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

A Serious Game ("Fight With Virus") for Preventing COVID-19 Health Rumors: Development and Experimental Study

BACKGROUND

Health rumors arbitrarily spread in mainstream social media on the internet. Health rumors emerged in China during the outbreak of COVID-19 in early 2020. Many midelders/elders (age over 40 years) who lived in Wuhan believed these rumors.

OBJECTIVE

This study focused on designing a serious game as an experimental program to prevent and control health rumors. The focus of the study was explicitly on the context of the social networking service for midelders/elders.

METHODS

This research involved 2 major parts: adopting the Transmission Control Protocol model for games and then, based on the model, designing a game named "Fight With Virus" as an experimental platform and developing a cognitive questionnaire with a 5-point Likert scale. The relevant variables for this experimental study were defined, and 10 hypotheses were proposed and tested with an empirical study. In total, 200 participants were selected for the experiments. By collecting relevant data in the experiments, we conducted statistical observations and comparative analysis to test whether the experimental hypotheses could be proved.

RESULTS

We noted that compared to traditional media, serious games are more capable of inspiring interest in research participants toward their understanding of the knowledge and learning of health commonsense. In judging and recognizing the COVID-19 health rumor, the test group that used game education had a stronger ability regarding identification of the rumor and a higher accuracy rate of identification. Results showed that the more educated midelders/elders are, the more effective they are at using serious games.

CONCLUSIONS

Compared to traditional media, serious games can effectively improve midelders'/elders' cognitive abilities while they face a health rumor. The gameplay effect is related to the individual's age and educational background, while income and gender have no impact.

Developing critical thinking skills through gamification

Misinformation as well as the proliferation of fake news has been a problem during COVID-19 pandemic. This has affected many vulnerable communities in Brazil. The ability to understand and sort out pieces of reliable information and fake news has become a fundamental cognitive skill. In this study we report on the development of a serious game (a card-based role-playing game) using Brazilian folk heroes aimed to develop critical thinking skills to empower vulnerable communities affected by misinformation and fake news. Four groups located in the city of Goiânia (Brazil) participated in this research: one group of people experiencing homelessness; two groups of favela residents (one urban and one in the suburbs) and one group of recyclable material collectors from a cooperative. We gained entry and built trust with each of these groups and worked together for 10 months during the pandemic. We conducted participatory observations, individual interviews with each participant and discussed their daily interaction with information, specifically in the context of the covid-19 pandemic. The analyses of the observations and interview data gave us a glimpse of the communicative needs of the groups. Inserting players into a narrative where they can make decisions based on critical thinking and their own reflections on the pandemic was important for building knowledge and developing critical thinking in these communities. The nature of the game (interactive and cooperative) allowed participants to focus on problem-solving skills and group work. It encouraged them to use real-life knowledge and skills to solve the fictional problems presented by the narrative.

Development and evaluation of a virtual reality training for emergency treatment of shortness of breath based on frameworks for serious games

Background

Virtual reality (VR) can offer an innovative approach to providing training in emergency situations, especially in times of COVID-19. There is no risk of infection, and the procedure is scalable and resource-efficient. Nevertheless, the challenges and problems that can arise in the development of VR training are often unclear or underestimated. As an example, we present the evaluation of the feasibility of development of a VR training session for the treatment of dyspnoea. This is based on frameworks for serious games, and provides lessons learned. We evaluate the VR training session with respect to usability, satisfaction, as well as perceived effectiveness and workload of participants.

Methods

The VR training was developed using the established framework (Steps 1-4) for serious games of Verschueren et al. and Nicholson's RECIPE elements for meaningful gamification. Primary validation (Step 4) was performed at the University of Bern, Switzerland, in a pilot study without control group, with a convenience sample of medical students (n=16) and established measurement tools.

Results

The theoretical frameworks permitted guided development of the VR training session. Validation gave a median System Usability Scale of 80 (IQR 77.5-85); for the User Satisfaction Evaluation Questionnaire, the median score was 27 (IQR 26-28). After the VR training, there was a significant gain in the participants' confidence in treating a dyspnoeic patient (median pre-training 2 (IQR 2-3) vs. post-training 3 (IQR 3-3), p=0.016).Lessons learned include the need for involving medical experts, medical educators and technical experts at an equivalent level during the entire development process. Peer-teaching guidance for VR training was feasible.

Conclusion

The proposed frameworks can be valuable tools to guide the development and validation of scientifically founded VR training. The new VR training session is easy and satisfying to use and is effective - and is almost without motion sickness.

Games in Times of a Pandemic: Structured Overview of COVID-19 Serious Games

BACKGROUND

The COVID-19 pandemic introduced an urgent need for effective strategies to disseminate crucial knowledge and improve people's subjective well-being. Complementing more conventional approaches to knowledge dissemination, game-based interventions were developed to create awareness and educate people about the pandemic, hoping to change their attitudes and behavior.

OBJECTIVE

This study provided an overview and analysis of digital and analog game-based interventions in the context of the COVID-19 pandemic. As major pandemics and other large-scale disruptive events are expected to increase in frequency in the coming decades, this analysis aimed to inform the design, uptake, and effects of similar future interventions.

METHODS

From November 2021 to April 2022, Scopus, Google, and YouTube were searched for articles and videos describing COVID-19-themed game-based interventions. Information regarding authorship, year of development or launch, country of origin, license, deployment, genre or type, target audience, player interaction, in-game goal, and intended transfer effects was extracted. Information regarding intervention effectiveness was retrieved where possible.

RESULTS

A diverse assortment of 23 analog and 43 digital serious games was identified, approximately one-third of them (25/66, 38%) through scientific articles. Most of these games were developed by research institutions in 2020 (13/66, 20%) and originated in Europe and North America (38/66, 58%). A limited number (20/66, 30%) were tested on relatively small samples, using a diversity of research methods to assess the potential changes in participants' knowledge, attitudes, and behaviors as well as their gameplay experience. Although most of the evaluated games (11/20, 55%) effectively engaged and motivated the players, increased awareness, and improved their understanding of COVID-19-related issues, the games' success in influencing people's behavior was often unclear or limited.

CONCLUSIONS

To increase the impact of similar future interventions aimed at disseminating knowledge and influencing people's attitudes and behaviors during a large-scale crisis, some considerations are suggested. On the basis of the study results and informed by existing game theories, recommendations are made in relation to game development, deployment, and distribution; game users, design, and use; game design terminology; and effectiveness testing for serious games.

Survey of healthcare worker perceptions of changes in infection control and antimicrobial stewardship practices in India and South Africa during the COVID-19 pandemic

Objective

To identify perceptions and awareness of changes in infection prevention and control (IPC) and antimicrobial stewardship (AMS) practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA).

Method

A self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics.

Results

The study received 321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively, with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) involved in antimicrobial prescribing.Respondents reported increased IPC practices since the pandemic and noted a need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic, they did not generally associate their practice with such an increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents.

Conclusions

HCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Digital adaptation of teaching disaster and deployment medicine under COVID-19 conditions: a comparative evaluation over 5 years

BACKGROUND

The COVID-19 pandemic has not only brought many aspects of disaster medicine into everyday awareness but also led to a massive change in medical teaching due to the necessity of contact restrictions. This study aimed to evaluate student acceptance of a curricular elective module on disaster and deployment medicine over a 5-year period and to present content adjustments due to COVID-19 restrictions.

METHODS

Since 2016, 8 semesters of the curricular elective module took place in face-to-face teaching (pre-COVID-19 group). From the summer semester of 2020 to the summer semester of 2021, 3 semesters took place as online and hybrid courses (mid-COVID-19 group). Student attitudes and knowledge gains were measured using pretests, posttests, and final evaluations. These data were statistically compared across years, and new forms of teaching under COVID-19 conditions were examined in more detail.

RESULTS

A total of 189 students participated in the module from the summer semester of 2016 through the summer semester of 2021 (pre-COVID-19: n = 138; mid-COVID-19: n = 51). There was a high level of satisfaction with the module across all semesters, with no significant differences between the groups. There was also no significant difference between the two cohorts in terms of knowledge gain, which was always significant (p < 0.05). COVID-19 adaptations included online seminars using Microsoft Teams or Zoom, the interactive live-streaming of practical training components, and digital simulation games.

CONCLUSION

The high level of satisfaction and knowledge gained during the module did not change even under a digital redesign of the content offered. The curricular elective module was consistently evaluated positively by the students, and the adaptation to online teaching was well accepted. Experiences with digital forms of teaching should also be used after the COVID-19 pandemic to create digitally supported blended learning concepts in the field of deployment and disaster medicine and thus further promote the expansion of teaching in this important medical field.

New Resident Training Strategy Based on Gamification Techniques: An Escape Room on Sepsis in Children

AIM

Adapting "escape rooms" for educational purposes is an innovative teaching method. The aim of this study was to ascertain the degree of learning of the residents. A secondary objective was to determine their degree of satisfaction.

METHODS

A prospective, observational study took place in October 2019. A sepsis-based escape room was designed and carried out. A mix of paediatric medical residents and paediatric nursing residents were enrolled. A prior knowledge test was carried out, which was repeated right at the end of the escape room and then again three months later. Furthermore, all participants completed an anonymous post-study survey.

RESULTS

We enrolled 48 residents, 79.2% of whom were women. The mean score for the pre-escape room exam was 7.85/9 (SD 1.65), that for the post-escape room exam was 8.75/9 (SD 0.53), and for the exam three months later, it was 8.30/9 (SD 0.94). Among the participants, 18.8% did not manage to leave before the established 60 min time limit. The results of the satisfaction survey showed high participant satisfaction.

CONCLUSIONS

The escape room proved to be a valuable educational game that increased students' knowledge of sepsis management and showed a positive overall perceived value among the participants.

Willingness to share contacts in case of COVID-19 positivity–predictors of collaboration resistance in a nation-wide Italian survey

Background

The unwillingness to share contacts is one of the least explored aspects of the COVID-19 pandemic. Here we report the factors associated with resistance to collaborate on contact tracing, based on the results of a nation-wide survey conducted in Italy in January-March 2021.

Methods and findings

The repeated cross-sectional on-line survey was conducted among 7,513 respondents (mean age 45.7, 50.4% women) selected to represent the Italian adult population 18–70 years old. Two groups were defined based on the direct question response expressing (1) unwillingness or (2) willingness to share the names of individuals with whom respondents had contact. We selected 70% of participants (training data set) to produce several multivariable binomial generalized linear models and estimated the proportion of variation explained by the model by McFadden R2, and the model’s discriminatory ability by the index of concordance. Then, we have validated the regression models using the remaining 30% of respondents (testing data set), and identified the best performing model by removing the variables based on their impact on the Akaike information criterion and then evaluating the model predictive accuracy. We also performed a sensitivity analysis using principal component analysis.

Overall, 5.5% of the respondents indicated that in case of positive SARS-CoV-2 test they would not share contacts. Of note, this percentage varied from 0.8% to 46.5% depending on the answers to other survey questions. From the 139 questions included in the multivariable analysis, the initial model proposed 20 independent factors that were reduced to the 6 factors with only modest changes in the model performance. The 6-variables model demonstrated good performance in the training (c-index 0.85 and McFadden R2 criteria 0.25) and in the testing data set (93.3% accuracy, AUC 0.78, sensitivity 30.4% and specificity 97.4%). The most influential factors related to unwillingness to share contacts were the lack of intention to perform the test in case of contact with a COVID-19 positive individual (OR 5.60, 95% CI 4.14 to 7.58, in a fully adjusted multivariable analysis), disagreement that the government should be allowed to force people into self-isolation (OR 1.79, 95% CI 1.12 to 2.84), disagreement with the national vaccination schedule (OR 2.63, 95% CI 1.86 to 3.69), not following to the preventive anti-COVID measures (OR 3.23, 95% CI 1.85 to 5.59), the absence of people in the immediate social environment who have been infected with COVID-19 (1.66, 95% CI 1.24 to 2.21), as well as difficulties in finding or understanding the information about the infection or related recommendations. A limitation of this study is the under-representation of persons not participating in internet-based surveys and some vulnerable groups like homeless people, persons with disabilities or migrants.

Conclusions

Our analysis revealed several groups that expressed unwillingness to collaborate on contact tracing. The identified patterns may play a principal role not only in the COVID-19 epidemic but also be important for possible future public health threats, and appropriate interventions for their correction should be developed and ready for the implementation.

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).

Serious Games: A new Approach to Foster Information and Practices About Covid-19?

The current Covid-19 pandemic poses an unprecedented global challenge in the field of education and training. As we have seen, the lack of proper information about the virus and its transmission has forced the general population and healthcare workers to rapidly acquire knowledge and learn new practices. Clearly, a well-informed population is more likely to adopt the correct precautionary measures, thus reducing the transmission of the infection; likewise, properly educated healthcare workers are better equipped to manage the emergency. However, the need to maintain physical distancing has made it impossible to provide in-presence information and training. In this regard, new technologies have proved to be an invaluable resource by facilitating distance learning. Indeed, e-learning offers significant advantages because it does not require the physical presence of learners and teachers. This innovative method applied to serious games has been considered potentially effective in enabling rapid and large-scale dissemination of information and learning through content interactivity. We will review studies that have observed the development and use of serious games to foster information and practices about Covid-19 aimed at promoting behavioral changes in the population and the healthcare personnel involved on the front line.

Use of a Serious Game to Teach Infectious Disease Management in Medical School: Effectiveness and Transfer to a Clinical Examination

Purpose

Physicians of all specialties must be familiar with important principles of infectious diseases, but curricular time for this content is limited and clinical teaching requires considerable resources in terms of available patients and teachers. Serious games are scalable interventions that can help standardize teaching. This study assessed whether knowledge and skills acquired in a serious game translate to better performance in a clinical examination.

Methods

Fifth-year undergraduate medical students (n = 100) at Goettingen Medical School were randomized to three groups receiving different levels of exposure to virtual patients presenting with signs and symptoms of either infective endocarditis or community-acquired pneumonia in a serious game simulating an accident and emergency department. Student performance was assessed based on game logfiles and an objective standardized clinical examination (OSCE).

Results

Higher exposure to virtual patients in the serious game did not result in superior OSCE scores. However, there was good agreement between student performance in the OSCE and in game logfiles (r = 0.477, p = 0.005). An Item Response Theory analysis suggested that items from the serious game covered a wider range of ability, thus better differentiating between students within a given cohort.

Conclusion

Repeated exposure to virtual patients with infectious diseases in a serious game did not directly impact on exam performance but game logfiles might be good and resource-sparing indicators of student ability. One advantage of using serious games in medical education is standardized content, a lower inhibition threshold to learn, and a need of less staff time compared to small-group clinical teaching.

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

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

Nationwide Deployment of a Serious Game Designed to Improve COVID-19 Infection Prevention Practices in Switzerland: Prospective Web-Based Study

Background

Lassitude and a rather high degree of mistrust toward the authorities can make regular or overly constraining COVID-19 infection prevention and control campaigns inefficient and even counterproductive. Serious games provide an original, engaging, and potentially effective way of disseminating COVID-19 infection prevention and control guidelines. Escape COVID-19 is a serious game for teaching COVID-19 infection prevention and control practices that has previously been validated in a population of nursing home personnel.

Objective

We aimed to identify factors learned from playing the serious game Escape COVID-19 that facilitate or impede intentions of changing infection prevention and control behavior in a large and heterogeneous Swiss population.

Methods

This fully automated, prospective web-based study, compliant with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was conducted in all 3 main language regions of Switzerland. After creating an account on the platform, participants were asked to complete a short demographic questionnaire before accessing the serious game. The only incentive given to the potential participants was a course completion certificate, which participants obtained after completing the postgame questionnaire. The primary outcome was the proportion of participants who reported that they were willing to change their infection prevention and control behavior. Secondary outcomes were the infection prevention and control areas affected by this willingness and the presumed evolution in the use of specific personal protective equipment items. The elements associated with intention to change infection prevention and control behavior, or lack thereof, were also assessed. Other secondary outcomes were the subjective perceptions regarding length, difficulty, meaningfulness, and usefulness of the serious game; impression of engagement and boredom while playing the serious game; and willingness to recommend its use to friends or colleagues.

Results

From March 9 to June 9, 2021, a total of 3227 accounts were created on the platform, and 1104 participants (34.2%) completed the postgame questionnaire. Of the 1104 respondents, 509 respondents (46.1%) answered that they intended to change their infection prevention and control behavior after playing the game. Among the respondents who answered that they did not intend to change their behavior, 86.1% (512/595) answered that they already apply these guidelines. Participants who followed the German version were less likely to intend to change their infection prevention and control behavior (odds ratio [OR] 0.48, 95% CI 0.24-0.96; P=.04) and found the game less engaging (P<.001). Conversely, participants aged 53 years or older had stronger intentions of changing infection prevention and control behavior (OR 2.07, 95% CI 1.44-2.97; P<.001).

Conclusions

Escape COVID-19 is a useful tool to enhance correct infection prevention and control measures on a national scale, even after 2 COVID-19 pandemic waves; however, the serious game's impact was affected by language, age category, and previous educational training, and the game should be adapted to enhance its impact on specific populations.

Emerging simulation technologies in global craniofacial surgical training

The last few decades have seen an exponential growth in the development and adoption of novel technologies in medical and surgical training of residents globally. Simulation is an active and innovative teaching method, and can be achieved via physical or digital models. Simulation allows the learners to repeatedly practice without the risk of causing any error in an actual patient and enhance their surgical skills and efficiency. Simulation may also allow the clinical instructor to objectively test the ability of the trainee to carry out the clinical procedure competently and independently prior to trainee's completion of the program. This review aims to explore the role of emerging simulation technologies globally in craniofacial training of students and residents in improving their surgical knowledge and skills. These technologies include 3D printed biomodels, virtual and augmented reality, use of google glass, hololens and haptic feedback, surgical boot camps, serious games and escape games and how they can be implemented in low and middle income countries. Craniofacial surgical training methods will probably go through a sea change in the coming years, with the integration of these new technologies in the surgical curriculum, allowing learning in a safe environment with a virtual patient, through repeated exercise. In future, it may also be used as an assessment tool to perform any specific procedure, without putting the actual patient on risk. Although these new technologies are being enthusiastically welcomed by the young surgeons, they should only be used as an addition to the actual curriculum and not as a replacement to the conventional tools, as the mentor-mentee relationship can never be replaced by any technology.

The co.LAB Generic Framework for Collaborative Design of Serious Games: Development Study

Background

Serious games are increasingly used at all levels of education. However, research shows that serious games do not always fulfill all the targeted pedagogical objectives. Designing efficient and engaging serious games is a difficult and multidisciplinary process that requires a collaborative approach. Many design frameworks have been described, most of which are dedicated to the development of specific types of serious games and take the collaborative dimension into account only to a limited extent.

Objective

Our aim was to create a generic serious game design framework that could be adapted to all kinds of serious games and implemented in a collaborative web platform.

Methods

We combined the results of a literature review with our experience in serious game design and development to determine the basic building blocks of a collaborative design framework. We then organized these building blocks into categories and determined the features that a generic design framework should include. Finally, based on the paradigm of complex systems and systemic modelling, we created the co.LAB generic design framework and specifications to allow its implementation in a collaborative web platform.

Results

Based on a total of 10 existing design methodologies or frameworks, 23 building blocks were identified and represent the foundation of the co.LAB framework. These blocks were organized into 5 categories: “context and objectives,” “game design,” “mechanics,” “learning design,” and “assessment.” The arrangement by categories provides a structure that can be visualized in multiple and complementary ways. The classical view links game and learning design while other views offer project, systemic, and process visualizations. For the implementation of the co.LAB framework in a web platform, we propose to convert the building blocks into “cards.” Each card would constitute a collaborative working space for the design of the corresponding block. To make the framework adaptive, cards could be added, adapted, or removed according to the kind of serious game intended. Enhancing the visualization of relationships between cards should support a systemic implementation of the framework.

Conclusions

By offering a structured view of the fundamental design elements required to create serious games, the co.LAB framework can facilitate the design and development of such games by virtue of a collaborative, adaptive, and systemic approach. The different visualizations of the building blocks should allow for a shared understanding and a consistent approach throughout the design and development process. The implementation of the co.LAB framework in a collaborative web platform should now be performed and its actual usability and effectiveness tested.

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.

Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers

OBJECTIVES

To compile current published reports on nosocomial outbreaks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), evaluate the role of healthcare workers (HCWs) in transmission, and evaluate outbreak management practices.

METHODS

Narrative literature review.

SHORT CONCLUSION

The coronavirus disease 2019 (COVID-19) pandemic has placed a large burden on hospitals and healthcare providers worldwide, which increases the risk of nosocomial transmission and outbreaks to "non-COVID" patients or residents, who represent the highest-risk population in terms of mortality, as well as HCWs. To date, there are several reports on nosocomial outbreaks of SARS-CoV-2, and although the attack rate is variable, it can be as high as 60%, with high mortality. There is currently little evidence on transmission dynamics, particularly using genomic sequencing, and the role of HCWs in initiating or amplifying nosocomial outbreaks is not elucidated. There has been a paradigm shift in management practices of viral respiratory outbreaks, that includes widespread testing of patients (or residents) and HCWs, including asymptomatic individuals. These expanded testing criteria appear to be crucial in identifying and controlling outbreaks.

Impact of a Serious Game on the Intention to Change Infection Prevention and Control Practices in Nursing Homes During the COVID-19 Pandemic: Protocol for a Web-Based Randomized Controlled Trial

BACKGROUND

Nursing home residents are at high risk of complications and death due to COVID-19. Lack of resources, both human and material, amplifies the likelihood of contamination in these facilities where a single employee can contaminate dozens of residents and colleagues. Improving the dissemination of and adhesion to infection prevention and control (IPC) guidelines is therefore essential. Serious games have been shown to be effective in developing knowledge and in increasing engagement, and could motivate nursing home employees to change their IPC practices.

OBJECTIVE

Our aim is to assess the impact of "Escape COVID-19," a serious game designed to enhance knowledge and application of IPC procedures, on the intention of nursing home employees to change their IPC practices.

METHODS

We will carry out a web-based randomized controlled trial following the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) guidelines and incorporating relevant elements of CHERRIES (Checklist for Reporting Results of Internet E-Surveys). Participants will be randomized to either the control or the serious game (intervention) group. First, both groups will be asked to answer a questionnaire designed to gather demographic data and assess baseline knowledge. The control group will then receive a quick reminder of the current national guidelines and links to IPC guidelines for health care professionals, while the other group will play the game. Both groups will then have to answer a second questionnaire designed to assess their willingness to change their IPC practices after having followed their respective material. After completing this questionnaire, they will be granted access to the material presented to the group they were not assigned to and receive a course completion certificate. The primary outcome will be the proportion of participants willing to change their IPC practices according to group. Secondary outcomes will include the analysis of specific questions detailing the exact changes considered by the participants. Factors associated with participant willingness or reluctance to change behavior will also be assessed. Attrition will also be assessed at each stage of the study.

RESULTS

The study protocol has been presented to our regional ethics committee (Req-2020-01262), which issued a declaration of no objection as such projects do not fall within the scope of the Swiss federal law on human research. Data collection began on November 5, 2020, and should be completed by December 4, 2020.

CONCLUSIONS

This study should determine whether "Escape COVID-19," a serious game designed to improve compliance with COVID-19 safe practices, modifies the intention to follow IPC guidelines among nursing home employees.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25595.