Development of CliniPup, a Serious Game Aimed at Reducing Perioperative Anxiety and Pain in Children: Mixed Methods Study

Pilot testing "Teach Ted": A digital application for children undergoing blood tests and their parents

Objective

In this pilot study, we evaluated the acceptability and preliminary evidence of the impact of a new educational mobile application, "Teach Ted", for children undergoing blood tests.

Methods

Parents of children (4-10 years) completed questionnaires on anxiety and pain before their child had a blood test, and after using Teach Ted and receiving their blood test. Health professionals at each patient's blood test (e.g. technician/nurse) completed questionnaires on patient outcomes and procedure-related outcomes (e.g. time taken).

Results

Nine parents and eight health professionals participated. All but one parent (n = 8/9) reported Teach Ted was useful. Seventy-eight percent (n = 7/9) reported they would use Teach Ted again. All health professionals who completed the acceptability measure (n = 3/3) strongly agreed that Teach Ted was relevant/helpful. Many parents perceived Teach Ted helped reduce their/child's anxiety (n = 3/5, 60% and n = 4/6, 67% respectively), although child's pain and child's/parent's anxiety remained similar before and after using Teach Ted (all p > 0.05). The average blood test duration was 7.6 min (range ≤1 to 22), which health professionals (n = 3/3) reported was not elongated by offering Teach Ted.

Conclusions

Participants reported that Teach Ted was acceptable. Further evaluation of Teach Ted's impact on patient's outcomes are needed.

Innovation

Teach Ted is an innovative mobile application with potential to educate young children about their upcoming procedure and mitigate negative outcomes.

Effect of virtual reality combined with repetitive transcranial magnetic stimulation on musculoskeletal pain and motor development in children with spastic cerebral palsy: a protocol for a randomized controlled clinical trial

PURPOSE

This trial aims to investigate the efficacy and safety of virtual reality (VR) combined with repetitive transcranial magnetic stimulation (rTMS) for improving musculoskeletal pain and motor development in children with unilateral spastic cerebral palsy (CP).

METHODS

This study protocol is for a randomized controlled trial consisting of 2 treatment sessions (3 days/week for 4 weeks in each session, with a 1-week interval between sessions). We will recruit children aged 3-10 years with unilateral spastic CP (Gross Motor Function Classification System level I or II). Participants will be randomly divided into 3 groups: the VR + rTMS group (immersive VR intervention, rTMS and routine rehabilitation therapy), rTMS group (rTMS and routine rehabilitation therapy), and control group (sham rTMS and routine rehabilitation therapy). VR therapy will involve a daily 40-minute movement training session in a fully immersive environment. rTMS will be applied at 1 Hz over the primary motor cortex for 20 min on the contralateral side. The stimulation intensity will be set at 90% of the resting motor threshold, with 1200 pulses applied. A daily 60-minute routine rehabilitation therapy session including motor training and training in activities of daily living will be administered to all participants. The primary outcome will be pain intensity, assessed by the Revised Face, Legs, Activity, Cry, and Consolability Scale (R-FLACC). The secondary outcomes will include motor development, evaluated by the 66-item version of the Gross Motor Function Measure (GMFM-66) and Fine Motor Function Measure (FMFM); balance capacity, measured by the interactive balance system; activities of daily living; and quality of life, measured by the Barthel index and the Chinese version of the Cerebral Palsy Quality of Life scale for Children (C-CP QOL-Child). Safety will be monitored, and adverse events will be recorded during and after treatment.

DISCUSSION

Combined application of VR therapy and rTMS may reveal additive effects on pain management and motor development in children with spastic CP, but further high-quality research is needed. The results of this trial may indicate whether VR therapy combined with rTMS achieves a better analgesic effect and improves the motor development of children with spastic CP.

TRIAL REGISTRATION

Registration number: ChiCTR230069853. Trial registration date: 28 March 2023. Prospectively registered.

Serious Games in the new era of digital-health interventions: A narrative review of their therapeutic applications to manage neurobehavior in neurodevelopmental disorders

Children and adolescents with neurodevelopmental disorders generally show adaptive, cognitive and motor skills impairments associated with behavioral problems, i.e., alterations in attention, anxiety and stress regulation, emotional and social relationships, which strongly limit their quality of life. This narrative review aims at providing a critical overview of the current knowledge in the field of serious games (SGs), known as digital instructional interactive videogames, applied to neurodevelopmental disorders. Indeed, a growing number of studies is drawing attention to SGs as innovative and promising interventions in managing neurobehavioral and cognitive disturbs in children with neurodevelopmental disorders. Accordingly, we provide a literature overview of the current evidence regarding the actions and the effects of SGs. In addition, we describe neurobehavioral alterations occurring in some specific neurodevelopmental disorders for which a possible therapeutic use of SGs has been suggested. Finally, we discuss findings obtained in clinical trials using SGs as digital therapeutics in neurodevelopment disorders and suggest new directions and hypotheses for future studies to bridge the gaps between clinical research and clinical practice.

The Impact of Three Communication Channels on the Dissemination of a Serious Game Designed to Enhance COVID-19 Prevention

Infection prevention interventions can only be effective if they are both well known and easily accessible. A randomized controlled trial showed that a serious game, "Escape COVID-19", was significantly more effective at improving the intention of adopting adequate infection prevention behavior than regular guidelines among long-term care facility employees. However, less than a fifth of all potential participants were finally recruited in this study. To determine whether a specific communication intervention was more effective than another, we carried out a retrospective analysis of account creation data over a six-month period. During the first period (53 days), information about the serious game was disseminated by a part-time worker. The second period (15 days) corresponded to a press release, while the third period (15 days) reflected an official communication from the Swiss Federal Office of Public Health. A total of 3995 accounts were created during the study period. Most accounts were created by health care workers (2699/3995, 67.6%). Median daily account creation was highest during the press release period (25; Q1:Q3 9:172) and lowest during the official communication period (6; Q1:Q3 4:20). The association between communication intervention and account creation was statistically significant both when considering the overall population (p = 0.013) and when only analyzing health care workers (p = 0.036).

Impact of Face-to-Face Teaching in Addition to Electronic Learning on Personal Protective Equipment Doffing Proficiency in Student Paramedics: Randomized Controlled Trial

Personal protective equipment doffing is a complex procedure that needs to be adequately performed to prevent health care worker contamination. During the COVID-19 pandemic, junior health care workers and students of different health care professions who had not been trained to carry out such procedures were often called upon to take care of infected patients. To limit direct contact, distance teaching interventions were used, but different trials found that their impact was rather limited. We therefore designed and carried out a randomized controlled trial assessing the impact of adding a face-to-face intervention using Peyton's four-step approach to a gamified e-learning module. Sixty-five student paramedics participated in this study. The proportion of doffing sequences correctly performed was higher in the blended learning group (33.3% (95%CI 18.0 to 51.8) versus 9.7% (95%CI 2.0 to 25.8), p = 0.03). Moreover, knowledge and skill retention four to eight weeks after the teaching intervention were also higher in this group. Even though this study supports the use of a blended learning approach to teach doffing sequences, the low number of student paramedics able to adequately perform this procedure supports the need for iterative training sessions. Further studies should determine how often such sessions should be carried out.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Interactive video games to reduce paediatric procedural pain and anxiety: a systematic review and meta-analysis

BACKGROUND

Procedural pain and anxiety in children can be poorly controlled, leading to significant short- and long-term sequelae, such as longer procedure times or future healthcare avoidance. Caregiver anxiety can exacerbate these effects. We aimed to evaluate the effect of interactive video game interventions on children's procedural pain and anxiety, including the effect of different types of video games on those outcomes.

METHODS

We conducted a systematic review and meta-analysis of the effectiveness of interactive video games compared with standard care in children (0-18 yr) undergoing painful procedures. We searched the databases MEDLINE, Embase, and PsycINFO. We conducted random-effects meta-analysis using 'R' of children's procedural pain and anxiety and caregivers' anxiety.

RESULTS

Of 2185 studies screened, 36 were eligible (n=3406 patients). Studies commonly involved venous access (33%) or day surgery (31%). Thirty-four studies were eligible for meta-analyses. Interactive video games appear to reduce children's procedural pain (standardised mean difference [SMD]=-0.43; 95% confidence interval [CI]: -0.67 to -0.20), anxiety (SMD=0.61; 95% CI: -0.88 to -0.34), and caregivers' procedural anxiety (SMD=-0.31; 95% CI: -0.58 to -0.04). We observed no difference between preparatory and distracting games, or between virtual reality and non-virtual reality games. We also observed no difference between interactive video games compared with standard care for most medical outcomes (e.g. procedure length), except a reduced need for restraint. Studies reported minimal adverse effects and typically had high intervention acceptability and satisfaction.

CONCLUSIONS

Our findings support introducing easily available video games, such as distraction-based conventional video games, into routine practice to minimise paediatric procedural pain and child/caregiver anxiety.

Impact of a Serious Game (Escape COVID-19) on the Intention to Change COVID-19 Control Practices Among Employees of Long-term Care Facilities: Web-Based Randomized Controlled Trial

BACKGROUND

Most residents of long-term care facilities (LTCFs) are at high risk of complications and death following SARS-CoV-2 infection. In these facilities, viral transmission can be facilitated by shortages of human and material resources, which can lead to suboptimal application of infection prevention and control (IPC) procedures. To improve the dissemination of COVID-19 IPC guidelines, we developed a serious game called "Escape COVID-19" using Nicholson's RECIPE for meaningful gamification, as engaging serious games have the potential to induce behavioral change.

OBJECTIVE

As the probability of executing an action is strongly linked to the intention of performing it, the objective of this study was to determine whether LTCF employees were willing to change their IPC practices after playing "Escape COVID-19."

METHODS

This was a web-based, triple-blind, randomized controlled trial, which took place between November 5 and December 4, 2020. The health authorities of Geneva, Switzerland, asked the managers of all LTCFs under their jurisdiction to forward information regarding the study to all their employees, regardless of professional status. Participants were unaware that they would be randomly allocated to one of two different study paths upon registration. In the control group, participants filled in a first questionnaire designed to gather demographic data and assess baseline knowledge before accessing regular online IPC guidelines. They then answered a second questionnaire, which assessed their willingness to change their IPC practices and identified the reasons underlying their decision. They were then granted access to the serious game. Conversely, the serious game group played "Escape COVID-19" after answering the first questionnaire but before answering the second one. This group accessed the control material after answering the second set of questions. There was no time limit. The primary outcome was the proportion of LTCF employees willing to change their IPC practices. Secondary outcomes included the factors underlying participants' decisions, the domains these changes would affect, changes in the use of protective equipment items, and attrition at each stage of the study.

RESULTS

A total of 295 answer sets were analyzed. Willingness to change behavior was higher in the serious game group (82% [119/145] versus 56% [84/150]; P<.001), with an odds ratio of 3.86 (95% CI 2.18-6.81; P<.001) after adjusting for professional category and baseline knowledge, using a mixed effects logistic regression model with LTCF as a random effect. For more than two-thirds (142/203) of the participants, the feeling of playing an important role against the epidemic was the most important factor explaining their willingness to change behavior. Most of the participants unwilling to change their behavior answered that they were already applying all the guidelines.

CONCLUSIONS

The serious game "Escape COVID-19" was more successful than standard IPC material in convincing LTCF employees to adopt COVID-19-safe IPC behavior.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25595.

Asynchronous Distance Learning of the National Institutes of Health Stroke Scale During the COVID-19 Pandemic (E-Learning vs Video): Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic has considerably altered the regular medical education curriculum while increasing the need for health care professionals. Senior medical students are being incrementally deployed to the front line to address the shortage of certified physicians. These students, some of whom will be fast-tracked as physicians, may lack knowledge regarding the initial management of time-critical emergencies such as stroke.

OBJECTIVE

Our aim was to determine whether an e-learning module could improve asynchronous distance knowledge acquisition of the National Institutes of Health Stroke Scale (NIHSS) in senior medical students compared to the traditional didactic video.

METHODS

A randomized, data analyst-blinded web-based trial was conducted at the University of Geneva Faculty of Medicine between April and June 2020. Fifth year medical students followed a distance learning path designed to teach the NIHSS. The control group followed the traditional didactic video created by Patrick Lyden, while the e-learning group followed the updated version of a previously tested, highly interactive e-learning module. The main outcome was the score on a 50-question quiz displayed upon completion of the learning material. The difference in the proportion of correct answers for each specific NIHSS item was also assessed.

RESULTS

Out of 158 potential participants, 88 started their allocated learning path and 75 completed the trial. Participants who followed the e-learning module performed better than those who followed the video (38 correct answers, 95% CI 37-39, vs 35 correct answers, 95% CI 34-36, P<.001). Participants in the e-learning group scored better on five elements than the video group: key NIHSS concepts (P=.02), the consciousness - global item (P<.001), the facial palsy item (P=.04), the ataxia item (P=.03), and the sensory item (P=.04).

CONCLUSIONS

Compared to the traditional didactic video, a highly interactive e-learning module enhances asynchronous distance learning and NIHSS knowledge acquisition in senior medical students.

A Serious Game Designed to Promote Safe Behaviors Among Health Care Workers During the COVID-19 Pandemic: Development of "Escape COVID-19"

BACKGROUND

As many countries fear and even experience the emergence of a second wave of COVID-19, reminding health care workers (HCWs) and other hospital employees of the critical role they play in preventing SARS-CoV-2 transmission is more important than ever. Building and strengthening the intrinsic motivation of HCWs to apply infection prevention and control (IPC) guidelines to avoid contaminating their colleagues, patients, friends, and relatives is a goal that must be energetically pursued. A high rate of nosocomial infections during the first COVID-19 wave was detected by IPC specialists and further cemented their belief in the need for an engaging intervention that could improve compliance with COVID-19 safe behaviors.

OBJECTIVE

Our aim was to develop a serious game that would promote IPC practices with a specific focus on COVID-19 among HCWs and other hospital employees.

METHODS

The first 3 stages of the SERES framework were used to develop this serious game. A brainswarming session between developers and IPC specialists was used to identify the target audience and acquisition objectives. Nicholson's RECIPE mnemonic (reflection, engagement, choice, information, play, exposition) for meaningful gamification was used to guide the general design. A common and simple terminology was used to suit the broad target audience. The game was tested on various platforms (smartphones, tablets, laptops, desktop computers) by different users during each development loop and before its final release.

RESULTS

The game was designed to target all hospital staff who could be in direct contact with patients within the Geneva University Hospitals. In total, 10 acquisition objectives were defined by IPC specialists and implemented into the game according to the principles of meaningful gamification. A simple storyboard was first created using Microsoft PowerPoint and was progressively refined through multiple iteration loops. Articulate Storyline was then used to create two successive versions of the actual game. In the final version, a unique graphic atmosphere was created with help from a professional graphic designer. Feedback mechanisms were used extensively throughout the game to strengthen key IPC messages.

CONCLUSIONS

The SERES framework was successfully used to create "Escape COVID-19," a serious game designed to promote safe IPC practices among HCWs and other hospital employees during the COVID-19 pandemic. This game can be obtained free of charge for research and educational purposes. A SCORM (shareable content object reference model) package is available to facilitate results and completion tracking on most current learning management systems.

How we assess the perioperative anxiety of surgical patients with pulmonary nodules: the revision of state-trait anxiety inventory

PURPOSE

The aim of the study was to develop a short form of State-Trait Anxiety Inventory (STAI) and calculate the norms for the assessment of anxiety in surgical patients in mainland China.

METHODS

Patients who were scheduled to carry out pulmonary surgery in our department were included. The sinicized 40-item STAI Form-Y was used to assess the anxiety on the surgery eve. Then the coefficient of variation, coefficient of correlation, stepwise regression analysis, principal component analysis, and structural equation model were successively to filter the items. The reliability and validity of the revised STAI was estimated and the norms were computed.

RESULTS

445 intact replies were collected. A 13-item STAI with 6 items in state subscale and 7 items in trait subscale produced similar scores with the full version of STAI. The Cronbach alpha coefficients for the state and trait subscales were 0.924 and 0.936, respectively. The determinant coefficients were 0.781 and 0.822, respectively. Moreover, the norms of both state subscale and trait subscale are provided according to the age and gender.

CONCLUSIONS

The revised short form of STAI has good reliability and validity. It is likely to be more acceptable by reducing the fatigue effects, and is suitable for follow-up study on the assessment and intervention of perioperative anxiety of surgical patients with pulmonary nodules.

Teaching Adequate Prehospital Use of Personal Protective Equipment During the COVID-19 Pandemic: Development of a Gamified e-Learning Module

BACKGROUND

The coronavirus disease (COVID-19) pandemic has led to increased use of personal protective equipment (PPE). Adequate use of this equipment is more critical than ever because the risk of shortages must be balanced against the need to effectively protect health care workers, including prehospital personnel. Specific training is therefore necessary; however, the need for social distancing has markedly disrupted the delivery of continuing education courses. Electronic learning (e-learning) may provide significant advantages because it requires neither the physical presence of learners nor the repetitive use of equipment for demonstration.

OBJECTIVE

Inclusion of game mechanics, or "gamification," has been shown to increase knowledge and skill acquisition. The objective of this research was to develop a gamified e-learning module to interactively deliver concepts and information regarding the correct choice and handling of PPE.

METHODS

The SERES framework was used to define and describe the development process, including scientific and design foundations. After we defined the target audience and learning objectives by interviewing the stakeholders, we searched the scientific literature to establish relevant theoretical bases. The learning contents were validated by infection control and prehospital experts. Learning mechanics were then determined according to the learning objectives, and the content that could benefit from the inclusion of game mechanics was identified.

RESULTS

The literature search resulted in the selection and inclusion of 12 articles. In addition to gamification, pretesting, feedback, avoiding content skipping, and demonstrations using embedded videos were used as learning mechanics. Gamification was used to enhance the interactivity of the PPE donning and doffing sequences, which presented the greatest learning challenges. The module was developed with Articulate Storyline 3 to ensure that it would be compatible with a wide array of devices, as this software generates HTML5-compatible output that can be accessed on smartphones, tablets, and regular computers as long as a recent browser is available.

CONCLUSIONS

A gamified e-learning module designed to promote better knowledge and understanding of PPE use among prehospital health care workers was created by following the SERES framework. The impact of this module should now be assessed by means of a randomized controlled trial.

A pilot study of the effectiveness of a serious game CliniPup® on perioperative anxiety and pain in children

INTRODUCTION/AIM

Children experience important anxiety before surgery. Anxiety and pain are positively correlated. Serious gaming is a non-pharmacological intervention to prepare children and parents for an operation. We aimed to evaluate the effectiveness of the serious game CliniPup® on anxiety and pain in children undergoing ambulatory surgery.

METHOD

A prospective randomized controlled pilot trial in 72 children aged 5 to 11 years old scheduled for day-care surgery (general surgery, dentistry, otorhinolaryngology, urology) was performed. Participants were randomly assigned into 3 groups: A (CliniPup®), B ("Empty game" without educational information), or C (no game, oral information at the outpatient clinic, current standard of care). Anxiety, pain, and behaviour were evaluated by validated instruments at six time-points: T0: baseline, T1: 1 week preoperatively, T2: at hospital admission, T3: before discharge, T4: 1 week postoperatively, T5: 1 month postoperatively.

RESULTS

After playing the game (T1), the estimated mean anxiety score (VASa) was lower in Group A (1.9 units) versus Group B (2.7 units). The estimated mean VASa at T1 for Group A was 2.6 units lower compared to Group C (p = 0.003). For Group B, VASa levels were 1.8 units lower than in Group C (p = 0.045). After correction for "surgery type", Group A continued to show a significantly lower VASa compared to Group C (p = 0.044). On the other time points, no difference in anxiety and pain were observed, nor in post-hospitalization behaviour.

CONCLUSION

Children that played the CliniPup® game one week before surgery had a significant reduction in preoperative anxiety after playing the game, but not on the other time points. No differences on peri-operative pain were observed during the different time points.

TYPE OF STUDY

Randomized Trial.

LEVEL OF EVIDENCE

Level II.

A Web-Based Serious Game for Health to Reduce Perioperative Anxiety and Pain in Children (CliniPup): Pilot Randomized Controlled Trial

Background

As pediatric ambulatory surgeries are rising and existing methods to reduce perioperative anxiety and pain are lacking in this population, a serious game for health (SGH), CliniPup, was developed to address this unmet need. CliniPup was generated using the SERES framework for serious game development.

Objective

The goal of the research was to clinically evaluate CliniPup as an adjunct therapy to existing pharmacological interventions aimed at reducing perioperative anxiety and pain in children undergoing ambulatory surgery.

Methods

CliniPup was evaluated in a prospective randomized controlled pilot trial in 20 children aged 6 to 10 years who underwent elective surgery and their parents. Study participants were randomly assigned to the test (n=12) or control group (n=8). Children in the test group played CliniPup 2 days prior to surgery, and children in the control group received standard of care. On the day of surgery, pediatric anxiety was measured with the modified Yale Preoperative Anxiety Scale and parental anxiety was assessed with the State-Trait Anxiety Inventory. Pediatric postoperative pain was assessed by the Wong-Baker Faces Pain Rating Scale. Child and parent user experience and satisfaction were also evaluated in the test group using structured questionnaires.

Results

Despite the small sample, preoperative anxiety scores were significantly lower (P=.01) in children who played CliniPup prior to surgery compared to controls. Parental preoperative anxiety scores were also lower in the test group (P=.10) but did not reach significance. No significant differences were observed in postoperative pain scores between groups (P=.54). The evaluation of user experience and satisfaction revealed that both children and parents were satisfied with CliniPup and would recommend the game to peers.

Conclusions

Results of the pilot trial introduce CliniPup as a potentially effective and attractive adjunct therapy to reduce preoperative anxiety in children undergoing ambulatory surgery with a trend toward positive impact on parental preoperative anxiety. These results support the use of the SERES framework to generate an evidence-based SGH that results in positive health outcomes for patients. Based on these preliminary findings, we propose a research agenda to further develop and investigate this tool.

Trial Registration

ClinicalTrials.gov NCT03874442; https://clinicaltrials.gov/ct2/show/NCT03874442 (Archived by WebCite at http://www.webcitation.org/78KZab8qc)