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Journal Description

JMIR Serious Games (JSG, ISSN 2291-9279; Impact Factor: 3.53) is a multidisciplinary journal devoted to computer/web/virtual reality/mobile applications that incorporate elements of gaming, gamification or novel hardware platforms such as virtual reality headsets or Microsoft Kinect to solve serious problems such as health behavior change, physical exercise promotion (exergaming), medical rehabilitation, diagnosis and treatment of psychological/psychiatric disorders, medical education, health promotion, teaching and education, or social change. The journal also considers commentary and research in the fields of video games violence and video games addiction.

The journal is indexed in PubMed, PubMed Central, DOAJ, and SCIE/Web of Science, and JCR (Journal Citation Reports) where it received an official impact factor by Clarivate. In June 2020, JSG received an impact factor of 3.53.  


Recent Articles:

  • Source:; Copyright: Bermix Studio; URL:; License: Licensed by JMIR.

    A Primer on Usability Assessment Approaches for Health-Related Applications of Virtual Reality


    Health-related virtual reality (VR) applications for patient treatment, rehabilitation, and medical professional training are on the rise. However, there is little guidance on how to select and perform usability evaluations for VR health interventions compared to the supports that exist for other digital health technologies. The purpose of this viewpoint paper is to present an introductory summary of various usability testing approaches or methods that can be used for VR applications. Along with an overview of each, a list of resources is provided for readers to obtain additionally relevant information. Six categories of VR usability evaluations are described using a previously developed classification taxonomy specific to VR environments: (1) cognitive or task walkthrough, (2) graphical evaluation, (3) post hoc questionnaires or interviews, (4) physical performance evaluation, (5) user interface evaluation, and (6) heuristic evaluation. Given the growth of VR in health care, rigorous evaluation and usability testing is crucial in the development and implementation of novel VR interventions. The approaches outlined in this paper provide a starting point for conducting usability assessments for health-related VR applications; however, there is a need to also move beyond these to adopt those from the gaming industry, where assessments for both usability and user experience are routinely conducted.

  • Riding on a ski simulator with virtual reality (VR) content. Source: Image created by the author (Hyo Taek Lee); Copyright: Hyo Taek Lee; URL:; License: Creative Commons Attribution (CC-BY).

    Effects of Virtual Reality and Non–Virtual Reality Exercises on the Exercise Capacity and Concentration of Users in a Ski Exergame: Comparative Study


    Background: Recently, ski exergames have been gaining popularity due to the growing interest in health improvement. Conventional studies evaluating the effects of ski exergames only considered exercise capacity and overlooked concentration. Ski exergames consist of a motion platform for exercise and virtual reality (VR) content in the game. The VR content enhances the exercise capacity and concentration of the user by providing a challenging goal. Objective: The aim of this study is to evaluate the effects of VR and non-VR exercises on the exercise capacity and concentration of users in a ski exergame. Methods: To examine the effects of the VR content in ski exergames, we performed 2 experiments, non-VR exercise and VR exercise, where participants exercised on the motion platform. If a user performs an exercise without using any VR content, it is a non-VR exercise. Contrastingly, in the case of VR exercise, a user exercises according to the VR content (a downhill scenario). In addition to the range of motion (ROM) of the ankle and rated perceived exertion (RPE) to assess exercise capacity, we used electroencephalography (EEG) to assess users’ concentration. Results: We evaluated the effects of the VR content by comparing the results obtained from VR and non-VR exercises. The ROM of the ankle with VR exercise was wider than that with non-VR exercise. Specifically, ROM of the ankle was 115.71° (SD 17.71°) and 78.50° (SD 20.43°) in VR exercise and non-VR exercise, respectively. The RPE difference between the 2 exercises was not statistically significant. The result of the sensorimotor rhythm waves (which are concentration-related EEG signals) was more favorable for VR exercise than non-VR exercise. The ratios of sensorimotor rhythm wave in EEG were 3.08% and 2.70% in the VR exercise and non-VR exercise, respectively. Conclusions: According to the results of this experiment, higher exercise capability and concentration were achieved with the VR exercise compared with non-VR exercise. The observations confirm that VR content can enhance both exercise capability and concentration of the user. Thus, the ski exergames can be used effectively by those who, in general, do not like exercise but enjoy games.

  • A surgical resident is training using SIMISGEST-VR. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Use of a Low-Cost Portable 3D Virtual Reality Simulator for Psychomotor Skill Training in Minimally Invasive Surgery: Task Metrics and Score Validity


    Background: The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery. Objective: The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality). Methods: In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability. Results: Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures. Conclusions: The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery.

  • Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Tablet App for Handwriting Skill Screening at the Preliteracy Stage: Instrument Validation Study


    Background: Difficulties in handwriting, such as dysgraphia, impact several aspects of a child’s everyday life. Current methodologies for the detection of such difficulties in children have the following three main weaknesses: (1) they are prone to subjective evaluation; (2) they can be administered only when handwriting is mastered, thus delaying the diagnosis and the possible adoption of countermeasures; and (3) they are not always easily accessible to the entire community. Objective: This work aims at developing a solution able to: (1) quantitatively measure handwriting features whose alteration is typically seen in children with dysgraphia; (2) enable their study in a preliteracy population; and (3) leverage a standard consumer technology to increase the accessibility of both early screening and longitudinal monitoring of handwriting difficulties. Methods: We designed and developed a novel tablet-based app Play Draw Write to assess potential markers of dysgraphia through the quantification of the following three key handwriting laws: isochrony, homothety, and speed-accuracy tradeoff. To extend such an approach to a preliteracy age, the app includes the study of the laws in terms of both word writing and symbol drawing. The app was tested among healthy children with mastered handwriting (third graders) and those at a preliterate age (kindergartners). Results: App testing in 15 primary school children confirmed that the three laws hold on the tablet surface when both writing words and drawing symbols. We found significant speed modulation according to size (P<.001), no relevant changes to fraction time for 67 out of 70 comparisons, and significant regression between movement time and index of difficulty for 44 out of 45 comparisons (P<.05, R2>0.28, 12 degrees of freedom). Importantly, the three laws were verified on symbols among 19 kindergartners. Results from the speed-accuracy exercise showed a significant evolution with age of the global movement time (circle: P=.003, square: P<.001, word: P=.001), the goodness of fit of the regression between movement time and accuracy constraints (square: P<.001, circle: P=.02), and the index of performance (square: P<.001). Our findings show that homothety, isochrony, and speed-accuracy tradeoff principles are present in children even before handwriting acquisition; however, some handwriting-related skills are partially refined with age. Conclusions: The designed app represents a promising solution for the screening of handwriting difficulties, since it allows (1) anticipation of the detection of alteration of handwriting principles at a preliteracy age and (2) provision of broader access to the monitoring of handwriting principles. Such a solution potentially enables the selective strengthening of lacking abilities before they exacerbate and affect the child’s whole life.

  • The figure represents a nursing professional holding a baby, from the main menu of the virtual learning environment. Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Web-Based Virtual Learning Environment for Medicine Administration in Pediatrics and Neonatology: Content Evaluation


    Background: Worldwide, patient safety has been a widely discussed topic and has currently become one of the greatest challenges for health institutions. This concern is heightened when referring to children. Objective: The goal of this study was to develop a virtual learning environment for medication administration, as a tool to facilitate the training process of undergraduate nursing students. Methods: Descriptive research and methodological development with a quantitative and qualitative approach were used with stages of design-based research as methodological strategies. For the development of the virtual environment, 5 themes were selected: rights of medication administration, medication administration steps, medication administration routes, medication calculation, and nonpharmacological actions for pain relief. After development, 2 groups—expert judges in the field of pediatrics and neonatology for environment validation and undergraduate nursing students for the assessment—were used to assess the virtual learning environment. For the validation of the virtual learning environment by expert judges, the content validity index was used, and for the evaluation of the students, the percentage of agreement was calculated. Results: The study included 13 experts who positively validated the virtual environment with a content validity index of 0.97, and 26 students who considered the content suitable for nursing students, although some adjustments are necessary. Conclusions: The results show the benefit of the virtual learning environment to the training of nursing students and professional nurses who work in health care. It is an effective educational tool for teaching medication administration in pediatrics and neonatology and converges with the conjectures of active methodologies.

  • Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Cognitive Training Using Fully Immersive, Enriched Environment Virtual Reality for Patients With Mild Cognitive Impairment and Mild Dementia: Feasibility and...


    Background: Cognitive training using virtual reality (VR) may result in motivational and playful training for patients with mild cognitive impairment and mild dementia. Fully immersive VR sets patients free from external interference and thus encourages patients with cognitive impairment to maintain selective attention. The enriched environment, which refers to a rich and stimulating environment, has a positive effect on cognitive function and mood. Objective: The aim of this study was to investigate the feasibility and usability of cognitive training using fully immersive VR programs in enriched environments with physiatrists, occupational therapists (OTs), and patients with mild cognitive impairment and mild dementia. Methods: The VR interface system consisted of a commercialized head-mounted display and a custom-made hand motion tracking module. We developed the virtual harvest and cook programs in enriched environments representing rural scenery. Physiatrists, OTs, and patients with mild cognitive impairment and mild dementia received 30 minutes of VR training to evaluate the feasibility and usability of the test for cognitive training. At the end of the test, the usability and feasibility were assessed by a self-report questionnaire based on a 7-point Likert-type scale. Response time and finger tapping were measured in patients before and after the test. Results: Participants included 10 physiatrists, 6 OTs, and 11 patients with mild cognitive impairment and mild dementia. The mean scores for overall satisfaction with the program were 5.75 (SD 1.00) for rehabilitation specialists and 5.64 (SD 1.43) for patients. The response time of the dominant hand in patients decreased after the single session of cognitive training using VR, but this was not statistically significant (P=.25). There was no significant change in finger tapping in either the right or left hand (P=.48 and P=.42, respectively). None of the participants reported headaches, dizziness, or any other motion sickness after the test. Conclusions: A fully immersive VR cognitive training program may be feasible and usable in patients with mild cognitive impairment and mild dementia based on the positive satisfaction and willingness to use the program reported by physiatrists, OTs, and patients. Although not statistically significant, decreased response time without a change in finger tapping rate may reflect a temporary increase in attention after the test. Additional clinical trials are needed to investigate the effect on cognitive function, mood, and physical outcomes.

  • A participant walking through the virtual environment in the Gait Real-Time Analysis Interactive Lab (GRAIL). Source: Image created by authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Effect of Spatial Disorientation in a Virtual Environment on Gait and Vital Features in Patients with Dementia: Pilot Single-Blind Randomized Control Trial


    Background: Orientation deficits are among the most devastating consequences of early dementia. Digital navigation devices could overcome these deficits if adaptable to the user’s needs (ie, provide situation-aware, proactive navigation assistance). To fulfill this task, systems need to automatically detect spatial disorientation from sensors in real time. Ideally, this would require field studies consisting of real-world navigation. However, such field studies can be challenging and are not guaranteed to cover sufficient instances of disorientation due to the large variability of real-world settings and a lack of control over the environment. Objective: Extending a foregoing field study, we aim to evaluate the feasibility of using a sophisticated virtual reality (VR) setup, which allows a more controlled observation of disorientation states and accompanying behavioral and physiological parameters in cognitively healthy older people and people with dementia. Methods: In this feasibility study, we described the experimental design and pilot outcomes of an ongoing study aimed at investigating the effect of disorientation on gait and selected physiological features in a virtual laboratory. We transferred a real-world navigation task to a treadmill-based virtual system for gait analysis. Disorientation was induced by deliberately manipulating landmarks in the VR projection. Associated responses in motion behavior and physiological parameters were recorded by sensors. Primary outcomes were variations in motion and physiological parameters, frequency of disorientation, and questionnaire-derived usability estimates (immersion and perceived control of the gait system) for our population of interest. At this time, the included participants were 9 cognitively healthy older participants [5/9 women, 4/9 men; mean age 70 years, SD 4.40; Mini–Mental State Examination (MMSE) mean 29, SD 0.70) and 4 participants with dementia (2/4 women, 2/4 men; mean age 78 years, SD 2.30 years; MMSE mean 20.50, SD 7.54). Recruitment is ongoing, with the aim of including 30 cognitively healthy older participants and 20 participants with dementia. Results: All 13 participants completed the experiment. Patients’ route was adapted by shortening it relative to the original route. Average instances of disorientation were 21.40, 36.50, and 37.50 for the cognitively healthy older control, cognitively healthy older experimental participants, and participants with dementia, respectively. Questionnaire outcomes indicated that participants experienced adequate usability and immersion; 4.30 for presence, 3.73 for involvement, and 3.85 for realism of 7 possible points, indicating a good overall ability to cope with the experiment. Variations were also observed in motion and physiological parameters during instances of disorientation. Conclusions: This study presents the first feasibility outcomes of a study investigating the viability of using a sophisticated VR setup, based on an earlier real-world navigation study, to study spatial disorientation among cognitively healthy older people and people with dementia. Preliminary outcomes give confidence to the notion that our setup can be used to assess motion and physiological markers of disorientation, even in people with cognitive decline. Trial Registration:;

  • Source: The Authors/Placeit; Copyright: The Authors/Placeit; URL:; License: Licensed by JMIR.

    Lessons Learned From an Evaluation of Serious Gaming as an Alternative to Mannequin-Based Simulation Technology: Randomized Controlled Trial


    Background: The use of new technology like virtual reality, e-learning, and serious gaming can offer novel, more accessible options that have been demonstrated to improve learning outcomes. Objective: The aim of this study was to compare the educational effectiveness of serious game–based simulation training to traditional mannequin-based simulation training and to determine the perceptions of physicians and nurses. We used an obstetric use case, namely electronic fetal monitoring interpretation and decision making, for our assessment. Methods: This study utilized a mixed methods approach to evaluate the effectiveness of the new, serious game–based training method and assess participants’ perceptions of the training. Participants were randomized to traditional simulation training in a center with mannequins or serious game training. They then participated in an obstetrical in-situ simulation scenario to assess their learning. Participants also completed a posttraining perceptions questionnaire. Results: The primary outcome measure for this study was the participants’ performance in an in-situ mannequin-based simulation scenario, which occurred posttraining following a washout period. No significant statistical differences were detected between the mannequin-based and serious game–based groups in overall performance, although the study was not sufficiently powered to conclude noninferiority. The survey questions were tested for significant differences in participant perceptions of the educational method, but none were found. Qualitative participant feedback revealed important areas for improvement, with a focus on game realism. Conclusions: The serious game training tool developed has potential utility in providing education to those without access to large simulation centers; however, further validation is needed to demonstrate if this tool is as effective as mannequin-based simulation. Trial Registration: Not applicable.

  • Controlling sense of embodiment. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Controlling the Sense of Embodiment for Virtual Avatar Applications: Methods and Empirical Study


    Background: The sense of embodiment (SoE) is the feeling of one’s own body, and research on the SoE extends from the rubber hand illusion to the full-body ownership illusion with a virtual avatar. Objective: The key to utilizing a virtual avatar is understanding and controlling the SoE, and it can be extended to several medical applications. In this study, we aimed to clarify these aspects by considering the following three subcomponents of SoE: sense of agency, ownership, and self-location. Methods: We defined a human avatar (HA), point light avatar (PLA), and out-of-body point light avatar (OBPLA) and compared them in three user studies. In study 1, 28 participants were recruited and the three avatar conditions (HA, PLA, and OBPLA) were compared. In study 2, 29 new participants were recruited, and there were two avatar conditions (HA ad PLA) and two motion synchrony conditions (synchrony and asynchrony). In study 3, 29 other participants were recruited, and there were two avatar conditions (PLA and OBPLA) and two motion synchrony conditions (synchrony and asynchrony). Dependent measures included sense of agency, ownership, and self-location; emotional response; presence; and simulator sickness. Results: The findings of study 1 showed that the three avatar generation methodologies can control the sense of ownership and self-location in a stepwise manner while maintaining a high sense of agency. In studies 2 and 3, we found dependencies among the three subcomponents of SoE and observed that they affected users’ subjective experiences. Conclusions: Our findings may have implications for boosting the effects of virtual avatar applications in medical areas, by understanding and controlling the SoE with a full-body illusion.

  • A child playing FoodRateMaster. Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Relationship Between Children’s Enjoyment, User Experience Satisfaction, and Learning in a Serious Video Game for Nutrition Education: Empirical Pilot Study


    Background: The design and use of serious video games for children have increased in recent years. To maximize the effects of these games, it is essential to understand the children’s experiences through playing. Previous studies identified that enjoyment and user experience satisfaction of the players are principal factors that can influence the success of serious video games and the learning of their players. However, research about the relationship between enjoyment and user experience satisfaction with learning in children 8 to 10 years old is sparse. Objective: We examined the relationship of enjoyment and user experience satisfaction with the learning of children aged 8 to 10 years while playing a serious video game for health, FoodRateMaster. This serious video game teaches children about the characteristics of healthy and unhealthy foods and how to identify them in their environment. Methods: Children aged 8 to 10 years were recruited from a primary school in Mexico. Participants completed 12 individual gaming sessions with FoodRateMaster in 6 weeks. A food knowledge questionnaire was administered before and after game play to assess the players’ food knowledge. In addition, after the gaming sessions, the children’s enjoyment and user experience satisfaction were evaluated using the EGameFlow questionnaire and the Game User Experience Satisfaction Scale (GUESS) questionnaire. Results: We found significant positive associations for children’s (n=60) posttest knowledge with enjoyment (r58=0.36, P=.005) and user experience satisfaction (r58=0.27, P=.04). The children’s posttest knowledge scores were also positively correlated with challenge (r58=0.38, P=.003), knowledge improvement (r58=0.38, P=.003), and goal clarity (r58=0.29, P=.02) EGameFlow subscales and with narrative (r58=0.35, P=.006), creative freedom (r58=0.26, P=.04), and visual esthetics (r58=0.32, P=.01) GUESS subscales. Regression analysis indicated that the EGameFlow (F7,52=2.74, P=.02, R2=0.27) and the GUESS (F8,51=2.20, P=.04, R2=0.26) ratings significantly predicted the children’s posttest knowledge scores. EGameFlow challenge (β=0.40, t52=2.17, P=.04) and knowledge improvement (β=0.29, t52=2.06, P=.04) subscales significantly contributed to predicting children’s learning. None of the GUESS subscales significantly contributed to predicting children’s learning. Conclusions: The findings of this study suggest that both enjoyment and user experience satisfaction for children aged 8 to 10 years were positively correlated with their learning and that were significant predictors of it. Challenge, knowledge improvement, narrative, creative freedom, and visual esthetics subscales correlated positively with children’s learning. In addition, challenge and knowledge improvement contributed to predicting their learning. These results are relevant to consider during the design stages of serious games developed for young children’s learning purposes.

  • Bim presentation. Source: Image created by the author Igor Sousa De Avelar/Placeit; Copyright: The Author Igor Sousa De Avelar/Placeit; URL:; License: Licensed by JMIR.

    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.

  • Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Effective Gamification of the Stop-Signal Task: Two Controlled Laboratory Experiments


    Background: A lack of ability to inhibit prepotent responses, or more generally a lack of impulse control, is associated with several disorders such as attention-deficit/hyperactivity disorder and schizophrenia as well as general damage to the prefrontal cortex. A stop-signal task (SST) is a reliable and established measure of response inhibition. However, using the SST as an objective assessment in diagnostic or research-focused settings places significant stress on participants as the task itself requires concentration and cognitive effort and is not particularly engaging. This can lead to decreased motivation to follow task instructions and poor data quality, which can affect assessment efficacy and might increase drop-out rates. Gamification—the application of game-based elements in nongame settings—has shown to improve engaged attention to a cognitive task, thus increasing participant motivation and data quality. Objective: This study aims to design a gamified SST that improves participants’ engagement and validate this gamified SST against a standard SST. Methods: We described the design of our gamified SST and reported on 2 separate studies that aim to validate the gamified SST relative to a standard SST. In study 1, a within-subject design was used to compare the performance of the SST and a stop-signal game (SSG). In study 2, we added eye tracking to the procedure to determine if overt attention was affected and aimed to replicate the findings from study 1 in a between-subjects design. Furthermore, in both studies, flow and motivational experiences were measured. Results: In contrast, the behavioral performance was comparable between the tasks (P<.87; BF01=2.87), and the experience of flow and intrinsic motivation were rated higher in the SSG group, although this difference was not significant. Conclusions: Overall, our findings provide evidence that the gamification of SST is possible and that the SSG is enjoyed more. Thus, when participant engagement is critical, we recommend using the SSG instead of the SST.

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