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CHI 2019 Paper
CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
Design Goals for Playful Technology to Support
Physical Activity Among Wheelchair Users
Liam Mason
University of Lincoln
Lincoln, UK
lmason@lincoln.ac.uk
Kathrin Gerling
KU Leuven, e-Media Research Lab
Leuven, Belgium
kathrin.gerling@kuleuven.be
Patrick Dickinson
University of Lincoln
Lincoln, UK
pdickinson@lincoln.ac.uk
Antonella De Angeli
University of Lincoln / University of Trento
Lincoln, UK / Trento, Italy
adeangeli@lincoln.ac.uk
ABSTRACT
Playful technology has the potential to support physical
activity (PA) among wheelchair users, but little is known
about design considerations for this audience, who experience significant access barriers. In this paper, we leverage the Integrated Behavioural Model (IBM) to understand
wheelchair users’ perspectives on PA, technology, and play.
First, we present findings from an interview study with eight
physically active wheelchair users. Second, we build on the
interviews in a survey that received 44 responses from a
broader group of wheelchair users. Results show that the anticipation of positive experiences was the strongest predictor
of engagement with PA, and that accessibility concerns act
as barriers both in terms of PA participation and technology
use. We present four design goals – emphasizing enjoyment,
involving others, building knowledge and enabling flexibility – to make our findings actionable for researchers and
designers wishing to create accessible playful technology to
support PA.
CCS CONCEPTS
• Applied computing → Computer games;
KEYWORDS
Accessibility, Games, Integrated Behavioral Model
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CHI 2019, May 4–9, 2019, Glasgow, Scotland Uk
© 2019 Association for Computing Machinery.
ACM ISBN 978-1-4503-5970-2/19/05. . . $15.00
https://doi.org/10.1145/3290605.3300262
Paper 32
ACM Reference Format:
Liam Mason, Kathrin Gerling, Patrick Dickinson, and Antonella
De Angeli. 2019. Design Goals for Playful Technology to Support
Physical Activity Among Wheelchair Users. In CHI Conference on
Human Factors in Computing Systems Proceedings (CHI 2019), May
4–9, 2019, Glasgow, Scotland Uk. ACM, New York, NY, USA, 12 pages.
https://doi.org/10.1145/3290605.3300262
1 INTRODUCTION
Regular physical activity (PA) is known to be important for
general health and wellbeing [1]. However, it has been shown
that many of the estimated 65 million manual wheelchair
users in the world do not achieve recommended levels of
activity [15], and miss out on the associated health benefits,
such as reduced physical pain and a lower risk of depression
[40]. The potential of playful technology to motivate and
support PA among non-disabled people has been addressed
by the research community: for example, systems such as the
Nike Fuelband [3], or video games like Dance Dance Revolution [26]) encourage significant PA. However, little work has
considered the design of technology to support PA among individuals with mobility impairments, and manual wheelchair
users in particular. Existing work in this space either focuses
on expert users (e.g. activity monitors for wheelchair athletes [10]), movement-based games with an emphasis on
player experience (such wheelchair-controlled video games
for older adults [20] or young people with mobility impairments [45]). This existing work does not directly address the
needs of the wider manual wheelchair user, from the perspective of supporting PA levels within current health guidelines.
Our work addresses this gap through an exploratory enquiry
into the role of playful technology to support PA among
manual wheelchair users, and identifies and addresses facilitators and barriers within the context of mobility impairment.
We follow a mixed-methods approach that combines interviews with a survey study, and we build on the Integrated
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CHI 2019 Paper
Behavior Model (IBM), a general theory that posits that intentions are the strongest predictor of human behaviour. We
use this framework to guide an exploration of wheelchair
users’ perspectives on PA, technology, and play, and present
initial findings from in-depth interviews with eight manual
wheelchair users which show comprehensive engagement
with PA, but also reveal a number of challenges, e.g., stigma,
environmental barriers and knowledge. We then draw from
these results to develop a questionnaire, which was widely
deployed online, and received 44 responses; analysis revealed
that wheelchair users’ PA behavior is positively influenced
by the anticipated experience, but subject to various environmental barriers. Furthermore, survey results support interview findings which demonstrate an interest in technology
and engagement with games. Drawing on both sets of results,
we propose design goals to be considered in the development
of technology to support PA among wheelchair users, and
reflect on the role of games and play in this setting.
Our paper makes the following contributions: (1) We provide
the first in-depth exploration of the role of technology in the
context of PA among wheelchair users, and (2) we provide an
example of how the IBM can be leveraged in exploratory HCI
research. (3) We provide design goals to inform the creation
of playful technology to support PA among wheelchair users,
drawing attention to factors relating positive perspectives
on PA, play, and accessibility.
2 BACKGROUND
In this section we summarise existing research on PA among
wheelchair users, predominantly from the perspective of
sport science and psychology; we also examine existing technology which has been designed to support PA for wheelchair
users. We furthermore provide an overview of the Integrated
Behavior Model (IBM) as theoretical foundation for our work.
Physical Activity and Wheelchair Use
Given the importance of PA, and often low levels of engagement by wheelchair users, some existing work has sought
to identify barriers to participation (e.g. [28]). Results show
that some issues generalize to all audiences, e.g., limited
time, or financial cost; however, others are more specific
to wheelchair users, such as the fear of stereotyping [44].
Focusing on young users, Buffart et al. [8] revealed barriers which included attitude, motivation, existing injury or
fear of developing injuries, limited facilities, and a lack of
information or knowledge. Facilitators included associated
fun, opportunity for socializing, and improved health and
fitness. Shields [37] broadly supports these outcomes, but
also highlights the importance of logistical and psychological barriers. Wadey and Day [42] considered PA among
adult users who had lost a limb, and identified a number of
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
themes, including wellbeing (personal, social, and physical),
inspiration, self-presentation, experience of PA, knowledge,
environment, and organisational functioning. Williams et
al. (2014) identified eight interrelated concepts as barriers,
benefits and/or facilitators of PA: wellbeing, environment,
physical body, body-self relationship, physically active identity, knowledge, restitution narrative and perceived absences.
Generally, previous work points at complex interaction between individual, social and environmental factors that can
either support or hinder participation [28]. These works all
highlight a need for a better understanding of the design
space to facilitate the development of technology to support
PA among wheelchair users.
Technology to Support PA Among Wheelchair Users
Previous work has explored different technologies to facilitate and support wheelchair users’ engagement with PA,
with one stream of work focusing on activity tracking, and
the other exploring the value of movement-based play.
Tracking Technology. Carrington et al. [10] explore the use
of FitbitT M with wheelchair athletes, and discuss low adoption rates due to accessibility challenges. In another study
using bespoke devices, the authors demonstrate that participants were excited, and perceived the tracking data as useful
for improving their own skills [9]. Following a similar line of
work, Malu and Findlater [27] highlight widespread accessibility challenges with existing technologies, and demonstrate
the desire of participants to engage with activity tracking,
underlining the potential utility of such solutions to users.
Playful Technology. While commercially available exergames
accessible for this audience are scarce [29], a number of researchers have explored movement-based play for wheelchair
users. For example, toolkits such a KinectWheels [19] and
Mokey [14] facilitate the integration of wheelchair-based
game input. Focusing on the potential of movement-based
play to encourage PA, Hicks et al. [23] created games for
young wheelchair users, concluding that participants were
very enthusiastic about the concept. Astrowheelie [12] and
GameWheels [35] are further examples of gaming systems
specifically designed for wheelchair users; in both cases,
the authors concluded that participants had fun while exercising. However, these games were designed to encourage
movement rather than more intense PA, and it remains unclear how they align with the general values and needs of
wheelchair users.
Integrated behavioral Model (IBM)
The IBM combines the theory of reasoned action (TRA), and
the theory of planned behavior (TPB) into a single model
[30]. TRA asserts that the most important determinant of a
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person’s behavior is behavioral intention (comprising attitude and subjective norms). Later, in an effort to account for
factors outside of the individual’s control, Ajzen proposed
TPB as an extension which added an additional construct;
perceived behavioral control [2]. The IBM is a general theory
of behavioral prediction that is applicable to the understanding of any given behavior. Similar to TRA and TPB, the
IBM proposes that intentions (attitudes, perceived norms,
and self-efficacy) are the primary determinant of behavior.
However, it also integrates four additional components that
directly affect behavior: knowledge, salience, environmental constraints, and habit [30], giving the best coverage of
factors relevant to our research setting. Attitudes are split
into experiential (feelings) and instrumental (beliefs) which
refers to an individual’s overall perception of a particular
behavior. For example, if a wheelchair user believed that
doing regular exercise would result in improved physical
health, and that health is a good thing, then they would have
a positive instrumental attitude toward PA. Perceived norm
reflects beliefs regarding other people’s attitudes (injunctive
norms) and behavior (descriptive norms) in relation to a behavior. Personal agency refers to an individual’s perceptions
of their ability to engage in a behavior, split into self-efficacy
(an individual’s belief in their effectiveness in performing a
task as well as by their actual skill) and perceived control
(an individual’s perceived amount of control over behavioral
performance).
Together, these factors influence the intention to engage,
which itself influences actual behavior. The goal for researchers
is to understand which of the behavioral determinants are
most strongly related to intention, and to use that knowledge
to develop interventions which influence health behaviors.
De Angeli et al. [13] demonstrated how the IBM can be used
as a method of eliciting user requirements, stating that it
provided rich information on motivations and barriers to
activities for older people, and concluding that the IBM was
efficient, reliable and easy to link to design thinking . Our
work also leverages the IBM as a theoretical framework for
further exploration of perspectives of wheelchair users on
PA, and the potential for the use of technology in this setting.
The IBM has been extensively applied in empirical research;
for example, it has been used in health care to promote HIV
prevention [24], understand binge drinking [6] and, (most
relevant to this study) to facilitate PA among children [5].
Interestingly, even though the IBM has previously been applied to PA and tested among several demographics, it has
not yet been used with wheelchair users. Thus, our study
contributes to the growing literature of theory-based determinants of PA among wheelchair users while paying special
attention to the role of technology and play in this setting.
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
Figure 1: Integrated behavioral Model (IBM)
3
STUDY: HOW DO WHEELCHAIR USERS
ENGAGE WITH PA AND TECHNOLOGY?
Following the protocols of the IBM, we carried out an initial
interview study which we then used to inform a more extensive online survey. Together, these explore the potential of
playful technology to support PA among wheelchair users.
To this end, we aim to answer two research questions (RQs):
RQ1: What perspectives (e.g. attitudes) of wheelchair users
could be used to design of technology which supports PA?
RQ2: What is the perceived potential of playful technology to support PA among wheelchair users, and what are
the associated opportunities and challenges?
This study used mixed methods for gathering data, and was
conducted in two phases. Qualitative open-ended elicitation
interviews were the foundation of the first phase of the research: These were conducted to empirically confirm the
IBM’s constructs, and to design a quantitative online survey. Using interviews to elicit information from wheelchair
users allowed us to develop appropriate items for each of
the model constructs. Montano describes that the qualitative
interview stage is considered essential to the development of
a survey that would be culturally appropriate, and relevant
to the populations being sampled [30].
Part 1: Interview Study
In this section we present results from our initial interviews
with manual wheelchair users, which address both of our
research questions concerning PA and the use of technology.
Participants and Procedure: Eight participants (2 female,
6 male; age ranging from 20 to 61 years old, mean 33.8) were
recruited. We used local advertising, and a number of social
media channels. All participants were manual wheelchair
users (two to 35 years of use, mean 11); four lived in rural
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
Table 1: Frequency and valence of IBM dimensions
Positive
Attitude
65
Perceived Norm 95
Personal Agency 75
Negative
10
113
128
areas, three were from urban areas, and one participant reported moving between rural and urban life. Six participants
were based in the UK, one in Latvia, and one in Norway. All
participants lived with family, partners or flatmates, and had
a broad range of experience with technology and games.
Semi-structured interviews were conducted in person, at a
suitable location chosen by the participant (3), or via means
of remote communication (5). At the beginning of each interview, participants were provided with information about the
study, and signed consent forms. Participants were asked to
reflect on their experiences with PA, through interview questions based on the IBM constructs and playful technology
use. This included questions such as: “how do you feel about
the idea of being physically active?”; “How much control
do you have over physical activity?”; and “Can you think
of any experiences you’ve had with physical activity and
technology?”. The research protocol was approved by the
ethics committee of University of Lincoln.
Data Analysis: Data were analyzed using Thematic Analysis following both a deductive and inductive approach, as laid
out by Braun and Clarke [7]. All the statements relevant to
constructs of the IBM that describe behavioral intention were
extrapolated in a deductive manner. Codes were constructed
according to the IBM, and gathered into five families labelled
using the original categories of the model (attitude, perceived
norm, and personal agency). Each code family was further
enriched with specific codes (e.g., “Defying stereotypes”) and
the emotional valence of each statement was assessed +/. An inductive approach was used to craft themes related
to the role of playful technology, in the context of PA and
wheelchair use. In order to ensure validity, 40% of the data
were double coded.
Results: We first report results of our deductive analysis,
which is based on factors of the IBM (see Figure 1), and
then provide an overview of the inductive analysis which
focuses on technology sub-themes including preferences for
game themes and technologies, subversive player behaviour,
accessibility, and negative attitudes toward games.
Attitudes. Generally, participants showed positive feelings towards experiential and instrumental attitudes in relation to PA, elaborating on physical and mental wellbeing, fun,
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and enjoyment. For example, one participant commented
that he was “Feeling like I’m actually able to do something
again” [Referring to wheelchair basketball] (P4), “I feel happier” (P7) and “I feel good” (P1). Participants also pointed out
several benefits of performing PA, e.g., “I like the idea that
I am not putting on weight”, “Keeping joints moving [helps]
back pain as well” (P2). One participant hoped that PA would
help “gaining physical strength maybe and catching up to
normal people in terms of going out and do stuff” (P4). Participants also mentioned the possibility of meeting new people
and making friends while performing PA. However, negative
attitudes were also revealed, e.g., experiencing social anxiety
and regret for not participating, or believing that PA might
result in injury, ranging from “Get blisters” (P4) to more serious concerns such as worsening their disability.
Perceived Norms. Social pressures to perform or not perform a particular behavior were highly relevant to participants’ perspectives on PA. Expectations of other stakeholders
were a sub-theme with both negative and positive implications: participants mentioned how other people motivated
them to participate in PA, with family being the biggest influence. However, family involvement could also be demotivating; for example, others being overly worried, or showing
a lack of understanding that led to intrusion (such as having
unrealistic expectations about weight loss). Apart from the
relevance of family, one participant described how they built
a connection with their physiotherapist that contributed to
participation in PA. In contrast, participants did not show
interest in the PA routines of others, such as friends or family
(descriptive norms).
Our data suggest that role models have a strong influence
on participants becoming physically active; they reported
numerous instances where the observation of disabled athletes inspired further engagement (for example, taking up
wheelchair basketball after watching it in the Olympics). A
recurring theme relevant to norms was the desire to defy
stereotypes, and, by extension, disability. Participants explained that they were motivated to carry out PA to prove
their abilities to non-disabled people, e.g., “There’s a few people that see me and think because I’m disabled I get tired […] I
get out and go.” (P3) and “I do like to piss people off, surprise
them, oh you play wheelchair basketball, ye now fuck off!” (P6).
However, interview results also revealed that participants
were aware of performance differences. For example, one
participant would not want to share activity data because
they expected non-disabled users to achieve better results.
Personal Agency. Most (7) participants reported PA routines that suggested high perceived self-efficacy; for example, one participant showed strong awareness of their own
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skills to the point where they could coach other wheelchair
users confidently. However, some participants felt that their
disability limited access to certain elements of PA, such as
participation in competitive sports. Our data also shows that
perceived agency is strongly influenced by access to specialized equipment. Some participants reported keeping a
spare wheelchair to maintain mobility at all times; in contrast, other participants were concerned about affordability
and storage space. Likewise, a recurring barrier was a lack of
spare time (or lack of control thereof): participants reported
that other aspects of their lives limited opportunity to engage
in PA (work or family life). In the context of agency and selfefficacy, participants did express an interest in technology
that supported this aspect.
Salience. All participants were aware of the importance
of PA, and regularly engage in it, though there were a variety of different responses given as to why it was important
to do so. Participants often referred to health benefits, but
they also mentioned psychological factors, such as being
social, and avoiding depression (instrumental attitude). As
previously mentioned, one participant engaged in PA to set
a good example for his children.
Knowledge. Participants were knowledgeable in terms of
activities they already engaged in. For example, one participant did not only play wheelchair basketball, but was also
involved in coaching wheelchair athletes and non-disabled
persons. However, when it came to new activities, participants often struggled to determine whether it would be
possible to gain access; “I have to inquire about any activities
I want to do […] which might be discouraging to even try”
(perceived control).
Habit. Routine was a strong theme that was apparent in
data. Group activities such as wheelchair basketball took
place on set days, participants reported going to the gym on
set days, and one participant mentioned regularly pushing
along the beach after dropping off their son. There was no
evidence of spontaneous PA, which requires no thought or
planning. The only related activity with no set occurrences
was movement-based video game play, mentioned by three
participants (involving Nintendo and Sony console systems).
Environment. A number of environmental barriers need to
be considered, spanning the natural, built (including infrastructure), and social environments of participants. In terms
of the natural environment, weather was a significant constraint. Rain and snow were causes of concern; however, one
participant commented that hot summer months were draining. Two participants lived in countries with much colder
climates (Norway and Latvia). One of the participants used
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
this to their advantage, taking part in winter sports, while
it caused problems for the other: “Winters and cold weather
definitely restrict me to be more active and outgoing, as it’s
hard to move around heavy snow or very low degrees, when
it’s extremely cold” (P7).
Infrastructure and the environment were mentioned by participants, half (4) of whom had cars. This allowed them to not
only access the locations where they perform PA, such as the
gym or clubs, but to also facilitate independent living in general. One participant said that they can go anywhere “as long
as I can get to my car” (P8), while another stated that a nearby
city was much more accessible for a wheelchair user because
“around here you don’t even get bloody footpaths really.” (P6).
The participants who did not drive mentioned more barriers
to transportation, such as expense, inconvenience of waiting
times, getting home in the dark, and non-accessible areas
such as stairs or roadworks. All participants who were part
of a club reported that they liked playing in a social environment. Others described how physiotherapists, coaches
or groups aid in PA. Two participants did not engage in social sports, and exercised on their own. These participants
appeared to be the least active, suggesting that they lack
knowledge to perform exercises that would benefit them.
Perspectives on Technology and Play In this section we
report findings from our inductive analysis, which reveals
perspectives on technology, games and play. All but one participant reported playing games, although time spent playing
games varied. Four participants mentioned using technology
to facilitate PA. Two participants described using the Nintendo Wii (and the game Nintendo Wii Fit in particular) to
engage in PA, but also mentioned that use had declined over
time. Through analysis, we crafted four sub-themes from the
data: Preferences for game themes, genres and technologies,
subversive user behavior, accessibility barriers, and negative
attitudes towards games.
Preferences for game themes, genres and technologies. Participants described specific game themes, genres and technologies they disliked, with little overlap between each other.
For example, participants mentioned genres they were not
interested in, “a warrior-based fighting game that doesn’t really interest me” (P4), “I like playing simulation games most.”,
and commented on new technologies, “Augmented reality
doesn’t interest me at all” (P1) along with features “Newest
multiplayer PC games” (P5). Also relating to genres, participants mentioned the appeal of certain types of games as a
means of escaping from the reality of their limited mobility,
e.g., “I am not able to play tennis, but I can play a Wii Game
Console tennis.” (P7). The sub-theme of brand loyalty was
strong, with almost all participants mentioning some form
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of preference such as not using the Kinect because it is associated with the Xbox, or only using Apple devices.
Subversive user behavior. There were several instances which
suggest that users may intentionally undermine game mechanics related to PA: some participants described how they
cheated while playing games to avoid activity. For example,
“[You only make an effort] until you actually realise you can
sit on a sofa and just wiggle the control.” (P5),”but I cheat using two things [stylus pens for input]” (P4). Likewise, one
participant, when describing their weight watchers system,
mentioned that they do not consistently track their progress,
ultimately making the system redundant.
Accessibility barriers. Several participants mentioned accessibility issues, spanning both practical barriers and wider
perspectives on inclusion. In terms of practical barriers, participants described difficulties with technology, such as malfunctions: “it would phone the police when you’re in a wheelchair
pushing it [using a smart watch]” (P6), or inaccessible user
interfaces “so I don’t have a spare hand available to do it, and
that is just asking me to drop my phone” (P4). Participants
were often advocates for wider inclusion. One participant
stated that they would not play a game that did not try to include accessibility features, stating that “when I hear someone
else who can’t try it out and the companies don’t do anything
I am like no, I don’t want to do it either” (P1).
Negative attitudes towards games. While (5) participants reported playing games themselves, three of them saw games
in a negative light, commenting that it was just “pushing
buttons” (P6), with some suggesting that games were not
comparable to sports. One participant criticized others for
playing Pokemon Go too much, with another not playing
games because he did not want to influence his son. At the
same time, our data showed that other mobile games (e.g.,
played on an iPad) were perceived in a more positive light.
Part 2: Online Survey
Survey Description and Procedure. Based on interview outcomes and the IBM, a questionnaire with a total of 62 questions was developed, split into three main sections: (1) a
section that explores demographics (age, wheelchair use,
engagement in PA, and technology use). Sample questions
include “How long have you been a wheelchair user?” and “I
would consider myself very physically active”. (2) measurement of the theoretical model constructs of the IBM using
5-point Likert scales (attitudes (8), perceived norm (11), personal agency (17)), with items such as “I enjoy PA”, “I am
motivated to engage in PA by defying stereotypes”, and “I
have a high amount of control in being physically active”.
(3) a final part that explored perspectives on technology in
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
general. and games in particular. through a number of closed
and open-ended questions. Sample questions include “I like
to play video games”, “I think digital technology could facilitate PA for me”, and “Are there any specific barriers you
encounter when using technology with PA ?”.
IBM items were presented in random order. Participants were
shown different questions based on their answers in the final
section; e.g., if a participant was strongly opposed to the idea
of leveraging games to engage in PA, they would be shown
questions further exploring this perspective. Pilot tests of
the survey were conducted with eight non-wheelchair users
(due to population size), leading to some questions being
re-worded or removed in order to ensure that language used
in the survey was understandable, and survey length was
appropriate (between 10 and 15 minutes). The final survey
was made available online using Qualtrics, access information was distributed through local wheelchair organizations
and social media (Facebook, Twitter, Reddit). At the start of
the survey, participants were presented with a consent form,
and indicated their agreement to complete the survey. They
were then directed to the survey questions, which they were
able to complete at a time and location of their choice.
Data Analysis. The survey received a total of 75 responses,
of which 44 were deemed complete and included in our
analysis. The data were analyzed using SPSS Version 16
statistical software. Open-ended questions were analyzed
using inductive Thematic Analysis, using NVivo 12.1.
Results. In this section, we give an overview of the survey
results. First, we provide in-depth descriptions of the respondent sample to put following quantitative and qualitative
data in perspective. We then report the results of the IBM
along with outcomes of qualitative analysis of open-ended
parts of the survey.
Characteristics of Respondents. Gender was reported as
male (23), female (18), other (1) and prefer not to say (2). Participant age ranged from 18 to 64 (18-24 (14), 25-34 (14), 35-44
(8), 45-54 (2) and 55-64 (6)). All responses were provided by
participants living in western societies including Europe, the
USA, and Australia. A total of 41 respondents were current
wheelchair users. Wheelchair use ranged from less than six
months to more than ten years (less than 6 months (2), 6
months to a year (4), one to two years (11), two to five years
(10), five to ten years (5) and 10+ years (9)), with amount
of use being varied (all the time (26), most of the time (11),
moderately (2) and very little (2)).
On a 5-point Likert scale participants reported their perceived level of PA as (M = 3.41, SD = 1.32), with the sample
as a whole reporting a high amount of enjoyment from PA
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(M 4.14, SD .88). Interestingly, spontaneity (M = 3.66 SD =
1.18) and routine (M = 3.67 SD = 1.18) shared very similar
results. Participants mentioned a wide variety of activities
that they participated in, and which they considered to be PA.
These were split into three categories: Everyday activities,
e.g., showering, shopping and commuting (17); recreational,
such as basketball, squash and archery (20); and health, such
as gym, yoga and physiotherapy (24). Some activities were
placed in multiple categories (e.g.,going to the gym for fun).
Participants’ engagement with games was relatively high
(M = 3.67, SD = 1.44), mentioning a wide range of game genres with the most common being role playing, action and
puzzle. Delving deeper into the use of video games and technology, participants reported a preference for playing video
games over other activities (M = 2.97, SD = 1.40), cheating
in video games (M=2.93, SD=1.38) and accessibility issues
(M= 3.03 SD=1.46), interestingly all had a high standard deviation suggesting varied views among participants. Loyalty
to platforms (M = 3.46, SD 1.37) and importance of game
theme (M = 3.84, SD = 1.19) reported on a whole a higher
response. Participants reported a positive outlook on the
potential of using technology to support PA (M = 3.71, SD =
1.06). However they also reported a low use of technology in
PA (M = 2.91, SD = 1.16). Participants showed a high level of
interest in the potential of engaging in PA with video games
(3-point scale Yes (12), maybe (12), no (3)) respondents also
reported that they had a preference for games that included
social interaction (M = 4.20, SD =.73).
It was not only important to understand whether participants would engage with technology in PA, but to also to
determine what sort of engagements would be appealing. Participants reported using a wide range of technology: Smart
phone (38), personal computer (33), tablet (25), Fitbit/fitness
trackers (15), Nintendo Wii (11), Nintendo Switch (8), Xbox
Kinect (8), VR systems (5) and PlayStation Move (3). Some
also mentioned a few devices that were not listed such as
Nintendo DS, Gameboy and Sony PSP. Participants also reported a sufficient amount of space available to engage in
PA at home (no room (2), can engage in basic wheelchair
movement (20), extensive movement possible (7)).
Analysis of IBM constructs
An overall index was computed for each dimension of the
IBM by averaging scores to related items (Table 2). Linear
regression was used to estimate the relationship between
the IBM indexes and the perceived level of PA. Due to the
limited size of the sample, a two-step procedure was applied.
In the first step, three separate regression analyses were performed one for each construct. Responses to the question
“I would consider myself physically active” were entered as
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CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK
the dependent variable because it allowed us to estimate the
relationship between the constructs of the IBM (predictor
variables) and the self-reported level of PA, exploring which
IBM constructs are most relevant to wheelchair users engaging in PA [5]. For each item, a preliminary inspection
was performed to ensure no violation of the assumptions
of normality, linearity and multicollinearity. Experiential
attitudes, descriptive norms, and perceived control were determined to be the most significant contributing factors for
each construct. Therefore, in the second step they were entered as the three predictors of the analysis. It resulted in a
statistically significant equation (F (3, 36) = 11.1, p < .001), R2 = .50, standard error .95. Experiential attitude made the strongest positive contribution with a standardized coefficient beta score of .55, followed by descriptive norm (.23), and perceived control (.09). Table 2: Mean scores and Standard Deviations for IBM constructs rated on 5-point Likert scales (5=highest). Predictor variables Experiential Attitude Instrumental Attitude Descriptive Norm Prescriptive Norm Self-efficacy Percieved Control M 3.84 3.87 3.92 3.51 3.34 2.65 SD .92 .44 .90 1.17 .59 .63 Qualitative survey findings Here, we give an overview of prominent themes discovered through qualitative analysis of participants’ open-ended feedback, focusing on elements of technology use and perspectives on games, in order of importance. Accessibility: A total of 27 responses relating to the theme of accessibility were reported. Firstly, participants specifically mentioned that their disability affects their use of technology and games, with three participants specifically describing the issues they had previously experienced with the popular location-based game Pokemon Go. Location tracking was also mentioned with one participant expressing that they would like a system that allowed for accessible routes. One participant even used a combination of Strava and Garmin (location based fitness tracking) because a Fitbit was not suitable for them. Controllers were also mentioned with one participant stating that "Motion controllers are too demanding" and another wanting "More adaptive controllers". The accessibility of portable devices was also mentioned "hard to use whilst moving [smartphone]", one participant suggested that it "has to be easily carry-able", with another preferring portable devices because consoles take too long to set up. Page 7 CHI 2019 Paper Other accessibility issues such as concentration were mentioned, along with motor issues impacting use of controllers. Knowledge: Participants also mentioned that they lacked knowledge about how to exercise; "I want to know how to exercise on a wheelchair. I will be member of a gym soon, but I don’t know what and how to exercise". Interestingly, one participant compares and learns techniques from other wheelchair users in their town. There were also cases of participants not knowing how to exercise with technology; "technology is the way forward, but difficult to understand for me". Identity: Similar to the interviews, stigma was a prevalent theme with many negative comments collected. The indicated disapproval of video games and/or technology was attributed to being "too old", "old fashioned" or "a girl". There were also examples of participants perceiving games as a waste of time, or a distraction, and something that they don’t want to "play with children". Regardless there were examples of participants finding games fun with one example of a participant stating "it makes me work harder to better myself". Interest: A lack of interest was demonstrated by a few participants; one noted that they used to track their fitness on a smart phone, but quickly lost interest. One participant stated they "would rather go outside", and replied "better things to do" in response to why they don’t like video games. However a few participants expressed an interest in trying. Summary of Key Findings RQ1: Attitudes and PA participation. The results show that experiential attitude (feelings) was the highest reported construct of the IBM that contributes to PA engagement across interviews and surveys, suggesting that wheelchair users engage in PA because it is enjoyable. Descriptive norms (social identity) was the second highest construct. However, results from interviews and surveys offered different perspectives, with interview responses showing no interest in what other activities others were doing. Finally, results show that perceived control was the least contributing factor, suggesting that control beliefs do not highly influence PA engagement. Qualitative results support elements of the IBM. Most prominently, the theme of knowledge directly links to the corresponding IBM construct; results show that participants struggled to determine if they could partake in new activities (interviews), or how to be physically active at all (survey). Additionally, both data sets showed desire for learning from others; however, many survey respondents were limited to online communities. Finally, the concept of routine was strongly evident across all participants, with PA participation often taking place at fixed times and locations. Paper 32 CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK RQ2: Technology use and games. Results show that participants use technology, but experience access barriers particularly in the context of leveraging technology to support PA. Considering the use of games, responses suggest high levels of familiarity with games, along with regular participation in play, but also revealed stigma that some individuals associate with playing games. There was wide variety in gaming preferences (e.g., genres) and platforms (e.g., mobile, consoles, or PC), suggesting a need for tailored solutions. 4 DESIGN GOALS We summarize our findings into four main design goals to be addressed in the design of (playful) technology to support PA among wheelchair users. Each design goal is accompanied by examples of commercially available technology and/or games that illustrate how these goals could be realized positively (or avoided in the case of anti-patterns [4]). Design Goal 1: Emphasize Enjoyment. Our results show that the anticipation of positive experiences is a strong predictor of wheelchair users’ engagement in PA (Relevant IBM Construct: Attitude - Experiental Attitude). To reflect this perspective, technology to support PA should first and foremost focus on the facilitation of enjoyable experiences, rather than potential health benefits (instrumental attitude), or aspects external to the activity. Medicalizing PA, and prioritizing health benefits of exercise over enjoyment is a common pitfall when designing for audiences with special needs [36] illustrate this challenge when addressing older adults). Playful technology in particular aligns with this goal, but could potentially be undermined by creation of primarily ‘serious’ or ‘persuasive’ games. Reflection on games that integrate PA while prioritizing enjoyment. Research by Mueller et al. (e.g., [[32], [43]) comprehensively illustrates how playful technology and games can be leveraged to increase the enjoyment of PA, strongly emphasizing the experience of the user. Guidelines that stem from this line of work (e.g., [31]) provide valuable insights that can help create enjoyment-centric rather than disability-focused systems. Likewise, there are many examples of commercially available games following this paradigm, e.g., the VR music game BeatSaber [17] which offers engaging game mechanics, and provides PA as a beneficial byproduct. Design Goal 2: Involving Others: Our results suggest that involving other parties (e.g. friends, or non-disabled individuals) appeals to wheelchair users, but also comes with challenges that require careful consideration (Relevant IBM Construct: Perceived Norm - Descriptive Norm). For example, simply including multiplayer game modes does not Page 8 CHI 2019 Paper necessarily facilitate the involvement of other players adequately. Designers should consider that some players may feel uncomfortable sharing their performance with others (especially in direct comparison with non-disabled players), whereas other players may be excited about activities that give them an opportunity to showcase accomplishments and learn from others. This is in line with previous work exploring competition between wheelchair users with peers and non-disabled people [21], demonstrating that competition and comparison can, depending on implementation, either expose vulnerability or contribute to empowerment. Thus, features involving multiple players could be made optional. Reflection on playful technology implementing social features in innovative ways. Games have a long history of social features, ranging from direct involvement of multiple persons in gameplay to elements such as shared scoreboards. Examples of design strategies interesting in this setting include games such as New Super Mario Bros. [34] (co-located multiplayer mode with asynchronous player roles), to applications that support engagement in PA over a distance [32]. Additionally, it might be valuable to explore gamified fitness applications such as Fitocracy [16] that enable users to find small online fitness groups, which is also valuable for playful technology with small target audiences. From a technical perspective, our findings further support the implementation of crossplatform solutions that are common in game development, thereby enabling players to use different technical platforms. Design Goal 3: Build Knowledge: Playful technology to support PA should enable wheelchair users to build and extend their knowledge of suitable PA routines, addressing the self-reported gap identified in our survey (Relevant IBM Construct: Knowledge). Previous research has demonstrated effectiveness in implicitly teaching new skills (e.g. scaffolding in puzzle games [25]). When developing playful technology to support PA among wheelchair users, gradually extending the mechanics of the game could support players wishing to expand their knowledge of exercise. Likewise, careful scaffolding could counteract fears of injury that were reported by some study participants. In this context, designers and developers could also reflect on how playful technology facilitates the transfer of skills and knowledge into daily life, supporting players wishing to explore other activities. Reflection on games that facilitate scaffolding and help players build knowledge. Game design has a long history of supporting scaffolding, e.g., through tutorials and gradual introduction of game elements that can be observed in many commercially available games [41]. For example, the first-person Paper 32 CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK shooter Portal [11] is a prominent example that applies stepby-step introduction of new functionality to facilitate learning. This approach could directly be applied to knowledge about PA when integrated as main mechanic that gradually increases in complexity. However, designers need to be aware that successful PA participation is not just a matter of knowledge of how to exercise, but also gradual skill building that is particularly relevant in the context of players who recently transitioned to wheelchair use. Design Goal 4: Enable Flexibility: There are a number of ways in which flexibility is important when creating technology to support PA. Firstly, flexibility is pertinent to interface design; i.e., hands-free operation may be important to some users, so as not to impair operation of their wheelchair. Secondly, users require control over the time and place at which they engage with PA, e.g., to negotiate environmental barriers (Relevant IBM Construct: Personal Agency - Perceived Control). Users also require flexibility in how they blend PA with existing routines (Relevant IBM Construct: Personal Agency - Habit). We note that many participants reported habitualized PA routines that leave little room for spontaneity; for example, attending the gym for a number of hours, but not engaging in other activities during the week (due to access barriers). Game-based PA interventions could thus potentially support flexibility by encouraging PA participation at other times and locations; for example, suggesting shorter, frequent, and more accessible exercises to counteract sedentary lifestyles [22]. Reflection on flexible playful technology in the context of PA. The concept of casual exergames [23] [18] - games that require PA and can be played in short chunks throughout the day - demonstrates that games can be leveraged to facilitate continuous participation in PA. However, developers need to be mindful that core mechanics also need to show flexibility to avoid access barriers. For example, games such as Pokemon Go [33] require players to access certain areas, which is problematic as the game does not account for environmental accessibility barriers such as stairs. This could be addressed through concepts such as accumulated-context exergames, where player activity is tracked throughout the day and asynchronously mapped onto the game world, offering choice in terms of time and location of PA [39]. 5 DISCUSSION This paper explores wheelchair users’ perspectives toward physical activity, technology, and games, leveraging the IBM as a theoretical model. Here, we discuss more nuanced findings with focus on wheelchair use and PA, pitfalls in the context of playful technology to support PA, and we reflect on the application of the IBM as HCI research tool. Page 9 CHI 2019 Paper Playful Technology, PA, and Wheelchair Use There is potential for playful technology to engage wheelchair users in PA: IBM results suggest that wheelchair users place experiential attitude far above the others (indicating a high degree of importance attached to PA among wheelchair users). It is unsurprising that injunctive norm, self-efficacy and perceived control were not positively correlated with the quantity of PA which wheelchair users engage in, because they are most relevant to accessibility (i.e., the built environment, which was repeatedly mentioned as a barrier to accessibility). Similarly, Smith [38] mentions that wheelchairrelated factors and accessibility are associated with participation, which aligns with both personal agency and perceived norm (injunctive norm in particular). Focusing on the importance of positive experiences for wheelchair users while understanding the impact of environmental factors, the remainder of this section reflects on three points for discussion. (1) Transferring to the Real World: Avoiding Technology Dependency: Our findings suggest a lack of knowledge on how to be physically active, an aspect particularly relevant for individuals transitioning to wheelchair use. Here, games and playful technology offer potential to guide users, supporting them in the development of new PA routines. However, it is important to note that people should be able to engage in PA without depending on technology, suggesting a need for technology-supported PA routines that facilitate scaffolding to technology-free activity. (2) Opening Up New Perspectives on PA Through Play: Following on our findings also show individuals have not previously used technology to engage in PA, opening up new perspectives that could promote regular PA. This shows the importance of playful technology because many participants where excited at the thought of engaging in PA with technology in both our results and other work [10]. (3) Limitations of Games (and Technology in General): Our results show that games in particular appealed to a wide audience, but were strongly rejected by some participants. For those individuals, the combination of PA with games could in fact increase the access barrier to PA rather than lowering it. Likewise, technology can help mitigate some environmental access barriers through design (e.g., awareness of access barriers in local communities when creating mobile systems). However, it is limited to workarounds rather than changing surroundings, suggesting that tangible access barriers need to be addressed on a practical rather than technology level. Leveraging the IBM for HCI Requirements Analysis Our work demonstrates that the IBM can serve as an effective and agile method of requirements analysis. However, there are two challenges that need to be considered in its Paper 32 CHI 2019, May 4–9, 2019, Glasgow, Scotland, UK application. First, it has not previously been used to study wheelchair users, and only a small number of previous studies have used it within the context of PA (e.g., [5]), making it difficult to relate outcomes to previous studies. Second, the IBM is a tool that provides high-level insights into predictors of behaviour rather than actionable design recommendations. In our work, we added specific questions around technology use and play to both interviews and surveys; then, we tied together IBM results and specific perspectives on technology through the provision of design goals. However, this suggests that the application of the IBM for requirements analysis affords an additional layer of interpretation of our results, suggesting potential in HCI research rather than as a tool for practitioners that directly leads to actionable outcomes. 6 LIMITATIONS AND FUTURE WORK There are a few limitations that need to be considered when interpreting the findings of our work. The IBM is a newer model in the field of health promotion, which makes it difficult to compare our results with findings from other published applications of the model, requiring individual interpretation. Additionally, the interview study only included eight participants, with an arguably biased demographic (mostly physically active individuals). This needs to be considered when interpreting results from this stage; however, the group of survey respondents was more diverse. Likewise, the survey focuses on quantitative insights. In this context, an in-depth exploration of negative attitudes and barriers to PA and technology use could help us further understand non-engagement with PA and technology. In the future, we plan to leverage our findings to support the development of playful experiences and games aimed to support PA among wheelchair users, exploring stationary versus mobile play, and the impact of social gaming settings on PA participation. 7 CONCLUSION Playful technology has the potential to support PA, but there has been little research regarding the design of playful technology for wheelchair users. Our work provides a mixedmethods enquiry into manual wheelchair users’ perspectives on PA and technology, leveraging the IBM to provide an indepth exploration. Findings highlight that anticipation of positive experiences is the strongest predictor of engagement with PA, supporting the development of playful solutions that by nature can highlight this element. 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[45] Zi Ye, Hamilton A Hernandez, TC Graham, Darcy Fehlings, Lauren Switzer, Md Ameer Hamza, and Irina Schumann. 2012. Liberi and the racer bike: exergaming technology for children with cerebral palsy. In Proceedings of the 14th international ACM SIGACCESS conference on Computers and accessibility. ACM, 225–226. Page 12 A one-page report should include: summary of the paper read (in the students’ own words – what was the research and why was it conducted?), why the paper or research is important to society, what are some strengths and weaknesses of the paper, and what the student learned. Be sure to include a citation and URL link to the paper selected at the end of the report. Purchase answer to see full attachment