Investigating Serious Games That Incorporate Medication Use for Patients: Systematic Literature Review

Investigating the Use of Serious Games for Cancer Control Among Children and Adolescents: Scoping Review

BACKGROUND

Effective health care services that meet the diverse needs of children and adolescents with cancer are required to alleviate their physical, psychological, and social challenges and improve their quality of life. Previous studies showed that serious games help promote people's health. However, the potential for serious games to be used for successful cancer control for children and adolescents has received less attention.

OBJECTIVE

This scoping review aimed to map the use of serious games in cancer prevention and cancer care for children and adolescents, and provide future directions for serious games' development and implementation within the context of cancer control for children and adolescents.

METHODS

This study followed a combination of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and the JBI (Joanna Briggs Institute) framework for the conduct of scoping reviews. PubMed, CINAHL Plus Full Text, Scopus, Web of Science Core Collection, and American Psychological Association (APA) PsycINFO databases were used for the search.

RESULTS

From the initial 2750 search results, 63 papers were included in the review, with 28 quantitative, 14 qualitative, and 21 mixed method studies. Most of the studies were cancer care serious game papers (55/63, 87%) and a small number of studies were cancer prevention serious game papers (8/63, 13%). The majority of the included studies were published between 2019 and 2023 (cancer prevention: 5/8, 63%; cancer care: 35/55, 64%). The majority of the studies were conducted in Europe (cancer prevention: 3/8, 38%; cancer care: 24/55, 44%) and North America (cancer prevention: 4/8, 50%; cancer care: 17/55, 31%). Adolescents were the most represented age group in the studies' participants (cancer prevention: 8/8, 100%; cancer care: 46/55, 84%). All (8/8, 100%) cancer prevention serious game papers included healthy people as participants, and 45 out of 55 (82%) cancer care serious game papers included patients with cancer. The majority of cancer prevention serious game papers addressed game preference as a target outcome (4/8, 50%). The majority of cancer care serious game papers addressed symptom management as a target outcome (28/55, 51%). Of the cancer care studies examining serious games for symptom management, the majority of the studies were conducted to treat psychological (13/55, 24%) and physical symptoms (10/55, 18%).

CONCLUSIONS

This review shows both the growth of interest in the use of serious games for cancer control among children and adolescents and the potential for bias in the relevant literature. The diverse characteristics of the included papers suggest that serious games can be used in various ways for cancer control among children and adolescents while highlighting the need to develop and implement serious games in underrepresented areas.

Quality Assessment of Smartphone Medication Management Apps in France: Systematic Search

BACKGROUND

Adherence to medication is estimated to be around 50% for chronically ill patients in high-income countries. Improving the effectiveness of adherence interventions could have a far greater impact on population health than any improvement in specific medical treatments. Mobile health (mHealth) is one of the most effective solutions for helping patients improve their medication intake, notably through the use of mobile apps with reminder systems. With more than 327,000 apps available in the mHealth field, it is difficult for health care professionals and patients alike to choose which apps to recommend and use.

OBJECTIVE

We aim to carry out a systematic search of medication management smartphone apps available in France that send reminders to patients and assess their quality using a validated scale.

METHODS

Mobile apps were identified in October and November 2022 after a systematic keyword search on the 2 main app download platforms: App Store (Apple Inc) and Google Play Store. Inclusion criteria were free availability, date of last update, and availability in French. Next, 2 health care professionals independently evaluated the included apps using the French version of the Mobile App Rating Scale (MARS-F), an objective scoring system validated for assessing the overall quality of apps in the mHealth field. An intraclass correlation coefficient was calculated to determine interrater reliability.

RESULTS

In total, 960 apps were identified and 49 were selected (25 from the App Store and 24 from the Google Play Store). Interrater reliability was excellent (intraclass correlation coefficient 0.92; 95% CI 0.87-0.95; P<.001). The average MARS-F score was 3.56 (SD 0.49) for apps on the App Store and 3.51 (SD 0.46) for those on the Google Play Store, with 10 apps scoring above 4 out of 5. Further, 2 apps were tested in at least one randomized controlled trial and showed positive results. The 2 apps with the highest ratings were Mediteo rappel de médicaments (Mediteo GmbH) and TOM rappel medicaments, pilule (Innovation6 GmbH), available on both platforms. Each app's MARS-F score was weakly correlated with user ratings on the App Store and moderately correlated on the Google Play Store.

CONCLUSIONS

To our knowledge, this is the first study that used a validated scoring system to evaluate medication management apps that send medication reminders. The quality of the apps was heterogeneous, with only 2 having been studied in a randomized controlled trial with positive results. The evaluation of apps in real-life conditions by patients is necessary to determine their acceptability and effectiveness. Certification of apps is also essential to help health care professionals and patients identify validated apps.

Assessing the Importance of Content Versus Design for Successful Crowdfunding of Health Education Games: Online Survey Study

Background

Health education games make health-related tasks enjoyable and interactive, thereby encouraging user participation. Entrepreneurs and health educators can leverage online crowdfunding platforms, such as Kickstarter, to transform their innovative ideas into funded projects.

Objective

This research focuses on health education game initiatives on Kickstarter. Through an online user survey, it aims to understand user perceptions and evaluate the significance of 8 distinct components that may influence the success of such crowdfunding initiatives.

Methods

A total of 75 participants evaluated games using 8 dimensions: game rules, learning objectives, narrative, content organization, motivation, interactivity, skill building, and assessment and feedback. The survey data were analyzed using descriptive statistical analysis, exploratory factor analysis, the Wilcoxon-Mann-Whitney test, and multivariate analysis.

Results

Exploratory data analysis showed that, among the 8 dimensions, skill building, content organization, and interactivity were the top-ranking dimensions most closely associated with crowdfunding health education game. The 8 dimensions can be grouped into 3 categories from the exploratory factor analysis: game content-, instruction-, and game design-related components. Further statistical analysis confirmed the correlation between these dimensions with the successful crowdfunding of health education games.

Conclusions

This empirical analysis identified critical factors for game proposal design that can increase the likelihood of securing crowdfunding support.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Assessing the Impact of a Serious Game (MedSMARxT: Adventures in PharmaCity) in Improving Opioid Safety Awareness Among Adolescents and Parents: Quantitative Study

BACKGROUND

The opioid crisis continues to worsen across the United States, affecting people of all demographics. Few evidence-based interventions exist for educating families, particularly those with adolescents, about opioid prescription safety. Serious games have demonstrated impacts in improving medication-related outcomes for various health conditions. The characterizing goal of this serious game is to improve opioid safety knowledge and awareness among adolescents and their families.

OBJECTIVE

This study evaluated the impact of a serious game, MedSMARxT: Adventures in PharmaCity, designed to foster opioid safety awareness among adolescents and their parents.

METHODS

A national sample of parents and their adolescent children was recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Eligible participants were adolescents aged between 12 and 18 years and their parents. Study participants were required to reside in the United States; speak, read, and understand English; and have access to a computer with a webcam. Parent-child dyads completed pregame and postgame surveys and participated in gameplay for up to 30 minutes. Primary outcome scales have been previously evaluated by the study team.

RESULTS

A total of 60 adolescent participants and 68 parent participants met full attention criteria for inclusion in this study. Statistical analysis confirmed that both adolescents' and parents' concept scores improved from baseline regarding opioid safety self-efficacy (adolescent: mean 0.35, SD 0.60; P<.001; parent: mean 0.28, SD 0.42; P<.001), perceived knowledge (adolescent: mean 1.08, SD 1.04; P<.001; parent: mean 0.56, SD 0.55; P<.001), behavioral intent (adolescent: mean 0.26, SD 0.39; P<.001; parent: mean 0.25, SD 0.32; P<.001), safe storage (adolescent: mean 0.12, SD 0.27; P<.001; parent: mean 0.03, SD 0.11; P=.03), disposal knowledge (adolescent: mean 0.10, SD 0.27; P=.006; parent: mean 0.07, SD 0.16; P<.001), and knowledge about misuse behavior (adolescent: mean 0.05, SD 0.14; P=.002; parent: mean 0.04, SD 0.10; P<.001). Participant groups, stratified by who completed and who did not complete gameplay, improved their knowledge and awareness, with no significant differences between subgroups.

CONCLUSIONS

The use of this serious game to improve opioid prescription safety practices among parents and adolescents was supported by the study findings. MedSMARxT: Adventures in PharmaCity is an intervention with the capability of teaching parents and adolescents about safe opioid prescription practices. Further studies and game refinement are needed to demonstrate the effectiveness of a game-based intervention in clinical settings and community pharmacies.

A Software Engineering Framework for Reusable Design of Personalized Serious Games for Health: Development Study

BACKGROUND

The use of serious games in health care is on the rise, as these games motivate treatment adherence, reduce treatment costs, and educate patients and families. However, current serious games fail to offer personalized interventions, ignoring the need to abandon the one-size-fits-all approach. Moreover, these games, with a primary objective other than pure entertainment, are costly and complex to develop and require the constant involvement of a multidisciplinary team. No standardized approach exists on how serious games can be personalized, as existing literature focuses on specific use cases and scenarios. The serious game development domain fails to consider any transfer of domain knowledge, which means this labor-intensive process must be repeated for each serious game.

OBJECTIVE

We proposed a software engineering framework that aims to streamline the multidisciplinary design process of personalized serious games in health care and facilitates the reuse of domain knowledge and personalization algorithms. By focusing on the transfer of knowledge to new serious games by reusing components and personalization algorithms, the comparison and evaluation of different personalization strategies can be simplified and expedited. In doing so, the first steps are taken in advancing the state of the art of knowledge regarding personalized serious games in health care.

METHODS

The proposed framework aimed to answer 3 questions that need to be asked when designing personalized serious games: Why is the game personalized? What parameters can be used for personalization? and How is the personalization achieved? The 3 involved stakeholders, namely, the domain expert, the (game) developer, and the software engineer, were each assigned a question and then assigned responsibilities regarding the design of the personalized serious game. The (game) developer was responsible for all the game-related components; the domain expert was in charge of the modeling of the domain knowledge using simple or complex concepts (eg, ontologies); and the software engineer managed the personalization algorithms or models integrated into the system. The framework acted as an intermediate step between game conceptualization and implementation; it was illustrated by developing and evaluating a proof of concept.

RESULTS

The proof of concept, a serious game for shoulder rehabilitation, was evaluated using simulations of heart rate and game scores to assess how personalization was achieved and whether the framework responded as expected. The simulations indicated the value of both real-time and offline personalization. The proof of concept illustrated how the interaction between different components worked and how the framework was used to simplify the design process.

CONCLUSIONS

The proposed framework for personalized serious games in health care identifies the responsibilities of the involved stakeholders in the design process, using 3 key questions for personalization. The framework focuses on the transferability of knowledge and reusability of personalization algorithms to simplify the design process of personalized serious games.

Characterizing Pharmacist Perspectives on Utilizing a Personalized Family Medication Safety Plan for Opioid Education with Adolescents and Parents

BACKGROUND

Exposure to prescription opioids during adolescence is associated with an increased risk of future opioid misuse. The pervasive and growing impact of the opioid epidemic requires evidence-based, co-designed interventions targeted at adolescents. MedSMA℞T Families is an intervention tailored to educate adolescents and their families about opioid misuse prevention and consists of two parts: the MedSMA℞T: Adventures in PharmaCity videogame and the family medication safety plan (FMSP).

OBJECTIVE

This study sought to explore pharmacists' perceptions of using the family medication safety plan to facilitate opioid education among parents and their adolescents. The purpose of this project was to also gather information for iterative adaptations to improve implementation and dissemination of the FMSP in pharmacy settings.

METHODS

Pharmacists were recruited from Pharmacy Practice Enhancement and Action Research Link (PearlRx) and the Pharmacy Society of Wisconsin (PSW). Twenty-one pharmacist interviews were conducted between September 2021 and March 2022. Consenting pharmacists reviewed the FMSP. Then, semi-structured interviews were conducted, recorded, and transcribed. Inductive thematic analyses were performed using NVivo software.

RESULTS

Four prevalent themes emerged: (1) the purpose of FMSP as a communication tool, (2) instructions to clarify how to use FMSP, (3) barriers to using FMSP, and (4) suggestions to improve FMSP format. Most pharmacists described the FMSP as a tool to encourage interactive opioid conversations between adolescents, families, and pharmacists. Pharmacists suggested creating multiple customizable formats and incorporating instructions on how to use the FMSP.

CONCLUSIONS

Pharmacists noted that the FMSP was an interactive and engaging communication tool to tailor opioid consultations with adolescents and their families. Patients might use the FMSP as a visual cue to help think of what question(s) they should ask pharmacists. Pharmacists stated that the FMSP could facilitate tailored opioid safety communication and medication consultations. Insights will inform future medication misuse prevention interventions as well as adaptation.

Patient perspectives on the use of mobile apps to support heart failure management: A qualitative descriptive study

BACKGROUND

Adherence to diet and medical therapies are key to improving heart failure (HF) outcomes; however, nonadherence is common. While mobile apps may be a promising way to support patients with adherence via education and monitoring, HF patient perspectives regarding the use of apps for HF management in unknown. This data is critical for these tools to be successfully developed, implemented, and adopted to optimize adherence and improve HF outcomes.

OBJECTIVE

To determine patients' needs, motivations, and challenges on the use of mobile apps to support HF management.

METHODS

A qualitative descriptive study using focus groups (n = 4,60 minutes) was conducted among HF patients from outpatient HF clinics in Toronto, Canada. The Diffusion of Innovation theory informed a ten-question interview guide. Interview transcripts were independently coded by two researchers and analyzed using content analysis.

RESULTS

Nineteen HF patients (65 ± 10 yrs, 12 men) identified a total of four key themes related to the use of mobile apps. The theme 'Factors impacting technology use by patients' identified motivations and challenges to app use, including access to credible information, easy and accessible user-interface. Three themes described patients' needs on the use of mobile apps to support HF management: 1) 'Providing patient support through access to information and self-monitoring', apps could provide education on HF-related content (e.g., diet, medication, symptoms); 2) 'Facilitating connection and communication', through information sharing with healthcare providers and connecting with other patients; 3) 'Patient preferences', app features such as reminders for medication, and visuals to show changes in HF symptoms were favoured.

CONCLUSIONS

HF patients perceive several benefits and challenges to app use for HF self-management. Capitalizing on the benefits and addressing the challenges during the app development process may maximize adoption of such tools in this patient population.

Gaming for Adherence to Medication using Ehealth in Rheumatoid arthritis (GAMER) study: a randomised controlled trial

Objective

To examine the effect on adherence to disease modifying anti-rheumatic drugs (DMARDs) in participants with rheumatoid arthritis (RA) of a serious game that targeted implicit attitudes toward medication.

Methods

A multicentre randomised controlled trial (RCT) was performed with adults with RA that used DMARDs and possessed a smartphone/tablet. Control and intervention groups received care as usual. The intervention group played the serious game at will during 3 months. Game play data and online questionnaires Compliance Questionnaire on Rheumatology (CQR), Beliefs about Medicine Questionnaire (BMQ), Health Assessment Questionnaire (HAQ) and Rheumatoid Arthritis Disease Activity Index (RADAI) were collected. Primary outcome was DMARD implementation adherence operationalised as the difference in proportion of non-adherent participants (<80% taking adherence) between intervention and control group after 3 months using a Chi-squared test. Two sample t-tests and Wilcoxon rank-sum test were performed to test for differences on secondary outcomes.

Results

Of the 110 intervention participants that started the study, 87 participants (79%) installed the game and had a median playtime of 9.7 hours at 3 months. Overall, 186 participants completed the study. Adherence in intervention group (63%) and control group (54%) did not differ significantly (p=0.13) at 3 months. Neither were there differences oberved in CQR continuous score, beliefs about medication (BMQ) or clinical outcomes (HAQ and RADAI).

Conclusion

A serious game aimed at reinterpreting attitudes toward medication failed to show an effect on adherence to DMARDs or clinical outcomes in patients with RA. The game was played frequently indicating that it can be an effective channel for reaching patients.

Trial registration number

NL7217.

Understanding and assessing gamification in digital healthcare interventions for patients with cardiovascular disease

Gamification is defined as the use of game design elements in contexts other than gaming to increase user engagement and experience. Gamification in cardiovascular care can contribute to positively change health behaviour with possible effects and benefits on physical health and mental well-being. Based on previous literature, in this article we describe: the conceptualization of gamification, the five gamification principles for gamified digital health programmes or applications, the six most common game elements used to impact health behaviour applied in gamified digital health interventions and finally scientifically validated instruments to use for assessment of gamification in terms of self-reported psychological outcomes.

The Geriatric Virtual Escape Room in Pharmacy Education: Female Students Escape Significantly Faster than Male Students

Due to COVID-19 and the limitation of face-face teaching, electronic adaptation for formative and continuous assessment methods were greatly used and documented between 2020 and 2021. This study aims to implement a virtual escape room that will help assist and refine problem-solving skills in fifth-year pharmacy students by reviewing Beer’s criteria and selecting the most appropriate management. A descriptive cross-sectional study was conducted following the implementation of the virtual escape room using google form. Students had to unlock five puzzles using Beer’s criteria. To evaluate pharmacy students’ perception of this method, they completed a survey to identify their views of the game. Of the 128 students enrolled in the geriatric course, all were able to escape (100%). A one-sample t-test indicated statistical significance between gender. Female students escaped statistically faster than male students (p < 0.00002) and were more likely to recommend the game to other students and thought the game encouraged them to think of the material in a new way, whereas male students were more neutral towards it. In conclusion, the geriatric virtual escape room was successfully implemented as a pilot innovative method to assist in virtual learning. However, future studies should investigate virtual gamification in pharmacy education and its impact on learning, as well as identify if there were any gender-specific differences in using these tools.

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.

Engaging youth in the design of prescription opioid safety education for schools

BACKGROUND

Opioid misuse continues to be a major concern in the United States, affecting both adults and adolescents. Unfortunately, even legitimate prescription opioid misuse in adolescence increases the risk for misuse later in life. Although adolescence is a critical period for learning, little is known about adolescents' preferences for opioid safety education. One potential avenue for prescription opioid education is the use of serious games. Serious games can result in better health outcomes and understanding for adolescents and allow them to safely experience real-life scenarios. However, few studies have examined the use of serious games for adolescent opioid education.

OBJECTIVE

This study explored adolescents' preferences for prescription opioid education and design of a serious game focused on opioid safety education.

METHODS

A focus group guide was adapted from 2 statewide surveys about participants' perspectives on opioids. Recruitment packets with consent documents and an introduction to the study were sent home to eligible students. Ten focus groups were conducted with 68 middle and high school students in Wisconsin. Adolescents were asked to discuss their preferences for prescription opioid safety education and to design a serious game to educate teens about opioid safety. Focus groups were audio-recorded, professionally transcribed, and underwent content and thematic analyses using NVivo 12 software.

RESULTS

Three preferred approaches for opioid safety education were identified, including the use of presentations, videos and websites, and serious games. Adolescents desired short presentations delivering personal stories to smaller audiences. They preferred websites and brief, engaging videos from reliable sources because of ease of access. Adolescents also preferred serious games for opioid education that were realistic and relatable.

CONCLUSION

When educating adolescents on prescription opioids, the use of presentations, particularly personal stories, brief and engaging websites and videos, or serious games with realistic and relatable scenarios should be incorporated.

Investigating the Use of a Serious Game to Improve Opioid Safety Awareness Among Adolescents: A Quantitative Study

BACKGROUND

The misuse of opioid medications among adolescents is a serious problem in the United States. Serious games (SGs) are a novel way to promote safe and responsible management of opioid medications among adolescents, thereby reducing the number of adolescent opioid misuse cases reported annually.

OBJECTIVE

This study aimed to examine the effect of the SG MedSMA℞T: Adventures in PharmaCity on adolescents' opioid safety knowledge, awareness, behavioral intent, and self-efficacy.

METHODS

A nationally representative sample of adolescents age 12 to 18 years old were recruited online through Qualtrics panels from October to November 2020. Data collection consisted of a pre-game survey, 30 minutes of gameplay, and a post-game survey. The pre- and post-game survey included 66 items examining participants' baseline opioid knowledge, safety, and use, and demographic information. The post-game survey had 25 additional questions regarding the MedSMA℞T game. Gameplay scenarios included five levels intended to mimic adolescents' daily life while educating players about appropriate opioid storage and disposable practices, negative consequences of sharing opioid medications, and use of Narcan®. Survey questions were divided into 10 categories to represent key concepts and summarized into concept scores. Differences in concept scores were described by overall mean (SD) when stratified by gender, race, school, grade, and age. Differences of change in concept score were analyzed using Kruskal-Wallis and correlation tests.

RESULTS

A total of 117 responses were analyzed. Results showed significant improvement on all concept scores except for Narcan® knowledge (mean change = -0.04, SD = 0.29, p = 0.600) and safe storage (mean change = 0.03, SD = 0.20, p = 0.088). Female participants had greater improvement than males for safe disposal (female mean (SD) = 0.12 (0.25), male = 0.04 (0.17), p = 0.050). Male participants had higher improvement than females for misuse behavior (female mean (SD) = 0.05 (0.28) male = 0.14 (0.27), p = 0.043). Perceived knowledge for participants who were non-white or Hispanic had higher improvement than non-Hispanic white participants (non-white mean (SD) = 1.10 (1.06), white = 0.75 (0.91), p = 0.026). Older grades were associated with greater improvement in opioid knowledge (correlation coefficient -0.23 (95% CI -0.40 to -0.05), p = 0.012). There were 28 (23.9%) participants who played all 5 levels of the game and had better improvement in opioid use self-efficacy.

CONCLUSIONS

Findings suggest MedSMA℞T: Adventures in PharmaCity can be used as an effective tool to educate adolescents on the safe and responsible use of prescribed opioid medications. Future testing of the effectiveness of this SG should involve a randomized control trial. Additionally, the feasibility of implementing and disseminating MedSMA℞T: Adventures in PharmaCity in schools and healthcare settings, such as adolescent health or primary care clinics, emergency departments, and pharmacies, should be investigated.

CLINICALTRIAL

Exploring Middle School Students' Perspectives on Utilizing Serious Games for Cancer Prevention Education: A Focus Group Study

BACKGROUND

Cancer in the United States is a leading cause of mortality. Educating adolescents about cancer risks can improve awareness and introduce healthy lifestyle habits. Public health efforts have made significant progress in easing the burden of cancer through the promotion of early screening and healthy lifestyle advocacy. However, there are limited interventions that educate the adolescent population about cancer prevention. Previous studies have demonstrated the effectiveness of serious games (SGs) to teach adolescents about healthy lifestyle choices, but limited research has examined the utility of using SGs to educate youth specifically on cancer prevention.

OBJECTIVE

This study aimed to investigate middle school students' preferences for the use of SGs for cancer prevention education. The study also characterized the students' perceptions of desired game design features for a cancer prevention SG.

METHODS

Focus groups were conducted to allow adolescents to review a game playbook and discuss gaming behaviors and preferences for a SG for cancer education. The game playbook was developed based on Cancer, Clear & Simple, a curriculum intended to educate individuals about cancer, prevention, self-care, screening, and detection. In the game, the player learns that they have cancer and is given the opportunity to go back in time to reduce their cancer risk. A focus group discussion guide was developed and consisted of questions about aspects of the playbook and participants' gaming experience. Adolescents were eligible to participate if they were 12 to 14 years, could speak and understand English, and had parents who could read English or Spanish. Each focus group consisted of five to ten adolescents. Focus groups were audio-recorded and professionally transcribed, then content and thematically analyzed by two study team members. Intercoder reliability (kappa coefficient) among the coders was reported as 0.97. Prevalent codes were identified and categorized into themes and subthemes.

RESULTS

A total of 18 focus groups were conducted with 139 participants from a Wisconsin middle school. Most participants had at least "some" gaming experience. Three major themes were identified: Educational Video Games, Game Content, and Purpose of Game. Participants preferred customizable characters and realistic storylines that allowed players to make choices that affect the characters' outcomes. Middle school students also preferred SGs over other educational methods such as lectures, books, videos, and websites. Participants desired SGs to be available across multiple platforms and suggested the use of SGs for cancer education in their school.

CONCLUSIONS

Adolescents consider SGs to be an entertaining tool to learn about cancer prevention and risk factors. The design preferences of adolescents should be considered to create a cancer education SG that is acceptable and engaging for youth.

CLINICALTRIAL

Examining adolescents' opioid knowledge and likelihood to Utilize an educational game to promote medication safety

BACKGROUND

Adolescents' knowledge on opioids is seldom studied, despite the fact young people are one of the groups most affected by the opioid crisis within the United States. There is a need to understand adolescents' perceptions about opioid misuse and safety to create the necessary tools to educate adolescents on safe opioid use.

OBJECTIVE

This study sought to understand adolescents' knowledge and perceptions of opioid use and safety as well as their receptiveness to using an educational game for improving medication safety knowledge.

METHODS

A 67-item survey was developed to assess adolescents' opioid perceptions, knowledge, and the likelihood of an educational game to enhance their opioid medication safety. A nationally representative sample of US adolescents aged 12 to 18 were recruited via a Qualtrics participant panel to complete the online survey from October through November 2020. Survey questions were grouped into 10 categories to represent key concepts and summarized into concept scores. Concepts were described through means, median, and range as well as percent correct for individual questions. Differences between groups were assessed using Kruskal-Wallis tests. Concept scores and their relation to the participant's age were described by the Pearson's correlation coefficient and the linear model coefficient.

RESULTS

A total of 592 responses were analyzed. Male and older participants reported greater perceived opioid knowledge than females. White participants reported higher rates of perceived opioid knowledge, behavioral intent, and knowledge of safe medication disposal than any other racial group. About 80% of participants were receptive to the use of an educational game to increase their opioid safety knowledge.

CONCLUSIONS

There are discrepancies in adolescents' knowledge on opioid safety and harm amongst genders, race, and age. Study findings support the use of an educational game to increase adolescents' opioid knowledge. Future studies should design an educational game intended for a diverse audience.

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.

Personalized and Self-Management: Systematic Search and Evaluation Quality Factors and User Preference of Drug Reference Apps in Taiwan

Background: Drug reference apps promote self-management and improve the efficiency and quality of work for physicians, nurses, pharmacists, and patients. This study aimed to describe a systematic and stepwise process to identify drug reference apps in Taiwan, assess the quality of these apps, and analyze the influential factors for user ratings. Methods: A two-step algorithm (KESS) consisting of keyword growing and systematic search was proposed. Seven independent reviewers were trained to evaluate these apps using Mobile App Rating Scale (MARS). A logistic regression model was fitted and average marginal effects (AME) were calculated to identify the effects of factors for higher user ratings. Results: A total of 23 drug reference apps in Taiwan were identified and analyzed. Generally, these drug reference apps were evaluated as acceptable quality with an average MARS score of 3.23. Higher user engagement, more functionality, better aesthetics, and more information associated with higher user ratings. Navigation is the most influential factor on higher user ratings (AME: 13.15%) followed by performance (AME: 11.03%), visual appeal (AME: 10.87%), credibility (AME: 10.67%), and quantity of information (AME: 10.42%). Conclusions: User experience and information clearly affect user ratings of drug reference apps. Five key factors should be considered when designing drug reference apps.

A Depth Camera-Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study

Background

The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed.

Objective

We developed a depth camera–based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy.

Methods

We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded.

Results

This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported.

Conclusions

Stomp Joy is an effective depth camera–based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size.

Pharmacoadherence: An Opportunity for Digital Health to Inform the Third Dimension of Pharmacotherapy for Diabetes

The basis of pharmacotherapy requires knowledge of two properties of a drug: pharmacokinetics (PK) and pharmacodynamics (PD). In the era of precision medicine, there is growing interest in determining between-individual variations in PK and PD. While these two dimensions of pharmacotherapy are key foci of investigation, a third property is also emerging as a critical factor in understanding how a drug affects an individual. This third property of a drug is known as phamacoadherence (PA). There can be wide variation in PA among people with diabetes, whether they are using oral or injectable medications. The use of new digital health interventions and telehealth communication tools, such as smart insulin pens, is now creating opportunities for health care professionals to have a more complete understanding of the PA of drugs, which allows for more personalized prescribing practices.

How to initiate eHealth in congenital heart disease patients?

Patients with congenital heart disease (CHD) are a vulnerable subgroup of cardiac patients. These patients have a high morbidity and high mortality rate. As the number of patients with CHD keeps growing, while also getting older, new tools for the care and follow-up of these vulnerable patients are warranted. eHealth has an enormous potential to revolutionize health care, and particularly for CHD patients, by expanding care beyond hospital walls and even moving some of the provided care to the comfort of home. As new eHealth tools continue to grow in number, such as invasive eHealth tools, health care delivered through eHealth continues to evolve. This teaching series summarizes current insights and discusses challenges yet to be overcome. Importantly, none of them are insurmountable. This all lays ground for a promising future for eHealth in the care of patients with CHD.

Mapping Behavioral Health Serious Game Interventions for Adults With Chronic Illness: Scoping Review

BACKGROUND

Serious games for health are increasingly being used to address health outcomes in patients with chronic illnesses. These studies vary in their study designs, patient populations, frameworks, outcome variables, and degree of specificity of the serious game intervention.

OBJECTIVE

This scoping review aims to clarify the conceptual features of the existing research related to serious games designed to improve cognitive and behavioral outcomes in adults with chronic illness.

METHODS

We applied the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for scoping reviews (PRISMA-ScR) methodology, including an a priori research question. We searched 4 electronic databases to identify articles published through November 2019. Inclusion criteria encompassed (1) adults 18 years or older; (2) patients with a diagnosis of chronic illness; (3) a serious game intervention; and (4) defined patient outcomes that assess patients' behavioral, cognitive, or health outcomes.

RESULTS

Of the 3305 articles identified, 38 were included in the review. We charted and analyzed the theoretical frameworks, key concepts, and outcome variables of these studies with summaries of features across articles. The majority of studies used a randomized controlled trial design (23/38, 61%), included a custom serious game intervention (22/38, 58%), and lacked a theoretical framework (25/38, 66%). Common outcome variables included quality of life (16/38, 42%), mood (15/38, 39%), cognitive function (13/38, 34%), symptoms (12/38, 32%), and physical activity (9/38, 24%). Key differences between studies included whether or not serious games aimed to train versus teach patients, be widely accessible versus tailored interventions, or replace versus complement current treatments.

CONCLUSIONS

This scoping review defines the current landscape of research in serious games for health research targeting behavioral and cognitive outcomes in adults with chronic disease. Studies have addressed a variety of patient populations and diverse patient outcomes. Researchers wanting to build on the current research should integrate theoretical frameworks into the design of the intervention and trial to more clearly articulate the active ingredients and mechanisms of serious games.

Developing a Theory-Driven Serious Game to Promote Prescription Opioid Safety Among Adolescents: Mixed Methods Study

Background

Adolescents in North America are severely affected by the opioid crisis, yet there are limited educational resources for educating teens about prescription opioid safety and misuse. Empirical literature lacks evidence regarding teen education about prescription opioid safety through serious games and lacks conceptual models and frameworks to guide the process of game development for this purpose.

Objective

This study aims to conceptualize and design a serious game prototype to teach teens about prescription opioid safety and propose a conceptual framework for developing a serious game to educate youth about safe and responsible use of prescription opioids.

Methods

The initial steps of the project comprised of the formulation of an integrated conceptual framework that included factors from health behavior models and game development models. This was followed by the formal process of serious game development, which resulted in a game prototype. The assessment of the game prototype was done through group discussions, individual interviews, and questionnaires with adolescents following gameplay. Field notes were used to keep track of the responses from the group discussions. Content and thematic analyses were used to analyze field notes and responses to the open-ended questionnaire, which were then used to refine the game prototype.

Results

A total of 10 playtests with over 319 adolescents and emerging young adults (AYAs) in community settings such as middle schools, high schools, and colleges were conducted by the project team between March and June 2019. The AYAs provided feedback on the initial game prototype using questionnaires administered through Qualtrics or in-person on paper. Preliminary feedback suggested that the teens found the game objectives, outcomes, and design appealing. Overall, the game was perceived as realistic, and learning outcomes seemed achievable. Suggestions for improvement included the need for additional direction on gameplay, clearer instructions, concise dialog, and reduced technical problems in the gameplay.

Conclusions

We propose a conceptual framework for developing a serious game prototype to educate youth about prescription opioid safety. The project used a theory-driven conceptual framework for the development of a serious game targeting the prevention of adolescent opioid misuse and garnered preliminary feedback on the game to improve the quality of gameplay and the prototype. Feedback through informal assessments in community settings suggests that the youth and their families are interested in a game-based approach to learn about prescription opioid safety in homes and schools. The next steps include modifications to the game prototype based on feedback from the community, integration of learning analytics to track the in-game behaviors of players, and formal testing of the final prototype.