@Article{info:doi/10.2196/16841,
author="Zhao, Yinan
and Feng, Hui
and Wu, Xinyin
and Du, Yan
and Yang, Xiufen
and Hu, Mingyue
and Ning, Hongting
and Liao, Lulu
and Chen, Huijing
and Zhao, Yishan",
title="Effectiveness of Exergaming in Improving Cognitive and Physical Function in People With Mild Cognitive Impairment or Dementia: Systematic Review",
journal="JMIR Serious Games",
year="2020",
month="Jun",
day="30",
volume="8",
number="2",
pages="e16841",
keywords="mild cognitive impairment; dementia; exergaming; physical; cognitive",
abstract="Background: Individuals with mild cognitive impairment and dementia have impaired physical and cognitive functions, leading to a reduced quality of life compared with those without such impairment. Exergaming, which is defined as a combination of exercise and gaming, is an innovative, fun, and relatively safe way to exercise in a virtual reality or gaming environment. Therefore, exergaming may help people living with mild cognitive impairment or dementia to overcome obstacles that they may experience regarding regular exercise and activities. Objective: The aim of this systematic review was to review studies on exergaming interventions administered to elderly individuals with mild cognitive impairment and dementia, and to summarize the results related to physical and cognitive functions such as balance, gait, executive function, and episodic memory. Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PsycINFO, Amed, and Nursing Database for articles published from the inception of the respective databases to January 2019. We included all clinical trials of exergaming interventions in individuals with mild cognitive impairment and dementia for review. The risk of bias was independently evaluated by two reviewers using the Cochrane Collaboration and Risk of Bias in Non-randomized Studies of Interventions tools. Results: Ten studies involving 702 participants were included for review. There was consistent evidence from 7 studies with a low risk of bias showing statistically significant effects of exergaming on cognitive functioning in people with mild cognitive impairment and dementia. With respect to physical function, 3 of 5 full-scale studies found positive results, and the intensity of most games was classified as moderate. Conclusions: Overall, exergaming is an innovative tool for improving physical and cognitive function in people with mild cognitive impairment or dementia, although there is high heterogeneity among studies in terms of the duration, frequency, and gaming platform used. The quality of the included articles was moderate to high. More high-quality studies with more accurate outcome indicators are needed for further exploration and validation of the benefits of exergaming for this population. ",
doi="10.2196/16841",
url="http://games.jmir.org/2020/2/e16841/",
url="https://doi.org/10.2196/16841",
url="http://www.ncbi.nlm.nih.gov/pubmed/32602841"
}


@Article{info:doi/10.2196/16354,
author="Radha, Mustafa
and den Boer, Niels
and Willemsen, Martijn C
and Paardekooper, Thom
and IJsselsteijn, Wijnand A
and Sartor, Francesco",
title="Assisting Home-Based Resistance Training for Normotensive and Prehypertensive Individuals Using Ambient Lighting and Sonification Feedback: Sensor-Based System Evaluation",
journal="JMIR Cardio",
year="2020",
month="Jun",
day="29",
volume="4",
number="1",
pages="e16354",
keywords="hypertension; sonification; respiratory guidance; intrinsic motivation; physical exertion",
abstract="Background: Physical exercise is an effective lifestyle intervention to improve blood pressure. Although aerobic sports can be performed anywhere, resistance exercises are traditionally performed at the gym; extending the latter to the home setting may promote an increase in the number of practitioners. Objective: This study aims to evaluate a sensor-based system that guides resistance exercises through ambient lighting and sonification (A/S) feedback in a home setting in 34 study participants who were normotensive and prehypertensive. Methods: Participants took part in a 1.5-hour exercise session in which they experienced the A/S feedback (ie, experimental condition) as well as a control condition (ie, no feedback) and a reference condition (ie, verbal feedback through a human remote coach). The system was evaluated for improving exercise form (range of motion, timing, and breathing patterns) as well as psychophysiological experience (perceived exertion, attentional focus, competence, and motivation). Results: A/S feedback was significantly better than the control for concentric (mean 2.48, SD 0.75 seconds; P<.001) and eccentric (mean 2.92, SD 1.05 seconds; P<.001) contraction times, concentric range of motion consistency (mean 15.64, SD 8.31 cm vs mean 17.94, SD 9.75 cm; P<.001), and perceived exertion (mean 3.37, SD 0.78 vs mean 3.64, SD 0.76; P<.001). However, A/S feedback did not outperform verbal feedback on any of these measures. The breathing technique was best in the control condition (ie, without any feedback). Participants did not show more positive changes in perceived competence with A/S feedback or verbal feedback. Conclusions: The system seemed to improve resistance exercise execution and perception in comparison with the control, but did not outperform a human tele-coach. Further research is warranted to improve the breathing technique. ",
doi="10.2196/16354",
url="https://cardio.jmir.org/2020/1/e16354",
url="https://doi.org/10.2196/16354",
url="http://www.ncbi.nlm.nih.gov/pubmed/32597789"
}


@Article{info:doi/10.2196/15635,
author="Pallavicini, Federica
and Pepe, Alessandro",
title="Virtual Reality Games and the Role of Body Involvement in Enhancing Positive Emotions and Decreasing Anxiety: Within-Subjects Pilot Study",
journal="JMIR Serious Games",
year="2020",
month="Jun",
day="17",
volume="8",
number="2",
pages="e15635",
keywords="virtual reality; virtual reality gaming; video games; emotions; positive emotions; anxiety; state anxiety",
abstract="Background: In the last few years, the introduction of immersive technologies, especially virtual reality, into the gaming market has dramatically altered the traditional concept of video games. Given the unique features of virtual reality in terms of interaction and its ability to completely immerse the individual into the game, this technology should increase the propensity for video games to effectively elicit positive emotions and decrease negative emotions and anxiety in the players. However, to date, few studies have investigated the ability of virtual reality games to induce positive emotions, and the possible effect of this new type of video game in diminishing negative emotions and anxiety has not yet been tested. Furthermore, given the critical role of body movement in individuals' well-being and in emotional responses to video games, it seems critical to investigate how body involvement can be exploited to modulate the psychological benefits of virtual reality games in terms of enhancing players' positive emotions and decreasing negative emotions and anxiety. Objective: This within-subjects study aimed to explore the ability of commercial virtual reality games to induce positive emotions and diminish negative emotions and state anxiety of the players, investigating the effects of the level of body involvement requested by the game (ie, high vs low). Methods: A total of 36 young adults played a low body-involvement (ie, Fruit Ninja VR) and a high body-involvement (ie, Audioshield) video game in virtual reality. The Visual Analogue Scale (VAS) and the State-Trait Anxiety Inventory, Form-Y1 (STAI-Y1) were used to assess positive and negative emotions and state anxiety. Results: Results of the generalized linear model (GLM) for repeated-measures multivariate analysis of variance (MANOVA) revealed a statistically significant increase in the intensity of happiness (P<.001) and surprise (P=.003) and, in parallel, a significant decrease in fear (P=.01) and sadness (P<.001) reported by the users. Regarding the ability to improve anxiety in the players, the results showed a significant decrease in perceived state anxiety after game play, assessed with both the STAI-Y1 (P=.003) and the VAS-anxiety (P=.002).  Finally, the results of the GLM MANOVA showed a greater efficacy of the high body-involvement game (ie, Audioshield) compared to the low body-involvement game (ie, Fruit Ninja VR), both for eliciting positive emotions (happiness, P<.001; and surprise, P=.01) and in reducing negative emotions (fear, P=.05; and sadness, P=.05) and state anxiety, as measured by the STAI-Y1 (P=.05). Conclusions: The two main principal findings of this study are as follows: (1) virtual reality video games appear to be effective tools to elicit positive emotions and to decrease negative emotions and state anxiety in individuals and (2) the level of body involvement of the virtual video game has an important effect in determining the ability of the game to improve positive emotions and decrease negative emotions and state anxiety of the players. ",
doi="10.2196/15635",
url="http://games.jmir.org/2020/2/e15635/",
url="https://doi.org/10.2196/15635",
url="http://www.ncbi.nlm.nih.gov/pubmed/32554371"
}


@Article{info:doi/10.2196/16261,
author="O'Loughlin, Erin
and Sabiston, Catherine M
and Kakinami, Lisa
and McGrath, Jennifer J
and Consalvo, Mia
and O'Loughlin, Jennifer L
and Barnett, Tracie A",
title="Development and Validation of the Reasons to Exergame (RTEX) Scale in Young Adults: Exploratory Factors Analysis",
journal="JMIR Serious Games",
year="2020",
month="Jun",
day="15",
volume="8",
number="2",
pages="e16261",
keywords="exergaming; youth; young adults; motivation; scale",
abstract="Background: Exergaming is associated with positive health benefits; however, little is known about what motivates young people to exergame. Objective: This study aimed to develop a new Reasons to Exergame (RTEX) scale and describe its psychometric properties (Study 1) including test-retest reliability (Study 2). We also examined the test-retest reliability of self-report exergaming behavior measures (Study 2). Methods: We identified scale items in consultation with experts. In Study 1, we conducted an Exploratory Factor Analysis of RTEX and examined how the factors identified relate to exergaming frequency and intensity in a population-based sample of 272 young adults. In Study 2, we examined the test-retest reliability of RTEX factors and self-report measures of past-week exergaming frequency and intensity among 147 college students. Results: We identified four factors in RTEX: exergaming for fitness, exergaming for enjoyment, preferring exergaming over other gaming options, and choosing exergaming over competing interests (eg, sports). Test-retest reliability of RTEX factors (ICC 0.7-0.8) and self-report exergaming frequency (ICC 0.4-0.9) was adequate. Exergaming for fitness and enjoyment were positively associated with the frequency of exergaming with friends and family, and with exergaming intensity. Preferring exergaming over other gaming options and choosing exergaming over competing interests (eg, sports) were not related to exergaming behavior. Conclusions: RTEX is a psychometrically sound scale with four factors that measure reasons to exergame. Replication of these findings is needed in larger, more diverse samples. ",
doi="10.2196/16261",
url="http://games.jmir.org/2020/2/e16261/",
url="https://doi.org/10.2196/16261",
url="http://www.ncbi.nlm.nih.gov/pubmed/32538792"
}


@Article{info:doi/10.2196/17112,
author="Wong, Rosa Sze Man
and Ho, Frederick Ka Wing
and Tung, Keith Tsz Suen
and Fu, King-Wa
and Ip, Patrick",
title="Effect of Pok{\'e}mon Go on Self-Harm Using Population-Based Interrupted Time-Series Analysis: Quasi-Experimental Study",
journal="JMIR Serious Games",
year="2020",
month="Jun",
day="12",
volume="8",
number="2",
pages="e17112",
keywords="Pok{\'e}mon Go; self-harm; mobile game; injury; mHealth interventions; interrupted time-series analysis",
abstract="Background: Pok{\'e}mon Go is a very popular location-based augmented reality game with widespread influences over the world. An emerging body of research demonstrates that playing Pok{\'e}mon Go can lead to improvements in physical activity and psychosocial well-being; however, whether Pok{\'e}mon Go reduces self-harm incidence at the population-level is still questionable. Objective: This study aimed to quantify how the launch of Pok{\'e}mon Go in Hong Kong affected the incidence of self-harm using a quasi-experimental design. Methods: An interrupted time-series design with Poisson segmented regression adjusted for time and seasonality trends was used on data from 2012 to 2018 to detect any changes in the number of accident and emergency attendances due to self-harm, after Pok{\'e}mon Go was launched. The findings were validated using a baseline control period and using other intentional injuries and minor noninjuries as control outcomes. We also assessed intervention effects by age group. Results: From January 1, 2012 to July 31, 2018, there were 13,463 accident and emergency attendances due to self-harm in Hong Kong. During the period after launching Pok{\'e}mon Go, self-harm attendances dropped by 34{\%} (adjusted incidence rate ratio: 0.66, 95{\%} CI 0.61-0.73). When analyzed by age group, a reduction in self-harm incidence was only apparent in adults (18 to 24 years of age: adjusted incidence rate ratio: 0.78, P=.02; 25 to 39 years of age: adjusted incidence rate ratio: 0.75, P<.001; 40 years of age and older: adjusted incidence rate ratio: 0.57, P<.001). Conclusions: Self-harm incidence in the population, particularly in adults, showed a significant decline in the period after Pok{\'e}mon Go was launched. Augmented reality games such as Pok{\'e}mon Go show great promise as a tool to enhance psychosocial well-being and improve mental health. ",
doi="10.2196/17112",
url="http://games.jmir.org/2020/2/e17112/",
url="https://doi.org/10.2196/17112",
url="http://www.ncbi.nlm.nih.gov/pubmed/32530429"
}


@Article{info:doi/10.2196/15339,
author="Fornasini, Silvia
and Dianti, Marco
and Bacchiega, Alessandro
and Forti, Stefano
and Conforti, Diego",
title="Using Geocaching to Promote Active Aging: Qualitative Study",
journal="J Med Internet Res",
year="2020",
month="Jun",
day="11",
volume="22",
number="6",
pages="e15339",
keywords="geocaching; active ageing; elderly empowerment; qualitative methods",
abstract="Background: Over the past few years, the development of technologies supporting active aging has been increasing. Among the activities that promote physical exercise by using technologies is geocaching---a treasure hunt of sorts in which participants use a receiver GPS to hide or find real or virtual objects. Although this activity is particularly suited to the promotion of healthy lifestyles in older people, geocaching remains to be unexplored in this area. Objective: This study aimed to investigate the effectiveness of activities combining geocaching and self-tracking technologies to promote active aging, evaluate the usability of technologies, and explore the ways in which technologies have been integrated in the organizational context under examination to determine the user experience of participants. Methods: A group of individuals aged 65 years and older (N=14) attending a senior center managed by a social cooperative was involved in the study. Some of them created the geocaching contents, and others, split into 2 teams, participated in the game. Each participant was given a pedometer bracelet and the geocaching app. The steps taken by individual participants along with the number of caches found by each group translated into team scores. Results: The main results of the study were as follows: (1) activities in favor of active aging that involve the use of new technologies can foster the participation of elderly people; in particular, adding gamification to self-tracking can be a valid strategy to promote physical exercise among the elderly; (2) for this to happen, involvement of older people firsthand is crucial, and there must be a focus on their active involvement and empowerment in every phase of the project; and (3) the mediation of conflicts and competition that arise from the gamification could only take place because of the strong support of the organization in the form of social workers. Conclusions: The results show that promoting active aging through technologies requires more effort than simply using these tools; it requires a wider process that involves an articulated organizational network with heterogeneous actors, technologies, and relations. ",
doi="10.2196/15339",
url="http://www.jmir.org/2020/6/e15339/",
url="https://doi.org/10.2196/15339",
url="http://www.ncbi.nlm.nih.gov/pubmed/32525486"
}


@Article{info:doi/10.2196/17884,
author="Poli, Arianna
and Kelfve, Susanne
and Klompstra, Leonie
and Str{\"o}mberg, Anna
and Jaarsma, Tiny
and Motel-Klingebiel, Andreas",
title="Prediction of (Non)Participation of Older People in Digital Health Research: Exergame Intervention Study",
journal="J Med Internet Res",
year="2020",
month="Jun",
day="5",
volume="22",
number="6",
pages="e17884",
keywords="technology; exclusion; recruitment; self-selection; nonparticipation",
abstract="Background: The use of digital technologies is increasing in health care. However, studies evaluating digital health technologies can be characterized by selective nonparticipation of older people, although older people represent one of the main user groups of health care. Objective: We examined whether and how participation in an exergame intervention study was associated with age, gender, and heart failure (HF) symptom severity. Methods: A subset of data from the HF-Wii study was used. The data came from patients with HF in institutional settings in Germany, Italy, the Netherlands, and Sweden. Selective nonparticipation was examined as resulting from two processes: (non)recruitment and self-selection. Baseline information on age, gender, and New York Heart Association Functional Classification of 1632 patients with HF were the predictor variables. These patients were screened for HF-Wii study participation. Reasons for nonparticipation were evaluated. Results: Of the 1632 screened patients, 71{\%} did not participate. The nonrecruitment rate was 21{\%}, and based on the eligible sample, the refusal rate was 61{\%}. Higher age was associated with lower probability of participation; it increased both the probabilities of not being recruited and declining to participate. More severe symptoms increased the likelihood of nonrecruitment. Gender had no effect. The most common reasons for nonrecruitment and self-selection were related to physical limitations and lack of time, respectively. Conclusions: Results indicate that selective nonparticipation takes place in digital health research and that it is associated with age and symptom severity. Gender effects cannot be proven. Such systematic selection can lead to biased research results that inappropriately inform research, policy, and practice. Trial Registration: ClinicalTrial.gov NCT01785121, https://clinicaltrials.gov/ct2/show/NCT01785121 ",
doi="10.2196/17884",
url="http://www.jmir.org/2020/6/e17884/",
url="https://doi.org/10.2196/17884",
url="http://www.ncbi.nlm.nih.gov/pubmed/32501275"
}


@Article{info:doi/10.2196/16000,
author="Yu, Chin-Wen
and Rau, Pei-Luen Patrick
and Liu, Xueqian",
title="Development and Preliminary Usability Evaluation of a Somatosensory Square Dance System for Older Chinese Persons: Mixed Methods Study",
journal="JMIR Serious Games",
year="2020",
month="May",
day="28",
volume="8",
number="2",
pages="e16000",
keywords="older persons; chinese square dance; somatosensory games; somatosensory square dance system; physical exercise",
abstract="Background: Chinese square dancing, known as guangchang wu in Chinese, is a well-known public fitness activity that provides an entertaining way for older Chinese women to improve their flexibility, lower extremity strength, overall coordination, and balance. However, injuries, noise conflicts, and lack of space are challenging aspects of this activity. Somatosensory games (SG) are an increasingly popular physical fitness approach to enhance the selective attention of older persons with indoor engagement and exercises. Objective: The objectives of this study were to develop a newly designed somatosensory square dance system for older Chinese people and to evaluate its usability. Methods: This is a mixed methods study. The newly designed somatosensory square dance system is a somatic training tool that provides adequate Chinese square dance fitness training based on Laban Movement Analysis (LMA) and design guidelines established in a previous stage. The usability evaluation involved a questionnaire and interviews. Twelve participants were interviewed before and after experiencing the 15-minute dancing and learning process within the program. In addition, participants scored their experience satisfaction in psychological, physiological, and relaxation sections on a scale of 1 to 5 using a questionnaire. Qualitative content analysis and quantitative analysis of the satisfaction scores supported understanding of usability problems. Results: Based on the interview results, 6/12 (50{\%}) of the participants thought the system could help them correct their dancing movements indoors without being affected by poor outdoor weather. Among the participants, 3/12 (25{\%}) indicated that this indoor system could enable them to enjoy fitness activities in a private space. Moreover, 3/12 participants (25{\%}) stated that this system could promote family relationships by providing easy dancing movements. All participants were highly satisfied with the relaxation aspect of the system (4.45/5). The participants were all psychologically satisfied and interested in the novel features of the system, with an average score of 4.16/5. Physiologically, participants affirmed that the system could help them maintain good health (4.91/5). Conclusions: The results of this study suggest that the somatosensory square dance system can be used as an indoor fitness tool to improve older Chinese square dancers' health conditions with reasonable dance training. Noise and space conflicts can be addressed. The Laban Elated Square Dance system, which was modified by therapists based on LMA and square dance design guidelines, was highly approved by dancers because it decreased the possibility of injuries, falls, and joint damage by considering the physical and psychological difficulties of older persons. Different features will be considered in the next stage, such as greater selection of exercises and difficulty level settings. Users' social needs will also be explored in subsequent stages. ",
doi="10.2196/16000",
url="http://games.jmir.org/2020/2/e16000/",
url="https://doi.org/10.2196/16000",
url="http://www.ncbi.nlm.nih.gov/pubmed/32463376"
}


@Article{info:doi/10.2196/13190,
author="Flogie, Andrej
and Aber{\v{s}}ek, Boris
and Kordigel Aber{\v{s}}ek, Metka
and Sik Lanyi, Cecilia
and Pesek, Igor",
title="Development and Evaluation of Intelligent Serious Games for Children With Learning Difficulties: Observational Study",
journal="JMIR Serious Games",
year="2020",
month="Apr",
day="16",
volume="8",
number="2",
pages="e13190",
keywords="serious games, experimental; social skills; cognitive competence; intellectual disability; learning disabilities",
abstract="Background: Positive results can be obtained through game-based learning, but children with physical disabilities have fewer opportunities to participate in enjoyable physical activity. Because intelligent serious games can provide personalized learning opportunities, motivate the learner, teach 21st-century skills, and provide an environment for authentic and relevant assessment, they may be used to help children and adolescents with different kinds of learning disabilities to develop social and cognitive competences. Objective: The aim of the study was to produce and evaluate a suite of intelligent serious games based on accessible learning objectives for improving key skills, personal development, and work sustainability among children with learning difficulties. Methods: We conducted this research between 2016 and 2018, with pupils aged 11 to 12 years with learning disabilities who were integrated into the mainstream educational system. We used a 4-step methodology to develop learner creativity and social competences: (1) needs analysis, (2) development of learning content, (3) development of intelligent serious games, and (4) a usability evaluation focusing on the research questions and hypothesis. This was based on an initial teachers' evaluation, using a survey, of students using 2 of the games, where the main goal was to determine user motivation and initiative and to improve the games and the evaluation process. The initial evaluation was followed by a pilot evaluation, which was performed for all proposed games, in all partner countries. Results: In an initial evaluation with 51 participants from Slovenia consisting of a pretest, followed by intelligent serious game intervention and concluding with a posttest, we observed statistically significant improvement in social and cognitive competences measured by tests. Based on these findings and observations, we improved the games and evaluation process. In the pilot test, conducted in all participating countries on a sample of 93 participants, the mean score on the teachers' observation form on the pretest (before students began using the intelligent serious games) was 3.9. In the posttest, after students had used intelligent serious games, the mean score was 4.1. Conclusions: We focused on developing and evaluating intelligent serious games for persons with learning disabilities, particularly for students with disabilities who are integrated into the mainstream educational system. Such games provide an opportunity for personalized learning and should be tailored to ensure that every learner can achieve the highest standard possible. However, we recommend that the games be adapted based on the students' needs and capabilities and a specially developed curriculum. The collected feedback showed that (1) children with learning disabilities need appropriately developed intelligent serious games, and (2) intelligent serious games, and the pertaining didactic methodology, should be based on an interoperable curriculum, so that teachers and trainers can use them. The student survey confirmed improvements in all aspects. ",
doi="10.2196/13190",
url="https://games.jmir.org/2020/2/e13190",
url="https://doi.org/10.2196/13190",
url="http://www.ncbi.nlm.nih.gov/pubmed/32297864"
}


@Article{info:doi/10.2196/14549,
author="Bossen, Dani{\"e}l
and Broekema, Aline
and Visser, Bart
and Brons, Annette
and Timmerman, Annieck
and van Etten-Jamaludin, Faridi
and Braam, Katja
and Engelbert, Raoul",
title="Effectiveness of Serious Games to Increase Physical Activity in Children With a Chronic Disease: Systematic Review With Meta-Analysis",
journal="J Med Internet Res",
year="2020",
month="Apr",
day="1",
volume="22",
number="4",
pages="e14549",
keywords="video games; computer games; pediatrics; chronic disease; exercise therapy; health education",
abstract="Background: Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. Objective: The primary purpose of this systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease. Methods: PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library, and CINAHL were systematically searched for articles published from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included to examine the effects of serious games on PA levels in children with a chronic disease. Two investigators independently assessed the intervention, methods, and methodological quality in all articles using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed. Results: This systematic review included 9 randomized controlled trials (886 participants). In 2 of the studies, significant between-group differences in PA levels in favor of the intervention group were reported. The meta-analysis on PA levels showed a nonsignificant effect on moderate to vigorous PA (measured in minutes per day) between the intervention and control groups (standardized mean difference 0.30, 95{\%} CI --0.15 to 0.75, P=.19). The analysis of body composition resulted in significantly greater reductions in BMI in the intervention group (standardized mean difference --0.24, 95{\%} CI --0.45 to 0.04, P=.02). Conclusions: This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects with significantly greater reductions in BMI in favor of the intervention group. A high percentage of nonuse was identified in the study of serious games, and little attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs, and limited details about the interventions were the main limitations. Future research should determine which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques. ",
doi="10.2196/14549",
url="https://www.jmir.org/2020/4/e14549",
url="https://doi.org/10.2196/14549",
url="http://www.ncbi.nlm.nih.gov/pubmed/32234697"
}


@Article{info:doi/10.2196/14182,
author="Brauner, Philipp
and Ziefle, Martina",
title="Serious Motion-Based Exercise Games for Older Adults: Evaluation of Usability, Performance, and Pain Mitigation",
journal="JMIR Serious Games",
year="2020",
month="Apr",
day="1",
volume="8",
number="2",
pages="e14182",
keywords="serious games; exercise game; health care; pain; ambient assisted living; technology acceptance",
abstract="Background: Many societies are facing demographic changes that challenge the viability of health and welfare systems. Serious games for health care and ambient assisted living (AAL) offer health benefits and support for older adults and may mitigate some of the negative effects of the demographic shift. Objective: This study aimed to examine the acceptance of serious games to promote physical health in AAL environments. Since AAL environments are designed specifically to support independent living in older adults, we studied the relationship among age and user diversity, performance in the game, and overall usability and acceptance evaluation. Methods: We developed a motion-based serious exercise game for prototypical AAL environments. In two evaluations, outside (n=71) and within (n=64) the AAL environment, we investigated the influence of age, gender, self-efficacy in interacting with technology, need for achievement on performance, effect of the game, usability evaluation of the game, and overall acceptance. Results: Both games were evaluated as easy to use and fun to play. Both game interventions had a strong pain-mitigating effect in older adults (game 1: −55{\%}, P=.002; game 2: −66{\%}, P=.01). Conclusions: Serious exercise games outside and inside AAL environments can contribute to individuals' health and well-being and to the stability of health care systems. ",
doi="10.2196/14182",
url="https://games.jmir.org/2020/2/e14182",
url="https://doi.org/10.2196/14182",
url="http://www.ncbi.nlm.nih.gov/pubmed/32234703"
}


@Article{info:doi/10.2196/12388,
author="Khalili-Mahani, Najmeh
and Assadi, Atousa
and Li, Kate
and Mirgholami, Mahsa
and Rivard, Marie-Eve
and Benali, Habib
and Sawchuk, Kim
and De Schutter, Bob",
title="Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study",
journal="JMIR Ment Health",
year="2020",
month="Mar",
day="26",
volume="7",
number="3",
pages="e12388",
keywords="silver gaming; serious games; stress; cognitive training; brain training games; exercise games; ICT",
abstract="Background: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants' motivations to adopt these technologies. Objective: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. Methods: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S1-BrainGame, S2-CarRace, and S3-Exergame). Each session included an identical sequence of activities (t1-Baseline, t2-Picture encode, t3-Play, t4-Stroop test, t5-Play, and t6-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session{\texttimes}activity or session{\texttimes}activity{\texttimes}cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session{\texttimes}group effects on the scores of the postgame appraisal questionnaire. Results: Session{\texttimes}activity effects were significant on all ambulatory measures ($\chi$210>20; P<.001) other than cortisol (P=.37). Compared with S1 and S2, S3 was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S1, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S3. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense ($\chi$21>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. Conclusions: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed. ",
doi="10.2196/12388",
url="http://mental.jmir.org/2020/3/e12388/",
url="https://doi.org/10.2196/12388",
url="http://www.ncbi.nlm.nih.gov/pubmed/32213474"
}


@Article{info:doi/10.2196/15428,
author="Almeida, Jo{\~a}o
and Nunes, Francisco",
title="The Practical Work of Ensuring the Effective Use of Serious Games in a Rehabilitation Clinic: Qualitative Study",
journal="JMIR Rehabil Assist Technol",
year="2020",
month="Feb",
day="28",
volume="7",
number="1",
pages="e15428",
keywords="serious games; exergames; physiotherapy rehabilitation; practical rehabilitation work; qualitative research",
abstract="Background: Many rehabilitation clinics adopted serious games to support their physiotherapy sessions. Serious games can monitor and provide feedback on exercises and are expected to improve therapy and help professionals deal with more patients. However, there is little understanding of the impacts of serious games on the actual work of physiotherapists. Objective: This study aimed to understand the impact of an electromyography-based serious game on the practical work of physiotherapists. Methods: This study used observation sessions in an outpatient rehabilitation clinic that recently started using a serious game based on electromyography sensors. In total, 44 observation sessions were performed, involving 3 physiotherapists and 22 patients. Observation sessions were documented by audio recordings or fieldnotes and were analyzed for themes using thematic analysis. Results: The findings of this study showed that physiotherapists played an important role in enabling the serious game to work. Physiotherapists briefed patients, calibrated the system, prescribed exercises, and supported patients while they played the serious game, all of which amounted to relevant labor. Conclusions: The results of this work challenge the idea that serious games reduce the work of physiotherapists and call for an overall analysis of the different impacts a serious game can have. Adopting a serious game that creates more work can be entirely acceptable, provided the clinical outcomes or other advantages enabled by the serious game are strong; however, those impacts will have to be assessed on a case-by-case basis. Moreover, this work motivates the technology development community to better investigate physiotherapists and their context, offering implications for technology design. ",
doi="10.2196/15428",
url="http://rehab.jmir.org/2020/1/e15428/",
url="https://doi.org/10.2196/15428"
}


@Article{info:doi/10.2196/16031,
author="Lu, Amy Shirong
and Green, Melanie C
and Thompson, Debbe",
title="Using Narrative Game Design to Increase Children's Physical Activity: Exploratory Thematic Analysis",
journal="JMIR Serious Games",
year="2019",
month="Nov",
day="21",
volume="7",
number="4",
pages="e16031",
keywords="narrative; physical activity; active game; children; thematic analysis",
abstract="Background: Physical activity is crucial for child obesity prevention and intervention. Narratives embedded in active games can increase children's physical activity. Objective: Little is known about the narrative characteristics that would motivate children to exercise. We attempted to fill the gaps in understanding regarding narrative design for active video games. Methods: In this exploratory study, four animated narratives of different genres were professionally generated. Children (N=41) between the ages of 8 and 12 years were interviewed to identify their preferences. Sessions were digitally recorded, transcribed, and analyzed using exploratory thematic analysis. Results: Findings revealed that the children rated the dystopian science fiction story as their favorite across all weight, race, and gender groups. The physical activity-friendly narrative strategies included virtuous characters, extraordinary character actions, interesting plots, super powers, and engaging cliffhangers. Alternatively, information not related to physical activity, difficult-to-follow plot lines, passive protagonists, and repetitive narrative tropes were less appealing for physical activity. Conclusions: This research provides preliminary evidence that narratives have characteristics that may increase child physical activity when playing active games. Future empirical studies should verify and test these design principles. ",
doi="10.2196/16031",
url="http://games.jmir.org/2019/4/e16031/",
url="https://doi.org/10.2196/16031",
url="http://www.ncbi.nlm.nih.gov/pubmed/31750833"
}


@Article{info:doi/10.2196/13833,
author="Faric, Nu{\v{s}}a
and Potts, Henry W W
and Hon, Adrian
and Smith, Lee
and Newby, Katie
and Steptoe, Andrew
and Fisher, Abi",
title="What Players of Virtual Reality Exercise Games Want: Thematic Analysis of Web-Based Reviews",
journal="J Med Internet Res",
year="2019",
month="Sep",
day="16",
volume="21",
number="9",
pages="e13833",
keywords="virtual reality; exercise; video games; sedentary lifestyle; weight loss; behavior; obesity; sports",
abstract="Background: Physical activity (PA) is associated with a variety of physical and psychosocial health benefits, but levels of moderate-to-vigorous intensity PA remain low worldwide. Virtual reality (VR) gaming systems involving movement (VR exergames) could be used to engage people in more PA. Objective: This study aimed to synthesize public reviews of popular VR exergames to identify common features that players liked or disliked to inform future VR exergame design. Methods: We conducted a thematic analysis of 498 reviews of the 29 most popular exergames sold in the top 3 VR marketplaces: Steam (Valve Corporation), Viveport (Valve Corporation), and Oculus (Oculus VR). We categorized reviews as positive and negative as they appeared in the marketplaces and identified the most common themes using an inductive thematic analysis. Results: The reviews were often mixed, reporting a wide variety of expectations, preferences, and gaming experiences. Players preferred highly realistic games (eg, closely simulated real-world sport), games that were intuitive (in terms of body movement and controls), and games that provided gradual increases in skill acquisition. Players reported feeling that they reached a high level of exertion when playing and that the immersion distracted them from the intensity of the exercise. Some preferred features included music and social aspects of the games, with multiplayer options to include friends or receive help from experienced players. There were 3 main themes in negative reviews. The first concerned bugs that rendered games frustrating. Second, the quality of graphics had a particularly strong impact on perceived enjoyment. Finally, reviewers disliked when games had overly complex controls and display functions that evoked motion sickness. Conclusions: Exergames prove to be a stimulating avenue for players to engage in PA and distract themselves from the negative perceptions of performing exercise. The common negative aspects of VR exergames should be addressed for increased uptake and continued engagement. ",
doi="10.2196/13833",
url="https://www.jmir.org/2019/9/e13833/",
url="https://doi.org/10.2196/13833",
url="http://www.ncbi.nlm.nih.gov/pubmed/31538951"
}


@Article{info:doi/10.2196/12324,
author="Feodoroff, Boris
and Konstantinidis, Ippokratis
and Frob{\"o}se, Ingo",
title="Effects of Full Body Exergaming in Virtual Reality on Cardiovascular and Muscular Parameters: Cross-Sectional Experiment",
journal="JMIR Serious Games",
year="2019",
month="Aug",
day="28",
volume="7",
number="3",
pages="e12324",
keywords="exergaming; gamification; Immersive virtual reality; exercise; cybersickness; flight simulation",
abstract="Background: In recent years, many studies have associated sedentary behavior in front of screens with health problems in infants, children, and adolescents. Yet options for exergaming---playing video games that require rigorous physical exercise---seem to fall short of the physical activity levels recommended by the World Health Organization. Objective: The purpose of this study was to investigate the effect of a fully immersive virtual reality (VR)-based training system on cardiovascular and muscular parameters of young adults. Methods: A cross-sectional experiment design was used to analyze muscle activity (surface electromyography), heart rate, perceived exertion (RPE), cybersickness symptoms, perceived workload, and physical activity enjoyment (PACES) in 33 participants performing two 5-minute flights on a new training device. Results: Participants' performance of the planking position required to play the game resulted in moderate aerobic intensity (108 [SD 18.69] bpm). Due to the mainly isometric contraction of the dorsal muscle chain (with a mean activation between 20.6{\%} [SD 10.57] and 26.7{\%} [SD 17.39] maximum voluntary isometric contraction), participants described the exercise as a moderate to vigorous activity (RPE 14.6 [SD 1.82]). The majority reported that they enjoyed the exercise (PACES 3.74 [SD 0.16]). However, six participants had to drop out because of cybersickness symptoms and two because of muscle pain due to prior injuries. Conclusions: Our findings suggest that fully immersive VR training systems can contribute to muscle-strengthening activities for healthy users. However, the dropout rate highlights the need for technological improvements in both software and hardware. In prevention and therapy, movement quality is a fundamental part of providing effective resistance training that benefits health. Exergaming on a regular basis has the potential to develop strong muscles and a healthy back. It is essential that future VR-based training systems take into account the recommendations of sport and exercise science. ",
doi="10.2196/12324",
url="http://games.jmir.org/2019/3/e12324/",
url="https://doi.org/10.2196/12324",
url="http://www.ncbi.nlm.nih.gov/pubmed/31464194"
}


@Article{info:doi/10.2196/13643,
author="Hall, Cougar
and Hoj, Taylor H
and Julian, Clark
and Wright, Geoff
and Chaney, Robert A
and Crookston, Benjamin
and West, Joshua",
title="Pedal-Assist Mountain Bikes: A Pilot Study Comparison of the Exercise Response, Perceptions, and Beliefs of Experienced Mountain Bikers",
journal="JMIR Form Res",
year="2019",
month="Aug",
day="13",
volume="3",
number="3",
pages="e13643",
keywords="public health; physical activity; heart rate",
abstract="Background: Mountain biking is an aerobic physical activity that has experienced rapid growth. The emergence of the electric pedal-assist mountain bike (eMTB), while not without its critics, presents the potential for an even larger segment of the population to enjoy the health benefits of mountain biking. Although the research focused on the use of e-bikes generally is growing, there is limited research specifically targeting eMTB use. Research is needed exploring the potential exercise response of riding an eMTB, together with the beliefs and perceptions of mountain bikers who have and have not experienced eMTB riding. Objective: This study aimed to compare conventional mountain bike and eMTB use. This was done by investigating 2 questions: (1) What proportion of exercise response is retained for an experienced mountain biker while using an eMTB when compared with a conventional mountain bike? and (2) What are the perceptions and beliefs of experienced mountain bikers toward eMTBs both before and after riding an eMTB? Methods: A convergent mixed methods data collection approach was used in the study. Participants completed both a pre- and postride questionnaire, and data regarding heart rate were collected. Heart rates from each ride were compared against each other. Results: The average heart rate during eMTB use was 94{\%} (31/33) of the average heart rate during conventional mountain bike use. Therefore, eMTB use in this study achieved a majority of the exercise response and exceeded established biometric thresholds for cardiovascular fitness. Paired t test statistics were calculated to compare beliefs of conventional mountain bikes and eMTBs and to compare mean heart rate and speed between conventional mountain bike and eMTB use on the study loop. Participants overwhelmingly perceived the potential impact of eMTB use to be positive on both pre- and post-eMTB ride questionnaires. Conclusions: Despite the measured benefit, participants' perceived exertion while riding the eMTB was low. ",
doi="10.2196/13643",
url="http://formative.jmir.org/2019/3/e13643/",
url="https://doi.org/10.2196/13643",
url="http://www.ncbi.nlm.nih.gov/pubmed/31411139"
}


@Article{info:doi/10.2196/13575,
author="Wu, Shanshan
and Jo, Eun-Ah
and Ji, Hongqing
and Kim, Kyung-Hee
and Park, Jung-Jun
and Kim, Bo Hyun
and Cho, Kyoung Im",
title="Exergaming Improves Executive Functions in Patients With Metabolic Syndrome: Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2019",
month="Jul",
day="31",
volume="7",
number="3",
pages="e13575",
keywords="exercise; executive functions; event-related potential; games; metabolic syndrome",
abstract="Background: Recent studies indicate that participation in exercise-related games can improve executive function, attention processing, and visuospatial skills. Objective: The aim of this study was to investigate whether exercise via exergaming (EXG) can improve executive function in patients with metabolic syndrome (MetS). Methods: A total of 22 MetS patients were recruited and randomly assigned to an EXG group or a treadmill exercise (TE) group. The reaction time (RT) and electrophysiological signals from the frontal (Fz), central (Cz), and parietal (Pz) cortices were collected during a Stroop task after 12 weeks of exercise. Results: During the Stroop congruence (facilitation) judgment task, both the EXG and TE groups showed significantly faster RT after 12 weeks of exercise training. For N200 amplitude, the EXG group demonstrated significantly increased electrophysiological signals from the Fz and Cz cortices. These changes were significantly larger in the EXG group than in the TE group. Separately, for the P300 amplitude, the EXG groups presented significantly increased electrophysiological signals from the Fz, Cz, and Pz cortices, whereas the TE group showed significantly increased electrophysiological signals from the Cz and Pz cortices only. During the Stroop incongruence (interference) judgment task, both the EXG and TE groups showed significantly faster RT. For P300 amplitude, the EXG group had significantly increased electrophysiological signals from the Fz and Cz cortices only, whereas the TE group had significantly increased electrophysiological signals from the Fz, Cz, and Pz cortices. Conclusions: EXG improves executive function in patients with MetS as much as normal aerobic exercise does. In particular, a unique benefit of EXG beyond increased aerobic capacity is the improved selective attention among cognitive functions. Thus, EXG could be recommended to someone who needs to improve their brain responses of concentration and judgment as well as physical fitness. Trial Registration: ClinicalTrials.gov NCT04015583; https://clinicaltrials.gov/ct2/show/NCT04015583 ",
doi="10.2196/13575",
url="https://games.jmir.org/2019/3/e13575/",
url="https://doi.org/10.2196/13575",
url="http://www.ncbi.nlm.nih.gov/pubmed/31368441"
}


@Article{info:doi/10.2196/13335,
author="O'Loughlin, Erin Kathleen
and Barnett, Tracie A
and McGrath, Jennifer J
and Consalvo, Mia
and Kakinami, Lisa",
title="Factors Associated with Sustained Exergaming: Longitudinal Investigation",
journal="JMIR Serious Games",
year="2019",
month="Jul",
day="31",
volume="7",
number="3",
pages="e13335",
keywords="video games; physical activity; adolescents",
abstract="Background: Exergaming is technology-driven physical activity (PA) which, unlike traditional video game play, requires that participants be physically active to play the game. Exergaming may have potential to increase PA and decrease sedentary behavior in youth, but little is known about sustained exergaming. Objective: The objectives of this study were to describe the frequency, correlates, and predictors of sustained exergaming. Methods: Data were available in AdoQuest (2005-11), a longitudinal investigation of 1843 grade 5 students in Montr{\'e}al, Canada. This analysis used data from grade 9 (2008-09) and 11 (2010-11). Participants at Time 1 (T1; mean age 14 years, SD 0.8 ) who reported past-week exergaming (n=186, 19.1{\%} of AdoQuest sample) completed mailed self-report questionnaires at Time 2 (T2; mean age 16 years, SD 0.8). Independent sociodemographic, psychological, and behavioral correlates (from T2)/predictors (from T1 or earlier) were identified using multivariable logistic regression. Results: Of 186 exergamers at T1, 81 (44{\%}) reported exergaming at T2. Being female and having higher introjected regulation (ie, a type of PA motivation indicative of internalizing PA as a behavior) were independent correlates. None of the predictors investigated were associated with sustained exergaming. Conclusions: Almost half of grade 9 exergamers sustained exergaming for 2 years. Exergaming may be a viable approach to help adolescents engage in and sustain PA during adolescence. Sex and PA motivation may be important in the sustainability of exergaming. ",
doi="10.2196/13335",
url="https://games.jmir.org/2019/3/e13335/",
url="https://doi.org/10.2196/13335"
}


@Article{info:doi/10.2196/13962,
author="Santos, Luciano Henrique De Oliveira
and Okamoto, Kazuya
and Funghetto, Silvana Schwerz
and Cavalli, Adriana Sch{\"u}ler
and Hiragi, Shusuke
and Yamamoto, Goshiro
and Sugiyama, Osamu
and Castanho, Carla Denise
and Aoyama, Tomoki
and Kuroda, Tomohiro",
title="Effects of Social Interaction Mechanics in Pervasive Games on the Physical Activity Levels of Older Adults: Quasi-Experimental Study",
journal="JMIR Serious Games",
year="2019",
month="Jul",
day="22",
volume="7",
number="3",
pages="e13962",
keywords="aged; physical activity; pervasive games; social interaction",
abstract="Background: The novel genre of pervasive games, which aim to create more fun and engaging experiences by promoting deeper immersion, could be a powerful strategy to stimulate physical activity among older adults. To use these games more effectively, it is necessary to understand how different design elements affect player behavior. Objective: The aim was to vary a specific design element of pervasive games for older adults, namely social interaction, to test the effect on levels of physical activity. Methods: Over 4 weeks, two variations of the same pervasive game were compared: social interaction for the test group and no social interaction for the control group. In both versions, players had to walk to physical locations and collect virtual cards, but the social interaction version allowed people to collaborate to obtain more cards. Weekly step counts were used to evaluate the effect on each group, and the number of places visited was used as an indicator of play activity. Results: A total of 32 participants were recruited (no social interaction=15, social interaction=17); 18 remained until the end of the study (no social interaction=7, social interaction=11). Step counts during the first week were used as the baseline (no social interaction: mean 17,099.4, SE 3906.5; social interaction: mean 17,981.9, SE 2171.1). For the following weeks, changes to individual baseline were as follows for no social interaction (absolute/proportional): 383.8 (SE 563.8)/1.1{\%} (SE 4.3{\%}), 435.9 (SE 574.5)/2.2{\%} (SE 4.6{\%}), and −106.1 (SE 979.9)/−2.6{\%} (SE 8.1{\%}) for weeks 2, 3, and 4, respectively. For social interaction they were 3841.9 (SE 1425.4)/21.7{\%} (SE 5.1{\%}), 2270.6 (SE 947.1)/16.5{\%} (SE 4.4{\%}), and 2443.4 (SE 982.6)/17.9{\%} (SE 4.7{\%}) for weeks 2, 3, and 4, respectively. Analysis of group effect was significant (absolute change: $\eta$2=.19, P=.01; proportional change: $\eta$2=.27, P=.009). Correlation between the proportional change and the play activity was significant (r=.34, 95{\%} CI 0.08 to 0.56), whereas for absolute change it was not. Conclusions: Social interaction design elements of the pervasive game may have some positive effects on the promotion of physical activity, although other factors might also have influenced this effect. Trial Registration: Japan Medical Association Clinical Trial Registration Number JMA-IIA00314; https://dbcentre3.jmacct.med.or.jp/JMACTR/App/JMACTRS06/JMACTRS06.aspx?seqno=7274 (Archived by WebCite at http://www.webcitation.org/761a6MVAy) ",
doi="10.2196/13962",
url="http://games.jmir.org/2019/3/e13962/",
url="https://doi.org/10.2196/13962",
url="http://www.ncbi.nlm.nih.gov/pubmed/31333202"
}


@Article{info:doi/10.2196/13051,
author="Joyner, Damon
and Wengreen, Heidi
and Aguilar, Sheryl
and Madden, Gregory",
title="Effects of the FIT Game on Physical Activity in Sixth Graders: A Pilot Reversal Design Intervention Study",
journal="JMIR Serious Games",
year="2019",
month="Jun",
day="18",
volume="7",
number="2",
pages="e13051",
keywords="children; accelerometer; step count",
abstract="Background: The FIT Game is a low-cost intervention that increases fruit and vegetable consumption in elementary school children. For this study, the FIT Game was adapted into an intervention designed to increase children's physical activity at school. Objective: We aimed to evaluate if the FIT Game could increase children's physical activity relative to their baseline levels. Methods: A total of 29 participants were recruited from a sixth-grade classroom. An ABAB reversal design was used. Participants wore an accelerometer while at school during pre/postintervention baseline (A) and intervention (B) phases. During the FIT Game intervention, daily physical activity goals encouraged the class to increase their median daily step count above the 60th percentile of the previous 10 days. When daily goals were met, game-based accomplishments were realized. Results: Children met their activity goals 80{\%} of the time during the intervention phases. Physical activity at school increased from a median of 3331 steps per day during the baseline to 4102 steps during the FIT Game phases (P<.001, Friedman test). Conclusions: Preliminary evidence showed that playing the FIT Game could positively influence children's physical activity at school. ",
doi="10.2196/13051",
url="http://games.jmir.org/2019/2/e13051/",
url="https://doi.org/10.2196/13051",
url="http://www.ncbi.nlm.nih.gov/pubmed/31215508"
}


@Article{info:doi/10.2196/11960,
author="Faric, Nu{\v{s}}a
and Yorke, Eleanor
and Varnes, Laura
and Newby, Katie
and Potts, Henry WW
and Smith, Lee
and Hon, Adrian
and Steptoe, Andrew
and Fisher, Abigail",
title="Younger Adolescents' Perceptions of Physical Activity, Exergaming, and Virtual Reality: Qualitative Intervention Development Study",
journal="JMIR Serious Games",
year="2019",
month="Jun",
day="17",
volume="7",
number="2",
pages="e11960",
keywords="exercise; obesity; video games; adolescent; adolescence; sports; health; leisure activities; virtual reality",
abstract="Background: Novel strategies to promote physical activity (PA) in adolescence are required. The vEngage study aims to test whether a virtual reality (VR) exergaming intervention can engage younger adolescents (aged 13 to 15 years) with PA. Objective: This study aimed to gather adolescents' views of using VR to encourage PA and identify the key features they would like to see in a VR exergaming intervention via interviews. Methods: Participants were recruited through 2 schools in London, United Kingdom. Semistructured interviews were conducted with adolescents about their views on PA and what might work to increase PA, technology, knowledge and experience of VR, and desired features in a VR exergaming intervention. Data were analyzed using Framework Analysis. Results: A total of 31 participants aged between 13 and 15 years (58{\%} female, 62{\%} from nonwhite ethnicities) participated in this interview study. The vast majority had no awareness of government PA recommendations but felt they should be more thoroughly informed. All participants were positive about the use of VR in PA promotion. Rewards, increasing challenges, and a social or multiplayer aspect were identified by participants as crucial aspects to include in a VR exercise game. Barriers were related to cost of high-end systems. Being able to exercise at home was very appealing. VR exergaming was viewed as a way to overcome multiple perceived social and cultural barriers to PA, particularly for girls. Conclusions: Key elements that should be incorporated into a VR game for health intervention were identified and described. These also included the use of rewards, novelty and enjoyment in immersive game play, multiplayer options, and real-world elements, as well as continual updates and new challenge levels. The use of VR to promote PA in adolescents is promising, but some barriers were raised. ",
doi="10.2196/11960",
url="http://games.jmir.org/2019/2/e11960/",
url="https://doi.org/10.2196/11960",
url="http://www.ncbi.nlm.nih.gov/pubmed/31210135"
}


@Article{info:doi/10.2196/10116,
author="Simmich, Joshua
and Deacon, Anthony J
and Russell, Trevor G",
title="Active Video Games for Rehabilitation in Respiratory Conditions: Systematic Review and Meta-Analysis",
journal="JMIR Serious Games",
year="2019",
month="Feb",
day="25",
volume="7",
number="1",
pages="e10116",
keywords="video games; exercise; physical activity; COPD; cystic fibrosis; asthma",
abstract="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. ",
doi="10.2196/10116",
url="http://games.jmir.org/2019/1/e10116/",
url="https://doi.org/10.2196/10116",
url="http://www.ncbi.nlm.nih.gov/pubmed/30801256"
}


@Article{info:doi/10.2196/11444,
author="H{\"o}chsmann, Christoph
and Infanger, Denis
and Klenk, Christopher
and K{\"o}nigstein, Karsten
and Walz, Steffen P
and Schmidt-Trucks{\"a}ss, Arno",
title="Effectiveness of a Behavior Change Technique--Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2019",
month="Feb",
day="13",
volume="7",
number="1",
pages="e11444",
keywords="behavior change; exercise adherence; gamification; intrinsic motivation; mhealth; mobile phone game; physical activity; type 2 diabetes",
abstract="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: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 ",
doi="10.2196/11444",
url="http://games.jmir.org/2019/1/e11444/",
url="https://doi.org/10.2196/11444",
url="http://www.ncbi.nlm.nih.gov/pubmed/30758293"
}


@Article{info:doi/10.2196/10724,
author="Hino, Kimihiro
and Asami, Yasushi
and Lee, Jung Su",
title="Step Counts of Middle-Aged and Elderly Adults for 10 Months Before and After the Release of Pok{\'e}mon GO in Yokohama, Japan",
journal="J Med Internet Res",
year="2019",
month="Feb",
day="05",
volume="21",
number="2",
pages="e10724",
keywords="augmented reality; location-based games; mobile phone; pedometer; physical activity; Pok{\'e}mon GO; smartphone",
abstract="Background: Smartphones have been integrated into our society and are expected to serve as tools to improve health outcomes. In the summer of 2016, Pok{\'e}mon GO, a location-based augmented reality game for smartphones was released; it attracted attention from the perspective of health, especially with its potential to increase physical activity (PA). A few studies have compared objectively measured step counts before and after the release of the game; however, they were conducted over a short study period and evaluated only young people. Objective: The objective of this study was to confirm whether there was a difference in step counts between middle-aged and elderly players and nonplayers before and after the release of Pok{\'e}mon GO. Methods: A total of 46 players and 184 nonplayers aged ≥40 years were matched for sex, age group, and PA level; they were respondents to a questionnaire randomly sent to citizens who were given free pedometers by Yokohama city. Their play status was identified through the questionnaire. To investigate the change in step counts before and after the release of Pok{\'e}mon GO according to play status, a 2-way repeated-measures analysis of variance was performed. Step counts 1 month before the release of the game were compared with those 8 months after the release. In addition, subgroup analyses according to sex, age group, PA level, and subjective health status were performed. Results: The mean ages of players and nonplayers were 56.5 (SD 9.9) years and 57.3 (SD 9.6) years, respectively, and the mean baseline step counts of players and nonplayers were 7641.8 (SD 2754.5) and 7903.3 (SD 2674.7), respectively. There was no significant difference in the age and baseline step counts according to a t test (2-tailed). In the analysis of all samples, the interaction between play status and time effect was significant for 3 of 8 months after release. In the subgroup analyses, the interaction was significant for 3 months in men, 7 months in the 55-64-year-old group, 2 months in workers, 4 months in the active group in PA level, and 2 months in participants with subjectively good health. The interaction was significant for only 1 month, at most, in other subgroups. Conclusions: The present study confirmed a difference in step counts between players and nonplayers before and after the release of Pok{\'e}mon GO. According to our analysis, step counts were higher until 7 months after the release. The player group maintained their step counts in winter, despite the decrease in step counts of nonplayers. In subgroup analyses, players were more likely to be men, aged <55 years, workers, active, and subjectively in good health. ",
doi="10.2196/10724",
url="https://www.jmir.org/2019/2/e10724/",
url="https://doi.org/10.2196/10724",
url="http://www.ncbi.nlm.nih.gov/pubmed/30720438"
}


@Article{info:doi/10.2196/11326,
author="Malone, Laurie A
and Thirumalai, Mohanraj
and Padalabalanarayanan, Sangeetha
and Neal, Whitney N
and Bowman, Sean
and Mehta, Tapan",
title="Energy Expenditure and Enjoyment During Active Video Gaming Using an Adapted Wii Fit Balance Board in Adults with Physical Disabilities: Observational Study",
journal="JMIR Serious Games",
year="2019",
month="Feb",
day="01",
volume="7",
number="1",
pages="e11326",
keywords="exergaming; video games; exercise; physical activity; disability; energy expenditure; enjoyment",
abstract="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: ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 (Archived by Webcite at http://www.webcitation.org/75fc0mN39). ",
doi="10.2196/11326",
url="http://games.jmir.org/2019/1/e11326/",
url="https://doi.org/10.2196/11326",
url="http://www.ncbi.nlm.nih.gov/pubmed/30707098"
}


@Article{info:doi/10.2196/10307,
author="Levac, Danielle
and Dumas, Helene M
and Meleis, Waleed",
title="A Tablet-Based Interactive Movement Tool for Pediatric Rehabilitation: Development and Preliminary Usability Evaluation",
journal="JMIR Rehabil Assist Technol",
year="2018",
month="Nov",
day="26",
volume="5",
number="2",
pages="e10307",
keywords="equipment design; rehabilitation; pediatrics; tablets; software",
abstract="Background: Motivating interactive tools may increase adherence to repetitive practice for children with disabilities, but many virtual reality and active video gaming systems are too challenging for children with significant needs. Objective: The objective of this study was to develop and conduct a usability evaluation of the Fun, Interactive Therapy Board (FITBoard), a movement toy bridging digital and physical interactions for children with disabilities. Methods: The FITBoard is a tablet app involving games controlled by hand, head, or foot touch of configurable, wired surfaces. Usability evaluation involved a cognitive walkthrough and think-aloud processes. Participants verbalized aloud while completing a series of 26 task actions involved in selecting a game and configuring the FITBoard to achieve the therapeutic goal. Therapists then responded to questions about usability perceptions. Unsuccessful actions were categorized as goal or action failures. Qualitative content analysis supported understanding of usability problems. Results: Participants included 5 pediatric physical therapists and 2 occupational therapists from 2 clinical sites. Goal failure was experienced by all participants in 2 tasks, and action failure was experienced by all participants in 2 tasks. For 14 additional tasks, 1 or more patients experienced goal or action failure, with an overall failure rate of 69{\%} (18 of 26 tasks). Content analysis revealed 4 main categories: hardware usability, software usability, facilitators of therapy goals, and improvement suggestions. Conclusions: FITBoard hardware and software changes are needed to address goal and action failures to rectify identified usability issues. Results highlight potential FITBoard applications to address therapeutic goals and outline important practical considerations for product use by therapists. Subsequent research will evaluate therapist, parent, and child perspectives on FITBoard clinical utility when integrated within regular therapy interventions. ",
doi="10.2196/10307",
url="http://rehab.jmir.org/2018/2/e10307/",
url="https://doi.org/10.2196/10307",
url="http://www.ncbi.nlm.nih.gov/pubmed/30478025"
}


@Article{info:doi/10.2196/10679,
author="Militello, Lisa K
and Hanna, Nathan
and Nigg, Claudio R",
title="Pok{\'e}mon GO Within the Context of Family Health: Retrospective Study",
journal="JMIR Pediatr Parent",
year="2018",
month="Oct",
day="03",
volume="1",
number="2",
pages="e10679",
keywords="family; pediatrics; mHealth; exercise; mobile health, public health",
abstract="Background: Pok{\'e}mon GO illuminated the potential for mobile phone gaming apps to engage users and promote health. However, much work is needed to fully understand the mechanisms through which digitally supported behavior change interventions operate, particularly for children and families. Objective: The aims of this study were (1) to explore the Pok{\'e}mon GO user experience from a family perspective and (2) to investigate Pok{\'e}mon GO within the context of family health. Methods: Between January and February 2017, congruent with one of the largest anticipated Pok{\'e}mon GO updates Gen 2, participants were recruited from parks, word of mouth, and social media to complete a Web-based survey. Participants were surveyed about family characteristics, interest, and experiences playing Pok{\'e}mon GO and healthy lifestyle beliefs. Using a revised Godin Leisure-Time Exercise Questionnaire, a retrospective pre-post design assessed changes in parent physical activity (PA) before and after playing Pok{\'e}mon GO. Results: Self-reported data from 160 parents and 31 children were included in the final analyses (representing 129 parents and 31 parent-child dyads). Gameplay most often occurred between sons aged 10 years or younger and mothers. ``Spending time together'' was the most cited reason for gameplay by both parents (122/160, 76.3{\%}) and children (24/31, 77{\%}), followed by ``it helped me go outdoors'' for parents (113/160, 70.1{\%}) and ``I am a Pok{\'e}mon fan'' by children (21/31, 68{\%}). Interestingly, open-ended responses indicated that gameplay could trigger both positive and negative emotional parent response. The most cited reason for app disengagement was boredom; conversely, the most cited reason for app re-engagement was in-app events. For parents, there were significant increases in minutes spent in mild (mean 23.36 [SD 66.02]; t97=3.50, P<.001) and moderate (mean 21.76 [SD 53.04]; t130=4.70, P<.001) PA per week after playing Pok{\'e}mon GO. However, child perceptions of parental influence on PA most significantly associated with parents who reported weekly strenuous PA both before (rs=.514, P=.003) and after (rs=.536, P=.003) Pok{\'e}mon GO uptake. Conclusions: Pok{\'e}mon GO transcended traditional understanding of digital health and uniquely reached across generations to engage users. Findings from this study highlight that, for a period of time, Pok{\'e}mon GO fostered social and physical well-being for children and families through a multifaceted approach. ",
doi="10.2196/10679",
url="http://pediatrics.jmir.org/2018/2/e10679/",
url="https://doi.org/10.2196/10679",
url="http://www.ncbi.nlm.nih.gov/pubmed/31518294"
}


@Article{info:doi/10.2196/10486,
author="Li, Jinhui
and Erdt, Mojisola
and Chen, Luxi
and Cao, Yuanyuan
and Lee, Shan-Qi
and Theng, Yin-Leng",
title="The Social Effects of Exergames on Older Adults: Systematic Review and Metric Analysis",
journal="J Med Internet Res",
year="2018",
month="Jun",
day="28",
volume="20",
number="6",
pages="e10486",
keywords="active video games; psychosocial well-being; ageing; literature review; citation analysis",
abstract="Background: Recently, many studies have been conducted to investigate the effects of exergames on the social well-being of older adults. Objective: The aim of this paper is to synthesize existing studies and provide an overall picture on the social effects of exergames on older adults. Methods: A comprehensive literature search with inclusive criteria was conducted in major social science bibliographic databases. The characteristics of exergames, participants, methodology, as well as outcome measurements were extracted from the relevant studies included in the review. The bibliometric and altmetric outreach of the included studies were also investigated. Results: A total of 10 studies were included in the review, with 8 studies having used the Nintendo Wii platform. Most of the studies recruited healthy older adults from local communities or senior activity centers. Three groups of social-related outcomes have been identified, including emotion-related, behavior-related, and attitude-related outcomes. A metric analysis has shown that the emotion-related and behavior-related outcomes received high attention from both the academic community and social media platforms. Conclusions: Overall, the majority of exergame studies demonstrated promising results for enhanced social well-being, such as reduction of loneliness, increased social connection, and positive attitudes towards others. The paper also provided implications for health care researchers and exergame designers. ",
doi="10.2196/10486",
url="http://www.jmir.org/2018/6/e10486/",
url="https://doi.org/10.2196/10486",
url="http://www.ncbi.nlm.nih.gov/pubmed/29954727"
}


@Article{info:doi/10.2196/jmir.9670,
author="Ma, Ben D
and Ng, Sai Leung
and Schwanen, Tim
and Zacharias, John
and Zhou, Mudi
and Kawachi, Ichiro
and Sun, Guibo",
title="Pok{\'e}mon GO and Physical Activity in Asia: Multilevel Study",
journal="J Med Internet Res",
year="2018",
month="Jun",
day="15",
volume="20",
number="6",
pages="e217",
keywords="physical activity; Pok{\'e}mon Go; public health intervention; exergame; weather",
abstract="Background: Physical activity has long been considered as an important component of a healthy lifestyle. Although many efforts have been made to promote physical activity, there is no effective global intervention for physical activity promotion. Some researchers have suggested that Pok{\'e}mon GO, a location-based augmented reality game, was associated with a short-term increase in players' physical activity on a global scale, but the details are far from clear. Objective: The objective of our study was to study the relationship between Pok{\'e}mon GO use and players' physical activity and how the relationship varies across players with different physical activity levels. Methods: We conducted a field study in Hong Kong to investigate if Pok{\'e}mon GO use was associated with physical activity. Pok{\'e}mon GO players were asked to report their demographics through a survey; data on their Pok{\'e}mon GO behaviors and daily walking and running distances were collected from their mobile phones. Participants (n=210) were Hong Kong residents, aged 13 to 65 years, who played Pok{\'e}mon GO using iPhone 5 or 6 series in 5 selected types of built environment. We measured the participants' average daily walking and running distances over a period of 35 days, from 14 days before to 21 days after game installation. Multilevel modeling was used to identify and examine the predictors (including Pok{\'e}mon GO behaviors, weather, demographics, and built environment) of the relationship between Pok{\'e}mon GO use and daily walking and running distances. Results: The average daily walking and running distances increased by 18.1{\%} (0.96 km, approximately 1200 steps) in the 21 days after the participants installed Pok{\'e}mon GO compared with the average distances over the 14 days before installation (P<.001). However, this association attenuated over time and was estimated to disappear 24 days after game installation. Multilevel models indicated that Pok{\'e}mon GO had a stronger and more lasting association among the less physically active players compared with the physically active ones (P<.001). Playing Pok{\'e}mon GO in green space had a significant positive relationship with daily walking and running distances (P=.03). Moreover, our results showed that whether Pok{\'e}mon GO was played, the number of days played, weather (total rainfall, bright sunshine, mean air temperature, and mean wind speed), and demographics (age, gender, income, education, and body mass index) were associated with daily walking and running distances. Conclusions: Pok{\'e}mon GO was associated with a short-term increase in the players' daily walking and running distances; this association was especially strong among less physically active participants. Pok{\'e}mon GO can build new links between humans and green space and encourage people to engage in physical activity. Our results show that location-based augmented reality games, such as Pok{\'e}mon GO, have the potential to be a global public health intervention tool. ",
doi="10.2196/jmir.9670",
url="http://www.jmir.org/2018/6/e217/",
url="https://doi.org/10.2196/jmir.9670",
url="http://www.ncbi.nlm.nih.gov/pubmed/29907559"
}


@Article{info:doi/10.2196/games.9571,
author="Arnaez, James
and Frey, Georgia
and Cothran, Donetta
and Lion, Margaret
and Chomistek, Andrea",
title="Physical Wellness Among Gaming Adults: Cross-Sectional Study",
journal="JMIR Serious Games",
year="2018",
month="Jun",
day="12",
volume="6",
number="2",
pages="e12",
keywords="video games; electronic gaming; traditional gaming; obesity; physical activity; sedentary behavior",
abstract="Background: Video and hobby gaming are immensely popular among adults; however, associations between gaming and health have primarily been investigated in children and adolescents. Furthermore, most research has focused on electronic gaming, despite traditional hobby gaming gaining prominence. Objective: To determine whether the number of platforms used, platform preference, and gaming time are associated with obesity, physical activity, sedentary behavior, and cardiovascular risk factors in an adult gaming population. Methods: We conducted a cross-sectional analysis using data obtained from 292 participants who attended a large Midwestern gaming convention. We collected data using a computer-based questionnaire that comprised questions on gaming behavior, demographics, physical activity (using the International Physical Activity Questionnaire), and health characteristics. In addition, we used multivariable-adjusted linear and logistic regression to model health outcomes as a function of the number of platforms used, platform preference, and weekday and weekend gaming time quartile. Results: After adjusting for covariates, we observed a significant linear trend for increasing odds of being obese and higher weekend sitting time by the number of platforms used (P=.03 for both). The platform preference and weekend gaming time quartile exhibited significant associations with odds of meeting physical activity recommendations (P=.047 and P=.03, respectively). In addition, we observed higher odds of being obese among those reporting that they sat most or all of the time while gaming [odds ratio (OR) 2.69 (95{\%} CI 1.14-6.31) and OR 2.71 (95{\%} CI 1.06-6.93), respectively]. Conclusions: In adult gamers, the number of platforms used, which platforms they prefer to play on, and the amount of time spent gaming on weekends could have significant implications for their odds of being obese and meeting physical activity recommendations. ",
doi="10.2196/games.9571",
url="http://games.jmir.org/2018/2/e12/",
url="https://doi.org/10.2196/games.9571",
url="http://www.ncbi.nlm.nih.gov/pubmed/29895516"
}


@Article{info:doi/10.2196/rehab.9123,
author="Dimaguila, Gerardo Luis
and Gray, Kathleen
and Merolli, Mark",
title="Person-Generated Health Data in Simulated Rehabilitation Using Kinect for Stroke: Literature Review",
journal="JMIR Rehabil Assist Technol",
year="2018",
month="May",
day="08",
volume="5",
number="1",
pages="e11",
keywords="health care information systems; Kinect; patient-generated health data; person-generated health data; review; simulated rehabilitation; stroke; stroke rehabilitation; video games; virtual rehabilitation",
abstract="Background: Person- or patient-generated health data (PGHD) are health, wellness, and clinical data that people generate, record, and analyze for themselves. There is potential for PGHD to improve the efficiency and effectiveness of simulated rehabilitation technologies for stroke. Simulated rehabilitation is a type of telerehabilitation that uses computer technologies and interfaces to allow the real-time simulation of rehabilitation activities or a rehabilitation environment. A leading technology for simulated rehabilitation is Microsoft's Kinect, a video-based technology that uses infrared to track a user's body movements. Objective: This review attempts to understand to what extent Kinect-based stroke rehabilitation systems (K-SRS) have used PGHD and to what benefit. Methods: The review is conducted in two parts. In part 1, aspects of relevance for PGHD were searched for in existing systematic reviews on K-SRS. The following databases were searched: IEEE Xplore, Association of Computing Machinery Digital Library, PubMed, Biomed Central, Cochrane Library, and Campbell Collaboration. In part 2, original research papers that presented or used K-SRS were reviewed in terms of (1) types of PGHD, (2) patient access to PGHD, (3) PGHD use, and (4) effects of PGHD use. The search was conducted in the same databases as part 1 except Cochrane and Campbell Collaboration. Reference lists on K-SRS of the reviews found in part 1 were also included in the search for part 2. There was no date restriction. The search was closed in June 2017. The quality of the papers was not assessed, as it was not deemed critical to understanding PGHD access and use in studies that used K-SRS. Results: In part 1, 192 papers were identified, and after assessment only 3 papers were included. Part 1 showed that previous reviews focused on technical effectiveness of K-SRS with some attention on clinical effectiveness. None of those reviews reported on home-based implementation or PGHD use. In part 2, 163 papers were identified and after assessment, 41 papers were included. Part 2 showed that there is a gap in understanding how PGHD use may affect patients using K-SRS and a lack of patient participation in the design of such systems. Conclusions: This paper calls specifically for further studies of K-SRS---and for studies of technologies that allow patients to generate their own health data in general---to pay more attention to how patients' own use of their data may influence their care processes and outcomes. Future studies that trial the effectiveness of K-SRS outside the clinic should also explore how patients and carers use PGHD in home rehabilitation programs. ",
doi="10.2196/rehab.9123",
url="http://rehab.jmir.org/2018/1/e11/",
url="https://doi.org/10.2196/rehab.9123",
url="http://www.ncbi.nlm.nih.gov/pubmed/29739739"
}


@Article{info:doi/10.2196/games.7758,
author="McBain, Thomas
and Weston, Matthew
and Crawshaw, Paul
and Haighton, Catherine
and Spears, Iain",
title="Development of an Exergame to Deliver a Sustained Dose of High-Intensity Training: Formative Pilot Randomized Trial",
journal="JMIR Serious Games",
year="2018",
month="Mar",
day="27",
volume="6",
number="1",
pages="e4",
keywords="high-intensity interval training; video games; heart rate; boxing; metabolic syndrome",
abstract="Background: Sport science can play a critical role in reducing health inequalities. The inverse relationship between life expectancy, cardiorespiratory fitness, and socioeconomic status could be addressed by performing high-intensity training (HIT), delivered in a class salient and accessible approach. Commercially available exergames have shown encouraging compliance rates but are primarily designed for entertainment purposes rather than focusing on health-related outcomes. A serious game tailored toward delivering an exercise stimulus, while reducing the aversive protocols associated with HIT, could be beneficial to engage and improve health outcomes in socially deprived males. Objective: The aims of this study were to develop an exergame capable of delivering HIT and evaluate the effect on selected health outcomes in men recruited in regions of socioeconomic deprivation. Methods: We conducted an exploratory trial in our target population, and participants were allocated to intervention (n=14) or control groups (n=10) by third-party minimization. The intervention was a 6-week training program consisting of three sessions of exergaming per week. The sessions involved a structured warm-up, then brief intermittent repetitions in the form of boxing rounds (10 s, 20 s, and 30 s) against their peers with a work/rest ratio of 0.25. Results: Retention to the intervention was 87.5{\%} (21/24). Over the duration of the intervention, session attendance was 67.5{\%} (170/252); repetition mean and peak heart rates ({\%} of maximal) and session ratings of perceived exertion (AU, arbitrary units) were 86.3 (5.4{\%}), 89.9 (6.1{\%}), and 7.5 (2.2 AU), respectively. The effect of the intervention, when compared with the control, was a likely small beneficial improvement in predicted maximum oxygen consumption (VO2 max, 3.0; 90{\%} confidence limits {\textpm}2.6{\%}). Effects on body mass, waist circumference, and blood pressure were either trivial or unclear. Conclusions: Over the 6-week intervention, the exergame delivered a consistent and sustained dose of HIT, with some beneficial effects on aerobic fitness in the target population. Trial Registration: ClinicalTrials.gov NCT03477773; https://clinicaltrials.gov/ct2/show/NCT03477773 (Archived by WebCite at http://www.webcitation.org/6yDLgVs35) ",
doi="10.2196/games.7758",
url="http://games.jmir.org/2018/1/e4/",
url="https://doi.org/10.2196/games.7758",
url="http://www.ncbi.nlm.nih.gov/pubmed/29588271"
}


@Article{info:doi/10.2196/rehab.8003,
author="Thirumalai, Mohanraj
and Kirkland, William B
and Misko, Samuel R
and Padalabalanarayanan, Sangeetha
and Malone, Laurie A",
title="Adapting the Wii Fit Balance Board to Enable Active Video Game Play by Wheelchair Users: User-Centered Design and Usability Evaluation",
journal="JMIR Rehabil Assist Technol",
year="2018",
month="Mar",
day="06",
volume="5",
number="1",
pages="e2",
keywords="sedentary lifestyle; video games; active video gaming; Wii Fit; equipment design; physical activity; exercise; wheelchairs; physical disability; rehabilitation; usability",
abstract="Background: Active video game (AVG) playing, also known as ``exergaming,'' is increasingly employed to promote physical activity across all age groups. The Wii Fit Balance Board is a popular gaming controller for AVGs and is used in a variety of settings. However, the commercial off-the-shelf (OTS) design poses several limitations. It is inaccessible to wheelchair users, does not support the use of stabilization assistive devices, and requires the ability to shift the center of balance (COB) in all directions to fully engage in game play. Objective: The aim of this study was to design an adapted version of the Wii Fit Balance Board to overcome the identified limitations and to evaluate the usability of the newly designed adapted Wii Fit Balance Board in persons with mobility impairments. Methods: In a previous study, 16 participants tried the OTS version of the Wii Fit Balance Board. On the basis of observed limitations, a team of engineers developed and adapted the design of the Wii Fit Balance Board, which was then subjected to multiple iterations of user feedback and design tweaks. On design completion, we recruited a new pool of participants with mobility impairments for a larger study. During their first visit, we assessed lower-extremity function using selected mobility tasks from the International Classification of Functioning, Disability and Health. During a subsequent session, participants played 2 sets of games on both the OTS and adapted versions of the Wii Fit Balance Board. Order of controller version played first was randomized. After participants played each version, we administered the System Usability Scale (SUS) to examine the participants' perceived usability. Results: The adapted version of the Wii Fit Balance Board resulting from the user-centered design approach met the needs of a variety of users. The adapted controller (1) allowed manual wheelchair users to engage in game play, which was previously not possible; (2) included Americans with Disabilities Act-compliant handrails as part of the controller, enabling stable and safe game play; and (3) included a sensitivity control feature, allowing users to fine-tune the controller to match the users' range of COB motion. More than half the sample could not use the OTS version of the Wii Fit Balance Board, while all participants were able to use the adapted version. All participants rated the adapted Wii Fit Balance Board at a minimum as ``good,'' while those who could not use the OTS Wii Fit Balance Board rated the adapted Wii Fit Balance Board as ``excellent.'' We found a significant negative correlation between lower-extremity function and differences between OTS and adapted SUS scores, indicating that as lower-extremity function decreased, participants perceived the adapted Wii Fit Balance Board as more usable. Conclusions: This study demonstrated a successful adaptation of a widely used AVG controller. The adapted controller's potential to increase physical activity levels among people with mobility impairments will be evaluated in a subsequent trial. Trial Registration: ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 (Archived by WebCite at http://www.webcitation.org/6xWTyiJWf) ",
doi="10.2196/rehab.8003",
url="http://rehab.jmir.org/2018/1/e2/",
url="https://doi.org/10.2196/rehab.8003",
url="http://www.ncbi.nlm.nih.gov/pubmed/29510972"
}


@Article{info:doi/10.2196/games.8979,
author="Lindqvist, Anna-Karin
and Castelli, Darla
and Hallberg, Josef
and Rutberg, Stina",
title="The Praise and Price of Pok{\'e}mon GO: A Qualitative Study of Children's and Parents' Experiences",
journal="JMIR Serious Games",
year="2018",
month="Jan",
day="03",
volume="6",
number="1",
pages="e1",
keywords="child; cell phone; parents; exercise; mobile apps",
abstract="Background: Physical activity has multiple health benefits; however, the majority of children around the world do not attain the recommended levels of daily physical activity. Research has shown that the game Pok{\'e}mon GO has increased the amount of physical activity of players and that the game has the potential to reach populations that traditionally have low levels of physical activity. Therefore, there is a need to understand which game components can promote initial and sustained physical activity. By using a qualitative research approach, it is possible to achieve rich descriptions and enhance a deep understanding of the components promoting physical activity among children in a game such as Pok{\'e}mon GO. Objective: The objective of this study was to explore children's and parents' experiences playing Pok{\'e}mon GO. Methods: Eight families comprising 13 children (aged 7-12 years) and 9 parents were selected using purposeful sampling. Data collected using focus groups were analyzed using qualitative latent content analysis. Results: The following three themes were revealed: (1) exciting and enjoyable exploration; (2) dangers and disadvantages; and (3) cooperation conquers competition. The first centers around the present and possible future aspects of Pok{\'e}mon GO that promote physical activity. The second focuses on unwanted aspects and specific threats to safety when playing the game. The third shows that cooperation and togetherness are highly valued by the participants and that competition is fun but less important. Conclusions: Components from Pok{\'e}mon GO could enhance the efficacy of physical activity interventions. Cooperation and exploration are aspects of the game that preferably could be transferred into interventions aimed at promoting children's physical activity. ",
doi="10.2196/games.8979",
url="http://games.jmir.org/2018/1/e1/",
url="https://doi.org/10.2196/games.8979",
url="http://www.ncbi.nlm.nih.gov/pubmed/29298750"
}


@Article{info:doi/10.2196/mhealth.8470,
author="Koh, Hyeseung Elizabeth
and Oh, Jeeyun
and Mackert, Michael",
title="Predictors of Playing Augmented Reality Mobile Games While Walking Based on the Theory of Planned Behavior: Web-Based Survey",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Dec",
day="11",
volume="5",
number="12",
pages="e191",
keywords="mobile phone; pedestrians; safety on the street; psychological models; predictive value of tests; intention; age factors; attitude; social norms; self-efficacy; habits; immersion; self-report",
abstract="Background: There has been a sharp increase in the number of pedestrians injured while using a mobile phone, but little research has been conducted to explain how and why people use mobile devices while walking. Therefore, we conducted a survey study to explicate the motivations of mobile phone use while walking Objective: The purpose of this study was to identify the critical predictors of behavioral intention to play a popular mobile game, Pokemon Go, while walking, based on the theory of planned behavior (TPB). In addition to the three components of TPB, automaticity, immersion, and enjoyment were added to the model. This study is a theory-based investigation that explores the underlying mechanisms of mobile phone use while walking focusing on a mobile game behavior. Methods: Participants were recruited from a university (study 1; N=262) and Amazon Mechanical Turk (MTurk) (study 2; N=197) in the United States. Participants completed a Web-based questionnaire, which included measures of attitude, subjective norms, perceived behavioral control (PBC), automaticity, immersion, and enjoyment. Participants also answered questions regarding demographic items. Results: Hierarchical regression analyses were conducted to examine hypotheses. The model we tested explained about 41{\%} (study 1) and 63{\%} (study 2) of people's intention to play Pokemon Go while walking. The following 3 TPB variables were significant predictors of intention to play Pokemon Go while walking in study 1 and study 2: attitude (P<.001), subjective norms (P<.001), and PBC (P=.007 in study 1; P<.001 in study 2). Automaticity tendency (P<.001), immersion (P=.02), and enjoyment (P=.04) were significant predictors in study 1, whereas enjoyment was the only significant predictor in study 2 (P=.01). Conclusions: Findings from this study demonstrated the utility of TPB in predicting a new behavioral domain---mobile use while walking. To sum up, younger users who are habitual, impulsive, and less immersed players are more likely to intend to play a mobile game while walking. ",
doi="10.2196/mhealth.8470",
url="http://mhealth.jmir.org/2017/12/e191/",
url="https://doi.org/10.2196/mhealth.8470",
url="http://www.ncbi.nlm.nih.gov/pubmed/29229586"
}


@Article{info:doi/10.2196/games.8048,
author="Marquet, Oriol
and Alberico, Claudia
and Adlakha, Deepti
and Hipp, J Aaron",
title="Examining Motivations to Play Pok{\'e}mon GO and Their Influence on Perceived Outcomes and Physical Activity",
journal="JMIR Serious Games",
year="2017",
month="Oct",
day="24",
volume="5",
number="4",
pages="e21",
keywords="Pok{\'e}mon GO; physical activity; excercise; exergames; gaming outcomes; games, recreational; motivation",
abstract="Background: Pok{\'e}mon GO is the most played augmented reality game in history. With more than 44 million players at the peak of its popularity, the game has sparked interest on its effects on the young population's health. Objective: This pilot study examined motivations to start playing Pok{\'e}mon GO among a sample of US college students, and how motivations were associated with perceived outcomes of the playing experience and physical activity derived while playing. Methods: In November 2016, we asked a sample of 47 US college students (all Pok{\'e}mon GO players) to complete online surveys and install an ecological momentary assessment (EMA) tool and step counter on their smartphones. The EMA tool prompted a set of questions on playing behavior and physical activity, 3 times per day (12:00 PM, 7:00 PM, and 10:00 PM), for 7 days. We used a factorial analysis to identify 3 distinctive groups of players based on their motivations to start playing Pok{\'e}mon GO. We tested differences across motivation groups related to 5 unique outcomes using 1-way analysis of variance. Results: We extracted 3 interpretable factors from the clustering of motivations to start playing Pok{\'e}mon GO: Pok{\'e}mon and video game fans (n=26, 55{\%} of the sample), physical activity seekers (n=8, 17{\%}), and curious {\&} social (n=13, 28{\%}). The clusters differed significantly on the enjoyment of different aspects of the game, particularly battling, discovering new places, and meeting new people, as well as differences in agreement that playing improved mood and made them more social. Days when playing Pok{\'e}mon GO were associated with higher number of steps reported at the end of the day, especially among physical activity seekers, but also for Pok{\'e}mon and video game fans. All groups perceived traffic as a major threat to playing. Conclusions: Days during which Pok{\'e}mon GO was played were positively associated with a set of beneficial health behaviors, including higher physical activity levels, more socialization, and better mood. Results, however, depended on personal motivations and expectations when joining the game. These results highlight the importance of taking motivation into account when attempting to extract conclusions from the Pok{\'e}mon GO phenomenon to enhance future exergames' designs or health interventions. ",
doi="10.2196/games.8048",
url="http://games.jmir.org/2017/4/e21/",
url="https://doi.org/10.2196/games.8048",
url="http://www.ncbi.nlm.nih.gov/pubmed/29066423"
}


@Article{info:doi/10.2196/mhealth.6675,
author="Leinonen, Anna-Maiju
and Pyky, Riitta
and Ahola, Riikka
and Kangas, Maarit
and Siirtola, Pekka
and Luoto, Tim
and Enwald, Heidi
and Ik{\"a}heimo, Tiina M
and R{\"o}ning, Juha
and Kein{\"a}nen-Kiukaanniemi, Sirkka
and M{\"a}ntysaari, Matti
and Korpelainen, Raija
and J{\"a}ms{\"a}, Timo",
title="Feasibility of Gamified Mobile Service Aimed at Physical Activation in Young Men: Population-Based Randomized Controlled Study (MOPO)",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Oct",
day="10",
volume="5",
number="10",
pages="e146",
keywords="accelerometry; adolescent; behavior change; health; Internet; self-monitoring; wearable",
abstract="Background: The majority of young people do not meet the recommendations on physical activity for health. New innovative ways to motivate young people to adopt a physically active lifestyle are needed. Objective: The study aimed to study the feasibility of an automated, gamified, tailored Web-based mobile service aimed at physical and social activation among young men. Methods: A population-based sample of 496 young men (mean age 17.8 years [standard deviation 0.6]) participated in a 6-month randomized controlled trial (MOPO study). Participants were randomized to an intervention (n=250) and a control group (n=246). The intervention group was given a wrist-worn physical activity monitor (Polar Active) with physical activity feedback and access to a gamified Web-based mobile service, providing fitness guidelines, tailored health information, advice of youth services, social networking, and feedback on physical activity. Through the trial, the physical activity of the men in the control group was measured continuously with an otherwise similar monitor but providing only the time of day and no feedback. The primary outcome was the feasibility of the service based on log data and questionnaires. Among completers, we also analyzed the change in anthropometry and fitness between baseline and 6 months and the change over time in weekly time spent in moderate to vigorous physical activity. Results: Mobile service users considered the various functionalities related to physical activity important. However, compliance of the service was limited, with 161 (64.4{\%}, 161/250) participants visiting the service, 118 (47.2{\%}, 118/250) logging in more than once, and 41 (16.4{\%}, 41/250) more than 5 times. Baseline sedentary time was higher in those who uploaded physical activity data until the end of the trial (P=.02). A total of 187 (74.8{\%}, 187/250) participants in the intervention and 167 (67.9{\%}, 167/246) in the control group participated in the final measurements. There were no differences in the change in anthropometry and fitness from baseline between the groups, whereas waist circumference was reduced in the most inactive men within the intervention group (P=.01). Among completers with valid physical activity data (n=167), there was a borderline difference in the change in mean daily time spent in moderate to vigorous physical activity between the groups (11.9 min vs −9.1 min, P=.055, linear mixed model). Within the intervention group (n=87), baseline vigorous physical activity was inversely associated with change in moderate to vigorous physical activity during the trial (R=−.382, P=.01). Conclusions: The various functionalities related to physical activity of the gamified tailored mobile service were considered important. However, the compliance was limited. Within the current setup, the mobile service had no effect on anthropometry or fitness, except reduced waist circumference in the most inactive men. Among completers with valid physical activity data, the trial had a borderline positive effect on moderate to vigorous physical activity. Further development is needed to improve the feasibility and adherence of an integrated multifunctional service. Trial registration: Clinicaltrials.gov NCT01376986; http://clinicaltrials.gov/ct2/show/NCT01376986 (Archived by WebCite at http://www.webcitation.org/6tjdmIroA) ",
doi="10.2196/mhealth.6675",
url="https://mhealth.jmir.org/2017/10/e146/",
url="https://doi.org/10.2196/mhealth.6675",
url="http://www.ncbi.nlm.nih.gov/pubmed/29017991"
}


@Article{info:doi/10.2196/games.8013,
author="Tobler-Ammann, Bernadette C
and Surer, Elif
and Knols, Ruud H
and Borghese, N Alberto
and de Bruin, Eling D",
title="User Perspectives on Exergames Designed to Explore the Hemineglected Space for Stroke Patients With Visuospatial Neglect: Usability Study",
journal="JMIR Serious Games",
year="2017",
month="Aug",
day="25",
volume="5",
number="3",
pages="e18",
keywords="usability; user perspective; mixed-methods; exergames; visuo-spatial neglect; stroke",
abstract="Background: Visuospatial neglect due to stroke is characterized by the inability to perceive stimuli emerging in the area opposite to the side of brain damage. Besides adopting conventional rehabilitation methods to treat neglect symptoms, the use of virtual reality (VR) is becoming increasingly popular. We designed a series of 9 exergames aimed to improve exploration of the neglected side of space. When new VR interventions are designed, it is important to assess the usability aspects of such management strategies within the target population. To date, most studies used questionnaires to assess user satisfaction with the intervention or product being tested. However, only a combination of both quantitative and qualitative data allows a full picture of user perspective. Objective: The purpose of this study was to quantitatively and qualitatively assess patient and therapist perspectives of a VR intervention based on the series of 9 exergames designed to explore hemineglected space. Specifically, we wanted to evaluate (1) perceived-user friendliness of the exergames, (2) attitude towards using the exergames, and (3) intention to use the exergames in the future. Methods: A total of 19 participants (7 patients, 12 therapists) evaluated the exergames they had used 5 times a week during 3 weeks. The Technology Acceptance Model (TAM) questionnaire was filled out after the intervention. Based on those responses, we conducted focus group interviews (with therapists) and individual interviews (with patients). To analyze the TAM questionnaires, we used descriptive statistics. We adopted content and comparative analysis to analyze the interviews and drew illustration maps to analyze the focus group interviews. Results: The therapists took a more critical stance with a mean TAM questionnaire total score of 48.6 (SD 4.5) compared to the patients who had a mean total score of 56.1 (SD 12.3). The perceived user-friendliness score was 5.6 (SD 1.4) for patients and 4.9 (SD 1.4) for therapists. The attitude towards using the exergames was rated 4.8 (SD 1.9) by patients and 3.6 (SD 1.4) by therapists, respectively. The intention to use the exergames in the future was rated 3.9 (SD 2.1) by patients and 3.7 (SD 1.8) by therapists. We gained information on how to improve the exergames in the interviews. Conclusions: Patients and therapists perceived the exergames as user-friendly; however, using the games further with the actual test version was not perceived as conceivable. The therapists were generally more critical towards future use than the patients. Therefore, involving both users to achieve acceptable and user-friendly versions of game-based rehabilitation for the future is deemed crucial and warranted. Trial Registration: Clinicaltrials.gov NCT02353962; https://clinicaltrials.gov/ct2/show/NCT02353962 (Archived by WebCite at http://www.webcitation.org/6soxIJlAZ) ",
doi="10.2196/games.8013",
url="http://games.jmir.org/2017/3/e18/",
url="https://doi.org/10.2196/games.8013",
url="http://www.ncbi.nlm.nih.gov/pubmed/28842390"
}


@Article{info:doi/10.2196/games.7923,
author="Tobler-Ammann, Bernadette C
and Surer, Elif
and de Bruin, Eling D
and Rabuffetti, Marco
and Borghese, N Alberto
and Mainetti, Renato
and Pirovano, Michele
and Wittwer, Lia
and Knols, Ruud H",
title="Exergames Encouraging Exploration of Hemineglected Space in Stroke Patients With Visuospatial Neglect: A Feasibility Study",
journal="JMIR Serious Games",
year="2017",
month="Aug",
day="25",
volume="5",
number="3",
pages="e17",
keywords="exergames; eye tracking; virtual reality; visuospatial neglect; feasibility",
abstract="Background: Use of exergames can complement conventional therapy and increase the amount and intensity of visuospatial neglect (VSN) training. A series of 9 exergames---games based on therapeutic principles---aimed at improving exploration of the neglected space for patients with VSN symptoms poststroke was developed and tested for its feasibility. Objectives: The goal was to determine the feasibility of the exergames with minimal supervision in terms of (1) implementation of the intervention, including adherence, attrition and safety, and (2) limited efficacy testing, aiming to document possible effects on VSN symptoms in a case series of patients early poststroke. Methods: A total of 7 patients attended the 3-week exergames training program on a daily basis. Adherence of the patients was documented in a training diary. For attrition, the number of participants lost during the intervention was registered. Any adverse events related to the exergames intervention were noted to document safety. Changes in cognitive and spatial exploration skills were measured with the Z{\"u}rich Maxi Mental Status Inventory and the Neglect Test. Additionally, we developed an Eye Tracker Neglect Test (ETNT) using an infrared camera to detect and measure neglect symptoms pre- and postintervention. Results: The median was 14 out of 15 (93{\%}) attended sessions, indicating that the adherence to the exergames training sessions was high. There were no adverse events and no drop-outs during the exergame intervention. The individual cognitive and spatial exploration skills slightly improved postintervention (P=.06 to P=.98) and continued improving at follow-up (P=.04 to P=.92) in 5 out of 7 (71{\%}) patients. Calibration of the ETNT was rather error prone. The ETNT showed a trend for a slight median group improvement from 15 to 16 total located targets (+6{\%}). Conclusions: The high adherence rate and absence of adverse events showed that these exergames were feasible and safe for the participants. The results of the amount of exergames use is promising for future applications and warrants further investigations---for example, in the home setting of patients to augment training frequency and intensity. The preliminary results indicate the potential of these exergames to cause improvements in cognitive and spatial exploration skills over the course of training for stroke patients with VSN symptoms. Thus, these exergames are proposed as a motivating training tool to complement usual care. The ETNT showed to be a promising assessment for quantifying spatial exploration skills. However, further adaptations are needed, especially regarding calibration issues, before its use can be justified in a larger study sample. ",
doi="10.2196/games.7923",
url="http://games.jmir.org/2017/3/e17/",
url="https://doi.org/10.2196/games.7923",
url="http://www.ncbi.nlm.nih.gov/pubmed/28842388"
}


@Article{info:doi/10.2196/jmir.6841,
author="Meekes, Wytske
and Stanmore, Emma Kate",
title="Motivational Determinants of Exergame Participation for Older People in Assisted Living Facilities: Mixed-Methods Study",
journal="J Med Internet Res",
year="2017",
month="Jul",
day="06",
volume="19",
number="7",
pages="e238",
keywords="technology; aged; accidental falls; rehabilitation; motivation",
abstract="Background: Exergames (exercise-based videogames) for delivering strength and balance exercise for older people are growing in popularity with the emergence of new Kinect-based technologies; however, little is known about the factors affecting their uptake and usage by older people. Objective: The aim of this study was to determine the factors that may influence the motivation of older people to use exergames to improve their physical function and reduce fall risk. Methods: Mixed methods were employed in which 14 semistructured interviews were conducted with older people (n=12, aged 59-91 years) from 2 assisted living facilities in the North West of the United Kingdom. The older people participated in a 6-week trial of exergames along with one manager and one physiotherapist; 81 h of observation and Technology Acceptance Model questionnaires were conducted. Results: The findings suggest that the participants were intrinsically motivated to participate in the exergames because of the enjoyment experienced when playing the exergames and perceived improvements in their physical and mental health and social confidence. The social interaction provided in this study was an important extrinsic motivator that increased the intrinsic motivation to adhere to the exergame program. Conclusions: The findings of this study suggest that exergames may be a promising tool for delivering falls prevention exercises and increasing adherence to exercise in older people. Understanding the motivation of older people to use exergames may assist in the process of implementation. ",
doi="10.2196/jmir.6841",
url="http://www.jmir.org/2017/7/e238/",
url="https://doi.org/10.2196/jmir.6841",
url="http://www.ncbi.nlm.nih.gov/pubmed/28684385"
}


@Article{info:doi/10.2196/mhealth.6233,
author="Liao, Gen-Yih
and Chien, Yu-Tai
and Chen, Yu-Jen
and Hsiung, Hsiao-Fang
and Chen, Hsiao-Jung
and Hsieh, Meng-Hua
and Wu, Wen-Jie",
title="What to Build for Middle-Agers to Come? Attractive and Necessary Functions of Exercise-Promotion Mobile Phone Apps: A Cross-Sectional Study",
journal="JMIR Mhealth Uhealth",
year="2017",
month="May",
day="25",
volume="5",
number="5",
pages="e65",
keywords="physical exercise; middle aged; mobile application; self efficacy; consumer preference",
abstract="Background: Physical activity is important for middle-agers to maintain health both in middle age and in old age. Although thousands of exercise-promotion mobile phone apps are available for download, current literature offers little understanding regarding which design features can enhance middle-aged adults' quality perception toward exercise-promotion apps and which factor may influence such perception. Objectives: The aims of this study were to understand (1) which design features of exercise-promotion apps can enhance quality perception of middle-agers, (2) whether their needs are matched by current functions offered in app stores, and (3) whether physical activity (PA) and mobile phone self-efficacy (MPSE) influence quality perception. Methods: A total of 105 middle-agers participated and filled out three scales: the International Physical Activity Questionnaire (IPAQ), the MPSE scale, and the need for design features questionnaire. The design features were developed based on the Coventry, Aberdeen, and London---Refined (CALO-RE) taxonomy. Following the Kano quality model, the need for design features questionnaire asked participants to classify design features into five categories: attractive, one-dimensional, must-be, indifferent, and reverse. The quality categorization was conducted based on a voting approach and the categorization results were compared with the findings of a prevalence study to realize whether needs match current availability. In total, 52 multinomial logistic regression models were analyzed to evaluate the effects of PA level and MPSE on quality perception of design features. Results: The Kano analysis on the total sample revealed that visual demonstration of exercise instructions is the only attractive design feature, whereas the other 51 design features were perceived with indifference. Although examining quality perception by PA level, 21 features are recommended to low level, 6 features to medium level, but none to high-level PA. In contrast, high-level MPSE is recommended with 14 design features, medium level with 6 features, whereas low-level participants are recommended with 1 feature. The analysis suggests that the implementation of demanded features could be low, as the average prevalence of demanded design features is 20{\%} (4.3/21). Surprisingly, social comparison and social support, most implemented features in current apps, were categorized into the indifferent category. The magnitude of effect is larger for MPSE because it effects quality perception of more design features than PA. Delving into the 52 regression models revealed that high MPSE more likely induces attractive or one- dimensional categorization, suggesting the importance of technological self-efficacy on eHealth care promotion. Conclusions: This study is the first to propose middle-agers' needs in relation to mobile phone exercise-promotion. In addition to the tailor-made recommendations, suggestions are offered to app designers to enhance the performance of persuasive features. An interesting finding on change of quality perception attributed to MPSE is proposed as future research. ",
doi="10.2196/mhealth.6233",
url="http://mhealth.jmir.org/2017/5/e65/",
url="https://doi.org/10.2196/mhealth.6233",
url="http://www.ncbi.nlm.nih.gov/pubmed/28546140"
}


@Article{info:doi/10.2196/jmir.6616,
author="Bartlett, Yvonne Kiera
and Webb, Thomas L
and Hawley, Mark S",
title="Using Persuasive Technology to Increase Physical Activity in People With Chronic Obstructive Pulmonary Disease by Encouraging Regular Walking: A Mixed-Methods Study Exploring Opinions and Preferences",
journal="J Med Internet Res",
year="2017",
month="Apr",
day="20",
volume="19",
number="4",
pages="e124",
keywords="persuasive technology; chronic obstructive pulmonary disease; physical activity; walking; mHealth; mobile apps",
abstract="Background: People with chronic obstructive pulmonary disease (PwCOPD) often experience breathlessness and fatigue, making physical activity challenging. Although many persuasive technologies (such as mobile phone apps) have been designed to support physical activity among members of the general population, current technologies aimed at PwCOPD are underdeveloped and only use a limited range of persuasive technology design principles. Objective: The aim of this study was to explore how acceptable different persuasive technology design principles were considered to be in supporting and encouraging physical activity among PwCOPD. Methods: Three prototypes for mobile apps using different persuasive technology design principles as defined by the persuasive systems design (PSD) model---namely, dialogue support, primary task support, and social support---were developed. Opinions of these prototypes were explored through 28 interviews with PwCOPD, carers, and the health care professionals (HCPs) involved in their care and questionnaires completed by 87 PwCOPD. Participants also ranked how likely individual techniques (eg, competition) would be to convince them to use a technology designed to support physical activity. Data were analyzed using framework analysis, Friedman tests, and Wilcoxon signed rank tests and a convergent mixed methods design was used to integrate findings. Results: The prototypes for mobile apps were received positively by participants. The prototype that used a dialogue support approach was identified as the most likely to be used or recommended by those interviewed, and was perceived as more persuasive than both of the other prototypes (Z=−3.06, P=.002; Z=−5.50, P<.001) by those who completed the questionnaire. PwCOPD identified dialogue support and primary task support techniques as more likely to convince them to use a technology than social support techniques (Z=−5.00, P<.001; Z=−4.92, P<.001, respectively). Opinions of social support techniques such as competition and collaboration were divided. Conclusions: Dialogue support and primary task support approaches are considered to be both acceptable and likely to be persuasive by PwCOPD, carers, and HCPs. In the future, these approaches should be considered when designing apps to encourage physical activity by PwCOPD. ",
doi="10.2196/jmir.6616",
url="http://www.jmir.org/2017/4/e124/",
url="https://doi.org/10.2196/jmir.6616",
url="http://www.ncbi.nlm.nih.gov/pubmed/28428155"
}


@Article{info:doi/10.2196/games.7197,
author="Rasche, Peter
and Schlomann, Anna
and Mertens, Alexander",
title="Who Is Still Playing Pok{\'e}mon Go? A Web-Based Survey",
journal="JMIR Serious Games",
year="2017",
month="Apr",
day="05",
volume="5",
number="2",
pages="e7",
keywords="games; recreational; mobile apps; cell phones; Pok{\'e}mon Go",
abstract="Background: Poor physical activity is one of the major health care problems in Western civilizations. Various digital gadgets aiming to increase physical activity, such as activity trackers or fitness apps, have been introduced over recent years. The newest products are serious games that incorporate real-life physical activity into their game concept. Recent studies have shown that such games increase the physical activity of their users over the short term. Objective: In this study, we investigated the motivational effects of the digital game ``Pok{\'e}mon Go'' leading to continued use or abandonment of the game. The aim of the study was to determine aspects that motivate individuals to play augmented reality exergames and how this motivation can be used to strengthen the initial interest in physical activity. Methods: A total of 199 participants completed an open self-selected Web-based survey. On the basis of their self-indicated assignment to one of three predefined user groups (active, former, and nonuser of Pok{\'e}mon Go), participants answered various questions regarding game experience, physical activity, motivation, and personality as measured by the Big Five Inventory. Results: In total, 81 active, 56 former, and 62 nonusers of Pok{\'e}mon Go were recruited. When asked about the times they perform physical activity, active users stated that they were less physically active in general than former and nonusers. However, based on a subjective rating, active users were more motivated to be physically active due to playing Pok{\'e}mon Go. Motivational aspects differed for active and former users, whereas fan status was the same within both groups. Active users are more motivated by features directly related to Pok{\'e}mon, such as catching all possible Pok{\'e}mon and reaching higher levels, whereas former users stress the importance of general game quality, such as better augmented reality and more challenges in the game. Personality did not affect whether a person started to play Pok{\'e}mon Go nor their abandonment of the game. Conclusions: The results show various motivating elements that should be incorporated into augmented reality exergames based on the game Pok{\'e}mon Go. We identified different user types for whom different features of the game contribute to maintained motivation or abandonment. Our results show aspects that augmented reality exergame designers should keep in mind to encourage individuals to start playing their game and facilitate long-term user engagement, resulting in a greater interest in physical activity. ",
doi="10.2196/games.7197",
url="http://games.jmir.org/2017/2/e7/",
url="https://doi.org/10.2196/games.7197",
url="http://www.ncbi.nlm.nih.gov/pubmed/28381393"
}


@Article{info:doi/10.2196/games.6421,
author="Kouwenhoven-Pasmooij, Tessa A
and Robroek, Suzan JW
and Ling, Sui Wai
and van Rosmalen, Joost
and van Rossum, Elisabeth FC
and Burdorf, Alex
and Hunink, MG Myriam",
title="A Blended Web-Based Gaming Intervention on Changes in Physical Activity for Overweight and Obese Employees: Influence and Usage in an Experimental Pilot Study",
journal="JMIR Serious Games",
year="2017",
month="Apr",
day="03",
volume="5",
number="2",
pages="e6",
keywords="eHealth; gamification; physical activity; fitness tracker; body mass index; engagement; social support; blended care",
abstract="Background: Addressing the obesity epidemic requires the development of effective interventions aimed at increasing physical activity (PA). eHealth interventions with the use of accelerometers and gaming elements, such as rewarding or social bonding, seem promising. These eHealth elements, blended with face-to-face contacts, have the potential to help people adopt and maintain a physically active lifestyle. Objective: The aim of this study was to assess the influence and usage of a blended Web-based gaming intervention on PA, body mass index (BMI), and waist circumference among overweight and obese employees. Methods: In an uncontrolled before-after study, we observed 52 health care employees with BMI more than 25 kg/m2, who were recruited via the company's intranet and who voluntarily participated in a 23-week Web-based gaming intervention, supplemented (blended) with non-eHealth components. These non-eHealth components were an individual session with an occupational health physician involving motivational interviewing and 5 multidisciplinary group sessions. The game was played by teams in 5 time periods, aiming to gain points by being physically active, as measured by an accelerometer. Data were collected in 2014 and 2015. Primary outcome was PA, defined as length of time at MET (metabolic equivalent task) ≥3, as measured by the accelerometer during the game. Secondary outcomes were reductions in BMI and waist circumference, measured at baseline and 10 and 23 weeks after the start of the program. Gaming elements such as ``compliance'' with the game (ie, days of accelerometer wear), ``engagement'' with the game (ie, frequency of reaching a personal monthly target), and ``eHealth teams'' (ie, social influence of eHealth teams) were measured as potential determinants of the outcomes. Linear mixed models were used to evaluate the effects on all outcome measures. Results: The mean age of participants was 48.1 years; most participants were female (42/51, 82{\%}). The mean PA was 86 minutes per day, ranging from 6.5 to 223 minutes, which was on average 26.2 minutes per day more than self-reported PA at baseline and remained fairly constant during the game. Mean BMI was reduced by 1.87 kg/m2 (5.6{\%}) and waist circumference by 5.6 cm (4.8{\%}). The univariable model showed that compliance, engagement, and eHealth team were significantly associated with more PA, which remained significant for eHealth team in the multivariable model. Conclusions: This blended Web-based gaming intervention was beneficial for overweight workers in becoming physically active above the recommended activity levels during the entire intervention period, and a favorable influence on BMI and waist circumference was observed. Promising components in the intervention, and thus targets for upscaling, are eHealth teams and engagement with the game. Broader implementation and long-term follow-up can provide insights into the sustainable effects on PA and weight loss and into who benefits the most from this approach. ",
doi="10.2196/games.6421",
url="http://games.jmir.org/2017/2/e6/",
url="https://doi.org/10.2196/games.6421",
url="http://www.ncbi.nlm.nih.gov/pubmed/28373157"
}


@Article{info:doi/10.2196/games.6254,
author="Brox, Ellen
and Konstantinidis, Stathis Th
and Evertsen, Gunn",
title="User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design",
journal="JMIR Serious Games",
year="2017",
month="Jan",
day="11",
volume="5",
number="1",
pages="e2",
keywords="user studies; usability testing; gestural input; user-centred design; accessibility; consumer health; exergames; participatory design; lessons learned",
abstract="Background: Seniors need sufficient balance and strength to manage in daily life, and sufficient physical activity is required to achieve and maintain these abilities. This can be a challenge, but fun and motivational exergames can be of help. However, most commercial games are not suited for this age group for several reasons. Many usability studies and user-centered design (UCD) protocols have been developed and applied, but to the best of our knowledge none of them are focusing on seniors' use of games for physical activity. In GameUp, a European cofunded project, some prototype Kinect exergames to enhance the mobility of seniors were developed in a user-centered approach. Objective: In this paper we aim to record lessons learned in 3 years of experience with exergames for seniors, considering both the needs of older adults regarding user-centered development of exergames and participation in UCD. We also provide a UCD protocol for exergames tailored to senior needs. Methods: An initial UCD protocol was formed based on literature of previous research outcomes. Senior users participated in UCD following the initial protocol. The users formed a steady group that met every second week for 3 years to play exergames and participate in the UCD during the 4 phases of the protocol. Several methods were applied in the 4 different phases of the UCD protocol; the most important methods were structured and semistructured interviews, observations, and group discussions. Results: A total of 16 seniors with an average age above 80 years participated for 3 years in UCD in order to develop the GameUp exergames. As a result of the lessons learned by applying the different methodologies of the UCD protocol, we propose an adjusted UCD protocol providing explanations on how it should be applied for seniors as users. Questionnaires should be turned into semistructured and structured interviews while user consultation sessions should be repeated with the same theme to ensure that the UCD methods produce a valid outcome. By first following the initial and gradually the adjusted UCD protocol, the project resulted in exergame functionalities and interface features for seniors. Conclusions: The main lessons learned during 3 years of experience with exergames for seniors applying UCD are that devoting time to seniors is a key element of success so that trust can be gained, communication can be established, and users' opinions can be recorded. All different game elements should be taken into consideration during the design of exergames for seniors even if they seem obvious. Despite the limitations of this study, one might argue that it provides a best practice guide to the development of serious games for physical activity targeting seniors. ",
doi="10.2196/games.6254",
url="http://games.jmir.org/2017/1/e2/",
url="https://doi.org/10.2196/games.6254",
url="http://www.ncbi.nlm.nih.gov/pubmed/28077348"
}


@Article{info:doi/10.2196/jmir.6759,
author="Althoff, Tim
and White, Ryen W
and Horvitz, Eric",
title="Influence of Pok{\'e}mon Go on Physical Activity: Study and Implications",
journal="J Med Internet Res",
year="2016",
month="Dec",
day="06",
volume="18",
number="12",
pages="e315",
keywords="physical activity; Pok{\'e}mon Go; mobile health; mHealth; wearable devices; mobile applications; games; exergames; public health",
abstract="Background: Physical activity helps people maintain a healthy weight and reduces the risk for several chronic diseases. Although this knowledge is widely recognized, adults and children in many countries around the world do not get recommended amounts of physical activity. Although many interventions are found to be ineffective at increasing physical activity or reaching inactive populations, there have been anecdotal reports of increased physical activity due to novel mobile games that embed game play in the physical world. The most recent and salient example of such a game is Pok{\'e}mon Go, which has reportedly reached tens of millions of users in the United States and worldwide. Objective: The objective of this study was to quantify the impact of Pok{\'e}mon Go on physical activity. Methods: We study the effect of Pok{\'e}mon Go on physical activity through a combination of signals from large-scale corpora of wearable sensor data and search engine logs for 32,000 Microsoft Band users over a period of 3 months. Pok{\'e}mon Go players are identified through search engine queries and physical activity is measured through accelerometers. Results: We find that Pok{\'e}mon Go leads to significant increases in physical activity over a period of 30 days, with particularly engaged users (ie, those making multiple search queries for details about game usage) increasing their activity by 1473 steps a day on average, a more than 25{\%} increase compared with their prior activity level (P<.001). In the short time span of the study, we estimate that Pok{\'e}mon Go has added a total of 144 billion steps to US physical activity. Furthermore, Pok{\'e}mon Go has been able to increase physical activity across men and women of all ages, weight status, and prior activity levels showing this form of game leads to increases in physical activity with significant implications for public health. In particular, we find that Pok{\'e}mon Go is able to reach low activity populations, whereas all 4 leading mobile health apps studied in this work largely draw from an already very active population. Conclusions: Mobile apps combining game play with physical activity lead to substantial short-term activity increases and, in contrast to many existing interventions and mobile health apps, have the potential to reach activity-poor populations. Future studies are needed to investigate potential long-term effects of these applications. ",
doi="10.2196/jmir.6759",
url="http://www.jmir.org/2016/12/e315/",
url="https://doi.org/10.2196/jmir.6759",
url="http://www.ncbi.nlm.nih.gov/pubmed/27923778"
}


@Article{info:doi/10.2196/jmir.4964,
author="Spook, Jorinde
and Paulussen, Theo
and Kok, Gerjo
and van Empelen, Pepijn",
title="Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (``Balance It''): A Pilot Study",
journal="J Med Internet Res",
year="2016",
month="Sep",
day="26",
volume="18",
number="9",
pages="e225",
keywords="Balance It; effect evaluation; serious game; self-regulation; prevention and control; health promotion; dietary intake; physical activity",
abstract="Background: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of ``Balance It,'' a serious self-regulation game intervention targeting students' overweight-related behaviors: dietary intake and physical activity (PA). Objective: We aimed to pilot the effects of Balance It on secondary vocational education students' dietary intake and PA. Methods: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8{\%} (145/231) were female, and 26.8{\%} (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. Results: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6{\%} (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users' snack consumption decreased more strongly (active users: mean change=--0.20; control group: mean change=--0.08; beta=--0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=--0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=--0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. Conclusions: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6{\%}). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight. ",
doi="10.2196/jmir.4964",
url="http://www.jmir.org/2016/9/e225/",
url="https://doi.org/10.2196/jmir.4964",
url="http://www.ncbi.nlm.nih.gov/pubmed/27670222"
}


@Article{info:doi/10.2196/games.5528,
author="Levac, Danielle
and Nawrotek, Joanna
and Deschenes, Emilie
and Giguere, Tia
and Serafin, Julie
and Bilodeau, Martin
and Sveistrup, Heidi",
title="Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play",
journal="JMIR Serious Games",
year="2016",
month="Jun",
day="01",
volume="4",
number="1",
pages="e9",
keywords="active video games, virtual reality, physical therapy, movement, reliability",
abstract="Background: Virtual reality active video games are increasingly popular physical therapy interventions for children with cerebral palsy. However, physical therapists require educational resources to support decision making about game selection to match individual patient goals. Quantifying the movements elicited during virtual reality active video game play can inform individualized game selection in pediatric rehabilitation. Objective: The objectives of this study were to develop and evaluate the feasibility and reliability of the Movement Rating Instrument for Virtual Reality Game Play (MRI-VRGP). Methods: Item generation occurred through an iterative process of literature review and sample videotape viewing. The MRI-VRGP includes 25 items quantifying upper extremity, lower extremity, and total body movements. A total of 176 videotaped 90-second game play sessions involving 7 typically developing children and 4 children with cerebral palsy were rated by 3 raters trained in MRI-VRGP use. Children played 8 games on 2 virtual reality and active video game systems. Intraclass correlation coefficients (ICCs) determined intra-rater and interrater reliability. Results: Excellent intrarater reliability was evidenced by ICCs of >0.75 for 17 of the 25 items across the 3 raters. Interrater reliability estimates were less precise. Excellent interrater reliability was achieved for far reach upper extremity movements (ICC=0.92 [for right and ICC=0.90 for left) and for squat (ICC=0.80) and jump items (ICC=0.99), with 9 items achieving ICCs of >0.70, 12 items achieving ICCs of between 0.40 and 0.70, and 4 items achieving poor reliability (close-reach upper extremity-ICC=0.14 for right and ICC=0.07 for left) and single-leg stance (ICC=0.55 for right and ICC=0.27 for left). Conclusions: Poor video quality, differing item interpretations between raters, and difficulty quantifying the high-speed movements involved in game play affected reliability. With item definition clarification and further psychometric property evaluation, the MRI-VRGP could inform the content of educational resources for therapists by ranking games according to frequency and type of elicited body movements. ",
doi="10.2196/games.5528",
url="http://games.jmir.org/2016/1/e9/",
url="https://doi.org/10.2196/games.5528",
url="http://www.ncbi.nlm.nih.gov/pubmed/27251029"
}


@Article{info:doi/10.2196/games.4561,
author="de Vette, Frederiek
and Tabak, Monique
and Dekker - van Weering, Marit
and Vollenbroek-Hutten, Miriam",
title="Engaging Elderly People in Telemedicine Through Gamification",
journal="JMIR Serious Games",
year="2015",
month="Dec",
day="18",
volume="3",
number="2",
pages="e9",
keywords="gamification; framework; elderly; older adults; eHealth; telemedicine; adherence; engagement; classification; player type; personality",
abstract="Background: Telemedicine can alleviate the increasing demand for elderly care caused by the rapidly aging population. However, user adherence to technology in telemedicine interventions is low and decreases over time. Therefore, there is a need for methods to increase adherence, specifically of the elderly user. A strategy that has recently emerged to address this problem is gamification. It is the application of game elements to nongame fields to motivate and increase user activity and retention. Objective: This research aims to (1) provide an overview of existing theoretical frameworks for gamification and explore methods that specifically target the elderly user and (2) explore user classification theories for tailoring game content to the elderly user. This knowledge will provide a foundation for creating a new framework for applying gamification in telemedicine applications to effectively engage the elderly user by increasing and maintaining adherence. Methods: We performed a broad Internet search using scientific and nonscientific search engines and included information that described either of the following subjects: the conceptualization of gamification, methods to engage elderly users through gamification, or user classification theories for tailored game content. Results: Our search showed two main approaches concerning frameworks for gamification: from business practices, which mostly aim for more revenue, emerge an applied approach, while academia frameworks are developed incorporating theories on motivation while often aiming for lasting engagement. The search provided limited information regarding the application of gamification to engage elderly users, and a significant gap in knowledge on the effectiveness of a gamified application in practice. Several approaches for classifying users in general were found, based on archetypes and reasons to play, and we present them along with their corresponding taxonomies. The overview we created indicates great connectivity between these taxonomies. Conclusions: Gamification frameworks have been developed from different backgrounds---business and academia---but rarely target the elderly user. The effectiveness of user classifications for tailored game content in this context is not yet known. As a next step, we propose the development of a framework based on the hypothesized existence of a relation between preference for game content and personality. ",
doi="10.2196/games.4561",
url="http://games.jmir.org/2015/2/e9/",
url="https://doi.org/10.2196/games.4561",
url="http://www.ncbi.nlm.nih.gov/pubmed/26685287"
}


@Article{info:doi/10.2196/games.4275,
author="Bird, Marie-Louise
and Clark, Brodie
and Millar, Johanna
and Whetton, Sue
and Smith, Stuart",
title="Exposure to ``Exergames'' Increases Older Adults' Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study",
journal="JMIR Serious Games",
year="2015",
month="Nov",
day="27",
volume="3",
number="2",
pages="e8",
keywords="health care reform; postural balance; pleasure; exercise; perception",
abstract="Background: High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (``exergames''), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults' perceptions of the use of technology to improve health are not known. Objective: The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods: Focus groups determined habitual use of technology and the participant's perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (``Your Shape Fitness Evolved 2012''). Games scores, rates of game participation, and enjoyment were also recorded. Results: A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83{\%}-100{\%}) were recorded. Conclusions: Older adults' have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults. ",
doi="10.2196/games.4275",
url="http://games.jmir.org/2015/2/e8/",
url="https://doi.org/10.2196/games.4275",
url="http://www.ncbi.nlm.nih.gov/pubmed/26614263"
}


@Article{info:doi/10.2196/jmir.4568,
author="Direito, Artur
and Jiang, Yannan
and Whittaker, Robyn
and Maddison, Ralph",
title="Apps for IMproving FITness and Increasing Physical Activity Among Young People: The AIMFIT Pragmatic Randomized Controlled Trial",
journal="J Med Internet Res",
year="2015",
month="Aug",
day="27",
volume="17",
number="8",
pages="e210",
keywords="physical fitness; motor activity; exercise; physical activity; adolescent; health promotion; telemedicine; mHealth; mobile applications; smartphone",
abstract="Background: Given the global prevalence of insufficient physical activity (PA), effective interventions that attenuate age-related decline in PA levels are needed. Mobile phone interventions that positively affect health (mHealth) show promise; however, their impact on PA levels and fitness in young people is unclear and little is known about what makes a good mHealth app. Objective: The aim was to determine the effects of two commercially available smartphone apps (Zombies, Run and Get Running) on cardiorespiratory fitness and PA levels in insufficiently active healthy young people. A second aim was to identify the features of the app design that may contribute to improved fitness and PA levels. Methods: Apps for IMproving FITness (AIMFIT) was a 3-arm, parallel, randomized controlled trial conducted in Auckland, New Zealand. Participants were recruited through advertisements in electronic mailing lists, local newspapers, flyers posted in community locations, and presentations at schools. Eligible young people aged 14-17 years were allocated at random to 1 of 3 conditions: (1) use of an immersive app (Zombies, Run), (2) use of a nonimmersive app (Get Running), or (3) usual behavior (control). Both smartphone apps consisted of a fully automated 8-week training program designed to improve fitness and ability to run 5 km; however, the immersive app featured a game-themed design and narrative. Intention-to-treat analysis was performed using data collected face-to-face at baseline and 8 weeks, and all regression models were adjusted for baseline outcome value and gender. The primary outcome was cardiorespiratory fitness, objectively assessed as time to complete the 1-mile run/walk test at 8 weeks. Secondary outcomes were PA levels (accelerometry and self-reported), enjoyment, psychological need satisfaction, self-efficacy, and acceptability and usability of the apps. Results: A total of 51 participants were randomized to the immersive app intervention (n=17), nonimmersive app intervention (n=16), or the control group (n=18). The mean age of participants was 15.7 (SD 1.2) years; participants were mostly NZ Europeans (61{\%}, 31/51) and 57{\%} (29/51) were female. Overall retention rate was 96{\%} (49/51). There was no significant intervention effect on the primary outcome using either of the apps. Compared to the control, time to complete the fitness test was --28.4 seconds shorter (95{\%} CI --66.5 to 9.82, P=.20) for the immersive app group and --24.7 seconds (95{\%} CI --63.5 to 14.2, P=.32) for the nonimmersive app group. No significant intervention effects were found for secondary outcomes. Conclusions: Although apps have the ability to increase reach at a low cost, our pragmatic approach using readily available commercial apps as a stand-alone instrument did not have a significant effect on fitness. However, interest in future use of PA apps is promising and highlights a potentially important role of these tools in a multifaceted approach to increase fitness, promote PA, and consequently reduce the adverse health outcomes associated with insufficient activity. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12613001030763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12613001030763 (Archived by WebCite at http://www.webcitation.org/6aasfJVTJ). ",
doi="10.2196/jmir.4568",
url="http://www.jmir.org/2015/8/e210/",
url="https://doi.org/10.2196/jmir.4568",
url="http://www.ncbi.nlm.nih.gov/pubmed/26316499"
}


@Article{info:doi/10.2196/resprot.4031,
author="Imam, Bita
and Miller, William C
and Finlayson, Heather C
and Eng, Janice J
and Payne, Michael WC
and Jarus, Tal
and Goldsmith, Charles H
and Mitchell, Ian M",
title="A Telehealth Intervention Using Nintendo Wii Fit Balance Boards and iPads to Improve Walking in Older Adults With Lower Limb Amputation (Wii.n.Walk): Study Protocol for a Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2014",
month="Dec",
day="22",
volume="3",
number="4",
pages="e80",
keywords="amputation; adult; aged; randomized controlled trial; telemedicine; walking",
abstract="Background: The number of older adults living with lower limb amputation (LLA) who require rehabilitation for improving their walking capacity and mobility is growing. Existing rehabilitation practices frequently fail to meet this demand. Nintendo Wii Fit may be a valuable tool to enable rehabilitation interventions. Based on pilot studies, we have developed ``Wii.n.Walk'', an in-home telehealth Wii Fit intervention targeted to improve walking capacity in older adults with LLA. Objective: The objective of this study is to determine whether the Wii.n.Walk intervention enhances walking capacity compared to an attention control group. Methods: This project is a multi-site (Vancouver BC, London ON), parallel, evaluator-blind randomized controlled trial. Participants include community-dwelling older adults over the age of 50 years with unilateral transtibial or transfemoral amputation. Participants will be stratified by site and block randomized in triplets to either the Wii.n.Walk intervention or an attention control group employing the Wii Big Brain cognitive software. This trial will include both supervised and unsupervised phases. During the supervised phase, both groups will receive 40-minute sessions of supervised group training three times per week for a duration of 4 weeks. Participants will complete the first week of the intervention in groups of three at their local rehabilitation center with a trainer. The remaining 3 weeks will take place at participants' homes using remote supervision by the trainer using Apple iPad technology. At the end of 4 weeks, the supervised period will end and the unsupervised period will begin. Participants will retain the Wii console and be encouraged to continue using the program for an additional 4 weeks' duration. The primary outcome measure will be the ``Two-Minute Walk Test'' to measure walking capacity. Outcome measures will be evaluated for all participants at baseline, after the end of both the supervised and unsupervised phases, and after 1-year follow up. Results: Study staff have been hired and trained at both sites and recruitment is currently underway. No participants have been enrolled yet. Conclusions: Wii.n.Walk is a promising in-home telehealth intervention that may have useful applications for older adults with LLA who are discharged from rehabilitation or live in remote areas having limited or no access to existing rehabilitation programs. Trial Registration: Clinicaltrial.gov NCT01942798; http://clinicaltrials.gov/ct2/show/NCT01942798 (Archived by WebCite at http://www.webcitation.org/6V0w8baKP). ",
doi="10.2196/resprot.4031",
url="http://www.researchprotocols.org/2014/4/e80/",
url="https://doi.org/10.2196/resprot.4031",
url="http://www.ncbi.nlm.nih.gov/pubmed/25533902"
}


@Article{info:doi/10.2196/jmir.3154,
author="Garrido Navarro, Juan Enrique
and Ruiz Penichet, Victor Manuel
and Lozano P{\'e}rez, Mar{\'i}a Dolores",
title="Movement-Based Interaction Applied to Physical Rehabilitation Therapies",
journal="J Med Internet Res",
year="2014",
month="Dec",
day="09",
volume="16",
number="12",
pages="e281",
keywords="exercise movement techniques; human--computer interaction; interaction devices; movement-based interaction; rehabilitation therapies",
abstract="Background: Health care environments are continuously improving conditions, especially regarding the use of current technology. In the field of rehabilitation, the use of video games and related technology has helped to develop new rehabilitation procedures. Patients are able to work on their disabilities through new processes that are more motivating and entertaining. However, these patients are required to leave their home environment to complete their rehabilitation programs. Objective: The focus of our research interests is on finding a solution to eliminate the need for patients to interrupt their daily routines to attend rehabilitation therapy. We have developed an innovative  system that allows patients with a balance disorder to perform a specific rehabilitation exercise at home. Additionally, the system features an assistive tool to complement the work of physiotherapists. Medical staff are thus provided with a system that avoids the need for them to be present during the exercise in specific cases in which patients are under suitable supervision. Methods: A movement-based interaction device was used to achieve a reliable system for monitoring rehabilitation exercises performed at home. The system accurately utilizes parameters previously defined by the specialist for correct performance of the exercise. Accordingly, the system gives instructions and corrects the patient's actions. The data generated during the session are collected for assessment by the specialist to adapt the difficulty of the exercise to the patient's progress. Results: The evaluation of the system was conducted by two experts in balance disorder rehabilitation.  They were required to verify the effectiveness of the system, and they also facilitated the simulation of real patient behavior. They used the system freely for a period of time and provided interesting and optimistic feedback. First, they evaluated the system as a tool for real-life rehabilitation therapy. Second, their interaction with the system allowed us to obtain important feedback needed to improve the system. Conclusions: The system improves the rehabilitation conditions of people with balance disorder. The main contribution comes from the fact that it allows patients to carry out the rehabilitation process at home under the supervision of physiotherapists. As a result, patients avoid having to attend medical centers. Additionally, medical staff have access to an assistant, which means their presence is not required in many exercises that involve constant repetition. ",
doi="10.2196/jmir.3154",
url="http://www.jmir.org/2014/12/e281/",
url="https://doi.org/10.2196/jmir.3154",
url="http://www.ncbi.nlm.nih.gov/pubmed/25491148"
}


@Article{info:doi/10.2196/games.3691,
author="Moller, Arlen C
and Majewski, Sara
and Standish, Melanie
and Agarwal, Pooja
and Podowski, Aleksandra
and Carson, Rebecca
and Eyesus, Biruk
and Shah, Aakash
and Schneider, Kristin L",
title="Active Fantasy Sports: Rationale and Feasibility of Leveraging Online Fantasy Sports to Promote Physical Activity",
journal="JMIR Serious Games",
year="2014",
month="Nov",
day="25",
volume="2",
number="2",
pages="e13",
keywords="physical activity; games for health; active video game; exergame; asynchronous; social support; multiplayer; enjoyment; intrinsic motivation; sports",
abstract="Background: The popularity of active video games (AVGs) has skyrocketed over the last decade. However, research suggests that the most popular AVGs, which rely on synchronous integration between players' activity and game features, fail to promote physical activity outside of the game or for extended periods of engagement. This limitation has led researchers to consider AVGs that involve asynchronous integration of players' ongoing physical activity with game features. Rather than build an AVG de novo, we selected an established sedentary video game uniquely well suited for the incorporation of asynchronous activity: online fantasy sports. Objective: The primary aim of this study was to explore the feasibility of a new asynchronous AVG---active fantasy sports---designed to promote physical activity. Methods: We conducted two pilot studies of an active fantasy sports game designed to promote physical activity. Participants wore a low cost triaxial accelerometer and participated in an online fantasy baseball (Study 1, n=9, 13-weeks) or fantasy basketball (Study 2, n=10, 17-weeks) league. Privileges within the game were made contingent on meeting weekly physical activity goals (eg, averaging 10,000 steps/day). Results: Across the two studies, the feasibility of integrating physical activity contingent features and privileges into online fantasy sports games was supported. Participants found the active fantasy sports game enjoyable, as or more enjoyable than traditional (sedentary) online fantasy sports (Study 1: t8=4.43, P<.01; Study 2: t9=2.09, P=.07). Participants in Study 1 increased their average steps/day, t8=2.63, P<.05, while participants in Study 2 maintained (ie, did not change) their activity, t9=1.57, P=.15). In postassessment interviews, social support within the game was cited as a key motivating factor for increasing physical activity. Conclusions: Preliminary evidence supports potential for the active fantasy sports system as a sustainable and scalable intervention for promoting adult physical activity. ",
doi="10.2196/games.3691",
url="http://games.jmir.org/2014/2/e13/",
url="https://doi.org/10.2196/games.3691",
url="http://www.ncbi.nlm.nih.gov/pubmed/25654304"
}


@Article{info:doi/10.2196/games.2933,
author="Lozano-Quilis, Jose-Antonio
and Gil-G{\'o}mez, Hermenegildo
and Gil-G{\'o}mez, Jose-Antonio
and Albiol-P{\'e}rez, Sergio
and Palacios-Navarro, Guillermo
and Fardoun, Habib M
and Mashat, Abdulfattah S",
title="Virtual Rehabilitation for Multiple Sclerosis Using a Kinect-Based System: Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2014",
month="Nov",
day="12",
volume="2",
number="2",
pages="e12",
keywords="multiple sclerosis; motor rehabilitation; virtual reality; natural interfaces; augmented reality",
abstract="Background: The methods used for the motor rehabilitation of patients with neurological disorders include a number of different rehabilitation exercises. For patients who have been diagnosed with multiple sclerosis (MS), the performance of motor rehabilitation exercises is essential. Nevertheless, this rehabilitation may be tedious, negatively influencing patients' motivation and adherence to treatment. Objective: We present RemoviEM, a system based on Kinect that uses virtual reality (VR) and natural user interfaces (NUI) to offer patients with MS an intuitive and motivating way to perform several motor rehabilitation exercises. It offers therapists a new motor rehabilitation tool for the rehabilitation process, providing feedback on the patient's progress. Moreover, it is a low-cost system, a feature that can facilitate its integration in clinical rehabilitation centers. Methods: A randomized and controlled single blinded study was carried out to assess the influence of a Kinect-based virtual rehabilitation system on the balance rehabilitation of patients with MS. This study describes RemoviEM and evaluates its effectiveness compared to standard rehabilitation. To achieve this objective, a clinical trial was carried out. Eleven patients from a MS association participated in the clinical trial. The mean age was 44.82 (SD 10.44) and the mean time from diagnosis (years) was 9.77 (SD 10.40). Clinical effectiveness was evaluated using clinical balance scales. Results: Significant group-by-time interaction was detected in the scores of the Berg Balance Scale (P=.011) and the Anterior Reach Test in standing position (P=.011). Post-hoc analysis showed greater improvement in the experimental group for these variables than in the control group for these variables. The Suitability Evaluation Questionnaire (SEQ) showed good results in usability, acceptance, security, and safety for the evaluated system. Conclusions: The results obtained suggest that RemoviEM represents a motivational and effective alternative to traditional motor rehabilitation for MS patients. These results have encouraged us to improve the system with new exercises, which are currently being developed. ",
doi="10.2196/games.2933",
url="http://games.jmir.org/2014/2/e12/",
url="https://doi.org/10.2196/games.2933",
url="http://www.ncbi.nlm.nih.gov/pubmed/25654242"
}


@Article{info:doi/10.2196/games.3413,
author="Lister, Cameron
and West, Joshua H
and Cannon, Ben
and Sax, Tyler
and Brodegard, David",
title="Just a Fad? Gamification in Health and Fitness Apps",
journal="JMIR Serious Games",
year="2014",
month="Aug",
day="04",
volume="2",
number="2",
pages="e9",
keywords="gamification; mobile phone; behavioral health; health and fitness apps",
abstract="Background: Gamification has been a predominant focus of the health app industry in recent years. However, to our knowledge, there has yet to be a review of gamification elements in relation to health behavior constructs, or insight into the true proliferation of gamification in health apps. Objective: The objective of this study was to identify the extent to which gamification is used in health apps, and analyze gamification of health and fitness apps as a potential component of influence on a consumer's health behavior. Methods: An analysis of health and fitness apps related to physical activity and diet was conducted among apps in the Apple App Store in the winter of 2014. This analysis reviewed a sample of 132 apps for the 10 effective game elements, the 6 core components of health gamification, and 13 core health behavior constructs. A regression analysis was conducted in order to measure the correlation between health behavior constructs, gamification components, and effective game elements. Results: This review of the most popular apps showed widespread use of gamification principles, but low adherence to any professional guidelines or industry standard. Regression analysis showed that game elements were associated with gamification (P<.001). Behavioral theory was associated with gamification (P<.05), but not game elements, and upon further analysis gamification was only associated with composite motivational behavior scores (P<.001), and not capacity or opportunity/trigger. Conclusions: This research, to our knowledge, represents the first comprehensive review of gamification use in health and fitness apps, and the potential to impact health behavior. The results show that use of gamification in health and fitness apps has become immensely popular, as evidenced by the number of apps found in the Apple App Store containing at least some components of gamification. This shows a lack of integrating important elements of behavioral theory from the app industry, which can potentially impact the efficacy of gamification apps to change behavior. Apps represent a very promising, burgeoning market and landscape in which to disseminate health behavior change interventions. Initial results show an abundant use of gamification in health and fitness apps, which necessitates the in-depth study and evaluation of the potential of gamification to change health behaviors. ",
doi="10.2196/games.3413",
url="http://games.jmir.org/2014/2/e9/",
url="https://doi.org/10.2196/games.3413",
url="http://www.ncbi.nlm.nih.gov/pubmed/25654660"
}


@Article{info:doi/10.2196/games.3092,
author="Simons, Monique
and de Vet, Emely
and Chinapaw, Mai JM
and de Boer, Michiel
and Seidell, Jacob C
and Brug, Johannes",
title="Personal, Social, and Game-Related Correlates of Active and Non-Active Gaming Among Dutch Gaming Adolescents: Survey-Based Multivariable, Multilevel Logistic Regression Analyses",
journal="JMIR Serious Games",
year="2014",
month="Apr",
day="04",
volume="2",
number="1",
pages="e4",
keywords="video games; interactive games; active games; adolescent; sedentary lifestyle; physical activity; determinants",
abstract="Background: Playing video games contributes substantially to sedentary behavior in youth. A new generation of video games---active games---seems to be a promising alternative to sedentary games to promote physical activity and reduce sedentary behavior. At this time, little is known about correlates of active and non-active gaming among adolescents. Objective: The objective of this study was to examine potential personal, social, and game-related correlates of both active and non-active gaming in adolescents. Methods: A survey assessing game behavior and potential personal, social, and game-related correlates was conducted among adolescents (12-16 years, N=353) recruited via schools. Multivariable, multilevel logistic regression analyses, adjusted for demographics (age, sex and educational level of adolescents), were conducted to examine personal, social, and game-related correlates of active gaming ≥1 hour per week (h/wk) and non-active gaming >7 h/wk. Results: Active gaming ≥1 h/wk was significantly associated with a more positive attitude toward active gaming (OR 5.3, CI 2.4-11.8; P<.001), a less positive attitude toward non-active games (OR 0.30, CI 0.1-0.6; P=.002), a higher score on habit strength regarding gaming (OR 1.9, CI 1.2-3.2; P=.008) and having brothers/sisters (OR 6.7, CI 2.6-17.1; P<.001) and friends (OR 3.4, CI 1.4-8.4; P=.009) who spend more time on active gaming and a little bit lower score on game engagement (OR 0.95, CI 0.91-0.997; P=.04). Non-active gaming >7 h/wk was significantly associated with a more positive attitude toward non-active gaming (OR 2.6, CI 1.1-6.3; P=.035), a stronger habit regarding gaming (OR 3.0, CI 1.7-5.3; P<.001), having friends who spend more time on non-active gaming (OR 3.3, CI 1.46-7.53; P=.004), and a more positive image of a non-active gamer (OR 2, CI 1.07--3.75; P=.03). Conclusions: Various factors were significantly associated with active gaming ≥1 h/wk and non-active gaming >7 h/wk. Active gaming is most strongly (negatively) associated with attitude with respect to non-active games, followed by observed active game behavior of brothers and sisters and attitude with respect to active gaming (positive associations). On the other hand, non-active gaming is most strongly associated with observed non-active game behavior of friends, habit strength regarding gaming and attitude toward non-active gaming (positive associations). Habit strength was a correlate of both active and non-active gaming, indicating that both types of gaming are habitual behaviors. Although these results should be interpreted with caution because of the limitations of the study, they do provide preliminary insights into potential correlates of active and non-active gaming that can be used for further research as well as preliminary direction for the development of effective intervention strategies for replacing non-active gaming by active gaming among adolescents. ",
doi="10.2196/games.3092",
url="http://games.jmir.org/2014/1/e4/",
url="https://doi.org/10.2196/games.3092",
url="http://www.ncbi.nlm.nih.gov/pubmed/25654657"
}


@Article{info:doi/10.2196/jmir.2403,
author="Lyons, Elizabeth Jane
and Hatkevich, Claire",
title="Prevalence of Behavior Changing Strategies in Fitness Video Games: Theory-Based Content Analysis",
journal="J Med Internet Res",
year="2013",
month="May",
day="07",
volume="15",
number="5",
pages="e81",
keywords="video game; theory; content analysis; fitness; physical activity; exergame",
abstract="Background: Fitness video games are popular, but little is known about their content. Because many contain interactive tools that mimic behavioral strategies from weight loss intervention programs, it is possible that differences in content could affect player physical activity and/or weight outcomes. There is a need for a better understanding of what behavioral strategies are currently available in fitness games and how they are implemented. Objective: The purpose of this study was to investigate the prevalence of evidence-based behavioral strategies across fitness video games available for home use. Games available for consoles that used camera-based controllers were also contrasted with games available for a console that used handheld motion controllers. Methods: Fitness games (N=18) available for three home consoles were systematically identified and play-tested by 2 trained coders for at least 3 hours each. In cases of multiple games from one series, only the most recently released game was included. The Sony PlayStation 3 and Microsoft Xbox360 were the two camera-based consoles, and the Nintendo Wii was the handheld motion controller console. A coding list based on a taxonomy of behavioral strategies was used to begin coding. Codes were refined in an iterative process based on data found during play-testing. Results: The most prevalent behavioral strategies were modeling (17/18), specific performance feedback (17/18), reinforcement (16/18), caloric expenditure feedback (15/18), and guided practice (15/18). All games included some kind of feedback on performance accuracy, exercise frequency, and/or fitness progress. Action planning (scheduling future workouts) was the least prevalent of the included strategies (4/18). Twelve games included some kind of social integration, with nine of them providing options for real-time multiplayer sessions. Only two games did not feature any kind of reward. Games for the camera-based consoles (mean 12.89, SD 2.71) included a greater number of strategies than those for the handheld motion controller console (mean 10.00, SD 2.74, P=.04). Conclusions: Behavioral strategies for increasing self-efficacy and self-regulation are common in home console fitness video games. Social support and reinforcement occurred in approximately half of the studied games. Strategy prevalence varies by console type, partially due to greater feedback afforded by camera-based controllers. Experimental studies are required to test the effects of these strategies when delivered as interactive tools, as this medium may represent an innovative platform for disseminating evidence-based behavioral weight loss intervention components. ",
doi="10.2196/jmir.2403",
url="http://www.jmir.org/2013/5/e81/",
url="https://doi.org/10.2196/jmir.2403",
url="http://www.ncbi.nlm.nih.gov/pubmed/23651701"
}