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Journal Description

JMIR Serious Games (JSG, ISSN 2291-9279; Impact Factor: 2.226) 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 2018, JSG received an official inaugural journal impact factor of 2.226 (Journal Citation Reports 2017, Clarivate Analytics), ranking JSG at the top of all gaming related academic journals, ahead of (for example) more established competitor journals such as the Games for Health Journal. 


Recent Articles:

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Serious Games in Surgical Medical Education: A Virtual Emergency Department as a Tool for Teaching Clinical Reasoning to Medical Students


    Background: Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use. Objective: This study aimed to test the effect of a serious game simulating an emergency department (“EMERGE”) on students’ declarative and procedural knowledge, as well as their satisfaction with the serious game. Methods: This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students’ impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale. Results: A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students’ overall impression of EMERGE was positive. Conclusions: Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge.

  • Source: Wikicommons; Copyright: Evan-Amos; URL:; License: Public Domain (CC0).

    Active Video Games for Rehabilitation in Respiratory Conditions: Systematic Review and Meta-Analysis


    Background: Exercise and physical activity are key components of treatment for chronic respiratory diseases. However, the level of physical activity and adherence to exercise programs are low in people with these diseases. Active video games (AVGs) may provide a more engaging alternative to traditional forms of exercise. Objective: This review examines the effectiveness of game-based interventions on physiological outcome measures, as well as adherence and enjoyment in subjects with chronic respiratory diseases. Methods: A systematic search of the literature was conducted, with full texts and abstracts included where they involved an AVG intervention for participants diagnosed with respiratory conditions. A narrative synthesis of included studies was performed. Additionally, meta-analysis comparing AVGs with traditional exercise was undertaken for 4 outcome measures: mean heart rate (HR) during exercise, peripheral blood oxygen saturation (SpO2) during exercise, dyspnea induced by the exercise, and enjoyment of the exercise. Results: A total of 13 full-text papers corresponding to 12 studies were included in the review. Interventions predominantly used games released for the Nintendo Wii (8 studies) and Microsoft Xbox Kinect (3 studies). There were 5 studies that examined the acute effects of a single session of AVGs and 7 studies that examined the long-term effects after multiple sessions of AVGs. Trials conducted over more than 1 session varied in duration between 3 and 12 weeks. In these, AVG interventions were associated with either similar or slightly greater improvements in outcomes such as exercise capacity when compared with a traditional exercise control, and they also generally demonstrated improvements over baseline or nonintervention comparators. There were a few studies of unsupervised AVG interventions, but the reported adherence was high and maintained throughout the intervention period. Additionally, AVGs were generally reported to be well liked and considered feasible by participants. For outcome measures measured during a single exercise session, there was no significant difference between an AVG and traditional exercise for HR (mean difference 1.44 beats per minute, 95% CI –14.31 to 17.18), SpO2 (mean difference 1.12 percentage points, 95% CI –1.91 to 4.16), and dyspnea (mean difference 0.43 Borg units, 95% CI –0.79 to 1.66), but AVGs were significantly more enjoyable than traditional exercise (Hedges g standardized mean difference 1.36, 95% CI 0.04-2.68). Conclusions: This review provides evidence that AVG interventions, undertaken for several weeks, can provide similar or greater improvements in exercise capacity and other outcomes as traditional exercise. Within a single session of cardiovascular exercise, an AVG can evoke similar physiological responses as traditional exercise modalities but is more enjoyable to subjects with chronic respiratory diseases. However, there is very limited evidence for adherence and effectiveness in long-term unsupervised trials, which should be the focus of future research.

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

    Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2...


    Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales “interest/enjoyment” (+2.0 (SD 1.9) points, P<.001) and “perceived competence” (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: NCT02657018;

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Young People’s Knowledge of Antibiotics and Vaccinations and Increasing This Knowledge Through Gaming: Mixed-Methods Study Using e-Bug


    Background: e-Bug, led by Public Health England, educates young people about important topics: microbes, infection prevention, and antibiotics. Body Busters and Stop the Spread are 2 new e-Bug educational games. Objective: This study aimed to determine students’ baseline knowledge, views on the games, and knowledge improvement. Methods: Students in 5 UK educational provisions were observed playing 2 e-Bug games. Before and after knowledge and evaluation questionnaires were completed, and student focus groups were conducted. Results: A total of 123 junior and 350 senior students completed the questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly about antibiotic use, appropriate sneezing behaviors, and vaccinations. In total, 26 student focus groups were conducted. Body Busters was engaging and enjoyable, whereas Stop the Spread was fast-paced and challenging but increased vaccination and health behavior intentions. Conclusions: e-Bug games are an effective learning tool for students to enhance knowledge about microbes, infection prevention, and antibiotics. Game-suggested improvements should help increase enjoyment.

  • Active video gaming on the adapted Wii Fit balance board. Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Energy Expenditure and Enjoyment During Active Video Gaming Using an Adapted Wii Fit Balance Board in Adults with Physical Disabilities: Observational Study


    Background: Individuals with physical disabilities have fewer opportunities to participate in enjoyable physical activity. One option for increasing physical activity is playing active video games (AVGs); however, many AVGs are inaccessible or offer limited play options. Objective: This study aimed to examine energy expenditure and enjoyment in adults with mobility impairment during AVG play using off-the-shelf (OTS) and adapted versions of the Wii Fit balance board (Nintendo). Methods: During visit 1, participants completed a functional assessment and the familiarization period. During visit 2, metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus game play, with two bouts on each of the boards. During the resting period, participants completed the Physical Activity Enjoyment Scale (PACES). Statistical analyses were computed using SPSS software. Data were analyzed separately for individuals who were able to play while standing on both boards (StdStd); those who could not play while standing on the OTS board, but were able to play while standing on the adapted board (aStd); and those who could only play while sitting on the adapted board (aSit). Results: Data were collected for 58 participants (StdStd, n=17; aStd, n=10; aSit, n=31). The sample included 31 men and 27 women with a mean age of 41.21 (SD 12.70) years. Energy expenditure (metabolic equivalent [MET]) during game play was significantly greater than that during rest for all players. Only 17 participants (StdStd group) were able to play using the OTS board. During game play on the adapted board, the average MET values for the two game sets were 2.261 (SD 0.718) kcal/kg/hour and 2.233 (SD 0.751) kcal/kg/hour for the aSit group, 3.151 (SD 1.034) and 2.990 (SD 1.121) for the aStd group, and 2.732 (SD 0.655) and 2.777 (SD 0.803) for the StdStd group. For game play on the adapted board, self-reported ratings of perceived exertion on a 0-10 scale suggested greater exercise intensity levels, with median scores ranging from moderate (3) to very hard (7). The PACES scores indicated that all players enjoyed using the adapted board, with a median score of 4 on a 5-point scale. Conclusions: The adapted Wii Fit balance board provided an opportunity for individuals with mobility impairments, including wheelchair users, to engage in AVG. All participants were able to utilize the adapted controller and enjoyed the AVG activity. Although the average MET values achieved during AVG represented light-intensity exercise (<3 METs), 16% of sitting participants and 41% of standing participants achieved moderate-intensity exercise (3-6 METs) in at least one of the games. Factors not accounted for, which may have influenced the intensity of exercise, include game selection, limited familiarization period, and discomfort wearing the COSMED portable metabolic system for measurement of oxygen consumption. Accessible AVG controllers offer an innovative approach to overcome various barriers to participation in physical activity. The next steps include assessment of an AVG intervention using an adapted board gaming controller on health and fitness outcomes. Trial Registration: NCT02994199; (Archived by Webcite at

  • A VR platform used for distraction during pedatric IV procedures. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized...


    Background: Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use. Objective: We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care. Methods: We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child’s hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used. Results: Of the 25 enrolled children, 24 were included in the primary analysis. No safety concerns or VR sickness occurred. The median procedure time was 10 (range 1-31) minutes in the VR group and was comparable to 9 (range 3-20) minutes in the SOC group (P=.76). Patients in both the groups reported a positive influence of distraction on procedural anxiety and pain. Overall, in 80% (34/45) of the VR evaluations, children, caregivers, and nurses reported that they would like to use VR for future procedures. Conclusions: We demonstrated that an orchestrated, VR environment could be developed and safely used during pediatric hemophilia care for distraction during IV interventions. This platform has the potential to improve patient experience during medical procedures. Trial Registration: Clinical NCT03507582; (Archived by WebCite at

  • Rainbow SPARX image. Source: Rainbow SPARX image; Copyright: Auckland Uniservices; URL:; License: Licensed by the authors.

    How LGBT+ Young People Use the Internet in Relation to Their Mental Health and Envisage the Use of e-Therapy: Exploratory Study


    Background: Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game–based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people. Objective: This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people’s and professionals’ views about e-therapies, drawing on the example of Rainbow SPARX. Methods: A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data. Results: LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes. Conclusions: LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people.

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Potential of an Interactive Drug Prevention Mobile Phone App (Once Upon a High): Questionnaire Study Among Students


    Background: In recent years, drug prevention networks and drug education programs have started using Web-based or mobile phone apps as novel prevention tools, testing their efficacy compared with face-to-face prevention. Objective: The aim of this study was to assess the potential of an interactive app called Once Upon a High (VoltEgySzer). Methods: The app approaches drug prevention from 6 different aspects, and it addresses youngsters with 6 different modules: (1) interactive comics/cartoons, telling stories of recovery; (2) quiz game; (3) roleplay game; (4) introduction of psychoactive drugs; (5) information on the somatic and psychological effects of psychoactive substances; (6) list of available treatment units, rehabs, and self-support groups in Hungary. Students of 2 vocational schools and 2 high schools filled out a questionnaire at a baseline (T0) and a 2-month follow-up (T1) data collection session. Students of 1 vocational school and 1 high school downloaded the Once Upon a High app (app group), whereas students from the other vocational school and high school did not (nonapp group). The time points of T0 and T1 questionnaires contained demographic variables, items with regard to substance use characteristics for both legal and illegal substances, including novel psychoactive substance, exercise habits, knowledge about psychoactive substances, attitudes toward substance users and validated instruments measuring the severity of tobacco (Fagerström Test for Nicotine Dependence), alcohol (Alcohol Use Disorder Identification Test), cannabis (Cannabis Abuse Screening Test), and synthetic cannabinoid consumption. Beliefs about substance use (Beliefs About Substance Abuse) and perceived self-efficacy (General Perceived Self-Efficacy) were also measured. At T1, members of the app group provided additional evaluation of the app. Results: There were 386 students who participated in the T0 session. After dropout, 246 students took part in T1 data collection procedure. Alcohol was the most frequently consumed psychoactive substance (334/364, 91.8% lifetime use), followed by tobacco (252/386, 65.3%, lifetime use) and cannabis (43/323, 13.3% lifetime use). Decreased self-efficacy (beta=−.29, P=.04) and increased daily physical exercise frequencies (beta=.04, P<.001) predicted higher frequencies of past month energy drink consumption, whereas elevated past month alcohol consumption was mainly predicted by a decrease in negative attitudes toward substance users (beta=−.13, P=.04) in the regression models. Once Upon a High was found to be effective only in reducing energy drink consumption (beta=−1.13, P=.04) after controlling for design effect, whereas perceived utility of the app showed correlation with a decreasing alcohol use (rS(44)=.32, P=.03). The roleplay module of the app was found to be the most preferred aspect of the app by the respondents. Conclusions: The Once Upon a High app can be a useful tool to assist preventive intervention programs by increasing knowledge and self-efficacy; however, its efficacy in reducing or preventing substance use needs to be improved and further studied. Additional potential impacts of the app need further testing.

  • Cigbreak app (montage). Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game


    Background: Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps. Objective: This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app. Methods: A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers. Results: Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend. Conclusions: A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.

  • Visual representation of the Emotion-in-Motion task. The images are not those used in the actual task. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Public Domain (CC0).

    Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study


    Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved. Objective: This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability. Methods: We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor. Results: Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60). Conclusions: Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback.

  • A child playing Heritages (developed by Breathing Games contributors). Source: A New Economy; Copyright: A New Economy; URL:; License: Licensed by the authors.

    Developing Digital Games to Address Airway Clearance Therapy in Children With Cystic Fibrosis: Participatory Design Process

    Authors List:


    Background: Children affected with cystic fibrosis do respiratory exercises to release the mucus stuck in their lungs. Objective: The objective of our study was to develop prototypes of digital games that use breath pressure to make this daily physiotherapy more fun. Methods: We used a participatory design approach and organized short events to invite contributors from different disciplines to develop game prototypes. From the 6 prototypes, 3 were tested by 10 children during a prestudy. The source code of the games, of which 2 continue to be developed, has been released on the internet under fair use licenses. Results: We discuss 7 themes of importance in designing games for health, combining our experience with a review a posteriori of literature. Conclusions: This study provides examples of games and their pitfalls as well as recommendations to create games for health in a participatory approach that enables everyone to improve and adapt the work done.

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

    Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review


    Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world.

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    Date Submitted: Mar 15, 2019

    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Computerized cognitive training has been proposed as a potential solution to age-related cognitive decline. However, published findings from evaluation studies of cognitive training games,...

    Background: Computerized cognitive training has been proposed as a potential solution to age-related cognitive decline. However, published findings from evaluation studies of cognitive training games, including from meta-studies and systematic reviews, provide evidence both for and against transferability from trained tasks to untrained cognitive ability. There continues to be no consensus on this issue from the scientific community. A number of researchers have proposed that the number of results supporting the efficacy of cognitive training may be inflated due to placebo effects. Boot et al. [1] (2013) suggest that placebo effects need to be better controlled by using an active control and measuring participant expectations for improvement on outcome measures. Objective: This review examines placebo control methodology for recent evaluation studies of computerized cognitive training programs with older adult subjects, specifically looking for use of active control and measurement of expectations. Methods: Data sources: PubMed. Study eligibility criteria: Studies of computerized cognitive training published between 2016 and 2018. Participants and interventions: Evaluation studies of computerized cognitive training with older adult subjects (age 50+). Study appraisal and synthesis methods: Methods sections of studies were searched for (1) control type (active or passive) and sub-type (active: active-ingredient or similar-form; passive: no-contact or passive-task); (2) if expectations were measured: how were they measured, and whether they were used in analysis; (3) whether researchers acknowledged lack of active control and lack of expectation measurement as limitations (where appropriate). Results: Results: 4 of 19 (~21%) of eligible studies measured expectations. 9 of 19 (~47%) included an active control condition, all of which were of the similar-form type. The majority (10 studies, or ~53%) used only a passive control. 9 of these studies found results supporting efficacy of cognitive training, 5 of which were for far transfer effects. Conclusions: Conclusions: 47% of reviewed studies had poor placebo control, yet still published results supporting the effectiveness of cognitive training programs. 5 of these positive results were for far transfer effects, which form the basis for broad claims by cognitive training game makers about the scientific validity of their product. For a minimum level of placebo control, future evaluation studies should use a similar-form active control and administer a questionnaire to participants at the end of the training period about their own perceptions of improvement. Researchers are encouraged to think of more methods for the valid measure of expectations at other time points in the training.

  • How to improve quality of care in overcrowded emergency departments? Development and evaluation of a virtual research environment.

    Date Submitted: Mar 15, 2019

    Open Peer Review Period: Mar 16, 2019 - May 11, 2019

    Background: Despite wide literature on ED overcrowding, scientific knowledge on emergency physicians’ cognitive processes coping with overcrowding is limited. Objective: We sought to develop and eva...

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    Date Submitted: Feb 25, 2019

    Open Peer Review Period: Feb 28, 2019 - Apr 25, 2019

    Background: Opportunities in digital distribution place mobile games as a promising platform in games for health. However, designing a game that can compete in the saturated mobile games market and de...

    Background: Opportunities in digital distribution place mobile games as a promising platform in games for health. However, designing a game that can compete in the saturated mobile games market and deliver persuasive health messages can feel like an insurmountable challenge. While user-centred design is widely advocated in the field; factors, such as; the user’s subject domain expertise, budget constraints and poor data collection methods can restrict the benefits of user involvement. Objective: To develop a playable and acceptable mobile game, targeted at adolescent and young adult key populations in the Philippines. Methods: Focus group discussions (FGDs) with Filipino gamers, most of whom identified as men who have sex with men (MSM), were used to; identify preferred game features, technical requirements and to assess game playability and acceptability. Discussions were transcribed and analysed thematically. Conceptual frameworks in health intervention acceptability and game design guided the interpretation and use of the data. In-game events were captured through the Unity Analytics service (v.2017.1) to monitor uptake and game use, and identify and fix issues impacting game performance, over a 12-month period. Results: Early user involvement revealed a strong desire for online multiplayer gameplay, yet most reported that access to these types of games was restricted due to technical and economic constraints. Role-playing games (RPG) with combat elements was identified as the most appealing gameplay style. Findings guided us to a game that could be played offline, which blended RPG elements; including narrative, character customisation and turn based combat with match-3 puzzles. While the resulting game exceeded expectations and was reported to be playable and acceptable, gameplay was at times perceived as repetitive with limited appeal among certain gamer types. Knowledge transfer was predominantly achieved through interpretation of the game’s narrative, highlighting this as an important design element in the game’s potential influence on behaviour determinants. Uptake of the game was positive; between 01/12/2017 - 01/12/2018, 3,325 unique device installs were reported globally. In-game events provided evidence of game adoption by young adult MSM in the Philippines. Game uptake and use was substantially higher in regions where direct engagement with target users took place and increased after resolution of an access issue on Android devices. Conclusions: The inclusion of informants that possessed relevant subject domain expertise provided design solutions that addressed contextual constraints. Multiple data collection methods, to inform the game design and evaluate acceptability, enabled us to triangulate findings so as to mediate the inherent biases of the different techniques. While success on the app stores is not an exact science, factors such as user-involvement, playability and the marketing strategy play an important role. Facilitating meaningful interactions between health professionals, the entertainment games industry and end users will support the games for health industry as it matures.

  • A Design of Educational Game to Prevent Cyber-Bullying among Teenagers and An Analysis of Its Effect

    Date Submitted: Feb 13, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    This paper is a case study on the design of an educational game for the prevention of cyberbullying and an analysis of its educational effect. I selected a game titled “Angry Daddy,” which was dev...

    This paper is a case study on the design of an educational game for the prevention of cyberbullying and an analysis of its educational effect. I selected a game titled “Angry Daddy,” which was developed based on the request of Korean government authority and analyzed the mode of development of the game and its educational effect. For this research, both qualitative and quantitative research methods were used. Moreover, advice regarding the game design was obtained from many experts belonging to various fields. Based on the analysis of the game design and its educational effect, it was confirmed that the following factors are important to design an educational game meant for the prevention of cyberbullying and to enhance its educational effect: First, cooperation between content experts and game development experts is essential to develop an educational game. Second, it should be verified whether the contents and the format of the game are appropriate by analyzing the play test results of the target audience. Third, it is essential to prepare a manual to guide teachers to apply the game to the field. Fourth, it was confirmed that educating students on sensitive topics like cyberbullying is very effective when educational games that make them feel and experience the outcomes of bullying are utilized. This research is expected to be helpful for future design of educational games and the research and development of the format of cyberbullying prevention education.

  • Impact of using a 3D visual metaphor serious game to teach history taking content to medical students: A pilot study

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: Background: History taking is a key component of clinical practice, however, this skill is often poorly performed by students and doctors. Objective: To determine whether a 3D serious gam...

    Background: Background: History taking is a key component of clinical practice, however, this skill is often poorly performed by students and doctors. Objective: To determine whether a 3D serious game is superior to another electronic medium (PDF text file) in learning the history taking content of a single organ system (cardiac). Methods: In 2015, a longitudinal mixed-methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) in a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). One participant left the PDF group after allocation was revealed and was excluded. 24 students in the game group and 14 students in the PDF group completed follow-up seven weeks later. Intervention: Using an iterative design process over a year and with input from a variety of clinical disciplines, a cardiac history taking game and PDF file were respectively designed informed by Cognitive Load Theory. Each group completed their respective intervention in 40 minutes. Three levels of Kirkpatrick's training evaluation model were examined using validated questionnaires: affective (perception/satisfaction), cognitive (knowledge gains/cognitive load), and behavioural attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated prior to data collection. Results: Compared to baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (p=<0.0001). Apart from the game group having a statistically significant difference in terms of satisfaction (p=<0.0001), there were no significant differences between groups in knowledge gain, self-efficacy, cognitive load, ease of use, acceptability or OSCE scores. However, qualitative findings indicated that the game was more engaging, enjoyable and served as a visual aid compared with the PDF file. Conclusions: Students favoured learning through utilisation of a serious game with regard to cardiac history taking. This may be relevant to other areas of medicine and highlights the importance of innovative methods of teaching the next generation of medical students. Clinical Trial: null

  • Game-based design for eHealth in practice

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 15, 2019 - Apr 12, 2019

    Background: Games are increasingly used in eHealth as a strategy for user engagement. While these game-based applications receive attention in literature, there is an enormous diversity of end users a...

    Background: Games are increasingly used in eHealth as a strategy for user engagement. While these game-based applications receive attention in literature, there is an enormous diversity of end users and objectives targeted by eHealth. Identifying game content that drives and sustains engagement is therefore challenging. Future developments would benefit from more openness on the game design process and motivational strategies applied. Objective: Our objective was to provide insight in our approach in the development of game-based eHealth in practice. By means of a case study, PERSSILAA, we elaborate the entire game design process and show the motivational strategies applied, to aid researchers and designers of future game-based applications. PERSSILAA is a self-management platform which aims to counter frailty by offering older adults training modules in the domains of healthy nutrition, physical and cognitive training to maintain a healthy lifestyle. Methods: We introduce four phases in the process towards game-based eHealth: 1) end-user research, 2) conceptualisation, 3) creative design and 4) refinement. Results: A total number of 168 participants participated in end-user research (1), resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games currently popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include: focusing game concepts on thinking, problem solving, variation, discovery and achievement, using high quality aesthetics. Stakeholder sessions with developing partners resulted in strategies for long-term engagement (2), using indicators of user performance on the platform’s training modules. These performance indicators, e.g. completed training sessions or exercises, form the basis for game progression. Results from prior phases were used in creative design (3) to create the game “Stranded!”. The user plays a shipwrecked person who has to gather parts for a life raft by completing in-game objectives. Iterative prototyping (4) resulted in the final prototype of the game-based application. A total number of 35 end users participated using simulated training modules. The online game-based application was used without reported errors for a six weeks. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the application (75/100) and intended future use (66/100) which implicates that the application is ready for use by a larger population. Conclusions: The study resulted in a game-based application for which the entire game design process within eHealth was transparently documented. We believe we have contributed to the transfer of knowledge on game design that supports engagement in eHealth applications. Our user evaluations indicate that results from end-user research and consequential strategies for long-term engagement led to game content that is engaging to the older adult end user.