Gamification of Medication Adherence in Epilepsy

Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation

Background

Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach "gamified behavioral simulation." In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions.

Objective

This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence.

Methods

A laboratory experiment was conducted using a modified popular and addictive open-source video game called "2048," which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups ("incentive" group, "reminder" group, "commitment device" group, and "elongated duration for symptoms" group).

Results

The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI -33.97% to -11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen.

Conclusions

Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial.

Attraction and achievement as 2 attributes of gamification in healthcare: an evolutionary concept analysis

This study conducted a conceptual analysis of gamification in healthcare utilizing Rogers’ evolutionary concept analysis methodology to identify its attributes and provide a method for its applications in the healthcare field. Gamification has recently been used as a health intervention and education method, but the concept is used inconsistently and confusingly. A literature review was conducted to derive definitions, surrogate terms, antecedents, influencing factors, attributes (characteristics with dimensions and features), related concepts, consequences, implications, and hypotheses from various academic fields. A total of 56 journal articles in English and Korean, published between August 2 and August 7, 2023, were extracted from databases such as PubMed Central, the Institute of Electrical and Electronics Engineers, the Association for Computing Machinery Digital Library, the Research Information Sharing Service, and the Korean Studies Information Service System, using the keywords “gamification” and “healthcare.” These articles were then analyzed. Gamification in healthcare is defined as the application of game elements in health-related contexts to improve health outcomes. The attributes of this concept were categorized into 2 main areas: attraction and achievement. These categories encompass various strategies for synchronization, enjoyable engagement, visual rewards, and goal-reinforcing frames. Through a multidisciplinary analysis of the concept’s attributes and influencing factors, this paper provides practical strategies for implementing gamification in health interventions. When developing a gamification strategy, healthcare providers can reference this analysis to ensure the game elements are used both appropriately and effectively.

Enhancing tuberculosis treatment adherence and motivation through gamified real-time mobile app utilization: a single-arm intervention study

BACKGROUND

Finding innovative methods to enhance Tuberculosis treatment adherence in Malaysia is imperative, given the rising trend of non-adhere TB patients. Direct Observed Therapy (DOTS) has been used to ensure Tuberculosis (TB) drug compliance worldwide. However, due to its inconvenience, digitalizing this system into a virtual monitoring system via a mobile app can help deliver a more efficient tuberculosis management system. A gamified video-observed therapy is developed that connects three users the patient, supervisor, and administrator, allowing drug monitoring and patient loss to follow up with the patient tracking system. Thus, the objective of this study is to determine the impact of Gamified Real-time Video Observed Therapy (GRVOTS) mobile apps on patient medication adherence rates and motivation.

METHODS

71 patients from 18 facilities participated in the 8-week single-arm intervention study. GRVOTS mobile apps were installed in their mobile apps, and patients were expected to fulfill tasks such as providing Video Direct Observe Therapy (VDOTS) daily as well as side effect reporting. At 3-time intervals of baseline,1-month, and 2-month intervals, the number of VDOT taken, the Malaysian Medication Adherence Assessment Tool (MyMAAT), and the Intrinsic Motivation Inventory (IMI) questionnaire were collected. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals.

RESULTS

This study involved 71 numbers of patients from 18 healthcare facilities who showed a significantly higher treatment adherence score of 90.87% than a standard score of 80% with a mean difference of 10.87(95% CI: 7.29,14.46; p < 0.001). The participants' MyMAAT and IMI scores significantly increased over 3-time intervals with the IMI Interest domain showing the highest mean difference 19.76 (95% CI: 16.37, 21.152: p < 0.001).

CONCLUSIONS

By utilizing GRVOTS, a mobile application based on gamification and real-time features, we can enhance motivation and medication adherence among TB patients, while also addressing the limitations of physical DOTS.

TRIAL REGISTRATION

IRCT20230308057657N1, Registered on (15/03/23).

Medication compliance of children with epilepsy: a cross-sectional survey

BACKGROUND

Good medication compliance is very important for the prognosis of children with epilepsy. We aimed to evaluate the status and influencing factors of medication compliance in children with epilepsy and to provide insights to the clinical nursing care of children with epilepsy.

METHODS

We selected epileptic children admitted to Children's Hospital of Nanjing Medical University from February 1, 2022 to August 31, 2022. Self-designed questionnaire and medication compliance scale were used to evaluate the characteristics and medication compliance of children with epilepsy. Pearson correlation analysis and multivariate logistic regression were used to analyze the influencing factors of medication compliance.

RESULTS

A total of 156 children with epilepsy were included, the incidence of poor compliance in children with epilepsy was 37.18%. Pearson correlation analysis indicated that age(r = 0.622), courses of epilepsy(r = 0.553), parental education level(r = 0.506), monthly household income(r = 0.652) and number of drugs taken(r = 0.577) were correlated with the compliance(all P<0.05). Logistic regression analyses indicated that age ≤ 6 y(OR = 2.104, 95%CI: 1.712 ~ 2.527), courses of epilepsy ≤ 3 years(OR = 2.661, 95%CI: 2.089 ~ 2.941), low parental education level(OR = 1.977, 95%CI: 1.314 ~ 2.351), monthly household income ≤ 5000 RMB(OR = 2.812, 95%CI: 2.194 ~ 3.181), number of drugs taken ≥ 3(OR = 3.025, 95%CI: 2.336 ~ 3.475) were the influencing factors of medication compliance in children with epilepsy(all P<0.05).

CONCLUSIONS

The medication compliance of children with epilepsy needs to be improved, and the medication compliance of children is affected by age, courses of epilepsy, parental education level, monthly household income and number of drugs taken. Clinical medical personnel take targeted nursing measures against these factors to improve the medication compliance of children with epilepsy.

Gamification to Improve Medication Adherence: A Mixed-method Usability Study for MedScrab

Medication non-adherence is a prevalent healthcare problem with poor health outcomes and added healthcare costs. MedScrab, a gamification-based mHealth app, is the first attempt to deliver crucial life-saving medication information to patients and increase their medication adherence. The paper presents the development of MedScrab and a two-phase mixed-method usability evaluation of MedScrab. Phase I qualitatively evaluated MedScrab using a think-aloud protocol for its usability. With 51 participants, qualitative data analysis of Phase I revealed two themes: positive functionality of the app and four areas of improvement. The improvement recommendations were incorporated into MedScrab's design. Phase I also validated a widely used mHealth App Usability Questionnaire (MAUQ). Quantitative data analysis of Phase I reduced the original 18-item MAUQ scale to a 15-item scale with two factors: ease of use (4 items) and usefulness and satisfaction (11 items). Phase II surveyed 83 participants from Amazon's Mechanical Turk using a modified MAUQ. The modified MAUQ scale showed strong internal consistency (Cronbach alpha = 0.959) and high factor loadings (between 0.623 and 0.987). The study design of the usability evaluation can serve as a methodological guide for designing, evaluating, and improving mHealth apps.The usability study showed that MedScrab was perceived as ease of use (6.24 out of 7) with high usefulness and satisfaction (5.72 out of 7). The quantitative data analysis results support the use of the modified MAUQ as a valid instrument to measure the usability of the MedScrab. However, the instrument should be used with adaptation based on the app's characteristics.

The impact of Exergames on emotional experience: a systematic review

Background

Gamification has proven to be a significant tool for health promotion, with a particular focus on physical activities such as Exergames, which improve not only physical, but also cognitive health. However, it is still not clear what effect the practice of Exergames has on changing the emotional experience.

Purpose

The objective of this systematic review is to evaluate the impact of Exergames training on emotional experience.

Methods

A systematic search was conducted in the PUBMED and SCOPUS databases. The relevant articles were screened independently by three researchers. Data concerning emotional measures and Exergame practice were extracted for analysis.

Results

The search yielded 38 articles, of which 16 were included. Exergames were found to significantly impact happiness, anxiety, depressive symptoms, mental health-related quality of life, self-worth, self-esteem, self-efficacy, perceived behavioral control, vigor, vitality, intrinsic motivation, perceived energy, and relaxation.

Conclusion

Our review supports the evidence that the practice of physical activity through Exergames, on the emotional experience generally generates an increase in positive emotions. In this sense, the results found support both the use of Exergames as a leisure activity that promotes wellbeing and emotional regulation, as well as for health promotion, public health, and clinical practice purposes. Our review strongly supports the notion that engaging in physical activity through Exergames generally leads to an increase in positive emotions. As a result, these findings endorse the utilization of Exergames as a leisure activity to promote well-being and emotional regulation. Moreover, Exergames hold potential for health promotion, public health, and clinical practice purposes.

Augmented and virtual reality in spine surgery

Augmented Reality (AR) and Virtual Reality (VR) have developed unprecedentedly in recent years, providing interesting opportunities for medical applications. Their integration into clinical assessment, surgical workflow, and training has shown tremendous potential to improve daily life activity in spine surgery. The paper explores the utilization of VR and AR in spine surgery, with their applications, benefits, challenges, and forthcoming prospects.

Gamified learning in dermatology and dermoscopy education: a paradigm shift

Teaching methods in medical education have been changing. More recent teaching modalities have gone beyond the traditional delivery of knowledge, promoting learning motivation, and improving teaching and learning outcomes. 'Gamification' and 'serious games' are methodologies that use the principles of games to facilitate learning processes and the acquisition of skills and knowledge, thereby improving attitudes towards learning when compared with traditional teaching methods. As dermatology is a visual field, images are a key component of different teaching strategies. Likewise, dermoscopy, a noninvasive diagnostic technique that allows the visualization of structures within the epidermis and upper dermis, also uses images and pattern recognition strategies. A series of Apps using game-based strategy have been created to teach and facilitate dermoscopy learning; however, studies are required to demonstrate their effectiveness. This review summarizes the current evidence of game-based learning strategies in medical education, including dermatology and dermoscopy.

The Effect of Mental Health App Customization on Depressive Symptoms in College Students: Randomized Controlled Trial

BACKGROUND

Mental health apps have shown promise in improving mental health symptoms, including depressive symptoms. However, limited research has been aimed at understanding how specific app features and designs can optimize the therapeutic benefits and adherence to such mental health apps.

OBJECTIVE

The primary purpose of this study is to investigate the effect of avatar customization on depressive symptoms and adherence to use a novel cognitive behavioral therapy (CBT)-based mental health app. The secondary aim is to examine whether specific app features, including journaling, mood tracking, and reminders, affect the usability of the mental health app.

METHODS

College students were recruited from a university study recruitment pool website and via flyer advertisements throughout campus. A total of 94 participants completed a randomized controlled trial in which they were randomized to either customization or no customization version of the app. Customization involved personalizing a virtual avatar and a travel vehicle to one's own preferences and use of one's name throughout the app. Participants completed a 14-day trial using a novel CBT-based mental health app called AirHeart. Self-report scores for depressive symptoms, anxiety, and stress were measured at baseline and after the intervention. Postintervention survey measures also included usability and avatar identification questionnaires.

RESULTS

Of the 94 enrolled participants, 83 (88%) completed the intervention and postintervention assessments. AirHeart app use significantly reduced symptoms of depression (P=.006) from baseline to the end of the 2-week intervention period for all participants, regardless of the customization condition. However, no differences in depressive symptoms (P=.17) or adherence (P=.80) were observed between the customization (39/83, 47%) and no customization (44/83, 53%) conditions. The frequency of journaling, usefulness of mood tracking, and helpfulness of reminders were not associated with changes in depressive symptoms or adherence (P>.05). Exploratory analyses showed that there were 3 moderate positive correlations between avatar identification and depressive symptoms (identification: r=-0.312, P=.02; connection: r=-0.305, P=.02; and lack of relatability: r=0.338, P=.01).

CONCLUSIONS

These results indicate that CBT mental health apps, such as AirHeart, have the potential to reduce depressive symptoms over a short intervention period. The randomized controlled trial results demonstrated that customization of app features, such as avatars, does not further reduce depressive symptoms over and above the CBT modules and standard app features, including journal, reminders, and mood tracking. However, further research elucidating the relationship between virtual avatar identification and mental health systems is needed as society becomes increasingly more digitized. These findings have potential implications for improving the optimization of mental health app designs.

TRIAL REGISTRATION

Open Science Framework t28gm; https://osf.io/t28gm.

Factors Influencing Adherence to mHealth Apps for Prevention or Management of Noncommunicable Diseases: Systematic Review

BACKGROUND

Mobile health (mHealth) apps show vast potential in supporting patients and health care systems with the increasing prevalence and economic costs of noncommunicable diseases (NCDs) worldwide. However, despite the availability of evidence-based mHealth apps, a substantial proportion of users do not adhere to them as intended and may consequently not receive treatment. Therefore, understanding the factors that act as barriers to or facilitators of adherence is a fundamental concern in preventing intervention dropouts and increasing the effectiveness of digital health interventions.

OBJECTIVE

This review aimed to help stakeholders develop more effective digital health interventions by identifying factors influencing the continued use of mHealth apps targeting NCDs. We further derived quantified adherence scores for various health domains to validate the qualitative findings and explore adherence benchmarks.

METHODS

A comprehensive systematic literature search (January 2007 to December 2020) was conducted on MEDLINE, Embase, Web of Science, Scopus, and ACM Digital Library. Data on intended use, actual use, and factors influencing adherence were extracted. Intervention-related and patient-related factors with a positive or negative influence on adherence are presented separately for the health domains of NCD self-management, mental health, substance use, nutrition, physical activity, weight loss, multicomponent lifestyle interventions, mindfulness, and other NCDs. Quantified adherence measures, calculated as the ratio between the estimated intended use and actual use, were derived for each study and compared with the qualitative findings.

RESULTS

The literature search yielded 2862 potentially relevant articles, of which 99 (3.46%) were included as part of the inclusion criteria. A total of 4 intervention-related factors indicated positive effects on adherence across all health domains: personalization or tailoring of the content of mHealth apps to the individual needs of the user, reminders in the form of individualized push notifications, user-friendly and technically stable app design, and personal support complementary to the digital intervention. Social and gamification features were also identified as drivers of app adherence across several health domains. A wide variety of patient-related factors such as user characteristics or recruitment channels further affects adherence. The derived adherence scores of the included mHealth apps averaged 56.0% (SD 24.4%).

CONCLUSIONS

This study contributes to the scarce scientific evidence on factors that positively or negatively influence adherence to mHealth apps and is the first to quantitatively compare adherence relative to the intended use of various health domains. As underlying studies mostly have a pilot character with short study durations, research on factors influencing adherence to mHealth apps is still limited. To facilitate future research on mHealth app adherence, researchers should clearly outline and justify the app's intended use; report objective data on actual use relative to the intended use; and, ideally, provide long-term use and retention data.

Mobile Applications for Epilepsy: Where Are We? Where Should We Go? A Systematic Review

The development of mobile health for epilepsy has grown in the last years, bringing new applications (apps) to the market and improving already existing ones. In this systematic review, we analyse the scope of mobile apps for seizure detection and epilepsy self-management, with two research questions in mind: what are the characteristics of current solutions and do they meet users’ requirements? What should be considered when designing mobile health for epilepsy? We used PRISMA methodology to search within App Store and Google Play Store from February to April of 2021, reaching 55 potential apps. A more thorough analysis regarding particular features was performed on 26 of those apps. The content of these apps was evaluated in five categories, regarding if there was personalisable content; features related to medication management; what aspects of seizure log were present; what type of communication prevailed; and if there was any content related to seizure alarm or seizure action plans. Moreover, the 26 apps were evaluated through using MARS by six raters, including two neurologists. The analysis of MARS categories was performed for the top and bottom apps, to understand the core differences. Overall, the lowest MARS scores were related to engagement and information, which play a big part in long-term use, and previous studies raised the concern of assuring continuous use, especially in younger audiences. With that in mind, we identified conceptual improvement points, which were divided in three main topics: customisation, simplicity and healthcare connection. Moreover, we summarised some ideas to improve m-health apps catered around long-term adherence. We hope this work contributes to a better understanding of the current scope in mobile epilepsy management, endorsing healthcare professionals and developers to provide off-the-shelf solutions that engage patients and allows them to better manage their condition.

Gamification and Game-Based Strategies for Dermatology Education: Narrative Review

BACKGROUND

Game-based approaches, or gamification, are popular learning strategies in medical education for health care providers and patients alike. Gamification has taken the form of serious educational games and simulations to enable learners to rehearse skills and knowledge in a safe environment. Dermatology learners in particular may benefit from gamification methods, given the visual and procedural nature of the field.

OBJECTIVE

This narrative review surveys current applications of gamification within general medical training, in the education of dermatology students, and in dermatology patient outreach.

METHODS

A literature search was performed using PubMed, Google Scholar, and ResearchGate to access and review relevant medical education- and dermatology-related gamification studies published in peer-reviewed journals. Two independent researchers with education and experience in dermatology screened publications to select studies featuring a diversity of gamification approaches and study subjects for in-depth examination.

RESULTS

A total of 6 general medical education-related and 7 dermatology-specific gamification studies were selected. Gamification generally increased motivation and engagement, improved reinforcement of learning objectives, and contributed to more enjoyable and positive educational experiences compared to traditional modes of instruction. Enhancing examination scores, building confidence, and developing stronger team dynamics were additional benefits for medical trainees. Despite the abundance of gamification studies in general medical education, comparatively few instances were specific to dermatology learning, although large organizations such as the American Academy of Dermatology have begun to implement these strategies nationally. Gamification may also a provide promising alternative means of diversifying patient education and outreach methods, especially for self-identification of malignant melanoma.

CONCLUSIONS

Serious games and simulations in general medical education have successfully increased learner motivation, enjoyment, and performance. In limited preliminary studies, gamified approaches to dermatology-specific medical education enhanced diagnostic accuracy and interest in the field. Game-based interventions in patient-focused educational pilot studies surrounding melanoma detection demonstrated similar efficacy and knowledge benefits. However, small study participant numbers and large variability in outcome measures may indicate decreased generalizability of findings regarding the current impact of gamification approaches, and further investigation in this area is warranted. Additionally, some relevant studies may have been omitted by the simplified literature search strategy of this narrative review. This could be expanded upon in a secondary systematic review of gamified educational platforms.

Electronic Games for Facilitating Social Interaction Between Parents With Cancer and Their Children During Hospitalization: Interdisciplinary Game Development

Background

Most cancer treatments today take place in outpatient clinics; however, it might be necessary for some patients to be admitted to hospital departments due to severe side effects or complications. In such situations, support from family and social relations can be crucial for the patients’ emotional well-being. Many young adolescents and children whose parents have cancer describe how they are not seen, heard, or listened to as the worried relatives they are. Within the intensive care unit, it has been recommended that early supportive interventions are tailored to include children of the intensive care patient; a similar approach might be relevant in the oncological setting. To our knowledge, no studies have explored how to involve young relatives who are visiting their parent at an oncological department. Recently, a framework for developing theory-driven, evidence-based serious games for health has been suggested. Such a process would include stakeholders from various disciplines, who only work toward one specific solution. However, it is possible that bringing together different disciplines, such as design, art, and health care, would allow a broader perspective, resulting in improved solutions.

Objective

This study aims to develop tools to enhance the social interaction between a parent with cancer and their child when the child visits the parent in the hospital.

Methods

In total, 4 groups of design students within the Visual Design program were tasked with developing games addressing the objective of strengthening relations in situ during treatment. To support their work, the applied methods included professional lectures, user studies, and visual communication (phase I); interviews with the relevant clinicians at the hospital (phase II), co-creative workshops with feedback (phase III), and evaluation sessions with selected populations (phase IV). The activities in the 4 phases were predefined. This modified user design had the child (aged 4-18 years) of a parent with cancer as its primary user.

Results

Overall, 4 different games were designed based on the same information. All games had the ability to make adults with cancer and their children interact on a common electronic platform with a joint goal. However, the interaction, theme, and graphical expression differed between the games, suggesting that this is a wide and fertile field to explore.

Conclusions

Playing a game can be an efficient way to create social interaction between a parent with cancer and a child or an adolescent, potentially improving the difficult social and psychological relations between them. The study showed that the development of serious games can be highly dependent on the designers involved and the processes used. This must be considered when a hospital aims to develop multiple games for different purposes.

Analysis of treatment adherence and cost among patients with epilepsy: a four-year retrospective cohort study in Pakistan

BACKGROUND

The adherence pattern of antiepileptic drugs (AEDs) among patients with epilepsy is relatively lower in the United States and different European countries. However, adherence and cost analysis of AEDs in Asian countries have not been thoroughly studied. Therefore, the present study aimed to analyze the cost and adherence of AEDs and its associated factors in patients followed in Pakistan.

METHODS

Data from prescriptions collected from patients with epilepsy who have visited the Outpatient Department (OPD) of different tertiary care hospitals at the cosmopolitan city of Karachi, Pakistan from December 2015 to November 2019. The mean follow-up period for each participant was about 22 months. Pairwise comparisons from Cox regression/hazard ratios were used to assess the predictors of adherence. Direct costs of AEDs were calculated and presented as the annual cost of drugs.

RESULTS

A total of 11,490 patients were included in this study, 51.2 % were male and 48.8 % were female with a mean age of 45.2 ± 15.8 y. Levetiracetam was found as the most prescribing AED in all study participants (32.9 %). Of them, 49.1 % of patients continued their initial recommended treatment. However, 31.3 % of patients have discontinued the therapy, while, 19.6 % were switched to other AED. Adherence with initial treatment was more profound in male (57.4 %) patients, compared to female with a mean age of 44.2 years. Lamotrigine users (60.6 %) showed a higher tendency to retain on initially prescribed drugs. The total cost of epilepsy treatment in the entire study cohort was 153280.5 PKR ($941.9). By applying the Cox regression analysis, it can be observed that the patients with increasing age (OR, 2.04), migraine (OR, 2.21), psychiatric disorders (OR, 4.28), other comorbidities (OR, 1.52) and users of other than top five prescribing AEDs (2.35) were at higher risk of treatment discontinuation. However, levetiracetam (OR, 0.69), valproic acid (OR, 0.52), carbamazepine (OR, 0.81), lamotrigine (OR, 0.80) or lacosamide (OR, 0.65) users have more chances to continue their initial therapy.

CONCLUSIONS

Similar to western countries, the majority of patients with epilepsy exhibited low adherence with AEDs. Various associated factors for improving adherence were identified in this study.

Investigating Serious Games That Incorporate Medication Use for Patients: Systematic Literature Review

Background

The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use.

Objective

This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use.

Methods

PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection.

Results

Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies.

Conclusions

Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives.

Architecture of a Dispersed Gamification System for Tourist Attractions

The paper addresses the issues of implementing e-guide-based gamification systems for tourist attractions by proposing a dispersed gamification system architecture in which its respective functional aspects are handled by multiple web services with various scopes of responsibility. The features provided by the proposed architecture are successfully matched to tourist attraction requirements identified during development of an e-guide gamification system for an international consortium of tourist attractions. The key contributions of the paper are: the new definition of gamification system extending beyond the concept of a set of game-based rules and including the information technology components necessary to implement it; mapping the abstract gamification system model into the domain of tourist attraction gamification and the analysis of advantages and disadvantages of various organizations of e-guide gamification systems; the introduction of a new, dispersed architecture of e-guide gamification system that addresses the identified needs of tourist attractions.