This paper is in the following e-collection/theme issue:

Research Letter (2) Learning and Education (73) Innovations in Cardiopulmonary Resuscitation (33) Gamification (124) Games and Gamification for Health (637) e-Learning and Medical Education (682)

Published on in Vol 12 (2024)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/55333, first published .
Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale

Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale

Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale

Authors of this article:

Uri Adrian Prync Flato1, 2 Author Orcid Image ;   Emilio José Beffa dos Santos3 Author Orcid Image ;   Isabella Bispo Diaz T Martins3 Author Orcid Image ;   Vinicius Gazin Rossignoli3 Author Orcid Image ;   Thais Dias Midega1 Author Orcid Image ;   Lucas Kallas-Silva2 Author Orcid Image ;   Ricardo Ferreira Mendes de Oliveira2 Author Orcid Image ;   Adriana do Socorro Lima Figueiredo Flato4 Author Orcid Image ;   Mario Vicente Guimarães1 Author Orcid Image ;   Hélio Penna Guimarães1 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1Hospital Israelita Albert Einstein, , Albert Einstein 626, 513, São Paulo, , Brazil

    2Faculdade Israelita de Ciências em Saúde Albert Einstein, , São Paulo, , Brazil

    3Internal Medicine Department, Universidade de Marília, , Marília, , Brazil

    4Instituto Sanare, , São Paulo, , Brazil

    Corresponding Author:

    Uri Adrian Prync Flato, MD, PhD




    Cardiovascular diseases are among the leading causes of death and morbidity worldwide [1,2]. Cardiopulmonary resuscitation (CPR) and early defibrillation increase survival chances [3]. Serious games (SGs) are tools used to enhance the learning process through entertainment. Current strategies focus on teaching CPR to the community and schoolchildren [4].

    While other games exist for teaching basic life support (BLS), no studies have validated these for children in low- to middle-income settings. The SG Children Save Hearts teaches the 5 resuscitation steps per International Liaison Committee on Resuscitation (ILCOR) guidelines. Before use in schools, it requires a formal usability assessment by game developers and health care professionals to ensure ease of use, learning, and interaction.

    The primary objective was to evaluate the usability of the SG Children Save Hearts among health care and IT professionals using the System Usability Scale (SUS) [5], a validated usability assessment tool.


    Ethical Considerations

    The study protocol was approved by the ethics committee of the University of Marília, Brazil (CAAE: 57160121400005496). All participants signed an informed consent form.

    Study Design

    We used a nonprobabilistic casual sample to include IT and health care professionals. The usability test was conducted in August 2022 in the university’s IT department after a 10-minute lecture on the SG’s purpose. Children Save Hearts was developed on the Microsoft Smile Game Builder platform and implemented on Microsoft Windows (versions 7 to 11), targeting schoolchildren aged 7 to 17 years. The script and storytelling are based on the ILCOR 2020 guidelines. The game uses a joystick and simple commands to simplify the user experience (Multimedia Appendix 1). The design and testing process is illustrated in Figure 1.

    ‎
    Figure 1. Design of a serious game for teaching cardiopulmonary resuscitation among schoolchildren. BLS: basic life support; MVP: minimum viable product; SAMU: Serviço de Atendimento Móvel de Urgência; SUS: System Usability Scale.

    After completing the SG, participants answered a 10-question survey on its usability using a Likert-type scale. The final grade was converted to a 0 to 100 scale (Multimedia Appendix 2). A grade above 70 was considered acceptable to proceed to a minimum viable product. A sample size of 17 users was required, based on a 10% estimated probability of encountering an interface error, to identify 85% of the problems.

    Statistical Analysis

    Categorical variables are presented as absolute and relative frequencies. Continuous variables are presented as medians with IQRs. Normality was assessed with the Shapiro-Wilk test. Comparisons were made between IT and health care professionals. Continuous variables were compared using an independent 2-tailed t test (for normal distributions) or the Mann-Whitney U test (for nonnormal distributions). All analyses were performed using R (version 4.1.0; R Foundation for Statistical Computing).


    Children Save Hearts was used by 17 volunteers with a median age of 22 (IQR 20‐26) years; 8 (47%) were male. Regarding professional training, 8 (47%) held a bachelor’s degree in IT and 9 (53%) were health care professionals. All participants played the game and answered the questionnaire. The median SUS score was 75 (IQR 72.5‐87.5; Table 1). Questions 2 and 4 had the lowest median scores, and questions 7 and 9 had the highest. Health care professionals gave higher grades to all 5 domains when compared to IT professionals. The average time spent in the game was 3.2 (SD 0.4) minutes.

    Table 1. Participant characteristics and System Usability Scale (SUS) scores by profession.
    All (N=17)IT professionals (n=8)HCPsa (n=9)P value
    Participant characteristics
     Age (years), median (IQR)22.00 (20.00-26.00)21.00 (18.75-22.75)24.00 (22.00-27.00).07b
     Male sex, n (%)8 (47)4 (50)4 (44)>.99c
    SUS scores, median (IQR)
     Question 13.00 (3.00-4.00)3.00 (2.00-3.25)4.00 (3.00-4.00).08b
     Question 22.00 (2.00-3.00)2.00 (1.75-3.00)3.00 (2.00-3.00).47b
     Question 33.00 (3.00-4.00)3.00 (3.00-4.00)4.00 (3.00-4.00).36b
     Question 42.00 (2.00-3.00)2.00 (1.75-2.25)2.00 (2.00-3.00).61b
     Question 53.00 (3.00-4.00)3.00 (3.00-3.00)4.00 (3.00-4.00).07b
     Question 64.00 (3.00-4.00)3.00 (2.00-3.25)4.00 (4.00-4.00).002b
     Question 73.00 (3.00-4.00)3.00 (3.00-3.00)4.00 (4.00-4.00).009b
     Question 84.00 (3.00-4.00)3.00 (2.75-3.25)4.00 (4.00-4.00).02b
     Question 94.00 (3.00-4.00)3.00 (3.00-3.25)4.00 (4.00-4.00).03b
     Question 103.00 (3.00-4.00)3.50 (3.00-4.00)3.00 (3.00-4.00).68b
    Analysis, median (IQR)
     Total score30.00 (29.00-35.00)27.50 (25.50-30.50)34.00 (30.00-35.00).05d
     SUS grade75.00 (72.50-87.50)68.75 (63.75-76.25)85.00 (75.00-87.50).05d
     Score for ease of learning domain (Q3, Q4, Q7, Q10)3.25 (2.75-3.25)3.00 (2.50-3.25)3.25 (2.75-3.50).54d
     Score for efficiency domain (Q5, Q6, Q8)3.67 (3.00-4.00)3.00 (2.50-3.17)4.00 (3.67-4.00).02b
     Score for ease of memorization domain (Q2)2.00 (2.00-3.00)2.00 (1.75-3.00)3.00 (2.00-3.00).47b
     Score for minimization of errors domain (Q6)4.00 (3.00-4.00)3.00 (2.00-3.25)4.00 (4.00-4.00).002b
     Score for satisfaction domain (Q1, Q4, Q9)2.67 (2.67-3.33)2.67 (2.33-2.83)3.33 (2.67-3.67).08b

    aHCP: health care professional.

    bMann-Whitney U test.

    cFisher test.

    d2-sample Student t test.


    We developed an SG, Children Save Hearts, to teach BLS to schoolchildren. When tested on 17 IT and health care professionals, it achieved an overall mean SUS score of 75, suitable for implementation.

    Novel technologies like virtual reality (VR) have been successfully used in Europe to teach CPR to schoolchildren [6]. However, transferring this technology to limited-income countries faces challenges, such as language barriers, VR device acquisition, cultural context, and technical support. Previous SGs for teaching CPR were developed and tested in high-income countries [7]. Educational strategies for teaching CPR in limited-income countries have focused on health care professionals and students [8], not schoolchildren, highlighting a significant gap in the literature. This is the first SG developed in Brazil in Portuguese for schoolchildren.

    Our study has some limitations. First, we had a small sample size due to insufficient data to calculate sample size in usability tests and financial constraints in contracting a software house. Continuous usability monitoring with larger sample sizes is needed to maintain external validation. Further studies should target schoolchildren to assess the effectiveness of teaching BLS in schools and explore user experiences to gain insights into how users feel about SGs.

    Active teaching methods are crucial to improving survival rates and translating accessible knowledge into practice. Programs like Kids Save Lives [9] and World Restart a Heart Day [10] are teaching schoolchildren that CPR is vital. Despite some usability issues, the game is adequate for testing in schoolchildren.

    Acknowledgments

    We would like to thank the University of Marília for the use of their facilities and resources. We also thank the participants for their time and dedication to our study.

    Data Availability

    Due to the nature and design of this study, the raw data supporting our findings cannot be made publicly available. The data set contains detailed information that could compromise the privacy and confidentiality of the participants involved. Protecting participant confidentiality is a priority for us, and thus, in adherence to ethical considerations and participant consent agreements, we are unable to deposit our data in publicly accessible repositories or present it within the manuscript or supplementary files.

    Authors' Contributions

    UAPF contributed to conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft), visualization, supervision, project administration, and funding acquisition. EJBdS contributed to conceptualization, validation, investigation, resources, writing (review and editing), visualization, and supervision. IBDTM contributed to software, validation, formal analysis, data curation, and writing (review and editing). VGR contributed to software, validation, investigation, data curation, and writing (review and editing). TDM contributed to methodology, validation, investigation, resources, data curation, writing (review and editing), and visualization. LK–S contributed to writing (original draft, review, and editing) and supervision. RFMdO contributed to writing (original draft, review, and editing) and supervision. AdSLFF contributed to validation, formal analysis, investigation, resources, data curation, and writing (original draft). MVG contributed to methodology, software, validation, investigation, and writing (review and editing). HPG contributed to conceptualization, methodology, writing (original draft), and project administration.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Serious game screenshots and setup.

    PPTX File, 8718 KB
    Multimedia Appendix 2

    System Usability Scale (SUS) questions and domains.

    DOCX File, 15 KB
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    ‎
    BLS: basic life support
    CPR: cardiopulmonary resuscitation
    ILCOR: International Liaison Committee on Resuscitation
    SG: serious game
    SUS: System Usability Scale
    VR: virtual reality

    Edited by Tiffany Leung; submitted 09.12.23; peer-reviewed by Ingjerd Straand, Nilton Cavalcante, Vitor Beninca; final revised version received 14.05.24; accepted 12.07.24; published 09.10.24.

    Copyright

    © Uri Adrian Prync Flato, Emilio José Beffa dos Santos, Isabella Bispo Diaz T Martins, Vinicius Gazin Rossignoli, Thais Dias Midega, Lucas Kallas-Silva, Ricardo Ferreira Mendes de Oliveira, Adriana do Socorro Lima Figueiredo Flato, Mario Vicente Guimarães, Hélio Penna Guimarães. Originally published in JMIR Serious Games (https://games.jmir.org), 9.10.2024.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included.