularity of smartphone-based entertainment with adolescents, game-based mobile health applications apps may represent an important means to increase compliance with remote monitoring and treatment of health issues. In the present study, we aimed to design and develop a smartphone-based pain diary app that would be engaging to adolescents with cancer through the gamification of pain assessment recordings. The gamification process involved adolescents playing the role of law-enforcement officers on a special investigative force that hunts down pain.
Gamification also included a compliance-based rewards system ie, proceeding up law-enforcement ranks and receiving videotaped acknowledgements for logging assessments by fictitious officers in the field. Pain assessment questions were developed using the e-Ouch electronic juvenile idiopathic arthritis pain diary [ 23 - 25 ] as a template.
Expert opinion ie, captured during a meeting with 10 pediatric oncologists and 10 pediatric pain experts was used to modify the arthritis diary questions to be cancer pain-specific. The following modifications were made: The final pain assessment questionnaire consisted of 20 questions on the multidimensional ie, sensory, affective, and evaluative nature of pain, as well as questions related to pain management strategies used and their effectiveness.
The design principles included: Pain Squad, a special police unit, was designed as an incentive for adolescents to use the app Figure 1. Twice a day, adolescents completed a pain-reporting mission by answering questions about pain intensity and location using a simple touchscreen interface. Questions took the form of: Filling out 3 reports in a row earned a promotion to the next rank in the squad.
The promotions were delivered in the form of short videos featuring the stars of Canadian-filmed TV shows Flashpoint and Rookie Blue Figure 3. Pain Squad is not a game in the strictest sense and does not have rules or objectives beyond participation. Instead, the software used features of games such as rewards and achievements. The design concept was refined during low-fidelity usability testing outlined below.
Screenshots of Pain Squad app assessment functionality showing the visual analogue slider scale top left , the selectable body-map top right , a multiple-choice question bottom left , and a free-text question bottom right. Pain Squad was programmed to be accessible to adolescents using an iPhone 4S. The app was built using client-server architecture.
The system also contained a password-protected Web-interface allowing researchers to create studies, add new study participants, and access results. Pain Squad used iPhone audible alerts to notify adolescents to complete pain assessments. The system generated 3 alerts for each pain assessment to be completed.
The timing of these alerts was tailored to the needs of adolescents by allowing adolescents to choose alarm times from a number of preset options. Data entered by adolescents were stored on the iPhone in an SQLLite database and communicated to the server whenever the application was online. The server was hosted at the tertiary care center behind a firewall in a network secure environment.
A user name and password were required to access data. Children and adolescents were eligible to participate if they: Adolescents were excluded if they had severe cognitive impairments or major co-morbid medical or psychiatric illnesses that would preclude pain assessment by self-report. Consent was obtained prior to involvement in any phase of the study and all adolescents completed a brief questionnaire on their demographic characteristics.
The research assistants gathered additional demographic and disease-related data from medical charts. Following the development of the cancer pain assessment questionnaire, app interface designs were trialed with adolescents. A qualitative usability testing approach was used with 3 iterative cycles of semi-structured audiotaped interviews. Fifteen adolescents 5 in each of 3 cycles were shown paper screenshots of the pain assessment application and were asked what they liked and disliked about the design, premise of the game, and question format. The list of questions was modified during the course of the interview process in light of emerging themes and field notes related to perceived ease of use.
Technical problems with the app were recorded by the research assistant.
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Adolescents were further asked to provide suggestions for improvement. Design elements were modified and new paper screenshots were generated and tested until no further changes were suggested. Following the development of a fully functional iPhone-based Pain Squad prototype, usability testing 2 iterative cycles with semi-structured audiotaped interviews was again conducted with 18 adolescents with cancer 21 adolescents were approached to participate and 3 declined.
In this phase, a research assistant first provided adolescents with a brief approximately 5 minutes demonstration of the Pain Squad app on the iPhone using a standardized pain vignette. Adolescents were then asked to complete the app, recording their own pain while thinking aloud about likes, dislikes, and difficulties with the app. At the end of each session, a research assistant asked a series of standardized open-ended questions related to ease of use, and what adolescents liked or disliked about the app. The research assistant recorded the answers to questions that explored emerging themes and field notes on ease of app use.
After the first iterative cycle, changes were made based on themes identified from adolescent opinion. A second iterative cycle was conducted with 8 adolescents, which generated no further recommendations for changes to the app. Adolescents participating in the high-fidelity testing also rated the content validity of the pain diary questions. In both low- and high-fidelity testing, demographic data were analyzed using SAS version 9.
Audiotaped usability interviews were transcribed verbatim. All transcripts from the usability testing phases were verified against the tapes and imported into NVivo 8. Field notes taken during the interviews were also transcribed and included in the analytic process. Using grounded theory latent coding [ 28 ], data were coded according to the study objective and categorized to reflect emerging themes. Changes to the prototype were made based on feedback from each iterative cycle of testing.
In addition, thematic analysis of high-fidelity usability interviews was performed according to adolescent age group years and years to identify any age-specific differences in opinion. This analysis was performed in the same manner described above. Following usability testing, a clinical feasibility test was conducted with adolescents with cancer to determine compliance and satisfaction with the app. For this phase, adolescents were trained on app use with standardized pain vignettes.
Fourteen adolescents were then loaned an iPhone 4S and asked to complete Pain Squad pain assessments twice daily in the morning and the evening for 14 days. Telephone assistance was available to adolescents in case of technical problems. On day 15, adolescents were prompted by the phone using an audible alert to complete the Pain Squad Evaluation Questionnaire on the iPhone, which ascertained likes and dislikes with the Pain Squad app. Data generated from these surveys were used to establish satisfaction and ease-of-use of Pain Squad, the degree to which the app interfered with daily activities as well as information on how long adolescents would be willing to use the diary.
The Evaluation Questionnaire also included a free-text question where adolescents were encouraged to enter any other information about the diary they felt important to discuss. Compliance and satisfaction were analyzed using SAS version 9. Comparisons between compliance data generated during feasibility testing were made using t tests. Demographic and disease characteristics of adolescents included in the low- and high-fidelity user-centered testing are shown in Table 1.
The age of participants in each phase of testing was similar approximately 13 years. Both male and female participants were included in all phases of the study and participants also had a variety of cancer diagnoses. Time since diagnosis was on average less than 2 years for participants in each study phase. Demographics and disease characteristics of adolescents included in low- and high-fidelity usability testing, content validity testing, and feasibility testing. Transcript analysis from low-fidelity testing revealed 4 distinct themes, which guided the development of the game-based app: During low-fidelity usability testing, and before a capital investment in programming was made, we endeavored to find a theme for the app that was well-liked by adolescents.
Adolescents with cancer had difficulty relating to the original game theme and expressed the need to change the game to improve app desirability. The original theme of the game centered around a private detective agency. The gumshoe concept fared poorly in usability trials and was considered difficult to relate to by adolescents.
In fact, the lack of understanding around the term gumshoe was the most strongly endorsed message in the first iteration of low-fidelity testing. Indeed, none of the adolescents interviewed knew what gumshoe meant. This was articulated by an adolescent who discussed unfamiliarity with the concept. I would guess that gumshoe means…just gum on a shoe? This new concept was trialed with adolescents in the second iteration of low-fidelity testing and received overwhelmingly positive endorsements.
No further changes to the design theme were required. App prototype home screens: Tapping "Start Survey" or "Start Case" begins the pain assessment.
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Tapping "Accomplishments" or "Rewards" allows review of rank and access to videotaped acknowledgements. Embedded in the Pain Squad app design was a reward system to encourage pain assessment competition. This reward system was highly regarded by adolescents as illustrated below. I think that [the reward system] is a really good idea! That makes it way more enjoyable.
I really like the moving up…idea and the rewards. The color scheme, fonts, and graphics used in the Pain Squad app were considered attractive to adolescents, helping to create interest in the app. During low-fidelity testing, adolescents made several positive comments regarding the appearance of the app screenshots:.
Green, blue, and yellow are really good colors for this app, for a detective. And I like the font. I would just scroll through and tap on the screen. I like how there are the different choices and the colors. Based on the screenshots shown, adolescents suggested several changes to improve usability of the game-based app. Screenshots of Pain Squad app visual analog scales showing before left and after right verbal and numerical rating anchors were added. Screenshots of Pain Squad app "body map" showing before left and after right body parts were combined as recommended by adolescents. Four themes highlighting the usability of the game-based app were identified through analysis of high-fidelity usability interviews.
These themes were: We found no differences in endorsed themes between younger year olds and older year olds adolescents. These themes therefore represent the convergent perspectives of study participants. Adolescents overwhelmingly endorsed the app as appealing and fun to use. Every adolescent interviewed said they would use the app daily for an extended period ie, 2 weeks if given the option.
This satisfaction with the app is illustrated in the following quote from an adolescent with cancer:. Oh cool! Instead of talking to somebody you could just put down how you feel…It was really simple. I liked everything. The game-like features of the app and the rewards program were also seen as appealing to adolescents with cancer. Adolescents appreciated the ability to role-play as a detective and advance through the law enforcement team ranks.
I liked the way your like a spy trying to solve a case because it made it more interesting. All adolescents interviewed also endorsed the ease-of-use of the app.
Adolescents also discussed their own familiarly with using electronic devices such as smartphones and did not foresee themselves having any problems using Pain Squad. As in the low-fidelity testing, specific suggestions for improvements to the app were made by adolescents. Adolescents in the first iteration of high-fidelity usability testing found that the wording of some of the questions was confusing. Like how much control you had?
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How could you like really have like the control? In the first iteration, 4 out of 10 adolescents also discussed the need to be able to select more specific areas on the body location map. The final first-iteration recommendation by adolescents involved the placement of selectable buttons on the screen. No further recommendations for changes were made in the second iteration of testing.
Screenshots of Pain Squad app "body map" showing before left and after right specificity of selectable pain location was improved. Content validity testing affirmed the importance of pain assessment questions for adolescents with cancer. Questions that did not achieve this rating related to the impact of pain on: Demographic and disease characteristics are shown in Table 1. Data collected from the feasibility testing provided data on the pain experience of adolescents with cancer. These data showed that average pain reported by an adolescent with cancer at the time of completing the diary was 2.
Additionally, average worst pain in the 12 hours preceding a reported pain episode was 5. Pain reports received were reviewed by the research team. The team did not need to intervene with any adolescents participants for safety reasons. Another adolescent was hospitalized for an emergency medical complication during the feasibility trial and did not bring the iPhone with her to the hospital.
Sub-group analyses of the feasibility trial cohort showed no difference in compliance rates according to gender females: Data from the post-study Pain Squad Evaluation Questionnaire showed that adolescents enjoyed using the game-based app, found it easy to use and found that it did not interfere with their daily activities. No adolescents surveyed indicated that they did not like the app design.
We present the design and development of a game-based mHealth app to routinely assess pain in adolescents with cancer. We further present data on compliance with completing assessments collected during a 2-week clinical feasibility study. Low-fidelity, user-centered design led to the identification of needed changes to improve the game-based premise of the app and its ease of use ie, changes to body map, inclusion of anchors to assessment scales. This phase further affirmed the content validity of the pain assessment questions.
The feasibility trial demonstrated high rates of compliance and overall satisfaction with the app. To our knowledge, the present study was the first to report on a user-centered approach to the design and development of a smartphone-based multidimensional pain assessment app for adolescents with cancer. A report on the user-centered design of an mHealth cancer symptom assessment diary for adolescents has been previously published [ 29 ]. This study however, did not include adolescents in the design of the interface and did not take a multidimensional approach to the assessment of pain.
Our study has used multiple iterative usability cycles both low- and high-fidelity to refine the Pain Squad app theme and design. Elucidating the opinions, insights, and recommendations of adolescents from the early stages in app design is critical to ensure a pain assessment tool that is well utilized and clinically helpful.
We have also established the content validity of the pain assessment questionnaire through question-importance ratings by end users. This study was also the first to report on the development and preliminary testing of a game-based mHealth pain assessment tool. We have gamified the concept of pain assessment by: Given the popularity of smartphones with adolescents and the entertainment value of these devices, we reasoned that gamifying health information collection ie, pain assessment data using iPhones might improve compliance with reporting.
The gamification of the app was highly endorsed by adolescents in both the low- and high-fidelity user-centered design phases. Adolescents helped to refine the game premise, positively rated app aesthetics eg, colour scheme, font, graphics and resoundingly endorsed the rewards component of the game. The clinical feasibility examination showed high compliance rates with the diary irrespective of time of day ie, morning vs evening or week weekday vs weekend. Compliance was also sustained for the duration of the trial, as there were no observed compliance differences between week 1 and week 2.
Sub-group analyses also showed no difference in compliance rates between male and female participants or in- and out-patient participants. A systematic review of 62 publications on electronic pain assessment diaries in both children and adults showed compliance rates to be generally high [ 30 ]. Additionally important to consider is the clinical context of our study. All of the participants in the feasibility trial were actively being treated for cancer. Cancer treatment is known to be physically exhausting for adolescents [ 31 , 32 ] and could theoretically have adversely effected pain diary completion.
Despite this potential adverse impact on reporting, the adolescents completed a large majority of pain assessments on a regular basis. We propose several possible reasons for the high rates of compliance observed in the present study. First, audible tailored alarms were used to signal participants to complete pain assessments.
Audible alarms have been used in previous mHealth assessment studies with adolescents and these studies have also reported high compliance rates [ 25 , 33 - 36 ]. These alarms act as a direct reminder to participants to log health information. Secondly, we propose that the gamification of the pain assessment app motivated adolescents to complete assessments. Gamification involves the use of videogame components in non-gaming systems to improve user satisfaction [ 37 ].