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Developing and evaluating a gamified self-management application for inflammatory bowel disease using the ADDIE model and Sukr framework

BMC Medical Informatics and Decision Making volume 25, Article number: 11 (2025) Cite this article

Abstract

Background

The prevalence and chronic nature of Inflammatory Bowel Diseases (IBD) is a significant global concern. As the essential part of treatments approach, patient adherence to treatment protocols and self-management practices are crucial to = IBD management. Healthcare initiatives focused on chronic conditions are strongly needed to consider various aspects of gamification and how it can positively affect self-management.

Aim

The current cognitive study aims to develop a mobile application to integrate the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) instructional design model and elaborate on a gamification design based on the reputable Sukr Wheel framework.

Methods

The current study uses the ADDIE approach to integrate behavior change strategies derived from the self-management theory using the Sukr Wheel gamification (My IBD Buddy) framework on the Android platform.

Results

The final evaluation was conducted over 14 days. User satisfaction comprised 22 participants aged 20 to 64, all diagnosed with inflammatory bowel diseases. System usability was measured on a scale ranging from 50 to 100. The average usability score for the entire user group was 80.68, indicating a “good” level of satisfaction among the program users based on the ranking scale.

Conclusion

“My IBD Buddy” mobile application, equipped with gamification for IBD patients, enhances self-efficacy and self-management.

Peer Review reports

Introduction

Inflammatory Bowel Diseases (IBD) are globally known as prevalent and chronic gastrointestinal conditions [1]. As an essential part of a therapeutic approach, enhancing patient adherence to treatment protocols and self-management practices for IBD are of an paramount importance [2]. Given the advancements in technology and users’ reliance on mobile phones and mobile applications, the technology can effectively manage chronic diseases [3]. While the existing applications can facilitate disease management, they often lack certain motivational aspects [4]. Fortunately, several methods and processes hold promise for effective changes to user behavior and contribution to healthcare systems through gamification [5]. Gamification entails integrating gaming elements and mechanics into non-gaming contexts [6]. The tool has found widespread use in various domains, including healthcare, to facilitate interaction, behavior modification, and enhancing motivation [7].

Self-management, which enables people to continue functioning satisfactorily on a daily basis in spite of chronic illnesses [8], is crucial for improving the quality of life, lowering health care utilization, and lessening the burden of these conditions [9,10,11,12]. Making decisions, acting, and using resources maximally to actively participate in medical management, embrace new behaviors, and manage emotions are all examples of self-management [13]. Novel self-management interventions that appeal to the interests of young people who grew up in a digital age are currently needed [11, 12, 14].

Although there has been much praise for the effectiveness of mobile health apps as a low-threshold treatment delivery mechanism [15], there is little evidence to support the effectiveness of commercially available applications [16]. Gamification has been recognized as a promising approach to boost intervention engagement, which can lower attrition and enhance the desired treatment outcomes [17, 18]. Gamification is the process of changing processes, systems, services, goods, or organizational structures to provide game-like experiences [18]. The use of game elements in activities not typically associated with games is known as gamification. Despite being a subset and component of gamification in general, rewards and incentives are only used within the intervention and have no real-world or tangible economic value [19]. As a current trend in gamification research, customizing the game elements to the user’s profile can enhance their experience when interacting with a gamified system [20, 21].

Five gamification principles that are theory-driven and unifying were presented by the model of gamification principles for internet interventions. Regarding the use of gamification, these principles are stand-alone, implementable items [22]. Five distinct but connected constructs make up the model: feedback, visibility, supporting player archetypes, meaningful purpose, and meaningful choice. The Wheel of Sukr framework is used to gamify chronic illness self-management that blends game techniques, behavior modification strategies, and chronic illness self-management methods. Fun, esteem, growth, motivation, sustainability, socializing, self-representation, and self-management are the eight themes that make up the Wheel of Sukr, and there are several components in every theme as well [23].Furthermore, the Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model is known as a systematic instructional design (SID) model. It is a widely used model to develop electronic learning applications, and is made up of stages of analysis, design/development, implementation, and evaluation [24, 25]. Also, as scientifically proven, implementing the ADDIE approach is effective to develop instructional systems in organizing health interventions, health domains, and effective patient follow-up. Moreover, it is an efficient information transfer method in adult education which is extensively used to develop multimedia instructional content [26].

Given the significant annual toll that gastrointestinal diseases take, both directly [27,28,29] and indirectly [30,31,32,33], healthcare systems face numerous challenges in providing these patients with equitable and cost-effective therapeutic solutions [34]. In patients with IBD, specific metrics are particularly important, such as compliance and adherence [35]. The problem becomes more complex in patients with IBD, whose medical diet involves a combination of medical and psychological approaches and necessitate high-demand manipulations [34, 36, 37]. Mobile apps with gamification features would, therefore, be a promising remedy.

Notably, there is a sharp contrast between the large number of mobile health applications available for treating GI tract disorders and the dearth of reliable related research [38, 39]. Alongside potential risks like inadequate data protection policies, privacy violations, treatment prescriptions without informed consent, inappropriate information, inaccessibility in emergency situations, and data abuse, there is still a wide gap [40, 41].

Aim

The present study aims to describe the systematic developmental process of a mobile application that integrates the ADDIE instructional design and development model and applies the Sukr Wheel framework to design a gamification self-management system for patients with IBD.

Methods

The ADDIE model is part of the systematic instructional design (SID) family, and consists of five steps: Analysis (A), Design (D), Development (D), Implementation (I), and Evaluation (E). It is widely used for developing e-learning applications, enabling educators and instructional designers to create structured and effective learning experiences, and also allowing for continuous revisions during the educational material design process [42, 43],Evidence shows that the ADDIE approach is effective for developing educational systems in healthcare organization and patient follow-up [44,45,46]. Moreover, it serves as an effective method for information transfer in adult education and is extensively used for producing multimedia educational content [47]. Figure 1 shows the stages of the ADDIE framework as modified based on the present study.

Fig. 1
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Phases of the application development based on the ADDIE model

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The Sukr Wheel framework is a structure for gamifying the self-management systems of chronic diseases, which combines behavior change methods, gamification techniques, and chronic disease self-management strategies and comprises the following eight components: Fun, Esteem, Growth, Motivation, Sustainability, Socialization, Self-Representation, And Self-Management [48, 49]. The Sukr framework highlights the connection between gamification and behavior change methods.

Analysis

The first step in the ADDIE model is analysis which employs a comprehensive perspective towards system design. This step mainly aims to identify the features and general requirements of the system. It includes the designation of the current trends of self-management in IBD, extraction of properties, characteristics, and major features of proposed system along with elucidation of the educational content structure in case of IBD disorder. In this stage, for the purpose of analysis, evidence-based scientific literature review methods were used along with interviews with experts. To achieve this goal, the following steps were defined:

Extracting informational and supportive needs in patients with IBD

This step used a multi-phase approach, including a comprehensive review, expert opinions via the Delphi technique, and patient surveys to identify and prioritize the informational and supportive needs of IBD patients.

Reviewing existing technologies and applications on IBD self-management

A survey was conducted to evaluate the existing mobile applications for the self-care management of IBD. Relevant keywords were used to identify and extract the features of these applications, which helped make the right decisions on idea innovation and support features in each mobile application.

Identifying general requirements of a self-management system used by IBD patients

Based on the available scientific studies and the expert panel’s opinions, the main features of the system were extracted.

Design

During this phase, researchers focused on developing educational content and the conceptual design of a mobile application to support patients with IBD. They addressed the key questions about educational content presentation, the media used, and implementation of gamification techniques. Expert meetings were held with gastroenterologists, psychologists, nursing faculty, and specialists in human-computer interaction and medical informatics. The discussions aimed to incorporate self-management concepts into gamified scenarios, select appropriate educational media, and establish effective educational strategies. The planning involved defining the features, functionalities, and protocols necessary for IBD manaement. It included the following steps:

Designing educational content

The application content was meticulously developed and evaluated to impart knowledge on comprehensive skills to manage IBD. It encompassed topics such as an overview of IBD definition, diagnostic tools, pharmacological and non-pharmacological management, sexual relationships, fertility, and issues related to IBD in women, risk of colorectal cancer in patients with IBD, cosmetic surgeries in these patients, use of other medications, other viral and infectious diseases concurrently occurred in patients with IBD, complementary medicine, nutrition and nutritional supplements, preventive care, and lifestyle behaviors. The designed educational content was evaluated by experts and target population in several steps to ensure content validity and appropriate presentation. The panel of experts included five faculty member gastroenterol pathologist, a nutritionist, a clinical psychologist, a gynecologist, and two internal nursing specialists using Suitability Assessment of Materials (SAM) and Patient Education Materials Assessment Tool (PEMAT) [50].

Paper-based initial design (sketch) of system modules and system features

A paper-drawn wireframe was iteratively designed to enhance comprehensibility and define the application modules. This wireframe aimed to encapsulate the entire subsystem.

Designing gamification mechanics based on the Sukr framework

Based on the designed subsystems, the game elements rooted in the Sukr framework, have been crafted to align with the goals and objectives of the system and its audience.

  1. 1)

    Fun

Based on the fun component within the Sukr framework, challenges, competitions, point scoring, rewards, and badges for completing activities or advancing in the self-management system for IBD were extracted. However, in meetings with clinical experts and medical informatics professionals, the research team concluded that competition should not be linked with self-management tasks or patients’ medical test results. Rather, they should relate to the frequency of user interaction with the system. Therefore, the concepts for this component were designed based on this principle.

  1. 2)

    Self-management

To implement the self-management component in the Sukr framework for the IBD self- management system, a logbook was used, including symptom reporting, data visualization, alerts based on input symptoms, symptom monitoring, and feedback based on the input information.

  1. 3)

    Growth

Providing rewards and incentives, leveling up on the leaderboard, earning points, displaying progress, and defining habits and small goals are aspects that sre considered in this section to change behavior, empower the user, and achieve small goals and habits. These elements formed the basis of designing the growth component.

  1. 4)

    Motivation

The focus of design in this step was to create motivation for task completion using motivational techniques, including changing the user’s position on the leaderboard, earning points for completing tasks, and providing rewards or congratulations on task completion.

  1. 5)

    Socialization

Considering that peer support is essential in chronic illnesses, this aspect was also addressed within the Sukr framework. Therefore, this design focused on establishing interaction with peers through social networks and sharing status updates.

  1. 6)

    Esteem

To foster a sense of esteem and admiration for patients with IBD, elements such as the leaderboard, progress bar, level ups, and badge awards were designed. It encourages patients to manage their conditions effectively and positions them as role models for peers.

  1. 7)

    Self-representation

To ensure the element of independence, which is a critical need in self-management for chronic diseases, a customizable user profile was designed, incorporating gender-appropriate avatars and patients’ ability of setting their own goals and habits. Control over choices and activities can lead to patient empowerment.

  1. 8)

    Sustainability

Elements that stimulate the narrative theme, facilitate interaction, and remind users to engage in the app through user interaction were designed to achieve the goal of sustainability component.

Application naming, designing graphic/narrative elements and user interface

This step involved assigning a name to application, designing an application logo, and formulating scenarios for multimedia educational content. Separate story scenarios were developed for each content to facilitate animation creation.

Evaluating the user interface (UI) wireframe

High-fidelity screen layouts, rooted in Figma wireframes, were implemented, and rigorously tested for pixel sizes, proportions, and density on mobile phones.

Development

The results of analysis and design phases provided the knowledge necessary for the development stage. This stage was divided into two parts, development of prototype and testing and evaluation of prototype.

Development of a prototype to manage IBD: multimedia content and educational animations

The initial version of the gamified mobile application and the educational content, based on animations for user understanding, was developed for the Android operating system using Android Studio 2022.

Evaluation of the prototype for IBD management

Evaluation by a software specialist (alpha test)

In this step, alpha testing of the initial draft of prototype was done by the application development team. In fact, at this stage, the bugs that were not discovered in the previous stages were discovered and fixed. Moreover, this test allows the quality and performance of the application to be evaluated before release.

User interface prototype evaluation using the exploratory method

Upon approval of the prototype version, the user interface of prototype was evaluated using the heuristic usability method using Nielsen’s 10 heuristics [51] by usability experts with a background in medical informatics, health information management, or health information technology with experience in designing, developing and assessing mobile health applications and proficient in conducting exploratory evaluations. Studies show that three to five specialists can identify 74 to 87% of usability issues [51,52,53,54]. Therefore, this number of evaluators was suitable for a heuristic evaluation of our system’s user interface. The evaluators independently assessed the prototype using a standard form based on Nielsen’s 10 heuristic method [55], rating any discrepancies based on severity on a five-point severity scale (“No Problem,” “Minor Problem,” “Moderate Problem,” “Major Problem,” and “Critical Problem”), which corresponded to severity levels ranging from zero to four, respectively [56,57,58,59]. This step was done in four phases:

  • Phase 1: Preparation and independent evaluation

Each evaluator independently assessed different sections of user interface using Nielsen’s checklist (Suppl. Table 1) and documented their findings in a problem identification checklist. The validity and reliability of checklist had been previously confirmed in another study [60]. The problem identification form was used to precisely describe the identified issues and included a four-column table with the problem name, problem description, problem location, and violated usability principle. According to this method, evaluators were asked not to share their opinions with each other before completing the evaluation, as one evaluator might not detect a large number of issues, whereas various evaluators could identify a wide range of unique problems. Therefore, a more comprehensive result could be obtained after combining the evaluators’ findings.

  • Phase 2: Consolidation identified issues

The issues identified by the independent evaluators were combined, and after removing duplicates, they were compiled into a single list. This consolidated list was then distributed among the evaluators for final discussion and validation. Evaluators held online meetings via Skype to discuss the identified issues and ultimately reached a consensus on the final list of problems.

  • Phase 3: Severity rating of issues

During this phase, evaluators re-examined the system’s user interface and independently rated the severity of issues based on three criteria (Fig. 2), and they rated the severity of problem on a 5-point scale (Table 1).

Fig. 2
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Criterias for severity rating of issues

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Table 1 Classification of problem severity
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  • Phase 4: Categorization

The average severity of each identified issue was measured, and each usability problem was categorized based on its average severity into one of the five categories [61, 62]. The severity scale of problems based on average severity is as follows:

  1. 0.

    No Problem: Average severity 0–0.5

  2. 1.

    Cosmetic: Average severity 0.6–1.5

  3. 2.

    Minor: Average severity 1.6-2.5

  4. 3.

    Major: Average severity 2.6-3.5

  5. 4.

    Catastrophic: Average severity 3.6-4

Prototype evaluation by panel of experts

The revised version of the prototype was provided to a panel of experts (medical informatics specialists, gastroenterologists, and psychology faculty member). They were asked to use the application processes for one week and record their suggestions for potential improvements in consultation with the development team. Additionally, the clinical experts were asked the following questions:

  1. 1.

    Do you find the application easy to use?

  2. 2.

    Is there any aspect that you think needs to be improved?

  3. 3.

    What model of mobile phone did you use the application on?

  4. 4.

    Did the application fit well on your mobile screen?

  5. 5.

    Do you think the application adequately covers all self-management content?

Furthermore, the time spent using the application and any errors encountered were also recorded.

Moreover, the comprehensibility and applicability of all educational modules were independently assessed by five evaluators using Patient Education Materials Assessment Tool for Audiovisual materials (PEMAT-AV) checklist tool (Suppl Table 2). It consists of 13 items measuring understandability and 4 measuring actionability [63].

The research team thoroughly analyzed and evaluated stepwise suggestions, which resulted in the development of the second and third drafts. These were iteratively presented to experts until it was affirmed that no further changes were needed and no program-related errors were found.

Implementation

The identified problems were thoroughly examined and rectified by the technical team leading to the development of a new draft. Based on the feedbacks provided by experts, the final version was implemented, and delivered to the experts to ensure the resolution of potential errors and shortcomings.

Evaluation of the implemented version by field experts and target users (Beta test)

A beta version of the MY IBD Buddy was implemented after comprehensive consultation with a panel of field experts including gastroenterology subspecialists, members of psychology and nursing faculties, and medical informatics academic members. Then, ten patients with IBD used the application for one week and reported possible shortcomings. The reported issues were addressed in consultation with the team of developers. When patients and clinical experts suggested no further changes, the finalized program was presented.

Evaluation of the final version user interface using the exploratory method

The final version was also assessed for user interface wireframe by usability development experts through an exploratory method. They evaluated and ranked the cases that did not comply with the afore-mentioned principles in terms of severity and deterioration on a 5-point scale [57, 64, 65]. Data collection was done through a standard form (Suppl Table 2) based on the method proposed by Jakob Nielsen’s 10 usability heuristics evaluation [55].

Evaluation of user satisfaction

Having completed the implementation phase, the application was assessed by target users via a System Usability Scale questionnaire (SUS) (Suppl Table 3). It consists of 10 items rated on a 5-point Likert scale ranging from strongly disagree (1 point) to strongly agree (5 points). This scale is considered a valid, reliable, and sensitive tool to measure user satisfaction with the system [66]. The final score would range between 0 and 100, a higher score showing a better usability potential of system. A score ≤ 50 is considered as not acceptable, > 68 as moderately acceptable, and ≥ 85 as highly acceptable [67,68,69]. The questionnaire was submited to patients, who visited specialty clinics, after considering certain inclusion and exclusion criteria. The inclusion and exclusion criteria are shown in Table 2. The sample size calculation was based on the number of participants according to the problem identification percentage curve [70,71,72]. According to this study, at a confidence level of 90%, approximately 22 subjects were required, and at a confidence level of 80%, approximately 15 subjects were needed. Therefore, the sample size for this study was estimated at 22 at a 90% confidence level.

Table 2 Inclusion and exclusion criteria
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The participants used the application for 14 days for at least 15 min a day. The patients were in close relationship with the technical team for any required issue or help. Following this time, they filled out the questionnaire in a web-based platform.

Results

Analysis

Extracting informational and supportive needs in patients with IBD

First, the guidelines of the American Gastroenterological Association, the American College of Gastroenterology, the American Crohn’s and Colitis Foundation, the European Crohn’s and Colitis Organization, and the consensus guidelines of the British Gastroenterology Association were reviewed. Similarly, a comprehensive literature review was made of the important components and indicators used in the thematic separation of educational content. The information and support needs of patients with IBD were extracted from a literature review of four databases (PubMed/Medline, CINAHL, APA PsycInfo, Psychology and Behavioral Sciences Collection, APA PsycArticles, and ProQuest). The search was done using the related words in a period of 22 years. Two key journals in IBD were manually searched [73, 74]. A total number of 75 studies on the evaluation of information and support needs of patients with IBD were examined, and in this study, 55 information needs and 34 support needs were extracted. The most important information needs of patients in this study were “nutrition/diet information”, “drugs and side effects information” and “treatment/treatment and side effects information” and “patient education” was one of the most important support needs of IBD patients [73, 74].

Then, in order to determine the important information and support components from experts’ point of view towards IBD, the Delphi technique was used [75]. Having conducted three rounds of Delphi, “Drug and treatment information and side effects” and “Skills to deal with and adapt to the disease” were, respectively, among the most important information and support needs identified from the experts’ point of view. Finally, in order to determine the priorities of information needs and support for patients with IBD, exploratory factor analysis and confirmatory factor analysis were performed [76] using the opinion of 521 patients, based on which 25 information needs and 15 support needs were identified. The most important information need from the patients’ point of view was found to be “nutrition/diet information” and the most important support need was “providing multidisciplinary services”.

Reviewing existing technologies and applications on IBD self-management

Mobile applications for IBD self-care available on Android and iOS platforms were reviewed to determine innovation and features supported in each application. The keywords used were “IBD”, “Crohn’s”, “ulcerative colitis” and “Colon”. Seven mobile applications were selected and downloaded based on the latest versions or updates in Google Play and App Store, and their information was recorded. Most mobile phone applications that were reviewed focused on tracking intestinal symptoms or teaching general information about IBD. None of the native or non-native mobile applications focused on teaching all aspects of disease, mental health and disease surveillance with gamified techniques. Also, how educational materials were presented in the existing applications was based on recorded videos or long and boring texts. It was decided to provide educational content in a multimedia format, including a combination of short and beautified texts with related images, sounding on the texts, and creating related animations based on educational concepts.

Identifying general requirements of a self-management system used by IBD patients

Based on the available relevant scientific studies and the results of steps 1 to 2, a list of general features and modules considered for the system was prepared and in an online and face-to-face meeting with seven experts including two adult gastroenterologists, one clinical psychologist, two experts affiliated with the nursing faculty, and two medical informatics specialists were examined and surveyed. Finally, the main features of the system were extracted. Interview sessions were held in three universities of medical sciences in Iran. Some interviews were conducted on Skype due to the distance. The focus at this stage was on the content of application for teaching self-care skills to IBD patients and how to present it.

Design

Considering scientific evidence, the decision-making process in the design phase required the participation of at least 14 specialists [77]. A total number of 51 online and face-to-face meetings were held with two experts in gastrointestinal and liver diseases, a clinical psychology, two nursing faculty members, five human-computer interaction specialists (UX/UI designers and mobile app developers), three medical informatics experts, and a game design expert.

Designing educational content

The mobile app content was designed to provide patients with information on comprehensive IBD management skills [50]. The researchers developed a training file in 12 chapters for the mobile application to cover the relevant content. The educational content designed to ensure the suitability of text content for the mobile application was evaluated by experts and the target group. The results of evaluation showed that the self-care educational materials for inflammatory bowel disease patients are valid in content and appearance.

Paper-based initial design (sketch) of system modules and system features

At this stage, a low fidelity wireframe was designed to better understand the generalities and specify the application modules. In this wireframe, the generalities of all subsystems were specified. This step was repeatedly reviewed and modified by the panel of specialists and finally its final version was designed. Figure 3 shows the initial home page design.

Fig. 3
figure 3

Low-fidelity wireframe of the main page of the application

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Designing gamification mechanics based on the Sukr framework

Based on the designed subsystems, the elements of game were developed according to the Sukr framework to match the goals and objectives of system and its audience. Attempts were made to include all elements of cycle and their links to the system modules (Table 3).

Table 3 Mapping gamification elements to subsystems of application
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Application naming, designing graphic/narrative elements and user interface

Story scenarios for making animations were presented separately for each content. Also, the logo of application was first designed on paper by the main researcher of project and after the approval of other members of the research team, after three modifications, the final version of logo was designed in Photoshop. The application logo considers all aspects of the lifestyle of IBD patients (Fig. 4).

Fig. 4
figure 4

Application logo

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Evaluating the user interface (UI) wireframe

Based on the results of the previous steps, the user interface high-fidelity wireframe was designed using Figma. All designs underwent scrutiny and evaluation by five UI/UX specialists, three medical informatics specialists, and a game design expert.

Development

Development of a prototype to manage IBD: multimedia content and educational animations

A prototype mobile application based on the operating system named “MY IBD Buddy” was developed using Android Studio2022. The multimedia content, such as story-based animations, was designed to effectively convey the educational content particularly in a stress-free context without background noise supported by a calming background music. The leading researcher used video scribe software to develop these animations.

Evaluation of the prototype for IBD management

Evaluation by a software specialist (alpha test)

In this stage, five software experts in the development team, including senior developers and testing experts, tested and evaluated the initial version of sample to ensure the system performance and find possible errors. The main identified bugs were quickly fixed and resolved.

User interface prototype evaluation using the exploratory method

The exploratory evaluation of user interface wireframe showed each feature received an average score of 3.6–08. These scores indicated the presence of minor to severe usability problems. The evaluation, carried out by five assessors, identified 105 issues in ease use. Having consolidated and summarized these issues, 50 unique problems were found. Among these, the most severe problem was associated with the principle of “free range of user action and control over the system,” while the least severe pertained to the principle of “compatibility between the system and the real world” (Table 4). Furthermore, any identified applicability defect was rectified during this stage. The overall mean scores for comprehensibility ranged from 94.33 to 97.5, and for feasibility, the range was between 97.99 and 100. Hence, the second and third versions of application were developed accordingly.

Table 4 Exploratory evaluation scoring of MY IBD Buddy user interface based on Nielsen’s principles (alpha)
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Prototype evaluation by panel of experts

Having fixed the functional defects and identified bugs, the system was evaluated by the field experts and their suggestions were used. Table 5 shows the experts’ main suggestions, including changes to the menu titles, adjustments to the organization of educational content, and modifications to the presentation of content within the mental health section. Also, all educational modules were evaluated separately by the same five evaluators using the PEMAT-AV tool in terms of comprehensibility and applicability. The mean overall scores for comprehensibility ranged between 94.33 and 97.5, and the overall mean scores for feasibility ranged between 97.99 and 100. Then, the proposals were evaluated and analyzed by the research team, and the next versions were developed and recurrently provided to the experts so that they found no errors left. The characteristics of usability expert participants are shown in Table 6.

Table 5 Experts’ summary opinions of the prototype MY IBD Buddy application
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Table 6 Characteristics of the usability expert’s participants
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Implementation

Evaluation of the implemented version by field experts and target users (Beta Test)

The final version of the MY IBD Buddy program included eight modules comprised of 1- login and registration page, 2- patient profile (a clinical disease history, drug and dietary allergies, automatic BMI calculator, smart weight recommendation, and a summary of the patient status including medications, tests, and tracking disease-related symptoms as tabulated), 3- My symptom monitoring and management with five sub modules: interaction monitoring (assessing satisfaction with the application), psychological monitoring (monitoring anxiety and depression status, quality of life, and disease self-efficacy), medical and clinical monitoring (monitoring disease activity using disease activity assessment indices and providing feedback to patients based on input symptoms, monitoring fecal calprotectin levels, and treatment adherence), educational monitoring (assessing disease-related knowledge), and nutritional monitoring (food diary). There are also other features such as 4- My medications (managing medications, viewing drug information, and proper drug usage methods, medication reminders, checking drug interactions, authorized and unauthorized drugs for IBD patients, viewing authorized and unauthorized drugs during pregnancy and breastfeeding for patients with IBD), 5- My Tests (manual and visual entry of blood, feces, and colonoscopy tests, interpretation of blood and fecal test results, saving tests), 6- Colonoscopy Readiness Program (a list and electronic form of pre-colonoscopy tasks, setting reminders, comprehensive pre- and post-colonoscopy instructions), 7- My Education (self-management concepts taught in 12 separate chapters, where the user, after viewing each chapter, must answer educational questions related to that chapter, gamified and presented in a narrative scenario, education on mental health concepts, relaxation and mindfulness techniques). Moreover, 8- My Support (interaction and communication with gastroenterology and mental health specialists, interaction with peers through a discussion forum) is another feature of the application (See supplementary file1. Suppl Figs. 1,2).

Evaluation of the final version user interface using the exploratory method

During the exploratory evaluation of user interface wireframe, each feature received an average score of 1 to 2.4, indicating a minor to moderate usability problem (Table 7). These problems were resolved by the technical team. Figure 5 compares the identified errors in the alpha and beta versions.

Table 7 Exploratory evaluation scoring of MY IBD Buddy user interface based on Nielsen principles (beta)
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Fig. 5
figure 5

MY IBD Buddy user interface evaluation based on Nielsen’s alpha and beta principles

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The reported errors and problems reported by 10 patients were resolved as well. At the end, the final version was released.

Evaluation of user satisfaction

Twenty two participants were diagnosed with IBD. They were aged 20 to 64 years, and evaluated the user satisfaction of application. The system usability was evaluated on a scale ranging from 50 to 100. The average usability score for the entire user group was 80.68, indicating a “good” level of satisfaction among the application users based on a ranking scale (Figs. 6 and 7). Table 8 provides a more detailed description of the participants’ demographic features.

Fig. 6
figure 6

System Usability Score (SUS)

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Fig. 7
figure 7

System Usability Score (SUS)

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Table 8 Demographic characteristics of the participants
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Discussion

The current study aimed to develop the first-ever remote medical system using gamification techniques to empower all subgroups of patients with inflammatory bowel diseases (IBD). A wide range of applications and communication technologies are used in the remote healthcare management of IBD, such as remote monitoring, remote consultation, and remote education. One purpose of the application is remote monitoring, including diagnosis, monitoring, treatment, patient education, or remote follow-up.

In the present research, the ADDIE model was used [78, 79] to ensure that the learning process was well-organized, structured, and successful by providing a methodical and adaptable approach to instructional design. Training developers and instructional designers had historically employed the ADDIE model as a generic process [25, 80, 81]. A methodical approach to instructional development is frequently described by the five stages of the ADDIE model, which stand for Analysis, Design, Development, Implementation, and Evaluation [82, 83]. This model aims to create instructional designs and learning resources more effectively and efficiently. It can also apply to the development of learning strategies, learning methods, media, and instructional materials, among other types of products [84, 85].

A comprehensive study of challenges in mobile applications for self-management in patients with IBD in 2018 revealed that only 6% of smartphone users used mobile applications for disease management and self-education [38]. Hence, the low usage of certain systems may be for several reasons, such as unattractive design, poor user interaction, and, most importantly, insufficient understanding of the needs of patients with IBD. A review emphasized the challenges faced by mobile applications for self-management of IBD patients, showing that a minimal number of smartphone users among IBD patients used mobile applications for disease management and education [38].

Therefore, the following were considered in designing this application: a precise recognition of patient needs, use of strategies to enhance attractiveness, and increased adherence to application through gamification based on the Sukr framework. The study outlines the development process of an application aimed at teaching psychological aspects such as stress and anxiety control, to monitor patient physical and mental status. The educational content of this program has been developed and validated by the research team [50]. Modules for monitoring physical and mental status and reporting were included in the program, acknowledging the broad range of issues related to IBD in each individual [86,87,88].

The monitoring module focuses on stress and depression, quality of life, knowledge, and disease activity to identify the status of IBD. The research emphasizes the importance of providing accurate, appropriate, and sufficient information, considering different formats such as video, audio, and text in the educational module, and incorporating gamification techniques to enhance motivation, engagement, and user satisfaction.

The development process also involved a multidisciplinary team of health experts, medical informatics specialists, and IBD patients. The application, named “MY IBD Buddy,” was developed based on the ADDIE instructional design model and the Sukr gamification framework. The evaluation results were promising, proving the validity, reliability and usability of the proposed application.

Moreover, the present study highlights the collaborative development process with a multidisciplinary team and patients, considering their needs and expectations. A lack of user and healthcare professional participation in developing digital systems in healthcare has been perceived as a limitation. The study attempts to include multimedia content in mobile applications and underscore the importance of integrating gamification to enhance user motivation and satisfaction.

The usability evaluation of MY IBD Buddy application was done by usability testing experts and the target population in three stages. The target group provided an average score of 80.68 to the system, surpassing the minimum score of 68 indicating a good satisfaction with the application on a ranking scale [89]. Participants’ feedback raised concerns that are easily soluble to enhance the usability of MY IBD Buddy [90]. Developers should consider participant feedback to increase the usability of a smartphone application. High usability contributes to the increased or decreased productivity, satisfaction, and acceptance by end-users. The development stages in the study successfully increased the satisfaction and acceptance of end-users, resulting in a usability score above the average for the initial prototype.

The OshiHealth app is designed for patients with gastroesophageal reflux disorder (GERD), celiac disease, IBD, irritable bowel syndrome, and other chronic gastrointestinal (GI) disorders. Through the application, users can message and have virtual visits to the Oshi Health team. In addition to using weekly surveys to monitor their IBD symptoms and well-being, users also integrate data from wearables and fitness devices and get push notifications to help them stay on track with their goals [91]. The Crohn’s & Colitis Foundation created the app GI Buddy, which lets users keep track of their food intake, activity, medications, and IBD symptoms. It also lets users schedule reminders for their doctor’s appointments. Moreover, there is a community feature that allows users to interact with other IBD patients [91].

Users of the paid symptom tracking app Colitis Diary can log their bowel movements, symptoms, and potential triggers using a calendar format, sleep, weather, nutrition, vital signs, drugs, medical events and tests/procedures, exercise, and free text notes. Indeed, there is a trending module that shows to users the triggers and contributing factors to their symptoms [91]. ColitisTracker is a free substitute that tracks symptoms, prescriptions, and free text notes in a calendar format. MyIBDCare facilitates the tracking of bowel movements, appointments, flare-ups, symptoms, and medications. It offers courses for education on sleep, medication, and exercise, as well as a newsfeed about IBD [91, 92].

Another study sought to evaluate a newly developed 16-week digital health program for patients with IBD, examining participant engagement, preliminary effectiveness, and the impact on participants’ energy levels (fatigue), stress, and sleep quality. The developers indicate that completing treatment may significantly improve patients’ reported stress and energy levels in a real-world context and support the viability of a digital health program for IBD patients [92]. As a novel application, IBDMonitor enables patients to meticulously document important information, including medication use, symptoms, lifestyle, and physiological, pathological, and everyday events. These patient-generated reports are made available to medical professionals in real-time, allowing them to make timely treatment adjustments [93].

Induction and maintenance of remission, symptom control, and inflammation management are the main goals of IBD treatment [93]. Patients who used digital interventions reported feeling more secure about their condition, more involved in their own care plans, and better cared for outside the hospital or clinical setting, according to a study on the effects of smartphone interventions on long-term health management of chronic diseases [92]. Also, digital interventions have been linked to increased convenience, productivity, and efficiency as well as decreased health care costs [92]. Engaging patients in their own healthcare is made possible by mobile applications through a variety of ways including virtual visits, care team messaging, surveys and questionnaires, symptom tracking and analysis, data integration from wearable devices, push notifications for reminders, forums, a community platform, newsfeed for research updates, educational modules, and public restroom locators [91].

A user-friendly interface, survey fatigue, and careful analysis of the most pertinent data points are just a few of the many factors that should be taken into account in designing any mobile application or technology platform [91]. Many web-based and smartphone applications have been created for mHealth at this time. Some of these have even undergone clinical research, but their use is still limited and irregular. To better understand how mobile health affects clinical outcomes and to determine the factors influencing the use of mobile health in our healthcare systems, more research or thorough understanding is required which justifies the current investigation.

Gamification concepts, also known as serious games, are a major trend in the development of mobile learning apps. These concepts use game and enjoyable elements to motivate and entice learners. The main goal of a serious game is to help the player achieve a learning goal in an enjoyable way, with the learner having the locus of control [91]. Gamification is a growing aspect of mHealth applications that has only recently been used to enhance self-management practices [93]. One emerging innovative practice is the use of gamification design principles to mHealth applications. Therefore, it is essential to talk about design considerations. The effectiveness of mHealth applications that use gamification mechanics is currently not well supported by empirical data.

Limitations

Despite the strengths of the present study, several limitations should be acknowledged. Although, according to some research, this ample size in usability testing can detect over 80% of issues, the number of participants in this evaluation may still need to be increased. Additionally, the follow-up duration might need to be increased due to the great variation in patients’ physical and mental conditions. Therefore, future research is recommended to consider a larger sample size and a longer follow-up. Furthermore, the current version of application has been developed only in Persian and for the Android operating system, excluding iPhone users. It is suggested that future application versions be developed to include support the iPhone platform and in potentially other languages to make it better available to a broader range of users.

Recommendations

The long-term use of “My IBD Buddy” app is recommended for routine disease management and evaluation of its effectiveness in clinical and non-clinical outcomes is currently designed as a protocol [94]. Additionally, providing an English version and the possibility of using the app by iPhone users should be considered in future versions.

Conclusion

The present study detailed on developing and evaluating a self-management mobile application, My IBD Buddy, using gamification techniques for patients with IBD. The findings showed that employing a standalone mobile application based on a standard educational model with gamification techniques can enhance patient self-efficacy and self-management skills. Moreover, the design and development of My IBD Buddy can serve as a practical and realistic model for the development of mobile health applications. The application, developed in Persian, proved satisfactory to users and increased their self-management awareness and daily condition control. User satisfaction correlates positively with meeting the needs of patients with IBD and customizing programs. The complex characteristic of IBD and the diverse range of symptoms in each individual make it impossible to develop a comprehensive program to cover all aspects of IBD self-management. Thus, developing specific applications for different aspects of IBD self-management or considering a range of capability levels in patients with IBD may be a more practical and constructive strategy. Encouraging individuals with IBD to use self-management programs can be achieved through tailored app development for various dimensions of IBD self-management. As the application development evolves, the application of interest can serve as a starting point for future research to improve self-management programs for patients with IBD.

Data availability

The datasets utilized and/or analyzed in the present study can be obtained from the corresponding author upon making a reasonable request.

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Authors and Affiliations

  1. Medical Informatics Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 13944-91388, Iran

    Narges Norouzkhani, Saeid Eslami & Hamed Tabesh

  2. Student Research Committee, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran

    Somaye Norouzi

  3. Population, Family and Spiritual Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

    Mahbobeh Faramarzi

  4. Internal Medicine Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 13944-91388, Iran

    Ali Bahari

  5. Internal Medicine Department, Babol University of Medical Sciences, Babol, 47176-47754, Iran

    Javad Shokri Shirvani

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  7. Hamed Tabesh
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Contributions

NN, SN, MF,AB,JSH,SE and HT conceptualized, designed, and conducted the studysis. NN drafted the manuscript with signifcant intellectual input from SN, and HT assisted with revising the article. All authors approved the fnal version of the manuscript.

Corresponding author

Correspondence to Hamed Tabesh.

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Ethics approval and consent to participate

This study followed the Helsinki Declaration and Ethics Publication on Committee (COPE). In addition, the present study was approved by the research ethics committee of the Mashhad University of Medical Sciences (#IR.MUMS.REC.1400.230). The researcher obtained all participants' verbal and written informed consent before conducting the study. It is important for participants to feel comfortable and secure when participating in a study. Ensuring that their data are exclusively analyzed by the researchers and that they retain the right to withdraw from the study at any time is a great way to establish trust and maintain ethical research practices.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Norouzkhani, N., Norouzi, S., Faramarzi, M. et al. Developing and evaluating a gamified self-management application for inflammatory bowel disease using the ADDIE model and Sukr framework. BMC Med Inform Decis Mak 25, 11 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12911-024-02842-3

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12911-024-02842-3

Keywords

BMC Medical Informatics and Decision Making

ISSN: 1472-6947

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