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The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children.
We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness.
Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction.
Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (
HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend.
Unhealthy lifestyle behaviors (eg, physical inactivity, unhealthy diet, and sedentary time) put individuals at high risk of developing several health conditions (eg, dental caries, hypertension, diabetes, cardiopathy, and cancer) and are key drivers of obesity and being overweight [
Two critical healthy lifestyle behaviors for children are healthy eating and physical activity. Children need to have a correct diet [
Lifestyle interventions should focus on healthy eating and physical activity to have a more significant effect on health [
In recent years, the development of serious games as innovative methods to support health education and treatment initiatives and programs has increased [
Serious games are increasingly being used to encourage children to adopt healthy lifestyle behaviors, leveraging the fact that most children enjoy playing video games [
Video games for promoting healthy lifestyle behaviors in children are aimed to improve knowledge about nutrition, eating habits, and exercise; increase physical activity while playing (exergames); change eating behaviors; or combine several approaches [
We aimed to design and develop a motion-controlled serious game for young children (HelperFriend) and evaluate its feasibility, acceptability, and preliminary effects. We hypothesized that children who played the game would demonstrate (1) better knowledge, (2) greater intention to carry out healthy lifestyle behaviors, and (3) improvements in dietary intake and that (4) children would enjoy playing the game.
HelperFriend was developed by a multidisciplinary team that included nutritionists, psychologists, physical activity experts, human–computer interaction experts, and software engineers based on published design methodology [
HelperFriend integrates experiential and vicarious learning. In experiential learning environment, learners engage in direct experiences to enhance their knowledge, skills, and values through human–environment interaction in a cycle of doing, reflecting, concluding, and trying the learned experience [
In addition, several behavior change techniques [
In HelperFriend, the players are secret agents who need to care for a group of children who forgot healthy lifestyle behaviors because a villain chef erased their memory. In each match, the player needs to ensure that one of these children engages in physical activity, eats well, and performs socioemotional activities to improve their health (
The main screen of HelperFriend: (A) child being cared for, (B) coins score, (C) button to carry out physical activity, (D) button for feeding the child, (E) button to carry out socioemotional activities, (F) health bar of the child, (G) game indicators section, and (H) finish button.
Each module increases in difficulty to keep players engaged and having fun until the end of the video game. Modules have 3 components. The education component teaches basic health knowledge. The training component encourages players to practice healthy lifestyle behaviors. The challenge component presents challenging situations in which players have to help the children.
This module (
Physical activity screens: (A) screen for selecting a physical activity, (B) child doing physical activity, (C) alert feedback screen because the player selected a sedentary activity, and (D) physical activity situation in which the child needs the player's help.
This module (
Healthy eating screens: (A) screen teaching player about complete diet, (B) screen for selecting food, (C) feeding information screen, and (D) feeding situation in which the child needs the player's help.
This module (
Socioemotional wellness screens: (A) screen where the child shows a socioemotional situation to the player, (B) screen for selecting a socioemotional activity, (C) alert feedback message because the player made an inadequate socioemotional activity choice, and (D) socioemotional situation in which the child needs the player's help.
We conducted a parallel randomized controlled pilot trial over 4 weeks between May and June 2019 in an elementary school in Mexico.
School administrators and teachers gave written permission for the trial to be performed at school facilities. All study procedures were approved by the institutional review board of the
Students (n=40) from 3 school groups was considered for this study. Inclusion criteria were being aged 8 to 11 years and not receiving pharmacological treatment. Exclusion criteria were having been diagnosed with or having an ongoing neuropsychiatric disorder, a physical problem (because the game required children to interact through whole-body movements), and obesity treatment in the past 6 months. Written informed consent was obtained from parents of children who expressed interest in participating in the study.
Children were randomly allocated to either the control group or the intervention group. The children in the intervention group played HelperFriend during six 30-minute game sessions. All playing sessions were conducted over 21 days. We set up 3 gaming stations in a room; each station contained a PC, a 50-inch screen, a Kinect sensor V2, and the HelperFriend video game. Participants in the control group received only a 45-minute talk about the importance of healthy behaviors, such as engaging in physical activity, eating healthy, and maintaining socioemotional health; no further intervention was applied.
Outcomes were assessed in both groups the week after being assigned to the groups (T0) and 4 weeks after baseline (T1). The primary outcome was the gain in knowledge measured using a questionnaire (developed by the research group and designed specifically for the serious game). The questionnaire was evaluated in a pilot with 5 children and adapted. The final questionnaire consisted of 82 questions in 3 sections: physical activity (13 questions, each with 3 response options), healthy eating (64 questions, each with 3 to 5 response options in food groups, food portions equivalence, correct diet, and healthy/unhealthy food subsections), and socioemotional wellness (5 questions, each with 4 response options).
Healthy behaviors knowledge questionnaire example questions.
Secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player experience satisfaction.
Children’s intention to conduct healthy behaviors was measured using a questionnaire tailored specifically for the serious game. The questionnaire was pilot-tested with 5 children and adapted. The final questionnaire (
Dietary behavior was measured with a food frequency intake questionnaire [
Player experience satisfaction was only assessed in the intervention group (at T1). An adapted version of the Game User Experience Satisfaction Scale [
Data were analyzed using SPSS software (version 26; IBM Corp). The statistical significance for all analyses was
Of 40 children approached for the trial, 27 (68%) children agreed to participate (age: mean 9.9 years, SD 0.9 years; girls: 16/27, 59%; boys: 11/27, 41%). The control group had 12 participants (age: mean 9.8 years, SD 0.62; girls: 7/12, 58%; boys: 4/12, 33%), and the intervention group had 15 participants (age: mean 9.9 years, SD 0.94; girls: 9/15, 60%; boys: 6/15, 40%). We created a game environment where children felt comfortable during game sessions; however, 1 child missed 1 session, and 6 children missed 2 sessions. Participants in the intervention group played an average of 3.1 hours.
Knowledge of intervention group participants increased significantly from T0 to T1 for physical activity (
Outcomes of healthy behaviors knowledge and intention to conduct healthy behaviors.
Measure | Items, n | Control group | Intervention group | Between-group postintervention comparison | |||||||||
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Baseline (T0), mean (SD) | Postintervention (T1), mean (SD) | Baseline (T0), mean (SD) | Postintervention (T1), mean (SD) | |||||||
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Physical activity | 13 | 4 (1.5) | 4.08 (1.6) | .39 | 4.5 (2) | 5.7 (2.4) | .03 | .03 | ||||
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Healthy eating | 64 | 38.9 (11.9) | 38.3 (12.9) | .27 | 40 (9.2) | 45.5 (7.1) | .003 | .04 | ||||
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Socioemotional wellness | 5 | 1.83 (1.2) | 1.83 (1.2) | .50 | 2.1 (1.2) | 2.9 (1.4) | .008 | .03 | ||||
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Physical activity | 4 | 2.4 (1.4) | 2.3 (1.4) | .22 | 2.13 (1.6) | 3.07 (0.8) | .006 | .03 | ||||
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Healthy eating | 24 | 13.9 (4.3) | 14.2 (3.5) | .35 | 13.5 (3.5) | 16.3 (2.2) | .002 | .03 | ||||
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Socioemotional wellness | 5 | 4.4 (1.2) | 4.5 (0.8) | .41 | 4.6 (0.5) | 4.9 (0.25) | .009 | .01 |
Intention to perform healthy behaviors in the intervention group increased from T0 to T1 for physical activity (
Participants in the intervention group reported reduced consumption frequency of ham, sausage, soft drinks, wheat burritos, hamburgers, breaded chicken, sopes, tamales, salt peanuts, sweet cookies, potatoes chips, cake, and sweet soft cakes. Participants in the control group indicated reduced self-reported frequency intake of 5 healthy foods (cantaloupe, carrot, fish soup, fish ceviche, and fresh fruit juice) and 1 unhealthy food (bottled fruit juice) (
Outcomes of food frequency intake.
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Classification | Baseline (T0) scorea, median (IQR) | Postintervention (T1) scorea, median (IQR) | |
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Ham | Unhealthy | 2 (1.3) | 1 (2) | .02 |
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Sausage | Unhealthy | 2 (1.3) | 1 (2) | .02 |
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Soft drinks | Unhealthy | 1 (2) | 1 (2) | .02 |
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Wheat burritos | Unhealthy | 1 (2) | 0 (1) | .03 |
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Hamburgers | Unhealthy | 1 (1) | 1 (1) | .01 |
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Breaded chicken | Unhealthy | 0 (1) | 0 (0) | .048 |
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Sopes | Unhealthy | 2 (1.3) | 0 (1) | .02 |
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Tamales | Unhealthy | 1 (1) | 0 (1) | .02 |
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Salt peanuts | Unhealthy | 1 (1.3) | 0 (1) | .04 |
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Sweet cookies | Unhealthy | 1 (1.3) | 0 (1.25) | .01 |
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Potato chips | Unhealthy | 1 (1) | 0 (1) | .03 |
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Cake | Unhealthy | 1 (1.3) | 0 (1) | .04 |
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Sweet soft cakes | Unhealthy | 1 (0.3) | 0 (1) | .02 |
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Cantaloupe | Healthy | 1 (1.25) | 0 (1) | .047 |
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Carrot | Healthy | 1 (2) | 0 (1) | .02 |
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Fish soup | Healthy | 0.5 (2) | 0 (0) | .03 |
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Fish ceviche | Healthy | 2 (1.15) | 0.5 (1) | .04 |
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Fresh fruit juice | Healthy | 1.5 (2.25) | 0 (1) | .02 |
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Bottle fruit juice | Unhealthy | 1.5 (1.25) | 0.5 (1) | .04 |
a0 indicated never, 1 indicated one to three times per month, 2 indicated once per week, 3 indicated two to four times per week, 4 indicated five to six times per week, 5 indicated daily, and 6 indicated two or more times per day.
Satisfaction ratings were significantly higher than the neutral value for all domains: playability (
Player satisfaction questionnaire results.
Measure | Items, n | Cronbach |
Mean (SD) | Neutral value | Lower | Upper | |
Playability | 9 | .76 | 4 (0.5) | 3 | <.001 | 2.8 | 5 |
Narrative | 2 | .56 | 3.9 (0.9) | 3 | <.001 | 1.5 | 5 |
Enjoyment | 3 | .73 | 4 (0.8) | 3 | <.001 | 2.7 | 5 |
Creative freedom | 2 | .73 | 4.1 (0.6) | 3 | <.001 | 3 | 5 |
Audio aesthetics | 3 | .90 | 4.1 (1) | 3 | <.001 | 1.7 | 5 |
Personal gratification | 4 | .75 | 4.2 (0.7) | 3 | <.001 | 2.5 | 5 |
Visual aesthetics | 2 | .85 | 4 (0.8) | 3 | <.001 | 2.5 | 5 |
Children in the intervention group significantly improved their knowledge about physical activity (
Second, we hypothesized that the intention to conduct physical activity, healthy eating, and healthy socioemotional behaviors would be higher after the intervention; we also verified this hypothesis. A previous study [
The third hypothesis stated that, after the intervention, children's diets would improve. A lower intake frequency was found for 13 unhealthy foods (such as soft drinks, hamburgers, sweet cookies, potatoes chips, and sweet soft cakes). These changes are relevant because Mexican children commonly consume these foods in schools and at home [
The fourth hypothesis was also verified; children felt good during gameplay, and game acceptance was high. HelperFriend obtained very positive results on personal gratification, playability, creative freedom, enjoyment, narrative, and visual and audio aesthetics—factors which have been shown to be correlated with and predictors of learning [
First, the results should be cautiously interpreted because a small group of children participated in the study. However, given that we aimed to evaluate the feasibility, acceptability, and preliminary effects of HelperFriend, our findings can offer valuable information in designing health games for children to improve lifestyle behaviors and that consider socioemotional issues. Second, medium- and long-term effects were not examined. Medium- and long-term studies could provide interesting findings since video games, especially those involving physical activity, can become boring quickly [
We plan to conduct a randomized controlled clinical trial with sample size calculation to address some of these limitations. Moreover, we plan to extend the exposure period and conduct repeated exposure to account for medium- and long-term effects. Finally, we plan to improve the intention questionnaire and include another behavioral test (eg, physical activity).
HelperFriend, a vicarious experiential health game for promoting physical activity, healthy eating, and socioemotional wellness, appears to be feasible and acceptable for young children. Preliminary results suggest that this game improves knowledge about and the intention to conduct healthy lifestyle behaviors and improves dietary intake in children. In future versions of HelperFriend, some game elements should be improved and other behavior change techniques that promote children's intake of healthy foods should be integrated. Given that this was a pilot study with a limited sample size, a well-powered randomized controlled trial is needed to determine the efficacy of HelperFriend.
Video of the game.
Intention to conduct healthy behaviors questionnaire.
This work was supported by Mexican National Council for Science and Technology (grant PDCPN-2015-824). We are thankful to the manager of
IEEC designed the game and experiment, performed all statistical analyses, and drafted the manuscript. EEPB developed the game and participated in running the experiment. MHA conducted the experiment and performed data collection and processing. EEDP and MENJ designed the game also provided the game's psychological and nutritional foundations. JMM and HPE analyzed and interpreted data and drafted the manuscript. All authors reviewed the final manuscript.
None declared.