Abstract :
Tuberculosis (TB) treatment in children requires long-term adherence to anti-tuberculosis drug therapy (OTD), which often leads to boredom and refusal to take medication. Non-adherence to treatment can increase the risk of treatment failure, relapse, and drug resistance. This study proposes a mobile health-based gamification framework designed to improve treatment adherence in pediatric TB patients by integrating game elements into the therapy monitoring process. The gamification framework was developed using a user-centered approach by identifying factors influencing adherence through interviews with pediatric patients, medication supervisors (PMOs), and healthcare professionals. Aspects of medication adherence were mapped using the Morisky Medication Adherence Scale (MMAS-8) and classified into dimensions of behavior, motivation, knowledge, and memory. User characteristics were analyzed using the HEXAD gamification user types questionnaire to determine the dominant user type. The analysis showed that the dominant user type in pediatric TB patients was the player type, followed by the socializer type and the free spirit type. Based on these findings, a gamification framework was designed that includes points, rewards, challenges, reminders, and progress visualization mechanisms. Expert evaluation using the After-Scenario Questionnaire (ASQ) demonstrated high levels of satisfaction and confidence that the proposed framework has the potential to improve treatment adherence. This study demonstrates that mobile health-based gamification design has strong potential as a behavior change strategy to support long-term pediatric TB treatment.
Keywords :
Gamification, Mobile Health, Pediatric Patients, Treatment Adherence, TuberculosisReferences :
- Alzghoul, B. (2024). The Effectiveness of Gamification in Changing Health-related Behaviors: A Systematic Review and Meta-analysis. The Open Public Health Journal, 17(1). https://doi.org/10.2174/0118749445234806240206094335
- Duarte, R., Munsiff, S. S., Nahid, P., Saukkonen, J. J., Winston, C. A., Abubakar, I., Acuña-Villaorduña, C., Barry, P. M., Bastos, M. L., Carr, W., Chami, H., Chen, L. L., Chorba, T., Daley, C. L., Garcia-Prats, A. J., Holland, K., Konstantinidis, I., Lipman, M., Mammen, M. J., … Wortham, J. M. (2025). Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline. In American Journal of Respiratory and Critical Care Medicine (Vol. 211, Issue 1, pp. 15–33). American Thoracic Society. https://doi.org/10.1164/rccm.202410-2096ST
- Eaton, C., Vallejo, N., McDonald, X., Wu, J., Rodríguez, R., Muthusamy, N., Mathioudakis, N., & Riekert, K. A. (2024). User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review. In Journal of Medical Internet Research (Vol. 26). JMIR Publications Inc. https://doi.org/10.2196/50508
- Ferreira, I. B. B., Menezes, R. C., Araújo-Pereira, M., Rolla, V. C., Kritski, A. L., Cordeiro-Santos, M., Sterling, T. R., Staats, C., Amorim, G., Trajman, A., & Andrade, B. B. (2025). Effects of missed anti-tuberculosis therapy doses on treatment outcome: a multi-center cohort study. The Lancet Regional Health – Americas, 48. https://doi.org/10.1016/j.lana.2025.101162
- Khaldi, A., Bouzidi, R., & Nader, F. (2023). Gamification of e-learning in higher education: a systematic literature review. In Smart Learning Environments (Vol. 10, Issue 1). Springer. https://doi.org/10.1186/s40561-023-00227-z
- Leddy, A. M., Jaganath, D., Triasih, R., Wobudeya, E., Bellotti De Oliveira, M. C., Sheremeta, Y., Becerra, M. C., & Chiang, S. S. (2022). Social Determinants of Adherence to Treatment for Tuberculosis Infection and Disease Among Children, Adolescents, and Young Adults: A Narrative Review. Journal of the Pediatric Infectious Diseases Society, 11, S79–S84. https://doi.org/10.1093/jpids/piac058
- Lolong, D. B., Aryastami, N. K., Kusrini, I., Tobing, K. L., Tarigan, I., Isfandari, S., Senewe, F. P., Raflizar, Endah, N., Sitorus, N., Pangaribuan, L., Simarmata, O. S., & Ariati, Y. (2023). Nonadherence to anti-tuberculosis treatment, reasons and associated factors among pulmonary tuberculosis patients in the communities in Indonesia. PLoS ONE, 18(8 August). https://doi.org/10.1371/journal.pone.0287628
- Mosleh, S. M., Khraisat, A., Shoqirat, N., & Obeidat, R. (2024). Using the Health Belief Model to Predict Self-Care Behaviors Among Patients With Cardiovascular Disease Post COVID-19 Pandemic: A Perspective From the United Arab Emirates. SAGE Open Nursing, 10. https://doi.org/10.1177/23779608241293667
- Omar, A. A., Mohamoud, J. H., Adam, M. H., Garba, B., Hassan, M. A., Mohamed, I. A., & Adam, Z. M. (2024). Assessment of Non-Adherence to Anti-TB Drugs and Associated Factors Among Patients Attending TB Treatment Centers During COVID-19 Pandemic in Mogadishu, Somalia: A Cross-Sectional Study. Infection and Drug Resistance, 17, 3879–3890. https://doi.org/10.2147/IDR.S468985
- Riegel, B., Jaarsma, T., Lee, C. S., & Strömberg, A. (2019). Integrating symptoms into the middle-range theory of self-care of chronic illness. In Advances in Nursing Science (Vol. 42, Issue 3, pp. 206–215). Lippincott Williams and Wilkins. https://doi.org/10.1097/ANS.0000000000000237
- Ryan, R. M., & Deci, E. L. (2020). Intrinsic and extrinsic motivation from a self-determination theory perspective: Definitions, theory, practices, and future directions. Contemporary Educational Psychology, 61. https://doi.org/10.1016/j.cedpsych.2020.101860
- Sardi, L., Idri, A., & Fernández-Alemán, J. L. (2017). A systematic review of gamification in e-Health. In Journal of Biomedical Informatics (Vol. 71, pp. 31–48). Academic Press Inc. https://doi.org/10.1016/j.jbi.2017.05.011
- Subirats, L., Nousiainen, T., Hooda, A., Rubio-Andrada, L., Fort, S., Vesisenaho, M., & Sacha, G. M. (2023). Gamification Based on User Types: When and Where It Is Worth Applying. Applied Sciences (Switzerland), 13(4). https://doi.org/10.3390/app13042269
- Tian, L., Weng, Y., Xu, A., Chen, Y., & Tang, J. (2024). Effect of behavior modification combined with health belief model education on adherence to skin moisturizing care in patients with psoriasis vulgaris. Scientific Reports, 14(1). https://doi.org/10.1038/s41598-024-83647-2
- Tondello, G. F., Wehbe, R. R., Diamond, L., Busch, M., Marczewski, A., & Nacke, L. E. (2016). The gamification user types Hexad scale. CHI PLAY 2016 – Proceedings of the 2016 Annual Symposium on Computer-Human Interaction in Play, 229–243. https://doi.org/10.1145/2967934.2968082
- (2024). Global Tuberculosis Report. https://www.who.int/publications/i/item/9789240101531
- Wu, Z., Lu, L., Li, Y., Chen, J., Zhang, Z., Ning, C., Yuan, Z., Pan, Q., Shen, X., & Zhang, W. (2023). Effect of mobile health reminders on tuberculosis treatment outcomes in Shanghai, China: A prospective cohort study. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.923319

