A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial

A Serious Videogame as an Additional Therapy Tool for Training Emotional Regulation and Impulsivity Control in Severe Gambling Disorder

Background: Gambling disorder (GD) is characterized by a significant lack of self-control and is associated with impulsivity-related personality traits. It is also linked to deficits in emotional regulation and frequently co-occurs with anxiety and depression symptoms. There is also evidence that emotional dysregulation may play a mediatory role between GD and psychopathological symptomatology. Few studies have reported the outcomes of psychological interventions that specifically address these underlying processes.

Objectives: To assess the utility of the Playmancer platform, a serious video game, as an additional therapy tool in a CBT intervention for GD, and to estimate pre-post changes in measures of impulsivity, anger expression and psychopathological symptomatology.

Method: The sample comprised a single group of 16 male treatment-seeking individuals with severe GD diagnosis. Therapy intervention consisted of 16 group weekly CBT sessions and, concurrently, 10 additional weekly sessions of a serious video game. Pre-post treatment scores on South Oaks Gambling Screen (SOGS), Barratt Impulsiveness Scale (BIS-11), I7 Impulsiveness Questionnaire (I7), State-Trait Anger Expression Inventory 2 (STAXI-2), Symptom Checklist-Revised (SCL-90-R), State-Trait Anxiety Inventory (STAI-S-T), and Novelty Seeking from the Temperament and Character Inventory-Revised (TCI-R) were compared.

Results: After the intervention, significant changes were observed in several measures of impulsivity, anger expression and other psychopathological symptoms. Dropout and relapse rates during treatment were similar to those described in the literature for CBT.

Conclusion: Complementing CBT interventions for GD with a specific therapy approach like a serious video game might be helpful in addressing certain underlying factors which are usually difficult to change, including impulsivity and anger expression.

Prendre le virage des partenariats

Deux projets démontrent que la mise en œuvre de données colligées sur le terrain peut contribuer à régler des problèmes dans le milieu de la santé pour favoriser de meilleurs résultats et de plus grandes efficiences. Dans le premier exemple, une vaste coalition de partenaires publics et privés de l'Alberta recourt aux techniques de mesures améliorées et à la méthodologie du Triple objectif pour améliorer les résultats cliniques de populations de cas complexes et lourds du quartier Eastwood d'Edmonton. On espère que les conclusions novatrices qui en sont tirées seront adaptées à d'autres régions de la province. Dans le deuxième exemple, la Childhood Obesity Foundation s'associe à Merck au Canada et à Ayogo (une société de thérapies numériques située à Vancouver) et utilise le concept novateur de la « ludification » pour mobiliser les jeunes de plus en plus sédentaires du Canada et modifier leurs comportements.

The impact of effective paediatric adherence promotion interventions: systematic review and meta-analysis

BACKGROUND

Understanding the impact of effective paediatric adherence promotion interventions on patients, families and the healthcare system is necessary to inform efforts to improve healthcare quality and control costs. Building on previous research suggesting that improving adherence may have far-reaching benefits, the objective of this study was to quantify the impact of effective adherence promotion interventions for children and adolescents with a chronic medical condition on patients, families and the healthcare system.

METHODS

Authors systematically reviewed articles indexed in PubMed, PsycINFO and CINAHL to identify randomized controlled trials of paediatric adherence promotion interventions. Interventions that improved paediatric adherence and examined patient-level, family-level or healthcare system-level outcomes in children and adolescents (M age ≤ 18 years) with a chronic medical condition were included. Two authors independently extracted and classified outcome variables as patient-level (quality of life and disease-related activity restrictions), micro-level (family functioning, family conflict, caregiver quality of life, caregiver sleep interruption, caregiver days away from work and patient missed school days) or macro-level variables (emergency department visits, hospitalizations, outpatient visits and urgent care visits). Outcome variables detailed in previously published reviews (i.e. disease severity) were excluded.

RESULTS

Twenty studies representing 19 unique samples met inclusion criteria. An additional eight articles representing trials that did not significantly improve adherence were included in post hoc analyses. Compared with control interventions, effective paediatric adherence promotion interventions improved patient quality of life and family-level outcomes and decreased healthcare utilization among children and adolescents with a chronic medical condition.

CONCLUSIONS

Interdisciplinary efforts to improve healthcare quality and reduce spending among children and adolescents with a chronic medical condition may be enhanced by incorporating effective paediatric adherence promotion interventions. As relatively few chronic medical conditions were represented in included studies, future research should examine the impact of paediatric adherence promotion interventions in other populations.

Does Digital Game Interactivity Always Promote Self-Efficacy?

Interactive digital games can promote self-efficacy by engaging players in enactive and observational learning. However, interactivity does not always lead to greater self-efficacy. Important constructs in social cognitive theory, such as performance outcome and perceived similarity, are often not accounted for in studies that have tested the effect of digital game interactivity on self-efficacy. This study assessed the effects of interactive digital games compared with passive digital games based on video comparison, a common experimental design used to test the effect of digital game interactivity on self-efficacy. In addition, this study also evaluated player performance and measured perceived similarity to the observed player. Findings suggested that in general, digital game interactivity predicted higher self-efficacy compared with noninteractive passive games. However, in the noninteractive conditions, the effects of performance on self-efficacy were moderated by perceived similarity between the observer and the observed player. When the observed player was perceived to be similar to the observer, the effects of performance on self-efficacy were comparable to the interactive game, but when the observed player was perceived as dissimilar to the observer, observing the dissimilar player failed to increase observer self-efficacy. Implications for interactivity manipulations and game developers are discussed.

"Moving the needle" through partnerships

Two projects illustrate how the application of real-world evidence can help to address healthcare challenges to generate better outcomes and efficiencies. In the first example, a broad coalition of public and private partners in Alberta is applying enhanced measurement techniques and the Triple Aim methodology to improve health outcomes among complex care, high needs patients in Edmonton's Eastwood community. The innovative findings, it is hoped, will be scaled to other areas of the province. In the second example, the Childhood Obesity Foundation, with support from Merck in Canada, and Ayogo (a Vancouver-based digital therapeutics company) are partnering to use innovative "gamification" to build engagement and change behaviours among Canada's increasingly sedentary youth.

Using Videogame Apps to Assess Gains in Adolescents' Substance Use Knowledge: New Opportunities for Evaluating Intervention Exposure and Content Mastery

Background

Videogame interventions are becoming increasingly popular as a means to engage people in behavioral interventions; however, strategies for examining data from such interventions have not been developed.

Objective

The objective of this study was to describe how a technology-based intervention can yield meaningful, objective evidence of intervention exposure within a behavioral intervention. This study demonstrates the analysis of automatic log files, created by software from a videogame intervention, that catalog game play and, as proof of concept, the association of these data with changes in substance use knowledge as documented with standardized assessments.

Methods

We analyzed 3- and 6-month follow-up data from 166 participants enrolled in a randomized controlled trial evaluating a videogame intervention, PlayForward: Elm City Stories (PlayForward). PlayForward is a videogame developed as a risk reduction and prevention program targeting HIV risk behaviors (substance use and sex) in young minority adolescents. Log files were analyzed to extract the total amount of time spent playing the videogame intervention and the total number of game levels completed and beaten by each player.

Results

Completing and beating more of the game levels, and not total game play time, was related to higher substance use knowledge scores at the 3- (P=.001) and 6-month (P=.001) follow-ups.

Conclusions

Our findings highlight the potential contributions a videogame intervention can make to the study of health behavior change. Specifically, the use of objective data collected during game play can address challenges in traditional human-delivered behavioral interventions.

Trial Registration

Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6cV9fxsOg)

The Application of Gaming Theory in Health Care

As the US health care system moves rapidly toward a population health management focus in communities and care settings, the chief nursing officer has an opportunity to lead innovation efforts for patient care. One innovative strategy for use to influence patient behavior change, ongoing clinical education, and prelicensure education is the application of gaming theory into learning strategies. With the ever-increasing emphasis the general public is placing on social media and online gaming, there has been a significant push by the health sector in recent years to harness this medium for use in health management, education, and behavior change. A number of organizations and insurers have dedicated significant resources to researching and developing games and apps to help patients manage diseases, track self-management activities, and motivate behavior change for healthy lifestyles. This article shares information about gaming theory and its application to health care including a review of the science behind the theory, the use of technology, and gaming education strategies for both patients and clinicians.

Medication adherence decision-making among adolescents and young adults with cancer

PURPOSE

Nearly half of all adolescents and young adults (AYAs) with cancer struggle to adhere to oral chemotherapy or antibiotic prophylactic medication included in treatment protocols. The mechanisms that drive non-adherence remain unknown, leaving health care providers with few strategies to improve adherence among their patients. The purpose of this study was to use qualitative methods to investigate the mechanisms that drive the daily adherence decision-making process among AYAs with cancer.

METHODS

Twelve AYAs (ages 15-31) with cancer who had a current medication regimen that included oral chemotherapy or antibiotic prophylactic medication participated in this study. Adolescents and young adults completed a semi-structured interview and a card sorting task to elucidate the themes that impact adherence decision-making. Interviews were transcribed verbatim and coded twice by two independent raters to identify key themes and develop an overarching theoretical framework.

RESULTS

Adolescents and young adults with cancer described adherence decision-making as a complex, multi-dimensional process influenced by personal goals and values, knowledge, skills, and environmental and social factors. Themes were generally consistent across medication regimens but differed with age, with older AYAs discussing long-term impacts and receiving physical support from their caregivers more than younger AYAs.

CONCLUSIONS

The mechanisms that drive daily adherence decision-making among AYAs with cancer are consistent with those described in empirically-supported models of adherence among adults with other chronic medical conditions. These mechanisms offer several modifiable targets for health care providers striving to improve adherence among this vulnerable population.

Pilot Development of an Electronic Pediatric Inflammatory Bowel Disease Quiz Game

OBJECTIVES

Data suggest physicians poorly assess disease-specific literacy and transition readiness in pediatric patients with inflammatory bowel disease (IBD). We piloted an electronic, interactive iPad quiz game that could be used in a clinical setting, with the aims of measuring IBD-related knowledge, and concomitant mood and quality of life (QOL) in a pediatric population.

METHODS

Two pediatric IBD clinics developed and tested 2 versions of "Emma." Patients between 10 and 18 years of age played Emma during an office visit. Each patient answered 12 randomly selected disease-related questions and 4 mood-related questions.

RESULTS

Sites 1 and 2 tested Emma v1 between May and August 2013. Emma v2 was tested from November 2013 to January 2014 and from September 2013 to January 2014. A total of 56 patients played Emma v1, whereas 60 played Emma v2. In Emma v2, 73.1% of questions were answered correctly. Patients recognized signs of IBD (88%), causes of diarrhea in addition to IBD (79.4%), and could define lactose intolerance (95.8%), but fewer patients understood serological testing used for disease monitoring (68%) or knew that magnetic resonance enterography did not involve radiation (22.9%). Patients tended to report good functioning in the areas of energy, mood, anxiety, and school-related QOL. Patients with Crohn disease, however, reported higher stress levels compared with patients with ulcerative colitis; older patients reported lower energy levels, and postsurgical patients reported lower QOL.

CONCLUSIONS

The Emma iPad game has the potential to evaluate gaps in IBD knowledge, assess emotional functioning, and increase patient engagement as a transition tool in the clinical setting.

Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials

OBJECTIVE

There are potential benefits of playing videogames for health improvement such as increasing knowledge about health-related issues by playing educational games and fighting a sedentary lifestyle by playing exergames. The number of systematic review articles about "videogames" and "health improvement" is limited. Therefore, the purpose of this study is to review those randomized controlled trials (RCTs) with the topic of "videogames" and "health improvement."

MATERIALS AND METHODS

Several electronic databases were searched for RCTs testing videogames on health outcomes that were published in English between January 2000 and April 2012.

RESULTS

Forty-five articles met the eligibility criteria and were categorized into five groups: (1) videogames and patient pain and stress reduction (nine articles), (2) videogames and patient behavioral change (19 articles), (3) videogames and patient rehabilitation (eight articles), (4) videogames as diagnostic tools (three articles), and (5) videogames and cognitive ability (six articles).

CONCLUSIONS

Most of the articles have shown promising results in using videogames within various fields of healthcare. Although exergames are the most prominent choice regarding health improvement, videogames have the potential to be used as a pain management tool, diagnostic tool, or educational tool. They also can be used as a facilitator in physical rehabilitation or cognitive loss prevention. More RCTs are needed to fully uncover the benefits of using videogames for improving patients' health.

Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials assessing the effectiveness of serious games in improving knowledge and/or self-management behaviors in young people with chronic conditions.

MATERIALS AND METHODS

The authors searched the databases PubMed, Cochrane Library, Web of Sciences, and PsychINFO for articles published between January 1990 and January 2014. Reference lists were hand-searched to retrieve additional studies. Randomized controlled trials that compared a digital game with either standard education or no specific education in a population of children and/or adolescents with chronic conditions were included.

RESULTS

The authors identified 9 studies in which the effectiveness of serious games in young people with chronic conditions was evaluated using a randomized controlled trials design. Six studies found a significant improvement of knowledge in the game group from pretest to posttest; 4 studies showed significantly better knowledge in the game group than in the control group after the intervention. Two studies reported significantly better self-management in the game group than in the control group after the intervention. Seven studies were included in the meta-analysis. For knowledge, pooled estimate of Hedges' gu was 0.361 (95% confidence intervals, 0.098-0.624), demonstrating that serious games improve knowledge in patients. For self-management, pooled estimate of Hedges' gu was 0.310 (95% confidence intervals, 0.122-0.497), showing that gaming improves self-management behaviors.

CONCLUSIONS

The authors' meta-analysis shows that educational video games can be effective in improving knowledge and self-management in young people with chronic conditions.

Can an intervention based on a serious videogame prior to cognitive behavioral therapy be helpful in bulimia nervosa? A clinical case study

BACKGROUND

Several studies have highlighted the implications of impulsivity and novelty seeking for both the maintenance and the process of recovery from bulimia nervosa (BN). Cognitive behavioral therapy (CBT) is the treatment of choice for BN, but for some cases, this treatment alone might not be sufficient for reducing the high levels of impulsivity. The paper presents a case report of a patient with BN, examining the effectiveness of using a videogame (VG; Playmancer) as an additional intervention designed to address impulsivity.

DESIGN

Psychometric and neuropsychological measures were collected at baseline. After this assessment, Playmancer was applied prior to CBT, following an "A-B-A-C-A" single case experimental design. Impulsivity levels were assessed with the Conner's Continuous Performance Test II (CPT-II). After the Playmancer treatment, the patient started CBT, and the levels of impulsivity were recorded again. Finally, psychometric and neuropsychological measures were collected after treatment. Weekly frequency of binges and vomiting were also recorded during the entire procedure.

RESULTS

After the VG intervention, psychometric measures such as anxiety levels, impulsivity and novelty seeking decreased. Regarding the neuropsychological measures, impulsivity levels (measured with the CPT-II) progressively decreased throughout the intervention, and an improvement in decision making capacities was observed. Furthermore, the frequency of binges also decreased during and after the VG intervention.

DISCUSSION

This case report suggests that using the Playmancer VG to reduce impulsivity prior to CBT may enhance the final results of the treatment for BN.

Clinical and Neurobiological Perspectives of Empowering Pediatric Cancer Patients Using Videogames

Pediatric oncology patients often experience fatigue and physical and mental deconditioning during and following chemotherapy treatments, contributing to diminished quality of life. Patient empowerment is a core principle of patient-centered care and reflects one's ability to positively affect his or her own health behavior and health status. Empowerment interventions may enhance patients' internal locus of control, resilience, coping skills, and self-management of symptoms related to disease and therapy. Clinical and technological advancements in therapeutic videogames and mobile medical applications (mobile health) can facilitate delivery of the empowerment interventions for medical purposes. This review summarizes clinical strategies for empowering pediatric cancer patients, as well as their relationship with developing a “fighting spirit” in physical and mental health. To better understand physiological aspects of empowerment and to elucidate videogame-based intervention strategies, brain neuronal circuits and neurotransmitters during stress, fear, and resilience are also discussed. Neuroimaging studies point to the role of the reward system pathways in resilience and empowerment in patients. Taken together, videogames and mobile health applications open translational research opportunities to develop and deliver empowerment interventions to pediatric cancer patients and also to those with other chronic diseases.

Self-management interventions for young people with chronic conditions: A systematic overview

OBJECTIVE

To provide a systematic overview of self-management interventions (SMI) for young people with chronic conditions with respect to content, formats, theories, and evaluated outcomes.

METHODS

Embase, Medline, PsycINFO, Web-of-Science, CINAHL, and Cochrane were searched. Reviews' reference lists were scrutinized. Selected studies were: Original research articles in English published between 2003 and March 2014; about the evaluation of SMI for 7 to 25-year-olds with somatic chronic conditions/physical disabilities; with clear outcomes and intervention descriptions. The classification of medical, role and emotion management served to review content. Formats, theories, and evaluated outcomes were summarized.

RESULTS

86 studies were reviewed. Most aimed at medical management and were unclear about theoretical bases. Although a variety of outcomes was evaluated and the distribution over self-management domains was quite unpredictable, outcomes conceptually related to specific content. A content-based framework for the evaluation of self-management interventions is presented.

CONCLUSIONS AND PRACTICE IMPLICATIONS

SMI relate to self-management tasks and skill-building. Yet, conceptualizations of self-management support often remained unclear and content focuses predominantly on the medical domain, neglecting psycho-social challenges for chronically ill young people. Future evaluations should match outcomes/themes to content and characteristics. Our framework and overview of SMI characteristics and outcomes may assist clinicians in providing self-management support.

Psychosocial interventions for adolescents and young adult cancer patients: A systematic review and meta-analysis

Adolescent and young adult (AYA) cancer patients experience unique psychosocial needs and developmental challenges. A cancer diagnosis can stress this development and disrupt AYAs in their normal life. The aim of this systematic review and meta-analysis was to assess the impact of psychosocial interventions on mental health in AYAs. A literature research was conducted, which resulted in twelve eligible studies. The standardized mean difference between intervention and control conditions was 0.13 (95% CI: -0.16 to 0.42) for quality of life, 0.27 (95% CI: -0.22 to 0.76) for cancer-related knowledge and -0.16 (95% CI: -0.73 to 0.42) on psychological distress indicating, small and non-significant effects for interventions improving mental health. This work strengthens the need for age-appropriated interventions in psycho-oncology. Future research should develop interventions more graduated by age. Randomized intervention studies with larger samples and focusing psychosocial outcomes are needed to establish evidence-based psycho-oncological interventions for AYAs.

Guest editorial: games for learning and dialogue on humanitarian work

Purpose

– The purpose of this guest editorial is to provide the introduction and context of the Special Issue on Games for Learning and Dialogue on Humanitarian Work. The Special Issue aims to promote the development, deployment, and analysis of games for the humanitarian sector: it investigates how games can meaningfully engage people and organizations in experiencing, understanding and improving complex systems.

Design/methodology/approach

– The editorial describes the need and motivation for building a body of knowledge on the use of games in the humanitarian sector. It further gives an overview of the three papers included in this Special Issue and how they contribute to building such a body of knowledge.

Findings

– Games enable participants to experience the complexity of humanitarian systems, linking decisions with consequences. Even though game-like approaches have been used for decades in disaster management, there is little written about it. The papers included in this Special Issue provide insights and frameworks to learn from, ranging from online tools that reveal inefficiencies in supply chains, to simulated emergency response exercises, to applied improvisation. In addition, the current papers highlight the need for more empirical study of the impact of games.

Research implications/limitations

– The Special Issue describes three unique cases, which by no means cover the entire practice of games in the humanitarian sector. However, they do provide insight into the diversity of game-like approaches and signal the current state of practice and research of games for learning and dialogue on humanitarian work.

Practical implications

– This editorial gives an overview of how games could be used in practice and why they are relevant for humanitarian work. It further highlights how the contributions in the Special Issue may help in improving humanitarian work.

Originality/value

– Although review papers and Special Issues have appeared on particular topics such as climate change, to our knowledge no significant academic attention has been given to humanitarian work with regards to games.

Development and usability evaluation of the mHealth Tool for Lung Cancer (mHealth TLC): a virtual world health game for lung cancer patients

OBJECTIVE

To test the feasibility and usability of mHealth TLC, an interactive, immersive 3-dimensional iPad health game that coaches lung cancer patients toward assertive communication strategies during first-person virtual clinics visits.

METHOD

We observed players and conducted semi-structured interviews. Research questions focused on scenario believability, the impact of technical issues, transparency of game goals, and potential of mHealth TLC to decrease lung cancer stigma (LCS) and improve patient-clinician communication.

RESULTS

Eight users confirmed mHealth TLC to be: (1) believable, (2) clinic-appropriate, and (3) helpful in support of informed healthcare consumers. Concerns were expressed about emotionally charged content and plans to use mHealth TLC in clinic settings as opposed to at home.

CONCLUSIONS

Although the dialog and interactions addressed emotionally charged issues, players were able to engage, learn, and benefit from role-play in a virtual world. Health games have the potential to improve patient-clinician communication, and mHealth TLC specifically may decrease LCS, and promote optimal self-management.

PRACTICE IMPLICATIONS

Process reflection revealed the need for health games to be created by experienced game developers in collaboration with health care experts. To prepare for this best practice, research institutions and game developers interested in health games should proactively seek out networking and collaboration opportunities.

Technology-mediated interventions for enhancing medication adherence

BACKGROUND

Despite effective therapies for many conditions, patients find it difficult to adhere to prescribed treatments. Technology-mediated interventions (TMIs) are increasingly being used with the hope of improving adherence.

OBJECTIVE

To assess the effects of TMI, intended to enhance patient adherence to prescribed medications, on both medication adherence and clinical outcomes.

METHODS

A secondary in-depth analysis was conducted of the subset of studies that utilized technology in at least one component of the intervention from an updated Cochrane review on all interventions for enhancing medication adherence. We included studies that clearly described an information and communication technology or medical device as the sole or major component of the adherence intervention.

RESULTS

Thirty-eight studies were eligible for in-depth review. Only seven had a low risk of bias for study design features, primary adherence, and clinical outcomes. Eighteen studies used a TMI for education and/or counseling, 11 studies used a TMI for self-monitoring and/or feedback, and nine studies used electronic reminders. Studies used a variety of TMIs, with telephone the most common technology in use. Studies targeted a wide distribution of diseases and used a variety of adherence and clinical outcome measures. A minority targeted children and adolescents. Fourteen studies reported significant effects in both adherence and clinical outcome measures.

CONCLUSIONS

This review provides evidence for the inconsistent effectiveness of TMI for medication adherence and clinical outcomes. These results must be interpreted with caution due to a lack of high-quality studies.

Good death for children with cancer: a qualitative study

OBJECTIVE

This study aims to explore the characteristics of a good death for children with cancer.

METHODS

A total of 10 pediatric cancer survivors, 10 bereaved family members and 20 medical professionals participated in in-depth interviews. Qualitative content analysis was performed on the transcribed data obtained from semi-structured interviews.

RESULTS

Thirteen characteristics including unique and specific for children of a good death were identified: (i) sufficient opportunities to play freely, (ii) peer supporters, (iii) continued access to the patient's usual activities and relationships, (iv) assurance of privacy, (v) respect for the patient's decisions and preferences, (vi) a sense that others acknowledge and respect the patient's childhood, (vii) comfort care to minimize distressing symptoms, (viii) hope, (ix) not aware of the patient's own impending death, (x) constant dignity, (xi) strong family relationships, (xii) no sense of being a burden to family members and (xiii) good relationships with medical staffs.

CONCLUSIONS

This study identifies important characteristics of a good death for children with cancer. These findings may help medical staffs provide optimal care for children with cancer and their families, enabling them to achieve a good death.

A meta-analysis of serious digital games for healthy lifestyle promotion

Several systematic reviews have described health-promoting effects of serious games but so far no meta-analysis has been reported. This paper presents a meta-analysis of 54 serious digital game studies for healthy lifestyle promotion, in which we investigated the overall effectiveness of serious digital games on healthy lifestyle promotion outcomes and the role of theoretically and clinically important moderators. Findings showed that serious games have small positive effects on healthy lifestyles (g=0.260, 95% CI 0.148; 0.373) and their determinants (g=0.334, 95% CI 0.260; 0.407), especially for knowledge. Effects on clinical outcomes were significant, but much smaller (g=0.079, 95% CI 0.038; 0.120). Long-term effects were maintained for all outcomes except for behavior. Serious games are best individually tailored to both socio-demographic and change need information, and benefit from a strong focus on game theories or a dual theoretical foundation in both behavioral prediction and game theories. They can be effective either as a stand-alone or multi-component programs, and appeal to populations regardless of age and gender. Given that effects of games remain heterogeneous, further explorations of which game features create larger effects are needed.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

How to systematically assess serious games applied to health care

The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game's rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games.

The War on Prevention

Cancer health information is dominated by enemy and war metaphors intended to motivate the public to “fight” cancer. However, enemy metaphoric framing may influence understanding of, and responses to, cancer. Cancer prevention benefits from avoiding risk increasing behaviors, yet self-limitation is not closely associated with fighting enemies. If so, the metaphor may hurt prevention intentions involving self-limitation. Participants read messages with minute wording variations that established different metaphoric frames. Results show that metaphorically framing cancer as an enemy lessens the conceptual accessibility of (Study 1) and intention for self-limiting prevention behaviors while not increasing intention for monitoring and treatment behaviors (Studies 2 and 3). Framing self-limiting prevention behaviors in terms of fighting an enemy increases their appeal, illustrating the benefits of metaphor matching (Study 3). Overall, these results suggest that enemy metaphors in cancer information reduce some prevention intentions without increasing others, making their use potentially harmful for public health.

Web-based, mobile-device friendly, self-report survey system incorporating avatars and gaming console techniques

We describe building an avatar-based self-report data collection tool to be used for a specific HIV prevention research project that is evaluating the feasibility and acceptability of this novel approach to collect self-reported data among youth. We discuss the gathering of requirements, the process of building a prototype of the envisioned system, and the lessons learned during the development of the solution. Specific knowledge is shared regarding technical experience with software development technologies and possible avenues for changes that could be considered if such a self-report survey system is used again. Examples of other gaming and avatar technology systems are included to provide further background.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Using an Educational Multimedia Application to Prepare Children for Outpatient Surgeries

Surgery is a highly stressful event for children and caregivers. Extensive effort has been made to improve preoperative care in order to alleviate worry about the surgical procedure itself. This study tested the impact of an educational multimedia intervention on the cognitive, emotional, and physiological responses of children undergoing surgery, as well as on parental state anxiety. Children (n = 90) were assigned to three different groups: an educational multimedia intervention (experimental group), an entertainment video game intervention (comparison group), and a control group (no intervention). Children who received the educational multimedia intervention reported lower level of worries about hospitalization, medical procedures, illness, and negative consequences than those in the control and in the comparison groups. Parental state anxiety was also lower in the both the educational and the entertainment video game interventions compared to the control group. These findings suggest that providing information to children regarding medical procedures and hospital rules and routines is important to reduce their preoperative worries, and also relevant for parental anxiety.

The effects of an informational video on patient knowledge, satisfaction and compliance with venous thromboembolism prophylaxis: a pilot study

OBJECTIVE

Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Educational videos have been effectively used to increase patient satisfaction and knowledge. This study examined possible benefits of an educational video about VTE.

METHODS

Medical patients receiving VTE prophylaxis were screened within 48 h of admission. Upon enrollment, patients were randomly assigned to either watch a 5 min educational video on VTE or not, in addition to standard VTE education. Within 24-48 h after randomization, all patients completed a survey assessing VTE prophylaxis knowledge and satisfaction.

RESULTS

Patients who watched the video averaged 83% correct responses to knowledge-based questions (regarding VTE risk, symptoms, and preventative measures) versus an average score of 62% for patients in the no video group (p<0.001). Patients who watched the video were more satisfied with their VTE education (4.8 vs. 3.4 out of 5, p<0.001).

CONCLUSION

This educational video effectively provided baseline information to patients about VTE and improved patient satisfaction.

PRACTICE IMPLICATIONS

A VTE educational video can be an effective tool for improving patient knowledge of the condition.

Combining non-pharmacological treatments with pharmacotherapies for neurological disorders: a unique interface of the brain, drug-device, and intellectual property

Mobile medical applications (mHealth), music, and video games are being developed and tested for their ability to improve pharmacotherapy outcomes and medication adherence. Pleiotropic mechanism of music and gamification engages an intrinsic motivation and the brain reward system, supporting therapies in patients with neurological disorders, including neuropathic pain, depression, anxiety, or neurodegenerative disorders. Based on accumulating results from clinical trials, an innovative combination treatment of epilepsy seizures, comorbidities, and the medication non-adherence can be designed, consisting of antiepileptic drugs and disease self-management software delivering clinically beneficial music. Since creative elements and art expressed in games, music, and software are copyrighted, therefore clinical and regulatory challenges in developing copyrighted, drug–device therapies may be offset by a value proposition of the exclusivity due to the patent–independent protection, which can last for over 70 years. Taken together, development of copyrighted non-pharmacological treatments (e-therapies), and their combinations with pharmacotherapies, offer incentives to chronically ill patients and outcome-driven health care industries.

Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness

OBJECTIVE

This meta-analysis examined the effectiveness of recent adherence-promoting interventions for youth with chronic health conditions.

METHODS

Peer-reviewed randomized controlled trials of adherence-promoting interventions for youth with a chronic illness published between 2007 and 2013 (n = 23) were reviewed. Intervention delivery (in-person vs. technology-based) and outcome measurement (e.g., self-report) were examined as potential moderators of treatment effects.

RESULTS

Mean effect sizes were small at posttreatment (d = 0.20, 95% confidence interval (CI): 0.08, 0.31, n = 23) and follow-up (d = 0.29, 95% CI: 0.15, 0.43, n = 9). Intervention delivery and outcome measurement did not account for variation in treatment effects (p > .05).

CONCLUSIONS

The small treatment effects of recent adherence-promoting intervention (APIs) reflect the methodological limitations of the included studies and the need to reexamine the delivery and mechanisms of adherence-promoting interventions.

Game playbooks: tools to guide multidisciplinary teams in developing videogame-based behavior change interventions

As mobile technologies and videogaming platforms are becoming increasingly prevalent in the realm of health and healthcare, so are the opportunities to use these resources to conduct behavioral interventions. The creation and empirical testing of game style interventions, however, is challenged by the requisite collaboration of multidisciplinary teams, including researchers and game developers who have different cultures, terminologies, and standards of evidence. Thus, traditional intervention development tools such as logic models and intervention manuals may need to be augmented by creating what we have termed "Game Playbooks" which are intervention guidebooks that are created by, understood by, and acceptable to all members of the multidisciplinary game development team. The purpose of this paper is to describe the importance and content of a Game Playbook created to aide in the development of a videogame intervention designed specifically for health behavior change in young teens as well as the process for creating such a tool. We draw on the experience of our research and game design team to describe the critical components of the Game Playbook and the necessity of creating such a tool.

Examining key design decisions involved in developing a serious game for child sexual abuse prevention

This paper presents a case study of the key decisions made in the design of Orbit, a child sexual abuse prevention computer game targeted at school students between 8 and 10 years of age. Key decisions include providing supported delivery for the target age group, featuring adults in the program, not over-sanitizing game content, having a focus on building healthy self-concept of players, making the game engaging and relatable for all players and evaluating the program. This case study has implications for the design of Serious Games more generally, including that research should underpin game design decisions, game designers should consider ways of bridging the game to real life, the learning that arises from the game should go beyond rote-learning, designers should consider how the player can make the game-world their own and comprehensive evaluations of Serious Games should be undertaken.

Effect of a novel video game on stroke knowledge of 9- to 10-year-old, low-income children

BACKGROUND AND PURPOSE

Improving actionable stroke knowledge of a witness or bystander, which in some cases are children, may improve response to an acute stroke event.

METHODS

We used a quasiexperimental pre-test post-test design to evaluate actionable stroke knowledge of 210 children aged 9 to 10 years in response to a single, 15-minute exposure to a stroke education video game conducted in the school computer laboratory. After immediate post-test, we provided remote password-protected online video game access and encouraged children to play at their leisure from home. An unannounced delayed post-test occurred 7 weeks later.

RESULTS

Two hundred ten children completed pretest, 205 completed immediate post-test, whereas 198 completed delayed post-test. One hundred fifty-six (74%) children had Internet access at home, and 41 (26%), mostly girls, played the video game remotely. There was significant improvement in stroke symptom composite scores, calling 911, and all individual stroke knowledge items, including a distractor across the testing sequence (P<0.05). Children who played the video game remotely demonstrated significant improvement in knowledge of 1 symptom (sudden imbalance) compared with children who did not (P<0.05), although overall composite scores showed no difference.

CONCLUSIONS

Stroke education video games may represent novel means for improving and sustaining actionable stroke knowledge of children.

Computer games supporting cognitive behaviour therapy in children

Therapeutic computer games might enhance children's motivation for psychotherapy, facilitate their understanding of important therapeutic concepts, structure therapy sessions, enhance treatment of migrant children and disseminate evidence-based treatment approaches. The game Treasure Hunt was developed to support cognitive behaviour therapy with children who come into treatment for various mental health problems. To evaluate the applicability and appropriateness of the game, 124 therapists answered a questionnaire on their impression of Treasure Hunt three months after download. Of these, 42 consented to participate in the further evaluation and sent questionnaires of 218 children in whose therapy Treasure Hunt had been used. A limitation of these data is an eventual positive bias, as therapists with a positive attitude towards therapeutic computer games may have been more likely to participate. Data show that the vast majority of children were satisfied their therapist had used the game during treatment. Therapists used Treasure Hunt for a broad range of diagnoses. They judged the game as helpful in the explanation of cognitive-behavioural concepts, used it as reinforcement and reported it enhanced child motivation for psychotherapy and strengthened the therapeutic relationship with the child.

The Efficacy of Casual Videogame Play in Reducing Clinical Depression: A Randomized Controlled Study

BACKGROUND

Depression is a debilitating illness that is estimated to affect more than 300 million people worldwide. Although there has been some success in treatment of this illness with pharmaceuticals and behavioral techniques like cognitive behavioral therapy, these are often costly and have stigma associated with them. The purpose of this study was to test whether a prescribed regimen of casual videogame (CVG) play could reduce symptoms associated with depression.

SUBJECTS AND METHODS

Participants were screened for depression using the Patient Health Questionnaire-9 (PHQ-9). They were then randomized into the control (n=29) or experimental (n=30) group. Experimental participants were prescribed to play CVGs three times per week (with 24 hours between each session), for 30 minutes, over a 1-month period. Control participants surfed the National Institute of Mental Health's Web page on depression. The instrument used to test the hypothesis was the PHQ-9.

RESULTS

Repeated-measures statistical analyses revealed there was a significant interaction of group and time, supporting the hypothesis that the groups would be different after the intervention. Moreover, when data were compared using tests of within-subjects contrasts between baseline (Time 1) and the end of the 1-month study (Time 3), we found significant decreases in depression symptoms in the experimental group. When this was compared with the control group changes, the results were still significant.

CONCLUSIONS

We found that a prescribed regimen of playing CVGs significantly reduced symptoms of clinical depression as measured by the PHQ-9. Clinicians should consider these low-cost CVGs as a possible intervention to address psychological and somatic symptoms associated with depression.

Adapting a Videogame to the Needs of Pediatric Cancer Patients and Survivors

OBJECTIVE

This study assessed whether two serious videogames, "Escape from Diab" (Diab) and "Nanoswarm: Invasion from Inner Space" (Nano) (both from Archimage, Inc., Houston, TX) shown to effect change in healthy children's diet and possibly physical activity are acceptable for obesity prevention among pediatric cancer patients and survivors at high risk of obesity.

PATIENTS AND METHODS

Pediatric (9-12-year-old) cancer patients and survivors (n=28) were randomly assigned to one of three groups: Group A, watched film adaptations of both game stories and played the first two episodes of each game; Group B, played all of Diab; or Group C, played all of Nano. Qualitative interviews about what the children liked and didn't like and what should be changed were conducted midway and at the end of each group's participation. Data were analyzed using thematic analysis.

RESULTS

Pediatric cancer patients and survivors enjoyed playing both games. Two themes emerged to guide future modifications of the game: Three patients reported difficulty with the energy balance and meal selection portion of Nano, and four patients stated endings showing a character dying made them sad.

CONCLUSIONS

Two serious videogames designed to promote healthier diet and increased physical activity among healthy children were also found to be acceptable by pediatric cancer patients and survivors. Easier options needed to be programmed into energy balance games in Nano. To avoid possible emotional reactions, such as sadness, Nano's ending will be revised so that a character does not die from his affliction. Minor changes will be made in other gameplay mechanics and storylines to meet target audience needs and preferences.

Lost in Translation

In light of a growing body of work demonstrating the ability of games to transform cognitive skill sets and change attitudes toward social issues, including in public health, it is crucial to understand the potentially divergent experiences and outcomes afforded by analog and digital platforms. In a recent empirical study, the authors addressed the basic question of whether transferring a public health game from an analog to a digital format would impact players’ perceptions of the game and the efficacy of the game for stimulating changes to beliefs and cognitions. Results revealed that the digital version of the game, despite being a nearly identical translation, was perceived by players to be more complicated than the analog version and, consequently, was less effective at facilitating learning and attitude change. The authors propose several explanations for this finding, based on psychological theories, to help elucidate critical distinctions between non-digital and digital game play phenomenology.

Patient-empowerment interactive technologies

Video games capture the rapt attention of an individual player's mind and body, providing new opportunities for personalized health care. An example of therapeutic interactive technologies is an incentive-based video game that translates physical exercise into mental empowerment via motivational metaphoric visualization in order to help patients psychologically overcome cancer. Such nonpharmacological interventions may enhance patients' resilience toward various chronic disorders via neuronal mechanisms that activate positive emotions and the reward system.

Interventions for promoting participation in shared decision-making for children with cancer

BACKGROUND

Children's rights to have their views heard in matters that affect their lives are now well established since the publication of the UN Convention treaty (1989). Children with cancer generally prefer to be involved in decision-making and consider it important that they have the opportunity to take part in decision-making concerning their health care, even in end-of-life decisions. There is considerable support for involving children in healthcare decision-making at a level commensurate with their experience, age and abilities. Thus healthcare professionals and parents need to know how they should involve children in decision-making and what interventions are most effective in promoting shared decision-making (SDM) for children with cancer.

OBJECTIVES

To examine the effects of SDM interventions on the process of SDM for children with cancer who are aged four to 18 years.

SEARCH METHODS

We searched the following sources: Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, Issue 9, 2012); PubMed (1946 to September 2012); EMBASE (1974 to September 2012); CINAHL (1982 to September 2012); PsycINFO (1806 to September 2012); BIOSIS (1980 to December 2009 - subscription ceased at that date); ERIC (1966 to September 2012); ProQuest Dissertations and Theses (1637 to September 2012); and Sociological Abstracts (1952 to September 2012). We searched for information about trials not registered in these resources, either published or unpublished, by searching the reference lists of relevant articles and review articles and the following conference proceedings (2005-2012):American Academy on Communication in Healthcare (AACH), European Society for Medical Oncology (ESMO), European Cancer Conference (ECCO), European Association for Communication in Healthcare (EACH), International Conference on Communication in Healthcare (ICCH), International Shared Decision Making Conference (ISDM 2005-2011 as held every two years), Annual Conference of the International Society for Paediatric Oncology (SIOP) and Annual Scientific Meeting of the Society for Medical Decision Making (SMDM).We searched the International Scientific and Technical Proceedings database (2005 to September 2012). We also searched Dissertation Abstracts (from 1980 to September 2012).We scanned the ISRCTN (International Standard Randomized Controlled Trial Number) register and the National Institute of Health (NIH) Register for ongoing trials at: www.controlled-trials.com and clinicaltrials.gov on the 1 October 2012. We contacted authors for further details. We also contacted experts in this field.We did not impose language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of SDM interventions for children with cancer aged four to 18 years. The types of decisions included were: treatment, health care, and research participation decisions. The primary outcome was SDM as measured with any validated scale.

DATA COLLECTION AND ANALYSIS

Two review authors undertook the searches, and three review authors independently assessed the studies obtained. We contacted study authors for additional information.

MAIN RESULTS

No studies met the inclusion criteria, and hence no analysis could be undertaken.

AUTHORS' CONCLUSIONS

No conclusions can be made on the effects of interventions to promote SDM for children with cancer aged four to 18 years. This review has highlighted the dearth of high-quality quantitative research on interventions to promote participation in SDM for children with cancer. There are many potential reasons for the lack of SDM intervention studies with children. Attitudes towards children's participation are slowly changing in society and such changes may take time to be translated or adopted in healthcare settings. The priority may be on developing interventions that promote children's participation in communication interactions since information-sharing is a prerequisite for SDM. Restricting this review to RCTs was a limitation and extending the review to non-randomised studies (NRS) may have produced more evidence. We plan to expand the types of studies in future updates. Clearly more research is needed.

Health promotion for adolescent childhood leukemia survivors: building on prevention science and ehealth

Teenage survivors of childhood acute lymphoblastic leukemia (ALL) have increased morbidity likely due to their prior multicomponent treatment. Habits established in adolescence can impact individuals' subsequent adult behaviors. Accordingly, healthy lifestyles, avoiding harmful actions, and appropriate disease surveillance are of heightened importance among teenage survivors. We review the findings from prevention science and their relevance to heath promotion. The capabilities and current uses of eHealth components including e-learning, serious video games, exergaming, behavior tracking, individual messaging, and social networking are briefly presented. The health promotion needs of adolescent survivors are aligned with those eHealth aspects to propose a new paradigm to enhance the wellbeing of adolescent ALL survivors.

Electronic media-based health interventions promoting behavior change in youth: a systematic review

IMPORTANCE

Little research has been done on the efficacy of electronic media-based interventions, especially on their effect on health or safety behavior. The current review systematically identified and evaluated electronic media-based interventions that focused on promoting health and safety behavior change in youth.

OBJECTIVE

To assess the type and quality of the studies evaluating the effects of electronic media-based interventions on health and safety behavior change.

EVIDENCE REVIEW

Studies were identified from searches in MEDLINE (1950 through September 2010) and PsycINFO (1967 through September 2010). The review included published studies of interventions that used electronic media and focused on changes in behavior related to health or safety in children aged 18 years or younger.

FINDINGS

Nineteen studies met the criteria and focused on at least 1 behavior change outcome. The focus was interventions related to physical activity and/or nutrition in 7 studies, on asthma in 6, safety behaviors in 3, sexual risk behaviors in 2, and diabetes mellitus in 1. Seventeen studies reported at least 1 statistically significant effect on behavior change outcomes, including an increase in fruit, juice, or vegetable consumption; an increase in physical activity; improved asthma self-management; acquisition of street and fire safety skills; and sexual abstinence. Only 5 of the 19 studies were rated as excellent.

CONCLUSIONS AND RELEVANCE

Our systematic review suggests that interventions using electronic media can improve health and safety behaviors in young persons, but there is a need for higher-quality, rigorous interventions that promote behavior change.

InSpire to Promote Lung Assessment in Youth: Evolving the Self-Management Paradigms of Young People With Asthma

Background

Asthma is the most common chronic disease in childhood, disproportionately affecting urban, minority, and disadvantaged children. Individualized care plans supported by daily lung-function monitoring can reduce morbidity and mortality. However, despite 20 years of interventions to increase adherence, only 50% of US youth accurately follow their care plans, which leads to millions of preventable hospitalizations, emergency room visits, and sick days every year. We present a feasibility study of a novel, user-centered approach to increasing young people’s lung-function monitoring and asthma self-care. Promoting Lung Assessment in Youth (PLAY) helps young people become active managers of their asthma through the Web 2.0 principles of participation, cocreation, and information sharing. Specifically, PLAY combines an inexpensive, portable spirometer with the motivational power and convenience of mobile phones and virtual-community gaming.

Objective

The objective of this study was to develop and pilot test InSpire, a fully functional interface between a handheld spirometer and an interactive game and individualized asthma-care instant-messaging system housed on a mobile phone.

Methods

InSpire is an application for mobile smartphones that creates a compelling world in which youth collaborate with their physicians on managing their asthma. Drawing from design-theory on global timer mechanics and role playing, we incentivized completing spirometry maneuvers by making them an engaging part of a game young people would want to play. The data can be sent wirelessly to health specialists and return care recommendations to patients in real-time. By making it portable and similar to applications normally desired by the target demographic, InSpire is able to seamlessly incorporate asthma management into their lifestyle.

Results

We describe the development process of building and testing the InSpire prototype. To our knowledge, the prototype is a first-of-its kind mobile one-stop shop for asthma management. Feasibility testing in children aged 7 to 14 with asthma assessed likability of the graphical user interface as well as young people’s interest in our incentivizing system. Nearly 100% of children surveyed said they would play games like those in PLAY if they involved breathing into a spirometer. Two-thirds said they would prefer PLAY over the spirometer alone, whereas 1/3 would prefer having both. No children said they would prefer the spirometer over PLAY.

Conclusions

Previous efforts at home-monitoring of asthma in children have experienced rapid decline in adherence. An inexpensive monitoring technology combined with the computation, interactive communication, and display ability of a mobile phone is a promising approach to sustainable adherence to lung-function monitoring and care plans. An exciting game that redefines the way youth conduct health management by inviting them to collaborate in their health better can be an incentive and a catalyst for more far-reaching goals.