Adolescents' Views on Active and Non-Active Videogames: A Focus Group Study

HelperFriend, a Serious Game for Promoting Healthy Lifestyle Behaviors in Children: Design and Pilot Study

Background

The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children.

Objective

We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness.

Methods

Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction.

Results

Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (t₁₄=2.01, P=.03), healthy eating (t₁₄=3.14, P=.003), and socioemotional wellness (t₁₄=2.75, P=.008). In addition, from T0 to T1, the intervention group improved their intention to perform physical activity (t₁₄=2.82, P=.006), healthy eating (t₁₄=3.44, P=.002), and socioemotional wellness (t₁₄=2.65, P=.009); and there was a reduction in their intake of 13 unhealthy foods. HelperFriend was well received by intervention group.

Conclusions

HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend.

Design Features Associated with User Engagement in Digital Games for Healthy Lifestyle Promotion in Youth: A Systematic Review of Qualitative and Quantitative Studies

User engagement in digital (serious) games may be important to increase their effectiveness. Insights into how to create engaging games for healthy lifestyle promotion are needed, as despite their potential, not all digital (serious) games are highly engaging. This study systematically reviewed game features that were associated with higher user engagement among youth. A systematic search was conducted in PubMed, Web of Science, CINAHL, and PsycARTICLES databases. Qualitative and quantitative studies were included, if they documented game features associated with youth engagement. Coding of game features was performed using the mechanics-dynamics-aesthetics (MDA) framework. A total of 60 studies met the inclusion criteria and were included in the registered systematic review (No. CRD42018099487). Results showed that various game features were associated with user engagement in digital (serious) games: an attractive storyline, adaptable to gender and age, including diverse (antagonist) characters the user may identify with, high-end realistic graphics, well-defined instructions, which can be skipped, in combination with clear feedback and a balance of educational and fun content. This review underpinned the relevance of investigating engaging game features specifically for youth, as deviations were found with characteristics that are engaging for other populations.

Active Videogames to Promote Traditional Active Play: Increasing the Reinforcing Value of Active Play Among Low-Active Children

Background: Exercise reinforcement predicts physical activity of children. Repeated exposures of physical activity may increase physical activity reinforcement (incentive sensitization). Active videogame (AVG) play produces light-to-moderate-intensity physical activity. Ideally, AVG play would transition to nonscreen-based active play through incentive sensitization of traditional active play (TAP), providing AVG does not increase sedentary videogame (SVG) reinforcement. Greater autonomy increases motivation toward traditional physical activity, but whether autonomy enhances incentive sensitization has not been studied. Objectives: To determine whether autonomy over AVG play promotes incentive sensitization of TAP or SVG. Methods: Inactive children (ages 8-12; 5th-97th body mass index percentile) were provided with AVG and SVG for 6 weeks and assigned to either a high autonomy (n = 25) or low autonomy (n = 24) group, differentiated by AVG choice and more freedom over amount of play. Both groups played AVG 3 days per week. SVG were played ad libitum. Participants completed an operant responding task to measure the relative reinforcing value (RRV) of AVG versus SVG (RRVAVG vs. SVG) and AVG versus TAP (RRVAVG vs. TAP) at baseline, 6 weeks, and 10 weeks. Results: RRVAVG vs. SVG increased over time (P = 0.056) but did not differ by autonomy or autonomy × time (P = 0.184). RRVAVG vs. TAP decreased over time (P = 0.033) but did not differ by autonomy or autonomy × time (P = 0.73). Conclusion: AVG play does not increase motivation toward SVG and increases motivation to play AVG relative to TAP. Providing higher autonomy did not promote incentive sensitization of play.

Games for Health for Children-Current Status and Needed Research

Videogames for health (G4H) offer exciting, innovative, potentially highly effective methods for increasing knowledge, delivering persuasive messages, changing behaviors, and influencing health outcomes. Although early outcome results are promising, additional research is needed to determine the game design and behavior change procedures that best promote G4H effectiveness and to identify and minimize possible adverse effects. Guidelines for ideal use of different types of G4H by children and adolescents should be elucidated to enhance effectiveness and minimize adverse effects. G4H stakeholders include organizational implementers, policy makers, players and their families, researchers, designers, retailers, and publishers. All stakeholders should be involved in G4H development and have a voice in setting goals to capitalize on their insights to enhance effectiveness and use of the game. In the future, multiple targeted G4H should be available to meet a population's diverse health needs in developmentally appropriate ways. Substantial, consistent, and sophisticated research with appropriate levels of funding is needed to realize the benefits of G4H.

Building a Better Mousetrap (Exergame) to Increase Youth Physical Activity

Although exergames have been demonstrated to induce moderate levels of physical activity (PA) if played as designed, there is conflicting evidence on use of exergaming leading to increased habitual PA. Exergames have increased PA in some home and school studies, but not others. Exergames have been used in community centers to good effect, but this has not generally been validated with research. PA from exergames may be enhanced by innovative use of sensors, "fun"-enhancing procedures, tailored messaging, message framing, story or narrative, goal setting, feedback, and values-based messaging. Research is needed on PA-enhancing procedures used within exergames for youth to provide a firmer foundation for the design and use of exergames in the future.

Replacing Non-Active Video Gaming by Active Video Gaming to Prevent Excessive Weight Gain in Adolescents

OBJECTIVE

The aim of the current study was to evaluate the effects of and adherence to an active video game promotion intervention on anthropometrics, sedentary screen time and consumption of sugar-sweetened beverages and snacks among non-active video gaming adolescents who primarily were of healthy weight.

METHODS

We assigned 270 gaming (i.e. ≥ 2 hours/week non-active video game time) adolescents randomly to an intervention group (n = 140) (receiving active video games and encouragement to play) or a waiting-list control group (n = 130). BMI-SDS (SDS = adjusted for mean standard deviation score), waist circumference-SDS, hip circumference and sum of skinfolds were measured at baseline, at four and ten months follow-up (primary outcomes). Sedentary screen time, physical activity, consumption of sugar-sweetened beverages and snacks, and process measures (not at baseline) were assessed with self-reports at baseline, one, four and ten months follow-up. Multi-level-intention to treat-regression analyses were conducted.

RESULTS

The control group decreased significantly more than the intervention group on BMI-SDS (β = 0.074, 95%CI: 0.008;0.14), and sum of skinfolds (β = 3.22, 95%CI: 0.27;6.17) (overall effects). The intervention group had a significantly higher decrease in self-reported non-active video game time (β = -1.76, 95%CI: -3.20;-0.32) and total sedentary screen time (Exp (β = 0.81, 95%CI: 0.74;0.88) than the control group (overall effects). The process evaluation showed that 14% of the adolescents played the Move video games every week ≥ 1 hour/week during the whole intervention period.

CONCLUSIONS

The active video game intervention did not result in lower values on anthropometrics in a group of 'excessive' non-active video gamers (mean ~ 14 hours/week) who primarily were of healthy weight compared to a control group throughout a ten-month-period. Even some effects in the unexpected direction were found, with the control group showing lower BMI-SDS and skin folds than the intervention group. The intervention did result in less self-reported sedentary screen time, although these results are likely biased by social desirability.

TRIAL REGISTRATION

Dutch Trial Register NTR3228.

Energy Expenditure During Xbox Kinect Play in Early Adolescents: The Relationship with Player Mode and Game Enjoyment

OBJECTIVE

There has been growing interest in the use of active videogames to influence levels of physical activity. Most studies have investigated energy expenditure in general, without taking into account moderating factors such as player mode and game enjoyment. This study therefore examines whether children's energy expenditure and game enjoyment are higher when games are played in a two-player mode than in a single-player mode.

MATERIALS AND METHODS

Forty-three children from the 7th grade who exhibited an inactive lifestyle engaged in six sports exergames on an Xbox(®) Kinect(®) (Microsoft, Redmond, WA) console. The player mode (single-player or two-player mode) was manipulated (within-subjects design). The primary parameters were "energy expenditure," which was measured with a SenseWear(®) device (Bodymedia Inc., Pittsburgh, PA), and "game enjoyment," which was assessed through self-report.

RESULTS

On average, Kinect play elicits moderate physical activity (approximately 4 metabolic equivalents of task). Games that are played in a two-player mode elicit more energy than games that are played in a single-player mode. However, this was only the case for simultaneous play (boxing, dancing, and tennis), not for turn-based play (bowling, baseball, and golf). Furthermore, participants generally liked exergaming, regardless of their sex or the player mode. Finally, no significant correlation was found between energy expenditure and game enjoyment.

CONCLUSIONS

This study has shown that Kinect play elicits physical activity of moderate intensity. Furthermore, Kinect play is generally enjoyed by both boys and girls. Simultaneous play may be the best suited to increase levels of physical activity in early adolescents who exhibit an inactive lifestyle.

Associations between active video gaming and other energy-balance related behaviours in adolescents: a 24-hour recall diary study

Background

Active video games may contribute to reducing time spent in sedentary activities, increasing physical activity and preventing excessive weight gain in adolescents. Active video gaming can, however, only be beneficial for weight management when it replaces sedentary activities and not other physical activity, and when it is not associated with a higher energy intake. The current study therefore examines the association between active video gaming and other energy-balance-related behaviours (EBRBs).

Findings

Adolescents (12–16 years) with access to an active video game and who reported to spend at least one hour per week in active video gaming were invited to participate in the study. They were asked to complete electronic 24-hour recall diaries on five randomly assigned weekdays and two randomly assigned weekend-days in a one-month period, reporting on time spent playing active and non-active video games and on other EBRBs. Findings indicated that adolescents who reported playing active video games on assessed days also reported spending more time playing non-active video games (Median = 23.6, IQR = 56.8 minutes per week) compared to adolescents who did not report playing active video games on assessed days (Median = 10.0, IQR = 51.3 minutes per week, P < 0.001 (Mann Whitney test)). No differences between these groups were found in other EBRBs. Among those who played active video games on assessed days, active video game time was positively yet weakly associated with TV/DVD time and snack consumption. Active video game time was not significantly associated with other activities and sugar-sweetened beverages intake.

Conclusions

The results suggest that it is unlikely that time spent by adolescents in playing active video games replaces time spent in other physically active behaviours or sedentary activities. Spending more time playing active video games does seem to be associated with a small, but significant increase in intake of snacks. This suggests that interventions aimed at increasing time spent on active video gaming, may have unexpected side effects, thus warranting caution.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-015-0192-6) contains supplementary material, which is available to authorized users.

Efficient and Effective Change Principles in Active Videogames

Active videogames have the potential to enhance population levels of physical activity but have not been successful in achieving this aim to date. This article considers a range of principles that may be important to the design of effective and efficient active videogames from diverse discipline areas, including behavioral sciences (health behavior change, motor learning, and serious games), business production (marketing and sales), and technology engineering and design (human-computer interaction/ergonomics and flow). Both direct and indirect pathways to impact on population levels of habitual physical activity are proposed, along with the concept of a game use lifecycle. Examples of current active and sedentary electronic games are used to understand how such principles may be applied. Furthermore, limitations of the current usage of theoretical principles are discussed. A suggested list of principles for best practice in active videogame design is proposed along with suggested research ideas to inform practice to enhance physical activity.

Personal, social, and game-related correlates of active and non-active gaming among dutch gaming adolescents: survey-based multivariable, multilevel logistic regression analyses

BACKGROUND

Playing video games contributes substantially to sedentary behavior in youth. A new generation of video games-active games-seems to be a promising alternative to sedentary games to promote physical activity and reduce sedentary behavior. At this time, little is known about correlates of active and non-active gaming among adolescents.

OBJECTIVE

The objective of this study was to examine potential personal, social, and game-related correlates of both active and non-active gaming in adolescents.

METHODS

A survey assessing game behavior and potential personal, social, and game-related correlates was conducted among adolescents (12-16 years, N=353) recruited via schools. Multivariable, multilevel logistic regression analyses, adjusted for demographics (age, sex and educational level of adolescents), were conducted to examine personal, social, and game-related correlates of active gaming ≥1 hour per week (h/wk) and non-active gaming >7 h/wk.

RESULTS

Active gaming ≥1 h/wk was significantly associated with a more positive attitude toward active gaming (OR 5.3, CI 2.4-11.8; P<.001), a less positive attitude toward non-active games (OR 0.30, CI 0.1-0.6; P=.002), a higher score on habit strength regarding gaming (OR 1.9, CI 1.2-3.2; P=.008) and having brothers/sisters (OR 6.7, CI 2.6-17.1; P<.001) and friends (OR 3.4, CI 1.4-8.4; P=.009) who spend more time on active gaming and a little bit lower score on game engagement (OR 0.95, CI 0.91-0.997; P=.04). Non-active gaming >7 h/wk was significantly associated with a more positive attitude toward non-active gaming (OR 2.6, CI 1.1-6.3; P=.035), a stronger habit regarding gaming (OR 3.0, CI 1.7-5.3; P<.001), having friends who spend more time on non-active gaming (OR 3.3, CI 1.46-7.53; P=.004), and a more positive image of a non-active gamer (OR 2, CI 1.07-3.75; P=.03).

CONCLUSIONS

Various factors were significantly associated with active gaming ≥1 h/wk and non-active gaming >7 h/wk. Active gaming is most strongly (negatively) associated with attitude with respect to non-active games, followed by observed active game behavior of brothers and sisters and attitude with respect to active gaming (positive associations). On the other hand, non-active gaming is most strongly associated with observed non-active game behavior of friends, habit strength regarding gaming and attitude toward non-active gaming (positive associations). Habit strength was a correlate of both active and non-active gaming, indicating that both types of gaming are habitual behaviors. Although these results should be interpreted with caution because of the limitations of the study, they do provide preliminary insights into potential correlates of active and non-active gaming that can be used for further research as well as preliminary direction for the development of effective intervention strategies for replacing non-active gaming by active gaming among adolescents.

Active video games as a tool to prevent excessive weight gain in adolescents: rationale, design and methods of a randomized controlled trial

Background

Excessive body weight, low physical activity and excessive sedentary time in youth are major public health concerns. A new generation of video games, the ones that require physical activity to play the games –i.e. active games- may be a promising alternative to traditional non-active games to promote physical activity and reduce sedentary behaviors in youth. The aim of this manuscript is to describe the design of a study evaluating the effects of a family oriented active game intervention, incorporating several motivational elements, on anthropometrics and health behaviors in adolescents.

Methods/Design

The study is a randomized controlled trial (RCT), with non-active gaming adolescents aged 12 – 16 years old randomly allocated to a ten month intervention (receiving active games, as well as an encouragement to play) or a waiting-list control group (receiving active games after the intervention period). Primary outcomes are adolescents’ measured BMI-SDS (SDS = adjusted for mean standard deviation score), waist circumference-SDS, hip circumference and sum of skinfolds. Secondary outcomes are adolescents’ self-reported time spent playing active and non-active games, other sedentary activities and consumption of sugar-sweetened beverages. In addition, a process evaluation is conducted, assessing the sustainability of the active games, enjoyment, perceived competence, perceived barriers for active game play, game context, injuries from active game play, activity replacement and intention to continue playing the active games.

Discussion

This is the first adequately powered RCT including normal weight adolescents, evaluating a reasonably long period of provision of and exposure to active games. Next, strong elements are the incorporating motivational elements for active game play and a comprehensive process evaluation. This trial will provide evidence regarding the potential contribution of active games in prevention of excessive weight gain in adolescents.

Trial registration

Dutch Trial register NTR3228.

Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial

BACKGROUND

Lifestyle intervention in type 2 diabetes mellitus (T2DM) is effective but needs a special local setting and is costly. Therefore, in a randomized-controlled trial we tested the hypothesis that the autonomous use of the interactive exercise game Wii Fit Plus over a period of 12 weeks improves metabolic control, with HbA1c reduction as the primary outcome, and weight loss, reduction of cardiometabolic risk factors, physical activity and quality of life (secondary outcomes) in T2DM patients.

METHODS

Participants (n = 220) were randomized into an intervention and a control group. The intervention group was provided with a Wii console, a balance board and the exercise game Wii Fit Plus for 12 weeks. The control group remained under routine care and received the items 12 weeks later. At baseline and after 12 weeks (and for the control group additionally after 12 weeks of intervention) the participants' health parameters, medication, physical activity and validated questionnaires for quality of life (PAID, SF12, WHO-5, CES-D) were requested and compared in a complete case analysis using the Mann-Whitney test and the Wilcoxon signed rank test.

RESULTS

80% of participants completed the 12-week study. Patients in the intervention group significantly improved HbA1c (from 7.1 ± 1.3% to 6.8 ± 0.9%; -0.3 ± 1.1%; p = 0.0002) in comparison to the control group (from 6.8 ± 0.9% to 6.7 ± 0.7%; -0.1 ± 0.5%) and also significantly reduced fasting blood glucose (from 135.8 ± 38.9 mg/dl to 126.6 ± 36.6 mg/dl; p = 0.04), weight (from 97.6 ± 19.2 kg to 96.3 ± 18.7 kg; p < 0.001) and body mass index (from 34.1 ± 6.5 kg/m2 to 33.5 ± 6.5 kg/m2; p < 0.001). Daily physical activity increased significantly (p < 0.001). Diabetes-dependent impairment, mental health, subjective wellbeing and quality of life also improved significantly, and the number of patients with depression decreased. Similar improvements were seen in the control group after exercise game intervention.

CONCLUSIONS

In this trial a low-threshold intervention with the interactive exercise game Wii Fit Plus was able to motivate T2DM patients to improve physical activity, glucometabolic control and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01735643.

Gaming, Adiposity, and Obesogenic Behaviors Among Children

Videogames in general have been maligned for causing obesity because of their inherent sedentariness, whereas exergames have been both maligned for requiring low levels of activity and extolled for requiring physical activity to move game play along. The intensity and duration of physical activity resulting from exergame play have shown varying results, and they have been explored for use in obesity treatment and prevention, primarily among children. Other videogames have been developed and tested to help children change their diet and physical activity practices with various outcomes. As a field of inquiry, we are in the earliest stages of understanding how, or under what circumstances, videogames can influence all these behavioral and health outcomes. To deal with these complexities, we have assembled a group of investigators who have made important, but diverse, contributions to this research agenda and asked them to address five key child obesity-related issues in a Roundtable format. Brief biosketches are presented at the end of this article.

Active gaming in Dutch adolescents: a descriptive study

BACKGROUND

Adequate levels of physical activity are part of a healthy lifestyle and in this way linked to better health outcomes. For children and adolescents, the physical activity guideline recommends at least 60 minutes of moderate-to-vigorous physical activity every day. However, many adolescents are not physically active enough and they spend a lot of their time on sedentary activities (such as video games). A new generation of video games that require body movements to play them, so-called "active games", could serve to increase physical activity in adolescents. The activity level while playing these games is comparable to light-to-moderate intensity physical activity. The current study aims to increase our understanding of 1) the demographic characteristics of adolescents who play active games regularly (≥ 1 hour per week) and non-regularly (< 1 hour per week), 2) time spent on active games, 3) the contribution of active games to daily physical activity and 4) the type and amount of activities being replaced by active gaming.

METHODS

A cross-sectional survey was conducted in a Dutch internet panel, questioning adolescents in conjunction with one of their parents. A random sample of 320 households (with stratification on gender of the parent and the adolescent, the age of the adolescent and the region of the household) was selected that owned a console or application for active video games and that had a child aged 12 through 16 years. 201 child-parent couples (63% response) completed an internet survey with questions about demographics, physical activity and sedentary behaviour, and gaming behaviour. The questionnaire also contained questions designed to assess whether and how active gaming replaces other activities. Besides descriptive analyses, independent t-test, Pearson's chi-square and Mann-Whitney test (when data were not normally distributed) were used for comparisons between regular and non-regular active gamers.

RESULTS

Eleven percent of the adolescents with an active game in their household never used the game. There were no significant differences in gender, education level (of adolescent and parent), ethnicity and sedentary behaviour between regular (n = 65) and non-regular active gamers (n = 114). Adolescents' (regular and non-regular active gamers) meantime spent on active gaming was 80 (± 136) minutes a week; this potentially amounts to 11% of total physical activity. When time spent on active gaming was included in the calculation of the percentage of adolescents that met the physical activity guideline, the percentage increased significantly (p < 0.05) from 67 to 73%. According to the adolescents, active gaming mainly replaces sedentary screen time such as TV viewing, internet and non-active gaming. Parental opinions concurred with this appraisal.

CONCLUSIONS

The results of this study confirm the idea that active gaming may contribute to an active lifestyle in adolescents, primarily because it potentially contributes substantially to time spent on physical activity. Secondly, active gamers indicate that they spent time on active games which they would have spent otherwise on less active activities.