Development, Usability, and Efficacy of a Serious Game to Help Patients Learn About Pain Management After Surgery: An Evaluation Study

Serious Gaming for Chemotherapy-Induced Nausea and Vomiting in Older Adults With Cancer: Protocol for a Randomized Clinical Trial

BACKGROUND

Older adults are at high risk for toxicity due to cancer treatment and increased risk for adverse events related to chemotherapy-induced nausea and vomiting (CINV). Unfortunately, older adults report multiple treatment-related symptoms but use few strategies to self-manage these symptoms due to erroneous beliefs related to the effectiveness of commonly taught self-management strategies. We developed a novel serious game, Managing at Home (MAH), to help older adults learn how to effectively self-manage CINV at home.

OBJECTIVE

This study has 2 aims. Aim 1 is to examine changes in CINV severity, self-management behaviors, functioning, quality of life, cognitive representation, and health care use within the intervention group from baseline (T1) to completion of the study (T6). Aim 2 is to determine the efficacy of the MAH intervention by comparing differences in primary outcomes (CINV severity and health care use) and secondary outcomes (self-management behaviors, functioning, and quality of life) between the intervention and control groups at each follow-up visit (T2-T6) and completion of the study (T6).

METHODS

This is a longitudinal randomized clinical trial. We will collect data from 500 older adults receiving cancer-related chemotherapy at baseline (T1) and at each treatment cycle until cycle 6 (T6). Participants will be enrolled if they are 60 years or older of age, are newly diagnosed with cancer, being treated with any chemotherapy agent with moderate or high emetic potential, are on a 2-, 3-, or 4-week treatment cycle, are proficient in English, and have a telephone. Previous diagnosis or treatment for cancer, end-stage disease with less than 6 months to live, and uncorrected visual or hearing impairment are exclusion criteria.

RESULTS

This study was funded in September 2022 and received institutional review board approval in October 2022. As of July 2023, the enrollment of participants is ongoing and currently has 130 enrolled participants. Data collection and analysis will be complete in 2027.

CONCLUSIONS

This study addresses self-management of CINV in older adults using an innovative serious game. The MAH intervention uses simulation and gaming technology to engage older adults in active learning in order to reframe erroneous perceptions about symptom self-management. If shown to be effective, it can easily be adapted to include other cancer-related symptoms or other chronic illnesses.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05838638; https://clinicaltrials.gov/study/NCT05838638.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64673.

Feasibility and acceptability of a serious game to study the effects of environmental distractors on emergency room nurse triage accuracy: A pilot study

BACKGROUND

Emergency triage, which involves complex decision-making under stress and time constraints, may suffer from inaccuracies due to workplace distractions. A serious game was developed to simulate the triage process and environment. A pilot study was undertaken to collect preliminary data on the effects of distractors on emergency nurse triage accuracy.

METHOD

A 2 × 2 factorial randomized controlled trial (RCT) was designed for the study. A sample of 70 emergency room nurses was randomly assigned to three experimental groups exposed to different distractors (noise, task interruptions, and both) and one control group. Nurses had two hours to complete a series of 20 clinical vignettes, in which they had to establish a chief complaint and assign an emergency level.

RESULTS

Fifty-five nurses completed approximately 15 vignettes each during the allotted time. No intergroup differences emerged in terms of triage performance. Nurses had a very favorable appreciation of the serious game focusing on triage.

CONCLUSION

The results show that both the structure of our study and the serious game can be used to carry out a future RCT on a larger scale. The lack of a distractor effect raises questions about the frequency and intensity required to find a significant impact on triage performance.

Efficacy of serious games for chronic pain management in older adults: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To synthesise and appraise the evidence of the efficacy of serious games in reducing chronic pain among older adults.

BACKGROUND

Chronic pain in older adults generally results in a substantial handicap due to decreased mobility, exercise avoidance and various concerns that affect their overall quality of life. While serious games have been widely used as a pain management approach, no reviews have thoroughly examined their efficacy for chronic pain management in older adult populations.

DESIGN

A systematic review and meta-analysis.

METHODS

The CINAHL, the Cochrane Library, Embase, Medline, PubMed and Web of Science databases were comprehensively searched to find articles published from their inception until 17 April 2023. RoB-2 was used to assess the risk of bias in the included studies. The efficacy of serious games for pain management in older individuals was investigated using pooled standardised mean differences (SMDs) in pain reduction using a random effect model.

RESULTS

The meta-analysis comprised nine randomised controlled trials that included 350 older adult patients with pain. Serious games effectively alleviated pain in this group (pooled SMD = -0.62; 95% confidence interval: -1.15 to -0.10), although pain-related disability and fear require further investigation.

CONCLUSIONS

Serious games tended to effectively reduce pain in this older adult group; however, due to a lack of randomised controlled trials, the analysis found lower effectiveness in reducing pain-related disability and fear. Further studies are accordingly required to confirm these findings.

RELEVANCE TO CLINICAL PRACTICE

The findings of the study emphasise the importance of serious games to increase the motivation of older adults to exercise as one of the safe and extensively used pain management strategies. Serious games that effectively reduce chronic pain in older adults are characterised as consisting of diverse physical activities delivered through consoles, computer-based activities and other technologies.

PATIENT OR PUBLIC CONTRIBUTIONS

Serious games are recommended as being potentially useful and practical for reducing pain in older adults.

Pain Management Mobile Applications: A Systematic Review of Commercial and Research Efforts

Shared decision making is crucial in the pain domain. The subjective nature of pain demands solutions that can facilitate pain assessment and management. The aim of the current study is to review the current trends in both the commercial and the research domains in order to reveal the key issues and guidelines that could further help in the effective development of pain-focused apps. We searched for scientific publications and commercial apps in 22 databases and the two major app stores. Out of 3612 articles and 336 apps, 69 met the requirements for inclusion following the PRISMA guidelines. An analysis of their features (technological approach, design methodology, evaluation strategy, and others) identified critical points that have to be taken into consideration in future efforts. For example, commercial and research efforts target different types of pain, while no participatory design is followed in the majority of the cases examined. Moreover, the evaluation of the final apps remains a challenge that hinders their success. The examined domain is expected to experience a substantial increase. More research is needed towards the development of non-intrusive wearables and sensors for pain detection and assessment, along with artificial intelligence techniques and open data.

The Internet Knows More Than My Doctor: A Qualitative Study of People with Rare Diseases and How They Use Online Support Groups (Preprint)

Background

Patients struggling with rare diseases may face challenges caused by care providers being unfamiliar with their condition. The life span of people with rare diseases may be the same as that of healthy people, but their quality of life is different. Patients with chronic pain are constantly looking for ways to mitigate their pain. Pain killers are not a permanent solution. In addition to the medical and nonmedical costs of rare diseases for both patients and health care providers, there is a need for sustainable sources of information that are available to help with pain and improve their quality of life, with the goal of reducing physician visits and hospital admissions.

Objective

This study investigated the challenges that patients with genetic disorders face in managing their health conditions and finding disease-related information as well as the effect of online peer support groups on pain mitigation and care management.

Methods

Interviews were conducted via Zoom between July 2021 and December 2021. Eligible participants were those who were aged >18 years, had a medical diagnosis of any type of Ehlers-Danlos syndrome (EDS) with chronic pain, and were members of any support group. Participants were recruited through an announcement in the research and survey section of The Ehlers-Danlos Syndrome Society web page. Interviews were analyzed using the framework approach. Data were systematically searched to identify patterns, analyze them, and identify themes. Interview audio files were transcribed and independently coded by two researchers (SA and AT). Through an iterative process, a final coding table was agreed upon by the researchers and used to thematically analyze the data.

Results

We interviewed 30 participants (mean age 37.7, SD 15 years; n=28, 93% were women; n=23, 77% were residing in the United States). Thematic analysis revealed that participants (patients with EDS) were constantly in pain and most of them have not received accurate and timely diagnoses for many years. They expressed their challenges with health care providers regarding diagnosis and treatment, and complained about their providers’ lack of support and knowledge. Participants’ main sources of information were web-based searches, academic journals, The Ehlers-Danlos Syndrome Society web page, and online peer support groups on Facebook, Reddit, Twitter, and Instagram. Although pain killers, cannabis, and opioids are providing some pain relief, most patients (28/30, 93%) focused on nonmedical approaches, such as hot or ice packs, physical therapy, exercises, massage, mindfulness, and meditation.

Conclusions

This study highlights the information gap between health care providers and patients with genetic disorders. Patients with EDS seek access to information from different web-based sources. To meet the needs of patients with genetic disorders, future interventions via web-based resources for improving the quality of care must be considered by health care professionals and government agencies.

Feasibility and Acceptability of 'VitaVillage': A Serious Game for Nutrition Education

Computer games have previously been used to improve nutrition knowledge in children. This paper describes the acceptability and feasibility of a serious game, "VitaVillage", for improving child nutrition knowledge. VitaVillage is a farming-style game in which the player undertakes quests and completes questions aimed at increasing several aspects of nutrition and healthy eating knowledge. Children aged 9-12 years in two primary schools (control vs. intervention) completed a nutrition knowledge questionnaire at baseline (T1) and after 1 week (T2). Participants at the intervention school (n = 75) played VitaVillage for 20 minutes on two occasions. Control participants (n = 94) received no nutrition education. Likeability question scores and written feedback from intervention participants was reported qualitatively. Paired sample t-tests were used to compare T1 and T2 nutrition knowledge changes between control and intervention participants. Engagement with VitaVillage improved children's overall nutrition knowledge (Mean increase of 2.25 points between T1 and T2, Standard Deviation (SD) 6.31, p = 0.035) compared to controls. The game was liked overall (mean score 77 (SD 24.6) on scale of 0-100) and positive feedback was given. Results indicate that VitaVillage has the potential to be successful as a nutrition education tool. In the future, VitaVillage's content and gameplay will be revised, extended and evaluated for its long-term impact on eating behaviour and knowledge changes.

Using a 360° Virtual Reality or 2D Video to Learn History Taking and Physical Examination Skills for Undergraduate Medical Students: Pilot Randomized Controlled Trial

BACKGROUND

Learning through a 360° virtual reality (VR) or 2D video represents an alternative way to learn a complex medical education task. However, there is currently no consensus on how best to assess the effects of different learning materials on cognitive load estimates, heart rate variability (HRV), outcomes, and experience in learning history taking and physical examination (H&P) skills.

OBJECTIVE

The aim of this study was to investigate how learning materials (ie, VR or 2D video) impact learning outcomes and experience through changes in cognitive load estimates and HRV for learning H&P skills.

METHODS

This pilot system-design study included 32 undergraduate medical students at an academic teaching hospital. The students were randomly assigned, with a 1:1 allocation, to a 360° VR video group or a 2D video group, matched by age, sex, and cognitive style. The contents of both videos were different with regard to visual angle and self-determination. Learning outcomes were evaluated using the Milestone reporting form. Subjective and objective cognitive loads were estimated using the Paas Cognitive Load Scale, the National Aeronautics and Space Administration Task Load Index, and secondary-task reaction time. Cardiac autonomic function was assessed using HRV measurements. Learning experience was assessed using the AttrakDiff2 questionnaire and qualitative feedback. Statistical significance was accepted at a two-sided P value of <.01.

RESULTS

All 32 participants received the intended intervention. The sample consisted of 20 (63%) males and 12 (38%) females, with a median age of 24 (IQR 23-25) years. The 360° VR video group seemed to have a higher Milestone level than the 2D video group (P=.04). The reaction time at the 10th minute in the 360° VR video group was significantly higher than that in the 2D video group (P<.001). Multiple logistic regression models of the overall cohort showed that the 360° VR video module was independently and positively associated with a reaction time at the 10th minute of ≥3.6 seconds (exp B=18.8, 95% CI 3.2-110.8; P=.001) and a Milestone level of ≥3 (exp B=15.0, 95% CI 2.3-99.6; P=.005). However, a reaction time at the 10th minute of ≥3.6 seconds was not related to a Milestone level of ≥3. A low-frequency to high-frequency ratio between the 5th and 10th minute of ≥1.43 seemed to be inversely associated with a hedonic stimulation score of ≥2.0 (exp B=0.14, 95% CI 0.03-0.68; P=.015) after adjusting for video module. The main qualitative feedback indicated that the 360° VR video module was fun but caused mild dizziness, whereas the 2D video module was easy to follow but tedious.

CONCLUSIONS

Our preliminary results showed that 360° VR video learning may be associated with a better Milestone level than 2D video learning, and that this did not seem to be related to cognitive load estimates or HRV indexes in the novice learners. Of note, an increase in sympathovagal balance may have been associated with a lower hedonic stimulation score, which may have met the learners' needs and prompted learning through the different video modules.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03501641; https://clinicaltrials.gov/ct2/show/NCT03501641.

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.

Gamifying health literacy: how can digital technology optimize patient outcomes in surgery?

The digital age is entrenched in our society, with constant innovation driving change in the way clinicians and patients manage their health concerns. Health literacy is emerging as an important modifiable factor that can affect clinical and patient outcomes, yet traditional forms of patient education have shown mixed results. Digital media and technologies, the concept of gamification as a means to improve patient health literacy, and its potential for misuse will be explored in this review, in the context of a digital, gamified tool that could support patients along their surgical journey.

Serious Game on a Smartphone for Adolescents Undergoing Hemodialysis: Development and Evaluation

Background

Adolescents with chronic kidney disease have a hard time adhering to hemodialysis as a therapy, indicating a need to establish new alternatives for motivation and adherence to treatment.

Objective

The objective of this study was to develop and evaluate a serious game to stimulate and motivate adolescents undergoing hemodialysis.

Methods

We describe the technological production followed by a qualitative analysis. We invited 8 adolescents undergoing hemodialysis in the city Goiânia, located in the midwest of Brazil, to participate. The final convenience sample included 7 (87.5% of the target population) adolescents. The process was conducted in 3 phases: creation of a serious game, evaluation of its use, and observation of its motivating effect on behavioral modification with a focus on acquiring the necessary competence for self-care.

Results

An app (Bim) in the modality of a serious game was developed to be used during hemodialysis; the player was encouraged to take care of a character with daily actions during his or her treatment. The game was made available to adolescents aged 10-14 years. Mobile devices were offered during the hemodialysis treatment for a period of 30-40 minutes, 3 times a week for 60 days. The usage definitions of the game were freely chosen by the participants. The qualitative evaluation of the use of the Bim app showed that it encompasses scenarios and activities that enable the exercise of daily actions for the treatment of patients. The behavioral evaluation showed that the Bim app worked as a motivating stimulus for behavioral adherence to hemodialysis requirements.

Conclusions

The easy-to-access app interface showed good operability for its users. The description of the character and proposed activities contributed to motivation and ability to cope with hemodialysis care.

Using Serious Games to Increase Prevention and Self-Management of Chemotherapy-Induced Nausea and Vomiting in Older Adults With Cancer

OBJECTIVES

To examine the frequency and types of preventive and self-management behaviors reported by participants, as well as report acceptability and usability data for the electronic Symptom Self-Management Training-Chemotherapy-Induced Nausea and Vomiting (CINV) serious game.

SAMPLE & SETTING

80 adults who were aged 60 years or older and newly diagnosed with cancer were recruited from a community cancer center.

METHODS & VARIABLES

Participants were randomized to an intervention or control group. A symptom management checklist was used to record preventive and self-management behaviors used after each chemotherapy treatment at home. Acceptability and usability were assessed using a brief survey.

RESULTS

The intervention group reported using more preventive behaviors, and the control group reported using more self-management behaviors. Antiemetics were the most common strategy used, followed by dietary strategies. Participants rated all aspects of the serious game highly for usability and acceptability.

IMPLICATIONS FOR NURSING

Oncology providers can help older adults plan for self-managing treatment-related side effects at home. Recording self-management behaviors may reinforce the importance of active prevention and management of CINV.

Serious Game e-Baby Família: an educational technology for premature infant care

OBJECTIVES

to develop and assess the serious game e-Baby Família with parents of premature infants.

METHODS

a methodological study regarding the development of the serious game, with participatory design in scope definition, starting from parents' learning needs about premature infant care. A qualitative approach was performed in the assessment stage with parents, with content analysis of the speech of the eight participants.

RESULTS

the following categories emerged: Realistic appearance of the virtual setting and game content and Gameplay implications for the use of e-Baby Família. The game was satisfactorily assessed regarding content, appearance and dynamics use, motivating participants to learn.

FINAL CONSIDERATIONS

in the context of prematurity as a public health problem in Brazil and the need to strengthen family health education for care, the serious game was assessed as motivating and appropriate for health learning.

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

Background

The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use.

Objective

This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use.

Methods

PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection.

Results

Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies.

Conclusions

Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives.

Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study

BACKGROUND

The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants' motivations to adopt these technologies.

OBJECTIVE

This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework.

METHODS

A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S₁-BrainGame, S₂-CarRace, and S₃-Exergame). Each session included an identical sequence of activities (t₁-Baseline, t₂-Picture encode, t₃-Play, t₄-Stroop test, t₅-Play, and t₆-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire.

RESULTS

Session×activity effects were significant on all ambulatory measures (χ²₁₀>20; P<.001) other than cortisol (P=.37). Compared with S₁ and S₂, S₃ was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S₁, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S₃. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (χ²₁>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group.

CONCLUSIONS

Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed.

Educational games developed for students in perioperative nursing: A systematic review and appraisal of the evidence

A systematic review was conducted on electronic databases of MEDLINE/PubMed, Scopus, ISI Web of Science, CINAHL, and Embase until December 2017, using relevant keywords for educational games developed for nursing students in perioperative field. To evaluate the level of strength and quality of the evidence, the Association of periOperative Registered Nurses (AORN) revised model for evidence appraisal was used. Of the 852 evidence, only 10 met the criteria and were reviewed and appraised. Educational games had focused on different learning domains, including skills, feelings, emotion, knowledge, performance, attitude, motivation, and interest. With respect to the evidence level, most evidence was categorized as V (expert opinion = 2, case report = 2, literature review = 1, and organizational experiences = 1), and only one was in level I (randomized controlled trial). The quality level of most evidence was high (n = 4) and low (n = 4), and the rating of most of them was moderate (n = 4) and limited (n = 4). Based on the findings, most evidence had inappropriate quality and was found to be weak. It seems that the investigated games are insufficient to promote the nursing students' learning outcomes in different domains. Accordingly, more high-quality studies are required to design and develop innovative and practical games for students in perioperative nursing by considering validity and reliability process.

Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights

Background

The idea of using serious games to effectuate better outcomes in health care has gained significant traction among a growing community of researchers, developers, and health care professionals. Many now recognize the importance of creating evidence-based games that are purposefully designed to address physical and mental health challenges faced by end users. To date, no regulatory resources have been established to guide the development of serious games for health (SGH). Developers must therefore look elsewhere for guidance. Although a more robust level of evidence exists in the research literature, it is neither structured nor is there any clear consensus. Developers currently use a variety of approaches and methodologies. The establishment of a well-defined framework that represents the consensus views of the SGH research community would help developers improve the efficiency of internal development processes, as well as chances of success. A consensus framework would also enhance the credibility of SGH and help provide quality evidence of their effectiveness.

Objective

This research aimed to (1) identify and evaluate the requirements, recommendations, and guidelines proposed by the SGH community in the research literature, and; (2) develop a consensus framework to guide developers, designers, researchers, and health care professionals in the development of evidence-based SGH.

Methods

A critical review of the literature was performed in October to November 2018. A 3-step search strategy and a predefined set of inclusion criteria were used to identify relevant articles in PubMed, ScienceDirect, Institute of Electrical and Electronics Engineers Xplore, CiteSeerX, and Google Scholar. A supplemental search of publications from regulatory authorities was conducted to capture their specific requirements. Three researchers independently evaluated the identified articles. The evidence was coded and categorized for analysis.

Results

This review identified 5 categories of high-level requirements and 20 low-level requirements suggested by the SGH community. These advocate a methodological approach that is multidisciplinary, iterative, and participatory. On the basis of the requirements identified, we propose a framework for developing theory-driven, evidence-based SGH. It comprises 5 stages that are informed by various stakeholders. It focuses on building strong scientific and design foundations that guide the creative and technical development. It includes quantitative trials to evaluate whether the SGH achieve the intended outcomes, as well as efforts to disseminate trial findings and follow-up monitoring after the SGH are rolled out for use.

Conclusions

This review resulted in the formulation of a framework for developing theory-driven, evidence-based SGH that represents many of the requirements set out by SGH stakeholders in the literature. It covers all aspects of the development process (scientific, technological, and design) and is transparently described in sufficient detail to allow SGH stakeholders to implement it in a wide variety of projects, irrespective of discipline, health care segments, or focus.

A Systematic Literature Review of the Design Approach and Usability Evaluation of the Pain Management Mobile Applications

The increasing popularity of mHealth is a promising opportunity for pain self-management. Mobile apps can be easily developed, but understanding the design and usability will result in apps that can retain more users. This research aims at identifying, analyzing, and synthesizing the current state-of-the-art of: (a) the design approach and (b) usability assessment of pain management mobile applications. A systematic literature review was conducted on 27 studies retrieved from Medline, PubMed, EMBASE, Web of Science, and Scopus. The review revealed that most of the apps were for chronic pain. No app was specifically for men or for the elderly. None of the studies involved expert-based system inspection methods. Only one study used two different approaches of automated and empirical evaluation. We mapped the identified usability issues to ISO 9241-11 and ISO/IEC 25010, and aggregated the recommendations for improvement. Moreover, we also identified certain issues that are solely concerned with the patient’s behavior. We organized the issues into taxonomies of design considerations for building usable pain self-management mobile applications. As pain is prevalent among the elderly, pain management will be much needed while moving toward an aging society. However, we found that the involvement of the elderly in the development of pain management mobile apps is very minimal, which may affect the utility and usability of the apps.

Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents

Background

Use of novel information and communication technologies are frequently discussed as promising tools to prevent and treat overweight and obesity in children and adolescents.

Objective

This survey aims to describe the preferences, motives, and needs of children and adolescents regarding nutrition and digital games.

Methods

We conducted a survey in 6 secondary schools in the southern region of Germany using a 43-item questionnaire. Questions referred to preferences, motives, and needs of children and adolescents regarding nutrition and digital games. In addition, knowledge regarding nutrition was assessed with 4 questions. We collected self-reported sociodemographic and anthropometric data. Descriptive statistical analyses were performed using SPSS.

Results

In total, 293 children and adolescents participated in the study, with ages 12-18 years (137 girls, 46.8%), weight 30.0-120.0 (mean 60.2 [SD 13.2]) kg, and height 1.4-2.0 (mean 1.7 [SD 0.1]) m. A total of 5.5% (16/290) correctly answered the 4 questions regarding nutrition knowledge. Study participants acquired digital nutritional information primarily from the internet (166/291, 57.0%) and television (97/291, 33.3%), while school education (161/291, 55.3%) and parents or other adults (209/291, 71.8%) were the most relevant nondigital information sources. Most participants (242/283, 85.5%) reported that they regularly play digital games. More than half (144/236, 61.0%) stated that they play digital games on a daily basis on their smartphones or tablets, and almost 70% (151/282, 66.5%) reported playing digital games for ≤30 minutes without any interruption. One-half of respondents (144/280, 51.4%) also stated that they were interested in receiving information about nutrition while playing digital games.

Conclusions

This survey suggests that nutrition knowledge in children and adolescents might be deficient. Most children and adolescents play digital games and express interest in acquiring nutritional information during digital gameplay. A digital game with a focus on sound nutrition could be a potential educational tool for imparting nutrition knowledge and promoting healthier nutrition behaviors in children and adolescents.

Cognitive Style and Mobile E-Learning in Emergent Otorhinolaryngology-Head and Neck Surgery Disorders for Millennial Undergraduate Medical Students: Randomized Controlled Trial

Background

Electronic learning (e-learning) through mobile technology represents a novel way to teach emergent otorhinolaryngology-head and neck surgery (ORL-HNS) disorders to undergraduate medical students. Whether a cognitive style of education combined with learning modules can impact learning outcomes and satisfaction in millennial medical students is unknown.

Objective

The aim of this study was to assess the impact of cognitive styles and learning modules using mobile e-learning on knowledge gain, competence gain, and satisfaction for emergent ORL-HNS disorders.

Methods

This randomized controlled trial included 60 undergraduate medical students who were novices in ORL-HNS at an academic teaching hospital. The cognitive style of the participants was assessed using the group embedded figures test. The students were randomly assigned (1:1) to a novel interactive multimedia (IM) group and conventional Microsoft PowerPoint show (PPS) group matched by age, sex, and cognitive style. The content for the gamified IM module was derived from and corresponded to the textbook-based learning material of the PPS module (video lectures). The participants were unblinded and used fully automated courseware containing the IM or PPS module on a 7-inch tablet for 100 min. Knowledge and competence were assessed using multiple-choice questions and multimedia situation tests, respectively. Each participant also rated their global satisfaction.

Results

All of the participants (median age 23 years, range 22-26 years; 36 males and 24 females) received the intended intervention after randomization. Overall, the participants had significant gains in knowledge (median 50%, interquartile range [IQR]=17%-80%, P<.001) and competence (median 13%, IQR=0%-33%, P=.006). There were no significant differences in knowledge gain (40%, IQR=13%-76% vs 60%, IQR=20%-100%, P=.42) and competence gain (0%, IQR= −21% to 38% vs 25%, IQR=0%-33%, P=.16) between the IM and PPS groups. However, the IM group had a higher satisfaction score (8, IQR=6-9 vs 6, IQR=4-7, P=.01) compared with the PPS group. Using Friedman’s two-way nonparametric analysis of variance, cognitive styles (field-independent, field-intermediate, or field-dependent classification) and learning modules (IM or PPS) had significant effects on both knowledge gain (both adjusted P<.001) and satisfaction (both adjusted P<.001).

Conclusions

Mobile e-learning is an effective modality to improve knowledge of emergent ORL-HNS in millennial undergraduate medical students. Our findings suggest the necessity of developing various modules for undergraduate medical students with different cognitive styles.

Trial Registration

Clinicaltrials.gov NCT02971735; https://clinicaltrials.gov/ct2/show/NCT02971735 (Archived by WebCite at http://www.webcitation.org/6waoOpCEV)