JMIR Publications

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  Serious Games for Health and Medicine

  Sep 13, 2018

  Investigating the Relationship Between Eye Movement and Brain Wave Activity Using Video Games: Pilot Study

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  • Chaoguang Wang  
  • Gino Yu  

  Abstract:

  Background: All eye movements are related in one way or another to our mental processes with lateral eye movements being associated with the different hemispheres of the brain. Eye movement techniques form the basis of eye movement desensitization and reprocessing therapy, wherein forced eye movements activate neurological pathways to treat the subject. Objective: The objective of our study was to examine the relationship between players' eye movements and their brain wave activities using a video game. Methods: We used similar eye movement techniques in the form of a video game called Lifeguard that could potentially stimulate different eye movement mode and create a more engaging experience for the user. By designing an experiment, we further explored the differences in electroencephalogram spectral power activity for the alpha, beta, theta, delta, and gamma frequency bands in Lifeguard and Tetris. Results: The game based on eye movement technologies resulted in decreased delta power and increased beta power, but significant difference between 2 games was not found. Conclusions: The applied uses of this research could mean that eye movement desensitization and reprocessing can be conducted in a more fun and engaging way through the use of gaming technology.

  • JMIR Serious Games 2018;6(3):e16

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  Serious Games for Health and Medicine

  Sep 10, 2018

  Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent...

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  Authors List:

  • Megan E Applegate  
  • Christopher R France  
  • David W Russ  
  • Samuel T Leitkam  
  • James S Thomas  

  Abstract:

  Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain.

  • JMIR Serious Games 2018;6(3):e10522

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  Serious Games for Health and Medicine

  Aug 24, 2018

  3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study

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  Authors List:

  • Guido Giunti  

  Abstract:

  Background: Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider. Objective: The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification. Methods: This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions. Results: The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process. Conclusions: This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.

  • JMIR Serious Games 2018;6(3):e11631

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  Serious Games for Education

  Aug 15, 2018

  The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation:...

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  • David Fernández-Ayuso  
  • Rosa Fernández-Ayuso  
  • Cristino Del-Campo-Cazallas  
  • José Luis Pérez-Olmo  
  • Borja Matías-Pompa  
  • Josué Fernández-Carnero  
  • Cesar Calvo-Lobo  

  Abstract:

  Background: High-fidelity simulation represents a primary tool in nursing education, especially when hands-on practical training is involved. Objective: We sought to determine the influence of high-fidelity clinical simulation, applied during cardiopulmonary resuscitation (CPR) training, on blood pressure, heart rate, stress, and anxiety levels in 2 groups of nursing students. One group had experience in health contexts, whereas the other group had none. Methods: We performed a quasi-experimental study. Data were collected between May and June 2015 and included measurements of all the resting values, before and after participation in CPR clinical simulations regarding the 2 groups of university students (ie, with and without experience). Results: An increase in vital signs was observed in students after participating in a clinical simulation scenario, especially the heart rate. In all students, increased stress and anxiety levels were observed before the first simulation case scenario. Also, in all study groups, a decrease in vital signs, stress levels, and anxiety was observed throughout the study. Conclusions: Participation in high-fidelity simulation experiences has both physiological and psychological effects on students.

  • JMIR Serious Games 2018;6(3):e11061

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  Serious Games for Health and Medicine

  Jul 26, 2018

  Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis

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  Authors List:

  • Sean Grant  
  • Asya Spears  
  • Eric R Pedersen  

  Abstract:

  Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population.

  • JMIR Serious Games 2018;6(3):e15

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  Serious Games for Health and Medicine

  Jul 6, 2018

  Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

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  Authors List:

  • Shaun W Jerdan  
  • Mark Grindle  
  • Hugo C van Woerden  
  • Maged N Kamel Boulos  

  Abstract:

  Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment.

  • JMIR Serious Games 2018;6(3):e14

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  Serious Games for Health and Medicine

  Jul 5, 2018

  Indigenous Adolescents’ Perception of an eMental Health Program (SPARX): Exploratory Qualitative Assessment

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  Authors List:

  • Matthew Shepherd  
  • Sally Merry  
  • Ian Lambie  
  • Andrew Thompson  

  Abstract:

  Background: Depression is a major health issue for indigenous adolescents, yet there is little research conducted about the efficacy and development of psychological interventions for these populations. In New Zealand there is little known about taitamariki (Māori adolescent) opinions regarding the development and effectiveness of psychological interventions, let alone computerized cognitive behavioral therapy. SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a computerized intervention developed in New Zealand to treat mild-to-moderate depression in young people. Users are engaged in a virtual 3D environment where they must complete missions to progress to the next level. In each level there are challenges and puzzles to completeIt was designed to appeal to all young people in New Zealand and incorporates several images and concepts that are specifically Māori. Objective: The aim was to conduct an exploratory qualitative study of Māori adolescents’ opinions about the SPARX program. This is a follow-up to an earlier study where taitamariki opinions were gathered to inform the design of a computerized cognitive behavior therapy program. Methods: Taitamariki were interviewed using a semistructured interview once they had completed work with the SPARX resource. Six participants agreed to complete the interview; the interviews ranged from 10 to 30 minutes. Results: Taitamariki participating in the interviews found SPARX to be helpful. The Māori designs from the SPARX game were appropriate and useful, and the ability to customize the SPARX characters with Māori designs was beneficial and appeared to enhance cultural identity. These helped young people to feel engaged with SPARX which, in turn, assisted with the acquisition of relaxation and cognitive restructuring skills. Overall, using SPARX led to improved mood and increased levels of hope for the participants. In some instances, SPARX was used by wider whānau (Māori word for family) members with reported beneficial effect. Conclusions: Overall, this small group of Māori adolescents reported that cultural designs made it easier for them to engage with SPARX, which, in turn, led to an improvement in their mood and gave them hope. Further research is needed about how SPARX could be best used to support the families of these young people.

  • JMIR Serious Games 2018;6(3):e13

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  Serious Games for Education

  Jul 4, 2018

  Web-Based Immersive Patient Simulator as a Curricular Tool for Objective Structured Clinical Examination Preparation in Surgery: Development and Evaluation

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  Authors List:

  • Seung-Hun Chon  
  • Sabrina Hilgers  
  • Ferdinand Timmermann  
  • Thomas Dratsch  
  • Patrick Sven Plum  
  • Felix Berlth  
  • Rabi Datta  
  • Hakan Alakus  
  • Hans Anton Schlößer  
  • Christoph Schramm  
  • Daniel Pinto dos Santos  
  • Christiane Bruns  
  • Robert Kleinert  

  Abstract:

  Background: Objective Structured Clinical Examination is a standard method of testing declarative and process knowledge in clinical core competencies. It is desirable that students undergo Objective Structured Clinical Examination training before participating in the exam. However, establishing Objective Structured Clinical Examination training is resource intensive and therefore there is often limited practice time. Web-based immersive patient simulators such as ALICE (Artificial Learning Interface of Clinical Education) can possibly fill this gap as they allow for the training of complex medical procedures at the user’s individual pace and with an adaptable number of repetitions at home. ALICE has previously been shown to positively influence knowledge gain and motivation. Objective: Therefore, the aim of this study was to develop a Web-based curriculum that teaches declarative and process knowledge and prepares students for a real Objective Structured Clinical Examination station. Furthermore, we wanted to test the influence of ALICE on knowledge gain and student motivation. Methods: A specific curriculum was developed in order to implement the relevant medical content of 2 surgical Objective Structured Clinical Examination stations into the ALICE simulator framework. A total of 160 medical students were included in the study, where 100 students had access to ALICE and their performance was compared to 60 students in a control group. The simulator performance was validated on different levels and students’ knowledge gain and motivation were tested at different points during the study. Results: The curriculum was developed according to the Kern cycle. Four virtual clinical cases were implemented with different teaching methods (structured feedback, keynote speech, group discussion, and debriefing by a real instructor) in order to consolidate declarative and process knowledge. Working with ALICE had significant impact on declarative knowledge gain and Objective Structured Clinical Examination performance. Simulator validation was positive for face, content, construct, and predictive validity. Students showed high levels of motivation and enjoyed working with ALICE. Conclusions: ALICE offers Web-based training for Objective Structured Clinical Examination preparation and can be used as a selective didactic intervention as it has positive effect on knowledge gain and student motivation.

  • JMIR Serious Games 2018;6(3):e10693

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  Serious Games for Health and Medicine

  Jun 12, 2018

  Physical Wellness Among Gaming Adults: Cross-Sectional Study

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  Authors List:

  • James Arnaez  
  • Georgia Frey  
  • Donetta Cothran  
  • Margaret Lion  
  • Andrea Chomistek  

  Abstract:

  Background: Video and hobby gaming are immensely popular among adults; however, associations between gaming and health have primarily been investigated in children and adolescents. Furthermore, most research has focused on electronic gaming, despite traditional hobby gaming gaining prominence. Objective: To determine whether the number of platforms used, platform preference, and gaming time are associated with obesity, physical activity, sedentary behavior, and cardiovascular risk factors in an adult gaming population. Methods: We conducted a cross-sectional analysis using data obtained from 292 participants who attended a large Midwestern gaming convention. We collected data using a computer-based questionnaire that comprised questions on gaming behavior, demographics, physical activity (using the International Physical Activity Questionnaire), and health characteristics. In addition, we used multivariable-adjusted linear and logistic regression to model health outcomes as a function of the number of platforms used, platform preference, and weekday and weekend gaming time quartile. Results: After adjusting for covariates, we observed a significant linear trend for increasing odds of being obese and higher weekend sitting time by the number of platforms used (P=.03 for both). The platform preference and weekend gaming time quartile exhibited significant associations with odds of meeting physical activity recommendations (P=.047 and P=.03, respectively). In addition, we observed higher odds of being obese among those reporting that they sat most or all of the time while gaming [odds ratio (OR) 2.69 (95% CI 1.14-6.31) and OR 2.71 (95% CI 1.06-6.93), respectively]. Conclusions: In adult gamers, the number of platforms used, which platforms they prefer to play on, and the amount of time spent gaming on weekends could have significant implications for their odds of being obese and meeting physical activity recommendations.

  • JMIR Serious Games 2018;6(2):e12

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  Serious Games for Health and Medicine

  Jun 7, 2018

  A Mobile Game to Support Smoking Cessation: Prototype Assessment

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  Authors List:

  • Bethany R Raiff  
  • Nicholas Fortugno  
  • Daniel R Scherlis  
  • Darion Rapoza  

  Abstract:

  Background: Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. Objective: We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. Methods: Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. Results: Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. Conclusions: This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit.

  • JMIR Serious Games 2018;6(2):e11

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  Serious Games for Health and Medicine

  May 23, 2018

  Training Working Memory in Adolescents Using Serious Game Elements: Pilot Randomized Controlled Trial

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  Authors List:

  • Wouter J Boendermaker  
  • Thomas E Gladwin  
  • Margot Peeters  
  • Pier J M Prins  
  • Reinout W Wiers  

  Abstract:

  Background: Working memory capacity has been found to be impaired in adolescents with various psychological problems, such as addictive behaviors. Training of working memory capacity can lead to significant behavioral improvements, but it is usually long and tedious, taxing participants’ motivation to train. Objective: This study aimed to evaluate whether adding game elements to the training could help improve adolescents’ motivation to train while improving cognition. Methods: A total of 84 high school students were allocated to a working memory capacity training, a gamified working memory capacity training, or a placebo condition. Working memory capacity, motivation to train, and drinking habits were assessed before and after training. Results: Self-reported evaluations did not show a self-reported preference for the game, but participants in the gamified working memory capacity training condition did train significantly longer. The game successfully increased motivation to train, but this effect faded over time. Working memory capacity increased equally in all conditions but did not lead to significantly lower drinking, which may be due to low drinking levels at baseline. Conclusions: We recommend that future studies attempt to prolong this motivational effect, as it appeared to fade over time.

  • JMIR Serious Games 2018;6(2):e10

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  Serious Games for Health and Medicine

  May 11, 2018

  Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study

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  Authors List:

  • Patrick Motz  
  • Megan Gray  
  • Taylor Sawyer  
  • Jennifer Kett  
  • Douglas Danforth  
  • Kellen Maicher  
  • Rachel Umoren  

  Abstract:

  Background: Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses.

  • JMIR Serious Games 2018;6(2):e8

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