@Article{info:doi/10.2196/60685,
author="Jansen, Marjolein
and van Iperen, D. Ingrid
and Kroner, Anke
and Hemler, Raphael
and Dekker-Holverda, Esther
and Spronk, E. Peter",
title="Kangaroo Stimulation Game in Tracheostomized Intensive Care--Related Dysphagia: Interventional Feasibility Study",
journal="JMIR Serious Games",
year="2025",
month="Mar",
day="5",
volume="13",
pages="e60685",
keywords="dysphagia",
keywords="swallowing",
keywords="intensive care",
keywords="ICU",
keywords="swallowing disturbance",
keywords="kangaroo stimulation",
keywords="game",
keywords="feasibility study",
keywords="surface electromyography",
keywords="training",
keywords="exercise",
keywords="Rephagia biofeedback",
keywords="muscle strength",
keywords="stamina",
keywords="timing",
keywords="tracheostomy",
keywords="clinical",
keywords="feasibility",
abstract="Background: Dysphagia is common in intensive care unit (ICU) patients. Using surface electromyography (sEMG) signals as biofeedback training exercises might offer a promising path to improving swallowing function. The Rephagia biofeedback system uses sEMG to assess muscle strength, stamina, and timing of the swallowing action. Objectives: The aim of this study was to evaluate the feasibility of the Rephagia system in ICU patients with dysphagia. Methods: This feasibility study included patients admitted to a 14-bed mixed medical-surgical ICU. All patients underwent a new tracheostomy placement during ICU stay due to persistent aspiration and ICU-acquired weakness, accompanied by verified dysphagia. Following Rephagia training, patients completed a questionnaire assessing comprehension, satisfaction, and motivation. Swallowing characteristics were assessed via mean sEMG peak values during exercise. Results: Twenty patients with a mean age of 69.4 (SD 8.2) years were included. The means of sEMG values at the beginning of a measurement were not significantly different at baseline versus everyone's last measurement (52 {\textmu}V [23 {\textmu}V] vs 57 {\textmu}V [22 {\textmu}V]; P=.50). The means of sEMG values obtained at the end of a measurement were not significantly different at baseline versus everyone's last measurement (56 {\textmu}V [18 {\textmu}V] vs 59 {\textmu}V [23 {\textmu}V]; P=.62). However, dysphagia improved in all patients. Patients understood the importance of the game in relation to their swallowing problems (16/80, 89\%), which kept them motivated to participate in the training sessions (9/18, 50\%). Conclusions: The Rephagia biofeedback system for stimulating swallowing actions in tracheotomized ICU patients with dysphagia is feasible. No relation was found between clinical improvement in swallowing function and sEMG signals. ",
doi="10.2196/60685",
url="https://games.jmir.org/2025/1/e60685"
}


@Article{info:doi/10.2196/55720,
author="Heuvelink, Annerieke
and Saini, Privender
and Ta?ar, {\"O}zg{\"u}r
and Nauts, Sanne",
title="Improving Pediatric Patients' Magnetic Resonance Imaging Experience With an In-Bore Solution: Design and Usability Study",
journal="JMIR Serious Games",
year="2025",
month="Feb",
day="13",
volume="13",
pages="e55720",
keywords="MRI",
keywords="magnetic resonance imaging",
keywords="imaging",
keywords="radiology",
keywords="pediatrics",
keywords="children",
keywords="patient guidance",
keywords="patient experience",
keywords="design",
keywords="usability",
keywords="breath hold",
abstract="Background: Annually, millions of children undergo a magnetic resonance imaging (MRI) examination. Hospitals increasingly aim to scan young children awake, as doing so benefits both patients and health care systems. To help hospitals reduce the need for anesthesia, we have developed solutions to prepare pediatric patients at home and in the hospital. Objective: The goal of our project was to design, develop, and test a solution that extends our preparation solutions by guiding and engaging children during their MRI examination. Methods: Pediatric In-bore was designed to deliver a familiar experience by reusing design elements from our preparation solutions. It offers child-friendly movies and auditory and visual guidance about examination progress and breath holding. To evaluate children's liking and understanding of the solution, we conducted a usability study. Ten healthy children participated in a mock MRI examination featuring pediatric In-bore. We observed task compliance (ability to lie still and hold one's breath) and conducted guided interviews to assess their experience and understanding of the guidance offered. Results: Participants (aged 5 to 10 years) were generally positive about pediatric In-bore. They liked the main character (Ollie the elephant) and her movie. Auditory and visual guidance were generally liked and understood. All but one participant successfully managed to lie still during the mock examination, and 6 (60\%) out of 10 participants successfully held their breath. Conclusions: Pediatric In-bore appears promising for engaging and guiding young children during awake MRI. It completes the Pediatric Coaching solution that now offers guidance throughout the MRI journey. Future research can expand on this work by evaluating the clinical impact of the Pediatric Coaching solution in a larger and more diverse sample of pediatric patients. ",
doi="10.2196/55720",
url="https://games.jmir.org/2025/1/e55720"
}


@Article{info:doi/10.2196/50693,
author="Ehrler, Frederic
and Gschwind, Liliane
and Hagberg, Hamdi
and Meyer, Philippe
and Blondon, Katherine",
title="A Medication Management App (Smart-Meds) for Patients After an Acute Coronary Syndrome: Pilot Pre-Post Mixed Methods Study",
journal="JMIR Cardio",
year="2025",
month="Jan",
day="23",
volume="9",
pages="e50693",
keywords="medication adherence",
keywords="gamified app",
keywords="narration",
keywords="acute coronary syndrome",
keywords="beliefs about medication",
keywords="self-reported adherence",
keywords="pilot study",
keywords="usability evaluation",
keywords="storytelling component",
abstract="Background: Medication nonadherence remains a significant challenge in the management of chronic conditions, often leading to suboptimal treatment outcomes and increased health care costs. Innovative interventions that address the underlying factors contributing to nonadherence are needed. Gamified mobile apps have shown promise in promoting behavior change and engagement. Objective: This pilot study aimed to evaluate the efficacy and usability of a gamified mobile app that used a narrative storytelling approach to enhance medication adherence among patients following acute coronary syndrome (ACS). The study aimed to assess changes in participants' beliefs about medication and self-reported adherence before and after the intervention. Additionally, user feedback regarding the narrative component of the app was gathered. Methods: Overall, 18 patients who recently experienced ACS were recruited for a 1-month intervention using the gamified app. Participants' beliefs about medication and self-reported adherence were assessed using standardized scales pre- and postintervention. The app's usability was also evaluated through a postintervention questionnaire. Statistical analyses were performed to determine the significance of changes in belief and adherence scores. Results: Although 33\% (6/18) of the participants did not use the intervention more than once, the remaining 12 remained engaged during the 30 days of the study. The results did not indicate a significant improvement in participants' beliefs about medication following the intervention. However, self-reported adherence significantly improved (P<.05) after the intervention with a mean score going from 29.1 (SD 6.9) to 32.4 (SD 5.6), with participants demonstrating a greater self-efficacy to their prescribed medication regimen. However, the results did not indicate a significant improvement in participants' beliefs about medication. With a mean average score of 80.6, the usability evaluation indicates a good usability rating for the gamified app. However, the narrative storytelling component of the app was not favored by the participants, as indicated by their feedback. Conclusions: This pilot study suggests that a gamified mobile app using narration may effectively enhance medication self-efficacy and positively influence patients' beliefs about medication following ACS. However, the narrative component of the app did not receive favorable feedback from participants. Future research should focus on exploring alternative methods to engage participants in the app's narrative elements while maintaining the positive impact on adherence and beliefs about medication observed in this study. ",
doi="10.2196/50693",
url="https://cardio.jmir.org/2025/1/e50693"
}


@Article{info:doi/10.2196/53045,
author="Su, Kuan-Chu
and Wu, Ko-Chiu
and Chou, Kuei-Ru
and Huang, Chia-Hsu",
title="Tongue Muscle Training App for Middle-Aged and Older Adults Incorporating Flow-Based Gameplay: Design and Feasibility Pilot Study",
journal="JMIR Serious Games",
year="2025",
month="Jan",
day="9",
volume="13",
pages="e53045",
keywords="exergame",
keywords="mobile app",
keywords="flow",
keywords="self-care",
keywords="feasibility",
keywords="older adults",
keywords="dysphagia",
keywords="tongue exercises",
abstract="Background: Complications due to dysphagia are increasingly prevalent among older adults; however, the tediousness and complexity of conventional tongue rehabilitation treatments affect their willingness to rehabilitate. It is unclear whether integrating gameplay into a tongue training app is a feasible approach to rehabilitation. Objective: Tongue training has been proven helpful for dysphagia treatment. Following the development of a tongue training app, a feasibility trial aimed to identify physiological and psychological factors that affect user and flow experience and explored whether training specialized muscles could produce a flow experience for optimal immersion. We aimed to provide a useful tool for medical rehabilitation so that older adults could retain tongue muscle flexibility. Methods: After consulting professional nurses, we developed a mobile gaming app for middle-aged and older adults to train their tongue muscles. This pilot study used an image recognition system to detect the tongue movements of 32 healthy middle-aged and older adults (7 males, 21.9\%; 25 females, 78.1\%) during 3 game training tasks, each requiring different reaction speeds. Their physiological and psychological signals, as well as the results of the Flow State Scale 2 (FSS2) questionnaire, were used for correlation analysis regarding relevant flow experiences to establish and evaluate the feasibility of our method. Results: Through exploratory factor analyses, a 2-factor (operation and immersion) structure was confirmed to have an adequate model fit ($\chi${\texttwosuperior}36=448.478; P<.001; Kaiser-Meyer-Olkin=0.757) and internal consistency reliability (Cronbach $\alpha$=0.802). The slow, medium, and fast levels all significantly affected the FSS2 score for operation (P=.001), the National Aeronautics and Space Administration Task Load Index (P<.001), and flow distance (P<.001). K-means clustering revealed that participants could be further categorized into 3 groups. Through the analysis of changes in the participants' physiological and psychological signals for each given task, Pearson correlation indicated that changes were primarily related to flow distance. For the 12 indicators measured in this study, the low, medium, and high operation groups showed significance in 58\% (7/12), 50\% (6/12), and 25\% (3/12) of the indicators, respectively. Similarly, the low, medium, and high immersion groups had changes in 50\% (6/12), 33\% (4/12), and 17\% (2/12) of indicators, respectively. Conclusions: Our research supports the further development of a gaming app to aid older adults with tongue muscle training and measure flow using physiological and psychological signals to enhance training accuracy and feasibility. Next, we aim to conduct a randomized pilot trial, improve app functions, offer alternative rehabilitation options, and encourage long-term participation. Future goals include enhancing long-term efficacy, diversifying training modes, and adding a multiuser interactive option for an added challenge. ",
doi="10.2196/53045",
url="https://games.jmir.org/2025/1/e53045"
}


@Article{info:doi/10.2196/58650,
author="Bierbooms, A. Joyce J. P.
and Sluis-Thiescheffer, W. Wouter R. J.
and Feijt, Anne Milou
and Bongers, B. Inge M.",
title="Co-Design of an Escape Room for e-Mental Health Training of Mental Health Care Professionals: Research Through Design Study",
journal="JMIR Form Res",
year="2025",
month="Jan",
day="7",
volume="9",
pages="e58650",
keywords="serious gaming",
keywords="mental health care professionals",
keywords="e-mental health",
keywords="skill enhancement",
keywords="training",
abstract="Background: Many efforts to increase the uptake of e-mental health (eMH) have failed due to a lack of knowledge and skills, particularly among professionals. To train health care professionals in technology, serious gaming concepts such as educational escape rooms are increasingly used, which could also possibly be used in mental health care. However, such serious-game concepts are scarcely available for eMH training for mental health care professionals. Objective: This study aims to co-design an escape room for training mental health care professionals' eMH skills and test the escape room's usability by exploring their experiences with this concept as a training method. Methods: This project used a research through design approach with 3 design stages. In the first stage, the purpose, expectations, and storylines for the escape room were formulated in 2 co-design sessions with mental health care professionals, game designers, innovation staff, and researchers. In the second stage, the results were translated into the first escape room, which was tested in 3 sessions, including one web version of the escape room. In the third stage, the escape room was tested with mental health care professionals outside the co-design team. First, 2 test sessions took place, followed by 3 field study sessions. In the field study sessions, a questionnaire was used in combination with focus groups to assess the usability of the escape room for eMH training in practice. Results: An escape room prototype was iteratively developed and tested by the co-design team, which delivered multiple suggestions for adaptations that were assimilated in each next version of the prototype. The field study showed that the escape room creates a positive mindset toward eMH. The suitability of the escape room to explore the possibilities of eMH was rated 4.7 out of 5 by the professionals who participated in the field study. In addition, it was found to be fun and educational at the same time, scoring 4.7 (SD 0.68) on a 5-point scale. Attention should be paid to the game's complexity, credibility, and flexibility. This is important for the usefulness of the escape room in clinical practice, which was rated an average of 3.8 (SD 0.77) on a 5-point scale. Finally, implementation challenges should be addressed, including organizational policy and stimulation of eMH training. Conclusions: We can conclude that the perceived usability of an escape room for training mental health care professionals in eMH skills is promising. However, it requires additional effort to transfer the learnings into mental health care professionals' clinical practice. A straightforward implementation plan and testing the effectiveness of an escape room on skill enhancement in mental health care professionals are essential next steps to reach sustainable goals. ",
doi="10.2196/58650",
url="https://formative.jmir.org/2025/1/e58650"
}


@Article{info:doi/10.2196/49847,
author="Chen, Jiayin
and Or, Kalun Calvin
and Li, Zhixian
and Yeung, Kwong Eric Hiu
and Chen, Tianrong",
title="Perceptions of Patients With Stroke Regarding an Immersive Virtual Reality--Based Exercise System for Upper Limb Rehabilitation: Questionnaire and Interview Study",
journal="JMIR Serious Games",
year="2025",
month="Jan",
day="1",
volume="13",
pages="e49847",
keywords="virtual reality",
keywords="stroke",
keywords="perception",
keywords="rehabilitation",
keywords="questionnaire",
keywords="interview",
abstract="Background: With substantial resources allocated to develop virtual reality (VR)--based rehabilitation exercise programs for poststroke motor rehabilitation, it is important to understand how patients with stroke perceive these technology-driven approaches, as their perceptions can determine acceptance and adherence. Objective: This study aimed to examine the perceptions of patients with stroke regarding an immersive VR-based exercise system developed to deliver shoulder, elbow, forearm, wrist, and reaching exercises. Methods: A questionnaire was used to assess the perceptions of 21 inpatients who had experienced stroke (mean time from stroke onset: 37.2, SD 25.9 days; Brunnstrom stage of stroke recovery for the arm: 3-5) regarding the perceived usefulness of, ease of use of, attitude toward, intrinsic motivation for, and intention to use the exercise system. The measurement items were rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher values indicating more positive perceptions. Descriptive statistics were used to summarize the responses. Moreover, we conducted semistructured interviews that were audio recorded, transcribed, and subjected to content analysis to identify thematic patterns. Results: The questionnaire results revealed that the patients' perceptions of the exercise system were positive (mean ratings >6). The content analysis revealed 6 positive themes from 73 statements about the exercise system: ease of use, usefulness, enjoyment, motivation, accessibility, and game design. Conversely, 15 statements reflected negative perceptions, which were clustered into 3 themes: difficulty in handling VR devices, uncomfortable experiences when using VR devices, and monotony. Conclusions: Integrating VR technology into poststroke functional exercises holds significant promise based on patient interests. However, patient preferences and adaptability must be considered to promote the technology's success. VR-guided exercises should be user-friendly, health-promoting, engaging, and well-designed. Furthermore, addressing challenges, such as bulkiness, motion sickness, discomfort, and exercise monotony, is crucial for the widespread adoption and diffusion of this technology. ",
doi="10.2196/49847",
url="https://games.jmir.org/2025/1/e49847"
}


@Article{info:doi/10.2196/59381,
author="R Pozuelo, Julia
and Nabulumba, Christine
and Sikoti, Doreen
and Davis, Meghan
and Gumikiriza-Onoria, Louise Joy
and Kinyanda, Eugene
and Moffett, Bianca
and van Heerden, Alastair
and O'Mahen, A. Heather
and Craske, Michelle
and 
and Sulaiman, Munshi
and Stein, Alan",
title="A Narrative-Gamified Mental Health App (Kuamsha) for Adolescents in Uganda: Mixed Methods Feasibility and Acceptability Study",
journal="JMIR Serious Games",
year="2024",
month="Dec",
day="19",
volume="12",
pages="e59381",
keywords="adolescents",
keywords="mental health",
keywords="Uganda",
keywords="gamified app",
keywords="digital interventions",
keywords="mobile phone",
keywords="user-centered design",
keywords="low- and middle-income countries",
abstract="Background: Many adolescents in Uganda are affected by common mental disorders, but only a few affordable treatment options are available. Digital mental health interventions offer promising opportunities to reduce these large treatment gaps, but interventions specifically tailored for Ugandan adolescents are limited. Objective: This study aimed to determine the feasibility and acceptability of the Kuamsha program, an intervention delivered through a gamified app with low-intensity telephonic guidance, as a way to promote mental health among adolescents from the general population in Uganda. Methods: A 3-month pre-post single-arm trial was conducted with adolescents aged between 15 and 19 years living in Wakiso District, Central Uganda. The intervention was coproduced with adolescents from the study site to ensure that it was culturally acceptable. The feasibility and acceptability of the intervention were evaluated using an explanatory sequential mixed methods approach. Feasibility was assessed by collecting data on trial retention rates and treatment adherence rates. Acceptability was assessed through a questionnaire and in-depth interviews with participants following the conclusion of the intervention period. As a secondary objective, we explored the changes in participants' mental health before and after the intervention. Results: A total of 31 adolescents were recruited for the study. Results from the study showed high levels of feasibility and acceptability. Trial retention rates exceeded 90\%, and treatment adherence was ?80\%. These results, evaluated against our predefined trial progression criteria, indicate a successful feasibility study, with all criteria exceeding the thresholds necessary to progress to a larger trial. App engagement metrics, such as time spent on the app and modules completed, exceeded existing literature benchmarks, and many adolescents continued to use the app after the intervention. In-depth interviews and questionnaire responses revealed high acceptability levels. Depressive symptoms trended toward reduction (mean difference: 1.41, 95\% CI --0.60 to 3.42, Cohen d=0.30), although this was not statistically significant (P=.16). Supporting this trend, we also observed a reduction in the proportion of participants with moderate depressive symptoms from 32\% (10/31) to 17\% (5/29) after the intervention, but this change was also not significant (P=.10). Conclusions: This study presents evidence to support the Kuamsha program as a feasible and acceptable digital mental health program for adolescents in Uganda. A fully powered randomized controlled trial is needed to assess its effectiveness in improving adolescents' mental health. ",
doi="10.2196/59381",
url="https://games.jmir.org/2024/1/e59381"
}


@Article{info:doi/10.2196/52340,
author="Knobel, J. Samuel E.
and Oberson, Raphael
and R{\"a}ber, Jonas
and Sch{\"u}tz, Narayan
and Egloff, Niklaus
and Botros, Angela
and Gerber, M. Stephan
and Nef, Tobias
and Heydrich, Lukas",
title="Evaluation of a New Mobile Virtual Reality Setup to Alter Pain Perception: Pilot Development and Usability Study in Healthy Participants",
journal="JMIR Serious Games",
year="2024",
month="Dec",
day="11",
volume="12",
pages="e52340",
keywords="immersive virtual reality",
keywords="embodiment",
keywords="pain management",
keywords="chronic pain",
keywords="full-body illusion",
keywords="cardiovisual illusion",
keywords="pain",
keywords="virtual reality",
keywords="pilot study",
keywords="development",
keywords="mobile virtual reality",
keywords="mobile",
keywords="virtual environment",
keywords="usability",
keywords="heart rate",
keywords="mobile phone",
abstract="Background: Chronic pain presents a significant treatment challenge, often leading to frustration for both patients and therapists due to the limitations of traditional methods. Research has shown that synchronous visuo-tactile stimulation, as used in the rubber hand experiment, can induce a sense of ownership over a fake body part and reduces pain perception when ownership of the fake body part is reported. The effect of the rubber hand experiment can be extended to the full body, for example, during the full-body illusion, using both visuo-tactile and cardiovisual signals. Objective: This study first aimed to evaluate the usability and accuracy of a novel, mobile virtual reality (VR) setup that displays participants' heartbeats as a flashing silhouette on a virtual avatar, a technique known as the cardiovisual full-body illusion. The second part of the study investigated the effects of synchronous cardiovisual stimulation on pain perception and ownership in 20 healthy participants as compared with asynchronous stimulation (control condition). Methods: The setup comprised a head-mounted display (HMD) and a heart rate measurement device. A smartphone-based HMD (Samsung Galaxy S8+) was selected for its mobility, and heart rates were measured using smartwatches with photoplethysmography (PPG). The accuracy of 2 smartwatch positions was compared with a 5-point electrocardiogram (ECG) standard in terms of their accuracy (number and percent of missed beats). Each participant underwent two 5-minute sessions of synchronous cardiovisual stimulation and two 5-minute sessions of asynchronous cardiovisual stimulation (total of 4 sessions), followed by pain assessments. Usability, symptoms of cybersickness, and ownership of the virtual body were measured using established questionnaires (System Usability Scale, Simulator Sickness Questionnaire, Ownership Questionnaire). Pain perception was assessed using advanced algometric methods (Algopeg and Somedic algometer). Results: Results demonstrated high usability scores (mean 4.42, SD 0.56; out of 5), indicating ease of use and acceptance, with minimal side effects (mean 1.18, SD 0.46; out of a possible 4 points on the Simulator Sickness Questionnaire). The PPG device showed high heart rate measurement precision, which improved with optimized filtering and peak detection algorithms. However, compared with previous work, no significant effects on body ownership and pain perception were observed between the synchronous and asynchronous conditions. These findings are discussed in the context of existing literature on VR interventions for chronic pain. Conclusions: In conclusion, while the new VR setup showed high usability and minimal side effects, it did not significantly affect ownership or pain perception. This highlights the need for further research to refine VR-based interventions for chronic pain management, considering factors like visual realism and perspective. ",
doi="10.2196/52340",
url="https://games.jmir.org/2024/1/e52340"
}


@Article{info:doi/10.2196/51771,
author="Widhalm, Klaus
and Maul, Lukas
and Durstberger, Sebastian
and Putz, Peter
and Klupper, Carissa
and Werner, Franz",
title="Real-Time Digitized Visual Feedback in Exercise Therapy for Lower Extremity Functional Deficits: Qualitative Study of Usability Factors During Prototype Testing",
journal="JMIR Serious Games",
year="2024",
month="Dec",
day="10",
volume="12",
pages="e51771",
keywords="visualization",
keywords="lower extremity",
keywords="digitized visual feedback",
keywords="exercise therapy",
keywords="functional deficit",
keywords="serious game",
keywords="rehabilitation",
keywords="osteoarthritis",
keywords="usability",
keywords="physiotherapy",
keywords="mobile phone",
abstract="Background: Osteoarthritis is one of the most common degenerative diseases of the musculoskeletal system and can ultimately lead to the need for surgery, such as total knee or hip arthroplasty. Functional movement deficits can be a prognostic factor for osteoarthritis in the lower extremities. Thus, training physiological movement patterns may help in the treatment of such functional deficits. Motivation to exercise frequently is of utmost importance and can be promoted by using digital real-time feedback. Objective: This qualitative study aims to gather user recommendations for prototype feedback visualizations in a real-time exercise-feedback system called homeSETT for the treatment of functional deficits. The system provides real-time feedback to participants while performing exercises that focus on functional deficits, such as lateral trunk lean, pelvic drop, and valgus thrust. The findings of this study should help to optimize the prototype feedback visualizations. Thus, the main research questions were how patients, physiotherapists, and physicians evaluate the presented, current state of prototype feedback visualizations for selected functional exercises, and what improvements and variations would be recommended. Methods: Testing of the prototype feedback visualizations took place at a movement laboratory using a 3D optoelectronic movement analysis system. Data on usability factors were acquired using the thinking aloud method during and semistructured interviews after prototype testing. Transcribed audio recordings of semistructured interviews as well as scribing logs of the thinking aloud method were examined using qualitative content analysis. Results: Data were analyzed from 9 participants, comprising 2 (22\%) patients, 2 (22\%) physicians, and 5 (56\%) physiotherapists. The mean age of the participants was 45 (SD 9) years and the mean work experience among the participating physiotherapists and physicians was 22 (SD 5) years. Each participant tested 11 different exercise-feedback combinations. Overall, results indicated that participants enjoyed the prototype feedback visualizations and believed that they could be used in therapeutic settings. Participants appreciated the simplicity, clarity, and self-explanatory nature of the feedback visualizations. While most participants quickly familiarized themselves, some struggled to recognize the feedback goals and connect the visualizations to their movements. Recommendations for improvement included optimizing color schemes, sensitivity, and difficulty adjustments. Adding instructional information and game design elements, such as repetition counting and reward systems, was deemed useful. The main study limitations were the small sample size and the use of feedback on performance as the sole feedback modality. Conclusions: The prototype feedback visualizations were positively perceived by the participants and were considered applicable in therapy settings. Insights were gathered on improving the color scheme, sensitivity, and recognizability of the feedback visualizations. The implementation of additional gamification and instructional elements was emphasized. Future work will optimize the prototype feedback visualizations based on study results and evaluate the homeSETT system's efficacy in eligible patient populations. ",
doi="10.2196/51771",
url="https://games.jmir.org/2024/1/e51771"
}


@Article{info:doi/10.2196/55231,
author="Gnadlinger, Florian
and Werminghaus, Maika
and Selmanagi{\'c}, Andr{\'e}
and Filla, Tim
and Richter, G. Jutta
and Kriglstein, Simone
and Klenzner, Thomas",
title="Incorporating an Intelligent Tutoring System Into a Game-Based Auditory Rehabilitation Training for Adult Cochlear Implant Recipients: Algorithm Development and Validation",
journal="JMIR Serious Games",
year="2024",
month="Dec",
day="3",
volume="12",
pages="e55231",
keywords="cochlear implant",
keywords="eHealth",
keywords="evidence-centered design",
keywords="hearing rehabilitation",
keywords="adaptive learning",
keywords="intelligent tutoring system",
keywords="game-based learning",
abstract="Background: Cochlear implants are implanted hearing devices; instead of amplifying sounds like common hearing aids, this technology delivers preprocessed sound information directly to the hearing (ie, auditory) nerves. After surgery and the first cochlear implant activation, patients must practice interpreting the new auditory sensations, especially for language comprehension. This rehabilitation process is accompanied by hearing therapy through face-to-face training with a therapist, self-directed training, and computer-based auditory training. Objective: In general, self-directed, computer-based auditory training tasks have already shown advantages. However, compliance of cochlear implant recipients is still a major factor, especially for self-directed training at home. Hence, we aimed to explore the combination of 2 techniques to enhance learner motivation in this context: adaptive learning (in the form of an intelligent tutoring system) and game-based learning (in the form of a serious game). Methods: Following the suggestions of the evidence-centered design framework, a domain analysis of hearing therapy was conducted, allowing us to partially describe human hearing skill as a probabilistic competence model (Bayesian network). We developed an algorithm that uses such a model to estimate the current competence level of a patient and create training recommendations. For training, our developed task system was based on 7 language comprehension task types that act as a blueprint for generating tasks of diverse difficulty automatically. To achieve this, 1053 audio assets with meta-information labels were created. We embedded the adaptive task system into a graphic novel--like mobile serious game. German-speaking cochlear implant recipients used the system during a feasibility study for 4 weeks. Results: The 23 adult participants (20 women; 3 men) fulfilled 2259 tasks. In total, 2004 (90.5\%) tasks were solved correctly, and 255 (9.5\%) tasks were solved incorrectly. A generalized additive model analysis of these tasks indicated that the system adapted to the estimated competency levels of the cochlear implant recipients more quickly in the beginning than at the end. Compared with a uniform distribution of all task types, the recommended task types differed ($\chi${\texttwosuperior}6=86.713; P<.001), indicating that the system selected specific task types for each patient. This is underlined by the identified categories for the error proportions of the task types. Conclusions: This contribution demonstrates the feasibility of combining an intelligent tutoring system with a serious game in cochlear implant rehabilitation therapies. The findings presented here could lead to further advances in cochlear implant care and aural rehabilitation in general. Trial Registration: German Clinical Trials Register (DRKS) DRKS00022860; https://drks.de/search/en/trial/DRKS00022860 ",
doi="10.2196/55231",
url="https://games.jmir.org/2024/1/e55231"
}


@Article{info:doi/10.2196/56844,
author="M{\o}rk, Gry
and Bonsaksen, Tore
and Larsen, S{\o}nnik Ole
and Kunnikoff, Martin Hans
and Lie, Stangeland Silje",
title="Virtual Reality Simulation in Undergraduate Health Care Education Programs: Usability Study",
journal="JMIR Med Educ",
year="2024",
month="Nov",
day="19",
volume="10",
pages="e56844",
keywords="360{\textdegree} videos",
keywords="health professions education",
keywords="virtual reality",
keywords="usability study",
keywords="undergraduates",
keywords="university",
keywords="students",
keywords="simulation",
abstract="Background: Virtual reality (VR) is increasingly being used in higher education for clinical skills training and role-playing among health care students. Using 360{\textdegree} videos in VR headsets, followed by peer debrief and group discussions, may strengthen students' social and emotional learning. Objective: This study aimed to explore student-perceived usability of VR simulation in three health care education programs in Norway. Methods: Students from one university participated in a VR simulation program. Of these, students in social education (n=74), nursing (n=45), and occupational therapy (n=27) completed a questionnaire asking about their perceptions of the usability of the VR simulation and the related learning activities. Differences between groups of students were examined with Pearson chi-square tests and with 1-way ANOVA. Qualitative content analysis was used to analyze data from open-ended questions. Results: The nursing students were most satisfied with the usability of the VR simulation, while the occupational therapy students were least satisfied. The nursing students had more often prior experience from using VR technology (60\%), while occupational therapy students less often had prior experience (37\%). Nevertheless, high mean scores indicated that the students experienced the VR simulation and the related learning activities as very useful. The results also showed that by using realistic scenarios in VR simulation, health care students can be prepared for complex clinical situations in a safe environment. Also, group debriefing sessions are a vital part of the learning process that enhance active involvement with peers. Conclusions: VR simulation has promise and potential as a pedagogical tool in health care education, especially for training soft skills relevant for clinical practice, such as communication, decision-making, time management, and critical thinking. ",
doi="10.2196/56844",
url="https://mededu.jmir.org/2024/1/e56844"
}


@Article{info:doi/10.2196/47754,
author="Fahr, Annina
and Kl{\"a}y, Andrina
and Coka, S. Larissa
and van Hedel, A. Hubertus J.",
title="Effectiveness of Game-Based Training of Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Randomized Multiple Baseline Design Study",
journal="JMIR Form Res",
year="2024",
month="Nov",
day="18",
volume="8",
pages="e47754",
keywords="neurorehabilitation",
keywords="single-case design",
keywords="interactive computer play",
keywords="cerebral palsy",
keywords="surface electromyography",
keywords="motor control",
keywords="mirror movements",
keywords="involuntary movements",
abstract="Background: Selective voluntary motor control (SVMC) is the ability to control joint movements independently. Impairments in SVMC can affect functional activities, but only a few interventions directly target SVMC. Therefore, we developed a game-based intervention for children with upper motor neuron lesions to improve SVMC. The intervention trained selective activation of a muscle or joint movement while providing immediate feedback about involuntarily occurring muscle activations or movements in another joint. The intervention was provided in a playful manner with a custom-made game environment and a technology-based interface to capture muscle activation or joint movements. Objective: This study aimed to investigate the effectiveness of this game-based intervention and explore treatment response--related factors in children with impaired SVMC undergoing inpatient neurorehabilitation. Methods: We conducted a single-case research study with a randomized, nonconcurrent, multiple baseline design. The study consisted of a random-length baseline phase where no SVMC-specific intervention was provided and an intervention phase with additional SVMC training. Concurrently in both phases, children attended their individual multimodal rehabilitation program at our clinic, Swiss Children's Rehab. During the intervention phase, participants completed ten 45-minute sessions with our game-based SVMC training. SVMC was measured repeatedly throughout both phases and at the 3-month follow-up with a short custom-made assessment. Results: Eighteen children with reduced SVMC from upper motor neuron lesions participated in the study. The mean age of the children was 12.7 (SD 2.9) years, and they mostly had spastic cerebral palsy. A linear mixed-effects model revealed a significant trend (P<.001) for improved SVMC already in the baseline phase. This trend did not change significantly (P=.15) when the game-based SVMC training was introduced in the intervention phase, suggesting no additional improvements due to the SVMC training. Although we could not find an overall treatment effect, we could explain 89.4\% of the total random variation of the treatment effect by patient and therapy characteristics. Children with spasticity in the trained movement (20.1\%), and those who trained the more affected side (23.5\%) benefited most from the intervention. At the 3-month follow-up, SVMC had deteriorated compared to the end of the intervention but was still better than at the beginning of the study. Conclusions: The regular concomitant rehabilitation program already yielded improvements in SVMC, while the game-based SVMC training showed no additional effects. Although the intervention did not show a group effect, we could identify patient and therapy characteristics that determine who is likely to profit from the intervention. Trial Registration: German Clinical Trials Register DRKS00025184; https://tinyurl.com/msnkek9b ",
doi="10.2196/47754",
url="https://formative.jmir.org/2024/1/e47754"
}


@Article{info:doi/10.2196/59141,
author="Kamnardsiri, Teerawat
and Kumfu, Sirintip
and Munkhetvit, Peeraya
and Boripuntakul, Sirinun
and Sungkarat, Somporn",
title="Home-Based, Low-Intensity, Gamification-Based, Interactive Physical-Cognitive Training for Older Adults Using the ADDIE Model: Design, Development, and Evaluation of User Experience",
journal="JMIR Serious Games",
year="2024",
month="Oct",
day="29",
volume="12",
pages="e59141",
keywords="exergame",
keywords="physical-cognitive training",
keywords="computer-based interventions",
keywords="gamification",
keywords="older adults",
keywords="instructional design model",
keywords="low-intensity",
abstract="Background: Declines in physical and cognitive function are natural biological processes, leading to an increased risk of falls. Promising evidence suggests that combined physical-cognitive exercise has beneficial effects in improving both physical and cognitive health. Although moderate-to-high exercise intensity is commonly recommended, it might be impractical for older adults facing physical limitations or contraindications. Thus, low-intensity exercise is a viable option. The main barriers to engaging in exercise in older adults include transportation, time, motivation, and enjoyment. To overcome these challenges, a home-based, gamification-based training system may provide an effective approach to enhance exercise adherence. Objective: This study aimed to develop and evaluate the usability of a low-intensity, gamification-based, interactive physical-cognitive exercise for older adults in a home-based setting. Methods: The prototype of a game-based physical-cognitive exercise was created following the ADDIE model (analysis, design, development, implementation, and evaluation) and assessed for user experience in older adults. A total of 15 older adults engaged in the game-based physical-cognitive exercise at home for 60 minutes per day, 3 days per week, for 4 weeks. The usability of the game-based training system was evaluated using the system usability scale (SUS) after completion of a 4-week training program. As for satisfaction, the 8-item Physical Activity Enjoyment Scale (PACES) questionnaire was used to assess participants' enjoyment level after 1 week and 4 weeks of training. Descriptive statistics were used to illustrate the SUS score. A Wilcoxon signed-rank test was used to compare the PACES scores between the first week and the end of the 4-week period, with significance set at P<.05. Results: As for experts' consensus, the game-based training consisted of 3 games: Ocean Diver, Road Runner, and Moving and Memorizing. The games had 3 levels of difficulty: beginner, intermediate, and advanced. A computer vision--based system was selected as the delivery platform for a home setting. The total SUS score for all participants was mean 87.22 (SD 5.76), indicating the user's perception of the usability of a system ranging from good to excellent. At the end of the 4-week training, the total PACES score was significantly greater than the first week, suggesting an improvement in enjoyment (first week: mean 44.93, SD 3.99 vs fourth week: mean 50.53, SD 4.70; P=.001). Conclusions: The prototype of low-intensity, gamification-based, interactive physical-cognitive training was designed and developed using the ADDIE model, which included both experts and end users in the process. The findings showed that the exergame prototype was a usable and practical approach for a home-based setting, enhancing older adults' enjoyment and motivation. Further research is warranted to determine the effectiveness of such gamification-based training in promoting physical and cognitive functions. ",
doi="10.2196/59141",
url="https://games.jmir.org/2024/1/e59141"
}


@Article{info:doi/10.2196/58963,
author="Wong, Po Ka
and Zhang, Bohan
and Lai, Yi Cynthia Yuen
and Xie, Jie Yao
and Li, Yan
and Li, Chen
and Qin, Jing",
title="Empowering Social Growth Through Virtual Reality--Based Intervention for Children With Attention-Deficit/Hyperactivity Disorder: 3-Arm Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2024",
month="Oct",
day="28",
volume="12",
pages="e58963",
keywords="attention deficit and hyperactivity disorder",
keywords="virtual reality",
keywords="social skills",
keywords="social skills training",
keywords="emotional control",
keywords="social growth",
keywords="digital world",
keywords="social learning theory",
abstract="Background: Attention-deficit/hyperactivity disorder (ADHD) usually begins in childhood and is often accompanied by impairments in social functioning. Virtual reality (VR) has emerged as an adjunctive tool to embed in social skills training to enhance the social skills of children with ADHD, but its effectiveness requires further investigation. Objective: This study aims to enhance the social skills of children with ADHD by examining the feasibility and effectiveness of VR-based training in comparison to traditional social skills training. Methods: A 3-arm randomized controlled trial was conducted with 90 children with ADHD aged 6-12 years. Participants were randomly assigned to 3 weeks of 12-session VR-based social skills training, traditional social skills training, or a waitlist control group of equivalent duration. Outcome measures included assessments by a clinical psychologist who was blinded to group assignments, the Social Skills Improvement System Rating Scale, the Behavior Rating Inventory of Executive Function, and the Simulator Sickness Questionnaire, conducted at baseline and after the intervention. Results: The preliminary results support the feasibility and acceptability of VR training for children with ADHD aged 6-12 years. Analysis showed that the VR and traditional social skills training groups experienced a statistically significant improvement in the clinical psychologist assessment of social skills and parent-rated self-control, initiative, and emotional control after the intervention compared with baseline. The VR group performed significantly better than the traditional social skills group on social skills assessed by clinical psychologists (F2,85=76.77; P<.001) and on parent-rated self-control (F2,85=18.77; P<.001), initiative (F2,85=11.93; P<.001), and emotional control (F2,85=17.27; P<.001). No significant between-group differences were found for parent-rated cooperation and inhibition (all P>.05). Conclusions: The findings provide preliminary evidence supporting the feasibility and superior effectiveness of VR-based social skills training compared to traditional approaches for enhancing social skills and related executive functions in children with ADHD. These results suggest that VR may be a valuable tool to embed within social skills interventions for this population. Further research is warranted to explore the long-term impacts and generalizability of these benefits. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): RR2-10.2196/48208 ",
doi="10.2196/58963",
url="https://games.jmir.org/2024/1/e58963"
}


@Article{info:doi/10.2196/52991,
author="Schwarz, Ayla
and Verkooijen, Kirsten
and de Vet, Emely
and Simons, Monique",
title="Perceived Barriers and Facilitators Regarding the Implementation of Gamification to Promote Physical Activity in the Neighborhood: Interview Study Among Intermediaries",
journal="JMIR Serious Games",
year="2024",
month="Aug",
day="28",
volume="12",
pages="e52991",
keywords="gamification",
keywords="gamified apps",
keywords="physical activity",
keywords="implementation",
keywords="intermediaries",
keywords="interview",
abstract="Background: In the Netherlands, neighborhood sport coaches (NSCs) play an important role as intermediaries in promoting physical activity (PA) in the neighborhood. Gamification is the use of game elements in nongame contexts; it can be implemented with or without technology and holds promise for promoting PA. NSCs infrequently make use of this option. Objective: This study aims to understand barriers to, and facilitators of, using gamification to promote PA, as perceived by NSCs. Methods: A total of 25 semistructured interviews were conducted with NSCs in the Netherlands. The interviews were audiotaped, transcribed, and analyzed by means of thematic analysis using ATLAS.ti (version 22; ATLAS.ti Scientific Software Development GmbH) software. The deductive coding was informed by the capability, opportunity, motivation, behavior model and the theoretical domains framework, complemented by inductive coding. Results: Barriers and facilitators identified as factors influencing the implementation of gamification were related to 7 themes. NSCs required technical, creative, and promotion skills; knowledge about existing gamification tools; and social support from their employer and professional network. Financial costs were identified as a barrier to the successful implementation of gamification. Lack of clarity regarding stakeholders' responsibility to implement gamification could further hamper implementation. In general, NSCs were positive about investing time in implementing gamification and expected positive effects from implementing it. Conclusions: To overcome identified barriers, a clear overview of tools, best practices, and available subsidies must be created, a gamification network must be established, the responsibility of NSCs must be clarified, and guidance must be offered on the promotion of gamification. ",
doi="10.2196/52991",
url="https://games.jmir.org/2024/1/e52991",
url="http://www.ncbi.nlm.nih.gov/pubmed/39196618"
}


@Article{info:doi/10.2196/55905,
author="Berglund, Aseel
and Or{\"a}dd, Helena",
title="Exploring the Psychological Effects and Physical Exertion of Using Different Movement Interactions in Casual Exergames That Promote Active Microbreaks: Quasi-Experimental Study",
journal="JMIR Serious Games",
year="2024",
month="Aug",
day="26",
volume="12",
pages="e55905",
keywords="physical activity",
keywords="exergames",
keywords="casual exergames",
keywords="enjoyment",
keywords="exertion",
keywords="motion-based games",
abstract="Background: Prolonged sedentary behavior, such as sitting or reclining, has consistently been identified as a stand-alone risk factor for heightened cardiometabolic risk and overall mortality. Conversely, interrupting sedentary periods by incorporating short, active microbreaks has been shown to mitigate the negative effects of sedentary behavior. Casual exergames, which mix elements of casual gaming with physical activity, are one prospective intervention to reduce sedentary behavior because they require physical exertion. Casual exergames have shown promise in fostering emotional and physical advantages when played in specific circumstances. However, little research exists on how different types of movement interactions impact the psychological effects as well as the physical exertion of playing casual exergames. Objective: The primary aim of this work was to explore the psychological effects and physical exertion of playing casual exergames lasting 2 minutes. More precisely, the investigation focused on comparing upper body and full body movement interactions. In addition, the work examined variations in body positions, considering both standing and seated positions during upper body movement interactions. Methods: Two casual exergames were developed and investigated through 2 quasi-experimental studies. In study 1, we investigated how players' perceptions of control, exertion, and immersion were affected by using upper body as opposed to full body exergame controllers when playing casual exergames. In study 2, we investigated differences in positive affect, performance, enjoyment, and exertion when playing casual exergames with upper body movement interactions in seated and standing positions. Results: Study 1 showed that perceived control was significantly higher for upper body movement interactions than for full body movement interactions (P=.04), but there were no significant differences regarding perceived exertion (P=.15) or immersion (P=.66). Study 2 showed that positive affect increased significantly for both standing (P=.003) and seated (P=.001) gameplay. The participants in the standing gameplay group showed slightly higher actual exertion; however, there were no differences between the groups in terms of positive affect, perceived exertion, enjoyment, or performance. Conclusions: Casual exergames controlled by upper body movement interactions in seated gameplay can produce similar psychological effects and physical exertion as upper body movement interactions in standing gameplay and full body movement interactions. Therefore, upper body and seated casual exergames should not be overlooked as a suitable microbreak activity. ",
doi="10.2196/55905",
url="https://games.jmir.org/2024/1/e55905"
}


@Article{info:doi/10.2196/58411,
author="Polecho?ski, Jacek
and Przepi{\'o}rzy?ski, Alan
and Polecho?ski, Piotr
and Tomik, Rajmund",
title="Effect of Elastic Resistance on Exercise Intensity and User Satisfaction While Playing the Active Video Game BoxVR in Immersive Virtual Reality: Empirical Study",
journal="JMIR Serious Games",
year="2024",
month="Jul",
day="16",
volume="12",
pages="e58411",
keywords="virtual reality",
keywords="VR",
keywords="game",
keywords="gaming",
keywords="immersive",
keywords="immersion",
keywords="health-related physical activity",
keywords="physical activity",
keywords="exercise",
keywords="active video games",
keywords="attractiveness",
keywords="enjoyment scale",
keywords="enjoyment",
keywords="serious games",
keywords="elastic resistance",
keywords="resistance",
abstract="Background: One of the main contemporary forms of physical activity (PA) involves exercises and games in an immersive virtual reality (VR) environment, which allows the user to practice various forms of PA in a small space. Unfortunately, most of the currently available VR games and workout applications are mostly based on upper body movements, especially the arms, which do not guarantee sufficiently high exercise intensity and health benefits. Therefore, it is worth seeking solutions to help increase the exercise load during PA in VR. Objective: The main aim of this study was to evaluate the effect of elastic arm resistance in the form of latex resistance bands of different elasticity levels on the intensity of students' PA while playing the BoxVR game. We further assessed the satisfaction of this form of exercise and its associations with PA intensity. Methods: A total of 21 healthy and physically fit men (mean age 22.5, SD 2.0 years) were included in the study. The tests consisted of 3 10-minute games. One game was run with no load and the other two were run with 1.5-meter latex resistance bands (low and high resistance). The order of the tests was randomized and the participants rested for 20 minutes after each exercise. Exercise intensity was estimated using objective (heart rate monitoring) and subjective (Borg scale) methods. The Physical Activity Enjoyment Scale was used to assess satisfaction with the PA. The effect of elastic resistance on exercise intensity and user enjoyment was estimated using ANOVA for repeated measures. Results: The ANOVA results indicated that incorporation of elastic resistance caused a significant change (F2,40=20.235, P<.001; $\eta${\texttwosuperior}p=0.503) in the intensity of PA in VR, which was low while playing without resistance and then increased to a moderate level with additional resistance. The use of elastic bands also changed participants' perceptions of the enjoyment of exercise in VR (F2,40=9.259, P<.001; $\eta${\texttwosuperior}p=0.316). The students rated their satisfaction with PA in VR on a 7-point scale highly and similarly when exercising without an upper limb load (mean 6.19, SD 0.61) and with slight elastic resistance (mean 6.17, SD 0.66), whereas their satisfaction declined significantly (mean 5.66, SD 0.94) when incorporating a higher load. Conclusions: The intensity of PA among students playing the BoxVR game is at a relatively low level. With the added resistance of elastic bands attached to the upper limbs, the intensity of the exercise increased to a moderate level, as recommended for obtaining health benefits. Participants rated the enjoyment of PA in VR highly. The use of slight elastic resistance did not negatively affect satisfaction with the BoxVR game, although user satisfaction declined with a higher load. Further research should be undertaken to increase the effectiveness of exercise in VR so that regular users can enjoy the health benefits. ",
doi="10.2196/58411",
url="https://games.jmir.org/2024/1/e58411"
}


@Article{info:doi/10.2196/59197,
author="Bhargava, Yesoda
and Baths, Veeky",
title="Experience of Youths and Older People With Virtual Reality Games for Cognitive Assessment: Inductive Thematic Analysis and Insights for Key Stakeholders",
journal="JMIR XR Spatial Comput",
year="2024",
month="Jun",
day="28",
volume="1",
pages="e59197",
keywords="virtual reality",
keywords="cognitive assessment games",
keywords="inductive thematic analysis",
keywords="youth",
keywords="older adult",
keywords="cognitive",
keywords="cognitive assessment",
keywords="virtual reality games",
keywords="game",
keywords="games",
keywords="thematic analysis",
keywords="neurological",
keywords="utility",
keywords="cognitive assessment tools",
keywords="game based",
keywords="cognitive games",
abstract="Background: Virtual reality (VR)--based goal-oriented games for cognitive assessment are rapidly emerging and progressively being used in neuropsychological settings. These games have been validated quantitatively, but minimal qualitative insights from users currently exist. Such insights on user experience are essential to answering critical questions linked to the games' large-scale usability, adoption in hospital settings, and game design refinement. Current qualitative studies on these games have used general questionnaires or web-based reviews to answer these questions, but direct observation from primary settings is missing. We believe that direct observation of participants playing these games and subsequent interaction with them is critical to developing a more objective, clear, and unbiased view of the games' efficacy, usability, and acceptability. Objective: In this study, we aimed to extract constructive and relevant insights directly from the participants who played VR-based goal-oriented games. We used these insights to answer vital questions linked to the practical utility of VR-based cognitive assessment. On the basis of these results, we also aimed to provide actionable insights to key stakeholders in the field, such as researchers, game developers, business personnel, and neuropsychology and allied professionals. Methods: Interview data from 82 younger (aged 18-28 years) and 42 older adult (aged >60 years) participants were used. The interview data were obtained from the 2 pilot studies we conducted on VR games for cognitive assessment. Inductive thematic analysis was conducted on the interview data, and later, the findings were carefully interpreted to develop implications for the key stakeholders. Results: We identified 5 themes: ergonomic issues, learning and training, postgame effects, game feedback, and system purpose. Regarding hardware, headset weight, adjustment straps, and controllers need to be improved to promote easy use of the device. Regarding software, graphics quality, immersion experience, and game mechanics are the primary deciding factors for a positive user experience. The younger group prioritized purpose and utility for long-term use, whereas the older participants cherished the entertainment aspect. Researchers and game developers must conceptualize and develop games that can provide maximum insights into real-world abilities. Manufacturing businesses need to improve the headset and accessories to make them more user-friendly. Finally, neuropsychology and allied practitioners must identify strategies to engage and train the participants to try VR-based cognitive assessment games. Conclusions: VR-based games for cognitive assessment are promising tools to improve the current practices of neuropsychological evaluations; however, a few changes are required to make the overall user experience enjoyable, purposeful, and sustainable. In addition, all the key stakeholders need to focus on meaning and purpose over the hype of VR and are advised to work in synergy. ",
doi="10.2196/59197",
url="https://xr.jmir.org/2024/1/e59197"
}


@Article{info:doi/10.2196/50086,
author="Espinoza Chamorro, Roberto
and Santos, O. Luciano H.
and Mori, Yukiko
and Liu, Chang
and Yamamoto, Goshiro
and Kuroda, Tomohiro",
title="Gamification Approach to Provide Support About the Deferral Experience in Blood Donation: Design and Feasibility Study",
journal="JMIR Hum Factors",
year="2024",
month="Jun",
day="14",
volume="11",
pages="e50086",
keywords="blood donation",
keywords="deferral experience",
keywords="Theory of Planned Behavior",
keywords="Self-Determination Theory",
keywords="gamification",
keywords="ICT design",
keywords="motivation",
keywords="patient education",
keywords="prototype",
keywords="feasibility",
abstract="Background: Multiple studies have examined the impact of deferral on the motivation of prospective blood donors, proposing various policies and strategies to support individuals who undergo this experience. However, existing information and communications technology systems focused on blood donation have not yet integrated these ideas or provided options to assist with the deferral experience. Objective: This study aims to propose an initial gamified design aimed at mitigating the impact of the deferral experience by addressing the drivers of awareness and knowledge, interaction and validation, and motivation. Additionally, the study explores the feasibility of implementing such a system for potential users. Methods: We conducted a literature review focusing on the dynamics of motivation and intention related to blood donation, as well as the deferral situation and its impact on citizens. Through this review, we identified weak donor identity, lack of knowledge, and reduced motivation as key factors requiring support from appropriate interventions. These factors were then defined as our key drivers. Taking these into account, we proposed a gamification approach that incorporates concepts from the MDA framework. The aim is to stimulate the aforementioned drivers and expand the concept of contribution and identity in blood donation. For a preliminary evaluation, we designed a prototype to collect feedback on usability, usefulness, and interest regarding a potential implementation of our proposed gamification approach. Results: Among the participants, a total of 11 citizens interacted with the app and provided feedback through our survey. They indicated that interacting with the app was relatively easy, with an average score of 4.13 out of 5 when considering the 11 tasks of interaction. The SUS results yielded a final average score of 70.91 from the participants' answers. Positive responses were received when participants were asked about liking the concept of the app (3.82), being likely to download it (3.55), and being likely to recommend it to others (3.64). Participants expressed positivity about the implementation of the design but also highlighted current shortcomings and suggested possible improvements in both functionality and usability. Conclusions: Although deferral is a common issue in blood donation, there is a missed opportunity in existing ICT services regarding how to effectively handle such experiences. Our proposed design and implementation seem to have captured the interest of prospective users due to its perceived positive usefulness and potential. However, further confirmation is needed. Improving the design of activities that currently rely heavily on extrinsic motivation elements and integrating more social components to create an enhanced activity loop for intrinsic motivation could further increase the value of the proposed project. Future research could involve conducting a more specialized and longitudinal design evaluation with a larger sample size. ",
doi="10.2196/50086",
url="https://humanfactors.jmir.org/2024/1/e50086",
url="http://www.ncbi.nlm.nih.gov/pubmed/38875005"
}


@Article{info:doi/10.2196/51508,
author="Webster, Amy
and Poyade, Matthieu
and Coulter, Elaine
and Forrest, Lisa
and Paul, Lorna",
title="Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study",
journal="JMIR Serious Games",
year="2024",
month="Apr",
day="26",
volume="12",
pages="e51508",
keywords="virtual reality",
keywords="multiple sclerosis",
keywords="upper limb rehabilitation",
keywords="coproduction",
keywords="activities of daily living",
keywords="exercise games",
keywords="upper limb impairment",
abstract="Background: Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation. Objective: This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games. Methods: Separate focus groups were conducted with people with MS, recruited through the MS Society UK's research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis. Results: People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities. Conclusions: VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS. ",
doi="10.2196/51508",
url="https://games.jmir.org/2024/1/e51508",
url="http://www.ncbi.nlm.nih.gov/pubmed/38669680"
}


@Article{info:doi/10.2196/47600,
author="Lee, J. Edmund W.
and Tan, W. Warrick
and Pham, Phat Ben Tan
and Kawaja, Ariffin
and Theng, Yin-Leng",
title="Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study",
journal="JMIR Serious Games",
year="2024",
month="Apr",
day="24",
volume="12",
pages="e47600",
keywords="wearables",
keywords="exergames",
keywords="older adults",
keywords="active aging",
keywords="rehabilitation",
keywords="stroke",
abstract="Background: Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults' views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness. Objective: In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation. Methods: We conducted a moderated usability study with 19 older adults, of which 11 (58\%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise. Results: Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements. Conclusions: Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation. ",
doi="10.2196/47600",
url="https://games.jmir.org/2024/1/e47600",
url="http://www.ncbi.nlm.nih.gov/pubmed/38656778"
}


@Article{info:doi/10.2196/49171,
author="Bj{\"o}rling, A. Elin
and Sonney, Jennifer
and Zade, Himanshu
and Rodriguez, Sofia
and Pullmann, D. Michael
and Moon, Hyun Soo",
title="Using Virtual Reality to Reduce Stress in Adolescents: Mixed Methods Usability Study",
journal="JMIR XR Spatial Comput",
year="2024",
month="Apr",
day="22",
volume="1",
pages="e49171",
keywords="virtual reality",
keywords="adolescents",
keywords="perceived stress",
keywords="participatory design",
keywords="depression",
abstract="Background: Adolescent mental health is a national mental health emergency amid surging rates of anxiety and depression. Given the scarcity and lack of scalable mental health services, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. Objective: The goal of this study was 2-fold: (1) to determine the feasibility, usability, and engagement of a participatory designed, nature-based virtual reality (VR) environment and (2) to determine the preliminary outcomes of our self-administered VR environment on depression, mindfulness, perceived stress, and momentary stress and mood. Methods: We conducted a within-person, 3-week, in-home study with a community-based sample of 44 adolescents. Participants completed surveys of perceived stress, depression, cognitive fusion, and mindfulness at intake, postintervention, and a 3-week follow-up. Participants were invited to use a nature-based, VR environment that included 6 evidence-based activities 3 to 5 times per week. They completed momentary stress and mood surveys 5 times each day and before and after each VR session. Postintervention, participants completed surveys on system and intervention usability and their experiences with using the VR system. Quantitative data were analyzed using descriptive statistics and mixed effects modeling to explore the effect of the VR environment on stress. Qualitative data were analyzed using collaborative thematic analysis. Results: Participants' use of the VR environment ranged from 1 session to 24 sessions (mean 6.27 sessions) at home over a 3-week period. The 44 participants completed all study protocols, indicating our protocol was feasible and the VR environment was engaging for most. Both the use of the VR system and novel VR intervention received strong usability ratings (mean 74.87 on the System Usability Scale). Most teens indicated that they found the tool to be easily administered, relaxing, and helpful with stress. For some, it offered space to process difficult emotions. The themes calm, regulating, and forget about everything resulted from open-ended exit interview data. Although the Relaxation Environment for Stress in Teens (RESeT) did not significantly affect repeated survey measurements of depression, mindfulness, nor cognitive fusion, it did positively affect momentary mood (pre-intervention: 10.8, post-intervention: 12.0, P=.001) and decrease momentary stress (pre-intervention: 37.9, post-intervention: 20.6, P=.001). We found a significant reduction in within-day momentary stress that strengthened with increased VR use over time during the study period (P=.03). Conclusions: These preliminary data inform our own VR environment design but also provide evidence of the potential for self-administered VR as a promising tool to support adolescent mental health. Self-administered VR for mental health may be an effective intervention for reducing adolescent stress. However, understanding barriers (including disengagement) to using VR, as well as further encouraging participatory design with teens, may be imperative to the success of future mental health interventions. ",
doi="10.2196/49171",
url="https://xr.jmir.org/2024/1/e49171"
}


@Article{info:doi/10.2196/51730,
author="Lin, Shu-Cheng
and Lee, Jing-Yu
and Yang, Yong
and Fang, Chu-Chun
and Fang, Hsiao-Lin
and Hou, Tien-Hung",
title="Exploring the Design of Upper Limb Strength Training Through High-Intensity Interval Training Combined With Exergaming: Usability Study",
journal="JMIR Serious Games",
year="2024",
month="Apr",
day="17",
volume="12",
pages="e51730",
keywords="muscle",
keywords="electromyography",
keywords="healthy",
keywords="home training",
keywords="exercise",
abstract="Background: High-intensity interval training (HIIT) has become a popular exercise strategy in modern society, with the Tabata training method being the most popular. In the past, these training methods were mostly done without equipment, but incorporating exergaming into the training may provide a new option for muscle training. Objectives: The aim of this study was to explore the differences in upper limb muscle activation using an HIIT program combined with exergaming. Methods: A total of 15 healthy male participants were recruited for the study, and the differences in muscle activation were compared between push-ups and exergaming (Nintendo Switch Ring Fit Adventure with the Ring-Con accessory) during HIIT. Prior to the tests, participants underwent pretests, including maximal voluntary contractions of various muscle groups, maximal push-up tests, and maximal movement tests using the exergaming device. The push-up and exergaming tests were conducted on separate days to avoid interference, with a warm-up period of 5 minutes on a treadmill before testing. Muscle activation in the lateral and anterior portions of the deltoid muscle, the sternal and clavicular heads of the pectoralis major muscle, and the latissimus dorsi muscle were measured during the maximal voluntary contractions and single-round tests for each exercise mode. A repeated measures ANOVA was used to assess the variations in muscle activation observed across the 2 distinct modes of exercise, specifically push-ups and exergaming. Results: In exergaming, the number of repetitions for push-ups was significantly fewer than for single-site exercises across both exhaustive (mean 23.13, SD 6.36 vs mean 55.67, SD 17.83; P=.001; effect size [ES]: 2.43) and single-round (mean 21.93, SD 7.67 vs mean 92.40, SD 20.47; P=.001; ES: 4.56) training. Heart rate differences were not significant (all P>.05), yet exergaming led to better muscle activation in specific muscle groups, particularly the right anterior deltoid (mean 48.00\%, SD 7.66\% vs mean 32.84\%, SD 10.27\%; P=.001; ES: 1.67) and right pectoralis major (sternal head: mean 38.99\%, SD 9.98\% vs mean 26.90\%, SD 12.97\%; P=.001; ES: 1.04; clavicular head: mean 43.54\%, SD 9.59\% vs mean 30.09\%, SD 11.59\%; P=.002; ES: 1.26) during exhaustive training. In single-round training, similar patterns were observed with the anterior deltoid (mean 51.37\%, SD 11.76\% vs mean 35.47\%, SD 12.72\%; P=.002; ES: 1.30) and pectoralis major (sternal head: mean 53.27\%, SD 10.79\% vs mean 31.56\%, SD 16.92\%; P=.001; ES: 1.53; clavicular head: mean 53.75\%, SD 13.01\% vs mean 37.95\%, SD 14.67\%; P=.006; ES: 1.14). These results suggest that exergaming may be more effective for targeted muscle activation. Conclusions: In conclusion, HIIT can increase muscle activation in the upper extremities and can be incorporated into exergaming strategies to provide a fun and engaging way to exercise. ",
doi="10.2196/51730",
url="https://games.jmir.org/2024/1/e51730"
}


@Article{info:doi/10.2196/50315,
author="Wiley, Katelyn
and Berger, Phaedra
and Friehs, Achim Maximilian
and Mandryk, Lee Regan",
title="Measuring the Reliability of a Gamified Stroop Task: Quantitative Experiment",
journal="JMIR Serious Games",
year="2024",
month="Apr",
day="10",
volume="12",
pages="e50315",
keywords="cognitive assessment",
keywords="gamification",
keywords="serious games",
keywords="Stroop task",
keywords="reliability",
abstract="Background: Few gamified cognitive tasks are subjected to rigorous examination of psychometric properties, despite their use in experimental and clinical settings. Even small manipulations to cognitive tasks require extensive research to understand their effects. Objective: This study aims to investigate how game elements can affect the reliability of scores on a Stroop task. We specifically investigated performance consistency within and across sessions. Methods: We created 2 versions of the Stroop task, with and without game elements, and then tested each task with participants at 2 time points. The gamified task used points and feedback as game elements. In this paper, we report on the reliability of the gamified Stroop task in terms of internal consistency and test-retest reliability, compared with the control task. We used a permutation approach to evaluate internal consistency. For test-retest reliability, we calculated the Pearson correlation and intraclass correlation coefficients between each time point. We also descriptively compared the reliability of scores on a trial-by-trial basis, considering the different trial types. Results: At the first time point, the Stroop effect was reduced in the game condition, indicating an increase in performance. Participants in the game condition had faster reaction times (P=.005) and lower error rates (P=.04) than those in the basic task condition. Furthermore, the game condition led to higher measures of internal consistency at both time points for reaction times and error rates, which indicates a more consistent response pattern. For reaction time in the basic task condition, at time 1, rSpearman-Brown=0.78, 95\% CI 0.64-0.89. At time 2, rSpearman-Brown=0.64, 95\% CI 0.40-0.81. For reaction time, in the game condition, at time 1, rSpearman-Brown=0.83, 95\% CI 0.71-0.91. At time 2, rSpearman-Brown=0.76, 95\% CI 0.60-0.88. Similarly, for error rates in the basic task condition, at time 1, rSpearman-Brown=0.76, 95\% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95\% CI 0.58-0.86. For error rates in the game condition, at time 1, rSpearman-Brown=0.76, 95\% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95\% CI 0.58-0.86. Test-retest reliability analysis revealed a distinctive performance pattern depending on the trial type, which may be reflective of motivational differences between task versions. In short, especially in the incongruent trials where cognitive conflict occurs, performance in the game condition reaches peak consistency after 100 trials, whereas performance consistency drops after 50 trials for the basic version and only catches up to the game after 250 trials. Conclusions: Even subtle gamification can impact task performance albeit not only in terms of a direct difference in performance between conditions. People playing the game reach peak performance sooner, and their performance is more consistent within and across sessions. We advocate for a closer examination of the impact of game elements on performance. ",
doi="10.2196/50315",
url="https://games.jmir.org/2024/1/e50315",
url="http://www.ncbi.nlm.nih.gov/pubmed/38598265"
}


@Article{info:doi/10.2196/36154,
author="Wang, Yu-Han",
title="Understanding Senior Adults' Needs, Preferences, and Experiences of Commercial Exergames for Health: Usability Study",
journal="JMIR Serious Games",
year="2024",
month="Apr",
day="5",
volume="12",
pages="e36154",
keywords="exergame",
keywords="senior user experience",
keywords="senior technology acceptance",
keywords="game technology",
keywords="psychological perception",
keywords="serious games",
keywords="exercise",
keywords="aging",
keywords="older adults",
keywords="physical activity",
abstract="Background: Many senior adults are at risk of mental and physical disorders due to a lack of sufficient exercise. Therefore, adherent exercise should be urgently promoted to improve senior adults' muscle strength, preventing falls and conditions caused by physical and cognitive decline. However, off-the-shelf exercise games, so-called exergames, are mainly targeted at the younger generation or children, while senior adults are neglected, when this age group strongly needs exercise. Exergames could serve as a health intervention for promoting exercise. Objective: This study aimed to investigate senior adults' experience, perceptions, and acceptance of game technology to promote exercise in order to suggest game design guidelines. Methods: In this usability study, participants engaged in playing Nintendo Switch and Xbox Kinect games, after which semistructured interviews were conducted. Before the gameplay, the participants provided their background information, exercise habits, and use of technology products. Next, all participants completed a workshop including 3 activities (brief instructions on how to play the games: 20 minutes; playing the selected exergames: 80 minutes; semistructured interviews: 20 minutes) for 2 hours a day for 3 days each. The participants played the latest Nintendo Switch games (eg, Just Dance, Boxing, Ring Fit Adventure) and Xbox Kinect games (eg, Kinect Adventures!, Mini Games). Just Dance, Zumba, and Boxing were played in activity 1; Ring Fit Adventure and Mini Games in activity 2; and Kinect Adventures! in activity 3. Reflexive thematic analysis was applied to identify the relative themes generated from the interviews. Results: In total, 22 participants (mean age 70.4, SD 6.1 years) were enrolled in the workshop in May 2021. The results of the generated themes included incomprehension of game instructions, psychological perception of game technology, and game art preferences. The subthemes generated from game art preferences included favorite game genres, characters, and scenes. Conclusions: There is a significant need for customized game tutorials considering senior adults' cognitive and physical aging. Furthermore, the adventure game genre is preferable to other games. Humanlike game characters are preferable, especially those with a fit and healthy body shape. Nature scenes are more enjoyable than indoor stages or rooms. Furthermore, the game intensity design and playing time should be carefully planned to meet the World Health Organization's criteria for physical activity in older adults. Intelligent recommendation systems might be helpful to support older adults with various health conditions. The guidelines suggested in this study might be beneficial for game design, exercise training, and game technology adoption of exergames for older adults to improve health. ",
doi="10.2196/36154",
url="https://games.jmir.org/2024/1/e36154",
url="http://www.ncbi.nlm.nih.gov/pubmed/38578674"
}


@Article{info:doi/10.2196/43078,
author="Lieder, Falk
and Chen, Pin-Zhen
and Prentice, Mike
and Amo, Victoria
and To{\vs}i{\'c}, Mateo",
title="Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study",
journal="JMIR Serious Games",
year="2024",
month="Mar",
day="22",
volume="12",
pages="e43078",
keywords="gamification",
keywords="points",
keywords="feedback",
keywords="behavior change",
keywords="habit formation",
keywords="chatbot",
keywords="digital interventions",
keywords="mobile phone",
keywords="artificial intelligence",
abstract="Background: Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission. Objective: In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change. Methods: As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot's optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants' water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day. Results: A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95\% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95\% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P?.17 in all cases). Conclusions: Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective. Trial Registration: Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8 ",
doi="10.2196/43078",
url="https://games.jmir.org/2024/1/e43078",
url="http://www.ncbi.nlm.nih.gov/pubmed/38517466"
}


@Article{info:doi/10.2196/48080,
author="Atagbuzia, Chukwudiebube
and Ng, H. Ean
and Natarajan, Ganapathy",
title="Improving Behavioral-Based Safety Training in Using Verbal Commands Through a Theory-Driven and Feedback-Based Nonimmersive Virtual Reality Game: Development and Usability Study",
journal="JMIR Form Res",
year="2024",
month="Mar",
day="12",
volume="8",
pages="e48080",
keywords="behavioral safety training",
keywords="SERES framework",
keywords="Reflection, Engagement, Choice, Information, Play, Exposition framework",
keywords="gamification",
keywords="gestalt laws of perception",
abstract="Background: The construction, chemical, aviation, medical, and health care industries have used serious games for safety training. To our knowledge, serious games have not been developed focusing on behavioral change to improve safety through the use of verbal commands and instilling players with heightened awareness of their spatial proximity to other people in their surroundings. Objective: We aimed to develop a theory-driven serious game for improving safety behavior using verbal commands and validate the implementation of the theoretical frameworks used for game development. The game developed, KitchenSpeak, was a first-person character (FPC) game where users respond to in-game prompts to use loud verbal commands when they are approaching another employee's blind spot. Methods: In addition to using the SERES framework in guiding the general game design and development, and the Reflection, Engagement, Choice, Information, Play, Exposition (RECIPE) framework to inform the design of the game mechanics, we also applied gestalt laws of perception for graphic design to guide the design of the game's user interface. We conducted 2 evaluative tests (alpha and beta) to collect end user and stakeholder feedback on the implementation of the theoretical frameworks, as well as to collect relevant information for full-scale implementation and a future validation study. Results: The alpha and beta tests had 8 and 40 participants, respectively. The alpha test results revealed that the theoretical frameworks were adequately applied; however, suggestions were also made to modify and improve the game. The beta test results suggested further improvements for the game design and found no differences in the perception of ease of play between participants with and without previous FPC gaming experience (P=.47; Kruskal-Wallis). Results suggested that the game met its design and theoretical requirements, and it would be easily playable by all players regardless of their previous experience in FPC games. Conclusions: A theory-driven and evidence-based FPC game titled KitchenSpeak was developed to teach the use of kitchen-speak terms in commercial kitchens. Evaluative tests were conducted to validate the implementation of the theoretical frameworks. Our main contributions are creating and validating game-based training to improve behavioral-based safety in the workplace and the incorporation of gestalt laws of perception for graphic design in the game's user interface. ",
doi="10.2196/48080",
url="https://formative.jmir.org/2024/1/e48080",
url="http://www.ncbi.nlm.nih.gov/pubmed/38470470"
}


@Article{info:doi/10.2196/44423,
author="Straand, Jevnaker Ingjerd
and F{\o}lstad, Asbj{\o}rn
and Bj{\o}rnestad, Ravndal Jone",
title="Exploring a Gaming-Based Intervention for Unemployed Young Adults: Thematic Analysis",
journal="JMIR Hum Factors",
year="2024",
month="Jan",
day="18",
volume="11",
pages="e44423",
keywords="positive psychology intervention",
keywords="digital mental health",
keywords="serious gaming",
keywords="intervention design",
keywords="research through design",
keywords="gaming-based intervention",
abstract="Background: Promoting positive psychologies that promote resilience such as a growth mindset could be beneficial for young, unemployed adults, as many lack the self-esteem and self-efficacy to cope with job search adversity. These young people may be reached at scale through the web-based delivery of self-administered positive psychology interventions. However, past studies report unsatisfying user experiences and a lack of user engagement. A gaming-based experience could be an approach to overcoming these challenges. Objective: Our research objective was to explore how young, unemployed adults experience a positive psychology intervention designed as a game to extract learning and principles for future intervention research and development. Methods: To respond to the research question, a team of researchers at the University of Stavanger worked with designers and developers to conceptualize and build a gaming-based intervention. Feedback from the users was collected through formative usability testing with 18 young adults in the target group. Retrospectively, recordings and notes were transcribed and subjected to thematic analysis to extract learnings for the purposes of this paper. Results: A total of 3 themes were identified that pinpoint what we consider to be key priorities for future gaming interventions for unemployed young adults: adaptation to user preferences (eg, need for responding to user preferences), empathic player interaction (eg, need for responsiveness to user inputs and a diverse set of interaction modes), and sensemaking of experience and context (eg, need for explicit presentation of game objectives and need for management of user expectations related to genre). Conclusions: Feedback from end users in usability-testing sessions was vital to understanding user preferences and needs, as well as to inform ongoing intervention design and development. Our study also shows that game design could make interventions more entertaining and engaging but may distort the intervention if the game narrative is not properly aligned with the intervention intent and objectives. By contrast, a lack of adaptation to user needs may cause a less motivating user experience. Thus, we propose a structured approach to promote alignment between user preferences and needs, intervention objectives, and gameplay. ",
doi="10.2196/44423",
url="https://humanfactors.jmir.org/2024/1/e44423",
url="http://www.ncbi.nlm.nih.gov/pubmed/38236624"
}


@Article{info:doi/10.2196/42733,
author="Vonthron, Francois
and Yuen, Antoine
and Pellerin, Hugues
and Cohen, David
and Grossard, Charline",
title="A Serious Game to Train Rhythmic Abilities in Children With Dyslexia: Feasibility and Usability Study",
journal="JMIR Serious Games",
year="2024",
month="Jan",
day="11",
volume="12",
pages="e42733",
keywords="serious game",
keywords="rhythm",
keywords="dyslexia",
keywords="musical abilities",
keywords="design framework",
keywords="reading skills",
keywords="children",
keywords="digital health intervention",
keywords="attention-deficit/hyperactivity disorder",
keywords="ADHD",
keywords="child development",
keywords="mobile phone",
abstract="Background: Rhythm perception and production are related to phonological awareness and reading performance, and rhythmic deficits have been reported in dyslexia. In addition, rhythm-based interventions can improve cognitive function, and there is consistent evidence suggesting that they are an efficient tool for training reading skills in dyslexia. Objective: This paper describes a rhythmic training protocol for children with dyslexia provided through a serious game (SG) called Mila-Learn and the methodology used to test its usability. Methods: We computed Mila-Learn, an SG that makes training remotely accessible and consistently reproducible and follows an educative agenda using Unity (Unity Technologies). The SG's development was informed by 2 studies conducted during the French COVID-19 lockdowns. Study 1 was a feasibility study evaluating the autonomous use of Mila-Learn with 2500 children with reading deficits. Data were analyzed from a subsample of 525 children who spontaneously played at least 15 (median 42) games. Study 2, following the same real-life setting as study 1, evaluated the usability of an enhanced version of Mila-Learn over 6 months in a sample of 3337 children. The analysis was carried out in 98 children with available diagnoses. Results: Benefiting from study 1 feedback, we improved Mila-Learn to enhance motivation and learning by adding specific features, including customization, storylines, humor, and increasing difficulty. Linear mixed models showed that performance improved over time. The scores were better for older children (P<.001), children with attention-deficit/hyperactivity disorder (P<.001), and children with dyslexia (P<.001). Performance improved significantly faster in children with attention-deficit/hyperactivity disorder ($\beta$=.06; t3754=3.91; P<.001) and slower in children with dyslexia ($\beta$=?.06; t3816=--5.08; P<.001). Conclusions: Given these encouraging results, future work will focus on the clinical evaluation of Mila-Learn through a large double-blind randomized controlled trial comparing Mila-Learn and a placebo game. ",
doi="10.2196/42733",
url="https://games.jmir.org/2024/1/e42733",
url="http://www.ncbi.nlm.nih.gov/pubmed/37830510"
}


@Article{info:doi/10.2196/46242,
author="Kim, Sunghak
and Jung, Timothy
and Sohn, Kyung Dae
and Chae, Yoon
and Kim, Ae Young
and Kang, Hyun Seung
and Park, Yujin
and Chang, Jung Yoon",
title="The Multidomain Metaverse Cancer Care Digital Platform: Development and Usability Study",
journal="JMIR Serious Games",
year="2023",
month="Nov",
day="30",
volume="11",
pages="e46242",
keywords="metaverse",
keywords="virtual reality",
keywords="cancer education",
keywords="cancer care",
keywords="digital health",
keywords="cancer treatment",
keywords="patient care",
keywords="cross-sectional survey",
keywords="digital health intervention",
abstract="Background: As cancer treatment methods have diversified and the importance of self-management, which lowers the dependence rate on direct hospital visits, has increased, effective cancer care education and management for health professionals and patients have become necessary. The metaverse is in the spotlight as a means of digital health that allows users to engage in cancer care education and management beyond physical constraints. However, it is difficult to find a multipurpose medical metaverse that can not only be used in the field but also complements current cancer care. Objective: This study aimed to develop an integrated metaverse cancer care platform, Dr. Meta, and examine its usability. Methods: We conducted a multicenter, cross-sectional survey between November and December 2021. A descriptive analysis was performed to examine users' experiences with Dr. Meta. In addition, a supplementary open-ended question was used to ask users for their suggestions and improvements regarding the platform. Results: Responses from 70 Korean participants (male: n=19, 27\% and female: n=51, 73\%) were analyzed. More than half (n=37, 54\%) of the participants were satisfied with Dr. Meta; they responded that it was an interesting and immersive platform (n=50, 72\%). Less than half perceived no discomfort when using Dr. Meta (n=34, 49\%) and no difficulty in wearing and operating the device (n=30, 43\%). Furthermore, more than half (n=50, 72\%) of the participants reported that Dr. Meta would help provide non--face-to-face and noncontact services. More than half also wanted to continue using this platform in the future (n=41, 59\%) and recommended it to others (n=42, 60\%). Conclusions: We developed a multidomain metaverse cancer care platform that can support both health professionals and patients in non--face-to-face cancer care. The platform was uniquely disseminated and implemented in multiple regional hospitals and showed the potential to perform successful cancer care. ",
doi="10.2196/46242",
url="https://games.jmir.org/2023/1/e46242",
url="http://www.ncbi.nlm.nih.gov/pubmed/38032697"
}


@Article{info:doi/10.2196/48063,
author="Martinho, Diogo
and Crista, V{\'i}tor
and Carneiro, Jo{\~a}o
and Matsui, Kenji
and Corchado, Manuel Juan
and Marreiros, Goreti",
title="Effects of a Gamified Agent-Based System for Personalized Elderly Care: Pilot Usability Study",
journal="JMIR Serious Games",
year="2023",
month="Nov",
day="23",
volume="11",
pages="e48063",
keywords="gamification",
keywords="cognitive assistants",
keywords="elderly care",
keywords="coaching system",
keywords="older people",
keywords="technology",
keywords="virtual assistant",
keywords="cognitive",
keywords="usability",
keywords="intervention",
keywords="physical activity",
keywords="agent-based system",
abstract="Background: The global percentage of older people has increased significantly over the last decades. Information and communication technologies have become essential to develop and motivate them to pursue healthier ways of living. This paper examines a personalized coaching health care service designed to maintain living conditions and active aging among older people. Among the technologies the service includes, we highlight the use of both gamification and cognitive assistant technologies designed to support older people and an application combining a cognitive virtual assistant to directly interact with the older person and provide feedback on their current health condition and several gamification techniques to motivate the older person to stay engaged with the application and pursuit of healthier daily habits. Objective: This pilot study aimed to investigate the feasibility and usability of a gamified agent-based system for older people and obtain preliminary results on the effectiveness of the intervention regarding physical activity health outcomes. Methods: The study was designed as an intervention study comparing pre- and posttest results. The proposed gamified agent-based system was used by 12 participants over 7 days (1 week), and step count data were collected with access to the Google Fit application programming interface. Step count data after the intervention were compared with average step count data before the intervention (average daily values over a period of 4 weeks before the intervention). A?1-tailed Student t test was used to determine the relationship between the dependent and independent variables. Usability was measured using the System Usability Scale questionnaire, which was answered by 8 of the 12 participants in the study. Results: The posttest results showed significant pre- to posttest changes (P=.30; 1-tailed Student t test) with a moderate effect size (Cohen d=0.65). The application obtained an average usability score of 78. Conclusions: The presented pilot was validated, showing the positive health effects of using gamification techniques and a virtual cognitive assistant. Additionally, usability metrics considered for this study confirmed high adherence and interest from most participants in the pilot. ",
doi="10.2196/48063",
url="https://games.jmir.org/2023/1/e48063",
url="http://www.ncbi.nlm.nih.gov/pubmed/37995116"
}


@Article{info:doi/10.2196/41371,
author="Tacchino, Andrea
and Ponzio, Michela
and Confalonieri, Paolo
and Leocani, Letizia
and Inglese, Matilde
and Centonze, Diego
and Cocco, Eleonora
and Gallo, Paolo
and Paolicelli, Damiano
and Rovaris, Marco
and Sabattini, Loredana
and Tedeschi, Gioacchino
and Prosperini, Luca
and Patti, Francesco
and Bramanti, Placido
and Pedrazzoli, Elisabetta
and Battaglia, Alberto Mario
and Brichetto, Giampaolo",
title="An Internet- and Kinect-Based Multiple Sclerosis Fitness Intervention Training With Pilates Exercises: Development and Usability Study",
journal="JMIR Serious Games",
year="2023",
month="Nov",
day="8",
volume="11",
pages="e41371",
keywords="exergame",
keywords="Multiple Sclerosis Fitness Intervention Training",
keywords="MS-FIT",
keywords="Pilates",
keywords="Kinect",
keywords="multiple sclerosis",
keywords="exercise",
keywords="serious games",
keywords="balance",
keywords="mobile phone",
abstract="Background: Balance impairments are common in people with multiple sclerosis (MS), with reduced ability to maintain position and delayed responses to postural adjustments. Pilates is a popular alternative method for balance training that may reduce the rapid worsening of symptoms and the increased risk of secondary conditions (eg, depression) that are frequently associated with physical inactivity. Objective: In this paper, we aimed to describe the design, development, and usability testing of MS Fitness Intervention Training (MS-FIT), a Kinect-based tool implementing Pilates exercises customized for MS. Methods: MS-FIT has been developed using a user-centered design approach (design, prototype, user feedback, and analysis) to gain the target user's perspective. A team composed of 1 physical therapist, 2 game programmers, and 1 game designer developed the first version of MS-FIT that integrated the knowledge and experience of the team with MS literature findings related to Pilates exercises and balance interventions based on exergames. MS-FIT, developed by using the Unity 3D (Unity Technologies) game engine software with Kinect Sensor V2 for Windows, implements exercises for breathing, posture, and balance. Feedback from an Italian panel of experts in MS rehabilitation (neurologists, physiatrists, physical therapists, 1 statistician, and 1 bioengineer) and people with MS was collected to customize the tool for use in MS. The context of MS-FIT is traveling around the world to visit some of the most important cities to learn the aspects of their culture through pictures and stories. At each stay of the travel, the avatar of a Pilates teacher shows the user the exercises to be performed. Overall, 9 people with MS (n=4, 44\% women; mean age 42.89, SD 11.97 years; mean disease duration 10.19, SD 9.18 years; Expanded Disability Status Scale score 3.17, SD 0.75) were involved in 3 outpatient user test sessions of 30 minutes; MS-FIT's usability was assessed through an ad hoc questionnaire (maximum value=5; higher the score, higher the usability) evaluating easiness to use, playability, enjoyment, satisfaction, and acceptance. Results: A user-centered design approach was used to develop an accessible and challenging tool for balance training. All people with MS (9/9, 100\%) completed the user test sessions and answered the ad hoc questionnaire. The average score on each item ranged from 3.78 (SD 0.67) to 4.33 (SD 1.00), which indicated a high usability level. The feedback and suggestions provided by 64\% (9/14) of people with MS and 36\% (5/14) of therapists involved in the user test were implemented to refine the first prototype to release MS-FIT 2.0. Conclusions: The participants reported that MS-FIT was a usable tool. It is a promising system for enhancing the motivation and engagement of people with MS in performing exercise with the aim of improving their physical status. ",
doi="10.2196/41371",
url="https://games.jmir.org/2023/1/e41371",
url="http://www.ncbi.nlm.nih.gov/pubmed/37938895"
}


@Article{info:doi/10.2196/49216,
author="Kim, Seong-Yeol
and Song, Minji
and Jo, Yunju
and Jung, Youngjae
and You, Heecheon
and Ko, Myoung-Hwan
and Kim, Gi-Wook",
title="Effect of Voice and Articulation Parameters of a Home-Based Serious Game for Speech Therapy in Children With Articulation Disorder: Prospective Single-Arm Clinical Trial",
journal="JMIR Serious Games",
year="2023",
month="Oct",
day="11",
volume="11",
pages="e49216",
keywords="articulation disorder",
keywords="home-based therapy",
keywords="serious game",
keywords="children",
keywords="speech",
keywords="voice",
abstract="Background: Articulation disorder decreases the clarity of language and causes a decrease in children's learning and social ability. The demand for non--face-to-face treatment is increasing owing to the limited number of therapists and geographical or economic constraints. Non--face-to-face speech therapy programs using serious games have been proposed as an alternative. Objective: The aim of this study is to investigate the efficacy of home therapy on logopedic and phoniatric abilities in children with articulation disorder using the Smart Speech game interface. Methods: This study is a prospective single-arm clinical trial. Children with articulation disorders, whose Urimal Test of Articulation and Phonology (U-TAP) was --2 SDs or less and the Receptive and Expressive Vocabulary Test score was --1 SD or more, were enrolled. A preliminary evaluation (E0) was conducted to check whether the children had articulation disorders, and for the next 4 weeks, they lived their usual lifestyle without other treatments. Prior to the beginning of the training, a pre-evaluation (E1) was performed, and the children trained at home for ?30 minutes per day, ?5 times a week, over 4 weeks (a total of 20 sessions). The Smart Speech program comprised oral exercise training, breathing training, and speech training; the difficulty and type of the training were configured differently according to the participants' articulation error, exercise, and vocal ability. After the training, postevaluation (E2) was performed using the same method. Finally, 8 weeks later, postevaluation (E3) was performed as a follow-up. A voice evaluation included parameters such as maximum phonation time (MPT), fundamental frequency (F0), jitter, peak air pressure (relative average perturbation), pitch, intensity, and voice onset time. Articulation parameters included a percentage of correct consonants (PCC; U-TAP word-unit PCC, U-TAP sentence-unit PCC, and three-position articulation test) and alternate motion evaluation (diadochokinesis, DDK). Data obtained during each evaluation (E1-E2-E3) were compared. Results: A total of 13 children with articulation disorders aged 4-10 years were enrolled in the study. In voice parameters, MPT, jitter, and pitch showed significant changes in repeated-measures ANOVA. However, only MPT showed significant changes during E1-E2 (P=.007) and E1-E3 (P=.004) in post hoc tests. Other voice parameters did not show significant changes. In articulation parameters, U-TAP, three-position articulation test (TA), and DDK showed significant changes in repeated-measures ANOVA. In post hoc tests, U-TAP (word, sentence) and TA showed significant changes during E1-E2 (P=.003, .04, and .01) and E1-E3 (P=.001, .03, and .003), and DDK showed significant changes during E1-E2 only (P=.03). Conclusions: Home-based serious games can be considered an alternative treatment method to improve language function. Trial Registration: Clinical Research Information Service KCT0006448; https://cris.nih.go.kr/cris/search/detailSearch.do/20119 ",
doi="10.2196/49216",
url="https://games.jmir.org/2023/1/e49216",
url="http://www.ncbi.nlm.nih.gov/pubmed/37819707"
}


@Article{info:doi/10.2196/39465,
author="Martin, Philippe
and Chapoton, Boris
and Bourmaud, Aur{\'e}lie
and Dumas, Agn{\`e}s
and Kivits, Jo{\"e}lle
and Eyraud, Clara
and Dubois, Capucine
and Alberti, Corinne
and Le Roux, Enora",
title="Health Promotion in Popular Web-Based Community Games Among Young People: Proposals, Recommendations, and Applications",
journal="JMIR Serious Games",
year="2023",
month="Jun",
day="9",
volume="11",
pages="e39465",
keywords="health promotion",
keywords="web-based community games",
keywords="young people",
keywords="interventional research",
keywords="recommendations",
abstract="Background: Young people use digital technology on a daily basis and enjoy web-based games that promote social interactions among peers. These interactions in web-based communities can develop social knowledge and life skills. Intervening via existing web-based community games represents an innovative opportunity for health promotion interventions. Objective: The aim of this study was to collect and describe players' proposals for delivering health promotion through existing web-based community games among young people, elaborate on related recommendations adapted from a concrete experience of intervention research, and describe the application of these recommendations in new interventions. Methods: We implemented a health promotion and prevention intervention via a web-based community game (Habbo; Sulake Oy). During the implementation of the intervention, we conducted an observational qualitative study on young people's proposals via an intercept web-based focus group. We asked 22 young participants (3 groups in total) for their proposals about the best ways to carry out a health intervention in this context. First, using verbatim transcriptions of the players' proposals, we conducted a qualitative thematic analysis. Second, we elaborated on recommendations for action development and implementation based on our experiences and work with a multidisciplinary consortium of experts. Third, we applied these recommendations in new interventions and described their application. Results: A thematic analysis of the participants' proposals revealed 3 main themes and 14 subthemes related to their proposals and process elements: the conditions for developing an attractive intervention within a game, the value of involving peers in developing the intervention, and the ways to mobilize and monitor gamers' participation. These proposals emphasized the importance of interventions involving and moderating a small group of players in a playful manner but with professional aspects. We established 16 domains with 27 recommendations for preparing an intervention and implementing it in web-based games by adopting the codes of game culture. The application of the recommendations showed their usefulness and that it was possible to make adapted and diverse interventions in the game. Conclusions: Integrated health promotion interventions in existing web-based community games have the potential for promoting the health and well-being of young people. There is a need to incorporate specific key aspects of the games and gaming community recommendations, from conception to implementation, to maximize the relevance, acceptability, and feasibility of the interventions integrated in current digital practices. Trial Registration: ClinicalTrials.gov NCT04888208; https://clinicaltrials.gov/ct2/show/NCT04888208 ",
doi="10.2196/39465",
url="https://games.jmir.org/2023/1/e39465",
url="http://www.ncbi.nlm.nih.gov/pubmed/37294609"
}


@Article{info:doi/10.2196/38484,
author="Malone, A. Laurie
and Mendonca, J. Christen
and Mohanraj, Sangeetha
and Misko, R. Samuel
and Moore, Joseph
and Brascome, Michael James
and Thirumalai, Mohanraj",
title="Usability of the GAIMplank Video Game Controller for People With Mobility Impairments: Observational Study",
journal="JMIR Serious Games",
year="2023",
month="Jan",
day="10",
volume="11",
pages="e38484",
keywords="exergaming",
keywords="physical disability",
keywords="equipment design",
keywords="video gaming",
keywords="physical activity",
keywords="exercise",
keywords="wheelchair",
abstract="Background: Replacing sedentary behaviors during leisure time with active video gaming has been shown to be an enjoyable option for increasing physical activity. However, most off-the-shelf active video gaming controllers are not accessible or usable for individuals with mobility impairments. To address this requirement, a universal video game controller (called the GAIMplank) was designed and developed. Objective: This study aimed to assess the usability of the GAIMplank video game controller for playing PC video games among individuals with mobility impairments. Measures of enjoyment, perceived exertion, and qualitative data on the user experience were also examined. Methods: Adults (aged 18-75 years) with a mobility impairment were recruited to participate in a single testing session in the laboratory. Before testing began, basic demographic information, along with minutes of weekday and weekend physical activity, minutes of weekday and weekend video game play, and video game play experience were collected. The GAIMplank was mapped to operate as a typical joystick controller. Depending on their comfort and functional ability, participants chose to play seated in a chair, standing, or in their own manual wheelchair. Leaning movements of the trunk created corresponding action in the game (ie, lean right to move right). The participants played a total of 5 preselected video games for approximately 5 minutes each. Data were collected to assess the usability of the GAIMplank, along with self-efficacy regarding execution of game play actions, rating of perceived exertion and enjoyment for each game, and overall qualitative feedback. Results: A total of 21 adults (n=15, 71\% men; n=6, 29\% women) completed the usability testing, with a mean age of 48.8 (SD 13.8; range 21-73) years. Overall, 38\% (8/21) of adults played while standing, 33\% (7/21) of adults played while seated in a chair, and 29\% (6/21) played in their own manual wheelchair. Scores from the System Usability Scale indicated above average (74.8, SD 14.5) usability, with scores best for those who played seated in a chair, followed by those standing, and then individuals who played seated in their own wheelchairs. Inconsistencies in the responsiveness of the controller and general feedback for minor improvements were documented. Rating of perceived exertion scores ranged from light to moderate intensity, with the highest scores for those who played seated in a chair. Participants rated their experience with playing each game from above average to very enjoyable. Conclusions: The GAIMplank video game controller was found to be usable and accessible, providing an enjoyable option for light-to-moderate intensity exercise among adults with mobility impairments. Minor issues with inconsistencies in controller responsiveness were also recorded. Following further development and refinement, the next phase will include a pilot exercise intervention using the GAIMplank system. ",
doi="10.2196/38484",
url="https://games.jmir.org/2023/1/e38484",
url="http://www.ncbi.nlm.nih.gov/pubmed/36626195"
}


@Article{info:doi/10.2196/36936,
author="Almeqbaali, Mariam
and Ouhbi, Sofia
and Serhani, Adel Mohamed
and Amiri, Leena
and Jan, K. Reem
and Zaki, Nazar
and Sharaf, Ayman
and Al Helali, Abdulla
and Almheiri, Eisa",
title="A Biofeedback-Based Mobile App With Serious Games for Young Adults With Anxiety in the United Arab Emirates: Development and Usability Study",
journal="JMIR Serious Games",
year="2022",
month="Aug",
day="2",
volume="10",
number="3",
pages="e36936",
keywords="connected mental health",
keywords="mental health",
keywords="anxiety",
keywords="digital game",
keywords="biofeedback",
keywords="app",
keywords="serious game",
keywords="gaming",
keywords="gamification",
keywords="young adult",
keywords="user-centered design",
keywords="stress",
keywords="stress relief",
keywords="user-centred design",
keywords="youth",
keywords="user feedback",
keywords="user experience",
keywords="usability",
keywords="user need",
keywords="development",
keywords="mHealth",
keywords="mobile health",
abstract="Background: Following the outbreak of COVID-19, several studies have reported that young adults encountered a rise in anxiety symptoms, which could negatively affect their quality of life. Promising evidence suggests that mobile apps with biofeedback, serious games, breathing exercises, and positive messaging, among other features, are useful for anxiety self-management and treatment. Objective: This study aimed to develop and evaluate the usability of a biofeedback-based app with serious games for young adults with anxiety in the United Arab Emirates (UAE). Methods: This study consists of two phases: Phase I describes the design and development of the app, while Phase II presents the results of a usability evaluation by experts. To elicit the app's requirements during Phase I, we conducted (1) a survey to investigate preferences of young adults in the UAE for mobile games for stress relief; (2) an analysis of serious games for anxiety; and (3) interviews with mental health professionals and young adults in the UAE. In Phase II, five experts tested the usability of the developed app using a set of Nielsen's usability heuristics. Results: A fully functional biofeedback-based app with serious games was co-designed with mental health professionals. The app included 4 games (ie, a biofeedback game, card game, arcade game, and memory game), 2 relaxation techniques (ie, a breathing exercise and yoga videos), and 2 additional features (ie, positive messaging and a mood tracking calendar). The results of Phase II showed that the developed app is efficient, simple, and easy to use. Overall, the app design scored an average of 4 out of 5. Conclusions: The elicitation techniques used in Phase I resulted in the development of an easy-to-use app for the self-management of anxiety. Further research is required to determine the app's usability and effectiveness in the target population. ",
doi="10.2196/36936",
url="https://games.jmir.org/2022/3/e36936",
url="http://www.ncbi.nlm.nih.gov/pubmed/35916692"
}


@Article{info:doi/10.2196/38509,
author="Ammann-Reiffer, Corinne
and Kl{\"a}y, Andrina
and Keller, Urs",
title="Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation",
journal="JMIR Serious Games",
year="2022",
month="Jul",
day="14",
volume="10",
number="3",
pages="e38509",
keywords="rehabilitation",
keywords="pediatric",
keywords="child",
keywords="adolescent",
keywords="walking",
keywords="feasibility study",
keywords="virtual reality",
keywords="head-mounted display",
keywords="therapy",
keywords="tool",
keywords="user",
keywords="usability",
keywords="visual",
keywords="auditory",
keywords="feedback",
keywords="youth",
abstract="Background: Many essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children's motivation and active participation during the rehabilitation process. Objective: This study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation. Methods: In a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists. Results: None of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists' acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients' movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions. Conclusions: This study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities.The participants' and therapists' positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation. ",
doi="10.2196/38509",
url="https://games.jmir.org/2022/3/e38509",
url="http://www.ncbi.nlm.nih.gov/pubmed/35834316"
}


@Article{info:doi/10.2196/35869,
author="Kwan, Ho Tsz
and Chan, Chung Denise Pui
and Lee, Shan Shui",
title="User Experience and Usability of Neumorphism and Gamification User Interface Designs in an HIV Self-Test Referral Program for Men Who Have Sex With Men: Prospective Open-Label Parallel-Group Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2022",
month="Jun",
day="22",
volume="10",
number="2",
pages="e35869",
keywords="HIV",
keywords="self-test",
keywords="men who have sex with men",
keywords="gamification",
keywords="neumorphism",
keywords="digital intervention",
keywords="HIV prevention",
keywords="user interface",
keywords="games",
keywords="digital health",
abstract="Background: Digital interventions have been applied for promoting HIV prevention and care among men who have sex with men (MSM). As user interface (UI) design plays a role in determining usability and user experience (UX), the intervention outcome could be affected. Objective: In this study, we hypothesized that 2 UI design styles, namely gamification and neumorphism, could impact usability and be differentially preferred by distinct groups of MSM. Methods: A prospective parallel-group open-label randomized controlled trial was conducted in Hong Kong. Eligible participants were adult MSM recruited by the research team or referred by enrolled participants, who followed instructions for performing an HIV self-test and promoted its use within their social network. Participants were randomized in a 1:1 ratio into either a gamification or neumorphism arm, with primarily visual differences in the UI only. The primary outcome was usability measured by the System Usability Scale (SUS) between the 2 arms. Distinct characteristics of promoters in the 2 arms who gave an SUS score of 80 or above were identified. Results: Of 463 MSM registered in the study, 232 and 231 were randomized to the gamification and neumorphism arms, respectively. Excluding those who did not request a self-test kit, data from 218 and 216 participants in the gamification and neumorphism arms, respectively, were analyzed (totally 434 participants). With a median SUS score of 80 overall, participants in the neumorphism arm gave a higher score (P<.001), with a higher proportion giving a promoter-level SUS score (P=.002). Promoters used social media for sex networking (P=.02), used pre-exposure prophylaxis in the preceding year (P=.006), had higher satisfaction in UI design (P<.001), and had made a self-test referral (P=.04). In general, higher usability was recorded among participants who were confident in performing the HIV self-test (P<.001), and this was associated with a promoter-level SUS score in both arms. While no other personal characteristics were associated with promoters in the neumorphism arm, those in the gamification arm had higher HIV-related knowledge (P=.01), preferred a specific partner body image type (P=.03), and progressed toward peer referral by completing online training (P=.04). Conclusions: Both gamified and neumorphic UI designs were well-accepted by MSM. UX and satisfaction of UI were both crucial in influencing the willingness of MSM to promote the application by referring their peers in the community to participate. The simplistic visual design of neumorphism conferred a more general acceptance in the community, whereas gamification was preferred in certain MSM subcommunities. Appropriate UI/UX design should be considered when developing digital interventions targeting the MSM community. Trial Registration: ClinicalTrials.gov NCT04379206; https://clinicaltrials.gov/ct2/show/NCT04379206 ",
doi="10.2196/35869",
url="https://games.jmir.org/2022/2/e35869",
url="http://www.ncbi.nlm.nih.gov/pubmed/35731564"
}


@Article{info:doi/10.2196/35295,
author="Redlinger, Eric
and Glas, Bernhard
and Rong, Yang",
title="Impact of Visual Game-Like Features on Cognitive Performance in a Virtual Reality Working Memory Task: Within-Subjects Experiment",
journal="JMIR Serious Games",
year="2022",
month="Apr",
day="28",
volume="10",
number="2",
pages="e35295",
keywords="HMD",
keywords="working memory",
keywords="gamification",
keywords="cognitive training",
keywords="serious game",
keywords="game",
keywords="cognitive activity",
keywords="user performance",
keywords="visual memory",
keywords="cognitive",
keywords="mobile phone",
abstract="Background: Although the pursuit of improved cognitive function through working memory training has been the subject of decades of research, the recent growth in commercial adaptations of classic working memory tasks in the form of gamified apps warrants additional scrutiny. In particular, the emergence of virtual reality as a platform for cognitive training presents opportunities for the use of novel visual features. Objective: This study aimed to add to the body of knowledge regarding the use of game-like visual design elements by specifically examining the application of two particular visual features common to virtual reality environments: immersive, colorful backgrounds and the use of 3D depth. In addition, electroencephalography (EEG) data were collected to identify potential neural correlates of any observed changes in performance. Methods: A simple visual working memory task was presented to participants in several game-like adaptations, including the use of colorful, immersive backgrounds and 3D depth. The impact of each adaptation was separately assessed using both EEG and performance assessment outcomes and compared with an unmodified version of the task. Results: Results suggest that although accuracy and reaction time may be slightly affected by the introduction of such game elements, the effects were small and not statistically significant. Changes in EEG power, particularly in the beta and theta rhythms, were significant but failed to correlate with any corresponding changes in performance. Therefore, they may only reflect cognitive changes at the perceptual level. Conclusions: Overall, the data suggest that the addition of these specific visual features to simple cognitive tasks does not appear to significantly affect performance or task-dependent cognitive load. ",
doi="10.2196/35295",
url="https://games.jmir.org/2022/2/e35295",
url="http://www.ncbi.nlm.nih.gov/pubmed/35482373"
}


@Article{info:doi/10.2196/30456,
author="Sadeghi, H. Amir
and Peek, J. Jette
and Max, A. Samuel
and Smit, L. Liselot
and Martina, G. Bryan
and Rosalia, A. Rodney
and Bakhuis, Wouter
and Bogers, JJC Ad
and Mahtab, AF Edris",
title="Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study",
journal="JMIR Serious Games",
year="2022",
month="Mar",
day="2",
volume="10",
number="1",
pages="e30456",
keywords="cardiac surgery",
keywords="cardiopulmonary resuscitation",
keywords="emergency resternotomy",
keywords="virtual reality",
keywords="simulation training",
keywords="serious games",
keywords="virtual reality simulation",
keywords="digital health",
keywords="medical training",
keywords="virtual training",
abstract="Background: Cardiac arrest after cardiac surgery commonly has a reversible cause, where emergency resternotomy is often required for treatment, as recommended by international guidelines. We have developed a virtual reality (VR) simulation for training of cardiopulmonary resuscitation (CPR) and emergency resternotomy procedures after cardiac surgery, the Cardiopulmonary Resuscitation Virtual Reality Simulator (CPVR-sim). Two fictive clinical scenarios were used: one case of pulseless electrical activity (PEA) and a combined case of PEA and ventricular fibrillation. In this prospective study, we researched the face validity and content validity of the CPVR-sim. Objective: We designed a prospective study to assess the feasibility and to establish the face and content validity of two clinical scenarios (shockable and nonshockable cardiac arrest) of the CPVR-sim partly divided into a group of novices and experts in performing CPR and emergency resternotomies in patients after cardiac surgery. Methods: Clinicians (staff cardiothoracic surgeons, physicians, surgical residents, nurse practitioners, and medical students) participated in this study and performed two different scenarios, either PEA or combined PEA and ventricular fibrillation. All participants (N=41) performed a simulation and completed the questionnaire rating the simulator's usefulness, satisfaction, ease of use, effectiveness, and immersiveness to assess face validity and content validity. Results: Responses toward face validity and content validity were predominantly positive in both groups. Most participants in the PEA scenario (n=26, 87\%) felt actively involved in the simulation, and 23 (77\%) participants felt in charge of the situation. The participants thought it was easy to learn how to interact with the software (n=24, 80\%) and thought that the software responded adequately (n=21, 70\%). All 15 (100\%) expert participants preferred VR training as an addition to conventional training. Moreover, 13 (87\%) of the expert participants would recommend VR training to other colleagues, and 14 (93\%) of the expert participants thought the CPVR-sim was a useful method to train for infrequent post--cardiac surgery emergencies requiring CPR. Additionally, 10 (91\%) of the participants thought it was easy to move in the VR environment, and that the CPVR-sim responded adequately in this scenario. Conclusions: We developed a proof-of-concept VR simulation for CPR training with two scenarios of a patient after cardiac surgery, which participants found was immersive and useful. By proving the face validity and content validity of the CPVR-sim, we present the first step toward a cardiothoracic surgery VR training platform. ",
doi="10.2196/30456",
url="https://games.jmir.org/2022/1/e30456",
url="http://www.ncbi.nlm.nih.gov/pubmed/35234652"
}


@Article{info:doi/10.2196/32117,
author="Zhu, KaiYan
and Zhang, QiongYao
and He, BingWei
and Huang, MeiZhen
and Lin, Rong
and Li, Hong",
title="Immersive Virtual Reality--Based Cognitive Intervention for the Improvement of Cognitive Function, Depression, and Perceived Stress in Older Adults With Mild Cognitive Impairment and Mild Dementia: Pilot Pre-Post Study",
journal="JMIR Serious Games",
year="2022",
month="Feb",
day="21",
volume="10",
number="1",
pages="e32117",
keywords="cognitive intervention",
keywords="dementia",
keywords="immersive virtual reality",
keywords="mild cognitive impairment",
keywords="cognitive impairment",
keywords="virtual reality",
keywords="VR",
keywords="older patients",
keywords="usability",
keywords="memory",
keywords="stress",
abstract="Background: The incidence of dementia is increasing annually, resulting in varying degrees of adverse effects for individuals, families, and society. With the continuous development of computer information technology, cognitive interventions are constantly evolving. The use of immersive virtual reality (IVR) as a cognitive intervention for older adults with mild cognitive impairment (MCI) and mild dementia (MD) is promising, although only few studies have focused on its use. Objective: The Chinese virtual supermarket (CVSM) IVR system was developed to provide a comprehensive and individual cognitive intervention program for older patients with MCI and MD. The aim of this study was to explore the feasibility and clinical effectiveness of this 5-week IVR-based cognitive intervention. Methods: A pretest-posttest study design was conducted with 31 older adults with MCI and MD from August 2020 to January 2021. All participants participated in a 5-week immersive virtual cognitive training program using the CVSM system. Feasibility was assessed as the incidence and severity of cybersickness symptoms and participant satisfaction based on questionnaires conducted after the intervention. Clinical effectiveness was evaluated using neuropsychological assessments, including several commonly used measures of cognitive function, depression, perceived stress, and activities of daily living. Measurements were obtained at baseline and after the intervention period. Results: A total of 18 patients with MCI (mean age 82.94 [SD 5.44] years; 12 females) and 13 patients with MD (mean age 85.7 [SD 4.67] years, 10 females) participated in this pilot study. Both groups showed significant improvements in all cognitive function measurements (P<.001). The MD group had a significantly greater improvement in general cognitive function compared to the MCI group in Montreal Cognitive Assessment Scale, Symbol Digit Modalities Test, Shape Trail Test, and Auditory Verbal Learning Test. Furthermore, an intervention effect was observed in the improvement of perceived stress (P=.048 for MD group, P=.03 for MCI group ). Conclusions: The use of the CVSM system may be effective in enhancing the cognitive function of patients with MCI and MD, including general cognitive function, memory, executive function, and attention. IVR technology enriches cognitive intervention approaches and provides acceptable, professional, personalized, and interesting cognitive training for older adults with cognitive impairment. Trial Registration: ClinicalTrials ChiCTR2100043753; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2100043753 ",
doi="10.2196/32117",
url="https://games.jmir.org/2022/1/e32117",
url="http://www.ncbi.nlm.nih.gov/pubmed/35188466"
}


@Article{info:doi/10.2196/28982,
author="Egashira, Mahiro
and Son, Daisuke
and Ema, Arisa",
title="Serious Game for Change in Behavioral Intention Toward Lifestyle-Related Diseases: Experimental Study With Structural Equation Modeling Using the Theory of Planned Behavior",
journal="JMIR Serious Games",
year="2022",
month="Feb",
day="21",
volume="10",
number="1",
pages="e28982",
keywords="lifestyle-related disease",
keywords="mechanism of behavior change",
keywords="serious game",
keywords="theory of planned behavior",
abstract="Background: Health activities should be tailored to individual lifestyles and values. To raise awareness of health behaviors, various practices related to health education, such as interactive activities among individuals with different backgrounds, have been developed. Moreover, serious games have been used as a tool for facilitating communication. However, there have been few investigations that are based on the framework of the theory of planned behavior on the mechanisms of health-related behavioral intention change from playing serious games. Objective: We aimed to investigate the mechanisms of behavioral intention change among various age groups after an intervention using a serious game to increase awareness of lifestyle-related diseases. Methods: Adults, undergraduates, and high school students played a serious game, called Negotiation Battle, and answered a questionnaire---Gaming Event Assessment Form for Lifestyle-related Diseases---before, immediately after, and 2-4 weeks after the game. The questionnaire was composed of 16 items based on the theory of planned behavior. We used structural equation modeling to compare responses from the 3 groups. Results: For all 3 age groups (adults: mean 43.4 years, range 23-67 years; undergraduates: mean 20.9 years, range 19-34 years; high school students: mean 17.9 years, 17-18 years), perceived behavior control was the key factor of behavioral intention change. Immediately after the game, causal relationships between perceived behavioral control and behavioral intention were enhanced or maintained for all groups---adults (before: path coefficient 1.030, P<.001; after: path coefficient 2.045, P=.01), undergraduates (before: path coefficient 0.568, P=.004; after: path coefficient 0.737, P=.001), and high school students (before: path coefficient 14.543, P=.97; after: path coefficient 0.791, P<.001). Analysis of free descriptions after intervention suggested that experiencing dilemma is related to learning and behavioral intention. Conclusions: The study revealed that the serious game changed the behavioral intention of adolescents and adults regarding lifestyle-related diseases, and changes in perceived behavioral control mediated the alteration mechanism. ",
doi="10.2196/28982",
url="https://games.jmir.org/2022/1/e28982",
url="http://www.ncbi.nlm.nih.gov/pubmed/35188465"
}


@Article{info:doi/10.2196/33459,
author="Ade-Ibijola, Abejide
and Young, Keagan
and Sivparsad, Nashik
and Seforo, Mpho
and Ally, Suhail
and Olowolafe, Adebola
and Frahm-Arp, Maria",
title="Teaching Students About Plagiarism Using a Serious Game (Plagi-Warfare): Design and Evaluation Study",
journal="JMIR Serious Games",
year="2022",
month="Feb",
day="16",
volume="10",
number="1",
pages="e33459",
keywords="serious games",
keywords="educational games",
keywords="plagiarism",
keywords="library games",
keywords="game mechanics",
keywords="education",
keywords="teaching",
abstract="Background: Educational games have been proven to support the teaching of various concepts across disciplines. Plagiarism is a major problem among undergraduate and postgraduate students at universities. Objective: In this paper, we propose a game called Plagi-Warfare that attempts to teach students about plagiarism. Methods: To do this at a level that is beyond quizzes, we proposed a game storyline and mechanics that allow the player (or student) to play as a mafia member or a detective. This either demonstrated their knowledge by plagiarizing within the game as a mafia member or catching plagiarists within the game as a detective. The game plays out in a 3D environment representing the major libraries of the University of Johannesburg, South Africa. In total, 30 students were selected to evaluate the game. Results: Evaluation of the game mechanics and storyline showed that the student gamers enjoyed the game and learned about plagiarism. Conclusions: In this paper, we presented a new educational game that teaches students about plagiarism by using a new crime story and an immersive 3D gaming environment representing the libraries of the University of Johannesburg. ",
doi="10.2196/33459",
url="https://games.jmir.org/2022/1/e33459",
url="http://www.ncbi.nlm.nih.gov/pubmed/35171103"
}


@Article{info:doi/10.2196/31471,
author="Ingadottir, Brynja
and Laitonen, Elina
and Stefansdottir, Adalheidur
and Sigurdardottir, Olafia Anna
and Brynjolfsdottir, Berglind
and Parisod, Heidi
and Nyman, Johanna
and Gunnarsdottir, Karitas
and J{\'o}nsd{\'o}ttir, Katr{\'i}n
and Salanter{\"a}, Sanna
and Pakarinen, Anni",
title="Developing a Health Game to Prepare Preschool Children for Anesthesia: Formative Study Using a Child-Centered Approach",
journal="JMIR Serious Games",
year="2022",
month="Jan",
day="20",
volume="10",
number="1",
pages="e31471",
keywords="anesthesia",
keywords="child-centred design",
keywords="children",
keywords="digital health",
keywords="educational games",
keywords="health games",
keywords="hospital",
keywords="patient education",
keywords="serious games",
keywords="surgery",
keywords="user-centred design",
keywords="video games",
abstract="Background: Every year, millions of children undergo medical procedures that require anesthesia. Fear and anxiety are common among young children undergoing such procedures and can interfere with the child's recovery and well-being. Relaxation, distraction, and education are methods that can be used to prepare children and help them cope with fear and anxiety, and serious games may be a suitable medium for these purposes. User-centered design emphasizes the involvement of end users during the development and testing of products, but involving young, preschool children may be challenging. Objective: One objective of this study was to describe the development and usability of a computer-based educational health game intended for preschool children to prepare them for upcoming anesthesia. A further objective was to describe the lessons learned from using a child-centered approach with the young target group. Methods: A formative mixed methods child (user)-centered study design was used to develop and test the usability of the game. Preschool children (4-6 years old) informed the game design through playful workshops (n=26), and usability testing was conducted through game-playing and interviews (n=16). Data were collected in Iceland and Finland with video-recorded direct observation and interviews, as well as children's drawings, and analyzed with content analysis and descriptive statistics. Results: The children shared their knowledge and ideas about hospitals, different emotions, and their preferences concerning game elements. Testing revealed the high usability of the game and provided important information that was used to modify the game before publishing and that will be used in its further development. Conclusions: Preschool children can inform game design through playful workshops about health-related subjects that they are not necessarily familiar with but that are relevant for them. The game's usability was improved with the participation of the target group, and the game is now ready for clinical testing. ",
doi="10.2196/31471",
url="https://games.jmir.org/2022/1/e31471",
url="http://www.ncbi.nlm.nih.gov/pubmed/35049507"
}


@Article{info:doi/10.2196/29964,
author="Robertson, C. Michael
and Baranowski, Tom
and Thompson, Debbe
and Basen-Engquist, M. Karen
and Swartz, Chang Maria
and Lyons, J. Elizabeth",
title="Using the Behaviour Change Wheel Program Planning Model to Design Games for Health: Development Study",
journal="JMIR Serious Games",
year="2021",
month="Dec",
day="3",
volume="9",
number="4",
pages="e29964",
keywords="physical activity",
keywords="video games",
keywords="eHealth",
keywords="intervention",
keywords="behavior and behavior mechanisms",
keywords="psychological theory",
keywords="serious games",
keywords="gamification",
keywords="older women",
keywords="older adults",
keywords="behavior change",
keywords="behavioral interventions",
keywords="mobile phone",
abstract="Background: Games for health are a promising approach to health promotion. Their success depends on achieving both experiential (game) and instrumental (health) objectives. There is little to guide game for health (G4H) designers in integrating the science of behavior change with the art of game design. Objective: The aim of this study is to extend the Behaviour Change Wheel program planning model to develop Challenges for Healthy Aging: Leveraging Limits for Engaging Networked Game-Based Exercise (CHALLENGE), a G4H centered on increasing physical activity in insufficiently active older women. Methods: We present and apply the G4H Mechanics, Experiences, and Change (MECHA) process, which supplements the Behaviour Change Wheel program planning model. The additional steps are centered on identifying target G4H player experiences and corresponding game mechanics to help game designers integrate design elements and G4H objectives into behavioral interventions. Results: We identified a target behavior of increasing moderate-intensity walking among insufficiently active older women and key psychosocial determinants of this behavior from self-determination theory (eg, autonomy). We used MECHA to map these constructs to intervention functions (eg, persuasion) and G4H target player experiences (eg, captivation). Next, we identified behavior change techniques (eg, framing or reframing) and specific game mechanics (eg, transforming) to help realize intervention functions and elicit targeted player experiences. Conclusions: MECHA can help researchers map specific linkages between distal intervention objectives and more proximal game design mechanics in games for health. This can facilitate G4H program planning, evaluation, and clearer scientific communication. ",
doi="10.2196/29964",
url="https://games.jmir.org/2021/4/e29964",
url="http://www.ncbi.nlm.nih.gov/pubmed/34870604"
}


@Article{info:doi/10.2196/29330,
author="Xu, Wenge
and Liang, Hai-Ning
and Baghaei, Nilufar
and Ma, Xiaoyue
and Yu, Kangyou
and Meng, Xuanru
and Wen, Shaoyue",
title="Effects of an Immersive Virtual Reality Exergame on University Students' Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Nov",
day="22",
volume="9",
number="4",
pages="e29330",
keywords="university students",
keywords="depression",
keywords="anxiety",
keywords="stress",
keywords="immersive virtual reality",
keywords="exergame",
abstract="Background: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. Objective: This study aimed to explore the feasibility of a 6-week iVR exergame--based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. Methods: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. Results: A total of 15 participants completed the 6-week study. Our results suggested that participants' mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93\%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93\%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73\%) would recommend the iVR exergame to their friends. Conclusions: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students. ",
doi="10.2196/29330",
url="https://games.jmir.org/2021/4/e29330",
url="http://www.ncbi.nlm.nih.gov/pubmed/34813487"
}


@Article{info:doi/10.2196/27848,
author="Kamnardsiri, Teerawat
and Phirom, Kochaphan
and Boripuntakul, Sirinun
and Sungkarat, Somporn",
title="An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Oct",
day="27",
volume="9",
number="4",
pages="e27848",
keywords="digital game",
keywords="interactive game-based training",
keywords="physical-cognitive training",
keywords="exergaming",
keywords="Kinect sensors",
keywords="older adults",
keywords="falls",
keywords="PACES",
keywords="user-centered design",
keywords="game-based exercise",
abstract="Background: Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults. Objective: The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults. Methods: In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants' characteristics and PACES scores. Results: The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided. Conclusions: These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined. ",
doi="10.2196/27848",
url="https://games.jmir.org/2021/4/e27848",
url="http://www.ncbi.nlm.nih.gov/pubmed/34704953"
}


@Article{info:doi/10.2196/27036,
author="Zhang, Bo
and Robb, Nigel",
title="Immersion Experiences in a Tablet-Based Markerless Augmented Reality Working Memory Game: Randomized Controlled Trial and User Experience Study",
journal="JMIR Serious Games",
year="2021",
month="Oct",
day="12",
volume="9",
number="4",
pages="e27036",
keywords="augmented reality",
keywords="markerless augmented reality",
keywords="immersion experience",
keywords="cognitive training games",
keywords="working memory",
keywords="markerless augmented reality n-back game",
abstract="Background: In recent years, augmented reality (AR), especially markerless augmented reality (MAR), has been used more prevalently to create training games in an attempt to improve humans' cognitive functions. This has been driven by studies claiming that MAR provides users with more immersive experiences that are situated in the real world. Currently, no studies have scientifically investigated the immersion experience of users in a MAR cognitive training game. Moreover, there is an observed lack of instruments on measuring immersion in MAR cognitive training games. Objective: This study, using two existing immersion questionnaires, investigates students' immersion experiences in a novel MAR n-back game. Methods: The n-back task is a continuous performance task that taps working memory (WM) capacity. We compared two versions of n-back training. One was presented in a traditional 2D format, while the second version used MAR. There were 2 experiments conducted in this study that coordinated with 2 types of immersion questionnaires: the modified Immersive Experiences Questionnaire (IEQ) and the Augmented Reality Immersion (ARI) questionnaire. Two groups of students from two universities in China joined the study, with 60 participants for the first experiment (a randomized controlled experiment) and 51 participants for the second. Results: Both groups of students experienced immersion in the MAR n-back game. However, the MAR n-back training group did not experience stronger immersion than the traditional (2D) n-back control group in the first experiment. The results of the second experiment showed that males felt deeply involved with the AR environment, which resulted in obtaining higher levels of immersion than females in the MAR n-back game. Conclusions: Both groups of students experienced immersion in the MAR n-back game. Moreover, both the modified IEQ and ARI have the potential to be used as instruments to measure immersion in MAR game settings. Trial Registration: UMIN Clinical Trials Registry UMIN000045314; https://upload.umin.ac.jp/cgi-open-bin/ctr\_e/ctr\_view.cgi?recptno=R000051725 ",
doi="10.2196/27036",
url="https://games.jmir.org/2021/4/e27036",
url="http://www.ncbi.nlm.nih.gov/pubmed/34636738"
}


@Article{info:doi/10.2196/22803,
author="Lukic, Xavier Yanick
and Klein, Shirin Shari
and Br{\"u}gger, Victoria
and Keller, Clare Olivia
and Fleisch, Elgar
and Kowatsch, Tobias",
title="The Impact of a Gameful Breathing Training Visualization on Intrinsic Experiential Value, Perceived Effectiveness, and Engagement Intentions: Between-Subject Online Experiment",
journal="JMIR Serious Games",
year="2021",
month="Sep",
day="14",
volume="9",
number="3",
pages="e22803",
keywords="breathing training",
keywords="serious game",
keywords="digital health",
keywords="mobile health",
keywords="mHealth",
keywords="mobile phone",
keywords="experiential value",
keywords="instrumental value",
keywords="online experiment",
abstract="Background: Slow-paced breathing has been shown to be positively associated with psychological and physiological health. In practice, however, there is little long-term engagement with breathing training, as shown by the usage statistics of breathing training apps. New research suggests that gameful smartphone-delivered breathing training may address this challenge. Objective: This study assesses the impact of breathing training, guided by a gameful visualization, on perceived experiential and instrumental values and the intention to engage in such training. Methods: A between-subject online experiment with 170 participants was conducted, and one-way multiple analysis of variance and two-tailed t test analyses were used to test for any difference in intrinsic experiential value, perceived effectiveness, and the intention to engage in either a breathing training with a gameful or a nongameful guidance visualization. Moreover, prior experience in gaming and meditation practices were assessed as moderator variables for a preliminary analysis. Results: The intrinsic experiential value for the gameful visualization was found to be significantly higher compared to the nongameful visualization (P=.001), but there was no difference in either perceived effectiveness (P=.50) or the intention to engage (P=.44). The preliminary analysis of the influence of meditation and gaming experience on the outcomes indicates that people with more meditation experience yielded higher intrinsic experiential values from using the gameful visualization than people with no or little meditation experience (P=.03). This analysis did not find any additional evidence of gaming time or meditation experience impacting the outcomes. Conclusions: The gameful visualization was found to increase the intrinsic experiential value of the breathing training without decreasing the perceived effectiveness. However, there were no differences in intentions to engage in both breathing training conditions. Furthermore, gaming and meditation experiences seem to have no or only a small positive moderating effect on the relationship between the gameful visualization and the intrinsic experiential value. Future longitudinal field studies are required to assess the impact of gameful breathing training on actual behavior, that is, long-term engagement and outcomes. ",
doi="10.2196/22803",
url="https://games.jmir.org/2021/3/e22803",
url="http://www.ncbi.nlm.nih.gov/pubmed/34519662"
}


@Article{info:doi/10.2196/30390,
author="Warsinsky, Simon
and Schmidt-Kraepelin, Manuel
and Rank, Sascha
and Thiebes, Scott
and Sunyaev, Ali",
title="Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="10",
volume="23",
number="9",
pages="e30390",
keywords="game-based interventions",
keywords="gamification",
keywords="serious games",
keywords="literature review",
keywords="reporting guidelines",
keywords="conceptual ambiguity",
abstract="Background: In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so. Objective: This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions. Methods: We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field. Results: Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions. Conclusions: Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions. ",
doi="10.2196/30390",
url="https://www.jmir.org/2021/9/e30390",
url="http://www.ncbi.nlm.nih.gov/pubmed/34505840"
}


@Article{info:doi/10.2196/26824,
author="Rodrigo-Yanguas, Maria
and Martin-Moratinos, Marina
and Menendez-Garcia, Angela
and Gonzalez-Tardon, Carlos
and Royuela, Ana
and Blasco-Fontecilla, Hilario",
title="A Virtual Reality Game (The Secret Trail of Moon) for Treating Attention-Deficit/Hyperactivity Disorder: Development and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Sep",
day="1",
volume="9",
number="3",
pages="e26824",
keywords="attention-deficit/hyperactivity disorder",
keywords="chess",
keywords="virtual reality",
keywords="serious video game",
keywords="psychotherapy",
keywords="cognitive training",
keywords="usability",
keywords="new technologies",
keywords="transfer",
keywords="randomized controlled trial",
abstract="Background: Attention-deficit/hyperactivity disorder (ADHD) affects between 4\% and 8\% of children worldwide. The treatment of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed for cognitive training related to core ADHD symptoms and executive dysfunction. Objective: We aimed to describe the development and usability of TSTM. Methods: The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion) of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation). Results: A total of 31/37 (86\%) and 30/37 (83\%) of participants liked playing TSTM and wanted to continue playing TSTM, respectively. Further, 5/37 (14\%) of participants reported that they experienced either perceived dizziness or virtual reality motion sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype and frequent video game players to infrequent video game players. Conclusions: Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD. Trial Registration: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065 ",
doi="10.2196/26824",
url="https://games.jmir.org/2021/3/e26824",
url="http://www.ncbi.nlm.nih.gov/pubmed/34468332"
}


@Article{info:doi/10.2196/26976,
author="Seol, Yoon Hye
and Kang, Soojin
and Lim, Jihyun
and Hong, Hwa Sung
and Moon, Joon Il",
title="Feasibility of Virtual Reality Audiological Testing: Prospective Study",
journal="JMIR Serious Games",
year="2021",
month="Aug",
day="31",
volume="9",
number="3",
pages="e26976",
keywords="hearing loss",
keywords="virtual reality",
keywords="speech performance",
keywords="real-world performance",
keywords="hearing",
keywords="audiology",
abstract="Background: It has been noted in the literature that there is a gap between clinical assessment and real-world performance. Real-world conversations entail visual and audio information, yet there are not any audiological assessment tools that include visual information. Virtual reality (VR) technology has been applied to various areas, including audiology. However, the use of VR in speech-in-noise perception has not yet been investigated. Objective: The purpose of this study was to investigate the impact of virtual space (VS) on speech performance and its feasibility to be used as a speech test instrument. We hypothesized that individuals' ability to recognize speech would improve when visual cues were provided. Methods: A total of 30 individuals with normal hearing and 25 individuals with hearing loss completed pure-tone audiometry and the Korean version of the Hearing in Noise Test (K-HINT) under three conditions---conventional K-HINT (cK-HINT), VS on PC (VSPC), and VS head-mounted display (VSHMD)---at --10 dB, --5 dB, 0 dB, and +5 dB signal-to-noise ratios (SNRs). Participants listened to target speech and repeated it back to the tester for all conditions. Hearing aid users in the hearing loss group completed testing under unaided and aided conditions. A questionnaire was administered after testing to gather subjective opinions on the headset, the VSHMD condition, and test preference. Results: Provision of visual information had a significant impact on speech performance between the normal hearing and hearing impaired groups. The Mann-Whitney U test showed statistical significance (P<.05) between the two groups under all test conditions. Hearing aid use led to better integration of audio and visual cues. Statistical significance through the Mann-Whitney U test was observed for --5 dB (P=.04) and 0 dB (P=.02) SNRs under the cK-HINT condition, as well as for --10 dB (P=.007) and 0 dB (P=.04) SNRs under the VSPC condition, between hearing aid and non--hearing aid users. Participants reported positive responses across almost all items on the questionnaire except for the weight of the headset.  Participants preferred a test method with visual imagery, but found the headset to be heavy. Conclusions: Findings are in line with previous literature that showed that visual cues were beneficial for communication. This is the first study to include hearing aid users with a more naturalistic stimulus and a relatively simple test environment, suggesting the feasibility of VR audiological testing in clinical practice. ",
doi="10.2196/26976",
url="https://games.jmir.org/2021/3/e26976",
url="http://www.ncbi.nlm.nih.gov/pubmed/34463624"
}


@Article{info:doi/10.2196/27884,
author="S{\'a}pi, Mariann
and Feh{\'e}r-Kiss, Anna
and Csern{\'a}k, Krisztina
and Domj{\'a}n, Andrea
and Pint{\'e}r, S{\'a}ndor",
title="The Effects of Exergaming on Sensory Reweighting and Mediolateral Stability of Women Aged Over 60: Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Jul",
day="21",
volume="9",
number="3",
pages="e27884",
keywords="exergaming",
keywords="sensory reweighting",
keywords="older women",
keywords="mediolateral sway",
keywords="vestibular",
abstract="Background: Older adults tend to experience difficulties in switching quickly between various reliable sensory inputs, which ultimately may contribute to an increased risk of falls and injuries. Sideward falls are the most frequent cause of hip fractures among older adults. Recently, exergame programs have been confirmed as beneficial tools for enhancing postural control, which can reduce the risk of falls. However, studies to explore more precisely which mechanism of exergaming directly influences older women's ability to balance are still needed. Objective: Our aim was to evaluate, in a single-group pretest/posttest/follow-up usability study, whether Kinect exergame balance training might have a beneficial impact on the sensory reweighting in women aged over 60. Methods: A total of 14 healthy women (mean age 69.57 [SD 4.66] years, mean body mass index 26.21 [SD 2.6] kg/m2) participated in the study. The volunteers trained with the commercially available games of Kinect for Xbox?360 console 3 times (30 minutes/session) a week over a 6-week period (total of 18 visits). Participants' postural sway in both the anteroposterior (AP) and mediolateral (ML) directions was recorded with NeuroCom Balance Master 6.0. To assess and measure postural sensory reweighting, the Modified Clinical Test of Sensory Interaction in Balance was used, where volunteers were exposed to various changes in visual (eyes open or eyes closed) and surface conditions (firm or foam surface). Results: In the ML direction, the Kinect exergame training caused a significant decrease in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P=.001), and on the foam surface with the eyes open (P=.001) and eyes closed (P<.001) conditions compared with baseline data. The follow-up measurements when compared with the baseline data showed a significant change in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P<.001) conditions, as well as on the foam surface with the eyes open (P=.003) and eyes closed (P<.001) conditions. Besides, on the firm surface, there were no significant differences in sway path values in the AP direction between the baseline and the posttraining measurements (eyes open: P=.49; eyes closed: P=.18). Likewise, on the foam surface, there were no significant differences in sway path values in the AP direction under both eyes open (P=.24) and eyes closed (P=.84) conditions. Conclusions: The improved posturography measurements of the sway path in the ML direction might suggest that the Kinect exergame balance training may have effects on sensory reweighting, and thus on the balance of women aged over 60. Based on these results, Kinect exergaming may provide a safe and potentially useful tool for improving postural stability in the crucial ML direction, and thus it may help reduce the risk of falling. ",
doi="10.2196/27884",
url="https://games.jmir.org/2021/3/e27884",
url="http://www.ncbi.nlm.nih.gov/pubmed/34287215"
}


@Article{info:doi/10.2196/28282,
author="Esmaeilzadeh, Pouyan",
title="The Influence of Gamification and Information Technology Identity on Postadoption Behaviors of Health and Fitness App Users: Empirical Study in the United States",
journal="JMIR Serious Games",
year="2021",
month="Jul",
day="5",
volume="9",
number="3",
pages="e28282",
keywords="gamification",
keywords="health and fitness apps",
keywords="IT identity",
keywords="continued intention to use",
keywords="information-sharing tendency",
keywords="mHealth",
keywords="app design",
keywords="user interaction",
abstract="Background: The use of health and fitness apps has been on the rise to monitor personal fitness and health parameters. However, recent research discovered that many users discontinue using these apps after only a few months. Gamification has been suggested as a technique to increase users' interactions with apps. Nevertheless, it is still not clear how gamification mechanisms encourage continued use and inspire user self-management. Objective: The main objective of this study was to articulate how gamification mechanisms in studies of designing and using health and fitness apps can contribute to the realization of information technology (IT) identity and positive behavioral outcomes. The broader goal was to shed light on how gamification mechanisms will translate into positive use behaviors in the context of mobile health apps. Methods: Data were collected from 364 users of health and fitness apps through an online survey to empirically examine the proposed model. Results: Based on identity theories, this study suggests the fully mediating role of IT identity to describe how gamification elements can lead to continued intention to use health and fitness apps, and increase users' tendency for information sharing through the apps. The findings indicate that perceived gamification can increase users' IT identity. In turn, a higher IT identity would encourage users to continue using the apps and share more personal health information with others through the apps. Conclusions: The results of this study can have practical implications for app designers to use gamification elements to increase users' dependency, relatedness, and emotional energy associated with health apps. Moreover, the findings can have theoretical contributions for researchers to help better articulate the process in which gamification can be translated into positive use behaviors. ",
doi="10.2196/28282",
url="https://games.jmir.org/2021/3/e28282/",
url="http://www.ncbi.nlm.nih.gov/pubmed/34812736"
}


@Article{info:doi/10.2196/29182,
author="Knobel, Johannes Samuel Elia
and Kaufmann, Charlotte Brigitte
and Gerber, Moreno Stephan
and Urwyler, Prabitha
and Cazzoli, Dario
and M{\"u}ri, M. Ren{\'e}
and Nef, Tobias
and Nyffeler, Thomas",
title="Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study",
journal="JMIR Serious Games",
year="2021",
month="Jul",
day="2",
volume="9",
number="3",
pages="e29182",
keywords="virtual reality",
keywords="serious game",
keywords="search task",
keywords="stroke",
keywords="neglect",
keywords="usability",
keywords="development",
keywords="immersion",
keywords="concept",
keywords="gaming",
abstract="Background: Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. Objective: This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. Methods: In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. Results: In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. Conclusions: The developed iVR serious game, ``bird search task,'' was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task. ",
doi="10.2196/29182",
url="https://games.jmir.org/2021/3/e29182",
url="http://www.ncbi.nlm.nih.gov/pubmed/34255653"
}


@Article{info:doi/10.2196/26820,
author="Brander, Mischa
and Egger, T. Stephan
and H{\"u}rlimann, Noa
and Seifritz, Erich
and Sumner, W. Robert
and Vetter, Stefan
and Magnenat, St{\'e}phane",
title="Virtual Reality Human--Human Interface to Deliver Psychotherapy to People Experiencing Auditory Verbal Hallucinations: Development and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Jun",
day="1",
volume="9",
number="2",
pages="e26820",
keywords="system usability",
keywords="virtual reality psychotherapy",
keywords="verbal auditory hallucinations",
abstract="Background: Digital technologies have expanded the options for delivering psychotherapy, permitting for example, the treatment of schizophrenia using Avatar Therapy. Despite its considerable potential, this treatment method has not been widely disseminated. As a result, its operability and functionality remain largely unknown. Objective: We aimed to study the usability of a therapeutic virtual reality human--human interface, created in a game engine. Methods: Participants were psychiatric hospital staff who were introduced to the therapeutic platform in a hands-on session. The System Usability Scale (SUS) was employed for evaluation purposes. Statistical evaluation was conducted using descriptive statistics, the chi-square test, analysis of variance, and multilevel factor analysis. Results: In total, 109 staff members were introduced to the therapeutic tool and completed the SUS. The mean SUS global score was 81.49 (SD 11.1). Psychotherapists (mean 86.44, SD 8.79) scored significantly higher (F2,106=6.136; P=.003) than nursing staff (mean 79.01, SD 13.30) and administrative personnel (mean 77.98, SD 10.72). A multilevel factor analysis demonstrates a different factor structure for each profession. Conclusions: In all professional groups in this study, the usability of a digital psychotherapeutic tool developed using a game engine achieved the benchmark for an excellent system, scoring highest among the professional target group (psychotherapists). The usability of the system seems, to some extent, to be dependent on the professional background of the user. It is possible to create and customize novel psychotherapeutic approaches with gaming technologies and platforms. Trial Registration: Clinicaltrials.gov NCT04099940; http://clinicaltrials.gov/ct2/show/NCT04099940 ",
doi="10.2196/26820",
url="https://games.jmir.org/2021/2/e26820",
url="http://www.ncbi.nlm.nih.gov/pubmed/33769295"
}


@Article{info:doi/10.2196/25997,
author="Yildirim, Oguzcan
and Surer, Elif",
title="Developing Adaptive Serious Games for Children With Specific Learning Difficulties: A Two-phase Usability and Technology Acceptance Study",
journal="JMIR Serious Games",
year="2021",
month="May",
day="31",
volume="9",
number="2",
pages="e25997",
keywords="serious games",
keywords="adaptive games",
keywords="specific learning difficulty",
keywords="usability",
keywords="system usability scale",
keywords="technology acceptance model",
keywords="training",
keywords="development",
keywords="adaptation",
keywords="gaming",
keywords="learning disability",
keywords="children",
keywords="education",
keywords="teacher",
abstract="Background: Specific learning difficulties (SpLD) include several disorders such as dyslexia, dyscalculia, and dysgraphia, and the children with these SpLD receive special education. However, the studies and the educational material so far focus mainly on one specific disorder. Objective: This study's primary goal is to develop comprehensive training material for different types of SpLD, with five serious games addressing different aspects of the SpLD. The second focus is measuring the impact of adaptive difficulty level adjustment in the children's and their educators' usability and technology acceptance perception. Receiving feedback from the children and their educators, and refining the games according to their suggestions have also been essential in this two-phase study. Methods: A total of 10 SpLD educators and 23 children with different types of SpLD tested the prototypes of the five serious games (ie, Word game, Memory game, Category game, Space game, and Math game), gave detailed feedback, answered the System Usability Scale and Technology Acceptance Model (TAM) questionnaires, and applied think-aloud protocols during game play. Results: The games' standard and adaptive versions were analyzed in terms of average playtime and the number of false answers. Detailed analyses of the interviews, with word clouds and player performances, were also provided. The TAM questionnaires' average and mean values and box plots of each data acquisition session for the children and the educators were also reported via System Usability Scale and TAM questionnaires. The TAM results of the educators had an average of 8.41 (SD 0.87) out of 10 in the first interview and an average of 8.71 (SD 0.64) out of 10 in the second interview. The children had an average of 9.07 (SD 0.56) out of 10 in the first interview. Conclusions: Both the educators and the children with SpLD enjoyed playing the games, gave positive feedback, and suggested new ways for improvement. The results showed that these games provide thorough training material for different types of SpLD with personalized and tailored difficulty systems. The final version of the proposed games will become a part of the special education centers' supplementary curriculum and training materials, making new enhancements and improvements possible in the future. ",
doi="10.2196/25997",
url="https://games.jmir.org/2021/2/e25997",
url="http://www.ncbi.nlm.nih.gov/pubmed/34057415"
}


@Article{info:doi/10.2196/25771,
author="Darzi, Ali
and McCrea, M. Sean
and Novak, Domen",
title="User Experience With Dynamic Difficulty Adjustment Methods for an Affective Exergame: Comparative Laboratory-Based Study",
journal="JMIR Serious Games",
year="2021",
month="May",
day="31",
volume="9",
number="2",
pages="e25771",
keywords="affective computing",
keywords="dynamic difficulty adaptation",
keywords="exergames",
keywords="physiological measurements",
keywords="task performance",
keywords="personality characteristics",
keywords="psychophysiology",
abstract="Background: In affective exergames, game difficulty is dynamically adjusted to match the user's physical and psychological state. Such an adjustment is commonly made based on a combination of performance measures (eg, in-game scores) and physiological measurements, which provide insight into the player's psychological state. However, although many prototypes of affective games have been presented and many studies have shown that physiological measurements allow more accurate classification of the player's psychological state than performance measures, few studies have examined whether dynamic difficulty adjustment (DDA) based on physiological measurements (which requires additional sensors) results in a better user experience than performance-based DDA or manual difficulty adjustment. Objective: This study aims to compare five DDA methods in an affective exergame: manual (player-controlled), random, performance-based, personality-performance--based, and physiology-personality-performance--based (all-data). Methods: A total of 50 participants (N=50) were divided into five groups, corresponding to the five DDA methods. They played an exergame version of Pong for 18 minutes, starting at a medium difficulty; every 2 minutes, two game difficulty parameters (ball speed and paddle size) were adjusted using the participant's assigned DDA method. The DDA rules for the performance-based, personality-performance--based, and all-data groups were developed based on data from a previous open-loop study. Seven physiological responses were recorded throughout the sessions, and participants self-reported their preferred changes to difficulty every 2 minutes. After playing the game, participants reported their in-game experience using two questionnaires: the Intrinsic Motivation Inventory and the Flow Experience Measure. Results: Although the all-data method resulted in the most accurate changes to ball speed and paddle size (defined as the percentage match between DDA choice and participants' preference), no significant differences between DDA methods were found on the Intrinsic Motivation Inventory and Flow Experience Measure. When the data from all four automated DDA methods were pooled together, the accuracy of changes in ball speed was significantly correlated with players' enjoyment (r=0.38) and pressure (r=0.43). Conclusions: Although our study is limited by the use of a between-subjects design and may not generalize to other exergame designs, the results do not currently support the inclusion of physiological measurements in affective exergames, as they did not result in an improved user experience. As the accuracy of difficulty changes is correlated with user experience, the results support the development of more effective DDA methods. However, they show that the inclusion of physiological measurements does not guarantee a better user experience even if it yields promising results in offline cross-validation. ",
doi="10.2196/25771",
url="https://games.jmir.org/2021/2/e25771",
url="http://www.ncbi.nlm.nih.gov/pubmed/34057423"
}


@Article{info:doi/10.2196/24449,
author="Lee, Seyeon
and Oh, Hyunyoung
and Shi, Chung-Kon
and Doh, Yim Young",
title="Mobile Game Design Guide to Improve Gaming Experience for the Middle-Aged and Older Adult Population: User-Centered Design Approach",
journal="JMIR Serious Games",
year="2021",
month="May",
day="20",
volume="9",
number="2",
pages="e24449",
keywords="mobile games",
keywords="older adults",
keywords="middle-aged adults",
keywords="design guideline",
keywords="gaming experience",
abstract="Background: The number of older adult gamers who play mobile games is growing worldwide. Earlier studies have reported that digital games provide cognitive, physical, and socioemotional benefits for older adults. However, current mobile games that understand older adults' gameplay experience and reflect their needs are very scarce. Furthermore, studies that have analyzed older adults' game experience in a holistic manner are rare. Objective: The purpose of this study was to suggest mobile game design guidelines for adults older than 50 years from a holistic gaming experience perspective. Adopting a human-centric approach, this study analyzes middle-aged and older adults' gameplay experience and suggests practical design guides to increase accessibility and satisfaction. Methods: We organized a living laboratory project called the ``Intergenerational Play Workshop.'' In this workshop, 40 middle-aged and older adults (mean age 66.75 years, age range 50-85 years) played commercial mobile games of various genres with young adult partners for 1 month (8 sessions). Using a convergent parallel mixed-method design, we conducted a qualitative analysis of dialogue, game diaries, and behavioral observations during the workshop and a quantitative analysis of the satisfaction level of the game elements for the mobile games that they played. Results: This project was active from April 2019 to December 2021, and the data were collected at the workshops from July 1 to August 28, 2019. Based on the identified themes of positive and negative experiences from the qualitative data, we proposed 45 design guides under 3 categories: (1) cognitive and physical elements, (2) psychological and socioemotional elements, and (3) consumption contextual elements. Our empirical research could reaffirm the proposals from previous studies and provide new guidelines for improving the game design. In addition, we demonstrate how existing commercial games can be evaluated quantitatively by using the satisfaction level of each game's elements and overall satisfaction level. Conclusions: The final guidelines were presented to game designers to easily find related information and enhance the overall understanding of the game experience of middle-aged and older adults. ",
doi="10.2196/24449",
url="https://games.jmir.org/2021/2/e24449",
url="http://www.ncbi.nlm.nih.gov/pubmed/34014175"
}


@Article{info:doi/10.2196/14746,
author="Park, Sungjin
and Kim, Sangkyun",
title="Leaderboard Design Principles to Enhance Learning and Motivation in a Gamified Educational Environment: Development Study",
journal="JMIR Serious Games",
year="2021",
month="Apr",
day="20",
volume="9",
number="2",
pages="e14746",
keywords="leaderboard design",
keywords="gamification",
keywords="learning motivation",
keywords="affordance",
abstract="Background: Gamification in education enhances learners' motivation, problem-solving abilities, decision-making abilities, and social skills such as communication. Numerous ongoing studies are examining the application of gamification design methodology and game mechanics to a learning environment. Leaderboards are a type of game mechanic that assist learners in goal setting and unleash the motivation for learning. Objective: The aim of this study was to develop leaderboard design principles to assist learners in efficient goal setting, improve learning motivation, and promote learning in gamified learning environments. Methods: This study implemented 2 different strategies. First, we analyzed previous research on leaderboards that focus on educational efficacy and influence on social interactions. Second, we collected and analyzed data related to cases of leaderboards being used in educational and sport environments. Results: This study determined 4 leaderboard design objectives from previous studies. Based on these objectives, we developed 3 leaderboard design principles. First, macro leaderboards and micro leaderboards should be designed and used together. Second, all the elements used to measure learners' achievements in an educational environment should be incorporated into the micro leaderboard. Third, leaderboards should be designed and considered for application in contexts other than learning environments. This study further analyzes best practices considering the 3 leaderboard design principles. Conclusions: This study contributes toward resolving problems associated with leaderboard design for the application of gamification in educational environments. Based upon our results, we strongly suggest that when teachers consider applying gamification in classrooms, the leaderboard design principles suggested in this research should be incorporated. ",
doi="10.2196/14746",
url="https://games.jmir.org/2021/2/e14746",
url="http://www.ncbi.nlm.nih.gov/pubmed/33877049"
}


@Article{info:doi/10.2196/24998,
author="Langlet, Sundstr{\"o}m Billy
and Odegi, Dorothy
and Zandian, Modjtaba
and Nolstam, Jenny
and S{\"o}dersten, Per
and Bergh, Cecilia",
title="Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Apr",
day="13",
volume="9",
number="2",
pages="e24998",
keywords="feeding and eating disorders",
keywords="anorexia nervosa",
keywords="bulimia nervosa",
keywords="binge eating disorder",
keywords="immersive virtual reality",
keywords="eating disorders",
keywords="virtual reality",
abstract="Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50\%, a dropout rate from 20\% to 50\%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall ``good'' rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the ``accuracy'' item. During the cognitive walkthrough, 32\% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. ",
doi="10.2196/24998",
url="https://games.jmir.org/2021/2/e24998",
url="http://www.ncbi.nlm.nih.gov/pubmed/33847593"
}


@Article{info:doi/10.2196/23710,
author="Garske, Alexander Christian
and Dyson, Matthew
and Dupan, Sigrid
and Nazarpour, Kianoush",
title="Perception of Game-Based Rehabilitation in Upper Limb Prosthetic Training: Survey of Users and Researchers",
journal="JMIR Serious Games",
year="2021",
month="Feb",
day="1",
volume="9",
number="1",
pages="e23710",
keywords="upper limb",
keywords="rehabilitation",
keywords="arm prosthesis",
keywords="serious games",
keywords="engagement",
keywords="transfer",
abstract="Background: Serious games have been investigated for their use in multiple forms of rehabilitation for decades. The rising trend to use games for physical fitness in more recent years has also provided more options and garnered more interest for their use in physical rehabilitation and motor learning. In this study, we report the results of an opinion survey of serious games in upper limb prosthetic training. Objective: This study investigates and contrasts the expectations and preferences for game-based prosthetic rehabilitation of people with limb difference and researchers. Methods: Both participant groups answered open and closed questions as well as a questionnaire to assess their user types. The distribution of the user types was compared with a Pearson chi-square test against a sample population. The data were analyzed using the thematic framework method; answers fell within the themes of usability, training, and game design. Researchers shared their views on current challenges and what could be done to tackle these. Results: A total of 14 people with limb difference and 12 researchers participated in this survey. The open questions resulted in an overview of the different views on prosthetic training games between the groups. The user types of people with limb difference and researchers were both significantly different from the sample population, with $\chi$25=12.3 and $\chi$25=26.5, respectively. Conclusions: We found that the respondents not only showed a general willingness and tentative optimism toward the topic but also acknowledged hurdles limiting the adoption of these games by both clinics and users. The results indicate a noteworthy difference between researchers and people with limb difference in their game preferences, which could lead to design choices that do not represent the target audience. Furthermore, focus on long-term in-home experiments is expected to shed more light on the validity of games in upper limb prosthetic rehabilitation. ",
doi="10.2196/23710",
url="http://games.jmir.org/2021/1/e23710/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33522975"
}


@Article{info:doi/10.2196/18153,
author="Zhang, Timothy
and Booth, Richard
and Jean-Louis, Royce
and Chan, Ryan
and Yeung, Anthony
and Gratzer, David
and Strudwick, Gillian",
title="A Primer on Usability Assessment Approaches for Health-Related Applications of Virtual Reality",
journal="JMIR Serious Games",
year="2020",
month="Oct",
day="28",
volume="8",
number="4",
pages="e18153",
keywords="virtual reality",
keywords="simulated environment",
keywords="usability",
keywords="evaluation",
keywords="assessment methods",
keywords="medical informatics",
keywords="nursing informatics",
doi="10.2196/18153",
url="http://games.jmir.org/2020/4/e18153/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33112243"
}


@Article{info:doi/10.2196/18127,
author="Yun, Jung Seo
and Kang, Min-Gu
and Yang, Dongseok
and Choi, Younggeun
and Kim, Heejae
and Oh, Byung-Mo
and Seo, Gil Han",
title="Cognitive Training Using Fully Immersive, Enriched Environment Virtual Reality for Patients With Mild Cognitive Impairment and Mild Dementia: Feasibility and Usability Study",
journal="JMIR Serious Games",
year="2020",
month="Oct",
day="14",
volume="8",
number="4",
pages="e18127",
keywords="mild cognitive impairment",
keywords="dementia",
keywords="virtual reality",
keywords="enriched environment",
abstract="Background: Cognitive training using virtual reality (VR) may result in motivational and playful training for patients with mild cognitive impairment and mild dementia. Fully immersive VR sets patients free from external interference and thus encourages patients with cognitive impairment to maintain selective attention. The enriched environment, which refers to a rich and stimulating environment, has a positive effect on cognitive function and mood. Objective: The aim of this study was to investigate the feasibility and usability of cognitive training using fully immersive VR programs in enriched environments with physiatrists, occupational therapists (OTs), and patients with mild cognitive impairment and mild dementia. Methods: The VR interface system consisted of a commercialized head-mounted display and a custom-made hand motion tracking module. We developed the virtual harvest and cook programs in enriched environments representing rural scenery. Physiatrists, OTs, and patients with mild cognitive impairment and mild dementia received 30 minutes of VR training to evaluate the feasibility and usability of the test for cognitive training. At the end of the test, the usability and feasibility were assessed by a self-report questionnaire based on a 7-point Likert-type scale. Response time and finger tapping were measured in patients before and after the test. Results: Participants included 10 physiatrists, 6 OTs, and 11 patients with mild cognitive impairment and mild dementia. The mean scores for overall satisfaction with the program were 5.75 (SD 1.00) for rehabilitation specialists and 5.64 (SD 1.43) for patients. The response time of the dominant hand in patients decreased after the single session of cognitive training using VR, but this was not statistically significant (P=.25). There was no significant change in finger tapping in either the right or left hand (P=.48 and P=.42, respectively). None of the participants reported headaches, dizziness, or any other motion sickness after the test. Conclusions: A fully immersive VR cognitive training program may be feasible and usable in patients with mild cognitive impairment and mild dementia based on the positive satisfaction and willingness to use the program reported by physiatrists, OTs, and patients. Although not statistically significant, decreased response time without a change in finger tapping rate may reflect a temporary increase in attention after the test. Additional clinical trials are needed to investigate the effect on cognitive function, mood, and physical outcomes. ",
doi="10.2196/18127",
url="http://games.jmir.org/2020/4/e18127/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33052115"
}


@Article{info:doi/10.2196/18822,
author="Lerner, Dieter
and Mohr, Stefan
and Schild, Jonas
and G{\"o}ring, Martin
and Luiz, Thomas",
title="An Immersive Multi-User Virtual Reality for Emergency Simulation Training: Usability Study",
journal="JMIR Serious Games",
year="2020",
month="Jul",
day="31",
volume="8",
number="3",
pages="e18822",
keywords="virtual reality",
keywords="educational virtual realities",
keywords="virtual patient simulation",
keywords="virtual emergency scenario",
keywords="simulation training",
keywords="head-mounted display",
keywords="immersive media",
keywords="training effectiveness",
keywords="presence experience",
keywords="anaphylaxis",
keywords="emergency medicine",
abstract="Background: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. Objective: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. Methods: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. Results: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. Conclusions: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through ``experience of presence'' or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training. ",
doi="10.2196/18822",
url="https://games.jmir.org/2020/3/e18822",
url="http://www.ncbi.nlm.nih.gov/pubmed/32735548"
}






@Article{info:doi/10.2196/14342,
author="Park, Sungjin
and Kim, Sangkyun",
title="A Badge Design Framework for a Gamified Learning Environment: Cases Analysis and Literature Review for Badge Design",
journal="JMIR Serious Games",
year="2019",
month="May",
day="29",
volume="7",
number="2",
pages="e14342",
keywords="badge design framework",
keywords="educational badge",
keywords="digital badge",
keywords="badge types",
keywords="gamified learning environment",
abstract="Background: In the past, the educational badge was an extrinsic means of rewarding the motivation to learn. Based on continued research, however, the badge began to be recognized as a scale to measure the learner's knowledge and skill and an important means of helping learners to gradually build intrinsic motivation by using certain extrinsic motivators. As the badge's value has grown, the importance of its design has garnered attention. Objective: The objective of this research was to establish a badge design framework that can be used in a gamified learning environment. Methods: Data were collected from previous studies on badge design, 943 badge cases were extracted from 11 online and offline gamification in education contents, and their patterns and features were analyzed. Results: Based on the analysis of results from previous studies and 943 collected badge cases, our study suggests three conditions for badge design. Through the literature review and collected badge cases, our study designed a badge design framework. First, it is necessary to distinguish whether the type of learning activity required for earning badges is physical or conceptual. Second, it is necessary to distinguish whether the scale of an activity required for earning badges requires individual learning or interaction-induced learning. Third, it is important to review whether the time and effort invested in earning badges is simple, repetitive, and short-term or continuous and long-term. Based on these three conditions, collected badge cases were analyzed. To verify self-developed badge types, we conducted a chi-square test on the collected cases and confirmed that there was a significant difference for each of the eight badge types (Pearson chi-square 1117.7, P<.001). Conclusions: Through its literature review on previous studies, this study demonstrated the badge's educational effectiveness. The badge design framework suggested in our study is expected to resolve some of the difficulties experienced during the badge design process in a gamified learning environment, encourage efficient badge design, and maximize learning effect. ",
doi="10.2196/14342",
url="http://games.jmir.org/2019/2/e14342/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31144664"
}




@Article{info:doi/10.2196/publichealth.8923,
author="Hightow-Weidman, Lisa
and Muessig, Kathryn
and Knudtson, Kelly
and Srivatsa, Mala
and Lawrence, Ellena
and LeGrand, Sara
and Hotten, Anna
and Hosek, Sybil",
title="A Gamified Smartphone App to Support Engagement in Care and Medication Adherence for HIV-Positive Young Men Who Have Sex With Men (AllyQuest): Development and Pilot Study",
journal="JMIR Public Health Surveill",
year="2018",
month="Apr",
day="30",
volume="4",
number="2",
pages="e34",
keywords="YMSM",
keywords="antiretroviral adherence",
keywords="smartphone app",
keywords="gamification",
keywords="social networking",
abstract="Background: HIV disproportionately impacts young men who have sex with men (YMSM) who experience disparities across the HIV care continuum. Addressing antiretroviral therapy (ART) adherence among YMSM is an urgent public health priority. Technology-based interventions---particularly mobile health platforms---can provide tailored adherence interventions and allow YMSM to engage and connect with others. Objective: The objective of this study was to describe the development of AllyQuest, a novel, theoretically-based, smartphone app designed to improve engagement in care and ART adherence and social support among HIV-positive YMSM. Methods: AllyQuest was built on an established platform for patient engagement that embeds social networking and fundamental game mechanics, such as challenges, points, and rewards. A medication tracker provides reminders to promote ART adherence via personalized adherence strategies that are user and context specific; a calendar allows for reflection on adherence over time. After iterative development with input from two youth advisory boards, usability testing was conducted to assess app functionality, comprehension of the educational content, use of intervention features, and overall impressions of app relevance and appeal. A 28-day pilot trial was conducted with 20 HIV+ YMSM to evaluate intervention feasibility and acceptability. Results: Mean age of participants was 21.8 years (range 19-24), and 95\% (19/20) of the participants were nonwhite. The mean time of app use was 158.4 min (SD 114.1), with a range of 13 to 441 min. There was a mean of 21.2 days of use (out of a total possible 28 days). There were 222 posts to the daily discussion social wall. Feasibility and acceptability ratings were high. Overall, participants found the app easy to use and navigate, not intrusive, and had few reported technical issues. Higher levels of app usage were positively correlated with HIV self-management outcomes, and there was a statistically significant (P<.05) positive association between the number of days logged into the app and knowledge and confidence in ability to reliably take HIV medications. Conclusions: AllyQuest represents a new, highly scalable solution that is well-suited to meet the specific prevention and care needs of HIV+ YMSM. The development of this intervention is both timely and vital, given the urgency of the ongoing HIV epidemic among YMSM. ",
doi="10.2196/publichealth.8923",
url="http://publichealth.jmir.org/2018/2/e34/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29712626"
}


@Article{info:doi/10.2196/rehab.8003,
author="Thirumalai, Mohanraj
and Kirkland, B. William
and Misko, R. Samuel
and Padalabalanarayanan, Sangeetha
and Malone, A. Laurie",
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",
keywords="video games",
keywords="active video gaming",
keywords="Wii Fit",
keywords="equipment design",
keywords="physical activity",
keywords="exercise",
keywords="wheelchairs",
keywords="physical disability",
keywords="rehabilitation",
keywords="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="http://www.ncbi.nlm.nih.gov/pubmed/29510972"
}


@Article{info:doi/10.2196/mhealth.9437,
author="Giunti, Guido
and Mylonopoulou, Vasiliki
and Rivera Romero, Octavio",
title="More Stamina, a Gamified mHealth Solution for Persons with Multiple Sclerosis: Research Through Design",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Mar",
day="02",
volume="6",
number="3",
pages="e51",
keywords="multiple sclerosis",
keywords="telemedicine",
keywords="fatigue",
keywords="mobile applications",
keywords="video games",
keywords="qualitative research",
keywords="exercise",
keywords="chronic disease",
keywords="user-computer interface",
keywords="software design",
abstract="Background: Multiple sclerosis (MS) is one of the world's most common neurologic disorders. Fatigue is one of most common symptoms that persons with MS experience, having significant impact on their quality of life and limiting their activity levels. Self-management strategies are used to support them in the care of their health. Mobile health (mHealth) solutions are a way to offer persons with chronic conditions tools to successfully manage their symptoms and problems. Gamification is a current trend among mHealth apps used to create engaging user experiences and is suggested to be effective for behavioral change. To be effective, mHealth solutions need to be designed to specifically meet the intended audience needs. User-centered design (UCD) is a design philosophy that proposes placing end users' needs and characteristics in the center of design and development, involving users early in the different phases of the software life cycle. There is a current gap in mHealth apps for persons with MS, which presents an interesting area to explore. Objective: The purpose of this study was to describe the design and evaluation process of a gamified mHealth solution for behavioral change in persons with MS using UCD. Methods: Building on previous work of our team where we identified needs, barriers, and facilitators for mHealth apps for persons with MS, we followed UCD to design and evaluate a mobile app prototype aimed to help persons with MS self-manage their fatigue. Design decisions were evidence-driven and guided by behavioral change models (BCM). Usability was assessed through inspection methods using Nielsen's heuristic evaluation. Results: The mHealth solution More Stamina was designed. It is a task organization tool designed to help persons with MS manage their energy to minimize the impact of fatigue in their day-to-day life. The tool acts as a to-do list where users can input tasks in a simple manner and assign Stamina Credits, a representation of perceived effort, to the task to help energy management and energy profiling. The app also features personalization and positive feedback. The design process gave way to relevant lessons to the design of a gamified behavioral change mHealth app such as the importance of metaphors in concept design, negotiate requirements with the BCM constructs, and tailoring of gamified experiences among others. Several usability problems were discovered during heuristic evaluation and guided the iterative design of our solution. Conclusions: In this paper, we designed an app targeted for helping persons with MS in their fatigue management needs. We illustrate how UCD can help in designing mHealth apps and the benefits and challenges that designers might face when using this approach. This paper provides insight into the design process of gamified behavioral change mHealth apps and the negotiation process implied in it. ",
doi="10.2196/mhealth.9437",
url="http://mhealth.jmir.org/2018/3/e51/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29500159"
}


@Article{info:doi/10.2196/jmir.8473,
author="Lumsden, Jim
and Skinner, Andy
and Coyle, David
and Lawrence, Natalia
and Munafo, Marcus",
title="Attrition from Web-Based Cognitive Testing: A Repeated Measures Comparison of Gamification Techniques",
journal="J Med Internet Res",
year="2017",
month="Nov",
day="22",
volume="19",
number="11",
pages="e395",
keywords="behavioral research/methods",
keywords="games, experimental",
keywords="computers",
keywords="cognition",
keywords="Internet",
keywords="play and playthings/psychology",
keywords="boredom",
keywords="task performance and analysis",
keywords="executive function",
keywords="inhibition (psychology)",
abstract="Background: The prospect of assessing cognition longitudinally and remotely is attractive to researchers, health practitioners, and pharmaceutical companies alike. However, such repeated testing regimes place a considerable burden on participants, and with cognitive tasks typically being regarded as effortful and unengaging, these studies may experience high levels of participant attrition. One potential solution is to gamify these tasks to make them more engaging: increasing participant willingness to take part and reducing attrition. However, such an approach must balance task validity with the introduction of entertaining gamelike elements. Objective: This study aims to investigate the effects of gamelike features on participant attrition using a between-subjects, longitudinal Web-based testing study. Methods: We used three variants of a common cognitive task, the Stop Signal Task (SST), with a single gamelike feature in each: one variant where points were rewarded for performing optimally; another where the task was given a graphical theme; and a third variant, which was a standard SST and served as a control condition. Participants completed four compulsory test sessions over 4 consecutive days before entering a 6-day voluntary testing period where they faced a daily decision to either drop out or continue taking part. Participants were paid for each session they completed. Results: A total of 482 participants signed up to take part in the study, with 265 completing the requisite four consecutive test sessions. No evidence of an effect of gamification on attrition was observed. A log-rank test showed no evidence of a difference in dropout rates between task variants ($\chi$22=3.0, P=.22), and a one-way analysis of variance of the mean number of sessions completed per participant in each variant also showed no evidence of a difference (F2,262=1.534, P=.21, partial $\eta$2=0.012). Conclusions: Our findings raise doubts about the ability of gamification to reduce attrition from longitudinal cognitive testing studies. ",
doi="10.2196/jmir.8473",
url="http://www.jmir.org/2017/11/e395/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29167090"
}


@Article{info:doi/10.2196/games.7969,
author="Ling, Yun
and Ter Meer, P. Louis
and Yumak, Zerrin
and Veltkamp, C. Remco",
title="Usability Test of Exercise Games Designed for Rehabilitation of Elderly Patients After Hip Replacement Surgery: Pilot Study",
journal="JMIR Serious Games",
year="2017",
month="Oct",
day="12",
volume="5",
number="4",
pages="e19",
keywords="rehabilitation exercise",
keywords="computer games",
keywords="hip replacement",
keywords="elderly",
keywords="physical therapists",
abstract="Background: Patients who receive rehabilitation after hip replacement surgery are shown to have increased muscle strength and better functional performance. However, traditional physiotherapy is often tedious and leads to poor adherence. Exercise games, provide ways for increasing the engagement of elderly patients and increase the uptake of rehabilitation exercises. Objective: The objective of this study was to evaluate Fietsgame (Dutch for cycling game), which translates existing rehabilitation exercises into fun exercise games. The system connects exercise games with a patient's personal record and a therapist interface by an Internet of Things server. Thus, both the patient and physiotherapist can monitor the patient's medical status. Methods: This paper describes a pilot study that evaluates the usability of the Fietsgame. The study was conducted in a rehabilitation center with 9 participants, including 2 physiotherapists and 7 patients. The patients were asked to play 6 exercise games, each lasting about 5 min, under the guidance of a physiotherapist. The mean age of the patients was 74.57 years (standard deviation [SD] 8.28); all the patients were in the recovery process after hip surgery. Surveys were developed to quantitatively measure the usability factors, including presence, enjoyment, pain, exertion, and technology acceptance. Comments on advantages and suggested improvements of our game system provided by the physiotherapists and patients were summarized and their implications were discussed. Results: The results showed that after successfully playing the games, 75\% to 100\% of the patients experienced high levels of enjoyment in all the games except the squats game. Patients reported the highest level of exertion in squats when compared with other exercise games. Lunges resulted in the highest dropout rate (43\%) due to interference with the Kinect v2 from support chairs. All the patients (100\%) found the game system useful and easy to use, felt that it would be a useful tool in their further rehabilitation, and expressed that they would like to use the game in the future. The therapists indicated that the exercise games highly meet the criteria of motor rehabilitation, and they intend to continue using the game as part of their rehabilitation treatment of patients. Comments from the patients and physiotherapists suggest that real-time corrective feedback when patients perform the exercises wrongly and a more personalized user interface with options for increasing or decreasing cognitive load are needed. Conclusions: The results suggest that Fietsgame can be used as an alternative tool to traditional motor rehabilitation for patients with hip surgery. Lunges and squats are found to be more beneficial for patients who have relatively better balance skills. A follow-up randomized controlled study will be conducted to test the effectiveness of the Fietsgame to investigate how motivating it is over a longer period of time. ",
doi="10.2196/games.7969",
url="http://games.jmir.org/2017/4/e19/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29025696"
}