Journal on Interactive Systems, 2022, 13:1, doi: 10.5753/jis.2022.

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 This work is licensed under a Creative Commons Attribution 4.0 International License..

Design Science Research: Balancing Science and Art in Building

a Game Applied to Health
Luma Wanderley de Oliveira  [ Universidade Federal de Goiás | [email protected] ]
Saulo Soares de Oliveira  [ Universidade Federal de Goiás | [email protected] ]
Marcos Alves Vieira  [ Universidade Federal de Goiás | [email protected] ]
Silvana de Lima Vieira dos Santos  [ Universidade Federal de Goiás | [email protected] ]
Sérgio Teixeira de Carvalho  [ Universidade Federal de Goiás | [email protected] ]

In the field of applied computing, such as in the development of games applied to health, there is a growing
interweaving of two distinct fields: ”Science” and ”Art”. The methodology of Design Science Research (DSR) can
contribute by directing with greater scientific rigor the development of technology-oriented research. The objective
of this paper is to present and discuss the use of the DSR methodology in applied computing research, in which the
developed artifact is a game applied to health. Three development cycles were defined. The first cycle prioritizes the
understanding of the problem, the second defines the development of the main artifact, and the third, in turn, deals
with the evaluation of the artifact. In this way, it was possible to instantiate a DSR model and generate artifacts that
contribute to the understanding and the practical development of the solution. We also present a discussion about
the conduct of the research and adaptations that this model could receive for research focused on game design for
applied game development. The conclusion is that a balance between ”Science” and ”Art” results in innovative work
that is in demand for production.

Keywords: Design Science Research, DSR, Applied Game, Serious Game, Arterial Hypertension

1 Introduction To contribute to the foundation of research related to com-

puting and technology (close to the “Art”), the Design Sci-
A recurring discussion in the field of computer science origi- ence Research (DSR) methodology was developed so that
nates from the conjecture about whether computer science is the entire artifact development process generates not only
really a science (Denning (2005)). When it comes to science, the technological product itself but also that the crossing of
some criteria delimit it: principles, fundamental recurrences, knowledge contributes to computer science itself, and not
explanation, discovery, analysis, and dissection. On the other only in the applied area.
hand, there is “Art” that refers to the useful practices of a
field and is more connected with practice, performance, spe- This paper aims to present and discuss the use of DSR
cialization, action, invention, synthesis, and construction. methodology in an applied computing research, where the
Therefore, computer science brings together both charac- developed artifact is a game that is applied to health to im-
teristics, sometimes closer to science, mainly in mathemat- prove patient engagement with the treatment of arterial hy-
ical areas, as in fundamentals and theory of computation, pertension, relating gameplay and self-care. A DSR model
sometimes closer to art, mainly in areas such as applied com- was instantiated, and development cycles were defined to ob-
puting, where there is a concern in the use of knowledge. For- tain the game, a web service and health goals.
mally: This paper is an extended and revised version of a paper
published in the Brazilian Symposium on Games and Digi-
Applied Computing is a branch of Computer Sci- tal Entertainment (SBGames) 2021 (Oliveira et al. (2021a)).
ence that uses the methodologies, methods, and Among the main extensions is a more detailed explanation
techniques of Computer Science as a means to about the generated artifacts in the stages of the DSR method-
solve problems, theoretical and/or practical, in ology and a discussion about the duality of science and art
other areas of knowledge (Gelain et al. (2014)). related to the research we present in this paper.
Thus, to establish scientific rigor in research with applied The paper is organized into six sections. Section II
computing features, the difficulty lies not only in developing presents the DSR methodology as a way to do science
a solution, but also in evaluating or validating the research through technology development. Section III provides a con-
hypothesis in another area. textualization of the research and discusses the use of the
If the computational solution to be developed is a game, methodology in the development of a game applied to health.
one should still be concerned with all aspects of game de- Section IV, in turn, presents the results obtained to the
sign (Pakarinen and Salanterä (2020); Bayrak (2020)). Con- present state of the research. Section V discusses the DSR
sequently, it can be seen that multidisciplinarity and transdis- methodology and the insights obtained through design think-
ciplinarity are fundamental elements for the work to be devel- ing, and finally, Section VI covers the conclusions and future
oped (Gelain et al. (2014); Muñoz and Dautenhahn (2021)). works.
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

2 Design Science Research A proposal for conducting this method was made by
Dresch et al. (2015) which considers twelve main steps (Fig.
Scientific knowledge seeks to explain the world through ob- 1): Problem identification; Problem awareness; Systematic
servation and the use of methods to validate hypotheses. It Literature Review; Identification of artifacts and problem
can be categorized into formal sciences, which encompass classes; Proposition of artifacts to solve the specific problem;
the study of abstract and symbolic relationships; natural sci- Design of the selected artifact; Development of the artifact;
ences, which comprise the study of natural phenomena; and Evaluation of the artifact; Explicitation of the findings; Con-
social sciences, which cover the study of human and social clusions; Generalization to a class of problems; Communica-
phenomena (Rochadel (2016)). tion of the results.
Technological advances have caused so many transforma-
tions in society that have influenced the way science is done: Table 1. Types of artifacts. Source: Reis (2019).
traditional sciences have limitations because it is not enough Artifact Description
to explore, describe, explain and predict phenomena, there is Constructs Consist of the conceptualization used to de-
still the need to design and produce systems for the advance- scribe the problems within the domain and to
ment of science (Dresch et al. (2015)). Therefore, mankind specify their respective solutions.
has been increasingly building artifacts for problem-solving. Models Set of propositions that express the relation-
Observing this context, Simon (1980) highlights the con- ships between constructs, i.e., describe or rep-
cept of Design Science, translated by science of the artificial, resent the context, the structure of reality to
aimed at research that is focused on problem-solving and con- be a useful representation.
sequently on the design of artifacts. Principles Guidelines to serve as a support or guide for
Design Science Research (DSR) was developed as a re- structuring systems – facts, principles, and
search method for advancing science and technology with the concepts to guide design.
intent to legitimate the production of scientific knowledge Methods Set of sequenced steps for executing a task,
from the construction of artifacts and using as an epistemo- based on a collection of constructs (language)
logical basis the science of the artificial (Dresch et al. (2015); and a representation (model) in a solution
Peffers et al. (2007); Rochadel (2016)). This epistemological- space.
methodological approach has been applied in the fields of in-
Instantiations It is the materialization of an artifact in its
formation systems, production engineering, and applied com-
environment, that is, it is the operationaliza-
puting, and relies on seven fundamental criteria that help con-
tion of the constructs, models and methods,
duct the research: the creation of new artifact, specific prob-
demonstrating the viability and effectiveness
lem, artifact evaluation, contribution in the market and the
of the models and methods that they encom-
academy, artifact development strictness, research execution,
pass.
and communication of the results (Dresch et al. (2015)).
Theories Speculative, methodical, and organized
knowledge – a set of instructions perspective
(of a hypothetical and synthetic nature) on
Problem identification how to do something to achieve a certain
goal. A theory includes other artifacts, such
Problem awareness
as constructs, models, design principles, and
methods.
Systematic Literature Review

Identification of artifacts
and problem classes
The artifacts mentioned in this approach correspond to
Proposition of artifacts to human creations, such as instantiations, frameworks, archi-
solve the specific problem tectures, design principles, methods and models (Table 1).
Desing of the selected artifact Therefore, it is said that DSR is based on two different types
of research that complement each other: design research and
Development of the artifact behavioral science research (Dresch et al. (2015)).

Evaluation of the artifact

Explicitation of the findings

3 Instantiation of the DSR Model for
the hypertension problem
Conclusions

Generalization to a The context of this research emerged through the interac-

class of problems tions between researchers and health professionals and ap-
Communication of the results
plied computing researchers at the Laboratory of Health In-
formatics (LabIS), forming a partnership between the Insti-
tute of Informatics (INF), the Faculty of Nursing (FE), and
Figure 1. DSR Steps. Adapted from: Leitao et al. (2021). the League of Arterial Hypertension (LHA), all belonging to
the Universidade Federal de Goiás - UFG.
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

The interest in addressing chronic non-communicable dis- fact were established. The artifact must:
eases was highlighted by the impact factor of these diseases
on society. Due to the characteristics of chronic diseases, the • enable welcoming and motivating the person;
patient must commit to medical treatment for his entire life • present simple and frequent tasks;
and, in most cases, must change lifestyle. Health profession- • follow a change plan;
als pointed out that there is a challenge for the patient’s ad- • reinforce desired behavior;
herence to the medical treatment of chronic diseases, being a • prevent relapses;
major issue for both the patient and the entire health system. • enable easy interaction when recording data.
The meetings were held remotely with a discussion about
the low adherence to health treatment and the care plan of With this, it was possible to establish the knowledge infor-
patients with chronic non-communicable diseases. It was em- mation about the problem and context, problem in context,
phasized that in the capital city of Goiânia there is a larger and acceptance criteria, as shown in Fig. 2.
number of individuals with hypertension and type 2 dia-
betes, and that these groups exhibit greater difficulty in the
Lifestyle Change stage.
Originally, the research was inclined to focus on people
with type 2 diabetes, due to the amount of accessible mate-
rial and the number of health professionals who work directly
with this public. However, the LHA’s support was crucial to
the final decision, as it helped to delimit the problem the re-
search would focus on and facilitate the evaluation process
and other health sector formalities.
Therefore, the group started to search for references and
concepts involving the care of arterial hypertension, such as:
Brazilian Guidelines, Basic Care Manuals, Criteria and Pa-
rameters of Care, and Recommendation Reports. As a con-
sequence, the interest in approaching self-care and remote
monitoring of arterial hypertension in a continuous care con-
text was delimited.
Simultaneously, while the problem and the context were
being delimited, there was in the group a growing research
around the use of ludic, in such a way that through systematic
reviews (Oliveira and Carvalho (2017); Souza et al. (2021))
it was found that a game can be a tool that adds a layer of
fun to routine activities, impacting the person’s experience
and producing emotional responses that can engage them in
these activities. Thus, the research question arose: can a game
support a person’s engagement in self-care for hypertension?
This research question relates several theoretical and tech-
nical aspects that range from the construction of the game
(artifact) and its acceptance in usability aspects, to the fac-
tors that relate adherence, engagement, and self-care in the
context of hypertension, thus framing the research in Design
Figure 2. Framework regarding the problem and context.
Science.
Consequently, the proposal is to evaluate the relationship
of engagement provided by an intervention through a game The next step was to define the target audience. In a macro
applied to self-care, adherence to treatment, and blood pres- view of the LHA population, it is mostly composed of women
sure control of hypertensive patients of LHA, who are fol- over 55, polypharmacy, 30% diabetics, with cases of depres-
lowed up in a specialized service in a Brazilian capital. sion and anxiety.
The model adopted for conducting the research is based The audience profile resulted in some requirements for the
on the DSR model adapted by Pimentel and collaborators construction of the artifact:
(Pimentel et al. (2020)) and it enforces the construction of
a theoretical framework for the research to make explicit the • Usability question - How to simplify data entry?
behavioral conjectures that influence the design of artifacts. • Acceptability question - Which games appeal to the au-
The twelve steps proposed by Dresch et al. (2015) are con- dience profile?
templated in this model, that is, by this stage, the problem has
been identified, there has been aware of it, and the literature To answer these two questions it was necessary to perform
review was conducted. searches in research databases (Souza and Trevisan (2014),
Based on the references and with the cooperation of the Cota et al. (2014), de Oliveira Santos et al. (2013)). It was
healthcare professionals, criteria for acceptance of the arti- defined that the use of smart devices (IoT, Internet of Things)
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

could be adopted as the most natural way (pervasive) of data that presents the health data in a format more suitable for
collection, and that games of the casual genre, such as Candy information consultation, and, finally, the game, the main in-
Crush, are popular among the adult/elderly audience, as they terface of ludic engagement for the person. In this way, the
present characteristics of having adjustable difficulty, easy scope of the main artifact was defined, as represented in Fig.
controls, clear objectives, and reduced daily playing time. 3.
Thus, the artifact’s scope was better delimited. The name
Salus Ciber Ludens (SCL), adopted for the project, derives
from a few terms: “Salus”, from Latin, refers to the health,
and life; “Ciber”, the element that makes up the English word
cybernetics (or cibernética, in Portuguese) and relates to
technology and connectivity; finally, “Ludens”, from Latin,
represents the ludic and the game. Thus, by uniting these con-
cepts, we have the SCL platform, which is a ludic system for
the integration of a game applied to health with patient mon-
Figure 3. Artifact delimitation.
itoring at home. Its goal is to improve the patient’s engage-
ment in the treatment of non-communicable chronic diseases,
such as hypertension.
Once the context, the problem, the research question, and Concluding the first cycle, a simulation was created using
the artifact were established, the process of developing the Discrete Event Systems. The use of simulation is a way to
artifact started. It can be noted that in these stages there was predict the behavior of complex systems that could not be
a lot of research around the problem and the proposal, which tested otherwise (Zeigler et al. (1997)). Thus, the DSR steps
were important to extract criteria to assess the research. To fa- of identifying the artifacts and problem classes and designing
cilitate the description of the process, three main cycles were the main artifact (the SCL) were performed.
defined: the first cycle, which covers the initial development
and the artifact concept; the second cycle, encompassing the 3.2 Second Cycle
coding and creation of assets; and the third cycle, compre-
hending the artifact’s evaluation. The second cycle of the DSR methodology started with the
The research is currently in its second cycle and the SCL definition of the overall SCL architecture (starting from the
is its main artifact, which is currently in the final stages of de- interaction flow), which is composed of three main mod-
velopment. At each stage of the artifact development, there ules and a web service for communication (see Fig. 8, SCL
is a refinement of the techniques and of the theoretical frame- overview).
work until the acceptance criteria are validated. In each cycle, In this cycle, the development of the application and the
smaller artifacts are generated that support the construction web service structure were started. The RESTful web service
of the main artifact, and these are validated to mitigate errors uses the HTTP communication protocol to transport data and
at the end of the process. distribute services. In this manner, any application that sup-
ports the HTTP protocol can request the available services.
The JSON data formatting standard allows for a lightweight
3.1 First Cycle
information exchange, i.e., it does not require extensive net-
The first cycle of the DSR methodology began with meetings work bandwidth consumption from both the client and the
with health professionals from the Faculty of Nursing (FE) of server.
the Universade Federal de Goiás - UFG. At this point in the development, the artifact’s verification
Once the target audience was decided, key parameters criteria were stipulated so that the devices, the application,
were defined that indicate through data whether the person and the game must communicate with the web service, being
is managing to perform self-care actions related to hyperten- able to both send and receive data. Also, in-game interactions
sion, such as what value of systolic and/or diastolic blood should always generate some feedback being the narrative
pressure can trigger events that not only notify the person, progression an immediate way of noticing weekly progres-
but also intervene in some way (in the game or in the ana- sion.
logic world). In addition to the development of the web service, health
Currently, to measure these parameters, the patient goes goals were also stipulated, which are the activities that the
to the LHA, takes the weekly measurements, and returns SCL should manage and support. In the game, these health
home with a device for Residential Blood Pressure Monitor- goals represent the goals to be met, and as they are fulfilled,
ing (RBPM). At home, many patients do not take the neces- progress is made in the game’s narrative.
sary measurements or forget to write down the data. There- Through the artifact’s development process, more con-
fore, as part of the solution the use of smart devices was spec- cepts were added to the instantiated DSR theoretical frame-
ified, i.e., devices that when used, collect data and send it to a work model, which became more complete with definitions
system (e.g., scales, RBPM devices, smartbands, body mea- such as health education and treatment adherence, use of IoT
suring tapes). in health care, cyber-physical systems, multimodal games,
Regarding the system, five main elements stand out: the player archetypes, interactive narratives, psychology and be-
smart devices, a microcontroller, a web service to perform havior, emotion map, and Kubler-Ross model (Kübler-Ross
the communication with the devices, a mobile application and Kessler (2005)).
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

These concepts helped to both ground and polish the be- 3.3 Third Cycle
havioral conjectures, as shown in Fig. 4:
The third cycle was initiated with further planning of the ar-
tifact evaluation, in which two forms of empirical evaluation
• People are more motivated to self-care when they know
were defined.
more about their disease;
• People are motivated by seeing progression in their ac- The first evaluation, using the Delphi Method (Wright
tivities and receiving immediate feedback; and Giovinazzo (2000), Alexandre and Coluci (2011)) with
• People interact better with technology if it is easy to use; judges from the computing and health fields, aims to validate
• People are motivated by ludic elements. the development aspects and observe if the artifact construc-
tion meets objective criteria from both fields.
In the second evaluation, through an intervention study,
the target audience will have contact with the produced ar-
tifact aiming to evaluate usability issues and whether the
objectives were achieved. To this end, questionnaires on
Adherence to Systemic Arterial Hypertension Treatment
(QATHAS) ((Rodrigues et al. (2014))) and the Hypertension
Self-Care Scale will be applied.
Extending the Empirical Evaluation framework presented
in the instantiation, the adopted intervention will last six
weeks with LHA support. Fig. 6 presents the frameworks
linked to the main artifact evaluation.

Figure 4. Theoretical framework and behavioral conjectures.

There was also an evolution in the State of the Technique Figure 6. Artifact evaluation questions, empirical evaluation, hypotheses
framework by establishing the technologies used in the de- for conjecture evaluation, epistemological-methodological framework, and
velopment such as IoT, pervasive computing and smart de- findings.
vices, RESTful communication protocols and microservices
architecture, and game design techniques regarding design,
coding, and illustration (Fig. 5). Through these evaluations it is possible to extract ques-
tions to evaluate the artifact, such as:

• Did the artifact facilitate monitoring the person’s

health?
• Did the artifact contribute to a healthier lifestyle
change?
• Did the artifact enable an adequate goal plan?
• Did patients enjoy using the artifact through smart de-
vices?
• Did the patients enjoy using the artifact as a whole?
• Did the healthcare team obtain more data about the pa-
tient when they were using the artifact?
• Did the artifact contribute to treatment adherence?
• Did the artifact support the self-care of the person with
hypertension?
Figure 5. State of the Technique, artifact, and verification criteria.
Fig. 7 presents the instantiated DSR model, resulting from
the composition of the discussed frameworks: problem and
The game design steps started to be discussed in the first context, artifact delimitation, theoretical framework and be-
cycle, and were further developed in the second cycle, whose havioral conjectures, state of the technique, artifact, and arti-
results are presented in Section 4. fact verification and evaluation criteria.
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

Figure 7. Instantiated DSR Model.

4 Results The visualization and management module is composed of

an application where it is possible to configure the system, as
This section presents the main artifacts generated using the well as make manual records, access statistics, and manage
DSR methodology. Table 2 lists the artifact generated and its the health goals used in the game.
type. Following this, each one is detailed. The ludic and motivational module contains the game it-
self. This game has its play mechanics to motivate the user.
Table 2. Generated artifacts
In this case, it is a casual tile-matching game with the use of
Artifact Artifact Type game narratives that are unlocked as the user achieves their
SCL Overview Model health goals.
Architecture Instantiation The game has as its target audience people newly diag-
Concept of key hypertension param- Construct nosed with hypertension and who have been indicated by the
eters by device medical team to use it. The presented thematic is to reach the
Interaction Flow Method storm and get it under control, analogously to the life of a hy-
Data flow simulation Instantiation pertensive person who needs to live with this condition, and
Game Instantiation having the need to adapt and manage to reduce their blood
Goals Model pressure level.
LHA patient evaluation Method The game is structured for a six-week duration, in which
each week, a set of activities (goals) is presented to the player.
For example, in the first week the topic is about the definition
of hypertension: through the smart devices, the player will
4.1 SCL Overview
perform weight monitoring, check his blood pressure, and
Fig. 8 presents the SCL overview, which is composed of continuously monitor his activities and heart rate. This data
three modules: Visualization and Management, Ludic and changes the character’s trajectory within the game, helping
Motivational, Sensing and Actuators. the player to engage in hypertension care.
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

Figure 8. SCL overview.

The sensing and actuator module relies on the smart de- query, third-party services, and so on. The formatting of the
vices’ communication method and their data processing so data sent must follow the JSON standards for text formatting
that they can be used by other modules. in addition to obeying the parameter rules made available
in the API documentation. When the server receives the re-
4.2 System Architecture quests it analyzes whether the data received is in accordance
with what is expected for the requested service. If everything
SCL’s Application Programming Interface (API) is based on is in order, the server performs the internal processes of val-
RESTful Web Service patterns with standardization of the idations/consultations/changes in the database. Finally, a re-
transported data in JSON format. The decision to implement sponse is sent, in JSON format, to the requesting client, as
an API aimed at allowing the distribution of data and services shown in Fig. 9.
in an easy and scalable way, where client applications do not The current planning and development covers three possi-
need to be aware of the complexity and processes performed ble types of client software: the mobile application, the mi-
on the server. crocontroller in the patient’s home, and the game. These three
Clients
client profiles are currently supported, but it is possible to
Mobile application
easily adapt to support new profiles. With this in mind, the
distributed services can be described as follows:

Server
RESTFul 1. Microcontroller (Brain): To serve this client, only a
JSON
Game HTTP
(GET, POST, PUT, DELETE)
Database single service was implemented. The microcontroller
Stateless
context was defined as Brain, since it will be the main
point of control and analysis of the received data from
Response

Sensors Brain the sensors distributed in the patient’s home, which

will be sent to the Web Service. The communication
in this context always starts from some sensor, such
as, for example, a Bluetooth Low Energy (BLE) scale,
BLE Signal
(broadcast)
in which the weight measurement value is read and
transmitted via Bluetooth. Brain receives the data
Figure 9. System architecture. sent, performs the necessary processing by identifying
the type of sensor and how to format the respective
message. After the analysis and validation process, the
All communication starts with a request from the client data is sent to the SCL Web Service via the HTTP
side to the server, which can be an application on the smart- POST method with the Brain/Value URL. Validations
phone, sensors installed in the patient’s home, a browser are performed to ensure data security and consistency
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

as well as performing the persistence processes. Table 3. Parameters and devices

Parameters Devices Controls
2. Mobile Application: For this context, public and Blood Pressure RBPM Pressure
private services were distributed. The public services Body mass index Scale Body mass
return public information from the server, such as the (weight and height)
WebService version, token release for authentication, Abdominal circum- Tape measure Body mass
server status, among other data. The private services ference
return private data that need authentication (through Heart rate Smartband Sedentarism
token) to be accessed, such as, for instance, data from Number of steps Smartband Sedentarism
the connected patient, patient’s data update, reading
performed by the registered devices, among others.

3. Database: Firebird, a relational database management

system, was chosen as the management system for the
SCL. Patient registration grants the patient access to the
Configure
application, however without any record of sensors or devices
readings. In order to start treatment and the use of sen-
sors, a contract must be registered with the patient. Thus,
it is possible to guarantee the use of sensors only for the
patient during the treatment/testing period. Separately, Configure the
each of the sensors has its own tables for data persis- application

tence.

To test the API, a Xiaomi Scale Body 2 that supports

Access the game
BLE communication was used. An ESP32 microcontroller on the
Interact with
home devices
(which supports Bluetooth and Wifi communication) plays mobile phone

the role of Brain. The test performed consisted of hav-

ing the ESP32 communicate with the scale, receive the
data from the device, connect to the server, transmit the
data via HTTP POST, and receive the received message re-
sponse. The server, in turn, makes the access checks to up-
date the database. The API documentation can be accessed
by following the link: https://documenter.getpostman.
Figure 10. Interaction flow.
com/view/7871307/TVCmQPkg.

through the application itself, they access the game and in-
4.3 Concept of key hypertension parameters
teract in both ways (mobile phone interface and device inter-
and devices face).
The key parameters of hypertension represent important data
that reflect the patient’s care regarding the progress of the 4.5 Data Flow Simulation
disease. With the list of parameters, it was possible to define
which types of devices are appropriate for collecting the data. A simulation environment based on the discrete-event sys-
The devices for measuring parameters are considered to tem modeling formalism (DEVS) (Zeigler et al. (2018)) uses
be frequently used by the patients of the League of Arterial events that represent both continuous and discrete processes.
Hypertension (LHA), so they should be kept in their homes Since both the microcontroller and the web service were
during the intervention period. In addition, they need to sup- not yet defined, it was decided to experiment with a Pub-
port some communication protocol such as Bluetooth or Wi- lisher/Subscriber architecture (Schmidt and O’Ryan (2003)).
Fi (except for the body measuring tape), referred to here as This simulation focused on monitoring the data mapping
smart devices. Initially, in addition to the data collection de- collected from the patient, the trajectory of that data, and the
vices, it is also planned to use actuators, such as a speakers game’s feedback action. The modeled scenario in the simu-
to play game alerts, notifications, alarms, etc. lator describes the situation where a patient is using, at first,
Table 3 presents the key parameters and maps the devices only a weekly scale and beacons1 that return his indoors lo-
needed to collect those data. cation, in real-time. These sensors access the cloud, using
the publisher/subscriber architecture, where each sensor is a
publisher of content in the cloud (which stores its last mea-
4.4 Interaction Flow surement), and the other elements of the system are the sub-
Fig. 10 outlines the patient interaction flow. It starts with the scribers who register their interest in the corresponding topic,
patient positioning and connecting the devices at the appro- 1 Beacon is a type of device that periodically transmits Bluetooth (Blue-
priate location. Next, they access the application and con- tooth Low Energy (BLE)) packages with data identification that contains
figure the parameters according to their routine care. Then, information used by the receivers.
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

receiving notifications when there is an update on the topic. the legend of the Dara people, the patient is also being
The system (which represents the mobile app) is responsible engaged in taking care of their own health.
for the subscriptions in the cloud and uses this data to monitor
the patient’s data, as well as being responsible for configur- 4. Target audience: People with hypertension.
ing the patient’s health care and sending commands to the
actuators distributed around the house. The game is respon- 5. Game genre: Casual, tile-matching puzzle style with
sible for reading the information from the sensors through narrative.
the application, configuring all the gameplay, and sending
commands to the system so that it can communicate with the 6. Target platform: Game intended for mobile devices for
actuators. accessibility and availability reasons. An internet con-
In the simulation, the patient must stay in the weight range nection is required to communicate with the server.
between 70Kg and 85Kg. If they leave this range, the game
presents a message and adds a task related to reducing or in- It is worth pointing out that the mechanics of the tile-
creasing weight in a healthy way. As for the gameplay on the matching game was chosen after studies about casual games
smartphone, a timer is presented in the game in order to make and the adult audience, and, mainly, for the ease of learning
the game more difficult and convey the feeling of time pres- the mechanics. Moreover, the success of other games in the
sure. As the patient completes the tasks, the speaker plays a same genre, such as Candy Crush, may attract the audience
voice that encourages the patient to continue their self-care by the gameplay similarity.
through the narrative of their journey. When the patient man- Another point to note is the game progression. While one
ages to stabilize their weight for a certain period of time, a can have fun in tile-matching, combining the elements, mul-
safe automatically opens, allowing the patient to pick up their tiplying the score, unlocking new animations, and having a
reward (which they have previously placed in this safe). more aesthetic experience, the real progress of the game hap-
pens through the narrative. If the patient meets their weekly
goals, then each week parts of the narrative will be revealed,
4.6 Game for a total of six weeks of intervention, six phases and six
The game is the main artifact of the SCL platform, whose lu- narrative snippets, as shown in Fig. 11.
dic module is essential to engage the patient in hypertension
care. This section presents the game’s overall concept. The
narrative is what unifies all the other elements and delivers
value to the patient’s experience.

1. Premise: “The game tells a legend of the Dara people,

who, blessed by nature, lived in abundance. On a
certain day, the whole village noticed that very dark
clouds appeared beyond the mountains. A terrible
storm formed, bringing chaos to the small village. Thus
begins the protagonist’s journey to save their people. In
this adventure, they go through challenges that include
caring for the body, the mind, and nature. Only then
will they have enough strength to be able to save their
people.”

2. Player motivation: Along the way, the patient encoun- Figure 11. Game stages.
ters tile-matching style puzzles. The victory condition
is to reach the storm and be able to control it (a
metaphor that is closely related to self-care). Perform- Fig. 12 shows some screenshots of the game. The first and
ing the self-care activities influences the game (by last images show a dialog, the second one shows the tile-
changing the difficulty, mandatory tasks, and alerts), matching and the third one shows an opening game cutscene.
as well as causing events in the actuators distributed In the tile-matching interface, the player must select (by
throughout the house. For example, if the patient needs dragging his finger) the runes (colored elements) on the
to take a blood pressure measurement, the speaker will screen, so that the combination of three or more identical
play the voice of the protagonist that will indicate to runes accumulate points. The runes symbolize the possible
the patient that it is time to use the RBPM and that by combinations of Levi’s (the protagonist) strengths, so that
performing this activity, the character will feel more she earns points and unlocks different animations. The yel-
able to continue his journey. Then, when the person low rune represents care about to the mental state; the green
enters the game again, they will receive notification of rune, care with food; the blue rune, the importance of sleep;
their action. the brown rune represents the importance of contact with na-
ture; and the red rune, health as a whole.
3. Differential: It is a game applied to health that uses the To validate this conception before the game coding stage,
home as a means to play. So, besides participating in a questionnaire was applied to five specialists in the fields of
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

second week, the theme is “Reducing sodium consumption”.

During this week the patient will be introduced to the alarms
that indicate when to take their medication. Also, they will
have to take two blood pressure measurements and will re-
ceive two notifications about this topic. And so on.
After the goals are validated, a positive reinforcement map
will be structured to support the individual in accomplish-
ing these activities. This reinforcement map characterizes the
achievements through a hierarchy of medals (achievements),
which bring a sense of progress and positive reinforcement.

4.8 Evaluation method by LHA patients

The evaluation by LHA patients was planned according to
Fig. 13.

Figure 12. Some game screenshots, representing the tile-matching, dialogs

and narrative video.

communication, game design, and computing. The objective

of this questionnaire was to verify the ease of understanding
of the game’s storyline and its suitability for the target audi-
ence.
The quantitative result of this questionnaire indicates that
the game is suitable for the audience and that the storyline is Figure 13. Evaluation scheme by LHA patients.
contributing to the promotion of self-care and that is easy to
understand. As for the characters, it would be interesting to
use non-binary genders. The qualitative results also showed The sample size was calculated considering a two-sided
that the storyline needs to better specify the challenges faced significance level at 95%, power of the test at 80%, and inter-
by the protagonist and present more figures for interaction. group ratio of 1:1 with estimated success of the intervention
at 70%, and adding 10% on top of the calculated value for
4.7 Health Goals possible loss to follow-up. The final calculated number was
31 participants in each group. Results were calculated using
The health goals have been validated by the health profes- OpenEpi, Version 3, open-source calculator – SSCohort.
sionals, who review the weekly activities and their progres- The participants for the Intervention and Control Groups
sion. Based on the themes defined by an LHA researcher, the will be selected according to the eligibility criteria and prior
health goals come as a way to encourage the person to do cer- consultation on the list of patients with weekly appointments
tain tasks and get oriented to certain matters, as shown in Fig. at the LHA.
14. The selected participants will be randomized into the two
In this validation, considering the target audience, the groups (intervention and control).
health professionals found: (a) the patient should have two The intervention will take place over six weeks, where the
blood pressure recordings per week for blood pressure con- intervention group will use the SCL and the control group
trol; and (b) the patient should have weight recording only in will maintain their normal hypertension care routines.
the first, third, and sixth week so that the patient has weight The final evaluation will occur with the application of the
control, but without causing anxiety. hypertension self-care scale, Systemic Arterial Hypertension
For example, on the first day, with a health professional at treatment adherence questionnaire - QATHAS (Rodrigues
the LHA, the patient will log their medications, weight, and et al. (2014)), socioeconomic questionnaire, and clinical and
height into the application. At home, they will have help set- anthropometric evaluation.
ting up the devices. These first records are already part of
the goals of the first week. The theme this week is “What
is high blood pressure?”, so the patient will receive three 5 Discussion
mobile phone notifications explaining about high blood pres-
sure. In addition, on two days of the week, the patient will be Conducting our research using DSR allowed us to consider
asked to take blood pressure measurements at home. In the that this methodology can be applied in research where there
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

Week 1 Week 2 Week 3

What is high blood pressure? Sodium consumption reduction Body weight reduction
Drugs registration Use medication alert x1 Use medication alert x1
Blood pressure measurement x2 Blood pressure measurement x2 Blood pressure measurement x2
Guidance on blood pressure x3 Guidance on sodium consumption x2 Guidance on nutrition x3
Weight registration x1 AC registration x1
Height registration x1 Weight registration x1

Week 4 Week 5 Week 6

Sedentarism Smoking Stress
Use medication alert x3 Use medication alert x2 Use medication alert x3
Blood pressure measurement x2 Blood pressure measurement x2 Blood pressure measurement x2
Physical activity recording Heartbeat recording x1 Heartbeat recording x1
Heartbeat recording x1 Guidance on nutrition x1 Guidance on nutrition x1
Guidance on nutrition x1 Guidance on sedentarism x2 Guidance on sedentarism x2
Guidance on sedentarism x2 Guidance on smoking x2 Guidance on blood pressure x2
AC registration x1
Weight registration x1
Figure 14. Health goals by week and theme.

is a focus on the development of an artifact to solve some In general, it was also possible to develop a mentality in
problem, suiting applied computing research. Design, provoking several reflections not only in the practi-
The use of the DSR methodology in the development of a cal, but also in the scientific domain. Based on the conduction
game applied to health, such as the SCL, is meeting the re- of the research, these were the main reflections regarding the
quirements both for research and related to the development progress and next works to be carried out:
of the technology itself. However, it is noteworthy that for
• creating a gaming platform for different types of players
this purpose it would be more practical to incorporate some
with different motivations;
elements from the body of knowledge of the game design
• study on how to advance in usability of smart devices
field.
in games;
As a suggestion to facilitate the use of the DSR methodol- • study on how to add more characters participating in the
ogy in game development, the researcher can choose a game system, adding value for health professionals and family
design framework, such as the Elemental Tetrad (Schell members in the monitoring;
(2015)), and add four rectangles that connect to that of the • study on how to expand the system for use in other dis-
Artifact (see Fig. 7 of the instantiated DSR model): Aesthet- eases and the consequent modularization of the system.
ics, Mechanics, Narrative, and Technology. Thereby, the re-
searcher has a starting point from the game design perspec- Thus, bringing back the duality between “Science” and
tive to anchor on. “Art”, it was possible to observe that the scope of science por-
As for the game being applied to a certain area, it is some- trayed Why does it work?, What underpins it?, What impacts
thing well defined in the context of the DSR methodology, it?, How does it relate? and How is this validated?, while the
especially well detailed in the part of knowledge about the scope of art portrayed How does it work?, How is it built?,
problem, context, and the acceptance criteria. What could be Who is it built for?.
improved in this aspect is in relation to the target audience,
that is, working with more specificity to who is the audience
of this artifact and what are their characteristics within this
6 Conclusion
context. This paper presented the DSR methodology by reporting on a
From a software engineering perspective, there is a sym- research development of the SCL applied health game. Each
biosis generated by the cycles and even a certain similarity of step of the development process was addressed, from the in-
processes in the use of the DSR methodology and agile devel- stantiation of the DSR model to the conceptual process of the
opment techniques, which are applied to game development. health part and the game in each development cycle.
However, caution should be exercised when instantiating the Following this, there was a brief discussion about adap-
model in order to avoid neglecting the theoretical foundation. tations that the DSR model could have for research with a
The use of this methodology allowed some contributions focus on game design for applied game development, taking
regarding the architectural vision of the SCL platform and into consideration the expertise in the field.
how to generalize it to understand and improve the commu- The many built artifacts together with the theoretical justi-
nication of IoT devices. Hence, this work brought the oppor- fications used to support them in a systematic development
tunity for research focused on this theme. In addition, the flow and validated by professionals in the field, and by the
research brought questions about the techniques of game de- target audience in order to test the hypothesis established by
velopment applied in the context of health. With this sub- the research, makes it interesting to use the DSR methodol-
ject, there was a deeper investigation of the use of Schell’s ogy for research in the area of applied computing.
Tetrad framework and the SCL, published in SBGames 2021 The work is at the end of the second cycle, which is fo-
(Oliveira et al. (2021b)). cused on the development of the artifacts and their individual
Design Science Research: Balancing Science and Art in Building a Game Applied to Health Oliveira et al. 2022

evaluation. The next cycle, the third, will start the process of Oliveira, L. and Carvalho, S. (2017). Gamificação como es-
evaluating the integration of these artifacts that make up the tratégia para promover self-care e engajar pacientes: Uma
main artifact, the SCL. revisão sistemática da literatura. In SBGames 2017.
It is worth noting that in a world that is increasingly con- Oliveira, L., Oliveira, S., de Lima Vieira dos Santos, S., and
nected and reflected in the digital one, such as the popular- Carvalho, S. (2021a). Desenvolvimento de um jogo para
ization of the metaverse, the science of the artificial is strong hipertensão utilizando a metodologia design science re-
and growing. Thus, there must be an adaptation of the way search: equilibrando a ciência e a arte. In SBGAMES 2021.
of doing science that is useful and produce artifacts that add Oliveira, S., Oliveira, L., Carvalho, S., and de Lima
knowledge. Vieira dos Santos, S. (2021b). Técnicas de design de jo-
Therefore, we conclude that the balance between “Sci- gos, saúde e iot - uma análise de um jogo autoral aplicado
ence” and “Art” results in innovative works that is in demand para o autocuidado da hipertensão. In SBGAMES 2021.
for production. Pakarinen, A. and Salanterä, S. (2020). The use of gaming in
healthcare. In Developing and Utilizing Digital Technol-
ogy in Healthcare for Assessment and Monitoring, pages
Acknowledgements 115–125. Springer.
Peffers, K., Tuunanen, T., Rothenberger, M. A., and Chat-
The authors would firstly thank CAPES (Coordination for the Im-
terjee, S. (2007). A design science research methodology
provement of Higher Education Personnel) and Fapeg (Research
for information systems research. Journal of management
Support Foundation of the State of Goiás) for funding this re-
information systems, 24(3):45–77.
search. This gratitude extends to the League of Arterial Hyperten-
Pimentel, M., Filippo, D., and Santos, T. M. (2020). De-
sion (LHA) of the Universidade Federal de Goiás - UFG, for con-
sign science research: pesquisa científica atrelada ao de-
tributing to this project, especially in the evaluation stages.
sign de artefatos. RE@ D-Revista de Educação a Distân-
cia e eLearning, 3(1):37–61.
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