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Pengunaut Trainer: A Playful VR App to Prepare Children for MRI Examinations -In-depth Game Design Analysis

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We present the concept, design, and evaluation of a playful mobile virtual reality (VR) app for children to reduce anxiety and stress during MRI examinations. The Pengunaut Trainer aims to help children to familiarize themselves with the medical environment so that they can be examined without fear, rendering sedation unnecessary. The young patients learn about the procedure and train to lie still during a virtual MRI scan. We conducted a clinical trial focusing on an in-depth analysis of the game design. 29 children trained over 14 days on average before their MRI examination. The participants were impressed by the VR experience and motivated to train. They reported high levels of immersion and positive affect. Anxiety and negative feelings towards the upcoming MRI examination were significantly reduced after the training period. Moreover, our results indicate that the Pengunaut Trainer could be effective in reducing anxiety and stress during the MRI scan. Our results and the positive feedback from parents and medical professionals prove the validity of our approach.
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Pengunaut Trainer: A Playful VR App To Prepare Children
for MRI Examinations – In-depth Game Design Analysis
Stefan Liszio
University of Duisburg-Essen
Entertainment Computing
stefan.liszio@uni-due.de
Linda Graf
University of Duisburg-Essen
Entertainment Computing
linda.graf@uni-due.de
Oliver Basu
University Hospital Essen
Clinic for Pediatrics III
o.basu@uk-essen.de
Maic Masuch
University of Duisburg-Essen
Entertainment Computing
maic.masuch@uni-due.de
ABSTRACT
We present the concept, design, and evaluation of a playful mo-
bile virtual reality (VR) app for children to reduce anxiety and
stress during MRI examinations. The Pengunaut Trainer aims
to help children to familiarize themselves with the medical
environment so that they can be examined without fear, ren-
dering sedation unnecessary. The young patients learn about
the procedure and train to lie still during a virtual MRI scan.
We conducted a clinical trial focusing on an in-depth analy-
sis of the game design. 29 children trained over 14 days on
average before their MRI examination. The participants were
impressed by the VR experience and motivated to train. They
reported high levels of immersion and positive affect. Anxiety
and negative feelings towards the upcoming MRI examination
were significantly reduced after the training period. Moreover,
our results indicate that the Pengunaut Trainer could be effec-
tive in reducing anxiety and stress during the MRI scan. Our
results and the positive feedback from parents and medical
professionals prove the validity of our approach.
Author Keywords
Virtual Reality; Magnetic Resonance Imaging; Anxiety
Reduction; Patient Preparation; Applied Games; Clinical Trial
CCS Concepts
Social and professional topics Children; Human-
centered computing
Virtual reality;
Applied computing
Computer games; Health informatics;
INTRODUCTION
Magnetic resonance imaging (MRI) is a safe and rapidly devel-
oping diagnostic procedure. MRI is an examination procedure
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Interaction Design and Children (IDC ’20), June 21–24, 2020, London, United
Kingdom
© 2020 Copyright held by the owner/author(s). Publication rights licensed to ACM.
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DOI: 10.1145/3392063.3394432
Figure 1. The mini-game "MRI Controller" is based on play therapy
concepts. Players can perform an MRI examination on a companion
before having a virtual MRI scan themselves.
with low side effects and is now one of the standard procedures
in radiology. As a painless examination method that does not
use X-rays or radioactive rays, but a strong magnetic field and
radio waves, MRI is particularly suitable for the diagnosis
of children. Nevertheless, many patients, both children and
adults, experience the MRI examination as extremely threat-
ening [32, 17]. The limited space of the bore, the noise, and
the impossibility to move are the most frequently mentioned
anxiety-inducing factors. Some patients describe their MRI
experience as a feeling of being "abandoned" or "buried alive"
[15]. Children often react with strong defensive reactions like
crying or fidgeting. Physical movement, however, impairs the
imaging because it produces motion artifacts which hamper
the diagnosis. Moreover, a lack of cooperation of anxious
children may delay the examination or even cause premature
termination. This is distressing for the patient, as the already
frightening examination has to be repeated. Furthermore, it
causes effort and costs for the hospital. For this reason, chil-
dren are often prepared with sedatives or anesthetics, which
is not without risk and also involves increased expense and
resources for the hospital. It is, therefore, advisable to seek
alternative solutions that take away the patients’ fear so that
they can be calm and relaxed during the examination.
We propose a child-oriented, gradual, and guided introduc-
tion to the potentially anxiety-inducing aspects of the MRI
examination using virtual reality (VR) technology. Therefore,
the specific demands of children must be taken into account
in the design and carefully implemented in order to achieve
the highest possible acceptance of the solution. Further, we
assume that a substantial and long-lasting increase of patient
comfort and cooperation can be achieved by combining var-
ious methods of patient preparation into one comprehensive
intervention. Liszio and Masuch [25] introduced a mobile
VR application (app), in which multiple solutions for patient
preparation are enhanced with playful and narrative elements.
The authors report findings from a clinical feasibility study
which indicate that children who used the app once before
the MRI examination experienced less anxiety compared to
children who did not use the app. They conclude that the
approach of such a playful VR app can be an effective method
to allay children’s fears of MRI examinations. However, the
authors suggest that a repeated and more intense engagement
with the contents of the app could lead to a stronger and more
persistent anxiety reduction.
The present paper takes up the ad-hoc approach of Masuch and
Liszio and extends it with features that facilitate and motivate
repeated training aiming at a persistent enhancement of the
emotional experience of children before MRI examinations.
Additionally, we conducted a field study in which 29 children
used the VR app at home. When the appointment for the
examination was made, the children received access to the
app (one week to three months before the appointment; actual
training lasted 14 days on average). The promising results
support our approach and provide information about the effect
of certain game design elements and how children, parents,
and medical staff evaluated the "Pengunaut Trainer".
FUNDAMENTAL STRATEGIES AND METHODS
Liszio and Masuch propose a concept for desensitizing chil-
dren to the MRI examination, which consists of four steps
of play therapeutic strategies (information, observation, mod-
eling, and exposure) [25]. However, their approach is only
designed for single-use directly before the scan. In this paper,
we revise and expand the concept with a focus on repeated
training over a longer period of time before the examination.
Therefore, we integrate measures to increase long-term moti-
vation and improve replayability. Figure 2 illustrates how we
combine psychological approaches of patient preparation with
aspects of applied game design on a conceptual basis.
Patient Preparation Strategies
Although there are many in-bore solutions for soothing and
entertaining patients during the scan, thorough patient infor-
mation and preparation are crucial for the patient’s well-being
and cooperation and, thus, a trouble-free examination [31].
Various methods of patient preparation have already been de-
veloped for this purpose.
Providing information about the examination can already help
to dissolve misconceptions and demystify the MRI exami-
nation. Törnqvist and colleagues report that although the
provision of information material before the MRI examination
to adult patients may not reduce anxiety towards the MRI
examination, it reduced the occurrence of motion artifacts
significantly [39]. However, for our purpose, it is crucial to
ensure that relevant information is presented in a way suitable
for children. In practice, the content of medical information
material is often designed intuitively and based on the practical
experience of medical staff [19]. In other words, information
material is often given to parents and children regardless of
how children in different age groups process the information.
Felder-Puig and colleagues found a significant reduction in
anxiety in children who were prepared for a surgery with an
adapted children’s book [11]. There are several children’s
books available on the subject of MRI examinations [1, 12].
Other promising approaches apply various psychological and
therapeutic methods to reduce MRI-related anxiety in pedi-
atric patients. A common reason for anxiety in children in
medical situations is a lack of understanding of the situation
[7]. Play therapy approaches can give children an explanation
of the examination procedure and practice the correct behavior
during the scan in a playful way. Toys and stuffed animals, as
well as images of other children, are used to demonstrate what
happens during an MRI examination [31]. Also, MRI mod-
els in the form of toys are used to enable children to explore
and get to know the scanner device in advance. Bharti and
colleagues found a significantly reduced need for sedation and
anesthesia in children who had previously played with a toy
MRI during play therapy sessions [4]. Furthermore, Pressdee
and colleagues suggest that it could be helpful if the children
had the opportunity to visit the real MRI device before the
examination and, for example, try out the table controls [31].
However, since this is often not possible due to the high work-
load of the MRI devices, some practitioners use non-functional
replicas or discarded MRI devices, referred to as mock MRI
scanners, to rehearse the examination with children in advance
[9]. These approaches are grounded in exposure therapy and
have been successful in reducing anxiety and sedation [8]. As
promising as these approaches are, they have the disadvantage
of being very costly. Not all hospitals have enough space,
financial, and personnel resources to integrate such mock MRI
scanners into their patient preparation procedures. Barnea-
Goraly and colleagues used a toy tunnel in combination with
recordings of the typical MRI noise as an inexpensive alter-
native to commercial mock scanners [3]. Thus some authors
propose the use of VR technology to simulate virtual MRI ex-
aminations as a cost-effective alternative to mock scanners and
as a measure of desensitization [22, 25, 6]. Nakarada-Kordic
and colleagues compared such a VR-based MRI simulation to
a real mock MRI scanner regarding the experienced anxiety
and relaxation of adult participants [29]. The authors found no
significant difference in the effect of the two approaches and
conclude that VR is a useful tool for desensitization and train-
ing that can also be used at home. Confronting patients with
the fear-inducing stimulus in immersive VEs, has proven to be
effective in the treatment of various anxiety disorders and pho-
bias. This approach is described under the term Virtual Reality
Exposure Therapy (VRET) [43]. The effectiveness of VRET
has been demonstrated, for instance, for claustrophobia, fear
of heights, fear of flying, PTSD, and social phobia [44, 42]. In
contrast to classical in vivo therapy, VRET is independent of
time and space. As an alternative to a direct confrontation with
Figure 2. The model illustrates the patient preparation strategies used in our approach to improve patient comfort and cooperation. Elements from
applied game design are used to motivate repeated training. Therefore, mobile VR technology is a solution to provide easy and inexpensive access to the
intervention. This concept is implemented in the form of the playful, child-oriented VR app Pengunaut Trainer.
the anxiety stimulus, imaginative procedures are usually used.
However, these are dependent on the patients’ imagination to
visualize the fear-inducing scenario. This individual ability
is not necessary for VRET. VRET is based on the graded ex-
posure of patients to the fear-inducing stimulus. Step by step
desensitization and a reduction of anxiety can be achieved.
This therapeutic approach can be used to accustom patients to
the MRI examination, especially with regard to experiential
aspects such as the limited space within the MRI bore and the
noise of the scanner [21].
Demystification and desensitization regarding the MRI ex-
amination are two critical factors to take away the patient’s
worries before and during the scan. However, it is also essen-
tial to provide the patient with techniques to help themselves
during the procedure. Such a coping strategy could be, for
instance, the practice of relaxation techniques. Lohaus and
Klein-Heßling conducted a large clinical trial and found sev-
eral relaxation techniques (i.e., progressive muscle relaxation,
an imaginative technique, and a combined approach) suitable
for short-term relaxation that go along with an enhanced mood
and physiological responses [26]. Peterson and Shigetomi
report increased calmness and cooperativeness of children
who performed relaxation techniques in combination with a
modeling approach during an invasive surgery [30].
The presented methods and strategies have proven to improve
the emotional experience of young patients in different med-
ical situations. In our approach, these aspects are integrated
with several elements from digital games to a comprehensive
playful, mobile VR app.
Mobile Virtual Reality
VR offers the unique opportunity to put users in a virtual en-
vironment (VE) that feels real to them. This effect is called
presence and depends on the degree of immersion [36], that
is, the type and number of senses addressed by the VR sys-
tem with simulated stimuli, as well as on the emotional and
cognitive quality of the displayed content [27]. VR has gained
increasing popularity in recent years in the scientific, indus-
trial, and medical sectors. However, the acquisition costs are
high for private individuals, because in addition to the VR
headset (i.e. head-mounted display; HMD), a powerful PC is
necessary to use VR. Another drawback for our undertaking
is that most state-of-the-art consumer HMDs are not suitable
for children due to their ergonomic features [16, 25]. There-
fore we consider the use of cost-effective mobile VR systems
to be more suitable. With such stand-alone VR systems, the
computation and display of the VR content are performed on
the device itself. They therefore do not need to be connected
to a PC. For this purpose, a smartphone can be attached to
the user’s head with a special mount (e.g., Google Cardboard,
Samsung Gear VR). This mount contains an optical lens sys-
tem that generates the required stereoscopic image for the 3D
impression. The smartphone tracks the user’s head-movements
and renders the virtual worlds appropriately. However, such
smartphone-based systems have the limitation of lower immer-
sive quality due to their technical characteristics (i.e., display
resolution, field-of-view, computing capacity) compared to
more advanced, and thus more expensive, "all-in-one" VR
systems recently released to the market (e.g., Oculus Quest,
HTC Vive Focus, Pico G2). These work in a similar way,
but do not require a smartphone since they are fully-fledged
stand-alone VR headsets that have the necessary computing
units and displays integrated. However, since these systems
are still new and, therefore, not very widespread, we decided
to use the more straightforward smartphone variant in our
approach (Figure 5, left). Designing an app to prepare for
the MRI examination as a VR smartphone app offers further
advantages. The user-friendly installation process is the same
as for classic smartphone apps. Additionally, already estab-
lished distribution channels (e.g., Google Play, Apple App
Store) can be used. Thus, parents can install the VR app easily
on their mobile phone and hospitals or radiological facilities
do not need a distribution or technical infrastructure. Conse-
quently, the preparation of patients for the MRI examination
can take place anywhere and at any time, which increases the
probability of it being applied.
Long-Term Motivation Strategies
The essence of our intervention is the repeated confrontation
with the fear-inducing stimuli in order to achieve desensiti-
zation and habituation. In order to ensure that our various
measures for patient preparation are effective, we must find
ways to motivate regular training. For this purpose, we rely on
the approach of applied game design, that is, the user-centered
transfer and implementation of design concepts from games
in order to pursue a defined goal [34].
Games
Digital games are used in a variety of contexts that are not di-
rectly related to entertainment. Besides the numerous positive
effects that games can have on the players, their effectiveness
in triggering positive emotions, improving mood and reducing
stress are of particular interest to our project [40]. Further, the
effect of reciprocal inhibition, that is, it impossible to experi-
ence positive and negative emotions (e.g., joy vs. anxiety) and
physical states (e.g., relaxation vs. stress) at the same time
[45], to associate the previously fear-inducing stimulus (i.e.,
the MRI examination) with positive feelings (i.e., fun and mas-
tery). Additionally, games or playful elements are often used
to motivate people to behave in a desired way, for instance in
rehabilitation [20]. According to Self-Determination Theory,
this is possible because certain playful elements can satisfy the
basic psychological needs of competence, autonomy, and relat-
edness [33]. A typical game design element which addresses
the need for competence is the organization into successive
levels with increasing difficulty [13]. The progression through
increasingly difficult levels can encourage the players to con-
stantly engage with the intervention and challenge themselves,
resulting in continuous training. Hence, this concept is ideal
for gradual exposure and especially for practicing lying still
during MRI examinations.
Rewards
A classical method from game design to promote the behav-
ior and motivation of players are rewards [13]. We assume
that rewards are a reasonable tool to motivate patients to en-
gage with the intervention. Nevertheless, virtual rewards as a
motivational tool have been criticized for reducing intrinsic
motivation if they are primarily used for controlling behavior
[33, 46]. However, if rewards are given as a form of infor-
mative feedback, they can increase the players’ feeling of
autonomy [33]. Moreover, rewards have to be meaningful to
the players in order to be a real incentive. Furthermore, the
rewards should not only be virtual but also anchored in the real
world. In this way, the intervention takes on a greater signifi-
cance in the daily life of the patients and the training progress
receives a tangible equivalent value. Thus, we suggest using a
real-world reward system that visualizes the players’ progress
in the training. Such a reward system can also satisfy the need
for feeling competent and motivate further training.
Companions
The integration of non-player characters (NPCs) can bring
the game world to life and facilitates storytelling. NPCs can
trigger the players’ perception of social presence, that is, the
feeling of being in the same (virtual) space with another player
[5]. A precondition for the experience of social presence is
that the players perceive the social entity as such and assumes
that the social entity is also aware of the player’s presence
[38]. If this is the case, social entities can decrease the feeling
of being alone in a VE [24]. A particular form of NPCs are
companions, that is, NPCs who follow the players through
the game world and story [41]. Since they satisfy the players’
need for relatedness [33], they have a positive effect on game
enjoyment. Furthermore, companions increase the perceived
realism and emotional immersion in the game world. In the
context of a play therapy approach, such companions can be
utilized as role models. We assume that if the players identify
with the characters, they may adapt their emotional experience
and behavior [10]. Consequently, patients could learn from
the companions in the game that they need not be afraid of the
MRI examination and how to behave during the scan [40].
Story
A compelling story gives the game a deeper meaning and
helps to transport information about the MRI examination.
The plot helps to introduce the training in the virtual MRI
scanner in a comprehensible and gradual manner. Moreover,
a meaningful story also enhances the emotional involvement
and identification with the characters and satisfies the players’
need for relatedness as it supports the suspension of disbelief
[20]. Furthermore, the story can help the children to gain
an understanding of the medical situation, its context and its
necessity. Thus, it promotes the receptiveness of the players
to the health intervention [28].
PENGUNAUT TRAINER
From the presented theoretical basics, we derived the concept
for a playful, child-oriented VR app to reduce anxiety of the
MRI examination through systematic training (Figure 2). In
the following, we introduce the details of the game design
concept of the Pengunaut Trainer.
Story and Game Structure
In the world of the Pengunaut Trainer, all characters are pen-
guins. The story starts at the reception area of a radiology
department, where the players are welcomed by the nurse
Florence Fin to the training for their MRI examination. After
a brief introduction to the game controls, the players meet
their companion Benny or Bella (depending on which compan-
ion the players have chosen previously) with his/her mother,
Beatrice Beak. Both characters introduce themselves and the
players learn that the companion must have an MRI exami-
nation because he/she often has stomach aches. Furthermore,
the players also learn that Benny/Bella wants to become a
Pengunaut (from "Penguin" and "Astronaut") and dreams of
traveling to the stars, just like the other characters do. The
companion then invites the players to play the first mini-game
"Robo Magneto". After the players have completed this game,
the radiologist MD Theodore Tails enters the room and leads
the players together with the companion and the mother into
the MRI control room, where he explains the process of the
MRI examination. The third and last room is the one where
the virtual MRI device stands. In this room, the second mini-
game "MRI Controller" starts, where the players can perform
an MRI scan first on a teddy bear and then on the compan-
ion. Finally, the actual training game "Stargazer", in which
Figure 3. The companions Benny and Bella and the other characters in
front of the 3D model of the virtual MRI scanner (left to right: Mother
Beatrice Beak, Benny, Bella, MD Theodore Tails, Nurse Florence Fin).
the players themselves experience a virtual MRI scan, starts.
Afterward, the story ends with the radiologist saying goodbye
to the players until the next training session.
Alongside the so-called "Story Mode", the Pengunaut Trainer
features a "Freeroam Mode". This mode is activated after the
first complete run through the story. In Freeroam Mode, the
players can move freely in the virtual world, replay all games,
and talk to the characters.
Virtual Environment
Since it is our goal to familiarize the players with the MRI en-
vironment, the VE must be close to reality. Therefore, despite
the fantasy story and characters, we decided to design a bright
and friendly, but realistic simulation of a typical radiology
department. The authentic representation of the MRI scanner
and the characteristic noises were especially important to us.
Characters and Companions
The characters in the Pengunaut Trainer are humanoid pen-
guins (Figure 3). By choosing animal characters, we achieve a
playful look suitable for children and avoid the adverse effects
of the "uncanny valley" [35]. The characters play stereotyped
roles in the story that reflect the typical social structures dur-
ing the medical situation of an MRI scan. We refrained from
individual personality traits in order to achieve the highest
possible generalizability. The players should be able to iden-
tify with the story and the characters in line with play therapy.
Thus, the players can project the behavior and emotional ex-
perience of the characters on themselves. The companion is a
penguin child who also needs to have an MRI examination. To
facilitate the players’ identification with the companion and to
increase the feeling of autonomy and relatedness, the players
can choose between a male companion, Benny, and a female
companion, Bella, at the beginning of the game. It is possible
to change the companion at any time.
Mini-Games
"Robo Magneto"
The first mini-game "Robo Magneto" is placed in the waiting
room and is played together with the companion (Figure 4,
upper left). This game aims to inform the players about the
magnetic properties of the MRI scanner and which objects
are allowed in the scanner room. The players can choose
between different objects placed on a table and select objects
they believe to be magnetic. The robot "Robo Magneto" scans
the object and gives audiovisual feedback. Additionally, the
companion comments each selection ("Oh look, these are
magnetic!"). If the object is magnetic, Robo Magneto stores
it in a box. This is repeated until the players have found all
magnetic objects (e.g., coins, keys, a mobile phone) and only
the objects that are allowed to be taken (e.g., a teddy bear, a
ball) to the MRI examination are left.
"MRI Controller"
The game "MRI Controller" is a direct implementation of the
previously presented game-therapeutic methods to familiarize
the players with the steps of the MRI examination. In this
game, the players operate the MRI device by using the buttons
to control the table and start the scan. First, a teddy bear is
scanned, followed by the companion (Figure 4, upper right).
These scans take one minute, during which the players hear
the characteristic sounds of the scanner for the first time. After
being scanned, the companion confirms that the examination
was not frightening. Subsequently, the doctor takes the players
back to the control room where they can view the images they
have taken.
"Stargazer"
The game "Stargazer" represents the last step of the gradual
exposure therapy, where the players themselves experience an
MRI scan in VR (Figure 4, lower right). The players are first
asked to lie down flat on their back in reality. Then they are
transported into the virtual MRI device. A calming off-voice
explains the steps and rules of the game. The voice asks the
players to imagine lying in a meadow on a warm summer
night and watching the stars. The narration comprises ele-
ments from progressive muscle relaxation, autogenic training,
and imaginative relaxation. Next, stars appear on the ceiling of
the virtual MRI device, which connect slowly to form constel-
lations when the players remain motionless (Figure 4, lower
left). The smartphone’s motion sensors are used to detect
the head movement. When the players move, the stars stop
connecting and the lines turn red to indicate that an error was
made. If the players keep moving, the off-voice reminds the
players that it is necessary to remain motionless during the
procedure. When all the stars are connected, the off-voice
explains around which constellation is visible and tells a short
background story.
The "Stargazer" comprises five increasingly difficult levels
with difficulty being determined by the length of the virtual
scan (one to eight minutes) and the increasing number of con-
secutive constellations as well as the number of connections
between the stars per constellation. The duration of the scan
in the last level is only five minutes, but no more stars are dis-
played. This means that this level is closest to the conditions of
a real MRI examination and represents the greatest challenge.
A level is considered completed when the players have not
shaken once. The length of five minutes that the players have
to lie motionless in the virtual MRI device corresponds to the
minimum length of a single MRI sequence. Because a scan
usually consists of several consecutive sequences and patients
are usually allowed to move between two sequences, Bharti
and colleagues suggest this time as a suitable measure for
Figure 4. Above left: "Robo Magneto", above right: "MRI Controller",
below: "Stargazer", left: star constellation "Giraffe", right: view of the
players from the virtual MRI bore
training children for the MRI examination [4]. The maximum
training time per day is fifteen minutes. Once a level has been
completed, players can only continue playing the next day, to
prevent players from completing all training sessions in one
day and spending too much time in the game.
Courage Formulas
The players can choose a courage formula, that is, a phrase
that suggests calmness and bravery. All courage formulas are
structured in the same way: the first part of the sentence con-
sists of two adjectives that stand for relaxation and tranquillity.
The middle part connects an animal associated with courage
or balance. The last part of the sentence stands for the natural
habitat of the animal, which stands for vastness and freedom.
The nurse encourages the players to learn the chosen courage
formula by heart and to recite it whenever they feel scared.
Additionally, it is repeated by the characters throughout the
game. The courage formulas are an implementation of the
concept of coping strategies and a form of relaxation technique
that roots in autogenic training and autosuggestion.
"I am gentle and balanced – like a horse – in the fresh paddock."
"I am strong and brave – like a wolf – in the silent forest."
"I am brave and calm – like a lion – in the vast steppe."
"I am proud and free – like an eagle – in the clear air."
"I am calm and patient – like a turtle – in the warm sand."
Space Pass
The Space Pass is a small booklet handed out to each player at
the beginning of the training. It contains a short picture story
about the adventures of the Pengunauts in space (Figure 5,
center). The pictures, however, are hidden behind scratch-off
stickers. Each time the players have completed a level, they are
allowed to scratch off one field. The players can scratch off the
last sticker, a big star, after the actual MRI examination. The
Space Pass serves as a real-world reward for the MRI training
and visualizes the training progression for the children. The
patients can also take it with them to the examination and thus
show the radiology staff how well they are prepared.
Figure 5. The participants received a smartphone mount ("VR Viewer",
left), the Space Pass (center) and an information brochure (right).
STUDY
We carried out a clinical trial to gain insight into how young
patients evaluate the Pengunaut Trainer. We aimed to inves-
tigate whether the training of the MRI examination reduces
the patients’ anxiety and increases their cooperativeness. Fur-
thermore, we focus on the evaluation of specific game design
elements. The study was conducted between October 24, 2018,
and November 7, 2019, at the Essen University Hospital and
the Child’s Hospital Cologne in Germany. The study protocol
and all materials were reviewed and approved by the ethical
board of the University Hospital Essen.
Method and Procedure
The participating hospitals’ databases were scanned daily for
patients registered for an MRI examination. Only patients
whose examination was at least one week and not more than
three months in the future and who met the inclusion criteria
were recruited (see section Selection and Participation of Chil-
dren). The participants were free to choose whether, when,
and how often they use the app within this period. Once both
patients and their parents agreed to participate in the study,
they received an anonymous study ID, a set of questionnaires,
and the training kit. The training kit comprises a download
code, a simple smartphone-mount as VR Viewer, the Space
Pass, and a brochure with information about the study and the
app for the parents (Figure 5). The study ID was necessary
to unlock the app to ensure that only registered participants
could use it. Also, the ID was necessary to match in-game
data with the questionnaire answers.
The study can be divided into three times of measurements:
(1) before the first training (Pre Training), (2) after the training
period and immediately before the MRI examination (Post
Training), and (3) directly after the MRI examination (Post
Scan). We distinguish between subjective measures in the
form of questionnaires and objective in-game data.
Questionnaires
The questionnaire set consists of five questionnaires in total.
The participating children filled out the paper-and-pencil ques-
tionnaires Q1-Q3 at the three times of measurement described
above. Additionally, parents and medical staff members filled
out questionnaires Q4 and Q5 in the Post Scan phase.
Questionnaires Q1-Q3 include the Positive and Negative Af-
fect Schedule tailored for Children (PANAS-C) [23] for the
assessment of the children’s emotional experience, as well as
the State-Trait Anxiety Inventory for Children (STAI-C) [37]
for measuring anxiety regarding the upcoming MRI examina-
tion. Q2 includes an adapted version of the Game Experience
Questionnaire (GEQ) [18], as well as questions about certain
aspects of the Pengunaut Trainer. Most of the free formu-
lated questions are rated on a scale from 1-3 (unless otherwise
stated) to keep it simple for the children. Q3 includes espe-
cially questions about the process of the MRI examination.
In-Game Tracking
In addition to the self-reported measures, we implemented an
in-game tracking system to record the participants’ behavior
while playing (e.g., number and duration of play sessions,
decisions for a companion, selection of courage formulas,
"Stargazer"-level). Moreover, before each training, the par-
ticipants were asked how they feel about the upcoming MRI
examination. Therefore, a 10-point Visual Analog Scale [14]
was displayed when starting the app (daily anxiety level). Ad-
ditionally, we integrated an in-game rating system for the
mini-games. After each mini-game session, the penguin nurse
asks the players to rate how they liked the respective game on
a three-point (negative, neutral, positive) smiley scale.
For data collection, the gameplay data was saved on the
smartphone and then sent to a University server via an SSL-
encrypted internet connection, where it was stored and pro-
cesses for further analysis. The participating parents were
explicitly informed about this when enrolling in the study and
have explicitly confirmed their consent. No personal data were
transmitted. Storage and processing were anonymous.
Participants
A total of 47 children participated in the study. Of these, 36
participants completed the study. 31 children actively trained
with the app (i.e., they played at least one complete session
in the "Stargazer" mini-game). We received 29 sufficiently
completed questionnaires. Thus, data of 29 children were in-
cluded in the analysis (Age: 5-11 years,
M=7.74,SD =2.07
;
gender: 17 girls, 12 boys). 15 patients never had an MRI
examination before, while the other 14 patients one to 30+
MRI examinations before. We received 25 completed ques-
tionnaires from the parents and 23 completed questionnaires
from the radiology staff members.
Results
General Game Rating
First, we evaluate how the children perceived the Pengu-
naut Trainer in general. Note that all single-item questions
were rated on a three-point scale if not otherwise stated (1
= not at all; 3 = very much). We asked how much fun the
participants had while playing with the Pengunaut Trainer
(
M=2.45,SD =0.63
), and how much difficulty they had
with understanding the story (
M=1.52,SD =0.79
). Also,
we asked how impressed they were by the VR experience
(
M=2.57,SD =0.50
) and how they liked VR in general
(
M=2.69,SD =0.47
). In the Post Training measurement, we
asked whether the children would use the Pengunaut Trainer
again (
M=2.07,SD =0,79
) and how likely they would rec-
ommend the app to other patients (M=2.50,SD =0.64).
We also asked the parents of the participating children to
rate the Pengunaut Trainer. 23 parents reported that they
NMin Max M SD
Competence 28 1.33 5.00 3.19 1.12
Immersion 28 1.50 4.83 3.27 0.99
Flow 28 1.40 4.80 2.84 0.87
Annoyance 28 1.00 5.00 1.56 0.92
Challenge 28 1.00 3.80 1.93 0.80
Negative Affect 28 1.00 3.75 1.75 0.78
Positive Affect 28 1.40 5.00 3.23 1.03
Table 1. Descriptive statistics of the dimensions of player experience
measured with the GEQ (Total of 33 items, Cronbach’s α= 0.87).
have tested the app themselves. On a six-point scale (1 =
not at all; 6 = very much), they rated how much they liked
playing with the app (
M=4.75,SD =1.22
). Using lists of
adjectives, they described the app as being child-friendly (
M=
5.33,SD =1.09
), useful (
M=5.17,SD =1.01
), and beautiful
(M=5.17,SD =0.87).
Player Experience
The mean scores of the dimensions of player experience are
summarized in Table 1 (1 = not at all; 5 = very much). It
becomes apparent that the dimensions associated with a neg-
ative player experience (annoyance,negative affect) reached
lower mean scores compared to the other dimensions. The
participants were asked how much they experience each of
the following four typical symptoms of simulator sickness
on a four-point scale (1 = low; 4 = very much): Dizziness
(
M=1.32,SD =0.72
), headache (
M=1.18,SD =0.61
),
nausea (
M=1.07,SD =0.26
), and concentration difficulties
(M=1.5,SD =0.69).
Companions and Social Presence
The children’s perception and evaluation of the companions
are of key importance for our approach. Therefore, we cal-
culated the total playtime of all players with Bella (413.03
minutes) and Benny (402.37 minutes). Since it is generally
possible to change the choice of companion, we calculate the
ratio of the time each player has spent with Benny in the game
to the time spent with Bella. Hence, we can determine which
one is the main companion. Based on this measure, 13 girls
chose Bella and 4 chose Benny as their companion, while 11
boys chose Benny and one boy chose Bella.
From the self-reported data, we can gain more insight into
how the participants felt about the companions. Since we did
not find significant differences between both companions, or
an influence of gender, the following results are equivalent for
Bella and Benny, who are therefore referred to as "the compan-
ion". All following questions were answered on a three-point
scale (1 = not at all; 3 = very much).
The participants were asked how much they liked the com-
panion (
M=2.82,SD =0.39
), whether they generally liked
the penguins as characters (
M=2.73,SD =0.53
), and how
it felt to "meet" them in the VE (
M=2.68,SD =0.55
). Ad-
ditionally, the participants described the companion using
a list of adjectives, indicating to what extent the individual
adjectives apply to the companion. The results show that
the children mostly associated positive adjectives like friendly
Figure 6. Share of negative, neutral, and positive ratings in the total
number of ratings given for each mini-game.
(
M=2.93,SD =0.27
), nice (
M=2.93,SD =0.27
), and help-
ful (
M=2.86,SD =0.45
) with the companions. Negative
adjectives like uninterested (
M=1.15,SD =0.45
), distanced
(
M=1.31,SD =0.62
), and cold (
M=1.33,SD =0.68
)
reached lower mean scores.
Another set of questions assessed whether the children expe-
rienced social presence with the companion. Therefore the
participants were asked whether they had the feeling that the
companion was in the same situation (
M=2.43,SD =0.74
)
and whether they felt like they were discovering the MRI
device together with the companion (
M=2.71,SD =0.54
).
The children were also asked whether they liked that they did
not have to train alone (
M=2.79,SD =0.42
) and that they
could see how Benny or Bella underwent the MRI scan first
(M=2.89,SD =0.42).
Mini-Games
We derive the overall scores of the three mini-games from
the in-game ratings given after each play session. Note that
each participant could play and rate each game multiple times.
Thus, in the first step, we calculate each player’s average rating
for each mini-game. Then, we calculated the overall score
as the average of average ratings. "Robo Magneto" reach an
overall score of 0.73, followed by "Stargazer" with a score
of 0.62, and "MRI Controller" with an overall score of 0.59.
As an alternative metric that provides additional insight in
the player’s ratings of the mini-games, we calculate the share
of negative, neutral, and positive ratings in the total number
of ratings per game (Figure 6). Since the game "Stargazer"
represents the actual training of the MRI examination, it is of
particular interest to know how often the participants played
this game. The average number of training sessions per player
was
M=3.17
(range = 1–15,
Mdn =3.0,SD =2.6
). 8 chil-
dren did not complete the first level. 4 children completed the
first level, 7 children completed the second, and 8 children
completed the third level, while one child each completed the
fourth and fifth level.
Courage Formula
The children rated on a three-point scale (1 = not at all; 3 = very
much) how they liked the courage formulas (
M=2.66,SD =
0.55
). Further, we asked how helpful the participants found
the courage formulas (
M=2.34,SD =0.77
), and how well
they remembered the formulas (
M=1.93,SD =0.84
). Thus,
Figure 7. The players can choose one of five courage formulas. Each
courage formula is associated with an animal. The diagram shows the
gender differences in the choice of the courage formulas.
the participants thought the courage slogans were positive and
helpful but had difficulties remembering them. We calculated
the total playtime for each animal in minutes. Therefore, the
children played 382.17 minutes with the wolf, 310.23 minutes
with the lion, 214.18 minutes with the eagle, 179.25 minutes
with the turtle, and 130.43 minutes with the horse. Figure 7
shows the children’s choice of the different courage formulas
grouped by gender. The courage formula associated with the
horse was chosen exclusively by girls, whereas boys preferred
the eagle and the wolf, with the wolf and the lion being chosen
equally by both genders. Additionally, we asked the children
after the MRI examination (Post Scan) if the courage formula
helped them during the scan (
M=1.83,SD =0.89
). The
children stated that they had thought less about it during the
examination (
M=1.72,SD =0.94
). However, we found a
significant positive correlation between the remembering of
the courage formula and positive affect (PANAS-C) during the
examination, r(23) = .46,p=.027.
Space Pass
We asked the children how much they liked the Space Pass
(
M=2.64,SD =0.56
) and how much fun they had scratch-
ing off the stickers after each completed "Stargazer"-level
(
M=2.64,SD =0.62
). Additionally, the parents were asked
how much they like the training kit (
M=4.71,SD =1.27
) on
a six-point scale (1 = not at all; 6 = very much). Furthermore,
the parents evaluated the pass on the basis of lists of adjectives.
The adjectives with the highest scores were child-friendly
(
M=5.38,SD =0.82
), beautiful (
M=5.04,SD =1.12
), use-
ful (M=4.92,SD =1.47), and fun (M=4.71,SD =1.60).
Preparation
We define the preparation phase as the period from registering
to the study (Pre Training) to the date of the MRI examina-
tion (Post Training). The participants were free to choose
whether and when to start the training. The actual training
phase is defined as the period from the time the participants
started the app for the first time and played for at least five
minutes until the last play session to the date of the MRI ex-
amination (Post Training). The average length of the training
phase was
M=14.34
days (
Mdn =13.0,SD =19.3
). The
total summed playtime of all participants is 1453.90 minutes
Figure 8. Positive affect towards the MRI examination was increased
after the training phase, while negative affect was reduced (PANAS-C).
(24.23 hours), which results in an average playtime of 53.48
minutes per player (
Mdn =48.83
). The average session length
in minutes was
M=17.10
(
Mdn =15.57,SD =14.04
). Af-
ter the training phase, that is, immediately before the MRI
examination (Post Training), we asked the participants how
much they feel prepared for the scan (
M=2.5,SD =0.51
).
They also rated the information provided by the Pengunaut
Trainer about the MRI examination (
M=2.66,SD =0.48
)
and whether they would have wished more detailed informa-
tion about the examination (
M=1.79,SD =0.78
). Since the
mini-game "Stargazer" is most relevant for the preparation,
we additionally asked the children how helpful they thought
"Stargazer" was for the practice of lying still during the exam-
ination (M=2.45,SD =0.63).
We also asked the parents to rate on a six-point scale (1 =
not at all; 6 = very much) how helpful they think the Pengu-
naut Trainer was in taking away the child’s fear of the MRI
examination (
M=5.00,SD =1.22
). Moreover, we asked par-
ents and the radiology staff members how well the Pengunaut
Trainer prepared the children for the examination (parents:
M=4.58,SD =1.50; staff: M=5.73,SD =0.76).
Anxiety Reduction in the Preparation Phase
Evaluating whether the Pengunaut Trainer can reduce the chil-
dren’s anxiety related to the forthcoming MRI examination,
we compared the positive and negative affect values (PANAS-
C; Figure 8) as well as the anxiety levels (STAI-C) before
(Pre Training) and after the training period (Post Training).
Since normality was given (Kolmogorov-Smirnov test), we
performed a paired sample t-test, which indicates that posi-
tive affect was significantly higher in the Post Training mea-
surement (Pre Training:
M=22.8,SD =10.1
; Post Training:
M=28.6,SD =8.7
;
t(22) = 3.44,p=.002,d=.62
),
while negative affect was significantly reduced (Pre Training:
M=17.6,SD =7.44
; Post Training:
M=13.5,SD =3.87
;
t(19) = 2.29,p=.033,d=.69
). The anxiety level was signif-
icantly reduced (Pre Training:
M=37.4,SD =7.9
; Post Train-
ing: M=34.4,SD =5.2; t(21) = 2.31,p=.031,d=.45).
In addition to Pre and Post Training measurement of the anxi-
ety in anticipation of the MRI examination, we evaluated the
children’s anxiety level continuously over the time of the train-
Figure 9. The orange line marks the weighted moving average of the
daily recorded anxiety level on the visual analog scale in the app. The
blue diamonds mark the number of responses per day.
ing with the visual analog scale presented when starting the
app. Figure 9 depicts the progression of the weighted moving
average of the anxiety values over time. The figure presents
the last 14 days before the MRI examination. The number
of responses per day varies, since not every child trained on
each day before the examination. The course of the anxiety
level shows a downward trend while the number of responses
increases, indicating that the participants trained more often,
the closer the MRI examination gets.
Post Scan Assessment
After completing the MRI examination (Post Scan), we asked
the participants again to rate on a three-point scale (1 = not at
all; 3 = very much) how well they felt prepared for the scan
by the Pengunaut Trainer (
M=2.48,SD =0.59
) and whether
they missed more information (
M=1.80,SD =0.76
). In or-
der to get an assessment of the course of the MRI examination,
we asked the children, parents, and the radiology staff indepen-
dently to answer the question "How well do you think went the
MRI examination?" on a seven-point scale (1 = very bad; 7 =
very good). The ratings of the three groups did not differ much
(children:
M=5.59,SD =1.8
, parents:
M=5.96,SD =1.6
,
staff:
M=6.04,SD =1.3
). Furthermore, we found signifi-
cant correlations of each groups answers (children x parents:
r(22) = .84,p< .001
, children x staff:
r(21) = .47,p=.038
,
parents x staff:
r(24) = .80,p< .001
). Moreover, children
who were well prepared by the app, according to their parents
and the staff, fidgeted less (parents:
r(24) = .555,p=.005
,
staff:
r(19) = .559,p=.013
) and were more cooperative (par-
ents: r(24) = .655,p=.001, staff: r(19) = .578,p=.01).
DISCUSSION
The consistently positive evaluation of the various aspects
of the Pengunaut Trainer validates our idea of a playful VR
app to prepare children for the MRI examination. In particu-
lar, the fact that the majority of children would recommend
the app to other patients is a tribute to the usefulness of the
Pengunaut Trainer. The children considered the training to
be a joyful and useful activity that helped them effectively.
They liked the VR experience, felt present in the virtual world,
and had no difficulties in the game. Parents and radiology
staff also approved our approach and described the Pengunaut
Trainer as being child-friendly and helpful. We observed a
significant reduction of anxiety and negative feelings from the
beginning of the training to the measurement just before the
MRI examination. Moreover, positive feelings towards the
MRI examination were significantly increased. These results
suggest that the Pengunaut Trainer is an effective intervention
to prepare children and increase their well-being.
All three mini-games received equally positive ratings by the
players. The in-game analysis of the player’s performance in
the "Stargazer" game, which represents the training of lying
inside the MRI bore, reveals that the participants trained about
three times on average for their MRI examination. The partic-
ipants rated the game very positively and completed several
levels, although it is the only game in the Pengunaut Trainer
where the performance of the players’ matters that is setbacks
and frustration are possible. Nevertheless, only a few children
reached higher game levels. Possibly the tracking of head
movements used to detect if the child was moving during the
virtual scan was oversensitive. Consequently, the level of diffi-
culty may have been too high in the advanced levels. Another
explanation could be that the children did not have enough
time for longer play sessions.
The participants appreciated the integration of a companion.
The children perceived the two characters, Bella and Benny,
as friendly and sympathetic and experienced social presence.
They expressed their delight that a companion was at their side
and that they could practice together for the MRI examination.
We observed a gender preference in the selection of the com-
panion. We have only considered the two traditional genders
in the design of the companions. In light of the increasing
questioning of binary gender categorization and the impor-
tance of identification with the characters for our approach, we
suggest adding gender-neutral characters in future versions.
The children liked the courage formulas and thought they were
helpful. The formulas associated with wolf, lion, and eagle
were most popular. However, some participants had problems
remembering them during the MRI examination. Although the
chosen courage formula is repeated several times throughout
the game, it may be advisable to increase this frequency.
The high occupancy rate of radiological facilities in German
hospitals results in long waiting times for an appointment.
The recruitment of patients within a standardized period (e.g.,
precisely 14 days before the MRI examination) was not possi-
ble since direct personal contact was only possible when the
patients were scheduled for the examination. Due to these
circumstances, there is a wide range of individual prepara-
tion phases in which the participants could use the Pengunaut
Trainer. Furthermore, a fixed prescribed period of use and
frequency appeared unreasonable to us, since we wanted to
stimulate a self-motivated training, which children and par-
ents do not perceive as an additional obligation. This also
implies that we cannot reliably determine how the parents
integrated the Pengunaut Trainer into the children’s everyday
life regarding the time and place of the training. Since the
parental smartphone was required to use the app, the children’s
access to the app may have been limited. It would, therefore,
be advisable to provide children with their own VR device,
though this would involve considerable costs. Furthermore,
we do not know if the parents have discussed what their chil-
dren experienced in the app with them. However, thanks to
the answers of the parents and radiology staff, we can exclude
that the participants underwent other preparation measures
that might have interfered with our intervention.
Although VR can offer practical benefits in various pediatric
and patient preparation use cases, it might not be the right solu-
tion for every patient. Some patients may be concerned about
the technology and find the complete isolation from the real
world by the VR headset unpleasant. Also, patients, regardless
of their age, differ in their coping style in terms of whether
they seek or avoid information [19]. Some children may prefer
to know less about the MRI examination and avoid thinking
about it rather than being reminded of it through continuous
training. Moreover, it is not to underestimate that even a vir-
tual MRI examination can frighten some children. Hence, it is
necessary to inform the parents thoroughly about the possible
adverse effects of the intervention. However, the course of
the anxiety level measured in the app showed a decreasing
tendency (Figure 9). We conclude that using the Pengunaut
Trainer neither kept the anxiety level constant nor increased
it, but, as also highlighted by the results from the question-
naires, it was effective in reducing anxiety before the MRI
examination. Empirical results on the effect of VR on children
are still scarce, and it is not yet known what side-effects the
regular exposition to VR could have on child development
[2]. Therefore, it is the responsibility of scientists and content
creators to work together with pediatricians and psychologists
to develop child-appropriate and safe VR content.
The focus of this paper is the in-depth analysis of the (game)
design decisions made in the development of the Pengunaut
Trainer. Therefore, we have examined how our target group
evaluates the various aspects of our playful VR app. Our re-
sults confirm the assumption of Liszio and Masuch [25], that
the application of playful elements and VR-based desensiti-
zation can be an effective solution to reduce children’s fear
of MRI examinations. The main objective of the said study
was to verify the feasibility of this approach. In this paper,
we present the results of a more comprehensive study. Most
notably, our results illustrate the superior effectiveness of re-
peated training compared to the one-time ad-hoc intervention
directly before the MRI examination. Hence, we support and
extend the preliminary considerations of Masuch and Liszio
with game design elements that promote long-term motiva-
tion and coping-strategies. With this improved approach, we
achieve a significant enhancement of the children’s emotional
experience before the MRI examination.
CONCLUSION
This paper explores how proven psychological strategies for
patient preparation can be combined with motivational ele-
ments from applied game design to enhance young patient’s
well-being and cooperativeness before and during MRI exam-
inations. Therefore, we introduced the concept and design
of the Pengunaut Trainer. The target group received the app
with great enthusiasm. Children, parents, and the radiology
staff rated the app, the mini-games, and the accompanying
material as fun and helpful in terms of preparation for the MRI
examination. Furthermore, we observed a significant anxiety
reduction and mood enhancement of the children during the
training phase.
Acknowledgments
We thank C. Kremzow-Tennie, D. Pohl, M. Quaß and I. Schaf-
feld for their dedicated work in this project. We also thank
C. van Nahl and the staff members of the radiology depart-
ment of the Essen University Hospital as well as Dr. med. M.
Stenzel of the Children Hospital Cologne for their support.
Finally, we thank all young patients and their parents for par-
ticipating in our studies. As part of the project "VR-RLX"
(EFRE-0800500), this work was supported by the European
Regional Development Fund (ERDF) 2014-2020.
Selection and Participation of Children
The hospital’s database was scanned daily for patients who
were registered for an MRI examination. Patients whose exam-
ination was at least one week and no more than three months
in the future and who met the inclusion criteria (i.e., devel-
opmental delay, limited cognitive abilities, autism, epilepsy,
blindness) were considered eligible. Before the children were
asked to participate, a pediatrician and a radiologist judged
whether the participation was safe and reasonable for each
patient. Children and parents were fully informed about the
purpose of the study and the potential adverse effects of VR
before both parties gave written consent. The registration
procedure was conducted by a children’s nurse. 29 children
(17 girls, 12 boys) aged 5 to 11 years participated in the study.
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