A foreign object lodged into the throat or the windpipe may cause choking. Unless the air passage is cleared, the person with choking can lose consciousness within 3-5 minutes. In worse cases, the lack of oxygen to the brain could cause brain damage or death. In these situations, it is recommended to administer, as quickly as possible, first-aid that consists of abdominal thrusts combined with back blows [1]. Unfortunately, not everyone is aware of this procedure, and the strategies to promote the awareness of this first-aid are necessary [2].

In order to educate about the risks, prevention, and treatment of choking, different approaches have been proposed. Organizations such as the Resuscitation Council [3], the Red Cross [1], or the American Heart Association [4] have defined guidelines that describe how choking interventions should be performed both safely and effectively. These organizations also offer courses, videos, and other materials to teach the procedure of the choking rescue. In addition, many countries have initiated campaigns to educate their citizens about the prevention, risks, and treatment of choking. Special attention has been given to children since they are the most susceptible to choking [5]. The effectiveness of these initiatives has also been studied and, in most of the cases, the general conclusion is that prevention strategies are effective and contribute to decreasing the choking incidence [6-8]. Moreover, several initiatives have focused on the development of first-aid training devices. The Zoll Medical Corporation has proposed a handheld device that uses several accelerometers to monitor abdominal thrusts [9]. Recently, Watson and Zhou [10] presented BreathEZ, a smartwatch app that provides both first-aid instructions for choking and real-time tactile and visual feedback on the quality of the abdominal thrust compressions.

In this paper, we propose to tackle the problem of choking by using serious game strategies. Serious games are digital games used for purposes other than mere entertainment and are applied in different areas such as military, government, education, and health care [11]. They can recreate scenarios to experiment with situations that otherwise would be impossible in the real world owing to the required safety, cost, and time [12]. In addition, serious games enhance the development of skills such as analytical and spatial, strategic, or psychomotor [13]. Although there are a large number of serious game apps related to health care, as far as we know, there are no serious games focused only on first-aid education for choking.

Serious games have become a powerful tool to develop and acquire new knowledge and skills. Different games have been developed for health care purposes and tested in a wide range of diseases, treatments, and other related topics [14-16]. These games focus not only on expert users but also on nonexperts.

Baranowski et al [17] presented a classification of games for health in 5 categories. One category, which was centered on health care professionals, consists of games designed to provide simulation environments and virtual patients to practice and acquire relevant skills [18]. An example in this category is MyCraft, which provides virtual consultation training on tuberculosis [19] and games to practice surgeries, blood management, image-guided procedures, assessment, prevention, and treatment [20-24]. The other 4 categories, which are centered on nonexperts such as patients or general users, consist of games designed to increase knowledge, change behavior, or involve health behavior in gameplay. An example of a game that increases knowledge and changes behavior is Yummy Tricks, which is a game intended to teach healthy eating habits [25-27] or the game by Ito et al, which was developed to evaluate the dissemination of public awareness on preschool children’s oral health [28,29]. Regarding games that involve behavior, exergames are the most representative of this category. These games incorporate physical activity in the gameplay and can be used for different purposes such as physical activity encouragement [30-33] or rehabilitation to recover from brain injuries, cognitive impairments [34], or motor deficiencies [35,36]. Finally, with respect to the games that influence health precursors, some examples are games that reduce stress and anxiety [37], deal with depression [38], or prepare for cancer treatments [39]. The game proposed in this paper can be classified as a game designed for nonexpert users to increase their knowledge on a health topic, particularly on first-aid survival techniques.

In the context of the first-aid techniques, different serious games have been proposed. The Virtual Heroes company [40] presented serious games for health care professionals, such as 3DiTeams [41], a first person, multiplayer training app, wherein the player is placed in a high-fidelity virtual hospital; Combat Medic [42], a web-based 3D collaborative virtual world to deal with hemorrhage, airway management, and tension pneumothorax; and HumanSim:Blast [43], wherein after a train station explosion, the player must identify and label zones on an area map, tag potential hazards, assess patient vitals, perform life-saving procedures, and triage patients. In a similar way, the BreakAway Company proposed Code Orange [44], a serious game wherein the players work in concert with the first-aid staff of a hospital to save people injured in a weapon of mass destruction event. Other games for emergency staff training are Nuclear Event Triage Challenge [45], Peninsula City [46], Burn Center [47], and CliniSpace [48]. In the field of cardiopulmonary resuscitation (CPR), Jerin et al proposed the automated external defibrillator challenge, which is a web-based serious game for teaching and training automated external defibrillation and first-aid maneuvers to lay people and emergency medical service professionals [49]. Other proposals are JUST [50], an immersive virtual reality situation training system for nonprofessional health emergency operators; MicroSim Prehospital [51] designed for prehospital training on emergency medical services; and Staying alive [52], an online 3D simulator that provides a learning experience of saving a virtual patient from cardiac arrest in 4 minutes; LISSA [53,54], which presents an emergency situation wherein CPR actions have to be applied to save the person with choking; 30:2 [55], a game designed to educate on CPR protocol to nonexperts; Relive [56], a first person 3D adventure where the player faces different rescue situations; Viva!Game [57], a web-based serious game designed to create awareness on cardiac arrest and CPR; and HeartRun [58], a mobile simulation game to train resuscitation and targeted at giving school children an understanding of this protocol. Recently, Benkhedda and Bendella [59] presented FASim, a 3D serious game that combines health care simulations with serious games and the functionalities of the multiagent systems in a single framework in order to learn the first-aid procedure for and the signs of a cardiac arrest. In the context of choking, Carvalho et al [60] proposed an Android app video game wherein different first-aid actions are presented to familiarize users with these scenarios, choking being one of them.

In most of the cases, the games focused on first-aid procedures have been designed for patients with health issues and the game being tailored to address their health issues adequately [61]. In general, little attention has been paid to nonexperts, although first-aid protocols would be a basic knowledge for everyone. To overcome this limitation, our aim was to exploit the advantages of serious games and use them to promote basic knowledge on choking recovery procedures. Regarding choking procedures, no games related to this topic have been proposed and this is the novel aspect of our approach. The advantages of game-based technologies over traditional education methods have been studied by many authors [62,63]. Game-based technologies are more effective because they use action instead of explanation, they are able to create personal motivation and satisfaction and accommodate multiple learning styles and skills, and they are able to provide an interactive and a decision-making context [64,65]. These facts combined with the extended use of portable gaming platforms makes computer-based games a perfect channel to promote learning contents [66] such as the ones required to educate about the choking procedure.

Serious games have become a useful training technology in the health care profession and for patients to learn about the procedures involved in health care. Serious games are applicable in different fields such as surgery, odontology, cardiology, nursing, diabetes, psychology, or first-aid [16,72-74]. First-aid, triage, and mass emergency are the most popular fields, wherein games have been developed for training residents, medical doctors, or students. However, little attention has been paid to general players with no health issues. In the context of first-aid education, the majority of the proposed games have focused on the CPR protocol [53-55]. However, no games have focused on the procedure to be applied in case of choking. To overcome this limitation, in this paper, we have proposed a game to introduce the main steps of the first-aid procedure in cases of choking for the general population. This game was tested on a sample population of 48 high school students. Although tests have been done with young people, this game in our study has been designed for the general public with no age restrictions.

In the proposed game, the player acquires the role of a helper who has to save a person in a choking emergency by detecting the choking symptoms and applying the main steps of the protocol. This serious game has been designed as a set of minigames, with each minigame focused on a single concept of the protocol. Several authors have demonstrated that the use of serious minigames requires less time to master the game, which has a positive impact on the learning process. In addition, minigames make the study of a subject from different angles more encouraging [75-77]. These advantages have been exploited in this game in our study. Our minigames have very simple mechanics and the interaction is reduced to touch or drag-and-drop actions. The simplicity of this game allows the player to achieve great mastery in a short period of time. The actions reproduce some steps of the protocol that will be transmitted by applying the learning-by-doing strategy. To relate the performed actions with the protocol step, different messages are also provided to the player in the form of instructions or feedback. In addition, there is a help icon to access an animation that presents the gameplay mechanics. Time and score restrictions are imposed to pass each minigame. These restrictions increase when the game advances with the aim of creating an addiction [76].

In the tests, we observed that the players do not access the provided help icon. The players preferred a trial-and-error strategy to discover the game mechanics than the provided animations. However, in some cases, the player reached the end of the game without performing any correct action. It seems that the players prefer the trial-and-error strategy rather than the help option. To avoid this situation, we modified the help activation in such a way that if the game detects a period of time with no correct actions, the help animation is automatically activated. The idea is to reduce this trial-and-error period in order to be more effective with the minigame. In addition, if the help option is on (playing with help mode) when a new game starts, the help animation is automatically activated with no game interruption.

In the tests, we also evaluated player impressions about the game complexity, enjoyability, etc. From the results, we observed that players enjoyed the game irrespective of their gender, their preferences for video games, or their previous experience in a choking emergency. Regarding the acquired knowledge, to evaluate it, pretests and posttests were carried out. We observed that the knowledge on choking and the first-aid procedure for choking was improved through the game. Therefore, the idea of using minigames to introduce the choking concepts becomes ideal for creating an awareness of the topic in an engaging and a quick manner [78]. From these results, we considered that by focusing on protocols composed of different steps, this same strategy can be applied by simply designing serious minigames for each step and integrating all of them in a common story or in a common scenario. In this way, the whole objective of learning a protocol can be decomposed into a set of subobjectives. Although the obtained results were satisfactory, we consider that different improvements need to be done. In our study, we focused on high school students, which is a limiting factor since all of them are in the same range of ages. To overcome this limitation, our idea is to extend the study to a more general population. In addition, we want to evaluate the minigames independently. We detected some game preferences and some difficulties in some minigames but these were obtained from the visual observation and we consider that these observations are not robust enough to be included in the paper. We aim to design a new experiment to carry out this evaluation. Moreover, we have not considered any particular player’s capabilities, needs, and interests. We also want to consider players with visual impairments [70].

In conclusion, serious games are increasingly gaining attention in health care to complement and promote the training of experts in the field. However, little attention has been paid to the use of serious games as a tool to promote health in a nonexpert population. Our study proposes a serious game with the aim of educating on the first-aid procedure for choking. Our game introduces the main steps of the procedure as a set of minigames. It has been tested in a pilot study, and very promising results have been obtained. The students enjoyed the game and, more importantly, their knowledge on the first-aid for choking was found to be greatly improved. We conclude that serious games are a good strategy to promote first-aid knowledge to nonexperts.