JMIR Publications

ABSTRACT

Background:

Cognitive impulsivity is a multi-faceted construct associated with symptom severity, functional impairment, and poor quality of life in eating disorders and mental ill-health. However, objective assessment of cognitive impulsivity is piecemeal and complex, with many assessment tools lacking psychometric evaluation and ecological validity. Further, validated assessment tools are rarely perceived to be engaging or meaningful by individuals who complete them, limiting their utility in research and forming a barrier to translation to clinical settings. Thus, though cognitive impulsivity predicts treatment engagement and outcomes, it is rarely assessed or addressed in a clinical context.

Objective:

In this study, we aimed to re-design and evaluate the Cognitive Impulsivity Suite (CIS), a validated gamified assessment battery of cognitive impulsivity, through user-centred co-design, agile game development, and user-centred evaluation. This collaborative study partnered researchers with individuals with lived experiences (LE) of eating disorders and commonly co-occurring mental ill-health, and game development experts.

Methods:

In a sequential mixed-methods design, we first defined user requirements, including guiding principles and specific design ideas, through inductive thematic analysis of data from two focus groups incorporating seven individuals with LE of eating disorders and commonly co-occurring mental health conditions (mean age 27.6; 4 women, 2 men, 1 non-binary), researchers, clinicians, and technology professionals. Agile game development was achieved through six week-long sprints, involving game developers and a play-testing team of researchers. During LE evaluation, we collected and analysed data from an expanded sample (n=18, mean age 30.5; 12 women, 3 men, 2 non-binary), using a pragmatic blending of qualitative and quantitative research methods. This included inductive and deductive thematic analysis of ‘thinking aloud’ data, descriptive statistics, and ANOVA tests of GUESS-18 surveys.

Results:

We co-designed guiding principles and ideas for aesthetics, story concepts, and game-play features, which closely aligned with leading theories of psychological well-being, clinical evidence concerning eating disorder recovery, and gamification frameworks. Qualitative evaluations of the new tool, CIS Papillon Park, showed user engagement and motivation were driven by opportunities for autonomy, personal accomplishment, and simulated interpersonal relationships, aligning with approaches to gamification based on self-determination theory. In quantitative evaluation, a mean score of 45.9 (72.9% [57.3-88.5]) showed CIS Papillon Park achieved sound overall user satisfaction according to the GUESS-18 composite scale, with subscale scores revealing strengths in usability, narrative, visual and audio aesthetics, and personal gratification.

Conclusions:

The contributions of this study are grounded in its integration of user-centred co-design and evaluation, agile game development, and theory-driven approaches to cognitive assessment and gamification, to redesign and evaluate a validated online task battery. The resulting CIS Papillon Park combines appealing aesthetics, gamification elements that address cognitive, emotional and social needs, and accessible playing experiences, which maximised user satisfaction and engagement while prioritising psychological safety. Next steps involve psychometric evaluation and dissemination.