JMIR Publications

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  Serious Games for Health and Medicine

  May 23, 2019

  A Motion-Activated Video Game for Prevention of Substance Use Disorder Relapse in Youth: Pilot Randomized Controlled Trial

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  Authors List:

  • Lorien C Abroms  
  • Marc Fishman  
  • Hoa Vo  
  • Shawn C Chiang  
  • Victoria Somerville  
  • Lawrence Rakhmanov  
  • Michael Ruggiero  
  • Daniel Greenberg  

  Abstract:

  Background: Body motion-activated video games are a promising strategy for promoting engagement in and adherence to addiction treatment among youth. Objective: This pilot randomized trial (N=80) investigated the feasibility of a body motion–activated video game prototype, Recovery Warrior 2.0, targeting relapse prevention in the context of a community inpatient care program for youth. Methods: Participants aged 15-25 years were recruited from an inpatient drug treatment program and randomized to receive treatment as usual (control) or game play with treatment as usual (intervention). Assessments were conducted at baseline, prior to discharge, and at 4 and 8 weeks postdischarge. Results: The provision of the game play intervention was found to be feasible in the inpatient setting. On an average, participants in the intervention group played for 36.6 minutes and on 3.6 different days. Participants in the intervention group mostly agreed that they would use the refusal skills taught by the game. Participants in the intervention group reported attending more outpatient counseling sessions than those in the control group (10.8 versus 4.8), but the difference was not significant (P=.32). The game had no effect on drug use at 4 or 8 weeks postdischarge, with the exception of a benefit reported at the 4-week follow-up among participants receiving treatment for marijuana addiction (P=.04). Conclusions: Preliminary evidence indicates that a motion-activated video game for addiction recovery appears to be feasible and acceptable for youth within the context of inpatient treatment, but not outpatient treatment. With further development, such games hold promise as a tool for the treatment of youth substance use disorder. Trial Registration: ClinicalTrials.gov NCT03957798; https://clinicaltrials.gov/show/NCT03957798 (Archived by WebCite at http://www.webcitation.org/78XU6ENB4)

  • JMIR Serious Games 2019;7(2):e11716

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  Games for Cognitive Assessment

  May 9, 2019

  Search and Match Task: Development of a Taskified Match-3 Puzzle Game to Assess and Practice Visual Search

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  Authors List:

  • Alvin Chesham  
  • Stephan Moreno Gerber  
  • Narayan Schütz  
  • Hugo Saner  
  • Klemens Gutbrod  
  • René Martin Müri  
  • Tobias Nef  
  • Prabitha Urwyler  

  Abstract:

  Background: Visual search declines with aging, dementia, and brain injury and is linked to limitations in everyday activities. Recent studies suggest that visual search can be improved with practice using computerized visual search tasks and puzzle video games. For practical use, it is important that visual search ability can be assessed and practiced in a controlled and adaptive way. However, commercial puzzle video games make it hard to control task difficulty, and there are little means to collect performance data. Objective: The aim of this study was to develop and initially validate the search and match task (SMT) that combines an enjoyable tile-matching match-3 puzzle video game with features of the visual search paradigm (taskified game). The SMT was designed as a single-target visual search task that allows control over task difficulty variables and collection of performance data. Methods: The SMT is played on a grid-based (width × height) puzzle board, filled with different types of colored polygons. A wide range of difficulty levels was generated by combinations of 3 task variables over a range from 4 to 8 including height and width of the puzzle board (set size) and the numbers of tile types (distractor heterogeneity). For each difficulty level, large numbers of playable trials were pregenerated using Python. Each trial consists of 4 consecutive puzzle boards, where the goal of the task is to find a target tile configuration (search) on the puzzle board and swap 2 adjacent tiles to create a line of 3 identical tiles (match). For each puzzle board, there is exactly 1 possible match (single target search). In a user study with 28 young adults (aged 18 to 31 years), 13 older (aged 64 to 79 years) and 11 oldest (aged 86 to 98 years) adults played the long (young and older adults) or short version (oldest adults) of the difficulty levels of the SMT. Participants rated their perception and the usability of the task and completed neuropsychological tests that measure cognitive domains engaged by the puzzle game. Results: Results from the user study indicate that the target search time is associated with set size, distractor heterogeneity, and age. Results further indicate that search performance is associated with general cognitive ability, selective and divided attention, visual search, and visuospatial and pattern recognition ability. Conclusions: Overall, this study shows that an everyday puzzle game–based task can be experimentally controlled, is enjoyable and user-friendly, and permits data collection to assess visual search and cognitive abilities. Further research is needed to evaluate the potential of the SMT game to assess and practice visual search ability in an enjoyable and adaptive way. A PsychoPy version of the SMT is freely available for researchers.

  • JMIR Serious Games 2019;7(2):e13620

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  Serious Games for Health and Medicine

  May 8, 2019

  An Interactive Mobile App Game to Address Aggression (RegnaTales): Pilot Quantitative Study

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  Authors List:

  • Jeffrey G Ong  
  • Nikki S Lim-Ashworth  
  • Yoon P Ooi  
  • Jillian S Boon  
  • Rebecca P Ang  
  • Dion H Goh  
  • Say H Ong  
  • Daniel S Fung  

  Abstract:

  Background: The rapid advancement in media technology has radically changed the way we learn and interact with one another. Games, with their engaging and interactive approach, hold promise in the delivery of knowledge and building of skills. This has potential in child and adolescent mental health work, where the lack of insight and motivation for therapy are major barriers to treatment. However, research on the use of serious games in mental health interventions for children and adolescents is still in its infancy. Objective: This study adds to the research on serious games in mental health interventions through the development and evaluation of RegnaTales, a series of 6 mobile apps designed to help children and adolescents manage anger. We examined the usability and playability of RegnaTales, as well as children’s aggression levels before and after the game play. Methods: A total of 72 children aged between 6 and 12 years were recruited for the study. Thirty-five participants had a clinical diagnosis of disruptive behavior disorders (DBD), whereas 37 were typically developing (TD) children. Each child played 1 of the 6 RegnaTales apps for approximately 50 min before completing the Playability and Usability Questionnaire. The Reactive-Proactive Aggression Questionnaire was completed before and after the game play. Results: The overall results showed high levels of enjoyment and playability. TD children and children with DBD had similar experienced fun and perceived playability scores on all 6 mobile apps. All 6 mobile apps garnered comparable experienced fun and perceived playability scores. Furthermore, 42% (5/12) to 67% (8/12) of the children indicated that they would like to play the games again. Importantly, children felt that they acquired skills in anger management, were motivated to use them in their daily lives, and felt confident that the skills would help them better manage their anger. Children reported significantly lower reactive aggression after playing the mobile apps Rage Raver (P=.001), Abaddon (P=.008), and RegnaTools (P=.03). These apps focused on the psychoeducation of the link between thoughts and emotions, as well as equipping the participants with various emotion regulation strategies such as relaxation and cognitive restructuring. Conclusions: This study presents evidence to support RegnaTales as a feasible serious game. The preliminary findings associated with reduction in reactive aggression, coupled with future research to further establish its efficacy, could warrant RegnaTales as a potential intervention for anger issues among clinical and community populations.

  • JMIR Serious Games 2019;7(2):e13242

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  Theoretical Foundations and...

  May 8, 2019

  Interactive Narrative in a Mobile Health Behavioral Intervention (Tumaini): Theoretical Grounding and Structure of a Smartphone Game to Prevent HIV Among...

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  Authors List:

  • Kate Winskell  
  • Gaëlle Sabben  
  • Christopher Obong'o  

  Abstract:

  The increasing availability of smartphones, including in low-income countries, offers an unprecedented opportunity to reach individuals with innovative health promotion interventions. Electronic games delivered via smartphone offer promising avenues for sexual health promotion and HIV prevention, especially for young people. By giving players real agency in a virtual and safe environment, well-designed games can provide a level of experiential learning unparalleled by many other behavioral interventions. The design of effective games for health relies on multidisciplinary insight and expertise. However, relatively few studies discuss the theoretical understanding underlying their intervention. Making explicit the theoretical grounding of a game-based intervention allows articulation of assumptions and strategies, anticipation of outcomes, and evaluation of impacts (including intermediate effects), thereby increasing understanding of pathways to change, with a view to contributing to the development of more effective games. It also helps strengthen the credibility and improve the accountability of games for health. We present the multidisciplinary theoretical framework—integrating intervention design, mediators, and behavioral outcomes—and the structure of an HIV prevention game for young African adolescents that has shown promise in a randomized pilot study in Western Kenya. The central component of Tumaini (hope for the future in Kiswahili) is an interactive role-playing narrative in which the player makes choices for characters that determine how their paths unfold. In addition, a series of mini-games reinforce skills, and the “My Story” component links the game world to the player’s own life and goals, and a reward system motivates continued play. With its “choose-your-own-adventure” format, Tumaini is intended to be replayed so that players can experience the consequences resulting from different choices made in the role-playing narrative. Grounded in theories of narrative and applied communication and in social behavioral theories, especially Social Cognitive Theory, Tumaini is designed to help young adolescents acquire the information, skills, and motivation they need to avoid and reduce sexual risks. We close by situating Tumaini within discussion of the theory and practice of using interactive narrative in health promotion, with a view to furthering theoretical elaboration.

  • JMIR Serious Games 2019;7(2):e13037

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  Viewpoints and Personal Experiences...

  May 7, 2019

  Do-It-Yourself Gamified Cognitive Training: Viewpoint

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  Authors List:

  • Sjors CF van de Weijer  
  • Mark L Kuijf  
  • Nienke M de Vries  
  • Bastiaan R Bloem  
  • Annelien A Duits  

  Abstract:

  Cognitive decline is an important nonmotor symptom in Parkinson disease (PD). Unfortunately, very few treatment options are available. Recent research pointed to small positive effects of nonpharmacological cognitive training in PD. Most of these trainings are performed under supervision and solely computerized versions of (traditional) paper-pencil cognitive training programs, lacking rewarding gamification stimulants that could help to promote adherence. By describing 3 different self-invented ways of cognitive gaming in patients with PD, we aimed to raise awareness for the potential of gamified cognitive training in PD patients. In addition, we hoped to inspire the readers with our case descriptions, highlighting the importance of both personalization and cocreation in the development of games for health. In this viewpoint, we have presented 3 PD patients with different ages, with different disease stages, and from various backgrounds, who all used self-invented cognitive training, including elements of personalization and gamification. To indicate generalization into a larger PD population, the recruitment results from a recent cognitive game trial are added. The presented cases show similarities in terms of awareness of their cognitive decline and the ways this process could potentially be counteracted, by looking for tools to train their cognition. On the basis of the response of the recruitment procedure, there seems to be interest in gamified cognitive training in a larger PD population too. Gamification may add to traditional therapies in terms of personalization and adherence. Positive results have already been found with gamified trainings in other populations, and the cases described here suggest that PD is also an attractive area to develop and test gamified cognitive trainings. However, no results of gamified cognitive trainings in PD have been published to date. This suggests an unmet need in this area and may justify the development of gamified cognitive training and its evaluation, for which our considerations can be used.

  • JMIR Serious Games 2019;7(2):e12130

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  Serious Games for Health and Medicine

  May 2, 2019

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

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  Authors List:

  • Sarah Verschueren  
  • Connor Buffel  
  • Geert Vander Stichele  

  Abstract:

  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.

  • JMIR Serious Games 2019;7(2):e11565

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  Games for Medical Education and Training

  May 1, 2019

  Comparing the Effects on Learning Outcomes of Tablet-Based and Virtual Reality–Based Serious Gaming Modules for Basic Life Support Training: Randomized Trial

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  Authors List:

  • Emin Aksoy  

  Abstract:

  Background: Serious gaming is recognized as a training tool due its potential for a risk-free educational environment. There is still limited research about using serious gaming modules for emergency skills training. Objective: The aim of this study is to compare the effects on the knowledge level of participants after using a tablet-based serious game and a virtual reality (VR)–based serious game for Basic Life Support using a pretest/posttest method. Methods: The study was designed as a randomized trial comparing pretest and posttest results. A tablet-based and VR-based serious game with identical content was used for 40 participants. Over half of them (22/40, 55%) were included in the VR group and just under half (18/40, 45%) were in the tablet group. Student t test and Wilcoxon signed rank tests were used to determine the relation between the dependent and independent variables. In order to determine the effect size of the results, the effect size calculator (Cohen d) for t test was used. There is a significant difference between pre- and posttest results in both groups (P=.001; Wilcoxon). Results: Mean posttest results were significantly higher in both groups. The posttest results were significantly higher in the VR group in terms of pre- and posttest changes (P=.021; Student t test). Conclusions: Past research studies have shown that serious gaming presents a favorable additional tool for medical education. The results indicate that both serious gaming modules are effective and that VR-based serious gaming is more efficient in terms of learning outcome than tablet-based gaming.

  • JMIR Serious Games 2019;7(2):e13442

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  Games for Medical Education and Training

  May 1, 2019

  Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial

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  Authors List:

  • Florian Ebner  
  • Amelie De Gregorio  
  • Fabienne Schochter  
  • Inga Bekes  
  • Wolfgang Janni  
  • Krisztian Lato  

  Abstract:

  Background: Medical education is evolving from "learning by doing" to simulation-based hands-on tutorials. Objective: The aim of this prospective 2-armed study was to evaluate a newly developed augmented reality ultrasound app and its effect on educational training and diagnostic accuracy. Methods: We recruited 66 medical students and, using imaging and measuring a kidney as quality indicators, tested them on the time they needed for these tasks. Both groups used textbooks as preparation; in addition, the study group had access to a virtual ultrasound simulation app for mobile devices. Results: There was no significant difference between the study arms regarding age (P=.97), sex (P=.14), and previous ultrasound experience (P=.66). The time needed to complete the kidney measurements also did not differ significantly (P=.26). However, the results of the longitudinal kidney measurements differed significantly between the study and control groups, with larger, more realistic values in the study group (right kidney: study group median 105.3 mm, range 86.1-127.1 mm, control group median 92 mm, range 50.4-112.2 mm; P<.001; left kidney: study group median 100.3 mm, range 81.7-118.6 mm, control group median 85.3 mm, range 48.3-113.4 mm; P<.001). Furthermore, whereas all students of the study group obtained valid measurements, students of the control group did not obtain valid measurements of 1 or both kidneys in 7 cases. Conclusions: The newly developed augmented reality ultrasound simulator mobile app provides a useful add-on for ultrasound education and training. Our results indicate that medical students’ use of the mobile app for training purposes improved the quality of kidney measurements.

  • JMIR Serious Games 2019;7(2):e12713

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  Formative Evaluation and Development...

  Apr 16, 2019

  Acceptability of a Plasticity-Focused Serious Game Intervention for Posttraumatic Stress Disorder: User Requirements Analysis

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  Authors List:

  • Matthew Jones  
  • Alena Denisova  
  • Stephen Mitchell  
  • Tom Owen  

  Abstract:

  Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention. Objective: The aim of this study was to assess the acceptability of a mobile phone–delivered plasticity-focused serious game to improve response to TF-CBT for PTSD, and carry out a user requirements analysis should the development of a prototype be warranted. Methods: We conducted 2 one-to-one interviews (n=2), one focus group involving service users who had received a diagnosis of PTSD (n=3) and one focus group involving psychological trauma service clinicians (n=4). Results: We found that the concept of a plasticity-focused mobile phone intervention for PTSD is acceptable to patients and clinicians. Service users and clinicians both believed that the usage should be guided by a therapist, and both contributed useful inputs regarding the audiovisual aspects of the proposed serious game. It was accepted that the game would not be suitable for all patients and that clinicians would need to appropriately prescribe the usage of the game. Conclusions: The findings highlight the acceptability of the proposed serious game and clarify the user requirements for such an intervention. It is the intention of the authors to carry out a user experience evaluation using a prototype serious game in a clinical population.

  • JMIR Serious Games 2019;7(2):e11909

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  Games for Medical Education and Training

  Apr 9, 2019

  What Can Be Achieved With Motivation-Based Teaching of Medical Students? A Monocentric Retrospective Audit of Retention Among Highly Motivated Graduates Who...

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  Authors List:

  • Martina Klincova  
  • Hana Harazim  
  • Daniel Schwarz  
  • Martina Kosinova  
  • Olga Smekalova  
  • Petr Stourac  

  Abstract:

  Background: Medical education, in general, is undergoing a significant shift from traditional methods. It becomes very difficult to discover effective teaching methods within the limited possibilities in patient hands-on education, especially as seen in anesthesiology and intensive care medicine (AIM) teaching. Motivation-based teaching is very popular in all other aspects of education, but it has received scant attention in medical education literature, even though it can make a real difference for both students and physicians. Objective: The primary aim of this retrospective audit was to find out if proper motivation-based teaching of students via the development of AKUTNE.CZ’s serious games can help retain graduates of the Faculty of Medicine of Masaryk University (FMMU) for the AIM specialty. Methods: Motivation-based teaching and the learning-by-doing concept were applied to a subject called Individual Project. Our topic, The Development of the Multimedia Educational Portal, AKUTNE.CZ, has been offered since 2010. The objective has been the development of supportive material in the form of interactive algorithms, serious games, and virtual patients for problem-based learning or team-based learning lectures aimed at acute medicine. We performed a retrospective questionnaire evaluation of all participants from the 2010-2017 period, focusing on their choice of medical specialty in 2017. The data were reported descriptively. Results: We evaluated 142 students who passed Individual Project with topic The Development of the Multimedia Educational Portal, AKUTNE.CZ during 2010 to 2017. In this period, they developed up to 77 electronic serious games in the form of interactive multimedia algorithms. Out of 139 students in general medicine, 108 students (77.7%) had already graduated and 37 graduates (34.3%) worked in the AIM specialty. Furthermore, 57 graduates (52.8%) chose the same specialty after graduation, matching the topic of their algorithm, and 37 (65%) of these graduates decided to pursue AIM. Conclusions: Motivation-based teaching and the concept of learning-by-doing by the algorithm/serious game development led to the significant retention of FMMU graduates in the AIM specialty. This concept could be considered successful, and as the concept itself can also be well integrated into the teaching of other medical specialties, the potential of motivation-based teaching should be used more broadly within medical education.

  • JMIR Serious Games 2019;7(2):e10155

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  Serious Games for Health and Medicine

  Apr 8, 2019

  FightHPV: Design and Evaluation of a Mobile Game to Raise Awareness About Human Papillomavirus and Nudge People to Take Action Against Cervical Cancer

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  Authors List:

  • Tomás Ruiz-López  
  • Sagar Sen  
  • Elisabeth Jakobsen  
  • Ameli Tropé  
  • Philip E Castle  
  • Bo Terning Hansen  
  • Mari Nygård  

  Abstract:

  Background: Human papillomavirus (HPV) is the most common sexually transmitted infection globally. High-risk HPV types can cause cervical cancer, other anogenital cancer, and oropharyngeal cancer; low-risk HPV types can cause genital warts. Cervical cancer is highly preventable through HPV vaccination and screening; however, a lack of awareness and knowledge of HPV and these preventive strategies represents an important barrier to reducing the burden of the disease. The rapid development and widespread use of mobile technologies in the last few years present an opportunity to overcome this lack of knowledge and create new, effective, and modern health communication strategies. Objective: This study aimed to describe the development of a mobile app called FightHPV, a game-based learning tool that educates mobile technology users about HPV, the disease risks associated with HPV infection, and existing preventive methods. Methods: The first version of FightHPV was improved in a design-development-evaluation loop, which incorporated feedback from a beta testing study of 40 participants, a first focus group of 6 participants aged between 40 and 50 years and a second focus group of 23 participants aged between 16 and 18 years. Gameplay data from the beta testing study were collected using Google Analytics (Google), whereas feedback from focus groups was evaluated qualitatively. Of the 29 focus group participants, 26 returned self-administered questionnaires. HPV knowledge before and after playing the game was evaluated in the 22 participants from the second focus group who returned a questionnaire. Results: FightHPV communicates concepts about HPV, associated diseases and their prevention by representing relationships among 14 characters in 6 episodes of 10 levels each, with each level being represented by a puzzle. Main concepts were reinforced with text explanations. Beta testing revealed that many players either failed or had to retry several times before succeeding at the more difficult levels in the game. It also revealed that players gave up at around level 47 of 60, which prompted the redesign of FightHPV to increase accessibility to all episodes. Focus group discussions led to several improvements in the user experience and dissemination of health information in the game, such as making all episodes available from the beginning of the game and rewriting the information in a more appealing way. Among the 26 focus group participants who returned a questionnaire, all stated that FightHPV is an appealing educational tool, 69% (18/26) reported that they liked the game, and 81% (21/26) stated that the game was challenging. We observed an increase in HPV knowledge after playing the game (P=.001). Conclusions: FightHPV was easy to access, use, and it increased awareness about HPV infection, its consequences, and preventive measures. FightHPV can be used to educate people to take action against HPV and cervical cancer.

  • JMIR Serious Games 2019;7(2):e8540

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  Serious Games for Health and Medicine

  Mar 27, 2019

  Exploring Efficacy of a Serious Game (Tobbstop) for Smoking Cessation During Pregnancy: Randomized Controlled Trial

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  Authors List:

  • Francesc X Marin-Gomez  
  • Rocio Garcia-Moreno Marchán  
  • Anabel Mayos-Fernandez  
  • Gemma Flores-Mateo  
  • Esther Granado-Font  
  • Maria Luisa Barrera Uriarte  
  • Jordi Duch  
  • Cristina Rey-Reñones  

  Abstract:

  Background: Tobacco use during pregnancy entails a serious risk to the mother and harmful effects on the development of the child. Europe has the highest tobacco smoking prevalence (19.3%) compared with the 6.8% global mean. Between 20% to 30% of pregnant women used tobacco during pregnancy worldwide. These data emphasize the urgent need for community education and implementation of prevention strategies focused on the risks associated with tobacco use during pregnancy. Objective: The aim of this study was to investigate the efficacy of an intervention that incorporates a serious game (Tobbstop) to help pregnant smokers quit smoking. Methods: A two-arm randomized controlled trial enrolled 42 women who visited 2 primary care centers in Catalonia, Spain, between March 2015 and November 2016. All participants were pregnant smokers, above 18 years old, attending consultation with a midwife during the first trimester of pregnancy, and had expressed their desire to stop smoking. Participants were randomized to the intervention (n=21) or control group (n=21). The intervention group was instructed to install the game on their mobile phone or tablet and use it for 3 months. Until delivery, all the participants were assessed on their stage of smoking cessation during their follow-up midwife consultations. The primary outcome was continuous tobacco abstinence until delivery confirmed by the amount of carbon monoxide at each visit, measured with a carboxymeter. Results: Continuous abstinence until delivery outcome was 57% (12/21) in the intervention group versus 14% (3/21) in the control group (hazard ratio=4.31; 95% CI 1.87-9.97; P=.001). The mean of total days without smoking until delivery was higher in the intervention group (mean 139.75, SD 21.76) compared with the control group (mean 33.28, SD 13.27; P<.001). In addition, a Kapplan-Meier survival analysis showed that intervention group has a higher abstinence rate compared with the control group (log-rank test, χ21=13.91; P<.001). Conclusions: Serious game use is associated with an increased likelihood to maintain abstinence during the intervention period if compared with those not using the game. Pregnancy is an ideal opportunity to intervene and control tobacco use among future mothers. On the other hand, serious games are an emerging technology, growing in importance, which are shown to be a good tool to help quitting smoking during pregnancy and also to maintain this abstinent behavior. However, because of the study design limitations, these outcomes should be interpreted with caution. More research, using larger samples and longer follow-up periods, is needed to replicate the findings of this study. Trial Registration: ClinicalTrials.gov NCT01734421; https://clinicaltrials.gov/ct2/show/NCT01734421 (Archived by WebCite at http://www.webcitation.org/75ISc59pB)

  • JMIR Serious Games 2019;7(1):e12835

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