The FIT Game: preliminary evaluation of a gamification approach to increasing fruit and vegetable consumption in school

Participants' Experience with Gamification Elements of a School-Based Health Promotion Intervention in Italy: A Mixed Methods Study

Gamified interventions consist of a combination of game elements designed to motivate and engage users, thus addressing issues of participant low participation and enthusiasm in interventions. Gamification does not work well in all situations and its success depends on the context and target users. However, there is a lack of research on analog health interventions. Qualitative and quantitative data were collected in parallel to examine participants' experiences with Food Game, an analog gamified intervention designed to promote healthier and more sustainable food choices among high school students. Teams of students compete to complete peer-led thematic challenges. Sixty-four students from the 2022/23 edition participated in focus group interviews (N = 11), and 119 completed a survey (56.1% response rate) with indicators of responsiveness and perceived motivational impact of the program's five game elements. Results indicate a relatively high level of engagement with the program. Students valued Food Game because it gave them the opportunity to demonstrate their sense of agency and autonomy and to work in a group with their peers, thus addressing basic needs for competence, relatedness, and autonomy as described by Self-Determination Theory and providing an empowering experience. The least motivating game element in the Food Game was the leaderboard and inter-team competition. Focus group data confirmed students' ambivalence about the competition embedded in the program and pointed to potential unintended consequences, including inter-team conflict, stress, and reduced intrinsic motivation to play. The strengths and weaknesses of Food Game approach to gamification are discussed, along with implications for prevention research and practice.

Gamified Health Promotion in Schools: The Integration of Neuropsychological Aspects and CBT-A Systematic Review

Background and Objectives: This systematic review examines the integration of gamified health promotion strategies in school settings, with a focus on their potential to positively influence health behaviors and promote well-being among adolescents. This study explores the incorporation of cognitive behavioral therapy (CBT), artificial intelligence, and neuropsychological principles in gamified interventions, aiming to enhance engagement and effectiveness. Materials and Methods: A narrative synthesis of 56 studies, following PRISMA guidelines, underscores the significant impact of these gamified interventions on mental health outcomes, emphasizing reductions in anxiety, depression, and burnout while improving coping skills and lifestyle habits. The focus of key areas in mental health outcomes, emotional regulation, cognitive flexibility, and adherence mechanisms is explored through quantitative and qualitative syntheses to underscore intervention effectiveness and design principles. Results: This review highlights the high-quality evidence supporting the use of gamification in educational settings and calls for further research to optimize design elements and address implementation barriers. The findings propose that well-designed gamified health interventions can effectively engage students, promote healthy behaviors, and improve mental well-being while acknowledging the need for further studies to explore underlying mechanisms and long-term effects. Conclusions: Gamified health interventions that embed CBT and neuropsychological principles are promising for promoting the mental well-being of schoolchildren. Although the evidence indicates that they are effective in improving psychological and behavioral outcomes, further research is needed to optimize design features and overcome implementation challenges to ensure wider and more sustainable application.

Gamification in personal health record systems: a regulatory fit perspective

OBJECTIVE

It has been known that individuals' regulatory focus differences (prevention orientation or promotion orientation) influence health-related behaviors. However, in the gamification literature, when classical and gamified applications are discussed, the gain frame is predominantly included, whereas the loss frame is not sufficiently considered. In this study, individuals' evaluations of gamified and non-gamified personal health record systems with different frames were examined.

METHODS

A 2 (type of personal health record system application: gamified vs. non-gamified) X 2 (frame: gain vs. loss) between-subject design was implemented, and users' regulatory foci were tested in this study. We predicted that systems that are gamified and aligned with users' regulatory foci will be evaluated more favorably than systems that are not aligned with users' regulatory foci.

RESULTS

Contrary to what the gamification literature suggests, we found that individuals do not always prefer gamified systems over non-gamified ones. Participants' regulatory focus might play a crucial role in their attitudes toward gamified platforms.

CONCLUSION

The findings might contribute to the design of personal health record systems by bearing the individual motivational differences of users in mind.

School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students

BACKGROUND

Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services.

METHODS

This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States.

RESULTS

Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals.

CONCLUSIONS

Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Is Generation Z Ready to Engage in Entomophagy? A Segmentation Analysis Study

This study examines the behavior and attitudes of adult Generation Z cohort members in relation to entomophagy. Specifically, it explores their familiarity with insect consumption, prior experience, and willingness to consume certain insect-based foods and drinks. Lastly, the Z cohort is segmented based on their behavior and attitudes. Through online quantitative research, a valid sample of 742 questionnaires was collected. Data analysis included descriptive statistics, reliability analysis, factor, hierarchical cluster, and K-means cluster analysis, as well as chi-square tests. Results revealed that 41.4% are familiar with what insect consumption is, and no one had previously engaged in entomophagy. The insect-based food that the Z cohort is most willing to try is bakery products containing insect flour. The 88.5% of the Z cohort is not willing to replace meat protein with insect protein, and 20.4% are interested in obtaining more information about entomophagy. Moreover, 6.3% of the Z cohort is "willing" to participate in sensory tests, but when contact information was requested, only one factual name with phone number was provided. Segmentation of the Z cohort's behavior was performed based on eight variables and four segments were identified: the "Future potential insect consumers" (29.1%), the "Rejecters" (26.7%), the "Disgusted, prefer to starve" (22.2%), and the "Inconsistent" (22.0%). Overall, the Z cohort is not food neophobic, but is unwilling to engage in entomophagy. Communication strategies are suggested to increase awareness and provide information about entomophagy and its benefits.

Scare-Away Risks: The Effects of a Serious Game on Adolescents’ Awareness of Health and Security Risks in an Italian Sample

Digital games can be defined as games supported by audiovisual apparatus and based on storytelling. This work aims to frame video games in the recent perspective offered by positive psychology and focuses on risk perception and on the promotion of protective behaviors in adolescent students, by means of a new Italian ad hoc created digital game named ‘Scare-away risks’ (Scacciarischi). In its storytelling, the different characters must defeat monsters that symbolically represent potential risks in home, school and work contexts. On this basis, the present study assumes that playing video games, as an engaging and motivating activity, can improve the adolescents’ psychological perception of home, school and work risks. To verify these hypotheses, a quasi-experiment comparing students who played Scacciarischi (experimental group) with a control group was conducted. At the end of the game, a questionnaire was administered to 149 participants, balanced for gender, investigating (a) the level of engagement during the game, (b) the perceived risks, (c) the locus of control, (d) the protective behavior intentions. The results showed that playing Scacciarischi is related to higher levels of engagement, internal locus of control, risk perception and protective behavioral intentions. In addition, both engagement and internal locus of control act as precursors of the other two variables. Finally, reflections about the importance of the engaging experience of Scacciarischi in the domain of safety, prevention and health issues are proposed.

Feasibility of Using Games to Improve Healthy Lifestyle Knowledge in Youth Aged 9-16 Years at Risk for Type 2 Diabetes: Pilot Randomized Controlled Trial

Background

Mobile games can be effective and motivating tools for promoting children’s health.

Objective

We aimed to determine the comparative use of 2 prototype serious games for health and assess their effects on healthy lifestyle knowledge in youth aged 9-16 years at risk for type 2 diabetes (T2D).

Methods

A 3-arm parallel pilot randomized controlled trial was undertaken to determine the feasibility and preliminary effectiveness of 2 serious games. Feasibility aspects included recruitment, participant attitudes toward the games, the amount of time the participants played each game at home, and the effects of the games on healthy lifestyle and T2D knowledge. Participants were allocated to play Diabetic Jumper (n=7), Ari and Friends (n=8), or a control game (n=8). All participants completed healthy lifestyle and T2D knowledge questionnaires at baseline, immediately after game play, and 4 weeks after game play. Game attitudes and preferences were also assessed. The primary outcome was the use of the game (specifically, the number of minutes played over 4 weeks).

Results

In terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants were recruited. Participants generally viewed the games positively. There were no statistical differences in healthy lifestyle knowledge or diabetes knowledge over time or across games. Only 1 participant accessed the game for an extended period, playing the game for a total of 33 min over 4 weeks.

Conclusions

It was not feasible to recruit the target sample for this trial. The 2 prototype serious games were unsuccessful at sustaining long-term game play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area.

Trial Registration

Australia New Zealand Clinical Trials Registry ACTRN12619000380190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377123

Fruit and vegetable intake at and away from school during participation in the FIT Game

BACKGROUND

The FIT Game is a multicomponent school-based incentive program aimed at increasing children's fruit and vegetable (FV) intake. There has been no previous report on how playing the game at school influences FV intake away from school.

AIM

To examine children's (n=37) FV intake away from school while participating in the FIT Game program at school.

METHODS

FV intake away from school was assessed using the ASA24-Kids-2014 Dietary Assessment Tool. Paired samples t-tests and the generalized linear model repeated measures analysis of variance were used to examine the difference in children's mean FV intake away from school.

RESULTS

During the final three days of the FIT Game intervention, we observed no change in FV consumption away from school (p=0.30). Similarly, no differences were observed between FV intake away from school before the implementation of the FIT Game and during the final three days (p=0.81).

CONCLUSIONS

The FIT Game modestly decreased the children's FV intake in a nonstatistically significant manner away from school. Our previous report showed an increase in children's FV intake at school; thus, the net effect of the game was a significant increase in total daily FV intake.

Gamified Challenges in Online Weight-Loss Communities

Gamified challenges, one of the most popular features of online weight-loss communities, enable users to set weight-loss goals and compete with other challenge participants via leaderboards. Using the data from a leading online weight-loss community, we study the effect of gamified challenges on the weight-loss outcome. Our findings indicate that participation in gamified challenges has a positive and significant effect on weight loss. We found that, on average, the participants achieved a weight loss of 0.742 kg by participating in at least one challenge a month. We found that effective challenges do not include a numeric weight goal (e.g., lose 5 kg), focus on exercise-only behavioral goals, and have a large active group size. Further, the results show that the absence (presence) of a numeric weight goal benefits users in exercise (diet) challenges. Moreover, a small active group size can help (hurt) users in exercise (diet) challenges. Our results suggest that gamification elements that induce competition should be used with caution in goal-setting environments, especially when gamifying dietary goals. Online weight-loss communities can recommend a useful combination of numeric weight goals, behavioral goals, and an optimal number of participants in each challenge to induce an encouraging level of social comparison.

Strategies to Improve School Meal Consumption: A Systematic Review

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

Using ClassCraft to Improve Primary School Students’ Knowledge and Interest in Sustainable Mobility

Teaching students awareness about sustainable mobility has been lacking to date. There is a need to expand the themes being addressed in order to achieve a change in attitude. Society needs to design a curriculum that teaches about sustainable mobility to guarantee a better environment for future generations. This article presents the most important results of an experiment based on gamification to promote the education of sustainable mobility in primary school classrooms. This new teaching method, aimed at children aged 10–12 years old, applies non-gambling play metaphors to real-life tasks to motivate a change in attitude. The didactic approach was developed using the ClassCraft platform to create specific activities that consider the environmental, economic, and social aspects of sustainable mobility. The initial analysis revealed a perception about sustainable mobility that focused on environmental problems with very little input on the economic and social aspects. The experience has shown that by using the gamified ClassCraft tool applying structured activities about all aspects of sustainable mobility, the pupils acquired new concepts that clarified the social and economic components and began to develop a conscience about how to become an active part in behavioural change.

A Randomized Controlled Trial Evaluating the FIT Game's Efficacy in Increasing Fruit and Vegetable Consumption

Few children eat the recommended amounts of fruits and vegetables (FV). Although incentive-based interventions can increase FV consumption, this approach is costly and may be viewed as controversial due to the possible negative effects on intrinsic motivation. The FIT Game was designed to address these challenges. Four elementary schools were randomly assigned to either cooperatively play the FIT Game (n = 881) for ~8 weeks or to a no-game Control condition (n = 978). The FIT Game was presented daily as comic-book formatted episodes projected onto a large screen in the school cafeteria throughout lunchtime. All children could see the episodes which communicated daily whole-school vegetable-eating goals and illustrated the progress of the game's heroes when these goals were collectively met. Photo estimates of FV consumption and skin carotenoid concentrations (biomarker of carotenoid consumption) were collected at baseline, during the last 5 days of the FIT Game, and 3 months after the intervention concluded. Control schools followed the same FV consumption-monitoring procedures for the same duration. At the conclusion of the intervention phase, children attending the FIT Game schools consumed more vegetables (d = 0.41), more fruit (d = 0.39), and had higher skin carotenoids (d = 0.66) than at baseline. These statistically significant increases were maintained at a 3-month follow-up for vegetables (d = 0.21, the food targeted for change) and carotenoids (d = 0.53). Thus, the no-cost virtual incentives of the FIT Game increased FV consumption in the short- and long-run, without negatively impacting intrinsic motivation.

Gamification for the Improvement of Diet, Nutritional Habits, and Body Composition in Children and Adolescents: A Systematic Review and Meta-Analysis

Currently, one of the main public health problems among children and adolescents is poor adherence to healthy habits, leading to increasingly high rates of obesity and the comorbidities that accompany obesity. Early interventions are necessary, and among them, the use of gamification can be an effective method. The objective was to analyse the effect of game-based interventions (gamification) for improving nutritional habits, knowledge, and changes in body composition. A systematic review and meta-analysis were performed in CINAHL, EMBASE, LILACS, MEDLINE, SciELO, and Scopus databases, following the PRISMA recommendations. There was no restriction by year of publication or language. Only randomized controlled trials were included. Twenty-three articles were found. After the intervention, the consumption of fruit and vegetables increased, as well as the knowledge on healthy food groups. The means difference showed a higher nutritional knowledge score in the intervention group 95% CI 0.88 (0.05–1.75). No significant effect of gamification was found for body mass index z-score. Gamification could be an effective method to improve nutritional knowledge about healthier nutritional habits. Promoting the development of effective educational tools to support learning related to nutrition is necessary in order to avoid and prevent chronic diseases.

Resting-State fMRI Study of ADHD and Internet Gaming Disorder

Objective: We aimed to understand whether Attention Deficit Hyperactivity Disorder (ADHD) and Internet gaming disorder (IGD) share similar brain functional connectivity (FC) between the frontal and subcortices. Method: We compared changes in clinical symptoms and brain activity using functional magnetic resonance imaging (fMRI) in 26 patients with ADHD but without IGD, 29 patients with ADHD and IGD, and 20 patients with IGD but without ADHD. Results: The functional connectivity (FC) from the cortex to subcortex in both groups was decreased relative to that in age-matched healthy participants. One-year treatment for ADHD and IGD symptoms increased the FC between the cortex and subcortex in all ADHD participants and all IGD participants with good prognoses compared with those in all ADHD participants and all IGD participants with poor prognoses. Conclusion: Patients with ADHD and IGD shared similar brain FC at baseline and FC changes in response to treatment.

Interventions using behavioural insights to influence children's diet-related outcomes: A systematic review

The global prevalence of children with overweight and obesity continues to rise. Obesity in childhood has dire long-term consequences on health, social and economic outcomes. Promising interventions using behavioural insights to address obesity in childhood have emerged. This systematic review examines the effectiveness and health equity implications of interventions using behavioural insights to improve children's diet-related outcomes. The search strategy included searches on six electronic databases, reference lists of previous systematic reviews and backward searching of all included studies. One-hundred and eight papers describing 137 interventions were included. Interventions using behavioural insights were effective at modifying children's diet-related outcomes in 74% of all included interventions. The most promising approaches involved using incentives, changing defaults and modifying the physical environment. Information provision alone was the least effective approach. Health equity implications were rarely analysed or discussed. There was limited evidence of the sustainability of interventions-both in relation to their overall effectiveness and cost-effectiveness. The limited evidence on health equity, long-term effectiveness and the cost-effectiveness of these interventions limit what can be inferred for policymakers. This review synthesises the use of behavioural insights to improve children's diet-related outcomes, which can be used to inform future interventions.

Does gamification improve fruit and vegetable intake in adolescents? a systematic review

BACKGROUND

Nutrition and diet-related non-communicable diseases are a major cause of death worldwide. Food preferences and eating behaviours are likely to be established during adolescence, making it an important period to promote healthy behaviours.

AIM

To review the effectiveness of gamification to improve fruit and vegetable intake in adolescents.

METHODS

A systematic search was conducted using eight databases and grey literature sources for articles published to date on the effectiveness of gamification on fruit and vegetable intake in adolescents. Search criteria included articles that were complete and peer reviewed, conducted empirical research, described gamified elements used, focused on individuals between 10 and 24 years, and were available in English.

RESULTS

Out of 402 studies identified by the search, 7 were included in the review. Overall, short-term gamified interventions showed promise in improving fruit and vegetable intake in those aged 10 to 24 years old. Gamification was primarily facilitated through extrinsic motivation (i.e. points, badges, vouchers, leaderboard, narration, avatars, challenges) rather than intrinsic motivation (i.e. team-based competition). Studies were moderate in quality and key methodological issues related to non-randomized study design, lack of comparison group, inadequate control for confounding, and small sample size.

CONCLUSIONS

Gamification can be an effective tool in changing nutrition-related behaviour in adolescents over the short term. Future research should consider gamified interventions that are of longer duration, incorporate additional intrinsic gamified elements, tailor game elements for population subgroups, and address methodological issues.

Gamification and Its Application in the Social Environment

This study sets out to conduct a systematic review of the emergence and evolution of gamification in the social environment, its main components, and its application as a learning tool through the motivation and engagement it generates in people. The results were obtained by consulting two major scientific databases, namely, Scopus and the Web of Science, which provided 136 articles published on the social environment from 2011 through to mid-2016 using the term gamification. The results of this study reveal how over time gamification has been gaining importance in the social environment through the use of its components. The highest number of scientific publications come from the United States and Spain. In addition, the use of gaming components increases motivation and engagement. It shows how gamification uses (individual or group) rewards according to the context to achieve the proposed objectives, being successfully implemented in education, health, services, and social learning.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Spielerische Ansätze in Prävention und Gesundheitsförderung: Serious Games und Gamification

Digitale Spieleanwendungen können im Bereich Prävention und Gesundheitsförderung eingesetzt werden, um etwa gesundheitsrelevante Informationen zu vermitteln oder Verhaltensänderungen zu evozieren. Dabei sind die beiden relevantesten spielerischen Ansätze Serious Games (Spiele mit ernsthaftem Hintergrund) und Gamification (Anwendung spieltypischer Elemente in spielfremden Kontexten). Der Begriff Serious Games umschreibt Spiele, die eingesetzt werden, um ernsthafte Inhalte, wie zum Beispiel gesundheitliche Themen, zu vermitteln. Bei Gamification werden Spieldesignelemente, wie beispielsweise Punkte, Bestenlisten, Auszeichnungen, Profilgestaltung und Teamevents, eingesetzt, um eine Motivations- und Leistungssteigerung etwa in Lernumgebungen zu bewirken. Der vorliegende narrative Beitrag beleuchtet die Wirkungsweise und Studienlage sowie die Vor- und Nachteile spielerischer Anwendungen in der Prävention und Gesundheitsförderung und führt einige dieser Anwendungen exemplarisch auf.

Serious Games und Gamification zeigen in der Prävention und Gesundheitsförderung ein großes Potenzial. Insbesondere bei schwer erreichbaren und desinteressierten Zielgruppen kann ein direkter Bezug zu deren Lebenswelt hergestellt werden. Grundlagen für den wirkungsvollen Einsatz spielerischer Ansätze in der Arbeit und Ausbildung von Gesundheitsberufen sind die bereits hohe Vertrautheit mit dem Medium Spiel sowie die direkte Adressierung der psychologischen Grundbedürfnisse zur Steigerung der Motivation.

Digital Gamification to Enhance Vaccine Knowledge and Uptake: Scoping Review

BACKGROUND

Vaccine hesitancy is a growing threat to population health, and effective interventions are needed to reduce its frequency. Digital gamification is a promising new approach to tackle this public health issue.

OBJECTIVE

The purpose of this scoping review was to assess the amount and quality of outcomes in studies evaluating gamified digital tools created to increase vaccine knowledge and uptake.

METHODS

We searched for peer-reviewed articles published between July 2009 and August 2019 in PubMed, Google Scholar, Journal of Medical Internet Research, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, and SocINDEX. Studies were coded by author, year of publication, country, journal, research design, sample size and characteristics, type of vaccine, theory used, game content, game modality, gamification element(s), data analysis, type of outcomes, and mean quality score. Outcomes were synthesized through the textual narrative synthesis method.

RESULTS

A total of 7 articles met the inclusion criteria and were critically reviewed. Game modalities and gamification elements were diverse, but role play and a reward system were present in all studies. These articles included a mixture of randomized controlled trials, quasi-experimental studies, and studies comprising quantitative and qualitative measures. The majority of the studies were theory-driven. All the identified gamified digital tools were highly appreciated for their usability and were effective in increasing awareness of vaccine benefits and motivation for vaccine uptake.

CONCLUSIONS

Despite the relative paucity of studies on this topic, this scoping review suggests that digital gamification has strong potential for increasing vaccination knowledge and, eventually, vaccination coverage.

A Serious Game Approach to Improve Food Behavior in Families-A Pilot Study

The objective of this pilot study was to investigate the effect of a specially developed serious game to improve food behavior in families with children aged 5-13 years using mixed methods. Fourteen families were randomized into a game-group and a non-game-group and divided into age groups (game-children (GC), game-parents (GP), non-game-children (nGC), and non-game-parents (nGP)). The families completed a baseline test, a three-week intervention period with or without a game element, and a follow-up test. Qualitative results showed a positive change in food behavior in all families. Quantitative results mainly showed an effect in food neophobia as a decrease was seen in all groups; however, it was only significant (p < 0.05) in three groups (GP, nGC, nGP). No changes were seen in willingness to taste, and only limited changes in liking and number of words used to describe the stimuli. In conclusion, qualitative results showed positive change in the children's food behavior in most families, indicating a positive effect of performing tastings and tasks together as a family-regardless of the presence of a game element. However, this was not as clear in the quantitative data, indicating that current quantitative tools are less suited to measure complex concepts like willingness to taste.

Using repeated visual exposure, rewards and modelling in a mobile application to increase vegetable acceptance in children

Children are not consuming the recommended amounts of fruit and vegetables. Repeated visual exposure, modelling, and rewards have been shown to be effective at increasing vegetable acceptance in young children. The aim of this study was to assess the effectiveness of an evidence-based mobile application (Vegetable Maths Masters) which builds on these principles to increase children's liking and acceptance of vegetables. Seventy-four children (37 male, 37 female) aged 3-6 years old were randomised to play with either the vegetable app or a similar control app that did not include any foods. Children played their allocated game for 10 min. Liking and acceptance of the vegetables used in Vegetable Maths Masters (carrot and sweetcorn) and other vegetables which were not used in the game (yellow pepper and tomato) were measured pre- and post-play in both groups. Parents provided data about their child's food fussiness and previous exposure to the foods being used. Children who played with the Vegetable Maths Masters app consumed significantly more vegetables after playing with the app and reported significant increases in their liking of vegetables, relative to the control group. The effect of the Vegetable Maths Masters app on the change in consumption of vegetables was mediated by the change in liking of vegetables. These findings suggest that evidence-based mobile apps can provide an effective tool for increasing children's liking and consumption of vegetables in the short-term. Further work is now required to establish whether these effects are maintained over time.

Effects of the FIT Game on Physical Activity in Sixth Graders: A Pilot Reversal Design Intervention Study

Background

The FIT Game is a low-cost intervention that increases fruit and vegetable consumption in elementary school children. For this study, the FIT Game was adapted into an intervention designed to increase children’s physical activity at school.

Objective

We aimed to evaluate if the FIT Game could increase children’s physical activity relative to their baseline levels.

Methods

A total of 29 participants were recruited from a sixth-grade classroom. An ABAB reversal design was used. Participants wore an accelerometer while at school during pre/postintervention baseline (A) and intervention (B) phases. During the FIT Game intervention, daily physical activity goals encouraged the class to increase their median daily step count above the 60th percentile of the previous 10 days. When daily goals were met, game-based accomplishments were realized.

Results

Children met their activity goals 80% of the time during the intervention phases. Physical activity at school increased from a median of 3331 steps per day during the baseline to 4102 steps during the FIT Game phases (P<.001, Friedman test).

Conclusions

Preliminary evidence showed that playing the FIT Game could positively influence children’s physical activity at school.

Use of gamification strategies and tactics in mobile applications for smoking cessation: a review of the UK mobile app market

OBJECTIVE

Mobile phone-based interventions have been proven to be effective tools for smoking cessation, at least in the short term. Gamification, that is, the use of game-design elements in a non-game context, has been associated with increased engagement and motivation, critical success factors for long-term success of mobile Health solutions. However, to date, no app review has examined the use of gamification in smoking cessation mobile apps. Our review aims to examine and quantify the use of gamification strategies (broad principles) and tactics (on-screen features) among existing mobile apps for smoking cessation in the UK.

METHODS

The UK Android and iOS markets were searched in February 2018 to identify smoking cessation apps. 125 Android and 15 iOS apps were tested independently by two reviewers for primary functionalities, adherence to Five A smoking cessation guidelines, and adoption of gamification strategies and tactics. We examined differences between platforms with χ² tests. Correlation coefficients were calculated to explore the relationship between adherence to guidelines and gamification.

RESULTS

The most common functionality of the 140 mobile apps we reviewed allowed users to track the days since/until the quit date (86.4%). The most popular gamification strategy across both platforms was performance feedback (91.4%). The majority of apps adopted a medium level of gamification strategies (55.0%) and tactics (64.3%). Few adopted high levels of gamification strategies (6.4%) or tactics (5.0%). No statistically significant differences between the two platforms were found regarding level of gamification (p>0.05) and weak correlations were found between adherence to Five A's and gamification strategies (r=0.38) and tactics (r=0.26).

CONCLUSION

The findings of this review show that a high level of gamification is adopted by a small minority of smoking cessation apps in the UK. Further exploration of the use of gamification in smoking cessation apps may provide insights into its role in smoking cessation.

Nutrition Education and Dietary Behavior Change Games: A Scoping Review

Games provide an attractive venue for engaging participants and increasing nutrition-related knowledge and dietary behavior change, but no review has appeared devoted to this literature. A scoping review of nutrition education and dietary behavior change videogames or interactive games was conducted. A systematic search was made of PubMed, Agricola, and Google Scholar. Information was abstracted from 22 publications. To be included, the publication had to include a videogame or interactive experience involving games (a videogame alone, minigames inserted into a larger multimedia experience, or game as part of a human-delivered intervention); game's design objective was to influence dietary behavior, a psychosocial determinant of a dietary behavior, or nutrition knowledge (hereinafter referred to as diet-related); must have been reported in English and must have appeared in a professional publication, including some report of outcomes or results (thereby passing some peer review). This review was restricted to the diet-related information in the selected games. Diversity in targeted dietary knowledge and intake behaviors, targeted populations/audiences, game mechanics, behavioral theories, research designs, and findings was revealed. The diversity and quality of the research in general was poor, precluding a meta-analysis or systematic review. All but one of the studies reported some positive outcome from playing the game(s). One reported that a web-based education program resulted in more change than the game-based intervention. Studies of games may have been missed; a number of dietary/nutrition games are known for which no evaluation is known; and the data presented on the games and research were limited and inconsistent. Conclusions and Implications: A firmer research base is needed to establish the efficacy and effectiveness of nutrition education and dietary behavior change games.

Young People's Knowledge of Antibiotics and Vaccinations and Increasing This Knowledge Through Gaming: Mixed-Methods Study Using e-Bug

Background

e-Bug, led by Public Health England, educates young people about important topics: microbes, infection prevention, and antibiotics. Body Busters and Stop the Spread are 2 new e-Bug educational games.

Objective

This study aimed to determine students’ baseline knowledge, views on the games, and knowledge improvement.

Methods

Students in 5 UK educational provisions were observed playing 2 e-Bug games. Before and after knowledge and evaluation questionnaires were completed, and student focus groups were conducted.

Results

A total of 123 junior and 350 senior students completed the questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly about antibiotic use, appropriate sneezing behaviors, and vaccinations. In total, 26 student focus groups were conducted. Body Busters was engaging and enjoyable, whereas Stop the Spread was fast-paced and challenging but increased vaccination and health behavior intentions.

Conclusions

e-Bug games are an effective learning tool for students to enhance knowledge about microbes, infection prevention, and antibiotics. Game-suggested improvements should help increase enjoyment.

Healthy Eating: Approaching the Selection, Preparation, and Consumption of Healthy Food as Choice Behavior

Healthy eating has important well-being and financial implications for our society. As such, it is critical that the field of behavior science and behavior analysis conduct more research in this area so that effective interventions may be developed. One barrier to addressing healthy eating may be conceptual. Far from being a single response, eating is comprised of a series of choice responses. These selection, preparation and consumption responses form a temporally delayed behavioral chain. When designing interventions to address healthy eating, therefore, one must not only consider the specific target response, but alternative response options, and the effect of changing one response on other choices in the chain. The purpose of this article is to refine the analysis of healthy eating behavior, provide examples of research conducted in this area, and discuss how these interventions may influence this chain of responses. It is hoped that by doing so, additional research will be conducted and disseminated so that individuals, organizations, and policy makers can implement more effective interventions for healthy eating.

Fruits and vegetables embedded in classic video games: a health-promoting potential?

The proliferation of the video game era has increased sedentary behaviours among children and adolescents. Contemporary interventions involve the use of video games to introduce fruit and vegetable (F&V) consumption among children and adolescents. A comprehensive list of licenced video games (n = 671) released for the Nintendo Entertainment System (NES) console were reviewed for thematic content and qualitative characteristics of the game's activity relevant to F&V. Seventy-five video games were included in the study sample and categorised by release year, prevalence of F&V, and thematic content. Mild associations were found comparing release year to F&V totals (r = 0.21) and release year to theme (r = 0.19). F&V themes embedded within classic video games could serve as health-promoting lessons for forthcoming video games. Future games produced by the video gaming industry should continue to focus on nutrition-embedded messages promoting F&V. Video game development and marketing could be an avenue that incorporates healthy nutrition themes.

Gamification in aquarium context

Purpose

The purpose of this paper is to consider issues related to gamification through the non-game aquarium context and explore how the intention of aquarium visitors to play a game that imparts knowledge about marine animals and promotes the conservation of these animals is influenced by visitors’ attitudes toward marine animals, motivations to visit the aquarium and perceptions of the game’s benefits.

Design/methodology/approach

This study surveyed individuals who have visited Taiwan’s National Museum of Marine Biology and Aquarium at least once in the past three years and who use smartphones. They were shown a description of a hypothetical game scenario that they were asked to imagine to be available while at the aquarium. The partial least squares method was used to analyze the data from 225 returns.

Findings

The study shows that gamification can satisfy a visitor’s desire to learn and enjoy the aquarium simultaneously. Gamification is limited by the visit motivation and the attitudes toward marine animals that visitors bring with them. The usefulness of gamification is limited when visitors desire relaxation during the visit.

Originality/value

This study considers the application of gamification in the context of aquariums and the tourism field and the non-technology-related antecedents to the use of gamification. Gamification is not silver bullet for every situation, and a good understanding of potential users is important for its success and targeting of players. The importance of intrinsic benefits over extrinsic benefits is confirmed. Thus, this study addresses several gaps in the gamification literature.

Gamification of nutrition: A preliminary study on the impact of gamification on nutrition knowledge, attitude, and behaviour of adolescents in Nigeria

BACKGROUND:

In Nigeria and many parts of sub-Saharan Africa, the availability of foods that are high in salt, sugar, and saturated fat is steadily increasing. This has led to an increase in the consumption of such foods among Nigerians, particularly among adolescents.

AIM:

This pilot study was undertaken to understand whether, and how, gamification of nutrition can have an impact on addressing the problem of unhealthy eating among Nigerian adolescents.

METHODS:

Gamification of nutrition through board games, clubs and vouchers was introduced in three secondary schools in Abuja, Nigeria over a span of three to four months. Semi-structured focus groups were conducted with grade 11 and 12 students in the three secondary schools. Participants were asked about their perceptions of the intervention and how it influenced their eating behaviour, attitudes and knowledge about nutrition.

RESULTS:

A total of 31 students participated in four focus groups. Participants reported that the intervention shifted their perceptions and preferences, leading them to alter their behaviour by incorporating more nutritious foods (such as fruits and vegetables) into their diet and engaging in more physical activity. Five themes emerged from the analyses: improved eating behaviour; increased physical activity; improved overall well-being; increased nutrition knowledge; and influencing others.

CONCLUSIONS:

The results from the focus groups suggest that gamification of nutrition can lead to improvements in dietary behaviour among adolescents over the short-term. More studies are needed to evaluate the long-term effects of nutrition interventions that use gamification techniques.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications

AIM

There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors.

METHODS

Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective.

RESULTS

We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity.

CONCLUSION

Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Food Waste in the National School Lunch Program 1978-2015: A Systematic Review

BACKGROUND

Food waste studies have been used for more than 40 years to assess nutrient intake, dietary quality, menu performance, food acceptability, cost, and effectiveness of nutrition education in the National School Lunch Program (NSLP).

OBJECTIVE

Describe methods used to measure food waste and respective results in the NSLP across time.

METHODS

A systematic review using PubMed, Science Direct, Informaworld, and Institute of Scientific Information Web of Knowledge was conducted using the following search terms: waste, school lunch, plate waste, food waste, kitchen, half method, quarter method, weight, and photography. Studies published through June 2015 were included. The systematic review followed preferred reporting items for systematic reviews and meta-analyses recommendations.

RESULTS

The final review included 53 articles. Food waste methodologies included in-person visual estimation (n=11), digital photography (n=11), direct weighing (n=23), and a combination of in-person visual estimation, digital photography, and/or direct weighing (n=8). A majority of studies used a pre-post intervention or cross-sectional design. Fruits and vegetables were the most researched dietary component on the lunch tray and yielded the greatest amount of waste across studies.

CONCLUSIONS

Food waste is commonly assessed in the NSLP, but the methods are diverse and reporting metrics are variable. Future research should focus on establishing more uniform metrics to measure and report on food waste in the NSLP. Consistent food waste measurement methods will allow for better comparisons between studies. Such measures may facilitate better decision making about NSLP practices, programs, and policies that influence student consumption patterns across settings and interventions.

The FIT Game III: Reducing the Operating Expenses of a Game-Based Approach to Increasing Healthy Eating in Elementary Schools

OBJECTIVE

Previously published versions of the healthy eating "FIT Game" were administered by teachers in all grades at elementary schools. The present study evaluated whether the game would retain its efficacy if teachers were relieved of this task; presenting instead all game materials on visual displays in the school cafeteria.

MATERIALS AND METHODS

Participants were 572 children attending two Title 1 elementary schools (grades K-5). Following a no-intervention baseline period in which fruit and vegetable consumption were measured from food waste, the schools played the FIT Game. In the game, the children's vegetable consumption influenced events in a good versus evil narrative presented in comic book-formatted episodes in the school cafeteria. When daily vegetable-consumption goals were met, new FIT Game episodes were displayed. Game elements included a game narrative, competition, virtual currency, and limited player autonomy. The two intervention phases were separated by a second baseline phase (within-school reversal design). Simulation Modeling Analysis (a bootstrapping technique appropriate to within-group time-series designs) was used to evaluate whether vegetable consumption increased significantly above baseline levels in the FIT Game phases (P < 0.05).

RESULTS

Vegetable consumption increased significantly from 21.3 g during the two baseline phases to 42.5 g during the FIT Game phases; a 99.9% increase. The Game did not significantly increase fruit consumption (which was not targeted for change), nor was there a decrease in fruit consumption.

CONCLUSION

Labor-reductions in the FIT Game did not reduce its positive impact on healthy eating.

Behavioral Economic Approaches to Influencing Children’s Dietary Decision Making at School

The health benefits of consuming fruits and vegetables (FVs) are clear, but most children do not eat them regularly. At school, FVs are available, but children often refuse them or throw them away. This review article illustrates the evidence for and against behavioral–economic approaches to increasing FV consumption in schools. Simple but effective interventions include prompting children to take FVs and serving vegetables before other foods are available. Also effective is reducing their handling costs (e.g., serving sliced fruit) and opportunity costs (e.g., scheduling lunch after recess). Still larger improvements can be achieved by improving the taste of FVs, or by incentivizing consumption. Although controversial, even small incentives can produce immediate and lasting effects. Game-based virtual incentives can reduce the costs of incentive systems, while minimizing concerns that children are being bribed into healthy habit formation.