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The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health.
This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes.
A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science.
A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter.
In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present.
We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health.
Games and simulations hold the promise of being learning machines [
A possible way to make such a connection can be found in thinking in terms of transfer. Although there are a wide variety of viewpoints and theoretical frameworks regarding transfer in the literature, transfer is seldom a starting point in developing serious games. Studies on serious games [
From an educational and technological perspective, transfer is a key concept in learning theory and education [
If we regard games and simulations as learning contexts that can be designed and specifically tailored for (at least a type of) transfer, it seems legitimate to focus attention on how transfer has been taken into account in designing game-like health interventions.
Transfer theory determines two classes of transfer, both encompassing a variety of transfer types [
The second class of transfer theories may be harder to grasp. According to Royer [
Games and simulations for health abundantly build on the principles of first-class literal transfer, but the adoption of second-class transfer types has proven to be scarce. In contrast to commercial off-the-shelf games, in serious game design, the usage of mindful abstractions and metaphorical representations is not common practice, despite the fact that it forms a natural fit with the second class of transfer theories. Earlier research has shown [
The most visible examples of the designers’ uptake of transfer in game-like interventions are apparent in the application of fidelity types: the way fidelity is used in a game-like intervention or simulation demonstrates the expected road to transfer. A dominant perspective on fidelity in serious game design is that high fidelity is conditional for learning and transfer, corresponding with the first class of transfer.
According to Alexander [
Focusing on the design of game-like interventions for health and health care, this study aimed to (1) find out whether the second class of transfer is recognized or present as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes.
In total, 6 databases were searched for potentially relevant abstracts: PubMed, Scopus, ERIC, PsycINFO, Information Science & Technology Abstracts, and EMBASE. These databases covered a wide range of published research from the field of health and social care. A combination of search terms were used to identify relevant papers under the following categories: (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior), where * represents a wildcard to allow for alternative suffixes. Search strategies were customized for each database. Searches included papers published between database inception and October 2016. The search was conducted between October 3, 2016 and October 21, 2016.
We included studies that discussed either digital simulations or games designed for health providers or on health topics. We included only original reports or papers that (1) addressed the design of a serious game or digital simulation; (2) involved an empirical study, either piloting a game-like intervention or validating the aspired effects; or (3) otherwise focused on a newly developed game or simulation, created specifically for the study in question. Papers were included when title and abstract were considered to be at least indicative of the presence of second class of transfer. Papers meeting any of the above criteria were selected for full-text screening.
The following exclusion criteria were used for full-text screening: (1) non–peer-reviewed papers such as abstracts, conference posters, or trade journals; (2) full text not available; (3) language other than English and Dutch; (4) papers that referred to transfer as transfer of data or disease; (5) not sufficient information; (6) repurposed commercial off-the-shelf games; (7) low fidelity as a means to reduce production costs; (8) nondigital games and simulations; and (9) papers using high fidelity solely as a description of the artifact rather than as a founded design decision. Also, in our screening, we considered the transfer class in relation to the fidelity type: high fidelity as a means for achieving literal transfer led to exclusion.
After removing the duplicates, the papers were screened based on title and abstract using Rayyan [
Our initial search yielded 19,564 records. After removing all duplicates (5226), 14,338 records remained for title and abstract screening, leaving 26 potential suitable papers for full-text assessment. We used Cohen kappa to assess the interrater reliability of paper inclusion. We found good agreement between the 2 reviewers (ϰ=.78, 95% CI 0.655-0.883). A total of 11 papers were excluded at full-text screening for various reasons. The total number of included papers is therefore 15. See
We studied the full-text papers on how transfer was regarded and described in serious games or simulations. All 15 studies mentioned transfer in the initial concept of the design and described forthcoming consequences, mostly expressed in terms of fidelity. Although we assumed that the second class of transfer would be identified in varying ways, we found several other reasons to use abstract concepts and low fidelity. In the following section, we have categorized the papers, based on similarities in conjoining characteristics.
Out of the selected studies, 3 [
Flowchart of the results of the initial searches, screening, and selection processes.
In our initial selection process, papers that presented literal transfer axiomatically were excluded. Out of the included studies, 3 [
For example, the game
Pervasive game design provides a different approach toward transfer. Of the papers, 2 [
Details of included papers.
Author | Title | Transfer classa | Fidelity and transfer |
Year |
Dankbaar, Alsma, Jansen, Van Merrienboer, Van Saase, and Schuit [ |
An experimental study on the effects of a simulation game on students’ clinical cognitive skills and motivation | First | Low fidelity, reducing cognitive load | 2016 |
Kuipers, Wartena, Dijkstra, Terlouw, van T Veer, Van Dijk, Prins, and Pierie [ |
iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare | First | Low-road transfer, skill automatization, metaphorical | 2016 |
Jalink, Gores, Heineman, Pierie, and Ten Cate Hoedemaker [ |
Face validity of a Wii U video game for training basic laparoscopic skills | First | Low-road transfer, skill automatization, metaphorical | 2015 |
Connors, Chrastil, Sanchez, and Merabet [ |
Action video game play and transfer of navigation and spatial cognition skills in adolescents who are blind | First | Low-road transfer, spatial recognition | 2014 |
Rosenberg, Baughman, and Bailenson [ |
Virtual superheroes: using superpowers in virtual reality to encourage prosocial behavior | Second | Figural, metaphorical | 2013 |
Schrader and Bastiaens [ |
The influence of virtual presence: effects on experienced cognitive load and learning outcomes in educational computer games | First | Low fidelity, reducing cognitive load | 2012 |
De Freitas and Dunwell [ |
Understanding the representational dimension of learning: the implications of interactivity, immersion and fidelity on the development of serious games | Second | Figural, metaphorical | 2012 |
Knoll and Moar [ |
The space of digital health games | Blended | Locative, situational | 2012 |
Rooney [ |
A theoretical framework for serious game design: exploring pedagogy, play, and fidelity and their implications for the design process | Blended, both | Abstraction, situational | 2012 |
Toups, Kerne, and Hamilton [ |
The team coordination game: zero-fidelity simulation abstracted from fire emergency response practice | Second | Nonmimetic, abstraction | 2011 |
Hochmitz and Yuviler-Gavish [ |
Physical fidelity versus cognitive fidelity training in procedural skills acquisition | First | Cognitive fidelity, skill acquisition | 2011 |
Stone [ |
The (human) science of medical virtual learning environments | First | Cost reduction | 2011 |
Wood, Beckmann, and Birney [ |
Simulations, learning, and real world capabilities | First | Low fidelity, execution skills, reducing cognitive load | 2009 |
Markovic, Petrovic, Kittl, and Edegger [ |
Pervasive learning games: a comparative study | First | Situational | 2007 |
Alessi [ |
Fidelity in the design of instructional simulations | Both | Varying fidelity under conditions | 1988 |
aRefers to the aspired transfer type described or sought after with the game-like intervention.
Of the studies, 3 describe game designs applying the second class of transfer, and one study [
De Freitas et al [
The third study [
Although the game offers a so-called zero-fidelity physical environment, it uses communication instruments that have the same characteristics as real-world radios. This implies at least a modicum of functional fidelity. Furthermore, the game is based on communication strategies and stress levels from real-world fire emergency situations, which suggests some level of psychological fidelity. The
In total, 7 studies [
The virtual superhero study [
The study reporting on
Using a mixed-method approach, the
To our knowledge, this is the first review to explore the aspired transfer in designing game-like interventions in health. We tried to find and describe examples of the application of second-class transfer types by answering 3 research questions, discussed below.
We tried to determine whether the second class of transfer types is recognized or present as a road for transfer in game-like interventions for health. In our initial search, we expected to find studies in which thinking about a desired transfer outcome would form a guiding principle in the design of game-like interventions. Moreover, clearer distinctions in suitable transfer types and established examples of figural transfer (or forms thereof) were anticipated. Both assumptions were proven wrong, and we had to broaden our inclusion criteria to capture studies regarding design considerations, including transfer.
Our results show that transfer is mainly mentioned as a desired outcome, not as a guide in the design process. The appearance of most included game-like artifacts can be explained by the designer’s fidelity approach. As obvious as this seems, this fidelity approach also expresses assumptions about the way the transfer is expected to take place. As described before, we found several reasons for choosing low fidelity over high fidelity and vice versa. As none of the studies were designed for achieving transfer via a specific type or class of transfer, the question arises why the
By nature, design-centered research focuses more on the design itself and puts less emphasis on the eventual aspired outcome. Although it is too strong to state that the design itself of game-like interventions in health is not taken into account in thinking about desirable transfer outcomes, our search results show that describing the game-like interventions in terms of transfer variables is uncommon. One might argue that the design of a drug is essential to its workings and that the same principle applies for game-like interventions. The design of the artifacts as exercised in the virtual superhero game [
As described, we searched for particular examples of aspired transfer in the second class of transfer types, and found none. In 3 studies, the reported effects can only be explained via the road of a second-class transfer type but are described in other terminology. Most studies report about psychological fidelity [
An interesting observation is that the included papers show that functional and physical fidelity can be high or low for varying, well-founded reasons and that psychological fidelity is regarded as a variable that preferably should be high. The
The 3 studies we identified exemplifying an instance of figural transfer introduced a metaphorical approach with recontextualized fidelity types. These game metaphors seem to address and replace both high functional and physical needs as well as promote immersion. At this point, we hypothesize that figural transfer builds upon immersion or virtual presence and subsequent suspension of disbelief [
As the literature on transfer has consistently confirmed, long-term transfer effects are hard to measure. This might be particularly the case for the second class of transfer. All 3 examples report transfer effects, albeit short term and only vaguely proven. As second-class transfer is the result of the effects interventions trigger in one’s head, the transfer outcomes are individual, often nonlinear, and even unpredictable if the second class is not implemented with due care. Precisely because of this, we anticipated more conscious and elucidated design examples.
Although this review is based on an extensive search of a large number of health and computer science databases, we hardly found any studies of second-class transfer types in game-like interventions for health. Studies tend to focus on the effectiveness of game-like interventions and the research methods used, not on design factors that lead or contribute to measured effects. Due to the very few direct hits, we focused on the subconscious application of the second class of transfer types by thoroughly screening titles and abstracts. The papers that were included were subject to interpretation, discussion, and consensus of the reviewers (DK, GT, and BW). To counteract subjectivity, papers were independently reviewed by 2 reviewers (DK and GT) and were only included on consensus from both reviewers. Remaining conflicts between the reviewers were resolved by the third reviewer (BW).
Studies about serious games and game-like interventions for health do not provide a conscious rationale for designing the artifacts for optimizing transfer conditions. We did not find any example of a game-like intervention that was the result of a cognizant design process focusing on transfer outcomes. In general, we found that definitions of low and high fidelity form the strongest influencers on the design of artifacts, mostly exemplified in visual quality or a true-to-life approach. High fidelity was aspired to for its first class, literal transfer aspects without exception. None of the studies explained second class of transfer or instances thereof, although in 3 instances, implicit design choices suggested otherwise. It is notable that studies on game-like interventions for health do not elucidate the design choices made, as they bridge the designer’s intent and the aspired transfer outcome.
The authors would like to thank Olga van Dijk from Medical Centrum Leeuwarden (NL), who developed the search strategy for the systematic review.
None declared.