Effectiveness of Virtual Reality on Rehabilitation of Chronic Non-Specific Low Back Pain Patients

BACKGROUND

Virtual reality (VR) is used extensively for musculoskeletal conditions, but its efficacy in chronic low back pain still needs more investigation.

OBJECTIVE

To discuss the effectiveness of VR on selected outcomes in Chronic Non-Specific Low Back Pain (CNSLBP).

METHODS

Thirty-five patients with CNSLBP joined this study. Postural correction exercises using the TBed VR gaming system in addition to hamstring stretching were employed, and moist heat on the low back was applied. Pre- and post-intervention values of pain, ROM, function, and balance (overall stability index) were obtained using the numerical rating pain scale (NPRS), Oswestry Disability Index, back range of motion (BROM), and Biodex system. Satisfaction level on a 1-10 scale and the degree of commitment to the exercise sessions were assessed after the intervention.

RESULTS

The patients completed the intervention period and outcome measures sessions. Paired t-tests reported statistically significant improvements and high effect size in pain, ROM, function, and balance after the end of the treatment (p < 0.001, Cohen's d > 0.69). The level of satisfaction was 9.25 ± 0.766, and the commitment to exercise sessions was high (98.75% attendance rate).

CONCLUSIONS

Applying postural correction using TBed VR gaming in addition to heat and stretching may improve pain, range of motion, function, and balance in patients with chronic low back pain.

Developing a Motion Sensor-Based Game to Support Frozen Shoulder Rehabilitation in Older Adults through a Participatory Design Approach

Objective: Although some serious games have been developed for physical therapy, little work has been conducted through a participatory design approach. Therefore, a game prototype was developed, which involved related stakeholders in the design process. Materials and Methods: The iterative participatory design process was adopted with the input of 18 patients with frozen shoulder symptoms, 4 health professionals, 2 game designers, and 5 researchers in an iterative process to design, test, and evaluate the game prototype. In total, 17 patients participated in the interviews to explore their needs and desires for a serious game. The health professionals participated in the interviews to understand the medical requirement and experience pertaining to frozen shoulder and were included in the workshop to give feedback on the game prototype. At the conclusion of the iterative design process, a Kinect-based prototype game with three levels was used for a case study with one patient who was diagnosed with frozen shoulder and has been receiving medical treatment in the hospital. Results: Based on the outcomes derived from data collected among diverse stakeholders, the prototype game underwent iterative development by the team and was assessed by a participant with frozen shoulder symptoms. Findings revealed that the participant demonstrated enhanced shoulder mobility and a reduction in pain intensity, despite the lack of significant improvement for health-related quality of life. Nevertheless, the participant reported a positive experience with the prototype game. Conclusion: This study underscores the importance of involving diverse stakeholders in the development process to create more effective and user-centric serious games for rehabilitation. The participatory approach, exemplified by the prototype game, demonstrates potential improvements in both user experience and overall effectiveness during the rehabilitation process.

Enhancing Serious Game Design: Expert-Reviewed, Stakeholder-Centered Framework

BACKGROUND

Traditional serious game design methods often overlook stakeholder needs. This study integrates stakeholder theory and enterprise architecture (EA), along with the Architecture Development Method, to propose a novel framework for serious game design. Crafted to aid practitioners, researchers, and specialists in leveraging resources more effectively, the framework is validated through a design science research methodology. Expert reviews have further refined its features, making it a robust tool for enhancing serious game design and implementation.

OBJECTIVE

This paper introduces a framework for designing serious games, covering stakeholder analysis, requirements gathering, and design implementation planning. It highlights the importance of expert review in validating and refining the framework, ensuring its effectiveness and reliability for use in serious game design. Through critical assessment by experts, the framework is optimized for practical application by practitioners, researchers, and specialists in the field, ensuring its utility in enhancing serious game development. The next step will be to validate the framework empirically by applying it to a serious game development project.

METHODS

We developed and validated a conceptual framework for serious game design by synthesizing stakeholder theory and EA through literature review, concept mapping, and theory development by way of a design science research approach. The framework is iteratively refined and validated via expert review, drawing on insights from professionals experienced in serious games, stakeholder theory, and EA. This method ensures the framework's practical relevance and effectiveness in addressing real-world design challenges.

RESULTS

An expert review by 29 serious game practitioners validated the framework's success in stakeholder management, confirming its stakeholder-centered effectiveness. Although the experts praised its structured approach, they suggested clearer guidance for game design elements. In addition, the experts, while acknowledging the framework's complexity, saw its depth as valuable for efficient management. The consensus calls for a refined balance between detailed functionality and user-friendly design, with the framework's impact on stakeholder capabilities revealing a spectrum of professional needs.

CONCLUSIONS

This paper presents a framework for creating effective and organizationally aligned serious games. Evaluated across execution, practical, and EA levels, it is logical but varies in ease of understanding, with experts calling for more accessibility at the EA level. It enhances stakeholder efficiency and management but is criticized for rigidity and a need for flexibility. Recommendations include streamlining the framework, enhancing clarity, reducing administrative tasks, and incorporating clear guidelines on technology use, motivational elements, and operational tools. This aims to help stakeholders produce more targeted and adaptable game designs. The next iteration will be developed after application to a project and team feedback.

High School Teachers' Experiences of Consumer Technologies for Stress Management During the COVID-19 Pandemic: Qualitative Study

BACKGROUND

Stress in education is an adverse reaction that teachers have to excessive pressures or other types of demands placed on them. Consumer digital technologies are already being used by teachers for stress management, albeit not in a systematic way. Understanding teachers' experiences and the long-term use of technologies to support stress self-management in the educational context is essential for meaningful insight into the value, opportunity, and benefits of use.

OBJECTIVE

The aim of this study was first to understand teachers' experiences of consumer technologies for stress management. They were chosen by teachers from a taxonomy tailored to their stress management. The second aim was to explore whether their experiences of use evolved over time as teachers transitioned from working at home during lockdown to working full time on school premises.

METHODS

A longitudinal study intended for 6 weeks in the summer term (2020) was extended because of COVID-19 into the autumn term, lasting up to 27 weeks. Teachers chose to use a Withings smartwatch or the Wysa, Daylio, or Teacher Tapp apps. In total, 2 semistructured interviews and web-based surveys were conducted with 8 teachers in South London in the summer term, and 6 (75%) of them took part in a third interview in the autumn term. The interviews were analyzed by creating case studies and conducting cross-case analysis.

RESULTS

The teachers described that the data captured or shared by the technology powerfully illustrated the physical and psychosocial toll of their work. This insight gave teachers permission to destress and self-care. The social-emotional confidence generated also led to empathy toward colleagues, and a virtuous cycle of knowledge, self-compassion, permission, and stress management action was demonstrated. Although the COVID-19 pandemic added a new source of stress, it also meant that teachers' stress management experiences could be contrasted between working from home and then back in school. More intentional self-care was demonstrated when back in school, sometimes without the need to refer to the data or technology.

CONCLUSIONS

The findings of this study demonstrate that taking a situated approach to understand the real-world, existential significance and value of data generates contextually informed insights. Where a strategic personal choice of consumer technology is enabled for high school heads of year, the data generated are perceived as holistic, with personal and professional salience, and are motivational in the educational context. Technology adoption was aided by the pandemic conditions of home working, and this flexibility would otherwise need workplace facilitation. These findings add to the value proposition of technologies for individual stress management and workforce health outcomes pertinent to educators, policy makers, and designers.

A Pilot Study of the Biofeedback Training to Reduce Salivary Cortisol Level and Improve Mental Health in Highly-Trained Female Athletes

Biofeedback (BFB) training can provide a useful resource for athletes to cope with stress. However, the effects of BFB training on acute and chronic endocrine stress responses, parasympathetic activity, and mental health in competitive athletes have not been explored yet. This pilot study examined the effects of a 7-week BFB training on psychophysiological parameters in highly trained female athletes. Six highly trained female volleyball players (mean age: 17.50 ± 1.05 years) volunteered to participate in the study. Athletes individually attended 21-session heart rate variability (HRV)-BFB training consisting of six minutes for 7 weeks. A BFB device (Nexus 10) was used to measure the athletes' physiological responses reflecting HRV. To assess the cortisol awakening response (CAR), saliva samples were collected immediately after awakening and 15 min, 30 min, and 60 min post-awakening. The Depression Anxiety Stress Scale-21 was filled out before and after the intervention to assess mental health. Furthermore, athletes provided saliva samples during eight sessions pre- and immediately post-session. Mid-day cortisol levels decreased significantly after the intervention. No significant change was observed in CAR and physiological responses after the intervention. A significant decrease in cortisol level was observed in BFB sessions in which cortisol level was assessed, except for two sessions. We concluded that short sessions of 7-week HRV-BFB training could be used as an effective method to control autonomic functions and stress of female athletes. Although the present study provides strong evidence for the psychophysiological well-being of athletes, further investigations with larger samples are needed.

Development of a smartphone virtual reality game to support the radiation therapy of children and adolescents in proton centers

Introduction

For most patients, cancer therapy with radiation is a new experience coming with many unknown challenges. This can be stressful, particularly for children and adolescents. With the aim of reducing this stress and anxiety, a virtual-reality (VR) game, which can be used by patients prior to treatment, was developed and evaluated in a proton therapy center.

Methods

The specifications were derived from literature and from interviews with medical staff and patients. The gantry including the sound of its moving components and the sound of the interlock and safety system were identified as the main features relevant for preparation of a radiation course. Potential implementation difficulties were identified in a literature study and regarded in the design. Within the VR game, patients could interact with modeled equipment of the treatment room and hear the reportedly stress-inducing sounds in a stress-free environment prior to the treatment. The VR game was evaluated in a second series of interviews with patients.

Results and Discussion

This exploratory study demonstrated the specification, implementation and safe application of a VR game dedicated to young proton therapy patients. Initial anecdotal evidence suggested that the VR gaming experience was well received and found to be helpful when preparing young patients for radiation therapy.

The effectiveness of serious games designed for infection prevention and promotion of safe behaviors of senior nursing students during the COVID-19 pandemic

BACKGROUND

Reminding health care workers, especially senior students, of the critical role they play in preventing COVID-19 transmission is more important than ever, therefore it is vital to reinforce graduate students' intrinsic motivation to implement infection prevention and control guidelines. Serious games are an interesting intervention that could improve adherence to COVID-19 safe behaviors to lower the high prevalence of nosocomial infections. These games, as a type of technology-enhanced simulation, can increase student satisfaction and engagement while still conveying vital ideas. For this reason, this study aimed to develop a serious game and evaluate its effectiveness to prevent the spread of infection and develop safe behaviors during the COVID-19 pandemic.

METHODS

In total, 62 nursing students completed a socio-demographic questionnaire, COVID-19 information form, and game usability form, with the students' responses analyzed pre-test and post-test.

RESULTS

Serious game implementation significantly increased senior students' knowledge of infection and safe behaviors concerning COVID-19. The students also considered the practice of serious games an effective teaching strategy. Favorite aspects of the serious game according to students' statements; It was reported as reflecting the real hospital environment, including the nursing care process and roles, being informative, being compatible by phone, and each stage of the game tested a new knowledge.

CONCLUSION

Employing serious games for nursing skills development is an appropriate teaching method for infection prevention and promotion of safe behaviors among senior nursing students during the COVID-19 pandemic. This game can be obtained free of charge for research and educational purposes.

Extended reality for mental health: Current trends and future challenges

Virtual and augmented reality have been used to diagnose and treat several mental health disorders for decades. Technological advances in these fields have facilitated the availability of commercial solutions for end customers and practitioners. However, there are still some barriers and limitations that prevent these technologies from being widely used by professionals on a daily basis. In addition, the COVID-19 pandemic has exposed a variety of new scenarios in which these technologies could play an essential role, like providing remote treatment. Disorders that traditionally had received less attention are also getting in the spotlight, such as depression or obsessive-compulsive disorder. Improvements in equipment and hardware, like Mixed Reality Head Mounted Displays, could help open new opportunities in the mental health field. Extended reality (XR) is an umbrella term meant to comprise Virtual reality (VR), mixed reality (MR), and augmented reality (AR). While XR applications are eminently visual, other senses are being explored in literature around multisensory interactions, such as auditory, olfactory, or haptic feedback. Applying such stimuli within XR experiences around mental disorders is still under-explored and could greatly enrich the therapeutic experience. This manuscript reviews recent research regarding the use of XR for mental health scenarios, highlighting trends, and potential applications as well as areas for improvement. It also discusses future challenges and research areas in upcoming topics such as the use of wearables, multisensory, and multimodal interaction. The main goal of this paper is to unpack how these technologies could be applied to XR scenarios for mental health to exploit their full potential and follow the path of other health technologies by promoting personalized medicine.

e-Estesia: A Serious Game for Reducing Arousal, Improving Emotional Regulation and Increasing Wellbeing in Individuals with Gambling Disorder

Gambling disorder (GD) is associated with deficits in emotion regulation and impulsivity-related personality traits. In recent years there has been an increase in the use of serious games (SG) to address these factors with positive results. The aim of this study was to analyze the efficacy of the intervention with a new SG (e-Estesia), as an adjunct to a CBT intervention for GD. The sample comprised two groups (experimental group (n = 40) and control group (n = 64)) of patients with GD diagnosis. Both groups received 16 weekly CBT sessions and, concurrently, only the experimental group received 15 additional sessions with e-Estesia. Pre-post treatment with e-Estesia administered in both groups were: DSM-5 Criteria, South Oaks Gambling Screen, Symptom Checklist-Revised and measure of relapses, dropout and compliance of treatment. As regards the experimental group were also administered: Difficulties in Emotion Regulation Scale, Emotion Regulation Questionnaire, and Impulsive Behavior Scale. No statistically significant differences in the general psychopathological state, emotion regulation or impulsivity were found when comparing the groups. However, patients enrolled in the e-Estesia intervention had significantly less relapses and better indicators of treatment compliance than the control group. Considering these results, the use of complementary tools such as SG are useful for addressing GD.

Evaluating the effect of digital game-based nutrition education on anemia indicators in adolescent girls: A randomized clinical trial

Iron deficiency anemia is the most common type of micronutrient deficiency in the world. Adolescence represents a period of increased risk of iron deficiency. Therefore, we aimed to determine the impact of nutrition education by a digital game on markers of iron-deficient anemia in adolescent girls. In this study, 176 adolescent girls were randomly dichotomized into the intervention and control groups. At the beginning and the end of the intervention, knowledge, attitude, and practice of both groups were assessed by a questionnaire. Girls in the intervention group received the necessary education through a digital game during a 14-week period, while those in the control group received basic nutritional education through PowerPoint and pamphlets. Additionally, serum transferrin, serum iron, transferrin saturation, ferritin, CBC difference, and total iron binding capacity (TIBC) tests were checked. In this study, nutrition education significantly increased the level of knowledge, attitude, and practice of adolescent girls regarding their diet (p ˂ .05). Hemoglobin level was also significantly raised (p ˂ .05). However, no significant effect was observed on other markers of iron-deficient anemia, such as serum iron, TIBC, and hematocrit, in the intervention group compared with the control group (p ˃ .05). The results of this study indicated the positive impact of nutrition education based on digital game on knowledge, attitude, and practice scores, as well as a significant difference in hemoglobin. It is recommended that educational games be designed for students in the future to promote health and nutrition information.

Socially-Oriented Persuasive Game to Promote Disease Awareness and Prevention

Persuasive games are widely implemented in the health domain to promote desirable behaviour change. Previous research shows that using persuasive games employing various strategies results in increased motivation and awareness that led to a positive change in behaviour. This paper investigates the efficacy of a competition-based persuasive game at creating awareness and motivating people to adhere to COVID-19 precautionary measures. To achieve this goal, we developed and evaluated a competition-based persuasive game to promote the awareness and adoption of COVID-19 precautionary measures. The results of our pretest and posttest study ( $N=67$ ) followed by a semistructured interview of 18 participants show the efficacy of the game with respect to promoting a positive change in attitude, intention, self-efficacy, knowledge, and promoting motivation and positive player experience among participants. The qualitative results provide insight into how and why persuasive games promote desirable behaviour. The paper contributes to the knowledge of how emerging technologies in the form of persuasive games can be designed and used to contribute to solving problems in our society.

Conventional Cervical Exercises Compared with a Mixed-Reality-Based Game in Asymptomatic Subjects: An Exploratory Crossover Pilot Study

Mixed reality presents itself as a potential technological tool for the management of people with musculoskeletal disorders, without having as many adverse side effects as immersive virtual reality. The objective of this study was to explore the possibilities of a mixed-reality game, performing task-oriented cervical exercises compared to conventional therapeutic exercises in sensorimotor outcome measures in asymptomatic subjects. A randomized crossover pilot study was performed with two intervention groups: a mixed-reality group (MRG) and a conventional exercise group (CEG). The cervical joint position error test (CJPET) and deep cervical flexor endurance test (DCFET) were measured as sensorimotor outcomes. Statistically significant differences were found in the pre–post comparison in the DCFET for both groups (MRG: t = −3.87, p < 0.01; CEG: t = −4.01, p < 0.01) and in the extension of the CJPET for the MRG (t = 3.50, p < 0.01). The rest of the measurements showed no significant differences comparing both groups pre- and postintervention (p > 0.05). Mixed reality has apparently the same positive effects as conventional exercises in sensorimotor outcomes in asymptomatic subjects. These results could help in future studies with mixed virtual reality in the management of people with musculoskeletal disorders.

A Serious Puzzle Game to Enhance Adherence to Antirheumatic Drugs in Patients With Rheumatoid Arthritis: Systematic Development Using Intervention Mapping

Background

Patients’ implicit attitudes toward medication need and concerns may influence their adherence. Targeting these implicit attitudes by combining game-entertainment with medication-related triggers might improve medication adherence in patients with rheumatoid arthritis (RA).

Objective

The aim of this study was to describe the systematic development of a serious game to enhance adherence to antirheumatic drugs by using intervention mapping.

Methods

A serious game was developed using the intervention mapping framework guided by a multidisciplinary expert group, which proceeded along 6 steps: (1) exploring the problem by assessing the relationship between medication adherence and implicit attitudes, (2) defining change objectives, (3) selecting evidence-based behavior change techniques that focused on adjusting implicit attitudes, (4) designing the intervention, (5) guaranteeing implementation by focusing on intrinsic motivation, and (6) planning a scientific evaluation.

Results

Based on the problem assessment and guided by the Dual-Attitude Model, implicit negative and illness-related attitudes of patients with RA were defined as the main target for the intervention. Consequently, the change objective was “after the intervention, participants have a more positive attitude toward antirheumatic drugs.” Attention bias modification, evaluative conditioning, and goal priming were the techniques chosen to implicitly target medication needs. These techniques were redesigned into medication-related triggers and built in the serious puzzle game. Thirty-seven patients with RA tested the game at several stages. Intrinsic motivation was led by the self-determination theory and addressed the 3 needs, that is, competence, autonomy, and relatedness. The intervention will be evaluated in a randomized clinical trial that assesses the effect of playing the serious game on antirheumatic drug adherence.

Conclusions

We systematically developed a serious game app to enhance adherence to antirheumatic drugs among patients with RA by using the intervention mapping framework. This paper could serve as a guideline for other health care providers when developing similar interventions.

Therapeutic use of serious games in mental health: scoping review

BACKGROUND

There has been an increase in the development and application of serious games to support management of mental ill health, but their full impact is unclear.

AIMS

Evaluation of the current evidence of acceptability and effectiveness of serious games in improving mental health disorders.

METHOD

A PRISMA-guided scoping review was conducted, using a predefined criteria and a relevant word combination on three databases: EMBASE, Medline and PsycINFO. Each included study was examined for game format, study type, number of participants, basic demographics, disorder targeted, recruitment, setting, control conditions, duration and follow-up, study attrition, primary outcomes and their results. Each study was given a Grading of Recommendations, Assessment, Development and Evaluations rating for quality.

RESULTS

Fourteen out of 513 studies met the inclusion criteria. The serious games focused on symptoms of anxiety (n = 4), attention-deficit hyperactivity disorder (n = 3), depression (n = 2), schizophrenia (n = 2), alcohol use disorder (n = 2) and bipolar disorder (n = 1). There were multiple significant outcomes favouring serious games across conditions covered in the review. Study quality varied, with studies rated high (n = 3), moderate (n = 6), low (n = 3) and very low (n = 2).

CONCLUSIONS

The available evidence suggests that serious games could be an effective format for an intervention to reduce mental health symptoms and improve outcomes of individuals. Better designed studies would further develop confidence in this area. This is a potential vehicle of change to deliver some of the much-needed psychiatric support to both economically developed and developing regions in a resource-utilitarian manner. Partnerships between the gaming industry, researchers and health services may benefit patients.

A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study

Background

There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population.

Objective

The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain.

Methods

A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game.

Results

A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session.

Conclusions

The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology.

The Effect of Serious Games for Nursing Students in Clinical Decision-Making Process: A Pilot Randomized Controlled Trial

Background: Serious games (SGs) have been proposed as a type of technology-enhanced simulation that may provide nursing students with an opportunity to practice their clinical reasoning and decision-making skills in a realistic and safe environment. Materials and Methods: The aim of this study is to determine the effect of serious play on nursing students' self-confidence (SC) and anxiety in clinical decision making. The randomized controlled trial evaluated the efficacy of SGs for undergraduate nursing students using pre- and posttests. The study was conducted during nursing students' clinical practice and teaching. All undergraduate nursing students (n = 120) attending internal medicine nursing lesson were approached. Sixty students out of 120 answered the questionnaires at both baseline and follow-up (30 in the experimental group [EG] and 30 in the control group). The students answered the questionnaire after taking the first clinical practice, taking the endocrine course. In the 1 week, the EG played the game and both groups returned to clinical practice. Questionnaire data were collected after clinical application. Results: SC and two subdimensions, using the information in hand to determine the problem, and knowing and taking action, were improved in the intervention group and a significant interaction effect was found for changes over time between the two groups. Anxiety scores between groups were not statistically significant differences. Conclusions: Nursing professional educators can adopt SGs to improve cognitive and attention skills, strengthen judgment, require making time efficient, practice making safe decisions, and encourage the exploration of decision.

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.

Design and Evaluation of a Hands-Free Video Game Controller for Individuals With Motor Impairments

Over the past few decades, video gaming has evolved at a tremendous rate although game input methods have been slower to change. Game input methods continue to rely on two-handed control of the joystick and D-pad or the keyboard and mouse for simultaneously controlling player movement and camera actions. Bi-manual input poses a significant play impediment to those with severe motor impairments. In this work, we propose and evaluate a hands-free game input control method that uses real-time facial expression recognition. Through our novel input method, our goal is to enable and empower individuals with neurological and neuromuscular diseases, who may lack hand muscle control, to be able to independently play video games. To evaluate the usability and acceptance of our system, we conducted a remote user study with eight severely motor-impaired individuals. Our results indicate high user satisfaction and greater preference for our input system with participants rating the input system as easy to learn. With this work, we aim to highlight that facial expression recognition can be a valuable input method.

Virtual Reality in the Treatment of Adults with Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Virtual reality (VR) can present advantages in the treatment of chronic low back pain. The objective of this systematic review and meta-analysis was to analyze the effectiveness of VR in chronic low back pain. This review was designed according to PRISMA and registered in PROSPERO (CRD42020222129). Four databases (PubMed, Cinahl, Scopus, Web of Science) were searched up to August 2021. Inclusion criteria were defined following PICOS recommendations. Methodological quality was assessed with the Downs and Black scale and the risk of bias with the Cochrane Risk of Bias Assessment Tool. Fourteen studies were included in the systematic review and eleven in the meta-analysis. Significant differences were found in favor of VR compared to no VR in pain intensity postintervention (11 trials; n = 569; SMD = −1.92; 95% CI = −2.73, −1.11; p < 0.00001) and followup (4 trials; n = 240; SDM = −6.34; 95% CI = −9.12, −3.56; p < 0.00001); and kinesiophobia postintervention (3 trials; n = 192; MD = −8.96; 95% CI = −17.52, −0.40; p = 0.04) and followup (2 trials; n = 149; MD = −12.04; 95% CI = −20.58, −3.49; p = 0.006). No significant differences were found in disability. In conclusion, VR can significantly reduce pain intensity and kinesiophobia in patients with chronic low back pain after the intervention and at followup. However, high heterogeneity exists and can influence the consistency of the results.

Estabilidade dinâmica de pessoas com AVE durante o movimento de cabeceio simulado em um jogo digital

RESUMO A estabilidade postural é um objetivo de tratamento na fisioterapia que pode ser alcançado por meio de exercícios de transferência de peso bilateral. Os jogos digitais surgem como alternativa para execução desses exercícios, mas sua avaliação ainda necessita de aprimoramento. Propõe-se aqui o uso de variáveis biomecânicas para verificar o comportamento da estabilidade postural dinâmica durante um movimento de cabeceio, simulado por um jogo digital com diferentes exigências de velocidades. Para isso, 16 voluntários pós-acidente vascular encefálico (AVE) - 12 homens e 4 mulheres, com idade média de 56 anos - e 16 hígidos pareados por sexo e idade participaram da coleta experimental, na qual eles foram submetidos ao jogo digital “cabeceio”, que tem cinco níveis de velocidade, do mais lento ao mais rápido, com duração de 30 segundos cada. A partir dos sinais cinemáticos foi possível calcular os indicadores de interesse, a área da base de suporte e a margem de estabilidade, definida como a menor distância entre as bordas da base de suporte e a projeção vertical do centro de massa (CM) extrapolado, que considera a velocidade do CM. Os valores da base de suporte não apresentaram diferenças entre os níveis de velocidade do jogo, mas sim entre grupos. A margem de estabilidade não diferiu entre níveis e grupos. Os níveis de velocidade do jogo, possivelmente, não estimularam os voluntários a buscar estratégias diferentes para manter a estabilidade, como dar um passo, mas os fizeram adotar bases de suporte diferentes, sendo que indivíduos com AVE adotaram uma base de suporte menor do que a dos hígidos.

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.

Co-creation and prototyping of an intervention focusing on health literacy in management of malaria at community-level in Ghana

INTRODUCTION

Collaborating with end-users to develop interventions tailored to fit unique circumstances is proposed as a way to improve relevance and effectiveness of an intervention. This study used a local needs driven approach to develop a health literacy intervention for caregivers in Ghana concerning management of malaria in children under 5 years.

METHOD

For the period, November 2017-February 2019, we carried out the study using a three-phase framework including: 1) Needs assessment based on data from questionnaires, focus groups, individual interviews and observations, 2) Co-creation of a board game and brochures for health education at Child Welfare Clinics to address needs in health literacy concerning malaria and 3) Development of a prototype of the game, brochures as well as determining feasibility. In addition to the research team, health administrators, community health workers, designers and caregivers contributed to the development of the intervention.

FINDINGS

The needs assessment contributed to the development of interactive and useful materials including a board game and brochures, to help bridge the gaps in health literacy among caregivers. Co-creation of the materials and prototyping yielded a varying sense of ownership among stakeholders. End-users' engagement and participation in developing the intervention resulted in a high interest and adherence to interventions. However, high attrition rates of health workers and caregivers' inconsistent use of the Child Welfare Clinics challenged sustainability of this intervention.

CONCLUSION

Co-creation led to an interactive intervention. The interactive nature of the board game and brochures resulted in a better caregiver-health provider relationship and a sense of recognition of a more participatory approach to health delivery. We recommend co-creation as an approach to develop needs-driven interventions in a context like Ghana. Still, a stronger buy-in at the top-level of health management would improve sustainability and reach a larger audience.

An innovation involving self-surveillance and serious gaming to increase smoking quit rate: Protocol for a pilot randomized controlled trial

Smoking is a health hazard. Current smoking cessation measures such as behavioral change counselling by trained professionals, nicotine replacement therapy and medications have limited success. Smoking intensity is assessed using a portable device to measure the smokers’ exhaled breath carbon monoxide (eCO) level. A systematic review suggests the potential of serious gaming to increase smoking quit rate. However, the related studies were unable to explain and determine the effect gamification on smoking cessation.

A handy personalized eCO measurement device linked to a smart-phone applications (app) has been developed (integrated STEADES-2 system). This novel system incorporates app-based video and print learning resources, authentication function and gamification using the eCO data as game element. Trained multidisciplinary healthcare professionals access the STEADES-2 data to monitor smoking status and support smokers via asynchronous virtual coaching. The pilot randomized controlled trial will enroll 20 smokers to use the STEADES-2 system (intervention group) and another 20 to the existing smoking cessation programme (control group) in primary care. The primary feasibility outcomes will include the recruitment response rate, the smokers’ usability of the STEADES-2 system, their self eCO monitoring, frequencies of participation in the serious games and interactions with their virtual coaches. Their smoking literacy, utility and experience of the STEADES-2 system are other outcomes. Smokers in both groups will be compared on their cigarette abstinence as secondary outcome based on eCO levels and urine cotinine test (primary outcomes after 12 weeks).

The results will be disseminated via conferences and publications.

Quantifying visuoperceptual profiles of children with cerebral visual impairment

The aim was to develop a visuoperceptual profile schema reflecting visuoperceptual strengths and weaknesses, using neuropsychological tests. Secondly, this schema was used to quantify individual visuoperceptual profiles of children with and without cerebral visual impairment (CVI), and to identify differences in their profiles. Clinical records (2001-2018) of 630 children (386 males, 244 females; median age 77 months; interquartile range 63-98 months) suspected for CVI were reviewed. Neurological history, visuoperceptual results, ophthalmological, and neuroimaging data were retrieved. To develop the visuoperceptual schema, exploratory factor analyses (EFAs) were performed, followed by a Delphi study. In individual interviews, six experts were asked to "name the different visuoperceptual dimensions" and "what visuoperceptual dimensions are targeted by each of the 24 visuoperceptual subtests." To reach consensus, two questionnaire rounds (44 statements and 20 statements, respectively, five experts) followed. EFAs showed clinically uninterpretable results. The Delphi study revealed seven visuoperceptual dimensions; (1) visual discrimination and matching, (2) object or picture recognition, (3) visual spatial perception, (4) figure-ground perception, (5) motion perception, (6) visual short-term memory, and (7) scene perception. The most discriminating dimensions between CVI and no CVI were object/picture recognition (r = 0.56), visual spatial perception (r = 0.52), visual discrimination and matching (r = 0.47), and figure-ground perception (r = 0.39). Motion perception and visual short-term memory (both r = 0.22) were less discriminating. Two case studies illustrate how to apply the visuoperceptual schema to characterize dysfunction and intact functions. Visuoperceptual profiling can serve as a basis for individualized therapies in heterogeneous disorders.

A Serious Game to Improve Emotion Regulation in Treatment-Seeking Individuals With Gambling Disorder: A Usability Study

Background: Serious games have shown positive results in increasing motivation, adherence to treatment and strengthening the therapeutic alliance in multiple psychiatric disorders. In particular, patients with impulse control disorders and other disorders in which the patient suffers from inhibitory control deficits (e.g., behavioral addictions) have been shown to benefit from serious games. Aim: The aim of this study was to describe the characteristics and to evaluate the usability of a new serious videogame, e-Estesia. This serious videogame was designed to improve emotion regulation in patients with gambling disorder (GD). Preliminary results from a pilot sample are also reported. Method: A pilot sample of 26 patients undergoing treatment for GD was recruited (ranging from 22 to 74 years, mean = 41.2 and SD = 12.9; 80.8% men). Participants used e-Estesia on a tablet, which was connected to a thoracic band that sent heart rate (HR) and heart rate variability (HRV) data to the videogame platform in order to provide biofeedback. The System Usability Scale was completed by patients to determine the usability of e-Estesia. Results and Discussion: e-Estesia performed comparatively well for all the explored groups (i.e., sex, age, and online vs. offline gambling: mean usability score = 83.8, SD = 13.1). Around 84.6% of the patients endorsed that it was easy to use. Female patients with GD presented higher HRV during the use of the serious videogame compared to men.

The Effect of a Health Game Prompt on Self-efficacy: Online Between-Subjects Experimental Survey

Background

Games for health are increasingly used as (part of) health interventions and more effect research into games for health is being done. This online experiment questions expectancies of games for health by investigating whether a game for health prompt might be considered arousal congruent cognitive reappraisal and as such positively effects self-efficacy before gameplay.

Objective

The aim of this study experiment is to test whether a game for health prompt effects self-efficacy and other well-being measurements, as a first step into investigating if a game prompt is a form of arousal congruent cognitive reappraisal.

Methods

This study used an online, 2D, between-subjects experimental survey design with self-efficacy as the main dependent variable. Stimulus is an assignment for health-related problem solving concerning living with diabetes type II, introduced as a game (n=125) versus the same assignment introduced as a task (n=107). Measurements after prompting the game/task assignment include self-efficacy, positive and negative affect, expected difficulty, flourishing, and self-esteem.

Results

The results indicate a small negative effect from prompting the game assignment on self-efficacy, compared with prompting a task assignment. This effect is mediated by the expected difficulty of the health game/task. No differences between the game and task groups were found in affect, flourishing, or self-esteem.

Conclusions

This experiment provides no support for the notion that a game for health prompt might be seen as arousal congruent cognitive reappraisal.

Digital Gaming Interventions in Psychiatry: Evidence, Applications and Challenges

Human evolution has regularly intersected with technology. Digitalization of various services has brought a paradigm shift in consumerism. Treading this path, mental health practice has gradually moved to Digital Mental Health Interventions (DMHI), to improve service access and delivery. Applied games are one such innovation that has gained recent popularity in psychiatry. Based on the principles of gamification, they target psychosocial and cognitive domains, according to the deficits in various psychiatric disorders. They have been used to deliver cognitive behaviour therapy, cognitive training and rehabilitation, behavioural modification, social motivation, attention enhancement, and biofeedback. Research shows their utility in ADHD, autistic spectrum disorders, eating disorders, post-traumatic stress, impulse control disorders, depression, schizophrenia, dementia, and even healthy aging. Virtual reality and artificial intelligence have been used in conjunction with gaming interventions to improvise their scope. Even though these interventions hold promise in engagement, ease of use, reduction of stigma, and bridging the mental-health gap, there are pragmatic challenges, especially in developing countries. These include network quality, infrastructure, feasibility, socio-cultural adaptability, and potential for abuse. Keeping this in the background, this review summarizes the scope, promise, and evidence of digital gaming in psychiatric practice, and highlights the potential caveats in their implementation.

Application of AR and VR in hand rehabilitation: A systematic review

BACKGROUND

The human hand is the part of the body most frequently injured in work related accidents, accounting for a third of all accidents at work and often involving surgery and long periods of rehabilitation. Several applications of Augmented Reality (AR) and Virtual Reality (VR) have been used to improve the rehabilitation process. However, there is no sound evidence about the effectiveness of such applications nor the main drivers of therapeutic success.

OBJECTIVES

The objective of this study was to review the efficacy of AR and VR interventions for hand rehabilitation.

METHODS

A systematic search of publications was conducted in October 2019 in IEEE Xplore, Web of Science, Cochrane library, and PubMed databases. Search terms were: (1) video game or videogame, (2) hand, (3) rehabilitation or therapy and (4) VR or AR. Articles were included if (1) were written in English, (2) were about VR or AR applications, (3) were for hand rehabilitation, (4) the intervention had tests on at least ten patients with injuries or diseases which affected hand function and (5) the intervention had baseline or intergroup comparisons (AR or VR intervention group versus conventional physical therapy group). PRISMA protocol guidelines were followed to filter and assess the articles.

RESULTS

From the eight selected works, six showed improvements in the intervention group, and two no statistical differences between groups. We were able to identify motivators of patients' adherence, namely real-time feedback to the patients, challenge, and increased individualized difficulty. Automated tracking, easy integration in the home setting and the recording of accurate metrics may increase the scalability and facilitate healthcare professionals' assessments.

CONCLUSIONS

This systematic review provided advantages and drivers for the success of AR/VR application for hand rehabilitation. The available evidence suggests that patients can benefit from the use of AR or VR interventions for hand rehabilitation.

An Internet-Based Psychological Intervention With a Serious Game to Improve Vitality, Psychological and Physical Condition, and Immune Function in Healthy Male Adults: Randomized Controlled Trial

Background

Recently, internet-based cognitive behavioral therapy (ICBT) and serious gaming interventions have been suggested to enhance accessibility to interventions and engagement in psychological interventions that aim to promote health outcomes. Few studies, however, have investigated their effectiveness in the context of simulated real-life challenges.

Objective

We aimed to examine the effectivity of a guided ICBT combined with a serious gaming intervention in improving self-reported psychophysiological and immunological health endpoints in response to psychophysiological and immune-related challenges.

Methods

Sixty-nine healthy men were randomly assigned to the intervention condition, receiving ICBT combined with serious gaming for 6 weeks, or the control condition, receiving no intervention. Self-reported vitality was the primary endpoint. Other self-reported psychophysiological and immunological endpoints were assessed following various challenges, including a bacillus Calmette-Guérin vaccination evoking pro-inflammatory responses, 1 and 4 weeks after the intervention period.

Results

Although the intervention did not affect vitality-associated parameters, self-reported sleep problems (P=.027) and bodily sensations (P=.042) were lower directly after the intervention compared with controls. Furthermore, wellbeing (P=.024) was higher in the intervention group after the psychophysiological challenges. Although no significant group differences were found for the psychophysiological and immunological endpoints, the data provided preliminary support for increased immunoglobulin antibody responses at the follow-up time points (P<.05). Differential chemokine endpoints between conditions were observed at the end of the test day.

Conclusions

The present study provides some support for improving health endpoints with an innovative ICBT intervention. Future research should replicate and further extend the present findings by consistently including challenges and a wide range of immune parameters into the study design.

Trial Registration

Nederlands Trial Register NTR5610; https://www.trialregister.nl/trial/5466

Serious Game e-Baby Família: an educational technology for premature infant care

OBJECTIVES

to develop and assess the serious game e-Baby Família with parents of premature infants.

METHODS

a methodological study regarding the development of the serious game, with participatory design in scope definition, starting from parents' learning needs about premature infant care. A qualitative approach was performed in the assessment stage with parents, with content analysis of the speech of the eight participants.

RESULTS

the following categories emerged: Realistic appearance of the virtual setting and game content and Gameplay implications for the use of e-Baby Família. The game was satisfactorily assessed regarding content, appearance and dynamics use, motivating participants to learn.

FINAL CONSIDERATIONS

in the context of prematurity as a public health problem in Brazil and the need to strengthen family health education for care, the serious game was assessed as motivating and appropriate for health learning.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Gamifying Motor Rehabilitation Therapies: Challenges and Opportunities of Immersive Technologies

Recovering from a traumatic incident (e.g, a stroke) implies rigorous and demanding therapies to ensure recovery of the lost capabilities. Due to the lack of short-term visible results, stroke patients tend to lose interest in their recovery process and frequently do not follow their therapists’ suggestions to continue performing their training at home, between physiotherapy sessions. This article explores the extent to which common computer games or specifically crafted games can serve as a rehabilitation practice, but also how conventional therapeutic devices might be transformed to be incorporated into games. Furthermore, we propose a platform that follows the opportunity of creating serious games that are designed for stroke patients with reduced upper limb mobility while following the same principles of common therapeutic procedures. This platform was carefully built with the purpose of allowing patients to comply tele-rehabilitation and promoting the execution of the recommended training at home. Following these ideas, we integrated two carefully designed games that have been tested and validated in our previous works, and we added a top-layer characterized by an online back-end application for therapists that allows them to observe their patients’ progress over time and draw different conclusions.

Cognitive-behavioral intervention via interactive multimedia online video game for active aging: study protocol for a randomized controlled trial

BACKGROUND

Due to the progressive aging of the population, programs to promote active aging have been recommended. However, older adults have difficulty accessing them. Interventions administered through online video games may increase their accessibility, and complementing these with a smartphone app will likely increase adherence and allow for ongoing professional monitoring. The objective of this study is to evaluate the efficacy of a cognitive-behavioral intervention for active aging administered through an online interactive multimedia video game that includes a smartphone app companion. The secondary objectives are to analyze the moderators and mediators of the change in the outcome variables and to evaluate the adherence to the intervention.

METHODS/DESIGN

A randomized controlled clinical trial will be conducted. Adults 45 years and older will be randomly assigned to a cognitive-behavioral intervention administered through an online multimedia video game that includes a smartphone app companion or to a control group that will receive online information on active aging (274 participants per group). The intervention will be administered in eight weekly 45-min modules. An investigator-blinded evaluation will be conducted using online self-administered tests at baseline, post-intervention, and 6- and 12-month follow-ups. The primary outcome will be mental health status as evaluated using the 36-item Short-Form Health Survey (SF-36) at post-intervention. Secondary outcomes will be emotional well-being, depressive symptoms, reinforcement, negative thoughts, self-reported memory, cognitive task performance, sleep hygiene behaviors, physical activity, eating habits, body mass index, social support, dropout, treatment adherence, and satisfaction with the intervention.

DISCUSSION

If the results are favorable, this study would involve the development of the first evidence-based active aging promotion intervention based on a video game that includes a smartphone app companion, providing evidence on its efficacy, accessibility, and clinical utility.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03643237. Registered 27 August 2018.

Editor's choice: Optimizing healthy food preferences by serious gaming

Objective: Serious gaming is an upcoming and promising tool in prevention and health promotion. The aim of this experimental study was to examine whether health-related serious gaming could optimize food-related outcomes and physical activity.Design: Eighty-one healthy participants (80% female) were randomly allocated to an experimental condition, in which participants played serious games based on transferring information, priming and evaluative conditioning, for half an hour, or a control condition, in which participants played non-health-related computer games.Main outcome measures: The primary study outcome was self-reported food preference and self-reported food choice, assessed by the Food Choice Task with food pairs differing in healthiness, or in both healthiness and attractiveness. Secondary outcomes were actual food choice and physical activity.Results: A significantly healthier food preference for pairs differing in healthiness was found on the Food Choice Task in the experimental compared to the control condition. No significant differences were found on the other outcomes.Conclusions: This study provides preliminary support for the effects of serious gaming based on optimizing food preferences. More research is needed to confirm the present findings and to further elucidate and optimize the effects of serious gaming on health behaviours.

Relationships Among Violent and Non-Violent Video Games, Anxiety, Self-Esteem, and Aggression in Female and Male Gamers

This study examines the differences in anxiety, self-esteem, and aggression levels between players of violent and non-violent video game and its connection to gender and age. This survey-based research utilizes survey data from 851 video gamers. The study included 61% men and 39% women. The ages of the participants ranged from 18 to 45. Participants were administered an anonymous survey including demographics, a questionnaire for video game habits, Rosenberg's self-esteem scale, a state anxiety inventory (STAI-S), and the Buss-Perry Aggression Questionnaire (BPAQ). The results revealed significant differences between males and females, as well as between younger and older gamers. Despite the majority of research showing a positive relationship between violent video game exposure and aggression levels, the results suggest that of the preference for a violent video game over a non-violent one is not, in itself, a cause for increased anxiety, self-esteem, and aggression levels.

Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights

Background

The idea of using serious games to effectuate better outcomes in health care has gained significant traction among a growing community of researchers, developers, and health care professionals. Many now recognize the importance of creating evidence-based games that are purposefully designed to address physical and mental health challenges faced by end users. To date, no regulatory resources have been established to guide the development of serious games for health (SGH). Developers must therefore look elsewhere for guidance. Although a more robust level of evidence exists in the research literature, it is neither structured nor is there any clear consensus. Developers currently use a variety of approaches and methodologies. The establishment of a well-defined framework that represents the consensus views of the SGH research community would help developers improve the efficiency of internal development processes, as well as chances of success. A consensus framework would also enhance the credibility of SGH and help provide quality evidence of their effectiveness.

Objective

This research aimed to (1) identify and evaluate the requirements, recommendations, and guidelines proposed by the SGH community in the research literature, and; (2) develop a consensus framework to guide developers, designers, researchers, and health care professionals in the development of evidence-based SGH.

Methods

A critical review of the literature was performed in October to November 2018. A 3-step search strategy and a predefined set of inclusion criteria were used to identify relevant articles in PubMed, ScienceDirect, Institute of Electrical and Electronics Engineers Xplore, CiteSeerX, and Google Scholar. A supplemental search of publications from regulatory authorities was conducted to capture their specific requirements. Three researchers independently evaluated the identified articles. The evidence was coded and categorized for analysis.

Results

This review identified 5 categories of high-level requirements and 20 low-level requirements suggested by the SGH community. These advocate a methodological approach that is multidisciplinary, iterative, and participatory. On the basis of the requirements identified, we propose a framework for developing theory-driven, evidence-based SGH. It comprises 5 stages that are informed by various stakeholders. It focuses on building strong scientific and design foundations that guide the creative and technical development. It includes quantitative trials to evaluate whether the SGH achieve the intended outcomes, as well as efforts to disseminate trial findings and follow-up monitoring after the SGH are rolled out for use.

Conclusions

This review resulted in the formulation of a framework for developing theory-driven, evidence-based SGH that represents many of the requirements set out by SGH stakeholders in the literature. It covers all aspects of the development process (scientific, technological, and design) and is transparently described in sufficient detail to allow SGH stakeholders to implement it in a wide variety of projects, irrespective of discipline, health care segments, or focus.

Smartphone and video game use and perceived effects in a community mental health service

BACKGROUND

Gaming is a growing area and there are conflicting reports on its harms and benefits. There is also increasing interest in the use of gaming clinically.

AIMS

This research aims to enhance our understanding of video and smartphone game use, and perceptions, among outpatients attending an Irish general adult mental health service.

METHODS

An anonymised, opportunistic survey of outpatients attending an Irish general adult mental health service was completed. Respondents were self-selecting and self-administering of the survey.

RESULTS

The response rate was 13% (n = 93). Younger patients were significantly more likely to own a smartphone (p = 0.00). Those who played videogames were significantly younger than those who did not (p = 0.00). Younger age groups were significantly more likely to have heard of (p = 0.00), and used (p = 0.01), Pokémon GO. Over 19% (n = 18) of respondents played video games. Nearly 24% (n = 16) of those with a smartphone played games on it daily. No respondents reported specifically using games for health reasons. The two individuals who found Pokémon GO usage increased their exercise levels, also reported mental health benefits from it. Individuals' gaming use and age did not significantly impact on whether they were positive or negative in their opinions towards video and smartphone games.

CONCLUSIONS

There is an opportunity to deliver interventions to Irish mental health service outpatients through smartphone and video games. Our small study suggests this to be underutilised currently. As more frequent users, perhaps younger individuals would most benefit from gamification of interventions and the use of existing games that have possible physical and mental health benefits. This requires further research.

Maximizing Authentic Learning and Real-World Problem-solving in Health Curricula Through Psychological Fidelity in a Game-Like Intervention: Development, Feasibility, and Pilot Studies

High fidelity is regarded as a hallmark of educational games and simulations for health education. Mainly physical and functional fidelity are associated with authenticity, resulting in the pursuit of a true-to-life simulation and suggesting the imposition of a generally accepted and often unintentional design rationale that assumes that the greater the fidelity of a game or simulation to the real world, the more authentic the intervention is perceived as. Psychological fidelity receives significantly less attention, although it correlates strongly to credibility, suspension of disbelief, and engagement. The BABLR simulator reduces physical and functional fidelity to a minimum and explores the use of psychological fidelity as the main carrier of an authentic learning experience. BABLR was assessed using 26 participants with varying backgrounds in health innovation and social work. In several pilot studies, we collected data on perceived realisticness and real-world relevance. Results show that experts, as well as participants, attest to BABLR's engagement, immersiveness, and motivational qualities. Practical implications of these findings for future research into developing low-fidelity simulations with high psychological fidelity will be discussed.

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.

Arbi Care application increases preschool children's hand-washing self-efficacy among preschool children

OBJECTIVE

This research aimed to examine the effectiveness of an Android mobile game application called Arbi Care as a means to prevent diarrhea and build self-efficacy in hand washing among preschool children.

METHOD

This research used a pre- and post-test control group and time series design approach. Respondents were chosen randomly from a group of four to six years children. The intervention group (n = 60) received Arbi Care intervention for 25 minutes, twice a week, for five weeks while the control group (n = 60) received standard education. Self-efficacy was measured by using questionnaire and observation. Measurement was carried out three times in the sixth, eight, and tenth week post-intervention. The data was analyzed using the GLMRM test.

RESULTS

There was a significant increase in the average score of self-efficacy in hand washing for the intervention group versus the control group. Moreover, there were significant differences in the results of average scores in which the intervention group showed much better self-efficacy improvement over the control group during the first, second, and final post-test after the intervention was given (p < 0.001).

CONCLUSIONS

An Android-based educational game can be an effective medium to improve hand washing self-efficacy among preschool children, thus helping to prevent diarrhea.

Exergaming for Children and Adolescents: Strengths, Weaknesses, Opportunities and Threats

Exergaming, or active video gaming, has become an emerging trend in fitness, education and health sectors. It is defined as digital games that require bodily movements to play, stimulating an active gaming experience to function as a form of physical activity (PA). Since exergaming is becoming more popular, claims have been made on the usefulness of exergaming. It has, for example, been entitled as being "the future of fitness" by the American College of Sports Medicine, promoting PA and health in children and adolescents. However, research also suggests that long-term engagement in exergaming is difficult to achieve, and there is a noticeable reservation towards exergaming by parents, teachers and caregivers. To provide an overview and to outline the future directions of exergaming, the aim of this review was to critically illustrate the strengths, weaknesses, opportunities and threats of exergaming to promote PA and health in children and youth. The available evidence indicates that exergaming has the potential to improve health via an increase in PA. However, it seems that this potential is frequently underexploited, and further developments such as customized exergames are needed.

Sweet care against sugar bitterness, designing health-based electronic game

Health-based electronic games present an innovative tool to deal with mental and behavioral disorders as well as physical. An appropriately designed game can optimize health care. The aim of this study was to establish a design for health-based electronic games model and to develop a sample game in diabetes. This study was carried out in two phases: first, the design of a health-based electronic game framework and second, the design and production of sweet care game. There were two intended information prerequisites: determination of effective components in models of behavior change and validation of these components on health topics and structural formation of a game. The game framework design was presented. In the second phase, a sample of the game was developed in the field of diabetes. Important components to empower people were ranked using the Friedman test in the following order: self-learning, treatment, mental empowerment, condition management, healthy eating and physical activity. The axis of self-learning received the highest rating from the perspective of the subjects with an average of 3.93 percent. Another part was the game framework with components as follows: application areas, educational content for change behavior, resources, game structure and game production. Finally, the sweet care game was designed on diabetes with educational, technological and clinical content. The health-based electronic game designed on a systematic framework could be applied as a tool to expanding the knowledge base on how to create effective health-based digital games that entertain while promoting behavior change.