Background Every year, millions of children undergo medical procedures that require anesthesia. Fear and anxiety are common among young children undergoing such procedures and can interfere with the child’s recovery and well-being. Relaxation, distraction, and education are methods that can be used to prepare children and help them cope with fear and anxiety, and serious games may be a suitable medium for these purposes. User-centered design emphasizes the involvement of end users during the development and testing of products, but involving young, preschool children may be challenging. Objective One objective of this study was to describe the development and usability of a computer-based educational health game intended for preschool children to prepare them for upcoming anesthesia. A further objective was to describe the lessons learned from using a child-centered approach with the young target group. Methods A formative mixed methods child (user)-centered study design was used to develop and test the usability of the game. Preschool children (4-6 years old) informed the game design through playful workshops (n=26), and usability testing was conducted through game-playing and interviews (n=16). Data were collected in Iceland and Finland with video-recorded direct observation and interviews, as well as children’s drawings, and analyzed with content analysis and descriptive statistics. Results The children shared their knowledge and ideas about hospitals, different emotions, and their preferences concerning game elements. Testing revealed the high usability of the game and provided important information that was used to modify the game before publishing and that will be used in its further development. Conclusions Preschool children can inform game design through playful workshops about health-related subjects that they are not necessarily familiar with but that are relevant for them. The game’s usability was improved with the participation of the target group, and the game is now ready for clinical testing.

BACKGROUND Every year, millions of children undergo medical procedures which require anesthesia. Fear and anxiety are common among young children undergoing such procedures and can interfere with the child’s recovery and wellbeing. Relaxation, distraction, and education are methods that can be used to prepare children and help them to cope with fear and anxiety and serious games may be a suitable medium for these purposes. User-centered design emphasizes the involvement of end-users during the development and testing of products, but involving young, pre-school children may be challenging. OBJECTIVE An objective of this study was to describe the development and usability of a computer-based educational health game intended for pre-school children to prepare them for upcoming anesthesia. A further objective was to describe the lessons learned from using a child-centered approach with the young target group. METHODS A formative mixed methods child (user)-centered study design was used to develop and test the usability of a serious game for pre-school aged children. The game’s purpose was to educate pre-school children about the upcoming event of anesthesia and teach them exercises to cope with fear and anxiety through relaxation, distraction, and positive self-talk. The study was interdisciplinary and involved researchers and clinicians from Iceland and Finland. Pre-school children (4-6 years-old) informed the game design through playful workshops (N=26) and usability testing was conducted through game-playing and interviews (N=16), where the ease of use, attractiveness, and functionality of the game were assessed. Data were collected in both countries with direct observation, interviews, and children’s drawings. The workshops and usability testing session were video-recorded and analyzed with content analysis and descriptive statistics. RESULTS The children were able to share with the researchers, through playing, their knowledge and ideas about hospitals, different emotions and their preferences concerning game elements such as soft toys, food, drinks, and rewards. Testing revealed the high usability of the game and provided important information that was used to modify the game before publishing and that will be used in its further development. CONCLUSIONS Pre-school children can inform game design through playful workshops about health-related subjects which they are not necessarily familiar with but that are relevant for them. The game’s usability was improved with the participation of the target group and is now ready for clinical testing by children undergoing medical procedures which include anesthesia, and children’s families. CLINICALTRIAL NA