Older Adults and Three-Dimensional Exergaming: Motivators and Barriers to Participation and Retention

Abstract

Background:

Cognitive and physical activity are important for daily functioning. However, limited research exists on the motivators and barriers associated with older adults participating and adhering to exergame studies that promote physical and cognitive activity. Our objective was to examine older adults' motivators and barriers to joining and completing a three-dimensional exergame study.

Methods:

Fourteen older adults who participated in the exergame study contributed to one of three focus group discussions. Inductive and deductive methods were used to analyze the qualitative data.

Results:

Motivators for joining were generativity, peer referrals, self-improvement, and curiosity. Accomplishment, immersion, and exercise were motivators for retention. Participants also cited the structured schedule and adaptive difficulty features as motivators for retention. Barriers to participation included frustration due to lack of level advancement and fatigue/pain during gameplay. Some (n = 3) reported camera tracking issues as a barrier. Unanticipated gender-based trends arose when examining perceptions of the study team's role and motivators for retention.

Conclusion:

These findings will inform future research strategies for participant recruitment, enrollment, and retention, in addition to providing insights into the design of motivating, enjoyable, and sustainable exergames for older adults.

Introduction

Physical activity is vital to daily functioning and health.^1–4 Still, nearly two-thirds of older adults are sedentary for 8.5+ hours each day.^5,6 Adherence to exercise interventions in older adults also remains challenging, with adherence rates (i.e., proportion of sessions attended) ranging from 58% to 77% and attrition rates (i.e., proportion who dropped out of the study) spanning from 14% to 35%.^7,8 Older adults who perform more cognitively stimulating activities have a lower risk for late-life cognitive impairment.^9–11 However, older individuals report greater effort and fatigability when performing cognitively demanding tasks compared with younger adults,¹² and adherence to cognitive training interventions is difficult to maintain.^13–16 Thus, it is crucial to understand motivators and barriers for older adults joining and adhering to studies promoting physical and cognitive activity.

Self-Determination Theory (SDT) posits that intrinsic motivation arises when three psychological needs are fulfilled—autonomy, competence, and social relatedness.^17–22 Autonomy involves feeling in control of one's decisions and behaviors; competence encompasses the need for mastery and feeling effective; and social relatedness reflects the desire to feel connected to others.¹⁷ Under SDT, videogames can promote all the three needs.^18,23

Novel technologies, such as exergames, have emerged to foster positive health outcomes. Exergames combine “exercise” and “videogames” to simultaneously promote physical and cognitive activity.²⁴ Given the difficulties with adherence and attrition in exercise and cognitive training studies,^8,14 exergames may offer a fun and unique opportunity for older adults to engage in cognitive and physical activity. Positive associations have emerged between exergames and improved health outcomes, including mobility, balance, physical and cognitive performance, and self-efficacy.^25–29 However, a large proportion of exergame research is quantitative in nature, with less research focused on qualitative components, which captures perspectives that may be missed with quantitative methods.^30,31

Previous studies on motivators for exergame use suggest that older adults prefer immersive, safe, and enjoyable exergames.^32–36 These works also emphasize that promoting social interaction, having simple onboarding processes, including adaptive difficulty features, targeting activities that translate to the real world, and improving physical, mental, or social health are important motivators for exergame study participation and retention. Barriers include technical difficulties, hesitance toward exergames, waning interest over time, functional limitations, and poor user interface.^37–41

Given the small sample sizes and varying eligibility criteria across studies, additional research is needed to confirm these findings. Furthermore, the majority of exergames used in previous studies are commercially available.^36,38 Few have been developed internally and adapted for use in older adults. Moreover, many studies are conducted in laboratory or clinical settings rather than community-based settings. This can limit the recruitment pool to individuals who are in better health, own a car, or can arrange for transportation to the study site.⁴² By meeting older adults in the community where they reside, researchers can enroll participants who may not have previously been able to join due to time or health limitations. Lastly, many studies focus on barriers and motivators for exergame use but do not further inquire about aspects related to the study design and recruitment process that may have motivated participants to join or stay in the study.

Our objective is to expand upon existing literature and understand the motivators and barriers influencing older adults' exergame study participation and retention. We used a novel, internally developed exergame adapted for use in older adults and conducted our study within a senior living setting. We applied SDT as a guiding framework to qualitatively explore the following research question: what motivators and barriers do older adults report for enrolling and remaining in a 5-week, three-dimensional (3D) exergame feasibility study? Identifying these motivators and barriers will inform future study design strategies and enhance our understanding of which gameplay features to consider when designing enjoyable, sustainable, and scalable exergames for older adults.

Methods

Exergame

The “I Am Dolphin” exergame was used as a 3D immersive exergame. Created at the Kata Design Studio at The Johns Hopkins University School of Medicine and adapted for older adults, the program uses a novel neuroanimation approach to promote enriched, immersive, and enjoyable animated experiences.⁴³ While originally designed for poststroke rehabilitation,^43,44 this exergame is also ideal for older adults since it promotes simultaneous incorporation of cognitive and physical activity through enriched, dynamic gameplay and complex upper body movement.

Participants

Fourteen older adults from a senior living center who participated in the Stimulation with Intricate Movements (SWIM) study were asked to participate in a semistructured focus group. The SWIM study assessed the feasibility and short-term impact of exergaming on older adults' cognitive and functional health. Eligibility criteria for the SWIM study are outlined in the Supplementary Data.

Participants completed 1-hour sessions three times each week for a total of 15 sessions. All sessions took place at the senior living center. Players' movements were tracked using a Kinect-based camera system. They used their dominant hand to navigate a complex, 3D ocean environment to help Bandit the dolphin virtually jump out of the water, eat fish, and stun sharks. Bandit's speed and defense skills were controlled using a remote in their nondominant hand. Upon completing all 110 levels, participants switched hands and progressed through the exergame again.

The exergame primarily targeted upper body activity, although participants often used lower extremity movements when engaging in the jump levels and standing during gameplay. A handful of participants would play the exergame while sitting, limiting their lower extremity movement but maintaining upper extremity activity. Furthermore, participants' range of motion and nature of body movements varied depending on their playing style. For example, one participant would make sweeping arm movements, while another would use tight motions near the wrist to navigate the oceanic environment.

Fourteen of the 15 SWIM participants were recruited for focus groups. One participant was not recruited for the focus group discussion because he or she was still completing the exergame study at the time focus groups transpired. All respondents recruited for the focus groups agreed to participate, including one who dropped out after 2 weeks due to a chronic vestibular disorder. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. All participants provided informed consent.

Procedure

The interview guide assessed general likes/dislikes, motivators to join and complete the study, and barriers experienced during the program (Supplementary Data). Focus groups took place in a private room at the senior living center. Participants were allocated into three sex-stratified groups of four to five people to spur discussion, promote comfort, and foster interaction.⁴⁵ The focus group facilitator (B.F.D.) was not involved in the recruitment or data collection process to mitigate reporting bias (e.g., feeling pressured only to discuss positive aspects of the study). The recorder (B.M.C.) managed the recordings and took field notes during each focus group. Discussions lasted ∼1.5 hours, were audio-recorded, transcribed by Production Transcripts (Glendale, CA), and checked for accuracy by B.F.D.

Data analysis

The focus group facilitator and recorder (B.F.D., B.M.C.) analyzed the transcribed data using the “Sort and Sift, Think and Shift” method.⁴⁶ This approach involves rigorous cycles of inductive and deductive methods to interpret qualitative data. First, one focus group transcript was inductively coded line-by-line, and common codes and general findings were recorded. After reviewing the interview guide, B.M.C. and B.F.D. created a deductive codebook to incorporate anticipated codes given the study goals, conceptual framework, and focus group questions. The researchers met with the principal investigator (M.C.C.) to compare inductive and deductive codebooks and combine them into a merged codebook before analyzing the transcripts (Supplementary Data). After coding each transcript, the two researchers met weekly to discuss progress, compare notes, posit rival or alternate explanations, and create additional codes if needed. Then, codes were combined into categories and categories into themes.⁴⁷ The f4analyse software was used to analyze the data.⁴⁸

Findings

The mean age of the sample was 78.9 years (SD = 8.7) (Table 1). Participants were mostly female (n = 10) and white (n = 12). Nine residents (64.2%) reported a greater than high school education, 12 (85.7%) had hypertension, and 13 (92.9%) completed the study. Primary motivators for joining were generativity (i.e., wanting to contribute to the well-being, growth, or development of others and help younger generations),^49,50 peer recommendations, self-improvement, and personal curiosity. Reasons for retention included feelings of accomplishment, the immersion, exercise, structured schedule, and adaptive difficulty features of the exergame. Key barriers to participation were frustration from lack of level advancement and exhaustion/pain during gameplay (Table 2). Three participants reported camera tracking issues as a barrier. We also observed unanticipated gender-based trends when examining motivators for retention and perceptions of the study team's role. These findings are described in detail below.

Table 1.

Focus Group Participant Descriptive Statistics

n = 14	Mean (SD) or n (%)
Age	78.9 (8.7)
Age range	63–96
Female	10 (71.4%)
White	12 (85.7%)
Education
≤High school	5 (35.7%)
>High school	9 (64.3%)
Self-reported overall health
Excellent	1 (7.1%)
Very good	1 (7.1%)
Good	7 (50.0%)
Fair	3 (21.4%)
Poor	2 (14.3%)
Self-reported chronic conditions
Hypertension	12 (85.7%)
Arthritis	11 (78.6%)
High cholesterol	9 (64.3%)
Diabetes	3 (21.4%)

Demographic and health characteristics collected at baseline SWIM evaluation.

SWIM, Stimulation with Intricate Movements.

Table 2.

Focus Group Findings and Corresponding Self-Determination Theory Axiom

Focus group findings	Corresponding SDT axiom
Motivators for joining
Generativity	Social relatedness
Peer referrals	Social relatedness
Self-improvement	Competence
Personal curiosity	Autonomy
Motivators for retention
Sense of accomplishment	Competence
Immersion	Competence
Exercise	Autonomy
Structured schedule	Autonomy
Adaptive difficulty	Competence
Barriers to participation
Frustration due to lack of level advancement	Competence
Fatigue/pain during gameplay	Autonomy
Camera tracking issues	Autonomy
Gender-based trends
Men's perceptions of the study team—facilitators of gameplay	Competence
Women's perceptions of the study team—sources of encouragement	Social relatedness
Men's motivators for retention—upholding commitments	Autonomy
Women's motivators for retention—self-improvement	Competence

SDT, Self-Determination Theory.

Motivators to join

Generativity

Motivators for joining were to help the study team, give back to the community, and leave a legacy. One participant said: “I've been through a doctoral study, and when [one of the researchers] said she might be involved in this as part of her degree, I had no problem setting my foot with it because I've been there, done that. And if I can help, then I was happy to help.” Another participant recently experienced the loss of a loved one to Alzheimer's disease and joined to help others in the future.

Peer referrals

Some participants enrolled through word-of-mouth, likening their participation to being in their “own little sorority or fraternity because we were talking about Bandit.” Discussions between residents in the study spurred interest among others who decided to join. Thus, conversations about the study seemed to leave potential participants with the desire to be socially connected and engage in shared experiences with their peers. Others joined after stopping by the gameplay room while the study team set up the console. Here, they could view the exergame and subsequently decided to join.

Self-improvement

Several participants joined after viewing in-person demonstrations at recruitment events. After seeing these demonstrations, one participant joined “to improve my motions and mind activity together.” Others sought to “be more perceptive to movements,” to gain “a little more self-confidence,” and to seize the opportunity to play a videogame. Overall, residents wanted to improve their skills, self-confidence, and see how far they could progress through the exergame.

Curiosity

Participants also enrolled because they were curious about the unique nature of the exergame and “thought it would be something interesting to do. Because sometimes it gets kind of boring. And it was something different.” The exergame's novel features piqued participants' curiosity and motivated them to enroll. They reported that the exergame study was an interesting and unique way to spend their time.

Motivators for retention

Accomplishment

Participants remained in the study to gain a sense of accomplishment and improve their skills (e.g., stunning sharks, advancing levels). One respondent explained: “I found it exciting!<LAUGHS> And I always wanted to do better, beat my score, or try to get to that next level. So it kept me coming.” Participants often shared gameplay experiences with their children, grandchildren, friends, and study team. One said: “I told all my family what I was doing… they would ask me each week how I did. They were very interested in my being there and my accomplishments.” Some reported how the exergame made them feel in control (e.g., “I felt very much in control with Bandit, and knowing that I could do that helped me realize that I can control a lot of different things in my life.”).

Immersion

None of the participants reported boredom, suggesting successful immersion during gameplay. One respondent stated: “The hour sped by. And there was no boredom on my part at all, because you, again, were looking to better your score, and either that or get to the next level.” Another said: “I don't think boredom is one of the issues at all. Because… the time went very quickly.” Overall, immersion during gameplay made time pass quickly and motivated participants to come back for more.

Exercise

Participants reported that the exergame was an enjoyable and clever way to get moving, stating: “You knew you were going to do some exercise, which is good. Because we do have exercise equipment here, but I don't think—I myself, have not ever used it.” Residents enjoyed incorporating physical activity into their weekly routine. One respondent said: “The exercise was a plus, because I found myself moving, as they say, moving and grooving <LAUGHS>, trying to, you know, reach that goal of getting that higher, getting to that next level.” Another participant called the exergame “sneaky exercise,” stating: “It's like sneaky exercise; you're not even aware that you're exercising.”

Structured schedule

Participants enjoyed the exergame's structured schedule (e.g., weekly sessions, set times), citing it as a motivator to get out of bed and be active. One stated: “I look[ed] forward to my time, and I'm not a morning person, but I got myself up, dressed, and ready to go! Any other time, huh! I'd be in my nightclothes up until 12 o'clock if I didn't have anywhere to go.”

Adaptive difficulty

Residents enjoyed the exergame's adaptive difficulty. Each session brought a different experience with new levels, challenges, and strategies. One participant said: “[It] was a challenge at times but overall, I looked forward to coming to every session and continuing my progress in the game” and “it did keep—hold your interest… it wasn't the same thing every time.” The ability to change the difficulty depending on gameplay performance motivated participants to return and (1) improve, (2) help Bandit, or (3) beat their high scores.

One resident who switched hands after beating the game with their dominant hand reported that the exergame made them “much more aware of [their] motion.” Another supported this, saying: “Oh, yeah… [it] just helped me make some connections in my brain that had gotten lazy, shall we say?” In contrast, one participant wanted more cognitive complexity incorporated into the exergame, stating: “Once you're able to win on a pretty regular basis, it becomes fairly routine.”

Barriers to participation

Frustration

Frustration was a common complaint, particularly for levels where aggressive sharks had to be stunned to advance to the next level. Participants provided descriptions regarding the types of sharks that were their least favorite and how unfair some levels were when they only had three lives and four sharks to stun. This detailed recollection was noteworthy since most completed the exergame months before focus groups occurred.

Frustration also arose from the inability to complete all exergame levels. Sometimes, participants would come close to beating a level and fail or repeat the same level numerous times before advancing. However, a pattern emerged where statements of frustration were coupled with words of affirmation and a sense of accomplishment once the level was completed (e.g., “There were days when I thought, I'm never going to get through this session today… but all of a sudden I did, and so I was happy about that.”)

Fatigue/pain

Given the wide range of ages and health conditions, some participants reported fatigue or pain during gameplay. One participant stated: “I have really bad knees that I couldn't stand for long periods of time, but the researchers allowed you to rest.” If pain or fatigue arose, study staff encouraged residents to stop and take a break. Participants said they felt these breaks provided adequate time for them to rest before continuing. However, some reported temporary shoulder, hip, or back pain after gameplay.

Camera tracking issues

Three residents reported frustration with camera tracking. Two of these participants often played sitting down, which led to problems getting the camera to track arm movements properly. The study team attempted to modify the room's configuration and camera placement throughout the session, limiting the time spent in gameplay. Modifications are currently underway to improve the camera tracking settings, particularly while sitting.

Gender-based trends

Unanticipated gender-based trends arose for two exergame components: (1) perceptions of the study team's role and (2) motivators for retention (Table 2).

Engagement with study team

Women interpreted the study team as sources of encouragement and companionship. Enjoyment arose from “talking with the people that were running the test. I got a lot of mental stimulation just from talking with the grad students.” One woman stated: “I liked having somebody in the room, because… if they walked out, we're there alone… They showed that they actually had an interest…they were very encouraging, they stopped if you were tired at all. You could stop at any time. They talked to you. And I thought they made the program work.” Conversely, men generally perceived the study team as facilitators that advanced the levels of the exergame. For example, one stated: “They just needed to be there to advance the game when you finish a level so you can change to a new level.”

Commitment

Women often cited gameplay-related motivators tied to self-improvement and enjoyment as reasons to remain in the study. One stated: “It just was a real opportunity to actually play a video game, and to have a chance, see how far I could get. It was an enjoyable thing to do. I wasn't going to quit it.” Some women (n = 2) mentioned upholding commitments as a motivator for retention, but it was not unanimous. In contrast, all men cited an obligation to fulfill commitments as a motivator for retention, stating: “A promise is a promise. So I stayed in it until it was over.” and “You signed up for this much duty, you do it.” Feelings of commitment were often coupled with a strong desire to continue playing the exergame even after the study ended.

Discussion

In this study, we qualitatively examined older adults' motivators and barriers to participating and remaining in a 3D neuroanimation exergame feasibility study. We achieved 100% participation in the focus group discussions, encompassing all 14 participants who finished the SWIM study at the time focus groups took place. Primary motivators for joining were generativity, peer referrals, self-improvement, and personal curiosity. Motivators for retention were to gain a sense of accomplishment, immersion, and exercise. Participants also cited the exergame's structured schedule and adaptive difficulty features as motivators for retention. Barriers to participation included frustration due to lack of level advancement and fatigue during gameplay. A few (n = 3) residents reported camera tracking issues as a barrier.

Our findings support previous work showing that older adults favor immersive exergames with adaptive difficulty features that promote social interaction and are enjoyable.^32–36 Our study extends these findings by identifying generativity and a structured schedule as key motivators for exergame participation. Given the challenges with adherence to exercise and cognitive training trials,^8,14 our findings also provide implications for increasing participation and retention among older adults in future exergame studies. For example, framing the study as a way to give back to the community and younger generations may increase one's motivation to participate. Upon enrollment, limiting frustration through the adaptive difficulty features and minimizing camera-tracking issues may increase participants' motivation to continue exergaming.

Overall, the barriers and facilitators reported in our focus group discussions can translate to other exergames and exercise studies among older adults. Researchers seeking to increase recruitment and retention while minimizing barriers among older adults in exergame studies can (1) ensure there is a social component to the game, whether through engaged study teams, peer referrals, or generativity, (2) create an immersive environment that allows players to progress at their own pace, (3) provide a fun and exciting way to be physically active, so much so that participants do not even realize they are exercising, (4) reduce frustration from technical issues or lack of level advancement, and (5) offer frequent rest breaks to ease fatigue or pain during gameplay.

Our findings align with SDT and support other interventions examining the value of generativity in promoting cognitive, physical, and social engagement.^51–55 Generativity was a common motivator to join the study, which supports the social relatedness component of SDT.¹⁸ Likewise, peer referrals arising as a motivator to join support the social relatedness component since participants often discussed their current levels, frustrations, and strategies for gameplay advancement with fellow residents and family members. Furthermore, the need for self-improvement reinforces the competence component of SDT, and personal curiosity as a motivator to join the study supports the autonomy component.

Feelings of accomplishment during gameplay reinforce the competence component, leading to residents wanting to complete the study. Participants also cited immersion during gameplay as a motivator for retention. This supports the competence axiom, such that residents were absorbed in gameplay and focused on mastering or learning different strategies to advance to the next exergame level. The exergame's immersive features increased players' motivation to keep coming back and improve their skills. The role of exercise as a motivator aligns with the autonomy component, where residents were self-determined to engage in “sneaky exercise.” Collectively, these findings may account for the high retention rates in the exergame study (93%) compared with other physical and cognitive activity interventions with older adults, which often report difficulties with retention and adherence.^7,14,16

One benefit of an inductive coding process is that unanticipated themes can emerge. We observed unexpected gender-based trends when examining motivators for retention and perceptions of the study team. These findings complement previous literature showing that men report higher levels of perceived obligatory commitment and rely more on competitive incentives to continue performing physical activities, while women prefer spending time with others and performing physical activities that involve supervision.^56,57 These findings will guide researchers and exergame creators as they design and implement exergame interventions specifically tailored to older adults.

Strengths

The exergame was well tolerated and enjoyed by our sample, which included individuals of varying ages, health conditions, and comorbidities (e.g., hypertension and arthritis). We also identified unique motivators for recruitment in men (e.g., upholding commitments, promoting autonomy), which can be used to recruit more men in exergame studies. We achieved 100% participation in our focus group discussions and thus ensured robust incorporation of participants' views into our analysis while minimizing selection bias.

Limitations

While the semistructured format was designed to stimulate discussion, it could have led participants to engage in groupthink. We attempted to reduce the potential for groupthink by carefully forming the focus groups and designing the interview guide to promote discussion and obtain individualized feedback. The uneven gender distribution of our sample (71% female) is also a limitation; however, this reflects the population of senior living facilities, which consists of ∼70% females, on average.⁵⁸ Our sample was mostly white and recruited from one senior living center. Future studies will benefit from recruiting more men and racial/ethnic minorities across multiple senior living centers to increase transferability.

Future directions

When recruiting older adults, researchers should leverage the desire for generativity by framing the study as a way to give back to the community. Self-improvement can be promoted through adaptive difficulty features appropriately scaffolded to mitigate frustration and structured gameplay schedules to support competence and autonomy. Peer referrals and engaged study teams can be encouraged to boost social relatedness. Exergame creators should ensure an enjoyable, immersive experience for older adults that promotes cognitive and physical activity and minimizes frustration. Researchers can attempt to reduce potential barriers to participation by (1) incorporating rest periods, (2) creating protocols that ensure participants can advance through levels while maintaining a challenge, and (3) optimizing camera tracking for users with various health conditions.

Conclusions

We assessed the motivators and barriers associated with older adults joining and remaining in a novel, 3D neuroanimation exergame study. Our findings align with SDT. Autonomy arose when users joined the study and reported that their actions alone controlled their gameplay performance and their decision to complete the study. Competence appeared from the desire to achieve something new, and residents were motivated to master the exergame and acquire new skills. Social relatedness emerged through peer referrals and regularly discussing experiences with friends, family, and the study team. Overall, exergaming satisfied the three psychological needs of SDT, which facilitated participants' intrinsic motivation to join and remain in the study. These findings will inform future efforts to develop enjoyable and sustainable exergames for older adults that promote positive health outcomes.

Footnotes

Acknowledgments

We would like to thank the SWIM participants who provided valuable and constructive feedback throughout the study. We would also like to thank the KATA team for their contributions to the “I Am Dolphin” exergame and Brightview Senior Living for allowing us to recruit participants and conduct the focus groups at their location.

Authors' Contributions

B.M.C. was responsible for the conceptualization (equal), investigation (equal), formal analysis (equal), writing and preparation of the original draft (lead), and reviewing/editing of the article (equal). B.F.D. was responsible for the conceptualization (equal), investigation (equal), formal analysis (equal), funding acquisition (supporting), and reviewing/editing of the article (equal). J.L.T. was responsible for the supervision (supporting), conceptualization (supporting), and reviewing/editing of the article (equal). K.D.M. was responsible for reviewing and editing of the article (equal). O.A. was responsible for reviewing and editing of the article (equal). J.W.K. was responsible for reviewing and editing of the article (equal). M.C.C. was responsible for the supervision (lead), conceptualization (supporting), funding acquisition (lead), and reviewing/editing of the article (equal).

Author Disclosure Statement

O.A. is the inventor of the “I Am Dolphin” exergame, and both J.W.K. and O.A. have equity in MindMaze, a company that may license it for commercial use. All other authors have no conflicts to disclose.

Funding Information

This work was supported by the National Institute on Aging Research Training in Age-Related Cognitive Disorders Training Grant [T32-AG027668 to B.M.C.]; and the Johns Hopkins Epidemiology and Biostatistics of Aging Research Fellowship [T32-AG000247 to B.M.C. and K.D.M.]. B.F.D. was supported by the Johns Hopkins University Malone Center for Engineering in Healthcare and School of Nursing Fellowship, and the Robert Wood Johnson Future of Nursing Postdoctoral Fellowship. The SWIM feasibility study was supported by the Johns Hopkins Roybal Center [P30-AG048773].

Supplementary Material

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