Effectiveness of Serious Games to Increase Physical Activity in Children With a Chronic Disease: Systematic Review With Meta-Analysis

Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework

BACKGROUND

Digital serious games (SGs) have rapidly become a promising strategy for entertainment-based health education; however, developing SGs for children with chronic diseases remains a challenge.

OBJECTIVE

In this study, we attempted to provide an updated scope of understanding of the development and evaluation of SG educational tools and develop a framework for SG education development to promote self-management activities and behavior change in children with chronic diseases.

METHODS

This study consists of a knowledge base and an analytical base. This study followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. To build the knowledge base, 5 stages of research were developed, including refining the review question (stage 1), searching for studies (stage 2), selecting relevant studies (stage 3), charting the information (stage 4), and collating the results (stage 5). Eligible studies that developed SG prototypes and evaluated SG education for children with chronic diseases were searched for in PubMed, Embase, Google Scholar, and peer-reviewed journals. In the analytical base, the context-mechanism-output approach and game taxonomy were used to analyze relevant behavioral theories and essential game elements. Game taxonomy included social features, presentation, narrative and identity, rewards and punishment, and manipulation and control. A total of 2 researchers selected the domains for the included behavioral theories and game elements. The intended SG framework was finalized by assembling SG fragments. Those SG fragments were appropriately reintegrated to visualize a new SG framework.

RESULTS

This scoping review summarized data from 16 randomized controlled trials that evaluated SG education for children with chronic diseases and 14 studies on SG frameworks. It showed that self-determination theory was the most commonly used behavioral theory (9/30, 30%). Game elements included feedback, visual and audio designs, characters, narratives, rewards, challenges, competitions, goals, levels, rules, and tasks. In total, 3 phases of a digital SG framework are proposed in this review: requirements (phase 1), design and development (phase 2), and evaluation (phase 3). A total of 6 steps are described: exploring SG requirements (step 1), identifying target users (step 2), designing an SG prototype (step 3), building the SG prototype (step 4), evaluating the SG prototype (step 5), and marketing and monitoring the use of the SG prototype (step 6). Safety recommendations to use digital SG-based education for children in the post-COVID-19 era were also made.

CONCLUSIONS

This review summarizes the fundamental behavioral theories and game elements of the available literature to establish a new theory-driven step-by-step framework. It can support game designers, clinicians, and educators in designing, developing, and evaluating digital, SG-based educational tools to increase self-management activities and promote behavior change in children with chronic diseases.

Effectiveness of a healthy lifestyle program based on a mobile serious game for childhood cancer survivors: A quasi-randomized trial

PURPOSE

This study aimed to develop and evaluate the effectiveness of a healthy lifestyle program based on a mobile serious game (HLP-MSG) to enhance the lifestyles of childhood cancer survivors (CCSs).

METHODS

This program proceeded in two stages: development and evaluation, using a non-synchronized design with a quasi-randomized trial. The participants were CCSs aged 6-13 years whose treatment was terminated at least 12 months prior. Data were collected at baseline, and post-intervention, with a follow-up after four weeks using the Child Healthy Lifestyle Profile (CHLP). The experimental (n = 26) and control groups (n = 25) were compared. Data were analyzed using descriptive statistics, chi-squared tests, t-tests, and repeated-measures ANOVA.

RESULTS

The HLP-MSG promoted a healthy lifestyle by solving 26 quests, including seven sub-elements (nutrition, exercise, hygiene, interpersonal relationships, stress management, meaning of life, and health responsibility). This study revealed significant differences in the interaction between measurement time and group assignment in the CHLP (p = .006) and physical activity (p = .013), one of the seven sub-dimensions.

CONCLUSIONS

A healthy lifestyle program based on a mobile serious game is a feasible health education modality to enhance the physical, psychological, social, and spiritual health of CCSs.

IMPLICATIONS TO PRACTICE

The findings add to scientific evidence on a mobile serious game for health education among CCSs. The HLP-MSG provides an evolutionary educational modality that can be delivered non-face-to-face to promote CCSs' continuous healthy behavior maintenance. Moreover, the HLP-MSG is adolescent-friendly and can be utilized as a healthcare tool for parents and children to cooperate.

Effect of a Mobile Game-Based Intervention to Enhance Child Safety: Randomized Controlled Trial

BACKGROUND

Evidence supports the effectiveness of serious games in health education, but little is known about their effects on the psychosocial well-being of children in the general population.

OBJECTIVE

This study aimed to investigate the potential of a mobile game-based safety education program in improving children's safety and psychosocial outcomes.

METHODS

Safe City is a mobile roleplaying game specifically designed to educate children in Hong Kong about safety. This randomized controlled trial included 340 children in grades 4 through 6. Intervention arm participants (n=170) were instructed to play the Safe City mobile game for 4 weeks, whereas control arm participants (n=170) received a safety booklet. All participants completed a survey on safety knowledge and behaviors and psychosocial problems at baseline (T1), 1 month postintervention (T2), and 3 months postintervention (T3). Cumulative game scores and mini-game performance were analyzed as a proxy for the extent of exposure to the game. Outcome data were analyzed using 2-sample 2-tailed t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. The association of game use with outcome changes postintervention was analyzed using generalized additive models.

RESULTS

No significant differences were found in mean changes between the intervention and control arms. However, use analyses showed that higher game scores were associated with improvements in safe behavior (P=.03) and internalizing problems (P=.01) at T3. Matching and Spot the Danger mini-game performance significantly predicted improvements in safety knowledge at T2 and T3.

CONCLUSIONS

Analysis of use has shown that playing the Safe City mobile game can result in significant improvements in safety knowledge and reductions in unsafe behavior and internalizing problems. These findings provide evidence for the positive impact of serious games on psychological and social well-being, highlighting the potential of technology-driven interventions to assist children in learning about safety and preventing injuries.

TRIAL REGISTRATION

ClinicalTrials.org NCT04096196; https://clinicaltrials.gov/show/NCT04096196.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17756.

An umbrella review of the benefits and risks associated with youths' interactions with electronic screens

The influence of electronic screens on the health of children and adolescents and their education is not well understood. In this prospectively registered umbrella review (PROSPERO identifier CRD42017076051 ), we harmonized effects from 102 meta-analyses (2,451 primary studies; 1,937,501 participants) of screen time and outcomes. In total, 43 effects from 32 meta-analyses met our criteria for statistical certainty. Meta-analyses of associations between screen use and outcomes showed small-to-moderate effects (range: r = -0.14 to 0.33). In education, results were mixed; for example, screen use was negatively associated with literacy (r = -0.14, 95% confidence interval (CI) = -0.20 to -0.09, P ≤ 0.001, k = 38, N = 18,318), but this effect was positive when parents watched with their children (r = 0.15, 95% CI = 0.02 to 0.28, P = 0.028, k = 12, N = 6,083). In health, we found evidence for several small negative associations; for example, social media was associated with depression (r = 0.12, 95% CI = 0.05 to 0.19, P ≤ 0.001, k = 12, N = 93,740). Limitations of our review include the limited number of studies for each outcome, medium-to-high risk of bias in 95 out of 102 included meta-analyses and high heterogeneity (17 out of 22 in education and 20 out of 21 in health with I2 > 50%). We recommend that caregivers and policymakers carefully weigh the evidence for potential harms and benefits of specific types of screen use.

Using Gaming to Promote Vaccination Among Youth: A Systematic Review

Introduction

While vaccines are crucial for disease prevention, disparities in vaccination coverage persist among youths aged 10 to 29 years, including within the United States. Serious games are emerging as a new strategy to address vaccine hesitancy. This systematic review aimed to aggregate and assess the current evidence on game-based interventions to improve youth vaccination rates, evaluating their impact and identifying factors influencing their effectiveness.

Methods

This systematic review was conducted through a meticulous search and evaluation of literature from databases including PubMed, Cumulative Index to Nursing and Allied Health Literature database, ProQuest platform, Cochrane Library, and Google Scholar. Studies were included if they (a) were designed with the purpose of improving youth vaccination rates; (b) were published in English; (c) were published between January 2011 and June 2023; and (d) evaluated the effect of game-based interventions. Search terms included Medical Subject Headings terms and keywords of the eligible articles.

Results

Out of 269 studies, 11 were included in the final analysis of this review. The earliest study dated back to 2013, with 5 being randomized controlled trial and 6 studies incorporating theoretical models in their design or outcome measures. The findings indicated a generally positive effect of game-based interventions on vaccine-related knowledge. However, the impact on actual vaccine uptake was limited. In-game avatar customization and collaboration games were found as effective tools for player engagement.

Conclusion

The review findings indicated that serious games boost vaccine knowledge but lack strong evidence for influencing youth vaccine uptake. More rigorous research and tailored game designs are needed to determine the effectiveness of game-based interventions and effectively address the diverse needs of youth in vaccine decision-making.

Comparison of effectiveness of Nintendo Wii-based exergaming and home-based fun video exercises in pediatric patients with chronic kidney disease

Functional capacity and quality of life (QoL) are reduced in children and adults with chronic kidney disease (CKD). Aerobic, strengthening exercises, and exergames are reported as effective in the treatment of symptoms associated with CKD. Unlike adult patients, there are insufficient studies investigating the effects of exercise on disease-related symptoms in pediatric CKD. This study aimed to compare the effects of Nintendo Wii-based exergaming and home-based fun video exercises on functional capacity, muscle strength, physical activity (PA), depression, fatigue, and QoL in pediatric patients with CKD. Twenty-three pediatric patients with CKD were included in the study and randomized to group I (Nintendo Wii Fit) and group II (home-based fun video exercises). Patients in both groups underwent exercise programs twice per week for 6 weeks. Functional capacity, muscle strength, PA, QoL, fatigue, and depression of the patients were evaluated before and after the treatments. Sixteen patients completed the study. After treatment, significant differences were observed in both groups on 6MWT, muscle strength, average daily steps, PedsQoL Child Self-Report PHSS, and the Visual Fatigue Scale. Left knee flexor muscle strength and average step counts were found to be superior in group I. Both exergaming and home-based fun video exercises provide positive effects on functional capacity, muscle strength, fatigue, PA, depression, and QoL in pediatric patients with CKD. We think that these exercise methods can help to protect physical and mental health of patients and should be included in treatment from the early stages of the disease.

Translating Promoting Factors and Behavior Change Principles Into a Blended and Technology-Supported Intervention to Stimulate Physical Activity in Children With Asthma (Foxfit): Design Study

Background

Children with asthma can decrease the impact of their disease by improving their physical activity (PA). However, health care providers lack interventions for children with asthma that effectively increase their PA levels and achieve behavior change. A technology-supported approach can positively influence PA and physical functioning in children.

Objective

The aims of this study were to develop a technology-supported intervention that facilitates health care providers in promoting PA for children (aged 8 to 12 years) with asthma and to systematically describe this developmental process.

Methods

Intervention mapping (IM) was applied to develop a blended and technology-supported intervention in cocreation with children with asthma, their parents, and health care providers. In accordance with the IM framework, the following steps were performed: conduct a needs assessment; define the intervention outcome, performance objectives, and change objectives; select theory-based intervention methods and strategies; create components of the intervention and conduct pilot tests; create an implementation plan; and create an evaluation plan.

Results

We developed the blended intervention Foxfit that consists of an app with a PA monitor for children (aged 8 to 12 years) with asthma and a web-based dashboard for their health care provider. The intervention focuses on PA in everyday life to improve social participation. Foxfit contains components based on behavior change principles and gamification, including goal setting, rewards, action planning, monitoring, shaping knowledge, a gamified story, personal coaching and feedback, and a tailored approach. An evaluation plan was created to assess the intervention’s usability and feasibility for both children and health care providers.

Conclusions

The IM framework was very useful for systematically developing a technology-supported intervention and for describing the translational process from scientific evidence, the needs and wishes of future users, and behavior change principles into this intervention. This has led to the technology-supported intervention Foxfit that facilitates health care providers in promoting PA in children with asthma. The structured description of the development process and functional components shows the way behavior change techniques are incorporated in the intervention.

Trial Registration

International Clinical Trial Registry Platform NTR6658; https://tinyurl.com/3rxejksf

Modification in the Motor Skills of Seniors in Care Homes Using Serious Games and the Impact of COVID-19: Field Study

BACKGROUND

The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. At the beginning of 2020, the COVID-19 pandemic led to many restrictions, which affected seniors in care facilities in the form of severe isolation. The isolation led, among other things, to a lack of exercise, which has led to a multitude of negative effects for this target group. Serious games can potentially help by being used anywhere at any time to strengthen skills with few resources.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a serious game to strengthen motor skills (study 1) and the influence of pandemic restrictions (study 2) on seniors in care facilities.

METHODS

The data on motor skills (measured by the Tinetti test) originated from an intervention study with repeated measurements that was interrupted by the pandemic conditions. Data were collected 4 times every 3 months with an intervention group (IG, training 3 times for 1 hour per week) and a control group (CG, no intervention). There were 2 substudies. The first considered the first 6 months until the pandemic restrictions, while the second considered the influence of the restrictions on motor skills.

RESULTS

The sample size was 70. The IG comprised 31 (44%) participants, with 22 (71%) female and 9 (29%) male seniors with an average age of 85 years. The CG comprised 39 (56%) participants, with 31 (79%) female and 8 (21%) male seniors with an average age of 87 years. In study 1, mixed-design ANOVA showed no significant interaction between measurement times and group membership for the first measurements (F2.136=1.414, P<.25, partial η2=.044), but there was a significant difference between the CG (mean 16.23, SD 1.1) and the IG (mean 19.81, SD 1.2) at the third time of measurement (P=.02). In study 2 the mixed-design ANOVA (used to investigate motor skills before and after the pandemic conditions between the 2 groups) couldn't reveal any significant interaction between measurement times and group membership: F1.67=2.997, P<.09, partial η2=.043. However, there was a significant main effect of the time of measurement: F1.67=5.44, P<.02, partial η²=.075.

CONCLUSIONS

During the first 6 months, the IG showed increased motor skills, whereas the motor skills of the CG slightly deteriorated and showed a statistically significant difference after 6 months. The pandemic restrictions leveled the difference and showed a significant negative effect on motor skills over 3 months. As our results show, digital games have the potential to break down access barriers and promote necessary maintenance for important skills. The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. This potentially great benefit for the challenges of tomorrow shows the relevance of the topic and demonstrates the urgent need for action and research.

TRIAL REGISTRATION

Deutsches Register klinischer Studien DRKS00016633; https://tinyurl.com/yckmj4px.

So your patient is a gamer: an exploration of benefits and harms

PURPOSE OF REVIEW

The appropriate amount and type of screen time for children remains a persistent topic of discussion between parents and pediatricians. During the COVID-19 pandemic, screen time has considerably increased. The need to quarantine and utilize remote learning prompted our review of the basis for current screen time recommendations and more recent research.

RECENT FINDINGS

The broad stroke of recent research points to an association of increased video game screen time with sedentary lifestyle and its related harms. However, there also are specific instances where video games have been found to be therapeutically useful for certain populations.

SUMMARY

In light of these findings, it is prudent for the pediatrician to explore more of the 'why' of video game use as opposed to purely the 'how much'. Given the future beneficial therapeutic uses of some video games, clinicians should keep their eyes on this space for its continued development.

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.

A review of the evolution of scientific literature on technology-assisted approaches using RGB-D sensors for musculoskeletal health monitoring

The human musculoskeletal (MSK) system (also known as the locomotor system) provides strength and assistance to perform functional tasks and daily life activities. The MSK health monitoring plays a vital role in maintaining the body mobility and quality of life. Manual approaches for musculoskeletal health monitoring are subjective and require a clinician's intervention. The evolution in motion tracking technology enables us to capture the fine details of body movements. The research community has proposed various approaches to help clinicians in diagnosis and monitor treatment sessions. This paper succinctly reviews the evolution of technology-assisted approaches for musculoskeletal health monitoring, using motion capture sensors. To streamline the search through the literature database, the PICOS framework and PRISMA method have been incorporated. The present study reviews methods to transform motion capture data into kinematics variables and factors that affect the tracking performance of RGB-D sensors. Furthermore, widely utilized time-series filters for skeletal data denoising and smoothing for kinematics analysis, stochastic models for movement modeling, rule-based and template-based approaches for rehabilitation exercises assessment, and telerehabilitation sessions for remote health monitoring are explored. This article analyzes skeletal tracking methods by providing advantages and drawbacks of the state of the art rehabilitation sessions assessment, skeletal joint kinematics analysis, and MSK Telerehabilitation approaches. It also discusses the possible future research avenues to improve musculoskeletal disorder diagnosis and treatment monitoring. Our review signifies that RGB-D sensor-based approaches are inexpensive and portable for disorder diagnosis and treatment monitoring. It can also be a viable option for clinicians to provide contactless healthcare access to patients in the current scenario of the COVID-19 pandemic.

COVID-19 Pandemic and Reduced Physical Activity: Is There an Impact on Healthy and Asthmatic Children?

Physical activity (PA) has been seen to improve asthma symptoms, lung function, and quality of life, as well as to reduce airway inflammation and bronchial responsiveness. As a consequence of the COVID-19 pandemic, the minimal amount of PA recommended by the World Health Organization-i.e., about 60 min/day of moderate-to-high intensity-is difficult to achieve for many children, particularly those living in urban areas. Short-term changes in PA because of the COVID-19 pandemic may become habitual, increasing the risk of adverse asthma outcomes in children. Indeed, prolonged home confinement during the COVID-19 pandemic reduces PA levels and increases sedentary behaviors, possibly impairing immune system function and increasing susceptibility to inflammatory diseases. However, there is limited evidence regarding the effects of lockdown due to COVID-19 on PA and sedentary behaviors in asthmatic children. Given that children stay longer indoors, indoor air pollution represents a major issue to consider during home confinement. This narrative review aims to summarize the available evidence about the impact of decreased PA and increased sedentary behaviors on children with asthma during the COVID-19 pandemic. In addition, strategies for supporting PA in children with asthma during the COVID-19 pandemic are suggested, also looking at the issue of indoor air quality.

Rehabilitation Exergames: Use of Motion Sensing and Machine Learning to Quantify Exercise Performance in Healthy Volunteers

Background

Performing physiotherapy exercises in front of a physiotherapist yields qualitative assessment notes and immediate feedback. However, practicing the exercises at home lacks feedback on how well patients are performing the prescribed tasks. The absence of proper feedback might result in patients performing the exercises incorrectly, which could worsen their condition. We present an approach to generate performance scores to enable tracking the progress by both the patient at home and the physiotherapist in the clinic.

Objective

This study aims to propose the use of 2 machine learning algorithms, dynamic time warping (DTW) and hidden Markov model (HMM), to quantitatively assess the patient’s performance with respect to a reference.

Methods

Movement data were recorded using a motion sensor (Kinect V2), capable of detecting 25 joints in the human skeleton model, and were compared with those of a reference. A total of 16 participants were recruited to perform 4 different exercises: shoulder abduction, hip abduction, lunge, and sit-to-stand exercises. Their performance was compared with that of a physiotherapist as a reference.

Results

Both algorithms showed a similar trend in assessing participant performance. However, their sensitivity levels were different. Although DTW was more sensitive to small changes, HMM captured a general view of the performance, being less sensitive to the details.

Conclusions

The chosen algorithms demonstrated their capacity to objectively assess the performance of physical therapy. HMM may be more suitable in the early stages of a physiotherapy program to capture and report general performance, whereas DTW could be used later to focus on the details. The scores enable the patient to monitor their daily performance. They can also be reported back to the physiotherapist to track and assess patient progress, provide feedback, and adjust the exercise program if needed.

School-Based Interventions for Promoting Physical Activity Using Games and Gamification: A Systematic Review Protocol

Games and/or gamification seem to be a promising area for educational and health research. These strategies are being increasingly used for improving health indicators, even in educational settings; however, there is little information about these terms within the school to promote physical activity (PA). Objective: the aim of this study is to describe a systematic review protocol of school-based interventions for promoting PA in pre-schoolers, children, and adolescent students using games and gamification. Methods: This review protocol is registered in International prospective register of systematic reviews (PROSPERO) (CRD42019123521). Scientific databases include PubMed, Web of Science, SportDiscus, Cochrane Library, ERIC, and PsycINFO. A standardized procedure will be executed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol (PRISMA-P) checklist for conducting systematic review protocols and the PICOS (Population, Interventions, Comparators, Outcomes, and Study design) tool to address an appropriate search strategy. Detailed information will be extracted, including a quantitative assessment using effect sizes to compare the interventions and a qualitative assessment using the Evaluation of Public Health Practice Projects (EPHPP) tool. Conclusion: This systematic review protocol contributes to establishing future systematic reviews using games and gamification strategies in school settings in order to examine their effect on PA outcomes among youth. Additionally, an update and clarification on the different terms in the school context have been included.

Two new species of the genus Mecyclothorax Sharp from New Guinea (Coleoptera: Carabidae: Psydrinae)

Chronic diseases typically require long-term management through healthy lifestyle practices and pharmacological intervention. Although efficacious treatments exist, disease control is often sub-optimal leading to chronic disease-related sequela. Poor disease control can partially be explained by the ‘one size fits all’ pharmacological approach. Precision medicine aims to tailor treatments to the individual. CURATE.AI is a dosing optimisation platform that considers individual factors to improve the precision of drug therapies. CURATE.AI has been validated in other therapeutic areas, such as cancer, but has yet to be applied in chronic disease care. We will evaluate the CURATE.AI system through a single-arm feasibility study (n = 20 hypertensives and n = 20 type II diabetics). Dosing decisions will be based on CURATE.AI recommendations. We will prospectively collect clinical and qualitative data and report on the clinical effect, implementation challenges, and acceptability of using CURATE.AI. In addition, we will explore how to enhance the algorithm further using retrospective patient data. For example, the inclusion of other variables, the simultaneous optimisation of multiple drugs, and the incorporation of other artificial intelligence algorithms. Overall, this project aims to understand the feasibility of using CURATE.AI in clinical practice. Barriers and enablers to CURATE.AI will be identified to inform the system’s future development.