Squire's Quest! Dietary outcome evaluation of a multimedia game

Effect of a Technology-Integrated Curriculum on Sugary Drink and Snack Intake of Elementary-Aged Youth Experiencing Low Income

OBJECTIVE

To describe the results of a technology-integrated intervention on sugar-sweetened beverage (SSB) and energy-dense snack intake with third graders experiencing low income.

DESIGN

A 2 × 2 quasi-randomized cluster-block, parallel-group experimental research design.

SETTING

Low-income schools in Rhode Island.

PARTICIPANTS

Two-hundred seventeen intervention and 242 control third-grade students in low-income (89.6% and 88.2% free/reduced meals, respectively), ethnically and racially diverse (63% Hispanic/20% Black and 62% Hispanic/18% Black, respectively) schools.

INTERVENTION(S)

A 13-week in-school program held once per week for 1 hour. The hands-on, technology-integrated program used a modified version of the Body Quest: Food of the Warrior curriculum.

MAIN OUTCOME MEASURE(S)

Intake of SSB and energy-dense snacks, both salty and sweet snacks, using baseline (week 1) and postassessment (week 13) previous day self-recall.

ANALYSIS

Generalized mixed modeling with nesting.

RESULTS

Intervention students significantly reduced their SSB intake by 38% (0.5 times/d; F[1, 540] = 4.26; P = 0.04) and salty snack intake by 58% (0.8 times/d; F[1, 534] = 6.58, P < 0.01) from baseline to postassessment as compared with the control students.

CONCLUSIONS AND IMPLICATIONS

Findings suggest a technology-integrated curriculum is effective in decreasing SSB and salty snacks in elementary-aged students of low-income, minoritized populations. Improved dietary habits can potentially influence other facets of students' lives.

Instructional educational games in pharmacy experiential education: a quasi-experimental assessment of learning outcomes, students' engagement and motivation

BACKGROUND

This study aimed to determine the impact of implementing instructional educational games on attaining the intended learning outcomes mapped with the competencies of a pharmacy practice experience course, and to assess students' attitudes towards motivation and engagement in this active learning activity.

METHODS

This was a quasi-experimental study that utilized a pretest-posttest for the research groups. Students were divided into teams and challenged to answer different questions related to the case scenarios. Different gaming platforms as Gamilab, Wisc-Online, and Quizizz were accordingly used to create different questions that help students memorize medications' brand names, and acquire the advanced community knowledge and skills. The attainment of the intended learning outcomes was assessed and compared between the experimental and control groups through the course total average of grades, and the subsequent averages of domains relating to the course competencies. Attitudes towards motivation and engagement in educational games activities were also assessed among the experimental group.

RESULTS

A total of 233 students were enrolled in the study. The experimental group had significantly higher total posttest average compared to the control group (Beta = 7.695, 95% CI = 4.964-10.425, P < 0.001). The experimental group had also significantly higher averages of competency domains related to foundational knowledge (Beta = 1.471, 95% CI = 0.723-2.219, P < 0.001), pharmaceutical care (Beta = 1.650, 95% CI = 0.673-2.627, P < 0.001), essentials to practice and care (Beta = 1.838, 95% CI = 0.626-3.050, P < 0.003), and approach to practice and care (Beta = 2.736, 95% CI = 1.384-4.088, P < 0.001) averages. The experimental group reflected positive attitudes toward gamification engagement and motivation, with greater than 60% of the students recommend engage educational games to be part of the course.

CONCLUSION

Incorporation of educational games into pharmacy practice experiences resulted in better learning outcomes. This kind of active learning appears to be acceptable and motivational for students, and is recommended for further research in didactic courses in the pharmacy curriculum.

Diet Quality among Pre-Adolescent African American Girls in a Randomized Controlled Obesity Prevention Intervention Trial

Consuming an unhealthy diet increases health risks. This study assessed the impact of a culturally adapted behaviorally innovative obesity prevention intervention (The Butterfly Girls and the Quest for Founder's Rock) on diet quality in pre-adolescent non-Hispanic Black/African American girls. The RCT consisted of three groups (experimental, comparison, and waitlist control); block randomization allocated participants to each group. The two treatment groups varied in terms of whether or not they set goals. Data were collected at baseline (prior to receiving the intervention), post 1 (3 months post-baseline), and post 2 (6 months post-baseline). Two dietitian-assisted 24 h dietary recalls were collected at each timepoint. Healthy Eating Index 2015 (HEI-2015) was used to determine diet quality. A total of 361 families were recruited; 342 completed baseline data collection. No significant differences in overall HEI score or component scores were observed. To attain more equitable health outcomes, future efforts to promote dietary intake change among at-risk children should explore other behavior change procedures and employ more child-friendly dietary assessment methods.

The Influence of Serious Games in the Promotion of Healthy Diet and Physical Activity Health: A Systematic Review

(1) Background: serious games seem to show promising strategies to promote treatment compliance and motivate behavior changes, and some studies have proven to contribute to the literature on serious games. (2) Methods: this systematic review aimed to analyze the effect of serious games in promoting healthy eating behaviors, effectively preventing childhood obesity, and improving physical activity in children. Five electronic bibliographic databases—PubMed, ACM Digital Library, Games for Health Journal, and IEEE Xplore were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria. Peer-reviewed journal articles published between 2003 and 2021 were selected for data extraction. (3) Results: a total of 26 studies were identified, representing 17 games. Half of the studies tested interventions for healthy eating and physical education. Most of the intervention’s games were designed according to specific behavioral change theories, predominantly the social cognitive theory. (4) Conclusions: studies confirmed the potential of serious games for obesity prevention but considering the restrictions encountered, we exhort for novel designs with different theoretical perspectives.

Technological tools for assessing children's food intake: a scoping review

Technological innovations can standardise and minimise reporting errors in dietary assessment. This scoping review aimed to summarise the characteristics of technological tools used to assess children's food intake. The review followed the Joanna Briggs Institute's manual. The main inclusion criterion was studied that assessed the dietary intake of children 0-9 years of age using technology. We also considered articles on validation and calibration of technologies. We retrieved 15 119 studies and 279 articles were read in full, after which we selected 93 works that met the eligibility criteria. Forty-six technologies were identified, 37 % of which had been developed in Europe and 32⋅6 % in North America; 65⋅2 % were self-administered; 27 % were used exclusively at home; 37 % involved web-based software and more than 80 % were in children over 6 years of age. 24HR was the most widely used traditional method in the technologies (56⋅5 %), and 47⋅8 % of the tools were validated. The review summarised helpful information for studies on using existing tools or that intend to develop or validate tools with various innovations. It focused on places with a shortage of such technologies.

Effectiveness of school-based nutrition intervention components on fruit and vegetable intake and nutrition knowledge in children aged 4-12 years old: an umbrella review

CONTEXT

School-based nutrition interventions can support healthy eating in children.

OBJECTIVE

To identify components of school-based nutrition interventions and synthesize the impact on consumption of fruits and vegetables (FV) and nutrition knowledge (NK) in children aged 4-12 y.

DATA SOURCES

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and PICOS inclusion criteria, relevant systematic reviews and/or meta-analyses, written in English, published between 2010 and August 2020, across 6 databases were identified.

DATA EXTRACTION

Two reviewers independently performed data extraction and assessed the study quality.

DATA ANALYSIS

The JBI Critical Appraisal Instrument for Systematic Reviews and Research Syntheses was used to assess review quality, and the Grading of Recommendations Assessment, Development, and Evaluation approach was used to rate strength of evidence.

RESULTS

From 8 included reviews, 7 intervention components were identified: FV provision, gaming/computer-delivered, curriculum, experiential learning, reward/incentives, nudging, and caregiver involvement. FV provision had the greatest effect on F intake, gaming/computer-delivered on V intake, and curriculum on NK.

CONCLUSION

FV provision and gaming/computer-delivered components showed, overall, some positive effect on FV intake, as did the curriculum component on NK. More evidence evaluating single-component effectiveness that considers the setting and context of nutrition interventions is required to strengthen the evidence base.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, registration no.: CRD42020152394.

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

A Video-Game-Based Oral Health Intervention in Primary Schools—A Randomised Controlled Trial

Background: Poor oral health practices and high levels of dental caries have been reported among children in the developing world. Video games have been successful in promoting oral health in children. The aim of this study was to assess the impact of an oral-health-education video game on children’s dietary knowledge and dietary and toothbrushing practices; Methods: Two Schools in Amman, Jordan were randomly selected and assigned to either intervention or control. Six- to eight-year old children took part. The intervention group played the oral-health-education video game; the control group received no intervention. The groups were compared in terms of changes in: child dietary knowledge, dietary and toothbrushing practices, plaque scores, and parental familiarity with preventive treatments. Data were submitted to statistical analysis with the significance level set at p ≤ 0.05. Results: Two hundred and seventy-eight children took part. Most (92%) had carious teeth. At baseline, children reported having more than one sugary snack a day and only 33% were brushing twice a day. Most parents were unaware of fluoride varnish (66%) or fissure sealants (81%). At follow-up, children in the intervention group had significantly better dietary knowledge, and parents in both groups became more familiar with fluoride varnish. There were no significant changes in children’s plaque scores, toothbrushing and dietary practices, or parental familiarity with fissure sealants in either group. Conclusions: Using an oral-health-education video game improved children’s dietary knowledge. However, future efforts should target children together with parents, and need to be supplemented by wider oral-health-promotion.

Serious Gaming for Behaviour Change: A Systematic Review

Over the years, there has been a significant increase in the adoption of game-based interventions for behaviour change associated with many fields such as health, education, and psychology. This is due to the significance of the players’ intrinsic motivation that is naturally generated to play games and the substantial impact they can have on players. Many review papers measure the effectiveness of the use of gaming on changing behaviours; however, these studies neglect the game features involved in the game design process, which have an impact of stimulating behaviour change. Therefore, this paper aimed to identify game design mechanics and features that are reported to commonly influence behaviour change during and/or after the interventions. This paper identified key theories of behaviour change that inform the game design process, providing insights that can be adopted by game designers for informing considerations on the use of game features for moderating behaviour in their own games.

Effects of nutritional intervention strategies in the primary prevention of overweight and obesity in school settings: systematic review and network meta-analysis

Objective

To examine the effects of different nutritional intervention strategies in the school setting on anthropometric and quality of diet outcomes by comparing and ranking outcomes in a network meta-analysis.

Design

Systematic review and network meta-analysis.

Data sources

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Education Resources Information Centre (ERIC), PsycInfo, CAB Abstracts, Campbell Library, Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) BiblioMap, Australian Education Index, Joanna Briggs Institute Evidence-Based Practice (JBI EBP) database, Practice-based Evidence in Nutrition (PEN) database, ClinicalTrials.gov, Current Controlled Trials, and World Health Organization International Clinical Trials Registry Platform.

Eligibility criteria for selecting studies

A systematic literature search was performed from inception to 2 May 2022. Cluster randomised controlled trials meeting these study criteria were included: generally healthy school students aged 4-18 years; intervention with ≥1 nutritional components in a school setting; and studies that assessed anthropometric measures (eg, body mass index, body fat) or measures related to the quality of diet (eg, intake of fruit and vegetables), or both. Random effects pairwise meta-analyses and network meta-analyses were performed with a frequentist approach. P scores, a frequentist analogue to surface under the cumulative ranking curve, ranging from 0 to 1 (indicating worst and best ranked interventions, respectively) were calculated. Risk of bias was assessed with Cochrane's RoB 2 tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to rate the certainty of evidence.

Results

51 cluster randomised controlled trials involving 75 954 participants and seven intervention nodes were included. Inconsistency could not be assessed (except for intake of fruit and vegetables) because the network meta-analyses were based mainly on star shaped networks with no direct evidence for specific pairs of nutritional interventions. Overall, little or no evidence was found to support a difference in body mass index, body weight, body fat, or waist circumference and moderate improvements in intake of fruit and vegetables with nutritional interventions in a school setting. Low to moderate certainty of evidence further suggested that multicomponent nutritional interventions likely reduced the prevalence (odds ratio 0.66, 95% confidence interval 0.55 to 0.80) and incidence (0.67, 0.47 to 0.96) of overweight compared with a control group. Based on low certainty of evidence, nutrition education and multicomponent interventions may be more effective than a control group (ie, usual practice) for increasing intake of fruit and vegetables. Multicomponent nutritional interventions were ranked the most effective for reducing body mass index (P score 0.76) and intake of fat (0.82). Nutrition education was ranked as best for body mass index z score (0.99), intake of fruit and vegetables (0.82), intake of fruit (0.92), and intake of vegetables (0.88).

Conclusions

The findings suggest that nutritional interventions in school settings may improve anthropometric and quality of diet measures, potentially contributing to the prevention of overweight and obesity in childhood and adolescence. The findings should be interpreted with caution because the certainty of evidence was often rated as low. The results of the network meta-analysis could be used by policy makers in developing and implementing effective, evidence based nutritional intervention strategies in the school setting.

Systematic review registration

PROSPERO CRD42020220451.

Feasibility and Acceptability of 'VitaVillage': A Serious Game for Nutrition Education

Computer games have previously been used to improve nutrition knowledge in children. This paper describes the acceptability and feasibility of a serious game, "VitaVillage", for improving child nutrition knowledge. VitaVillage is a farming-style game in which the player undertakes quests and completes questions aimed at increasing several aspects of nutrition and healthy eating knowledge. Children aged 9-12 years in two primary schools (control vs. intervention) completed a nutrition knowledge questionnaire at baseline (T1) and after 1 week (T2). Participants at the intervention school (n = 75) played VitaVillage for 20 minutes on two occasions. Control participants (n = 94) received no nutrition education. Likeability question scores and written feedback from intervention participants was reported qualitatively. Paired sample t-tests were used to compare T1 and T2 nutrition knowledge changes between control and intervention participants. Engagement with VitaVillage improved children's overall nutrition knowledge (Mean increase of 2.25 points between T1 and T2, Standard Deviation (SD) 6.31, p = 0.035) compared to controls. The game was liked overall (mean score 77 (SD 24.6) on scale of 0-100) and positive feedback was given. Results indicate that VitaVillage has the potential to be successful as a nutrition education tool. In the future, VitaVillage's content and gameplay will be revised, extended and evaluated for its long-term impact on eating behaviour and knowledge changes.

Trends in the Number of Behavioural Theory-Based Healthy Eating Interventions Inclusive of Dietitians/Nutritionists in 2000-2020

Nutrition interventions developed using behaviour theory may be more effective than those without theoretical underpinnings. This study aimed to document the number of theory-based healthy eating interventions, the involvement of dietitians/nutritionists and the behaviour theories employed from 2000 to 2020. We conducted a review of publications related to healthy eating interventions that used behaviour change theories. Interventional studies published in English between 2000 and 2020 were retrieved from searching Medline, Cinahl, Embase, Psycinfo and Cochrane Central. Citation, country of origin, presence or absence of dietitian/nutritionist authors, participants, dietary behaviours, outcomes, theories and any behaviour change techniques (BCTs) stated were extracted. The publication trends on a yearly basis were recorded. A total of 266 articles were included. The number of theory-based interventions increased over the two decades. The number of studies conducted by dietitians/nutritionists increased, but since 2012, increases have been driven by other researchers. Social cognitive theory was the most used behaviour theory. Dietitians/nutritionists contributed to growth in publication of theory-based healthy eating interventions, but the proportion of researchers from other professions engaged in this field increased markedly. The reasons for this growth in publications from other professions is unknown but conjectured to result from greater prominence of dietary behaviours within the context of an obesity epidemic.

A Review of Interventions to Enhance HIV Medication Adherence

PURPOSE OF REVIEW

Adherence to antiretroviral treatment (ART) is crucial for the successful treatment of HIV. Unfortunately, it is estimated that 45% of persons living with HIV (PLWH) have poor adherence to ART. To provide health care professionals and PLWH with effective tools for supporting adherence, researchers have investigated the effectiveness of psychosocial interventions to enhance adherence to ART. In this paper, interventional studies, systematic reviews, and meta-analyses that examine ART adherence interventions for PLWH are reviewed.

RECENT FINDINGS

There is great variability among interventions in terms of quality, sample, measures, and outcome characteristics. Despite a diverse and wide-ranging assortment of ART adherence interventions, consistent lessons have been learned. Interventions that focus on individual and interpersonal factors have been effective for improving ART adherence; however, the improvement in adherence tends to be short-lived. Additionally, interventions are most successful when tailored to those at risk for poor adherence. Finally, theory-based interventions are more likely to be effective than non-theory-based interventions. A variety of individual-level psychological interventions have been shown to be effective in improving ART adherence in the short term. Digital and mobile interventions have the potential to improve dissemination and implementation of these evidence-based interventions and could be used to extend intervention effects. Future interventions that address issues of accessibility, inequality, structural and institutional barriers to ART adherence should also be tested and prioritized. Implementation science frameworks can be used to assess and address issues of accessibility and systematic barriers to care.

User-Agent Bond in Generalizable Environments: Long-Term Risk-Reduction via Nudged Virtual Choices

Avatars or agents are digitized self-representations of a player in mediated environments. While using agents to navigate through mediated environments, players form bonds with their self-agents or characters, a process referred to as identification. Identification can involve automatic, but temporary, self-concept "shifts in implicit self-perceptions" (Klimmt et al., 2010, p. 323) of the media user by adopting or emphasizing the action choices on behalf of the social expectation of the avatar in the mediated environment. In the current study, we test the possibility that users' identification with video game avatars-a bond built between avatars and players- would account for subsequent behavior changes. We did so by using 3-month longitudinal data involving a narratively-based serious game: Socially Optimized Learning in Virtual Environments (SOLVE), a 3D-interactive game designed to reduce risky sexual behaviors among young men who have sex with men (n = 444). Results show that video game identification predicts both the reduction of risky sexual behaviors over time, and reduction in the number of non-primary partners with whom risky sex occurs. And when players identify with the game character, they tend to make healthier choices, which significantly mediates the link between video game identification and reduction of risky behaviors.

Food Literacy Interventions in Elementary Schools: A Systematic Scoping Review

BACKGROUND

Childhood is a critical period for developing food-related skills and knowledge, known as food literacy (FL). Schools may be an important setting for interventions aiming to improve FL in children. This systematic scoping review aimed to characterize food literacy interventions in elementary schools.

METHODS

Databases (PubMed, Web of Science, and EBSCO) were searched for FL interventions in elementary schools (students aged 4-12 years). Studies were assessed according to design, duration, theoretical underpinning, and ascertainment of FL outcome(s). Interventions were assessed according to FL competencies (functional, interactive, and critical).

RESULTS

After exclusions, 116 studies were eligible for review, including 105 original interventions. Interventions ranged from 45 minutes to 4 years. Social cognitive theory was the most referenced theory and common interventions included; classroom lessons, games, school gardens, food preparation, and cooking classes. Most studies measured FL outcomes quantitatively (96%, N = 111). All studies addressed functional FL (N = 116), while 77% (N = 89) addressed interactive FL and 28% (N = 32) addressed critical FL.

CONCLUSIONS

This first international review of FL programs in elementary schools found great heterogeneity in school-based FL intervention design and measurement of FL. Few interventions addressed critical FL, which should be a focus for future interventions.

Effect of implementing a mobile game on improving dietary information in diabetic patients

Background: Nowadays, digital games are not just entertainment, but beside routine treatments, they are used in patient care, especially in patients with diabetes. Application of digital games in patient's education can improve self-management of diabetes. The aim of the present study was to evaluate the effect of a mobile game (Amoo) implementation on enhancing dietary information in patients with type 2 diabetes. Methods: A mobile game (called Amoo), which was developed by researchers of this study, was applied to assess the self-education of patients with diabetes. Sixty patients with type 2 diabetes participated in the study. The participants took part in a pre-intervention test to determine their dietary information. The participants were randomly divided into one of two groups, including the intervention group: played the game for 15 minutes daily for 6 weeks, and the control group: did not involve in the game. A post-intervention test was run to show a possible improvement in dietary information. Data were analyzed using paired t test and suitable non-parametric testes including Mann-Whitney and Wilcoxon signed rank tests as well as Spearman and Pearson correlation coefficients via IBM SPSS statistics version 21 (SPSS, v 21.0, IBM, Armonk, NY, USA). A P-value less than 0.05 was considered as a significant level. Results: The results indicated a statistically significant difference between the pre and post test scores in the intervention group (p<0.001). However, there was no significant difference in fasting blood sugar (p=0.125). Conclusion: The mobile game (Amoo) could enhance the knowledge of patients with type 2 diabetes about food calories and glycemic index. This means that mobile games may serve as an educational aid to these patients.

Using Serious Games for Antismoking Health Campaigns: Experimental Study

BACKGROUND

Serious games for health have been gaining in popularity among scholars and practitioners. However, there remain a few questions to be addressed.

OBJECTIVE

This study tests the effects of a serious game and fear appeals on smoking-related outcomes. More specifically, this research aims to understand how serious games function as a more effective vehicle for a health campaign than a traditional medium, such as a print-based pamphlet. Further, while serious games utilize a variety of persuasive strategies in the game's content, it is not clear whether fear appeals, which are widely used persuasive-message strategies for health, can be an effective strategy in serious games. Thus, we are testing the effect of fear appeals in a serious game.

METHODS

We created a computer game and a print brochure to educate participants about the risks of smoking. More specifically, a flash-based single-player game was developed in which players were asked to avoid cigarettes in the gameplay context. We also developed an online brochure based on existing smoking-related brochures at a university health center; antismoking messages on the computer game and in the brochure were comparable. Then, an experiment using a 2 (media type: game vs. print) x 2 (fearful image: fear vs. no-fear) between-subjects design was conducted. The study recruitment was announced to undergraduate students enrolled in a large, public Midwestern university in the United States. After a screening test, a total of 72 smokers, who reported smoking in the past 30 days, participated in the experiment.

RESULTS

Overall, gameplay, when compared to print-based pamphlets, had greater impacts on attitudes toward smoking and the intention to quit smoking. Further, the game's persuasive effects were especially pronounced when messages contained fear appeals. When fearful images were presented, participants in the game condition reported significantly more negative attitudes toward social smoking than those in the print condition [F(1,67)=7.28; P=.009; η_p2=0.10]. However, in the no-fear condition, there was no significant difference between the conditions [F(1,67)=0.25; P=.620]. Similarly, the intention to quit smoking [F(1,67)=4.64; P=.035; η_p2=0.07] and susceptibility [F(1,67)=6.92; P=.011; η_p2=0.09] were also significantly different between the conditions, but only when fear appeals were used.

CONCLUSIONS

This study extends fear appeal research by investigating the effects of different media types. It offers empirical evidence that a serious game can be an effective vehicle for fear appeals.

Impact of Pediatric Mobile Game Play on Healthy Eating Behavior: Randomized Controlled Trial

BACKGROUND

Video and mobile games have been shown to have a positive impact on behavior change in children. However, the potential impact of game play patterns on outcomes of interest are yet to be understood, especially for games with implicit learning components.

OBJECTIVE

This study investigates the immediate impact of fooya!, a pediatric dietary mobile game with implicit learning components, on food choices. It also quantifies children's heterogeneous game play patterns using game telemetry and determines the effects of these patterns on players' food choices.

METHODS

We analyzed data from a randomized controlled trial (RCT) involving 104 children, aged 10 to 11 years, randomly assigned to the treatment group (played fooya!, a dietary mobile game developed by one of the authors) or the control group (played Uno, a board game without dietary education). Children played the game for 20 minutes each in two sessions. After playing the game in each session, the children were asked to choose 2 out of 6 food items (3 healthy and 3 unhealthy choices). The number of healthy choices in both sessions was used as the major outcome. We first compared the choice and identification of healthy foods between treatment and control groups using statistical tests. Next, using game telemetry, we determined the variability in game play patterns by quantifying game play measures and modeled the process of game playing at any level across all students as a Markov chain. Finally, correlation tests and regression models were used to establish the relationship between game play measures and actual food choices.

RESULTS

We saw a significant main effect of the mobile game on number of healthy foods actually chosen (treatment 2.48, control 1.10; P<.001; Cohen d=1.25) and identified (treatment 7.3, control 6.94; P=.048; Cohen d=.25). A large variation was observed in children's game play patterns. Children played an average of 15 game levels in 2 sessions, with a range of 2 to 23 levels. The greatest variation was noted in the proportion of scoring activities that were highly rewarded, with an average of 0.17, ranging from 0.003 to 0.98. Healthy food choice was negatively associated with the number of unhealthy food facts that children read in the game (Kendall τ=-.32, P=.04), even after controlling for baseline food preference.

CONCLUSIONS

A mobile video game embedded with implicit learning components showed a strong positive impact on children's food choices immediately following the game. Game telemetry captured children's different play patterns and was associated with behavioral outcomes. These results have implications for the design and use of mobile games as an intervention to improve health behaviors, such as the display of unhealthy food facts during game play. Longitudinal RCTs are needed to assess long-term impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04082195; https://clinicaltrials.gov/ct2/show/NCT04082195, registered retrospectively.

A Health Game Targeting Children's Implicit Attitudes and Snack Choices

Objective: The present study investigated whether a health game can be used to affect children's implicit attitudes toward food (IAsTF) and subsequent snack choices. Materials and Methods: The health game used was based on an evaluative conditioning paradigm. The experiment followed a between-subjects design with two conditions (health game vs. control), N = 79 (12.42 years ±1.64, body mass index: 25.06 ± 7.40). IAsTF were assessed at baseline and postintervention using an implicit association test (IAT). Baseline IAT scores were used to categorize IAsTF as healthy (favoring fruits) versus unhealthy IAsTF (favoring chocolates). In addition, three digital snack choices were recorded. Results: No main effect of condition on posttest IAsTF was found. However, baseline IAsTF moderated the effect of condition on posttest IAsTF; participants with less healthy baseline IAsTF playing the health game had healthier posttest IAsTF compared to those playing the control game. Regarding the snack choices, participants playing the health game favored fruit over chocolate in one of the snack choices. Baseline IAsTF did not moderate the effect of condition on snack choices. Conclusion: Tentative support was found that health games can be used to improve IAsTF, in particular among participants with less healthy ones at baseline.

"GiochiAMO," a Gaming Intervention to Prevent Smoking and Alcohol Habits Among Children: A Single-Arm Field Trial

Objectives: To evaluate the efficacy of the "GiochiAMO" prevention program on modifying children's knowledge and belief regarding the use and abuse of alcohol and tobacco smoking. Materials and Methods: "GiochiAMO" is a multicomponent single-arm field trial based on card and board games to teach and enhance knowledge about risk factors related to smoking and alcohol consumption. A structured questionnaire was administered before and after the intervention to assess any change in knowledge. Results: A total of 167 students between 9 and 11 years of age took part in the intervention. Data concerning knowledge about cigarette smoking showed a statistically significant improvement (P = 0.008) with an increase of the mean scores from 5.93 (standard deviation [SD] = 2.05) to 7.90 (SD = 2.03). The scores related to the life skills of the intervention performed in the fourth grade classes demonstrated statistically significant improvements (P = 0.027). The scores related to the knowledge about alcohol consumption highlighted a statistically significant improvement (P < 0.001), with mean scores that rose from 7.44 (SD = 1.99) to 9.41 (SD = 1.94). The scores related to the life skills of the intervention performed in the fifth grade classes demonstrated improvements, although they were not statistically significant (P = 0.770). Conclusions: "GiochiAMO" demonstrated significantly improved knowledge about the risk and consequences of cigarette smoking and alcohol consumption on health. Longer follow-up studies, including a larger sample size, will be needed.

Short-Term Effects of the Serious Game "Fit, Food, Fun" on Nutritional Knowledge: A Pilot Study among Children and Adolescents

“Serious games” are a novel and entertaining approach for nutritional education. The aim of this pilot study was to evaluate the short-term effectiveness of “Fit, Food, Fun” (FFF), a serious game to impart nutritional knowledge among children and adolescents. Data collection was conducted at two secondary schools in Bavaria, Germany. The gameplay intervention (gameplay group; GG) consisted of a 15-minute FFF gameplay session during each of three consecutive days. The teaching intervention (teaching group; TG) was performed in a classic lecture format. Nutritional knowledge was evaluated via questionnaires at baseline and post-intervention. Statistical analyses were performed using R (R Core Team, 2018). In total, baseline data were available for 39 participants in the GG and 44 participants in the TG. The mean age was 13.5 ± 0.7 years in the GG and 12.8 ± 0.9 years in the TG. There was a significant (p-value < 0.001) improvement in nutritional knowledge in both intervention groups. Moreover, a between-group difference with a significantly (p-value = 0.01) higher increase in nutritional knowledge was detected for the TG. This pilot study provides evidence for the short-term effectiveness of both educational interventions on the improvement in nutritional knowledge. Finally, the FFF game might be an adequate educational tool for the transfer of nutritional knowledge among children and adolescents.

Analysis of Fruit and Vegetable Consumption by Children in School Canteens Depending on Selected Sociodemographic Factors

Background and Objectives: Eating habits acquired or changed during childhood are likely to track into adulthood. Due to the fact that nutritional behaviours are not so strongly formed among children, it is easier to change and develop them in children than in adults. The aim of this study was to assess the impact of selected sociodemographic factors affecting fruit and vegetable consumption (i.e., age, parents' body mass index, parents' level education, duration of breastfeeding, child's time spent in front of computer/television) among children in school canteens. Materials and Methods: The sample consisted of 106 participants (52 girls, 54 boys) aged 6-12. The frequency of consuming fruits and vegetables at a school canteen was assessed using bar code cards for two weeks. Body composition estimates were obtained using a foot-to-foot bioelectrical impedance analysis, body height was measured using a stadiometer Seca 213. The questionnaire contained questions about selected factors which can have an influence on fruit and vegetable consumption. In the study group, 13.2% of participants were overweight and 17.9% were obese. Results: Our results showed a statistically significant relationship between age and fruit and vegetable consumption, and it increased with age in both sexes. Conclusions: Bearing in mind the various conditions discussed when shaping the eating habits of pre-school- and early-school-aged children, the importance of proper nutritional education should be stressed both among children and parents.

Perceptions of Low-Income Students Completing a Nutrition Education Program

OBJECTIVE

To capture students' perceptions of participating in a nutrition education program.

DESIGN

Focus groups (n = 16).

SETTING

Low-income schools in Rhode Island.

PARTICIPANTS

A total of 64 low-income, ethnically and racially diverse third-grade students, 93.5% of whom were eligible for free or reduced-price meals, 62% of whom were Hispanic, and 16% of whom were black.

MAIN OUTCOME MEASURE(S)

Perceptions about the program's impact on food and beverage consumption, the value of the program, potential changes for improvement, and barriers to change.

ANALYSIS

Focus groups were recorded, transcribed, and coded using a hybrid approach of inductive and deductive thematic analysis. Interrater agreement was calculated.

RESULTS

Students perceived that the program positively influenced their attitudes toward making healthy choices and what they and their families were eating. Students reported increased empowerment, bravery to try new foods, and knowledge. Students enjoyed the program but suggested increasing the duration and frequency of lessons and including peer-to-peer education. Students felt that the tastiness of unhealthy food was a barrier to choosing healthier food.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that the program may have improved students' knowledge, empowerment, and bravery, and that this had a positive influence on healthy food consumption for students and their families. Input from students will help inform future modifications to the curriculum.

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.

Healthy eating interventions delivered in the family home: A systematic review

Unhealthy eating habits have long term health implications and can begin at a young age when children still consume the majority of their meals at home. As parents are the principal agents of change in children's eating behaviours, the home environment is the logical location for the delivery of interventions targeting healthy family eating. Despite the recent proliferation of published studies of behaviour-change interventions delivered in the home, there has been little attempt to evaluate what makes such interventions successful. This review provides a systematic evaluation of all healthy eating interventions delivered to families in the home environment to date and seeks to identify the successful elements of these interventions and make recommendations for future work. Thirty nine studies are described, evaluated and synthesised. Results show that evidence- and theory-based interventions tended to be more successful than those that did not report detailed formative or evaluative work although details of theory application were often lacking. Careful analysis of the results did not show any further systematic similarities shared by successful interventions. Recommendations include the need for more clearly theoretically driven interventions, consistent approaches to measuring outcomes and clarity regarding target populations and desired outcomes.

Videogames That Encourage Healthy Behavior Did Not Alter Fasting Insulin or Other Diabetes Risks in Children: Randomized Clinical Trial

Background: Previous research indicates games for health have substantial promise in promoting change in children's diet and physical activity (PA) behavior for obesity and diabetes prevention, but the research has generally not been rigorous. The study reported here was an efficacy trial of two role-playing videogames played in sequence, "Escape from Diab" (hereinafter called Diab) and "Nanoswarm: Invasion from Inner Space" (hereinafter called Nano), on diabetes and obesity risk factors: fasting insulin and body mass index (BMI), and risk-related behaviors: diet, PA, and sedentary behavior (SB). Design: A two-group (treatment vs. wait list control) randomized clinical trial was used with baseline, immediate postintervention (∼3 months postbaseline), and 2 months postassessments. Intervention: Diab and Nano were desktop or laptop role-playing videogames with nine sessions (each episode/session lasting ∼60 minutes). Two storylines attempted to immerse players and used ethnically diverse characters to model desired behaviors. Tailored goal setting, problem solving, and motivational statements were used. Methods: A sample of 200 overweight or obese children (ages 10-12 years from 85th to 99th BMI percentile [%ile]) was recruited, primarily using a volunteer list. Fasting insulin was the primary dependent variable. BMI, fruit, vegetable and sweetened beverage intakes, PA, and SBs were secondary outcomes. Generalized linear mixed models were used to test for the treatment effects. Results: No significant differences were detected in any of the tested outcome variables. Conclusions: The lack of differences may indicate that games cannot change dietary behaviors and thereby not change-related clinical outcomes. Alternatively, there seem to have been changes in (1) the types of videogames children expect and like to play since a pilot study was conducted, (2) productization challenges, and/or (3) problems in staff management of the trial. All may have contributed to the lack of effect.

Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents

Background

Use of novel information and communication technologies are frequently discussed as promising tools to prevent and treat overweight and obesity in children and adolescents.

Objective

This survey aims to describe the preferences, motives, and needs of children and adolescents regarding nutrition and digital games.

Methods

We conducted a survey in 6 secondary schools in the southern region of Germany using a 43-item questionnaire. Questions referred to preferences, motives, and needs of children and adolescents regarding nutrition and digital games. In addition, knowledge regarding nutrition was assessed with 4 questions. We collected self-reported sociodemographic and anthropometric data. Descriptive statistical analyses were performed using SPSS.

Results

In total, 293 children and adolescents participated in the study, with ages 12-18 years (137 girls, 46.8%), weight 30.0-120.0 (mean 60.2 [SD 13.2]) kg, and height 1.4-2.0 (mean 1.7 [SD 0.1]) m. A total of 5.5% (16/290) correctly answered the 4 questions regarding nutrition knowledge. Study participants acquired digital nutritional information primarily from the internet (166/291, 57.0%) and television (97/291, 33.3%), while school education (161/291, 55.3%) and parents or other adults (209/291, 71.8%) were the most relevant nondigital information sources. Most participants (242/283, 85.5%) reported that they regularly play digital games. More than half (144/236, 61.0%) stated that they play digital games on a daily basis on their smartphones or tablets, and almost 70% (151/282, 66.5%) reported playing digital games for ≤30 minutes without any interruption. One-half of respondents (144/280, 51.4%) also stated that they were interested in receiving information about nutrition while playing digital games.

Conclusions

This survey suggests that nutrition knowledge in children and adolescents might be deficient. Most children and adolescents play digital games and express interest in acquiring nutritional information during digital gameplay. A digital game with a focus on sound nutrition could be a potential educational tool for imparting nutrition knowledge and promoting healthier nutrition behaviors in children and adolescents.

Testing a novel multicomponent intervention to reduce meat consumption in young men

Both epidemiological studies and randomised controlled trials have shown that meat-eating can be harmful to human health. Meat-eating is also considered to be a moral issue, impacting negatively on the environment and the welfare of animals. To date, very little scientific research has aimed to reduce this dietary behavior. Therefore, the current research tests the effectiveness of a 4-week multicomponent intervention designed to reduce meat-eating. Using a randomised controlled trial procedure, thirty-two young men (mean age: 23.5 ± 3.1 years old) were randomly assigned into two equal groups, the intervention vs control group. Based on research in social and health psychology, the intervention was composed of five components expected to reduce meat consumption: a social norm component; an informational/educational component; an appeal to fear; a mind attribution induction; and a goal setting/self-monitoring component. Measures of different types of meat intake (using dietary journals) were taken at baseline (Time 1) as well as 2 (Time 2) and 4 weeks later (Time 3). Emotions and attitudes toward meat-eating and animals were also assessed at Time 3. Significant reductions in total and weekend red meat consumption as well as cold cuts consumed on the weekend were observed in the intervention condition from Time 1 to Time 3. Moreover, reduced positive emotions toward eating meat mediated the reduction in red meat consumption. The component of the intervention that participants most often perceived as having led to a reduction in their meat consumption was the informational component. In conclusion, results provide support for the effectiveness of the multicomponent intervention and for the mediating role of positive emotions when predicting behavioral changes in meat consumption.

Participant Outcomes from Methods of Recruitment for Videogame Research

OBJECTIVE

The most productive methods of recruitment for a videogame for health (G4H) trial are not known. Success or failure of recruitment methods has been reported for a variety of clinical trials, but few specifically for G4H trials. This study's goal was to recruit 444 overweight or obese (body mass index percentile between the 84.5th-99.4th percentiles) children between the ages of 10-12 years. The article reports the results of different methods of participant recruitment.

MATERIALS AND METHODS

Participants had to agree to three fasting blood samples (baseline, immediately after, and 2 months later); be willing to wear an accelerometer for 7 days at each assessment; read and speak English fluently (because the games were in English); have no history of any condition that would affect what he/she could eat or how much physical activity he/she could get; and have an eligible home computer purchased in the last 5 years with high-speed internet. Hardware criteria reflected the types of computers upon which Diab-Nano could be effectively played. Recruitment was conducted over a 35-month period and included electronic media, print advertising, community recruitment, and an internal volunteer list. Respondents were guided to a web-based screening questionnaire that asked for source of hearing about the study.

RESULTS

Although diverse recruitment methods were used, slow recruitment resulted in obtaining only 45% of the recruitment goal (n = 199). Electronic media (e.g., radio, television, and internet), which reached millions of targeted parents, resulted in only 76 respondents, of whom 13 became participants; print media (e.g., magazine, newsletter/newspaper, and mail), which also reached large numbers of parents, resulted in 192 respondents, of whom 19 became participants; community recruitment (e.g., school, friend or family, doctors office, flyer, work, community program) resulted in 162 respondents, of whom 38 became participants; and the internal volunteer list resulted in 413 respondents, of whom 128 became participants.

CONCLUSION

Inclusionary and exclusionary criteria and restricted access by gatekeepers could be deterrents to successful recruitment. The documented payoff of alternative comprehensive methods of recruitment should benefit other investigations in optimally allocating their recruitment resources.

Serious games as an educational strategy to control childhood obesity: a systematic literature review1

Objectives:

to identify in the literature the efficacy of serious games to improve knowledge for and/or behavioral changes among overweight or obese children.

Method:

Systematic Literature Review. The Cochrane Systematic Reviews Handbook was used. The studies were collected from the following databases: Public Medline; Web Of Science; Science Direct; Latin American and Caribbean Health Sciences Literature; and the Health Game Research and Cumulative Index to Nursing & Allied Health Literature. The descriptors were video games and obesity, while the key word was serious games. Inclusion criteria were: studies classified as Randomized Clinical Trials written in English, Spanish or Portuguese and in which children were the subjects of the study.

Results:

2,722 studies were identified in the initial search and six studies remained in the final sample. The papers focused on encouraging behavioral changes in players, including physical exercise and improved eating habits. The studies report that serious games are a potential strategy to encourage positive coping with childhood obesity.

Conclusion:

research in this field is an expanding and promising strategy and serious games represent an alternative means to provide health education to children.

Healthy lifestyle promotion in primary schools through the board game Kaledo: a pilot cluster randomized trial

The board game Kaledo was proven to be effective in improving nutrition knowledge and in modifying dietary behavior in students attending middle and high school. The present pilot study aims to reproduce these results in younger students (7-11 years old) attending primary school. A total of 1313 children from ten schools were recruited to participate in the present study. Participants were randomized into two groups: (1) the treatment group which consisted of playing Kaledo over 20 sessions and (2) the no intervention group. Anthropometric measures were carried out for both groups at baseline (prior to any treatment) and at two follow-up post-assessments (8 and 18 months). All the participants completed a questionnaire concerning physical activity and a 1-week food diary at each assessment. The primary outcomes were (i) BMI z-score, (ii) scores on physical activity, and (iii) scores on a dietary questionnaire. BMI z-score was significantly lower in the treated group compared to the control group at 8 months. Frequency and duration of self-reported physical activity were also significantly augmented in the treated group compared to the control group at both post-assessments. Moreover, a significant increase in the consumption of healthy food and a significant decrease in junk food intake were observed in the treated group.

CONCLUSION

The present results confirm the efficacy of Kaledo in younger students in primary schools, and it can be used as a useful nutritional tool for obesity prevention programs in children. What is Known: • Kaledo is a new educational board game to improve nutrition knowledge and to promote a healthy lifestyle. • In two cluster randomized trials conducted in Campania region (Italy), we showed that Kaledo could improve nutrition knowledge and dietary behavior and have a positive effect on the BMI z-score in children with age ranging from 9 to 14 years old attending school. • Kaledo may be used as an effective tool for obesity prevention programs in middle and high school students. What is New: • Investigating the effects of Kaledo on younger primary school children (7-11 year olds), Kaledo could be an effective tool in obesity prevention programs for children as young as 7 years old.

Rationale and Design of an Online Educational Program Using Game-Based Learning to Improve Nutrition and Physical Activity Outcomes Among University Students in the United Kingdom

OBJECTIVE

To assess the impact of an online game-based educational program on nutrition knowledge and dietary and physical activity habits among university students in the United Kingdom.

DESIGN

Randomized controlled trial with pre- and postintervention comparisons.

SETTING

Two higher education settings in London, UK.

SUBJECTS

Current undergraduate and postgraduate students of two universities (n = 88) aged 18-34 years are randomly allocated to an intervention (n = 44) or a control group (n = 44).

INTERVENTION

The intervention group will receive access to an educational website and online quizzes with gamification elements, including information about healthy eating and physical activity. The control group will receive no information. Duration of the intervention will be 10 weeks.

MEASURES OF OUTCOME

Primary outcome is nutrition knowledge. Secondary outcomes include dietary and activity habits. Nutrition knowledge and dietary and activity habits will be assessed using questionnaires. Weekly steps will be counted using pedometers. Assessment of anthropometric and metabolic risk factors will take place.

ANALYSIS

Quantitative analysis will investigate changes in nutrition knowledge between the two groups of the study population. Linear regression analysis will be used, if the data follow the normal distribution (otherwise binomial regression analysis), to examine whether field of study, residence status, body mass index (BMI), and demographic factors affect nutrition knowledge. Associations between changes in knowledge and dietary and physical activity behavior will be assessed by correlations.

CONCLUSIONS/IMPLICATIONS

The study will provide insights with regard to the design and use of online game-playing as a cost-effective approach to improve nutritional knowledge among university students.

A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial

Background

There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa.

Objective

To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change.

Methods

Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics.

Results

Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game’s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk.

Conclusions

The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design.

Trial Registration

ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)

Epic Allies, a Gamified Mobile Phone App to Improve Engagement in Care, Antiretroviral Uptake, and Adherence Among Young Men Who Have Sex With Men and Young Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

In the United States, young men who have sex with men (YMSM) and transgender women who have sex with men (YTWSM) bear a disproportionate burden of prevalent and incident HIV infections. Once diagnosed, many YMSM and YTWSM struggle to engage in HIV care, adhere to antiretroviral therapy (ART), and achieve viral suppression. Computer-based interventions, including those focused on behavior change, are recognized as effective tools for engaging youth.

Objective

The purpose of the study described in this protocol is to evaluate the efficacy of Epic Allies, a theory-based mobile phone app that utilizes game mechanics and social networking features to improve engagement in HIV care, ART uptake, ART adherence, and viral suppression among HIV-positive YMSM and YTWSM. The study also qualitatively assesses intervention acceptability, perceived impact, and sustainability.

Methods

This is a two-group, active-control randomized controlled trial of the Epic Allies app. YMSM and YTWSM aged 16 to 24 inclusive, with detectable HIV viral load are randomized 1:1 within strata of new to care (newly entered HIV medical care ≤12 months of baseline visit) or ART-nonadherent (first entered HIV medical care >12 months before baseline visit) to intervention or control conditions. The intervention condition addresses ART adherence barriers through medication reminders and adherence monitoring, tracking of select adherence-related behaviors (eg, alcohol and marijuana use), an interactive dashboard that displays the participant’s adherence-related behaviors and provides tailored feedback, encouragement messages from other users, daily HIV/ART educational articles, and gamification features (eg, mini-games, points, badges) to increase motivation for behavior change and app engagement. The control condition features weekly phone-based notifications to encourage participants to view educational information in the control app. Follow-up assessments are administered at 13, 26, and 39 weeks for each arm. The primary outcome measure is viral suppression. Secondary outcome measures include engagement in care, ART uptake, ART adherence, and psychosocial barriers to engagement in care and ART adherence, including psychological distress, stigma, and social support.

Results

Baseline enrollment began in September 2015 and was completed in September 2016 (n=146), and assessment of intervention outcomes continued through August 2017. Results for primary and secondary outcome measures are expected to be reported in ClinicalTrials.gov by April 30, 2018.

Conclusions

If successful, Epic Allies will represent a novel adherence intervention for a group disproportionately impacted by HIV in the United States. Adherent patients would require less frequent clinic visits and experience fewer HIV-related secondary infections, thereby reducing health care costs and HIV transmission. Epic Allies could easily be expanded and adopted for use among larger populations of YMSM and YTWSM, other HIV-positive populations, and for those diagnosed with other chronic diseases such as diabetes and hypertension.

Trial Registration

ClinicalTrials.gov NCT02782130; https://clinicaltrials.gov/ct2/show/NCT02782130 (Archived by Webcite at http://www.webcitation.org/6yGODyerk)

Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach

BACKGROUND

Although mobile technologies such as smartphone apps are promising means for motivating people to adopt a healthier lifestyle (mHealth apps), previous studies have shown low adoption and continued use rates. Developing the means to address this issue requires further understanding of mHealth app nonusers and adoption processes. This study utilized a stage model approach based on the Precaution Adoption Process Model (PAPM), which proposes that people pass through qualitatively different motivational stages when adopting a behavior.

OBJECTIVE

To establish a better understanding of between-stage transitions during app adoption, this study aimed to investigate the adoption process of nutrition and fitness app usage, and the sociodemographic and behavioral characteristics and decision-making style preferences of people at different adoption stages.

METHODS

Participants (N=1236) were recruited onsite within the cohort study Konstanz Life Study. Use of mobile devices and nutrition and fitness apps, 5 behavior adoption stages of using nutrition and fitness apps, preference for intuition and deliberation in eating decision-making (E-PID), healthy eating style, sociodemographic variables, and body mass index (BMI) were assessed.

RESULTS

Analysis of the 5 behavior adoption stages showed that stage 1 ("unengaged") was the most prevalent motivational stage for both nutrition and fitness app use, with half of the participants stating that they had never thought about using a nutrition app (52.41%, 533/1017), whereas less than one-third stated they had never thought about using a fitness app (29.25%, 301/1029). "Unengaged" nonusers (stage 1) showed a higher preference for an intuitive decision-making style when making eating decisions, whereas those who were already "acting" (stage 4) showed a greater preference for a deliberative decision-making style (F4,1012=21.83, P<.001). Furthermore, participants differed widely in their readiness to adopt nutrition and fitness apps, ranging from having "decided to" but not yet begun to act (stage 2; nutrition: 6.88%, 70/1017; fitness: 9.23%, 95/1029) to being "disengaged" following previous adoption (stage 5; nutrition: 13.77%, 140/1017; fitness: 15.06%, 155/1029).

CONCLUSIONS

Using a behavior stage model approach to describe the process of adopting nutrition and fitness apps revealed motivational stage differences between nonusers (being "unengaged," having "decided not to act," having "decided to act," and being "disengaged"), which might contribute to a better understanding of the process of adopting mHealth apps and thus inform the future development of digital interventions. This study highlights that new user groups might be better reached by apps designed to address a more intuitive decision-making style.

What's technology cooking up? A systematic review of the use of technology in adolescent food literacy programs

Over one-third of adolescents are overweight or obese. Food literacy (FL), the ability to plan and manage, select, prepare, and eat healthy foods, is a contemporary concept that provides a mechanism to understand the relationship between food-related knowledge and skills and dietary intake. Innovative interventions which focus on the core concepts of FL and include generationally appropriate technology have the potential to provide positive impact on the dietary habits of adolescents. This systematic review followed PRISMA guidelines and employed the Downs and Black criteria for rating studies. Titles and abstracts of 545 articles were collected and reviewed from 13 electronic databases. Studies were selected if they were peer-reviewed, included adolescents 12-19 years-old, incorporated concepts related to FL, and employed technology as part of the intervention. Eight studies, six randomized controlled trials (RCT) and two interventions without controls were included. Seven of the interventions used Internet or web-based platforms to access program components and all RCTs incorporated game elements. Studies included between two and four constructs of FL. All reported positive changes in food intake with five reporting significant positive pre- and post-intervention changes. Few technology-driven FL-related studies exist within the literature. Although all studies reported improvements in dietary intake, due to variation in program design, delivery, and evaluation it is difficult to tease out the effect of the technology component. Continued research is needed to: 1) determine the degree to which FL should be included in interventions to effect a positive change on dietary intake; 2) develop adolescent-specific FL measures to more appropriately evaluate changes in knowledge, food-related skills, and dietary intake; and 3) design technology-driven interventions so that technology components can be analyzed separately from other program elements.

Can oral health education be delivered to high-caries-risk children and their parents using a computer game? - A randomised controlled trial

BACKGROUND

Families of children undergoing general anaesthesia (GA) for caries management requested that oral health advice is delivered using audio-visual media.

OBJECTIVE

To compare an oral health education computer game to one-to-one education.

DESIGN

A blind randomised controlled trial of 4- to 10-year-old children scheduled for GA due to caries. Primary outcome measures were (1) parent and child satisfaction with education method; (2) improvements in child's dietary knowledge; and (3) changes in child's diet and toothbrushing habits. Measures were taken at baseline, post-intervention, and three months later.

RESULTS

One hundred and nine families took part. Both methods of education were highly satisfactory to children and parents. Children in both groups showed significant improvement in recognition of unhealthy foods immediately post-education (P < 0.001). Fifty-five per cent of all participants completed telephone follow-up after 3 months and reported improvements in diet, including reducing sweetened drinks (P = 0.019) and non-core foods (P = 0.046) intake, with no significant differences between the groups. Children reported twice-daily toothbrushing but no changes in snack selection. Attendance for a 3-month dental review was poor (11%).

CONCLUSION

Oral health education using a computer game can be as satisfactory and as effective in improving high-risk-children's knowledge as one-to-one education. The education received can lead to the positive dietary changes in some families.

Acceptability of Group Visits for Attention-Deficit Hyperactivity Disorder in Pediatric Clinics

OBJECTIVE

Children with attention-deficit hyperactivity disorder (ADHD) have ongoing needs that impair home and school functioning. Group visit models are a promising way to deliver timely parenting support but family and provider acceptance has not previously been examined. The objective was to describe the acceptability of ADHD group visits in busy pediatric clinics based on caregivers, child participants and facilitators.

METHODS

Data were analyzed from school-age children and caregivers who participated in one of two 12-month long randomized controlled studies of the ADHD group visit model from 2012 to 2013 or 2014 to 2015. Feedback was obtained using semi-structured questions at each study end, by telephone or at the last group visit. Sessions were audio-recorded, transcribed and themes were extracted by participant type.

RESULTS

A total of 34 caregivers, 41 children and 9 facilitators offered feedback. Caregivers enjoyed the "support group" aspect and learning new things from others. Caregivers reported improved understanding of ADHD and positive changes in the relationship with their child. Children were able to recall specific skills learned including how skills helped at home or school. Facilitators acknowledged systems-level challenges to offering group visits but felt the group format helped increase understanding of families' needs, improved overall care, and provided innovative ways to engage with families.

CONCLUSION

The majority of comments from families and facilitators highlighted a variety of benefits of the use of a group visit model for ADHD chronic care. Despite systems-level barriers to implementation, families and facilitators felt the benefits outweighed the challenges.

Children With Type 1 Diabetes Mellitus: Self-Management Experiences in School

BACKGROUND

Children with type 1 diabetes mellitus (T1DM) need to perform self-management activities at school and in other environments. Learning about their experiences at school is crucial to assist them in this challenging task.

METHODS

Qualitative interviews were conducted with children with T1DM, aged between 7 and 12. A scenario was created and puppets were used during the interviews to help the participating children to communicate about school, daily routines, and experiences in diabetes management. Data were collected over a period of 1 year and analyzed according to content analysis procedures.

RESULTS

Nineteen children, 13 boys and 6 girls, at the mean age of 9.8 ± 1.8 years and mean time since diagnosis of 3.3 years, participated in the study. Three themes were identified: lack of information on T1DM, diabetes self-care at school, and support received by the children.

CONCLUSIONS

The study provides useful information to understand the children's experiences in managing the disease at school. The partnership between school staff, health teams, children with T1DM, and their families need to be enhanced to promote appropriate strategies that improve the management of diabetes in this setting.

Chances and Limitations of Video Games in the Fight against Childhood Obesity-A Systematic Review

OBJECTIVE AND METHOD

A systematic literature search was conducted to assess the chances and limitations of video games to combat and prevent childhood obesity. This search included studies with video or computer games targeting nutrition, physical activity and obesity for children between 7 and 15 years of age.

RESULTS

The study distinguished between games that aimed to (i) improve knowledge about nutrition, eating habits and exercise; (ii) increase physical activity; or (iii) combine both approaches. Overall, the games were well accepted. On a qualitative level, most studies reported positive effects on obesity-related outcomes (improvement of weight-related parameters, physical activity or dietary behaviour/knowledge). However, the observed effects were small. The games did not address psychosocial aspects.

CONCLUSIONS

Using video games for weight management exclusively does not deliver satisfying results. Video games as an additional guided component of prevention and treatment programs have the potential to increase compliance and thus enhance treatment outcome. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A Systematic Review of Methods for Increasing Vegetable Consumption in Early Childhood

Purpose of Review

This study aims to synthesise the body of research investigating methods for increasing vegetable consumption in 2- to 5-year-old children, while offering advice for practitioners.

Recent Findings

Repeated exposure is a well-supported method for increasing vegetable consumption in early childhood and may be enhanced with the inclusion of non-food rewards to incentivise tasting. Peer models appear particularly effective for increasing 2–5-year-olds’ vegetable consumption. There is little evidence for the effectiveness of food adaptations (e.g. flavour-nutrient learning) for increasing general vegetable intake among this age group, although they show some promise with bitter vegetables.

Summary

This review suggests that practitioners may want to focus their advice to parents around strategies such as repeated exposure, as well as the potential benefits of modelling and incentivising tasting with non-food rewards. Intervention duration varies greatly, and considerations need to be made for how this impacts on success.

Participatory science and innovation for improved sanitation and hygiene: process and outcome evaluation of project SHINE, a school-based intervention in Rural Tanzania

Background

Diarrheal disease is a major cause of mortality and morbidity in low and middle income countries with children being disproportionately affected. Project SHINE (Sanitation & Hygiene INnovation in Education) is a grassroots participatory science education and social entrepreneurship model to engage youth and the wider community in the development of sustainable strategies to improve sanitation and hygiene.

Methods

Based in rural and remote Tanzania, this pilot study engaged pastoralist high-school students and communities in the development and evaluation of culturally and contextually relevant strategies to improve sanitation and hygiene. Using a train-the-trainer approach, key activities included teacher workshops, school-based lessons, extra-curricular activities, community events and a One Health sanitation science fair which showcased projects related to water, sanitation and hygiene in relation to human and animal health. The process and outcome of the study were evaluated through qualitative interviews and focus group discussions with diverse project participants, as well as pre- and post- questionnaires completed by students on knowledge, attitudes and practices concerning sanitation and hygiene.

Results

The questionnaire results at baseline and follow-up showed statistically significant improvements on key measures including a decrease in unhygienic behaviors, an increase in the perceived importance of handwashing and intention to use the toilet, and increased communication in the social network about the importance of clean water and improved sanitation and hygiene practices, however there were no significant changes in sanitation related knowledge. Qualitative data highlighted strong leadership emerging from youth and enthusiasm from teachers and students concerning the overall approach in the project, including the use of participatory methods. There was a high degree of community engagement with hundreds of community members participating in school-based events. Sanitation science fair projects addressed a range of pastoralist questions and concerns regarding the relationship between water, sanitation and hygiene. Several projects, such as making soap from local materials, demonstrate potential as a sustainable strategy to improve health and livelihoods in the long-term.

Conclusions

The Project SHINE model shows promise as an innovative capacity building approach and as an engagement and empowerment strategy for youth and communities to develop locally sustainable strategies to improve sanitation and hygiene.

Fourth-grade children's dietary reporting accuracy by meal component: Results from a validation study that manipulated retention interval and prompts

We examined reporting accuracy by meal component (beverage, bread, breakfast meat, combination entrée, condiment, dessert, entrée, fruit, vegetable) with validation-study data on 455 fourth-grade children (mean age = 9.92 ± 0.41 years) observed eating school meals and randomized to one of eight dietary recall conditions (two retention intervals [short, long] crossed with four prompts [forward, meal-name, open, reverse]). Accuracy category (match [observed and reported], omission [observed but unreported], intrusion [unobserved but reported]) was a polytomous nominal item response variable. We fit a multilevel cumulative logit model with item variables meal component and serving period (breakfast, lunch) and child variables retention interval, prompt and sex. Significant accuracy category predictors were meal component (p < 0.0003), retention interval (p < 0.0003), meal-component × serving-period (p < 0.0003) and meal-component × retention-interval (p = 0.001). The relationship of meal component and accuracy category was much stronger for lunch than breakfast. For lunch, beverages were matches more often, omissions much less often and intrusions more often than expected under independence; fruits and desserts were omissions more often. For the meal-component × retention-interval interaction, for the short retention interval, beverages were intrusions much more often but combination entrées and condiments were intrusions less often; for the long retention interval, beverages were matches more often and omissions less often but fruits were matches less often. Accuracy for each meal component appeared better with the short than long retention interval. For lunch and for the short retention interval, children's reporting was most accurate for entrée and combination entrée meal components, whereas it was least accurate for vegetable and fruit meal components. Results have implications for conclusions of studies and interventions assessed with dietary recalls obtained from children.

A systematic review of children's dietary interventions with parents as change agents: Application of the RE-AIM framework

INTRODUCTION

Interventions targeting children's dietary behavior often include strategies that target parents as implementation agents of change, though parent involvement on intervention effectiveness is unclear. The present study systematically assessed (1) reporting of reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of child dietary intervention studies with parents as change agents and (2) evaluated within these studies the comparative effectiveness of interventions with and without a parent component.

METHODS

The search was conducted in PubMed, PsycINFO, and Cochrane Library. Eligible studies were required to include a condition with a parental component, a comparison/control group, and target a child dietary behavior outcome. Forty-nine articles met criteria. Raters extracted RE-AIM and parent implementation information for each study.

RESULTS

Effectiveness (72.5%) was the highest reported RE-AIM element, followed by reach (27.5%), adoption (12.5%), implementation (10%), and maintenance (2.5%). Median reporting of parent implementation was highest for adoption and enactment (20%), followed by receipt (7.5%), and maintenance (2.5%). Six studies tested comparative effectiveness of parental involvement on child dietary outcomes.

CONCLUSION

Current RE-AIM reporting among children's dietary interventions is inchoate. The contribution of parental involvement on intervention effectiveness remains unclear. Increased focus should be placed on reporting of external validity information, to enable better translation of research to practical applications.

Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors ("Balance It"): A Pilot Study

Background

Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA).

Objective

We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA.

Methods

In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m²) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants.

Results

After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R² change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R² change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R² change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R² change=.08) in terms of unhealthy eating.

Conclusions

The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight.