%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 1 %P e10902 %T A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized Controlled Trial %A Dunn,Amy %A Patterson,Jeremy %A Biega,Charmaine F %A Grishchenko,Alice %A Luna,John %A Stanek,Joseph R %A Strouse,Robert %+ Nationwide Children's Hospital, Division of Hematology, Oncology and BMT, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, United States, 1 614 722 3564, amy.dunn@nationwidechildrens.org %K anxiety %K distraction %K hemophilia %K intravenous %K mobile phone %K needle %K pediatric %K virtual reality %D 2019 %7 09.01.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use. Objective: We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care. Methods: We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child’s hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used. Results: Of the 25 enrolled children, 24 were included in the primary analysis. No safety concerns or VR sickness occurred. The median procedure time was 10 (range 1-31) minutes in the VR group and was comparable to 9 (range 3-20) minutes in the SOC group (P=.76). Patients in both the groups reported a positive influence of distraction on procedural anxiety and pain. Overall, in 80% (34/45) of the VR evaluations, children, caregivers, and nurses reported that they would like to use VR for future procedures. Conclusions: We demonstrated that an orchestrated, VR environment could be developed and safely used during pediatric hemophilia care for distraction during IV interventions. This platform has the potential to improve patient experience during medical procedures. Trial Registration: Clinical Trials.gov NCT03507582; https://clinicaltrials.gov/ct2/show/NCT03507582 (Archived by WebCite at http://www.webcitation.org/73G75upA3) %M 30626567 %R 10.2196/10902 %U https://games.jmir.org/2019/1/e10902/ %U https://doi.org/10.2196/10902 %U http://www.ncbi.nlm.nih.gov/pubmed/30626567 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12456 %T A Virtual Reality Food Court to Study Meal Choices in Youth: Design and Assessment of Usability %A Allman-Farinelli,Margaret %A Ijaz,Kiran %A Tran,Helen %A Pallotta,Hermes %A Ramos,Sidney %A Liu,Junya %A Wellard-Cole,Lyndal %A Calvo,Rafael A %+ Charles Perkins Centre, School of Life and Environmental Sciences, University of Sydney, Building D17, NSW, 2006, Australia, 61 0290367045, margaret.allmanfarinelli@sydney.edu.au %K virtual reality %K nutrition promotion %K food policy %K take-out food %K obesity %K young adults %D 2019 %7 09.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Regular consumption of take-out and fast foods with sugary drinks is associated with poor quality diets and higher prevalence of obesity. Among the settings where such food is consumed is the food court typically found in shopping malls prominent in many countries. Objective: The objective of this research was to develop a virtual reality food court that could be used to test food environmental interventions, such as taxation, and ultimately to facilitate the selection of healthier food choices. Methods: Fourteen food courts in Sydney, Australia were selected to include those in the city center and suburbs of high and low socioeconomic status. Researchers visited the courts to collect information on number and type of food outlets, all menu items for sale, cost of foods and beverages and sales promotions. This information was used to assemble 14 food outlets typically found in food courts, and representative menus were compiled. The UNITY gaming platform was used to design a virtual reality food court that could be used with HTC VIVE goggles. Participants navigated the virtual reality food court using the head-mounted display, keyboard, and mouse and selected a lunch meal, including food and beverage. A validated questionnaire on presence within the virtual reality food court and system usability was completed at the end of the session. The constructs for presence included a sense of control, sensory fidelity, realism, distraction, and involvement. Questions were rated on a scale from 1 (worst) through 7 (best) for each of 28 questions giving a maximum total score of 196. The systems usability scale (SUS) that gives a final score out of 100 was also assessed. Results: One hundred and sixty-two participants with a mean age of 22.5 (SD 3.1) years completed the survey. The mean score for total presence was 144 (SE 1.4) consisting of control: 62.1 (SE 0.8), realism: 17.5 (SE 0.2), involvement: 9.6 (SE 0.2), sensory fidelity: 34.9 (SE 0.4), and distraction: 24.0 (SE 0.3). The mean SUS was 69 (SE 1.1). Conclusions: Virtual reality shows promise as a tool to study food choice for test interventions to inform practice and policy. %R 10.2196/12456 %U http://formative.jmir.org/2019/1/e12456/ %U https://doi.org/10.2196/12456 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10133 %T Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions Through Avatar Customization: Crowdsourced Quasi-Experimental Study %A Birk,Max Valentin %A Mandryk,Regan Lee %+ University of Saskatchewan, Department of Computer Science, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 3069662327, max.birk@usask.ca %K cognitive therapy %K computer-assisted therapy %K video games %K attentional bias %K cognitive bias %K motivation %D 2019 %7 08.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The success of internet-based mental health interventions in practice—that is, in the wild—depends on the uptake and retention of the application and the user’s focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in the wild has been shown to increase uptake and retention in internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use and the effect on intervention efficacy. Objective: Designers of internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve digital interventions. The aim of this study was to investigate the effects of 1 motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification). Methods: We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state anxiety (State-Trait Anxiety Inventory), we randomly assigned half of the participants in each condition to either an attentional retraining condition (Attention Bias Modification Training) or a control condition. After training, participants were exposed to a negative mood induction using images with strong negative valance (International Affective Picture System), after which we measured state anxiety again. Results: Avatar customization decreased posttraining state anxiety when controlling for baseline state anxiety for those in the attentional retraining condition; however, those who did not train experienced decreased resilience to the negative mood induction (F1,252=6.86, P=.009, ηp2=.027). This interaction effect suggests that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F5,252=12.46, P<.001, R2=.23), regardless of condition (F1,252=.79, P=.38). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training but increased poststimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F1,252=6.19, P=.01). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F10,248=18.5, P<.001, R2=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health. Conclusions: Our results suggest that applying motivational design—specifically avatar customization—is a viable strategy to increase engagement and subsequently training efficacy in a computerized cognitive task. %M 30622095 %R 10.2196/10133 %U https://www.jmir.org/2019/1/e10133/ %U https://doi.org/10.2196/10133 %U http://www.ncbi.nlm.nih.gov/pubmed/30622095 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11683 %T Use of In-Game Rewards to Motivate Daily Self-Report Compliance: Randomized Controlled Trial %A Taylor,Sara %A Ferguson,Craig %A Peng,Fengjiao %A Schoeneich,Magdalena %A Picard,Rosalind W %+ Affective Computing Group, Department of Media Arts and Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, E14-348V, Cambridge, MA, 02142, United States, 1 6128608622, sataylor@mit.edu %K self-reports %K protocol compliance %K recreational games %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Encouraging individuals to report daily information such as unpleasant disease symptoms, daily activities and behaviors, or aspects of their physical and emotional state is difficult but necessary for many studies and clinical trials that rely on patient-reported data as primary outcomes. Use of paper diaries is the traditional method of completing daily diaries, but digital surveys are becoming the new standard because of their increased compliance; however, they still fall short of desired compliance levels. Objective: Mobile games using in-game rewards offer the opportunity to increase compliance above the rates of digital diaries and paper diaries. We conducted a 5-week randomized control trial to compare the completion rates of a daily diary across 3 conditions: a paper-based participant-reported outcome diary (Paper PRO), an electronic-based participant-reported outcome diary (ePRO), and a novel ePRO diary with in-game rewards (Game-Motivated ePRO). Methods: We developed a novel mobile game that is a combination of the idle and pet collection genres to reward individuals who complete a daily diary with an in-game reward. Overall, 197 individuals aged 6 to 24 years (male: 100 and female: 97) were enrolled in a 5-week study after being randomized into 1 of the 3 methods of daily diary completion. Moreover, 157 participants (male: 84 and female: 69) completed at least one diary and were subsequently included in analysis of compliance rates. Results: We observed a significant difference (F2,124=6.341; P=.002) in compliance to filling out daily diaries, with the Game-Motivated ePRO group having the highest compliance (mean completion 86.4%, SD 19.6%), followed by the ePRO group (mean completion 77.7%, SD 24.1%), and finally, the Paper PRO group (mean completion 70.6%, SD 23.4%). The Game-Motivated ePRO (P=.002) significantly improved compliance rates above the Paper PRO. In addition, the Game-Motivated ePRO resulted in higher compliance rates than the rates of ePRO alone (P=.09). Equally important, even though we observed significant differences in completion of daily diaries between groups, we did not observe any statistically significant differences in association between the responses to a daily mood question and study group, the average diary completion time (P=.52), or the System Usability Scale score (P=.88). Conclusions: The Game-Motivated ePRO system encouraged individuals to complete the daily diaries above the compliance rates of the Paper PRO and ePRO without altering the participants’ responses. Trial Registration: ClinicalTrials.gov NCT03738254; http://clinicaltrials.gov/ct2/show/NCT03738254 (Archived by WebCite at http://www.webcitation.org/74T1p8u52) %M 30609986 %R 10.2196/11683 %U https://www.jmir.org/2019/1/e11683/ %U https://doi.org/10.2196/11683 %U http://www.ncbi.nlm.nih.gov/pubmed/30609986 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e11249 %T How LGBT+ Young People Use the Internet in Relation to Their Mental Health and Envisage the Use of e-Therapy: Exploratory Study %A Lucassen,Mathijs %A Samra,Rajvinder %A Iacovides,Ioanna %A Fleming,Theresa %A Shepherd,Matthew %A Stasiak,Karolina %A Wallace,Louise %+ School of Health, Wellbeing and Social Care, The Open University, Walton Hall, Milton Keynes, MK7 6AA, United Kingdom, 44 1908652987, mathijs.lucassen@open.ac.uk %K sexuality %K LGBT %K transgender %K depression %K adolescent %K psychotherapy %K mental health %K computer games %K computerized CBT %K e-therapy %D 2018 %7 21.12.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Lesbian, gay, bisexual, and transgender (LGBT) youth and other young people diverse in terms of their sexuality and gender (LGBT+) are at an elevated risk of mental health problems such as depression. Factors such as isolation and stigma mean that accessing mental health services can be particularly challenging for LGBT+ young people, and previous studies have highlighted that many prefer to access psychological support on the Web. Research from New Zealand has demonstrated promising effectiveness and acceptability for an LGBT+ focused, serious game–based, computerized cognitive behavioral therapy program, Rainbow Smart, Positive, Active, Realistic, X-factor thoughts (SPARX). However, there has been limited research conducted in the area of electronic therapy (e-therapy) for LGBT+ people. Objective: This study aimed to explore how and why LGBT+ young people use the internet to support their mental health. This study also sought to explore LGBT+ young people’s and professionals’ views about e-therapies, drawing on the example of Rainbow SPARX. Methods: A total of 3 focus groups and 5 semistructured interviews were conducted with 21 LGBT+ young people (aged 15-22 years) and 6 professionals (4 health and social care practitioners and 2 National Health Service commissioners) in England and Wales. A general inductive approach was used to analyze data. Results: LGBT+ youth participants considered that the use of the internet was ubiquitous, and it was valuable for support and information. However, they also thought that internet use could be problematic, and they highlighted certain internet safety and personal security considerations. They drew on a range of gaming experiences and expectations to inform their feedback about Rainbow SPARX. Their responses focused on the need for this e-therapy program to be updated and refined. LGBT+ young people experienced challenges related to stigma and mistreatment, and they suggested that strategies addressing their common challenges should be included in e-therapy content. Professional study participants also emphasized the need to update and refine Rainbow SPARX. Moreover, professionals highlighted some of the issues associated with e-therapies needing to demonstrate effectiveness and challenges associated with health service commissioning processes. Conclusions: LGBT+ young people use the internet to obtain support and access information, including information related to their mental health. They are interested in LGBT-specific e-therapies; however, these must be in a contemporary format, engaging, and adequately acknowledge the experiences of LGBT+ young people. %M 30578194 %R 10.2196/11249 %U http://games.jmir.org/2018/4/e11249/ %U https://doi.org/10.2196/11249 %U http://www.ncbi.nlm.nih.gov/pubmed/30578194 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 12 %P e189 %T Serious Games for Improving Genetic Literacy and Genetic Risk Awareness in the General Public: Protocol for a Randomized Controlled Trial %A Oliveri,Serena %A Mainetti,Renato %A Gorini,Alessandra %A Cutica,Ilaria %A Candiani,Giulia %A Borghese,Nunzio Alberto %A Pravettoni,Gabriella %+ Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, 20141, Italy, 39 3296761854, serena.oliveri@unimi.it %K adventure games %K cardiovascular risk %K decision making %K genetic literacy %K genetic risk %K heredity %K knowledge transfer %K mini-games %K mutation %K serious games %D 2018 %7 18.12.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Genetic testing and genetic risk information are gaining importance in personalized medicine and disease prevention. However, progress in these fields does not reflect increased knowledge and awareness of genetic risk in the general public. Objective: Our aim is to develop and test the efficacy of a suite of serious games, developed for mobile and Web platforms, in order to increase knowledge of basic genetic concepts and promote awareness of genetic risk management among lay people. Methods: We developed a new ad-hoc game and modified an arcade game using mechanics suitable to explain genetic concepts. In addition, we developed an adventure game where players are immersed in virtual scenarios and manage genetic risk information to make health-related and interpersonal decisions and modulate their lifestyle. The pilot usability testing will be conducted with a convenience sample of 30 adults who will be categorized into 3 groups and assigned to one game each. Participants will be asked to report any positive or negative issues arising during the game. Subsequently, they will be asked to complete the Game Experience Questionnaire. Finally, a total of 60 teenagers and adults will be enrolled to assess knowledge transfer. Thirty participants will be assigned to the experimental group and asked to play the serious games, and 30 participants will be assigned to the control group and asked to read leaflets on the genetic concepts conveyed by the games. Participants of both groups will fill out a questionnaire before and after the intervention to assess their topic-specific knowledge of genetics. Furthermore, both groups will complete the self-efficacy questionnaire, which assesses the level of confidence in using genetic information. Results: We obtained evidence of game usability in 2017. The data will be submitted to a peer-reviewed journal and used to improve the game design. Knowledge-transfer testing will begin in 2018, and we expect to collect preliminary data on the learning outcomes of serious games by December 2018. Conclusions: It is important to educate the general public about the impact of genetics and genetic testing on disease prevention and the consequent decision-making implications. Without such knowledge, individuals are more likely to make uninformed decisions or handover all decisions regarding genetic testing to their doctors. Technological innovations such as serious games might become a valid instrument to support public education and empowerment. International Registered Report Identifier (IRRID): DERR1-10.2196/9288 %M 30563813 %R 10.2196/resprot.9288 %U https://www.researchprotocols.org/2018/12/e189/ %U https://doi.org/10.2196/resprot.9288 %U http://www.ncbi.nlm.nih.gov/pubmed/30563813 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10252 %T Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game %A Edwards,Elizabeth A %A Caton,Hope %A Lumsden,Jim %A Rivas,Carol %A Steed,Liz %A Pirunsarn,Yutthana %A Jumbe,Sandra %A Newby,Chris %A Shenvi,Aditi %A Mazumdar,Samaresh %A Smith,Jim Q %A Greenhill,Darrel %A Griffiths,Chris J %A Walton,Robert T %+ Centre for Primary Care and Public Health, Blizard Institute, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB, United Kingdom, 44 020 7882 2498, dr.elizabeth.ann.edwards@gmail.com %K smoking cessation %K health behaviors %K behavioral medicine %K games for health %K mHealth %K eHealth %D 2018 %7 29.11.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps. Objective: This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app. Methods: A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers. Results: Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend. Conclusions: A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings. %M 30497994 %R 10.2196/10252 %U http://games.jmir.org/2018/4/e10252/ %U https://doi.org/10.2196/10252 %U http://www.ncbi.nlm.nih.gov/pubmed/30497994 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10993 %T Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study %A Notebaert,Lies %A Grafton,Ben %A Clarke,Patrick JF %A Rudaizky,Daniel %A Chen,Nigel TM %A MacLeod,Colin %+ Centre for the Advancement of Research on Emotion, School of Psychological Science, University of Western Australia, 35 Stirling Highway, M304, Crawley, 6009, Australia, 61 086488 ext 8080, lies.notebaert@uwa.edu.au %K attentional bias %K anxiety disorders %K experimental games %D 2018 %7 28.11.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved. Objective: This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability. Methods: We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor. Results: Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60). Conclusions: Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback. %M 30487121 %R 10.2196/10993 %U http://games.jmir.org/2018/4/e10993/ %U https://doi.org/10.2196/10993 %U http://www.ncbi.nlm.nih.gov/pubmed/30487121 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e18 %T Developing Digital Games to Address Airway Clearance Therapy in Children With Cystic Fibrosis: Participatory Design Process %A Balli,Fabio %+ Concordia University, 1455 de Maisonneuve West, Montreal, QC, H3G 1M8, Canada, 1 514 848 2424, info@fabioballi.net %K digital games %K children %K cystic fibrosis %K game design %K treatment adherence and compliance %K intersectoral collaboration %K access to information %K recommendations %K telemedicine %K mobile phone %D 2018 %7 21.11.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Children affected with cystic fibrosis do respiratory exercises to release the mucus stuck in their lungs. Objective: The objective of our study was to develop prototypes of digital games that use breath pressure to make this daily physiotherapy more fun. Methods: We used a participatory design approach and organized short events to invite contributors from different disciplines to develop game prototypes. From the 6 prototypes, 3 were tested by 10 children during a prestudy. The source code of the games, of which 2 continue to be developed, has been released on the internet under fair use licenses. Results: We discuss 7 themes of importance in designing games for health, combining our experience with a review a posteriori of literature. Conclusions: This study provides examples of games and their pitfalls as well as recommendations to create games for health in a participatory approach that enables everyone to improve and adapt the work done. %M 30463835 %R 10.2196/games.8964 %U http://games.jmir.org/2018/4/e18/ %U https://doi.org/10.2196/games.8964 %U http://www.ncbi.nlm.nih.gov/pubmed/30463835 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11068 %T An App That Incorporates Gamification, Mini-Games, and Social Connection to Improve Men's Mental Health and Well-Being (MindMax): Participatory Design Process %A Cheng,Vanessa Wan Sze %A Davenport,Tracey A %A Johnson,Daniel %A Vella,Kellie %A Mitchell,Jo %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, Sydney, NSW 2050, Australia, 61 286276941, vanessa.cheng@sydney.edu.au %K football %K mental health %K well-being %K video games %K adolescent %K young adult %K cell phone %K gamification %K sport %K men’s health %K social connection %D 2018 %7 19.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Men have different mental health needs as compared with women, and women make up the primary audience of most digital mental health interventions. An Australian football-themed (specifically Australian Football League, AFL) app named MindMax incorporating psychoeducation, gamification, mini-games, and social connection was developed in an effort to address this issue. Objective: The aim of this study was to identify the best way to structure and present MindMax, an app that aims to deliver psychoeducational modules, and create a Web-based community centering on well-being, AFL, and video games for men aged 16 to 35 years who are interested in AFL or video games. Methods: We conducted 6 participatory design (PD) workshops with people aged 16 to 35 years in 3 cities in Australia, to identify the best way to present MindMax, and contracted a digital development agency to develop MindMax. We then iteratively tested MindMax prototypes with 15 user experience testing interviews across 3 separate time points: 2 before app launch and 1 after app launch. Results: A total of 40 individuals (25 male and 15 female) participated in the PD workshops, and a total of 15 individuals (10 male and 5 female) participated in user experience interviews. Broadly, participants expressed a preference for activities requiring active engagement that practiced useful skills. They were also sensitive to how content was presented and wanted the ability to customize their own app experience. Although participants agreed that social motivations were important for engagement with an app, they recommended not to mimic existing social networks. Conclusions: In basing itself strongly within the AFL subculture and by incorporating gamification as well as mini-games, MindMax aimed to tackle mental health help-seeking barriers for people who enjoy AFL or video games, with a particular emphasis on men, and to provide psychoeducation on strategies to increase mental health and well-being. If MindMax is successful, this would indicate that generalizing this approach to other traditional sporting codes and even competitive video gaming leagues (esports) would be fruitful. %M 30455165 %R 10.2196/11068 %U http://mental.jmir.org/2018/4/e11068/ %U https://doi.org/10.2196/11068 %U http://www.ncbi.nlm.nih.gov/pubmed/30455165 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10965 %T Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review %A Oing,Theodore %A Prescott,Julie %+ School of Education and Psychology, University of Bolton, Deane Road, Bolton, BL3 5AB, United Kingdom, 44 0120490 ext 3676, j.prescott@bolton.ac.uk %K virtual reality %K virtual reality exposure therapy %K phobic disorders %K anxiety disorders %D 2018 %7 07.11.2018 %9 Review %J JMIR Serious Games %G English %X Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world. %M 30404770 %R 10.2196/10965 %U http://games.jmir.org/2018/4/e10965/ %U https://doi.org/10.2196/10965 %U http://www.ncbi.nlm.nih.gov/pubmed/30404770 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11640 %T Gamified Cognitive Bias Modification Interventions for Psychiatric Disorders: Review %A Zhang,Melvyn %A Ying,Jiangbo %A Song,Guo %A Fung,Daniel SS %A Smith,Helen %+ National Addiction Management Service, Institute of Mental Health, 10 Buangkok Green Medical Park, Singapore,, Singapore, 65 6389 2504, melvynzhangweibin@gmail.com %K attention bias %K cognitive bias %K gamification %K psychiatry %D 2018 %7 25.10.2018 %9 Review %J JMIR Ment Health %G English %X Background: Automatic biases, such as attentional biases and avoidance and interpretative biases, have been purported to be responsible for several psychiatric disorders. Gamification has been considered for cognitive bias modification, mainly to address the core issues of diminishing motivation to train over time, as bias modification intervention tasks tend to be highly repetitive. While a prior review has suggested how gamification strategies could be applied to such tasks, there remains a lack of systematic evaluation of gamified cognitive bias modification interventions in the literature. Objective: The objective of this review is to understand the overall effectiveness of a gamified approach for cognitive bias modification and inform future research that seeks to integrate gamification technologies into existing conventional bias modification interventions. Methods: To identify the relevant articles for our review, the following search terminologies were used: (“cognitive bias” OR “attention bias” OR “interpret* bias” OR “approach bias” OR “avoidance bias”) AND (“training” OR “modification” OR “practice” OR “therapy”) AND (“gamification” OR “game elements” OR “game” OR “gaming” OR “game mechanics”). PubMed, MEDLINE, PsycINFO, and Scopus databases were searched systematically for articles published after 2000. Articles were included if they described a gamified cognitive bias modification task and included participants with underlying psychopathological symptoms. Data were systematically extracted from the identified articles, and a qualitative synthesis was performed. Results: Four studies evaluated gamified cognitive bias modification interventions. Two studies included participants with anxiety symptoms, one with affective symptoms, and one with alcohol problems. The conventional visual probe task paradigm was used in 3 studies, and the attentional visual search task paradigm was used in the last study. We found gaming elements incorporated to include that of animations, sounds, feedback, and a point-scoring system for response time and difficulty. Of the 4 identified studies, only 2 reported their gamified interventions to be effective. Conclusions: Our review is the first to systematically synthesize the evidence for gamified cognitive bias modification interventions. The results arising from our review should be considered in the future design and conceptualization of gamified cognitive bias modification interventions. International Registered Report Identifier (IRRID): RR2-10.2196/10154 %M 30361194 %R 10.2196/11640 %U http://mental.jmir.org/2018/4/e11640/ %U https://doi.org/10.2196/11640 %U http://www.ncbi.nlm.nih.gov/pubmed/30361194 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10839 %T Virtual Reality Clinical Research: Promises and Challenges %A Garrett,Bernie %A Taverner,Tarnia %A Gromala,Diane %A Tao,Gordon %A Cordingley,Elliott %A Sun,Crystal %+ School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada, 1 16047538942, bernie.garrett@ubc.ca %K virtual reality %K clinical research %K VR standards %K VR theory %K VR immersion %K VR presence %D 2018 %7 17.10.2018 %9 Viewpoint %J JMIR Serious Games %G English %X Background: Virtual reality (VR) therapy has been explored as a novel therapeutic approach for numerous health applications, in which three-dimensional virtual environments can be explored in real time. Studies have found positive outcomes for patients using VR for clinical conditions such as anxiety disorders, addictions, phobias, posttraumatic stress disorder, eating disorders, stroke rehabilitation, and for pain management. Objective: This work aims to highlight key issues in the implementation of clinical research for VR technologies. Methods: A discussion paper was developed from a narrative review of recent clinical research in the field, and the researchers’ own experiences in conducting VR clinical research with chronic pain patients. Results: Some of the key issues in implementing clinical VR research include theoretical immaturity, a lack of technical standards, the problems of separating effects of media versus medium, practical in vivo issues, and costs. Conclusions: Over the last decade, some significant successes have been claimed for the use of VR. Nevertheless, the implementation of clinical VR research outside of the laboratory presents substantial clinical challenges. It is argued that careful attention to addressing these issues in research design and pilot studies are needed in order to make clinical VR research more rigorous and improve the clinical significance of findings. %M 30333096 %R 10.2196/10839 %U http://games.jmir.org/2018/4/e10839/ %U https://doi.org/10.2196/10839 %U http://www.ncbi.nlm.nih.gov/pubmed/30333096 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10213 %T Digital Gaming to Improve Adherence Among Adolescents and Young Adults Living With HIV: Mixed-Methods Study to Test Feasibility and Acceptability %A Castel,Amanda D %A Qasmieh,Saba %A Greenberg,Daniel %A Ellenberger,Nicole %A Howell,Tyriesa Howard %A Griffith,Caleb %A Wilbourn,Brittany C %A Ganesan,Kavitha %A Hussein,Nadia %A Ralte,Gabriel %A Rakhmanina,Natella %+ Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, 5th Floor, 950 New Hampshire Avenue Northwest, Washington, DC,, United States, 1 202 994 8325, acastel@gwu.edu %K youth %K HIV %K adherence %K video games %K Wisepill %K adolescents %K digital technology %K serious games %D 2018 %7 15.10.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: An estimated 50% of adolescents and young adults (AYA) living with HIV are failing to adhere to prescribed antiretroviral treatment (ART). Digital games are effective in chronic disease management; however, research on gaming to improve ART adherence among AYA is limited. Objective: We assessed the feasibility and acceptability of video gaming to improve AYA ART adherence. Methods: Focus group discussions and surveys were administered to health care providers and AYA aged 13 to 24 years living with HIV at a pediatric HIV program in Washington, DC. During focus group discussions, AYA viewed demonstrations of 3 game prototypes linked to portable Wisepill medication dispensers. Content analysis strategies and thematic coding were used to identify adherence themes and gaming acceptance and feasibility. Likert scale and descriptive statistics were used to summarize response frequencies. Results: Providers (n=10) identified common adherence barriers and strategies, including use of gaming analogies to improve AYA ART adherence. Providers supported exploration of digital gaming as an adherence intervention. In 6 focus group discussions, 12 AYA participants identified disclosure of HIV status and irregular daily schedules as major barriers to ART and use of alarms and pillboxes as reminders. Most AYA were very or somewhat likely to use the demonstrated game prototypes to help with ART adherence and desired challenging, individually tailored, user-friendly games with in-game incentives. Game prototypes were modified accordingly. Conclusions: AYA and their providers supported the use of digital games for ART adherence support. Individualization and in-game incentives were preferable and informed the design of an interactive technology-based adherence intervention among AYA living with HIV. %M 30322838 %R 10.2196/10213 %U http://games.jmir.org/2018/4/e10213/ %U https://doi.org/10.2196/10213 %U http://www.ncbi.nlm.nih.gov/pubmed/30322838 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e10161 %T The Untapped Potential of the Gaming Community: Narrative Review %A Goodman,William %A McFerran,Ethna %A Purves,Richard %A Redpath,Ian %A Beeken,Rebecca J %+ Leeds Institute of Health Sciences, Leeds University, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, United Kingdom, 44 1133430741, r.beeken@leeds.ac.uk %K video games %K advertisements %K health behavior %D 2018 %7 25.9.2018 %9 Viewpoint %J JMIR Serious Games %G English %X Background: Video gamers are a population at heightened risk of developing obesity due to the sedentary nature of gaming, increased energy intake, and the disruption caused to their sleep. This increases their risk of developing a number of noncommunicable diseases. To date, research seeking to improve health behaviors has focused on developing novel video games to promote behavior change. Although positive results have emerged from this research, large-scale success has been limited due to the lack of transferability to mainstream games and the focus on children and adolescents. The gaming community has a number of unique aspects, which have received comparatively less attention than the development of new video games. Objective: The purpose of this paper is to highlight under-researched areas that have the potential to encourage positive health behavior among this community. Methods: A narrative review of the lay and academic literature was conducted to provide context and support to our claims that further research could be beneficial in this area. Results: Research has found that advertising can have implicit effects on an individual’s memories, which could influence later decisions. However, the effect of the exponential growth of in-game advertisements and the brand sponsorship of gaming events and professional gamers have not been explored in the gaming community. The possibility of using advertising techniques to encourage positive health behaviors within games or at these events has also not been explored. Research suggests that virtual communities can be effective at disseminating health information, but the efficacy of this needs to be explored using known community influencers within the gaming community. Conclusions: This paper has highlighted a number of potential avenues for the development of interventions within the gaming community. Further research must be conducted alongside game developers to ensure that any in-game developed interventions do not deter gameplay and gamers to ensure that potential approaches are acceptable. %M 30274962 %R 10.2196/10161 %U http://games.jmir.org/2018/3/e10161/ %U https://doi.org/10.2196/10161 %U http://www.ncbi.nlm.nih.gov/pubmed/30274962 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e16 %T Investigating the Relationship Between Eye Movement and Brain Wave Activity Using Video Games: Pilot Study %A Wang,Chaoguang %A Yu,Gino %+ Digital Entertainment Lab, School of Design, Hong Kong Polytechnic University, , Kowloon,, China (Hong Kong), 852 2766 5070, gino.yu@polyu.edu.hk %K video games %K games for health %K eye movement desensitization reprocessing (EMDR) %K electroencephalography (EEG) %K player experience %D 2018 %7 13.09.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: All eye movements are related in one way or another to our mental processes with lateral eye movements being associated with the different hemispheres of the brain. Eye movement techniques form the basis of eye movement desensitization and reprocessing therapy, wherein forced eye movements activate neurological pathways to treat the subject. Objective: The objective of our study was to examine the relationship between players' eye movements and their brain wave activities using a video game. Methods: We used similar eye movement techniques in the form of a video game called Lifeguard that could potentially stimulate different eye movement mode and create a more engaging experience for the user. By designing an experiment, we further explored the differences in electroencephalogram spectral power activity for the alpha, beta, theta, delta, and gamma frequency bands in Lifeguard and Tetris. Results: The game based on eye movement technologies resulted in decreased delta power and increased beta power, but significant difference between 2 games was not found. Conclusions: The applied uses of this research could mean that eye movement desensitization and reprocessing can be conducted in a more fun and engaging way through the use of gaming technology. %M 30213777 %R 10.2196/games.8908 %U http://games.jmir.org/2018/3/e16/ %U https://doi.org/10.2196/games.8908 %U http://www.ncbi.nlm.nih.gov/pubmed/30213777 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e10522 %T Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study %A Applegate,Megan E %A France,Christopher R %A Russ,David W %A Leitkam,Samuel T %A Thomas,James S %+ Wyss Institute for Biologically Inspired Engineering, 60 Oxford Street, Cambridge, MA, 02138, United States, 1 815 474 6743, applegate@seas.harvard.edu %K fatigue %K low back pain %K Sørensen test %K trunk mass %K virtual reality %D 2018 %7 10.09.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain. %M 30201604 %R 10.2196/10522 %U http://games.jmir.org/2018/3/e10522/ %U https://doi.org/10.2196/10522 %U http://www.ncbi.nlm.nih.gov/pubmed/30201604 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e11631 %T 3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study %A Giunti,Guido %+ Salumedia Tecnologias, Av de la República Argentina, 24, Edificio Torre de Los Remedios, 5 planta modulo A, Seville, 41011, Spain, 34 717702622, drguidogiunti@gmail.com %K chronic conditions %K consumer health informatics %K gamification %K health behavioral change %K medical informatics %K mHealth %K user-centered design %K information systems %D 2018 %7 24.08.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider. Objective: The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification. Methods: This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions. Results: The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process. Conclusions: This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients. %M 30143476 %R 10.2196/11631 %U http://games.jmir.org/2018/3/e11631/ %U https://doi.org/10.2196/11631 %U http://www.ncbi.nlm.nih.gov/pubmed/30143476 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e250 %T Effectiveness of Serious Gaming During the Multidisciplinary Rehabilitation of Patients With Complex Chronic Pain or Fatigue: Natural Quasi-Experiment %A Vugts,Miel AP %A Joosen,Margot CW %A Mert,Agali %A Zedlitz,Aglaia ME %A Vrijhoef,Hubertus JM %+ Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 13 466 2969, m.a.p.vugts@uvt.nl %K behavioral intervention %K chronic pain %K serious games %K musculoskeletal disease %K rehabilitation %K therapy %D 2018 %7 15.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes. Objective: The objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence. Methods: We conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses. Results: Of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played ≥75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=−0.119, SE=0.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=−2.748, SE=1.072, P=.011) but not in “insufficiency” or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant. Conclusions: The findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why. Trial Registration: Netherlands Trial Registry NTR6020; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6020 (Archived by WebCite at http://www.webcitation.org/71IIoTXkj) %M 30111527 %R 10.2196/jmir.9739 %U http://www.jmir.org/2018/8/e250/ %U https://doi.org/10.2196/jmir.9739 %U http://www.ncbi.nlm.nih.gov/pubmed/30111527 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e10482 %T A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial %A Winskell,Kate %A Sabben,Gaëlle %A Akelo,Victor %A Ondeng'e,Ken %A Obong'o,Christopher %A Stephenson,Rob %A Warhol,David %A Mudhune,Victor %+ Rollins School of Public Health, Hubert Department of Global Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 (404)727 5286, swinske@emory.edu %K HIV %K youth %K Sub-Saharan Africa %K Kenya %K serious game %K narrative %K smartphone %K pilot study %K randomized controlled trial %K mhealth %K prevention %D 2018 %7 01.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa. Objective: To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change. Methods: Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics. Results: Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game’s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk. Conclusions: The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design. Trial Registration: ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW) %M 30068501 %R 10.2196/10482 %U http://mhealth.jmir.org/2018/8/e10482/ %U https://doi.org/10.2196/10482 %U http://www.ncbi.nlm.nih.gov/pubmed/30068501 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e247 %T Investigating the Direct Impact of a Gamified Versus Nongamified Well-Being Intervention: An Exploratory Experiment %A Kelders,Saskia Marion %A Sommers-Spijkerman,Marion %A Goldberg,Jochem %+ Center for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Drienerlolaan 5, Enschede,, Netherlands, 31 534896055, s.m.kelders@utwente.nl %K gamification %K well-being %K engagement %K electronic mental health %K mental health %D 2018 %7 26.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Gamification is a promising strategy to increase the effectiveness of Web-based mental health interventions by enhancing engagement. However, because most studies focus on the longer term effects of gamification (eg, effectiveness or adherence at the end of the intervention period), there is limited insight into how gamification may enhance engagement. Research implies that gamification has a direct impact at the time of use of the intervention, which changes the experience of the users, and thereby motivates users. However, it is unclear what this direct impact of gamification might be and how it can be measured. Objective: The objective of this study was to explore the direct impact of gamification on behavioral, cognitive, and affective engagement in the context of a Web-based mental health intervention and to explore whether and how the different components of engagement are related. Methods: A pilot (n=19) and a real-life (n=75) randomized between-groups experiment was carried out, where participants used a gamified or nongamified version of the same Web-based well-being intervention for a single session. Participants (68%, 64/94 female, mean age 23 years) were asked to use the intervention in one session for research purposes. Gamification elements included a map as visualization of the different lessons, a virtual guide, and badges. Later, behavioral, cognitive, and affective engagement were measured. Results: The pilot experiment showed no differences between the gamified and nongamified intervention. However, in the real-life experiment, participants in the gamified intervention scored higher on cognitive engagement, that is, involvement (P=.02) and some elements of affective engagement, that is, flow as a combination of cognitive and affective engagement (P=.049), and the emotions ”interest” (P=.03) and “inspiration” (P=.009). Furthermore, the effect of gamification on cognitive engagement was mediated by the influence of gamification on specific positive emotions. Conclusions: The gamified intervention seemed to be able to increase cognitive engagement and the combination of cognitive and affective engagement but not behavioral and affective engagement alone. However, positive emotions seem to play an important role in mediating the effect of gamification on engagement. In conclusion, we cannot say that gamification ”works” but that the design of an intervention, in this case, gamification, can have an impact on how participants experience the intervention. %M 30049669 %R 10.2196/jmir.9923 %U http://www.jmir.org/2018/7/e247/ %U https://doi.org/10.2196/jmir.9923 %U http://www.ncbi.nlm.nih.gov/pubmed/30049669 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e15 %T Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis %A Grant,Sean %A Spears,Asya %A Pedersen,Eric R %+ RAND Corporation, 1776 Main Street, Santa Monica, CA,, United States, 1 310 393 0411 ext 6438, sgrant@rand.org %K behavioral health %K replication %K veterans %K video games %D 2018 %7 26.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. %M 30049668 %R 10.2196/games.9327 %U http://games.jmir.org/2018/3/e15/ %U https://doi.org/10.2196/games.9327 %U http://www.ncbi.nlm.nih.gov/pubmed/30049668 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e14 %T Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research %A Jerdan,Shaun W %A Grindle,Mark %A van Woerden,Hugo C %A Kamel Boulos,Maged N %+ Department of Digital Health, Centre for Health Science, University of the Highlands and Islands, Old Perth Road, Inverness, IV2 3JH, United Kingdom, 44 734 298 7169, shaun.jerdan@uhi.ac.uk %K virtual reality %K well-being %K behavior change %D 2018 %7 06.07.2018 %9 Review %J JMIR Serious Games %G English %X Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment. %M 29980500 %R 10.2196/games.9226 %U http://games.jmir.org/2018/3/e14/ %U https://doi.org/10.2196/games.9226 %U http://www.ncbi.nlm.nih.gov/pubmed/29980500 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e13 %T Indigenous Adolescents’ Perception of an eMental Health Program (SPARX): Exploratory Qualitative Assessment %A Shepherd,Matthew %A Merry,Sally %A Lambie,Ian %A Thompson,Andrew %+ School of Counselling, Human Services and Social Work, Faculty of Education, The University of Auckland, Gate 4, 60 Epsom Ave, Epsom, Auckland,, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K Māori youth %K indigenous %K depression %K computerized CBT %K consumer views %K serious games %K virtual worlds %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue for indigenous adolescents, yet there is little research conducted about the efficacy and development of psychological interventions for these populations. In New Zealand there is little known about taitamariki (Māori adolescent) opinions regarding the development and effectiveness of psychological interventions, let alone computerized cognitive behavioral therapy. SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a computerized intervention developed in New Zealand to treat mild-to-moderate depression in young people. Users are engaged in a virtual 3D environment where they must complete missions to progress to the next level. In each level there are challenges and puzzles to completeIt was designed to appeal to all young people in New Zealand and incorporates several images and concepts that are specifically Māori. Objective: The aim was to conduct an exploratory qualitative study of Māori adolescents’ opinions about the SPARX program. This is a follow-up to an earlier study where taitamariki opinions were gathered to inform the design of a computerized cognitive behavior therapy program. Methods: Taitamariki were interviewed using a semistructured interview once they had completed work with the SPARX resource. Six participants agreed to complete the interview; the interviews ranged from 10 to 30 minutes. Results: Taitamariki participating in the interviews found SPARX to be helpful. The Māori designs from the SPARX game were appropriate and useful, and the ability to customize the SPARX characters with Māori designs was beneficial and appeared to enhance cultural identity. These helped young people to feel engaged with SPARX which, in turn, assisted with the acquisition of relaxation and cognitive restructuring skills. Overall, using SPARX led to improved mood and increased levels of hope for the participants. In some instances, SPARX was used by wider whānau (Māori word for family) members with reported beneficial effect. Conclusions: Overall, this small group of Māori adolescents reported that cultural designs made it easier for them to engage with SPARX, which, in turn, led to an improvement in their mood and gave them hope. Further research is needed about how SPARX could be best used to support the families of these young people. %M 29980495 %R 10.2196/games.8752 %U http://games.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/games.8752 %U http://www.ncbi.nlm.nih.gov/pubmed/29980495 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 6 %P e10024 %T Effective Behavioral Changes through a Digital mHealth App: Exploring the Impact of Hedonic Well-Being, Psychological Empowerment and Inspiration %A Lin,Yuting %A Tudor-Sfetea,Carina %A Siddiqui,Sarim %A Sherwani,Yusuf %A Ahmed,Maroof %A Eisingerich,Andreas B %+ Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom, 44 207 594 7850, y.lin14@imperial.ac.uk %K mHealth %K gamification %K cognitive behavioral therapy %K empowerment %K well-being %K inspiration %K mobile app %K behavior change and prevention %K digital %D 2018 %7 15.06.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: New mobile health (mHealth) software apps are emerging and are providing the foundation to radically transform the practice and reach of medical research and care. For this study we collaborated with Quit Genius, a cognitive behavioral therapy (CBT) based mHealth app that helps users quit smoking, to explore the effective design of a digital mHealth app; one that delivers important benefits to its users and helps them change their behaviors for a healthier lifestyle. Objective: The specific aims of this study were to (1) explore the key role of CBT program progress, (2) examine the gamification design app elements that deliver significant benefits (ie, empowerment, well-being, inspiration) to users, (3) explore the effectiveness of these app elements to help users quit smoking or reduce the number of cigarettes smoked, and (4) identify and describe any potential drivers and hindrances arising from the app design elements. Methods: We developed an online survey and sent an email invitation to 4144 individuals, who had previously or were at the time using the Quit Genius mHealth app, to encourage participation in the study. We matched the online survey data with objective app usage data of the study participants. Results: A dataset of 190 completed responses was used. At the time of the survey, respondents had completed an average of 60% of the CBT program in the Quit Genius mHealth app. Of the respondents, 36.3% (69/190) noted to have quit smoking successfully after using the Quit Genius app. As for those who remained smokers after using the app (N=121), the number of cigarettes smoked per day was significantly reduced by 59.6%. The ability of the app to enhance users’ hedonic well-being and psychologically empower them in their daily lives was identified as being key in helping users quit smoking. Specifically, the results show that users whose well-being was enhanced through the app were 1.72 times more likely to quit smoking successfully. Moreover, a one-unit increase on a 7-point Likert scale in the app’s ability to empower smokers in their daily lives led to a reduction of cigarettes smoked per day of 53%. The app’s inspiration to users, however, was negatively associated with quitting success and the reduction in cigarette smoked per day. Conclusions: The findings offer important insights for the effective design of digital mHealth apps. Specifically, we find that perceived psychological empowerment and enhanced hedonic well-being from the mobile solution may be a more impactful way to support the effectiveness of mobile cognitive behavioral therapy for smoking cessation than eliciting strong inspiration. %M 29907557 %R 10.2196/10024 %U http://mhealth.jmir.org/2018/6/e10024/ %U https://doi.org/10.2196/10024 %U http://www.ncbi.nlm.nih.gov/pubmed/29907557 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e12 %T Physical Wellness Among Gaming Adults: Cross-Sectional Study %A Arnaez,James %A Frey,Georgia %A Cothran,Donetta %A Lion,Margaret %A Chomistek,Andrea %+ Department of Epidemiology and Biostatistics, School of Public Health, Indiana University Bloomington, PH 070, 1025 E 7th St, Bloomington, IN, 47405, United States, 1 812 360 6324, jarnaez@indiana.edu %K video games %K electronic gaming %K traditional gaming %K obesity %K physical activity %K sedentary behavior %D 2018 %7 12.06.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Video and hobby gaming are immensely popular among adults; however, associations between gaming and health have primarily been investigated in children and adolescents. Furthermore, most research has focused on electronic gaming, despite traditional hobby gaming gaining prominence. Objective: To determine whether the number of platforms used, platform preference, and gaming time are associated with obesity, physical activity, sedentary behavior, and cardiovascular risk factors in an adult gaming population. Methods: We conducted a cross-sectional analysis using data obtained from 292 participants who attended a large Midwestern gaming convention. We collected data using a computer-based questionnaire that comprised questions on gaming behavior, demographics, physical activity (using the International Physical Activity Questionnaire), and health characteristics. In addition, we used multivariable-adjusted linear and logistic regression to model health outcomes as a function of the number of platforms used, platform preference, and weekday and weekend gaming time quartile. Results: After adjusting for covariates, we observed a significant linear trend for increasing odds of being obese and higher weekend sitting time by the number of platforms used (P=.03 for both). The platform preference and weekend gaming time quartile exhibited significant associations with odds of meeting physical activity recommendations (P=.047 and P=.03, respectively). In addition, we observed higher odds of being obese among those reporting that they sat most or all of the time while gaming [odds ratio (OR) 2.69 (95% CI 1.14-6.31) and OR 2.71 (95% CI 1.06-6.93), respectively]. Conclusions: In adult gamers, the number of platforms used, which platforms they prefer to play on, and the amount of time spent gaming on weekends could have significant implications for their odds of being obese and meeting physical activity recommendations. %M 29895516 %R 10.2196/games.9571 %U http://games.jmir.org/2018/2/e12/ %U https://doi.org/10.2196/games.9571 %U http://www.ncbi.nlm.nih.gov/pubmed/29895516 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e11 %T A Mobile Game to Support Smoking Cessation: Prototype Assessment %A Raiff,Bethany R %A Fortugno,Nicholas %A Scherlis,Daniel R %A Rapoza,Darion %+ Health and Behavioral Integrated Treatments Research Unit, Department of Psychology, Rowan University, 201 Mullica Hill Road, Glassboro, NJ, 08028, United States, 1 856 256 4500 ext 53782, raiff@rowan.edu %K smoking %K smoking cessation %K contingency management %K mobile apps %K virtual rewards %K health games %K video games %K digital games %K carbon monoxide %K incentives %D 2018 %7 07.06.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. Objective: We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. Methods: Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. Results: Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. Conclusions: This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit. %R 10.2196/games.9599 %U http://games.jmir.org/2018/2/e11/ %U https://doi.org/10.2196/games.9599 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 5 %P e138 %T Evaluating a Serious Gaming Electronic Medication Administration Record System Among Nursing Students: Protocol for a Pragmatic Randomized Controlled Trial %A Booth,Richard %A Sinclair,Barbara %A McMurray,Josephine %A Strudwick,Gillian %A Watson,Gavan %A Ladak,Hanif %A Zwarenstein,Merrick %A McBride,Susan %A Chan,Ryan %A Brennan,Laura %+ Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, 1151 Richmond Street, FIMS and Nursing Building, Room 2333, London, ON, N6A 3K7, Canada, 1 5196612111 ext 86571, rbooth6@uwo.ca %K video games %K high fidelity simulation training %K nursing education %K medication errors %D 2018 %7 28.05.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Although electronic medication administration record systems have been implemented in settings where nurses work, nursing students commonly lack robust learning opportunities to practice the skills and workflow of digitalized medication administration during their formative education. As a result, nursing students’ performance in administering medication facilitated by technology is often poor. Serious gaming has been recommended as a possible intervention to improve nursing students’ performance with electronic medication administration in nursing education. Objective: The objectives of this study are to examine whether the use of a gamified electronic medication administration simulator (1) improves nursing students’ attention to medication administration safety within simulated practice, (2) increases student self-efficacy and knowledge of the medication administration process, and (3) improves motivational and cognitive processing attributes related to student learning in a technology-enabled environment. Methods: This study comprised the development of a gamified electronic medication administration record simulator and its evaluation in 2 phases. Phase 1 consists of a prospective, pragmatic randomized controlled trial with second-year baccalaureate nursing students at a Canadian university. Phase 2 consists of qualitative focus group interviews with a cross-section of nursing student participants. Results: The gamified medication administration simulator has been developed, and data collection is currently under way. Conclusions: If the gamified electronic medication administration simulator is found to be effective, it could be used to support other health professional simulated education and scaled more widely in nursing education programs. Trial Registration: ClinicalTrials.gov NCT03219151; https://clinicaltrials.gov/show/NCT03219151 (Archived by WebCite at http://www.webcitation.org/6yjBROoDt) Registered Report Identifier: RR1-10.2196/9601 %R 10.2196/resprot.9601 %U http://www.researchprotocols.org/2018/5/e138/ %U https://doi.org/10.2196/resprot.9601 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e10 %T Training Working Memory in Adolescents Using Serious Game Elements: Pilot Randomized Controlled Trial %A Boendermaker,Wouter J %A Gladwin,Thomas E %A Peeters,Margot %A Prins,Pier J M %A Wiers,Reinout W %+ Department of Interdisciplinary Social Science, Utrecht University, Heidelberglaan 1, Utrecht, 3584 CS, Netherlands, 31 302531897, w.j.boendermaker@uu.nl %K cognitive function %K memory %K video games %K motivation %D 2018 %7 23.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Working memory capacity has been found to be impaired in adolescents with various psychological problems, such as addictive behaviors. Training of working memory capacity can lead to significant behavioral improvements, but it is usually long and tedious, taxing participants’ motivation to train. Objective: This study aimed to evaluate whether adding game elements to the training could help improve adolescents’ motivation to train while improving cognition. Methods: A total of 84 high school students were allocated to a working memory capacity training, a gamified working memory capacity training, or a placebo condition. Working memory capacity, motivation to train, and drinking habits were assessed before and after training. Results: Self-reported evaluations did not show a self-reported preference for the game, but participants in the gamified working memory capacity training condition did train significantly longer. The game successfully increased motivation to train, but this effect faded over time. Working memory capacity increased equally in all conditions but did not lead to significantly lower drinking, which may be due to low drinking levels at baseline. Conclusions: We recommend that future studies attempt to prolong this motivational effect, as it appeared to fade over time. %M 29792294 %R 10.2196/games.8364 %U http://games.jmir.org/2018/2/e10/ %U https://doi.org/10.2196/games.8364 %U http://www.ncbi.nlm.nih.gov/pubmed/29792294 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 5 %P e195 %T Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial %A Haubruck,Patrick %A Nickel,Felix %A Ober,Julian %A Walker,Tilman %A Bergdolt,Christian %A Friedrich,Mirco %A Müller-Stich,Beat Peter %A Forchheim,Franziska %A Fischer,Christian %A Schmidmaier,Gerhard %A Tanner,Michael C %+ Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200 a, Heidelberg, 69121, Germany, 49 06221 ext 5635987, patrick.haubruck@med.uni-heidelberg.de %K games, experimental %K education, professional %K general surgery %K emergency medicine %K problem-based learning %K chest tubes %K simulation training %K clinical competence %D 2018 %7 21.05.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce. Objective: The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS). Methods: In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module “Thoracocentesis” discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants’ performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance. Results: A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I50=7.0] points; control group: 30.5 [I50=8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group. Conclusions: The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods. Trial Registration: German Clinical Trials Register (DRKS) DRKS00009994; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009994 (Archived by Webcite at http://www.webcitation.org/6ytWF1CWg) %M 29784634 %R 10.2196/jmir.9956 %U http://www.jmir.org/2018/5/e195/ %U https://doi.org/10.2196/jmir.9956 %U http://www.ncbi.nlm.nih.gov/pubmed/29784634 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 5 %P e135 %T A Digital App to Aid Detection, Monitoring, and Management of Dyslexia in Young Children (DIMMAND): Protocol for a Digital Health and Education Solution %A Sood,Mariam R %A Toornstra,Annet %A Sereno,Martin I %A Boland,Mark %A Filaretti,Daniele %A Sood,Anuj %+ Synergation Limited, 61 Hillside Road, Northwood, Middlesex, HA6 1PZ, United Kingdom, 44 7554401772, mariam_reeny@yahoo.com %K dyslexia %K digital health %K early education %K special education needs %K study skills %K EdTech %K serious games %D 2018 %7 17.05.2018 %9 Proposal %J JMIR Res Protoc %G English %X Background: Dyslexia, a specific learning difficulty and a disability as defined in the Equality Act 2010, is a lifelong condition that affects a child from the start of education. Dyslexia is characterized by difficulties in language processing (reading, spelling, and writing) which do not correspond with the child’s general intellectual abilities. Although dyslexia cannot be cured, there is a consensus that interventions are more effective and have greater impact the earlier they are administered. Effective interventions start with diagnosis. Currently, formal diagnosis requires an assessment by a dyslexia specialist or educational psychologist. These assessments are expensive and are not easy for a non-specialist teacher or parent to interpret. Consequently, formal assessments are normally performed at a much later age, when interventions are less likely to be effective. Combining the latest in scientific research, expertise of dyslexia practitioners and real-time interactivity facilitated by digital technologies, we aim to provide a cost-effective and convenient solution that focuses on early dyslexia detection and management. Objective: We discuss the rationale and protocol for the design and development of a digital health solution aimed at improving the early detection, monitoring and management of dyslexia (DIMMAND) in young children (4-8 years). The primary objective is to create a game-based digital solution aimed at children, parents, and teachers that firstly assesses, then monitors and manages progress in a convenient, cost-effective and private environment. Methods: The proposed solution will be designed and developed in phases. In the initial phase, the full functional specification of the games that constitute the app will be designed, together with the overall architecture of the solution. Prototype proof-of-concept implementation for few of these games, and commercialization strategies will also be developed. The follow-on phases will see the design implemented into a validated solution. Results: In the initial phase, we worked closely with dyslexia specialists, adult dyslexics, teachers of special-needs children, parents of dyslexic children, and senior dyslexia representatives for large organizations. These interactions provided insights into the range of language difficulties faced by dyslexics, which solutions are used by teachers and professionals, and an overall understanding of the market. We comprehensively defined the ethical, privacy, and data security issues. The detailed design spec of the games, the methodology to be followed to interpret the results, and flow diagrams illustrating how the game screens will be presented was completed. As proof of concept, a few reading, visual, and auditory games were developed and successfully tested by stakeholders on different digital devices. The stakeholders provided regular feedback and confirmed the viability of our game-based solution. Conclusions: DIMMAND has the potential to provide significant positive health care and economic impact. It is expected to reduce intervention costs, improve dyslexia detection at an early age and aid self-management. Registered Report Identifier: RR1-10.2196/9583 %M 29773528 %R 10.2196/resprot.9583 %U http://www.researchprotocols.org/2018/5/e135/ %U https://doi.org/10.2196/resprot.9583 %U http://www.ncbi.nlm.nih.gov/pubmed/29773528 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e8 %T Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study %A Motz,Patrick %A Gray,Megan %A Sawyer,Taylor %A Kett,Jennifer %A Danforth,Douglas %A Maicher,Kellen %A Umoren,Rachel %+ Division of Neonatology, Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA,, United States, 1 206 543 3675, rumoren@uw.edu %K prenatal counseling %K simulation %K ethics %D 2018 %7 11.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses. %M 29752249 %R 10.2196/games.9611 %U http://games.jmir.org/2018/2/e8/ %U https://doi.org/10.2196/games.9611 %U http://www.ncbi.nlm.nih.gov/pubmed/29752249 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e9 %T Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial %A Pramana,Gede %A Parmanto,Bambang %A Lomas,James %A Lindhiem,Oliver %A Kendall,Philip C %A Silk,Jennifer %+ Department of Health Information Management, University of Pittsburgh, 6025 Forbes Tower, Pittsburgh, PA, 15260, United States, 1 4123836649, parmanto@pitt.edu %K gamification %K mobile health %K ecological momentary intervention %K cognitive behavioral therapy %K child anxiety treatment %K SmartCAT %K childhood anxiety disorders %D 2018 %7 10.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. %M 29748165 %R 10.2196/games.8902 %U http://games.jmir.org/2018/2/e9/ %U https://doi.org/10.2196/games.8902 %U http://www.ncbi.nlm.nih.gov/pubmed/29748165 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 5 %N 1 %P e11 %T Person-Generated Health Data in Simulated Rehabilitation Using Kinect for Stroke: Literature Review %A Dimaguila,Gerardo Luis %A Gray,Kathleen %A Merolli,Mark %+ Health and Biomedical Informatics Centre, University of Melbourne, Level 1, 202 Berkeley Street, Melbourne,, Australia, 61 3 9035 8703, dgl@student.unimelb.edu.au %K health care information systems %K Kinect %K patient-generated health data %K person-generated health data %K review %K simulated rehabilitation %K stroke %K stroke rehabilitation %K video games %K virtual rehabilitation %D 2018 %7 08.05.2018 %9 Review %J JMIR Rehabil Assist Technol %G English %X Background: Person- or patient-generated health data (PGHD) are health, wellness, and clinical data that people generate, record, and analyze for themselves. There is potential for PGHD to improve the efficiency and effectiveness of simulated rehabilitation technologies for stroke. Simulated rehabilitation is a type of telerehabilitation that uses computer technologies and interfaces to allow the real-time simulation of rehabilitation activities or a rehabilitation environment. A leading technology for simulated rehabilitation is Microsoft’s Kinect, a video-based technology that uses infrared to track a user’s body movements. Objective: This review attempts to understand to what extent Kinect-based stroke rehabilitation systems (K-SRS) have used PGHD and to what benefit. Methods: The review is conducted in two parts. In part 1, aspects of relevance for PGHD were searched for in existing systematic reviews on K-SRS. The following databases were searched: IEEE Xplore, Association of Computing Machinery Digital Library, PubMed, Biomed Central, Cochrane Library, and Campbell Collaboration. In part 2, original research papers that presented or used K-SRS were reviewed in terms of (1) types of PGHD, (2) patient access to PGHD, (3) PGHD use, and (4) effects of PGHD use. The search was conducted in the same databases as part 1 except Cochrane and Campbell Collaboration. Reference lists on K-SRS of the reviews found in part 1 were also included in the search for part 2. There was no date restriction. The search was closed in June 2017. The quality of the papers was not assessed, as it was not deemed critical to understanding PGHD access and use in studies that used K-SRS. Results: In part 1, 192 papers were identified, and after assessment only 3 papers were included. Part 1 showed that previous reviews focused on technical effectiveness of K-SRS with some attention on clinical effectiveness. None of those reviews reported on home-based implementation or PGHD use. In part 2, 163 papers were identified and after assessment, 41 papers were included. Part 2 showed that there is a gap in understanding how PGHD use may affect patients using K-SRS and a lack of patient participation in the design of such systems. Conclusions: This paper calls specifically for further studies of K-SRS—and for studies of technologies that allow patients to generate their own health data in general—to pay more attention to how patients’ own use of their data may influence their care processes and outcomes. Future studies that trial the effectiveness of K-SRS outside the clinic should also explore how patients and carers use PGHD in home rehabilitation programs. %M 29739739 %R 10.2196/rehab.9123 %U http://rehab.jmir.org/2018/1/e11/ %U https://doi.org/10.2196/rehab.9123 %U http://www.ncbi.nlm.nih.gov/pubmed/29739739 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e7 %T Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study %A Metcalf,Mary %A Rossie,Karen %A Stokes,Katie %A Tallman,Christina %A Tanner,Bradley %+ Clinical Tools, Inc, 101 Market Street, Suite A, Chapel Hill, NC,, United States, 1 919 960 8118, metcalf@clinicaltools.com %K addiction treatment %K Kinect %K serious games %K motion control games %K virtual reality %D 2018 %7 16.04.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: New technologies such as virtual reality, augmented reality, and video games hold promise to support and enhance individuals in addiction treatment and recovery. Quitting or decreasing cigarette or alcohol use can lead to significant health improvements for individuals, decreasing heart disease risk and cancer risks (for both nicotine and alcohol use), among others. However, remaining in recovery from use is a significant challenge for most individuals. Objective: We developed and assessed the Take Control game, a partially immersive Kinect for Windows platform game that allows users to counter substance cues through active movements (hitting, kicking, etc). Methods: Formative analysis during phase I and phase II guided development. We conducted a small wait-list control trial using a quasi-random sampling technique (systematic) with 61 participants in recovery from addiction to alcohol or tobacco. Participants used the game 3 times and reported on substance use, cravings, satisfaction with the game experience, self-efficacy related to recovery, and side effects from exposure to a virtual reality intervention and substance cues. Results: Participants found the game engaging and fun and felt playing the game would support recovery efforts. On average, reported substance use decreased for participants during the intervention period. Participants in recovery for alcohol use saw more benefit than those in recovery for tobacco use, with a statistically significant increase in self-efficacy, attitude, and behavior during the intervention. Side effects from the use of a virtual reality intervention were minor and decreased over time; cravings and side effects also decreased during the study. Conclusions: The preliminary results suggest the intervention holds promise as an adjunct to standard treatment for those in recovery, particularly from alcohol use. %M 29661748 %R 10.2196/games.9231 %U http://games.jmir.org/2018/2/e7/ %U https://doi.org/10.2196/games.9231 %U http://www.ncbi.nlm.nih.gov/pubmed/29661748 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e6 %T Gamified Cognitive Control Training for Remitted Depressed Individuals: User Requirements Analysis %A Vervaeke,Jasmien %A Van Looy,Jan %A Hoorelbeke,Kristof %A Baeken,Chris %A Koster,Ernst HW %+ Psychopathology and Affective Neuroscience Lab, Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 92649446, jasmien.vervaeke@ugent.be %K depression %K cognitive dysfunction %K cognitive remediation %K relapse prevention %K qualitative research %K secondary prevention %D 2018 %7 05.04.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high incidence and relapse rates of major depressive disorder demand novel treatment options. Standard treatments (psychotherapy, medication) usually do not target cognitive control impairments, although these seem to play a crucial role in achieving stable remission. The urgent need for treatment combined with poor availability of adequate psychological interventions has instigated a shift toward internet interventions. Numerous computerized programs have been developed that can be presented online and offline. However, their uptake and adherence are oftentimes low. Objective: The aim of this study was to perform a user requirements analysis for an internet-based training targeting cognitive control. This training focuses on ameliorating cognitive control impairments, as these are still present during remission and can be a risk factor for relapse. To facilitate uptake of and adherence to this intervention, a qualitative user requirements analysis was conducted to map mandatory and desirable requirements. Methods: We conducted a user requirements analysis through a focus group with 5 remitted depressed individuals and individual interviews with 6 mental health care professionals. All qualitative data were transcribed and examined using a thematic analytic approach. Results: Results showed mandatory requirements for the remitted sample in terms of training configuration, technological and personal factors, and desirable requirements regarding knowledge and enjoyment. Furthermore, knowledge and therapeutic benefits were key requirements for therapists. Conclusions: The identified requirements provide useful information to be integrated in interventions targeting cognitive control in depression. %M 29622525 %R 10.2196/games.8609 %U http://games.jmir.org/2018/2/e6/ %U https://doi.org/10.2196/games.8609 %U http://www.ncbi.nlm.nih.gov/pubmed/29622525 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 1 %P e5 %T Virtual Travel Training for Autism Spectrum Disorder: Proof-of-Concept Interventional Study %A Simões,Marco %A Bernardes,Miguel %A Barros,Fernando %A Castelo-Branco,Miguel %+ Faculty of Medicine, University of Coimbra, Azinhaga Santa Comba, Celas, Coimbra, 3000-548, Portugal, 351 239480029, mcbranco@fmed.uc.pt %K Autism Spectrum Disorder %K serious games %K virtual reality %K virtual reality therapy %K travel train %K bus. %D 2018 %7 20.03.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social interaction and repetitive patterns of behavior, which can lead to deficits in adaptive behavior. In this study, a serious game was developed to train individuals with ASD for an important type of outdoor activity, which is the use of buses as a means of transportation. Objective: The aim of this study was to develop a serious game that defines a “safe environment” where the players became familiar with the process of taking a bus and to validate if it could be used effectively to teach bus-taking routines and adaptive procedures to individuals with ASD. Methods: In the game, players were placed in a three-dimensional city and were submitted to a set of tasks that involved taking buses to reach specific destinations. Participants with ASD (n=10) underwent between 1 to 3 training sessions. Participants with typical development (n=10) were also included in this study for comparison purposes and received 1 control session. Results: We found a statistically significant increase in the measures of knowledge of the process of riding a bus, a reduction in the electrodermal activity (a metric of anxiety) measured inside the bus environments, and a high success rate of their application within the game (93.8%). Conclusions: The developed game proved to be potentially useful in the context of emerging immersive virtual reality technologies, of which use in therapies and serious games is still in its infancy. Our findings suggest that serious games, using these technologies, can be used effectively in helping people with ASD become more independent in outdoor activities, specifically regarding the use of buses for transportation. %M 29559425 %R 10.2196/games.8428 %U http://games.jmir.org/2018/1/e5/ %U https://doi.org/10.2196/games.8428 %U http://www.ncbi.nlm.nih.gov/pubmed/29559425 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e77 %T Digital Gaming for Improving the Functioning of People With Traumatic Brain Injury: Randomized Clinical Feasibility Study %A Välimäki,Maritta %A Mishina,Kaisa %A Kaakinen,Johanna K %A Holm,Suvi K %A Vahlo,Jukka %A Kirjonen,Markus %A Pekurinen,Virve %A Tenovuo,Olli %A Korkeila,Jyrki %A Hämäläinen,Heikki %A Sarajuuri,Jaana %A Rantanen,Pekka %A Orenius,Tage %A Koponen,Aki %+ School of Nursing, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,, China (Hong Kong), 852 2766 6409, maritta.valimaki@polyu.edu.hk %K rehabilitation %K traumatic brain injury %K video games %D 2018 %7 19.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Traumatic brain injury (TBI) is a major health problem that often requires intensive and long-term rehabilitation. Objective: The aim of this study was to determine whether rehabilitative digital gaming facilitates cognitive functioning and general well-being in people with TBI. Methods: A total of 90 Finnish-speaking adults with TBI (18-65 years) were recruited from an outpatient neuroscience clinic. The participants were randomly allocated to one of the three groups: a rehabilitation gaming group (n=29, intervention), an entertainment gaming group (n=29, active control), or a passive control group (n=32). The gaming groups were instructed to engage in gaming for a minimum of 30 min per day for 8 weeks. Primary and secondary outcomes were measured at three time points: before the intervention, after the intervention, and 3 months following the intervention. The primary outcome was cognitive status measured by processing speed and visuomotor tasks (The Trail Making Test; Wechsler Adult Intelligence Scale-Fourth Edition, WAIS-IV, symbol search, coding, and cancellation tasks). Secondary outcomes were attention and executive functions (Simon task), working memory (WAIS-IV digit span and Paced Auditory Serial Addition Test, PASAT), depression (Patient Health Questionnaire-9), self-efficacy (General Self-efficacy Scale), and executive functions (Behavior Rating Inventory of Executive Function-Adult Version). Feasibility information was assessed (acceptability, measurement instruments filled, dropouts, adherence, usability, satisfaction, and possible future use). Cognitive measurements were conducted in face-to-face interviews by trained psychologists, and questionnaires were self-administered. Results: The effects of rehabilitation gaming did not significantly differ from the effects of entertainment gaming or being in a passive control group. For primary outcomes and PASAT tests, the participants in all three groups showed overall improvement in test scores across the three measurement points. However, depression scores increased significantly between baseline and after 8 weeks and between baseline and after 3 months in the rehabilitative gaming group. No differences were found in patients’ self-efficacy between the three measuring points in any of the groups. Participants did use the games (rehabilitation group: 93%, 27/29; entertainment group 100%, 29/29). Games were seen as a usable intervention (rehabilitation group: 70%, 14/29; entertainment group: 83%, 20/29). The rehabilitation group was less satisfied with the gaming intervention (68%, 13/29 vs 83%, 20/29), but they were more willing to use the game after the intervention period (76%, 16/29 vs 63%, 15/29). Total time spent on gaming during the intervention period was low (15.22 hour rehabilitation gaming group, 19.22 hour entertainment gaming group). Conclusions: We did not find differences between the groups in improvement in the outcome measures. The improvements in test performance by all three groups may reflect rehearsal effects. Entertainment gaming had elements that could be considered when rehabilitative games are designed for, implemented in, and assessed in larger clinical trials for persons with TBI. Trial Registration: ClinicalTrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH) %M 29555622 %R 10.2196/jmir.7618 %U http://www.jmir.org/2018/3/e77/ %U https://doi.org/10.2196/jmir.7618 %U http://www.ncbi.nlm.nih.gov/pubmed/29555622 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 4 %N 1 %P e8 %T Mobile Technology in E-Learning for Undergraduate Medical Education on Emergent Otorhinolaryngology–Head and Neck Surgery Disorders: Pilot Randomized Controlled Trial %A Lee,Li-Ang %A Wang,Shu-Ling %A Chao,Yi-Ping %A Tsai,Ming-Shao %A Hsin,Li-Jen %A Kang,Chung-Jan %A Fu,Chia-Hsiang %A Chao,Wei-Chieh %A Huang,Chung-Guei %A Li,Hsueh-Yu %A Chuang,Cheng-Keng %+ Department of Surgery, Linkou Chang Gung Memorial Hospital, No 5, Fu-Hsing Street, Guishan District, Taoyuan, 33305, Taiwan, 886 33281200 ext 3971, chuang89@cgmh.org.tw %K e-learning %K gamification %K mobile technology %K randomized controlled trial %K video lecture %D 2018 %7 08.03.2018 %9 Original Paper %J JMIR Med Educ %G English %X Background: The use of mobile technology in e-learning (M-TEL) can add new levels of experience and significantly increase the attractiveness of e-learning in medical education. Whether an innovative interactive e-learning multimedia (IM) module or a conventional PowerPoint show (PPS) module using M-TEL to teach emergent otorhinolaryngology–head and neck surgery (ORL-HNS) disorders is feasible and efficient in undergraduate medical students is unknown. Objective: The aim of this study was to compare the impact of a novel IM module with a conventional PPS module using M-TEL for emergent ORL-HNS disorders with regard to learning outcomes, satisfaction, and learning experience. Methods: This pilot study was conducted at an academic teaching hospital and included 24 undergraduate medical students who were novices in ORL-HNS. The cognitive style was determined using the Group Embedded Figures Test. The participants were randomly allocated (1:1) to one of the two groups matched by age, sex, and cognitive style: the IM group and the PPS group. During the 100-min learning period, the participants were unblinded to use the IM or PPS courseware on a 7-inch tablet. Pretests and posttests using multiple-choice questions to evaluate knowledge and multimedia situational tests to evaluate competence were administered. Participants evaluated their satisfaction and learning experience by the AttrakDiff2 questionnaire, and provided feedback about the modules. Results: Overall, the participants had significant gains in knowledge (median of percentage change 71, 95% CI 1-100, P<.001) and competence (median of percentage change 25, 95% CI 0-33, P=.007) after 100 min of learning. Although there was no significant difference in knowledge gain between the two groups (median of difference of percentage change 24, 95% CI −75 to 36; P=.55), competence gain was significantly lower in the IM group compared with the PPS group (median of difference of percentage change −41, 95% CI −67 to −20; P=.008). However, the IM group had significantly higher scores of satisfaction (difference 2, 95% CI 2-4; P=.01), pragmatic quality (difference 1.7, 95% CI 0.1-2.7; P=.03), and hedonic stimulation (difference 1.9, 95% CI 0.3-3.1; P=.01) compared with the PPS group. Qualitative feedback indicated that the various games in the IM module attracted the participants’ attention but that the nonlinearly arranged materials affected their learning. Conclusions: Using M-TEL for undergraduate medical education on emergent ORL-HNS disorders, an IM module seems to be useful for gaining knowledge, but competency may need to occur elsewhere. While the small sample size reduces the statistical power of our results, its design seems to be appropriate to determine the effects of M-TEL using a larger group. Trial Registration: ClinicalTrials.gov NCT02971735; https://clinicaltrials.gov/ct2/show/NCT02971735 (Archived by WebCite at http://www.webcitation.org/6waoOpCEV) %M 29519776 %R 10.2196/mededu.9237 %U http://mededu.jmir.org/2018/1/e8/ %U https://doi.org/10.2196/mededu.9237 %U http://www.ncbi.nlm.nih.gov/pubmed/29519776 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e59 %T Evaluation of a Mobile Phone–Based Intervention to Increase Parents’ Knowledge About the Measles-Mumps-Rubella Vaccination and Their Psychological Empowerment: Mixed-Method Approach %A Fadda,Marta %A Galimberti,Elisa %A Fiordelli,Maddalena %A Schulz,Peter Johannes %+ Health Ethics and Policy Lab, Department of Health Sciences and Technology, ETH Zurich, Auf der Mauer 17, Zurich, 8092, Switzerland, 41 4463 ext 24187, marta.fadda@hest.ethz.ch %K qualitative research %K measles-mumps-rubella vaccine %K surveys and questionnaires %K mobile applications %K knowledge %K patient participation %D 2018 %7 07.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is mixed evidence on the effectiveness of vaccination-related interventions. A major limitation of most intervention studies is that they do not apply randomized controlled trials (RCTs), the method that, over the last 2 decades, has increasingly been considered as the only method to provide proof of the effectiveness of an intervention and, consequently, as the most important instrument in deciding whether to adopt an intervention or not. This study, however, holds that methods other than RCTs also can produce meaningful results. Objective: The aim of this study was to evaluate 2 mobile phone–based interventions aimed at increasing parents’ knowledge of the measles-mumps-rubella (MMR) vaccination (through elements of gamification) and their psychological empowerment (through the use of narratives), respectively. The 2 interventions were part of an RCT. Methods: We conducted 2 studies with the RCT participants: a Web-based survey aimed at assessing their rating of the tool regarding a number of qualities such as usability and usefulness (N=140), and qualitative telephonic interviews to explore participants’ experiences with the app (N=60). Results: The results of the survey showed that participants receiving the knowledge intervention (alone or together with the empowerment intervention) liked the app significantly better compared with the group that only received the empowerment intervention (F2,137=15.335; P<.001). Parents who were exposed to the empowerment intervention complained that they did not receive useful information but were only invited to make an informed, autonomous MMR vaccination decision. Conclusions: The results suggest that efforts to empower patients should always be accompanied by the provision of factual information. Using a narrative format that promotes parents’ identification can be an appropriate strategy, but it should be employed together with the presentation of more points of views and notions regarding, for instance, the risks and benefits of the vaccination at the same time. Trial Registration: International Standard Randomized Controlled Trial Number 30768813; http://www.isrctn.com/ ISRCTN30768813 (Archived by WebCite at http://www.webcitation.org/6xOQSJ3w8) %M 29514772 %R 10.2196/mhealth.8263 %U http://mhealth.jmir.org/2018/3/e59/ %U https://doi.org/10.2196/mhealth.8263 %U http://www.ncbi.nlm.nih.gov/pubmed/29514772 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e51 %T More Stamina, a Gamified mHealth Solution for Persons with Multiple Sclerosis: Research Through Design %A Giunti,Guido %A Mylonopoulou,Vasiliki %A Rivera Romero,Octavio %+ Salumedia Tecnologias, Avda. Republica Argentina nº 24, Edificio Torre de los Remedios 5ª planta modulo A, Sevilla, 41011, Spain, 34 717702622, drguidogiunti@gmail.com %K multiple sclerosis %K telemedicine %K fatigue %K mobile applications %K video games %K qualitative research %K exercise %K chronic disease %K user-computer interface %K software design %D 2018 %7 02.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X 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. %M 29500159 %R 10.2196/mhealth.9437 %U http://mhealth.jmir.org/2018/3/e51/ %U https://doi.org/10.2196/mhealth.9437 %U http://www.ncbi.nlm.nih.gov/pubmed/29500159 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 1 %P e3 %T Empirical Evidence for the Outcomes of Therapeutic Video Games for Adolescents With Anxiety Disorders: Systematic Review %A Barnes,Steven %A Prescott,Julie %+ Department of Education and Psychology, University of Bolton, Deane Road, Bolton, BB3 5AB, United Kingdom, 44 0120490 ext 3676, j.prescott@bolton.ac.uk %K anxiety disorder %K video games %K adolescent %K CBT %K eHealth %K mental health %K mobile health %D 2018 %7 28.02.2018 %9 Review %J JMIR Serious Games %G English %X Background: Extant evidence suggests that the proportion of adolescents suffering from anxiety disorders (ADs) has increased by up to 70% since the mid-1980s, with experience of anxiety at this stage associated with significant negative short- and long-term life outcomes. The existing therapeutic interventions (eg, cognitive behavioral therapy, CBT; attention bias modification, ABM) have proven to have clinically measurable benefits in reducing anxiety, but their efficacy is often compromised by social and practical barriers. The growing discrepancy between demand for, and access to, clinical interventions for anxiety has led to the development of a range of eHealth (health care practice supported by electronic processes and communication) and mHealth (versions of eHealth using mobile devices) interventions. One such protocol is therapeutic games, which aim to provide clinical frameworks in dynamic, adaptable, and personalized virtual environments. Although some evidence exists to suggest therapeutic games are associated with reductions in subjective anxiety and observed stress reactivity, there is currently, to our knowledge, no systematic review of the adherence to, and effectiveness of, therapeutic games for adolescent anxiety. Objective: The aim of this review was to establish the effectiveness of therapeutic games in making clinically measurable reductions in anxiety symptoms in adolescent samples. Methods: A systematic search of the existing academic literature published between 1990 and July 2017 was conducted using the databases Journal of Medical Internet Research, Journal Storage, Psychology Articles, Psychology Info, ScienceDIRECT, and Scopus. Records linked to empirical papers on therapeutic games for anxiety using adolescent samples were evaluated. Results: A total of 5 studies (N=410 participants) met the inclusion criteria, and 3 gamified anxiety interventions for adolescents were identified. The papers included a mixture of randomized controlled trials, quasi-experimental studies, and usability studies comprising quantitative and qualitative measures, with varying degrees of mixed methods. Extant evidence shows potential for therapeutic games to create clinically measurable reductions in symptoms of anxiety in adolescent samples, though findings are complicated in some cases by a low sample size, and in other cases by research design and methodological complications, including anxiety reductions in control groups caused by a control-game selection. Conclusions: Although research in this field appears to be extremely limited, as demonstrated by the small number of papers meeting the inclusion criteria for this review, early findings suggest that therapeutic games have potential in helping to engage adolescents with anxiety and lead to clinically measurable reductions in symptoms. %M 29490893 %R 10.2196/games.9530 %U http://games.jmir.org/2018/1/e3/ %U https://doi.org/10.2196/games.9530 %U http://www.ncbi.nlm.nih.gov/pubmed/29490893 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e56 %T Cognitive Style and Mobile E-Learning in Emergent Otorhinolaryngology-Head and Neck Surgery Disorders for Millennial Undergraduate Medical Students: Randomized Controlled Trial %A Lee,Li-Ang %A Chao,Yi-Ping %A Huang,Chung-Guei %A Fang,Ji-Tseng %A Wang,Shu-Ling %A Chuang,Cheng-Keng %A Kang,Chung-Jan %A Hsin,Li-Jen %A Lin,Wan-Ni %A Fang,Tuan-Jen %A Li,Hsueh-Yu %+ Department of Otorhinolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Guishan District, Taoyuan, 33305, Taiwan, 886 33281200 ext 3972, 5738@cgmh.org.tw %K cognitive style %K e-learning %K mobile technology %K randomized controlled trial %D 2018 %7 13.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic learning (e-learning) through mobile technology represents a novel way to teach emergent otorhinolaryngology-head and neck surgery (ORL-HNS) disorders to undergraduate medical students. Whether a cognitive style of education combined with learning modules can impact learning outcomes and satisfaction in millennial medical students is unknown. Objective: The aim of this study was to assess the impact of cognitive styles and learning modules using mobile e-learning on knowledge gain, competence gain, and satisfaction for emergent ORL-HNS disorders. Methods: This randomized controlled trial included 60 undergraduate medical students who were novices in ORL-HNS at an academic teaching hospital. The cognitive style of the participants was assessed using the group embedded figures test. The students were randomly assigned (1:1) to a novel interactive multimedia (IM) group and conventional Microsoft PowerPoint show (PPS) group matched by age, sex, and cognitive style. The content for the gamified IM module was derived from and corresponded to the textbook-based learning material of the PPS module (video lectures). The participants were unblinded and used fully automated courseware containing the IM or PPS module on a 7-inch tablet for 100 min. Knowledge and competence were assessed using multiple-choice questions and multimedia situation tests, respectively. Each participant also rated their global satisfaction. Results: All of the participants (median age 23 years, range 22-26 years; 36 males and 24 females) received the intended intervention after randomization. Overall, the participants had significant gains in knowledge (median 50%, interquartile range [IQR]=17%-80%, P<.001) and competence (median 13%, IQR=0%-33%, P=.006). There were no significant differences in knowledge gain (40%, IQR=13%-76% vs 60%, IQR=20%-100%, P=.42) and competence gain (0%, IQR= −21% to 38% vs 25%, IQR=0%-33%, P=.16) between the IM and PPS groups. However, the IM group had a higher satisfaction score (8, IQR=6-9 vs 6, IQR=4-7, P=.01) compared with the PPS group. Using Friedman’s two-way nonparametric analysis of variance, cognitive styles (field-independent, field-intermediate, or field-dependent classification) and learning modules (IM or PPS) had significant effects on both knowledge gain (both adjusted P<.001) and satisfaction (both adjusted P<.001). Conclusions: Mobile e-learning is an effective modality to improve knowledge of emergent ORL-HNS in millennial undergraduate medical students. Our findings suggest the necessity of developing various modules for undergraduate medical students with different cognitive styles. Trial Registration: Clinicaltrials.gov NCT02971735; https://clinicaltrials.gov/ct2/show/NCT02971735 (Archived by WebCite at http://www.webcitation.org/6waoOpCEV) %M 29439943 %R 10.2196/jmir.8987 %U http://www.jmir.org/2018/2/e56/ %U https://doi.org/10.2196/jmir.8987 %U http://www.ncbi.nlm.nih.gov/pubmed/29439943 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 1 %P e2 %T User-Centered Design of Learn to Quit, a Smoking Cessation Smartphone App for People With Serious Mental Illness %A Vilardaga,Roger %A Rizo,Javier %A Zeng,Emily %A Kientz,Julie A %A Ries,Richard %A Otis,Chad %A Hernandez,Kayla %+ Center for Addiction Science and Technology, Psychiatry and Behavioral Sciences, Duke University, 2812 Erwin Road, Suite 403 Box 13, Durham, NC, 27705, United States, 1 9196813441, roger.vilardaga@duke.edu %K smoking cessation %K mHealth %K serious mental illness %K user-centered design %K gamification %K acceptance and commitment therapy %D 2018 %7 16.01.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking rates in the United States have been reduced in the past decades to 15% of the general population. However, up to 88% of people with psychiatric symptoms still smoke, leading to high rates of disease and mortality. Therefore, there is a great need to develop smoking cessation interventions that have adequate levels of usability and can reach this population. Objective: The objective of this study was to report the rationale, ideation, design, user research, and final specifications of a novel smoking cessation app for people with serious mental illness (SMI) that will be tested in a feasibility trial. Methods: We used a variety of user-centered design methods and materials to develop the tailored smoking cessation app. This included expert panel guidance, a set of design principles and theory-based smoking cessation content, development of personas and paper prototyping, usability testing of the app prototype, establishment of app’s core vision and design specification, and collaboration with a software development company. Results: We developed Learn to Quit, a smoking cessation app designed and tailored to individuals with SMI that incorporates the following: (1) evidence-based smoking cessation content from Acceptance and Commitment Therapy and US Clinical Practice Guidelines for smoking cessation aimed at providing skills for quitting while addressing mental health symptoms, (2) a set of behavioral principles to increase retention and comprehension of smoking cessation content, (3) a gamification component to encourage and sustain app engagement during a 14-day period, (4) an app structure and layout designed to minimize usability errors in people with SMI, and (5) a set of stories and visuals that communicate smoking cessation concepts and skills in simple terms. Conclusions: Despite its increasing importance, the design and development of mHealth technology is typically underreported, hampering scientific innovation. This report describes the systematic development of the first smoking cessation app tailored to people with SMI, a population with very high rates of nicotine addiction, and offers new design strategies to engage this population. mHealth developers in smoking cessation and related fields could benefit from a design strategy that capitalizes on the role visual engagement, storytelling, and the systematic application of behavior analytic principles to deliver evidence-based content. %M 29339346 %R 10.2196/games.8881 %U http://games.jmir.org/2018/1/e2/ %U https://doi.org/10.2196/games.8881 %U http://www.ncbi.nlm.nih.gov/pubmed/29339346 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 4 %P e23 %T The Role of Transfer in Designing Games and Simulations for Health: Systematic Review %A Kuipers,Derek A %A Terlouw,Gijs %A Wartena,Bard O %A van 't Veer,Job TB %A Prins,Jelle T %A Pierie,Jean Pierre EN %+ NHL Stenden University of Applied Sciences, Rengerslaan 10, Leeuwarden, 8917 DD, Netherlands, 31 0646064240, kuipersd@nhl.nl %K transfer %K computer simulation %K video games %K serious games %K games for health %K fidelity %K abstract learning %K immersion %K metaphor %D 2017 %7 24.11.2017 %9 Review %J JMIR Serious Games %G English %X Background: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. Objective: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. Methods: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. Results: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. Conclusions: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health. %M 29175812 %R 10.2196/games.7880 %U http://games.jmir.org/2017/4/e23/ %U https://doi.org/10.2196/games.7880 %U http://www.ncbi.nlm.nih.gov/pubmed/29175812 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 4 %P e22 %T Breaking Health Insurance Knowledge Barriers Through Games: Pilot Test of Health Care America %A Champlin,Sara %A James,Juli %+ Mayborn School of Journalism, The University of North Texas, 1155 Union Cir, Denton, TX, 76203, United States, 1 9403697651, sara.champlin@unt.edu %K health insurance %K games, experimental %K young adult %K information literacy %D 2017 %7 16.11.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Having health insurance is associated with a number of beneficial health outcomes. However, previous research suggests that patients tend to avoid health insurance information and often misunderstand or lack knowledge about many health insurance terms. Health insurance knowledge is particularly low among young adults. Objective: The purpose of this study was to design and test an interactive newsgame (newsgames are games that apply journalistic principles in their creation, for example, gathering stories to immerse the player in narratives) about health insurance. This game included entry-level information through scenarios and was designed through the collation of national news stories, local personal accounts, and health insurance company information. Methods: A total of 72 (N=72) participants completed in-person, individual gaming sessions. Participants completed a survey before and after game play. Results: Participants indicated a greater self-reported understanding of how to use health insurance from pre- (mean=3.38, SD=0.98) to postgame play (mean=3.76, SD=0.76); t71=−3.56, P=.001. For all health insurance terms, participants self-reported a greater understanding following game play. Finally, participants provided a greater number of correct definitions for terms after playing the game, (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t31=−3.61, P=.001. Significant differences from pre- to postgame play differed by health insurance term. Conclusions: A game is a practical solution to a difficult health issue—the game can be played anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its execution. %M 29146564 %R 10.2196/games.7818 %U http://games.jmir.org/2017/4/e22/ %U https://doi.org/10.2196/games.7818 %U http://www.ncbi.nlm.nih.gov/pubmed/29146564 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 4 %P e20 %T Mommio’s Recipe Box: Assessment of the Cooking Habits of Mothers of Preschoolers and Their Perceptions of Recipes for a Video Game %A Ugalde,Maciel %A Brand,Leah %A Beltran,Alicia %A Dadabhoy,Hafza %A Chen,Tzu-An %A O'Connor,Teresia M %A Hughes,Sheryl O %A Baranowski,Tom %A Buday,Richard %A Nicklas,Theresa A %A Baranowski,Janice %+ Childrens Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St., Houston, TX, 77584, United States, 1 7137986762, tbaranow@bcm.edu %K parenting %K video game %K child %K preschool %K cooking %K vegetables %D 2017 %7 17.10.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Vegetables are an important part of a healthy diet because they help prevent several chronic diseases. Mothers of preschoolers reported difficulty getting their young children to eat vegetables, and many did not know how to cook child-pleasing recipes. Objective: The cooking habits of mothers of preschoolers, their perceptions of recipes designed for their children, and the involvement of their children in food preparation were assessed to inform a food parenting video game called Mommio. Methods: A cross-sectional survey design was used. Eligibility criteria included mothers of 3- to 5-year-old children who reported difficulty getting their children to eat vegetables. Participants completed a demographic questionnaire with questions about their food preparation practices. They were asked to select up to 4 of the 10 provided recipes they wanted to try and to prepare and report back on their experiences. Results: Most (46) of the 50 recipes included in Mommio’s in-game recipe box were evaluated at least once and some up to 5 times with a total of 85 evaluations. This well-educated, mostly employed, sample of 27 mothers of preschoolers preferred simple, quick recipes. They ate primarily at home, made dinners from scratch, and indicated that the 46 recipes were generally simple, quick, and easy to prepare. Involvement in preparation enhanced their child’s acceptance of the food. Prior food and preparation preferences influenced the children’s acceptance of the dish at the ensuing meal. Conclusions: The high rate of home recipe preparation indicated that including a recipe selection and preparation component in a food parenting video game could be attractive and may enhance effectiveness. Mothers reported that the recipes provided were generally easy to prepare, tasted good, and the instructions were easy to understand, suggesting they could be helpful to the mothers when playing a vegetable parenting game. Some mothers reported that involving their children in recipe preparation influenced their children’s willingness to eat the vegetables. The highest rated recipes are being included in the game, and mothers will be encouraged to involve their children in recipe preparation. %M 29042344 %R 10.2196/games.8142 %U http://games.jmir.org/2017/4/e20/ %U https://doi.org/10.2196/games.8142 %U http://www.ncbi.nlm.nih.gov/pubmed/29042344 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 9 %P e171 %T Protocol for Co-Design, Development, and Open Trial of a Prototype Game-Based eHealth Intervention to Treat Anxiety in Young People With Long-Term Physical Conditions %A Thabrew,Hiran %A Stasiak,Karolina %A Merry,Sally %+ University of Auckland, Department of Psychological Medicine, Level 12 Support Block, Auckland Hospital, Park Road, Grafton, Auckland, 1149, New Zealand, 64 21402055, h.thabrew@auckland.ac.nz %K long-term physical conditions %K chronic illness %K anxiety %K eHealth %K gaming %K young people %K treatment %K cognitive behavior therapy %K biofeedback %D 2017 %7 22.09.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Approximately 10% to 12% of New Zealand young people (and 21% of Maori young people) have long-term physical conditions and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse management of physical conditions, school absence, and poorer long-term outcomes. Recently, electronic health (eHealth) interventions have been shown to be as good as face-to-face therapy and biofeedback techniques have been shown to enhance relaxation during the treatment of anxiety. In addition, young people with long-term physical conditions have expressed a preference for more technologically based support, including game-based interventions, to deal with psychological issues, particularly anxiety. Objective: The aim of this study is to develop a prototype game-based eHealth intervention to address anxiety in young people with long-term physical conditions. The game will be based on the principles of cognitive behavior therapy (CBT) and will integrate a module of biofeedback-based relaxation. Methods: During the first phase of the study, up to 48 young people with long-term physical conditions aged 13 to 18 years, attending a tertiary pediatric hospital will be invited to participate in a 3-stage series of co-design workshops. Following the design, development, and refinement of a working prototype, during the second phase of the study, a further 20 young people with long-term physical conditions and anxiety will be recruited from the same location to participate in an open pilot trial to evaluate its acceptability, usability, and preliminary efficacy. Results: Changes in anxiety will be measured using the Generalized Anxiety Disorder 7-item scale (GAD-7) and the Spence Child Anxiety Scales (SCAS) at the end of every module (recommended to be completed weekly), post intervention, and 3 months later. Usability of the intervention will be measured using the System Usability Scale (SUS) and by measuring frequency and quantity of use of the intervention. Acceptability of the intervention will be assessed using brief, open-ended questionnaires and semi-structured interviews, the data from which will be analyzed using a general inductive approach. Recruitment to the study commenced in January 2017 and data collection will be completed by the end of December 2017. Conclusions: If acceptable and useful, this game-based eHealth intervention may offer a cost-effective and clinically useful intervention for addressing the psychological needs of over 16,000 young people with long term health conditions in New Zealand. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ANZCTR): ACTRN12616001253493p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443 (Archived by WebCite at http://www.webcitation.org/6sYB716lf) %M 28939545 %R 10.2196/resprot.7250 %U http://www.researchprotocols.org/2017/9/e171/ %U https://doi.org/10.2196/resprot.7250 %U http://www.ncbi.nlm.nih.gov/pubmed/28939545 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 9 %P e314 %T Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial %A Fiellin,Lynn E %A Hieftje,Kimberly D %A Pendergrass,Tyra M %A Kyriakides,Tassos C %A Duncan,Lindsay R %A Dziura,James D %A Sawyer,Benjamin G %A Mayes,Linda %A Crusto,Cindy A %A Forsyth,Brian WC %A Fiellin,David A %+ play2PREVENT Lab, Yale School of Medicine, Yale University, 367 Cedar Street, New Haven, CT, 06510, United States, 1 203 737 3347, lynn.fiellin@yale.edu %K adolescent %K videogame %K intervention %K randomized controlled trial %K human immunodeficiency virus %K risk reduction %K primary prevention %D 2017 %7 18.09.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed. Objective: We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents. Methods: Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age. Results: A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56). Conclusions: An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months. Trial Registration: Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6syumc9C0). %M 28923788 %R 10.2196/jmir.8148 %U http://www.jmir.org/2017/9/e314/ %U https://doi.org/10.2196/jmir.8148 %U http://www.ncbi.nlm.nih.gov/pubmed/28923788 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 3 %P e15 %T Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke %A Ballester,Belén Rubio %A Nirme,Jens %A Camacho,Irene %A Duarte,Esther %A Rodríguez,Susana %A Cuxart,Ampar %A Duff,Armin %A Verschure,Paul F.M.J %+ Laboratory of Synthetic Perceptive, Emotive and Cognitive Systems, Center of Autonomous Systems and Neurorobotics, Department of Information and Communication Technologies, Pompeu Fabra, Roc Boronat, 138, Barcelona, 08018, Spain, 34 +34652969755, paul.verschure@upf.edu %K stroke %K movement disorder %K recovery of function, neuroplasticity %K transcranial magnetic stimulation %K physical therapy %K hemiparesis %K computer applications software %D 2017 %7 07.08.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Most stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization. Objective: The aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy. Methods: We conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization. Results: Results from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales. Conclusions: These findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes. Trial Registration: International Standard Randomized Controlled Trial Number NCT02699398 (Archived by ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT02699398?term=NCT02699398&rank=1) %M 28784593 %R 10.2196/games.6773 %U http://games.jmir.org/2017/3/e15/ %U https://doi.org/10.2196/games.6773 %U http://www.ncbi.nlm.nih.gov/pubmed/28784593 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 3 %P e31 %T Development and Evaluation of Digital Game-Based Training for Managers to Promote Employee Mental Health and Reduce Mental Illness Stigma at Work: Quasi-Experimental Study of Program Effectiveness %A Hanisch,Sabine Elisabeth %A Birner,Ulrich Walter %A Oberhauser,Cornelia %A Nowak,Dennis %A Sabariego,Carla %+ Department of Medical Informatics, Biometry and Epidemiology, Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, Ludwig-Maximilians-University Munich, Ebene K U1, Marchioninistr. 17, Munich, 81377, Germany, 49 17677504067, bine.hanisch@gmail.com %K stigma %K mental health %K workplace %K prevention %K health promotion %K leadership %K eHealth %K Internet %D 2017 %7 04.08.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: To counteract the negative impact of mental health problems on business, organizations are increasingly investing in mental health intervention measures. However, those services are often underused, which, to a great extent, can be attributed to fear of stigmatization. Nevertheless, so far only a few workplace interventions have specifically targeted stigma, and evidence on their effectiveness is limited. Objective: The objective of this study was to develop and evaluate a digital game-based training program for managers to promote employee mental health and reduce mental illness stigma at work. Methods: We describe the empirical development of Leadership Training in Mental Health Promotion (LMHP), a digital game-based training program for leaders. A 1-group pre-post design and a 3-month follow-up were used for training evaluation. We applied multilevel growth models to investigate change over time in the dependent variables knowledge, attitudes, self-efficacy, and intentions to promote employee mental health in 48 managers of a global enterprise in the United Kingdom. Participants were mainly male (44/48, 92%) and ranged in age from 32 to 58 (mean 46.0, SD 7.2) years. Results: We found a positive impact of the Web-based training program on managers’ knowledge of mental health and mental illness (P<.001), on attitudes toward people with mental health problems (P<.01), and on their self-efficacy to deal with mental health situations at work (P<.001), with the exception of intentions to promote employee mental health, which was initially high. Conclusions: Results provide first evidence of the effectiveness of LMHP to positively affect managers’ skills to promote employee mental health at work. Furthermore, the high rate of participation in LMHP (48/54, 89%) supports the use of digital game-based interventions to increase user engagement and user experience in mental health programs at work. %M 28778839 %R 10.2196/mental.7600 %U http://mental.jmir.org/2017/3/e31/ %U https://doi.org/10.2196/mental.7600 %U http://www.ncbi.nlm.nih.gov/pubmed/28778839 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e117 %T Pacing, Conventional Physical Activity and Active Video Games to Increase Physical Activity for Adults with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Protocol for a Pilot Randomized Controlled Trial %A Ferrar,Katia Elizabeth %A Smith,Ashleigh E %A Davison,Kade %+ Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, University of South Australia, GPO Box 2471, CEA-14, Adelaide,, Australia, 61 8 8302 2554, katia.ferrar@mymail.unisa.edu.au %K fatigue syndrome, chronic %K video games %K exercise %D 2017 %7 01.08.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious illness of biological origin characterized by profound physical and cognitive exhaustion and postexertion malaise. Pacing is a common strategy used to manage available energy and complete activities of daily living; yet little research has investigated this as a strategy to increase physical activity levels. Typically, people living with ME/CFS are faced by unique barriers to physical activity participation and are less physically active than healthy peers. As such they are at increased risk of physical inactivity–related health consequences. Active video games may be a feasible and acceptable avenue to deliver physical activity intervention by overcoming many of the reported barriers to participation. Objective: The primary objective of this pilot study is to determine the feasibility and acceptability of active video games to increase physical activity levels of people with ME/CFS. The secondary aims are to explore the preliminary effectiveness of pacing and active video gaming to pacing alone and pacing plus conventional physical activity to increase the physical activity levels of adults with ME/CFS and explore the relationship between physical activity and cumulative inflammatory load (allostatic load). Methods: This study will use a mixed method design, with a 3-arm pilot randomized controlled trial, exit interviews, and collection of feasibility and process data. A total of 30 adults with ME/CFS will be randomized to receive either (1) pacing, (2) pacing and conventional physical activity, or (3) pacing and active video gaming. The intervention duration will be 6 months, and participants will be followed up for 6 months postintervention completion. The intervention will be conducted in the participant’s home, and activity intensity will be determined by continuously monitored heart rate and ratings of perceived exertion. Feasibility and acceptability and process data will be collected during and at the end of the intervention. Health-related outcomes (eg, physical activity, blood samples, quality of life, and functioning) will be collected at baseline, end of intervention, and 6 months after intervention completion. Results: This protocol was developed after 6 months of extensive stakeholder and community consultation. Enrollment began in January 2017; as of publication, 12 participants were enrolled. Baseline testing is scheduled to commence in mid-2017. Conclusions: This pilot study will provide essential feasibility and acceptability data which will guide the use of active video games for people with ME/CFS to increase their physical activity levels. Physical activity promotion in this clinical population has been poorly and under-researched, and any exploration of alternative physical activity options for this population is much needed. Trial Registration: Australia New Zealand Clinical Trials Registry: ACTRN12616000285459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370224 (Archived by WebCite at http://www.webcitation.org/6qgOLhWWf) %M 28765100 %R 10.2196/resprot.7242 %U http://www.researchprotocols.org/2017/8/e117/ %U https://doi.org/10.2196/resprot.7242 %U http://www.ncbi.nlm.nih.gov/pubmed/28765100 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 3 %P e16 %T Designing Serious Computer Games for People With Moderate and Advanced Dementia: Interdisciplinary Theory-Driven Pilot Study %A Tziraki,Chariklia %A Berenbaum,Rakel %A Gross,Daniel %A Abikhzer,Judith %A Ben-David,Boaz M %+ Communication, Aging and Neuropsychology Lab (CANlab), Baruch Ivcher School of Psychology, Interdisciplinary Center (IDC), Herzliya, PO Box 167, Herzliya, 4610101, Israel, 972 9 960 2429, boaz.ben.david@idc.ac.il %K serious games %K dementia %K functionality %K learning in context %K speed of processing %D 2017 %7 31.07.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: The field of serious games for people with dementia (PwD) is mostly driven by game-design principals typically applied to games created by and for younger individuals. Little has been done developing serious games to help PwD maintain cognition and to support functionality. Objectives: We aimed to create a theory-based serious game for PwD, with input from a multi-disciplinary team familiar with aging, dementia, and gaming theory, as well as direct input from end users (the iterative process). Targeting enhanced self-efficacy in daily activities, the goal was to generate a game that is acceptable, accessible and engaging for PwD. Methods: The theory-driven game development was based on the following learning theories: learning in context, errorless learning, building on capacities, and acknowledging biological changes—all with the aim to boost self-efficacy. The iterative participatory process was used for game screen development with input of 34 PwD and 14 healthy community dwelling older adults, aged over 65 years. Development of game screens was informed by the bio-psychological aging related disabilities (ie, motor, visual, and perception) as well as remaining neuropsychological capacities (ie, implicit memory) of PwD. At the conclusion of the iterative development process, a prototype game with 39 screens was used for a pilot study with 24 PwD and 14 healthy community dwelling older adults. The game was played twice weekly for 10 weeks. Results: Quantitative analysis showed that the average speed of successful screen completion was significantly longer for PwD compared with healthy older adults. Both PwD and controls showed an equivalent linear increase in the speed for task completion with practice by the third session (P<.02). Most important, the rate of improved processing speed with practice was not statistically different between PwD and controls. This may imply that some form of learning occurred for PwD at a nonsignificantly different rate than for controls. Qualitative results indicate that PwD found the game engaging and fun. Healthy older adults found the game too easy. Increase in self-reported self-efficacy was documented with PwD only. Conclusions: Our study demonstrated that PwD’s speed improved with practice at the same rate as healthy older adults. This implies that when tasks are designed to match PwD’s abilities, learning ensues. In addition, this pilot study of a serious game, designed for PwD, was accessible, acceptable, and enjoyable for end users. Games designed based on learning theories and input of end users and a multi-disciplinary team familiar with dementia and aging may have the potential of maintaining capacity and improving functionality of PwD. A larger longer study is needed to confirm our findings and evaluate the use of these games in assessing cognitive status and functionality. %M 28760730 %R 10.2196/games.6514 %U http://games.jmir.org/2017/3/e16/ %U https://doi.org/10.2196/games.6514 %U http://www.ncbi.nlm.nih.gov/pubmed/28760730 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 7 %P e140 %T An Intervention Using Gamification to Increase Human Immunodeficiency Virus and Sexually Transmitted Infection Screening Among Young Men Who Have Sex With Men in California: Rationale and Design of Stick To It %A Mejia,Christopher M %A Acland,Daniel %A Buzdugan,Raluca %A Grimball,Reva %A Natoli,Lauren %A McGrath,Mark R %A Klausner,Jeffrey D %A McCoy,Sandra I %+ School of Public Health, University of California, 779 University Hall, MS #7360, Berkeley, CA, 94720-7360, United States, 1 510 642 0513, smccoy@berkeley.edu %K gamification %K men who have sex with men %K young men who have sex with men %K HIV screening %K STI screening %K self-determination theory %K game design %K game elements %K incentives %K intrinsic motivation %K homosexuality, male %K human immunodeficiency virus %K sexually transmitted diseases %D 2017 %7 17.07.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: In the United States, young men who have sex with men (YMSM) remain disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Although routine HIV/STI screening is pivotal to the timely diagnosis of HIV and STIs, initiation of appropriate treatment, and reduced onward disease transmission, repeat screening is underused. Novel interventions that incorporate elements of games, an approach known as gamification, have the potential to increase routinization of HIV/STI screening among YMSM. Objective: The study aims to test the hypothesis that an incentive-based intervention that incorporates elements of gamification can increase routine HIV/STI screening among YMSM in California. Methods: The study consists of a formative research phase to develop the intervention and an implementation phase where the intervention is piloted in a controlled research setting. In the formative research phase, we use an iterative development process to design the intervention, including gathering information about the feasibility, acceptability, and expected effectiveness of potential game elements (eg, points, leaderboards, rewards). These activities include staff interviews, focus group discussions with members of the target population, and team meetings to strategize and develop the intervention. The final intervention is called Stick To It and consists of 3 components: (1) online enrollment, (2) Web-based activities consisting primarily of quizzes and a countdown “timer” to facilitate screening reminders, and (3) in-person activities that occur at 2 sexual health clinics. Participants earn points through the Web-based activities that are then redeemed for chances to win various prizes during clinic visits. The pilot study is a quasi-experimental study with a minimum of 60 intervention group participants recruited at the clinics, at community-based events, and online. We will compare outcomes in the intervention group with a historical control group consisting of individuals meeting the inclusion criteria who attended study clinics in the 12 months prior to intervention implementation. Eligible participants in the pilot study (1) are 18 to 26 years old, (2) were born or identify as male, 3) report male sexual partners, and 4) have a zip code of residence within defined areas in the vicinity of 1 of the 2 implementation sites. The primary outcome is repeat HIV/STI screening within 6 months. Results: This is an ongoing research study with initial results expected in the fourth quarter of 2017. Conclusions: We will develop and pilot test a gamification intervention to encourage YMSM to be regularly screened for HIV/STIs. The results from this research will provide preliminary evidence about the potential effectiveness of using gamification to amplify health-related behavioral change interventions. Further, the research aims to determine the processes that are essential to developing and implementing future health-related gamification interventions. Trial Registration: Clinicaltrials.gov NCT02946164; https://clinicaltrials.gov/ct2/show/NCT02946164 (Archived by WebCite at http://www.webcitation.org/6ri3G4HwD) %M 28716771 %R 10.2196/resprot.8064 %U http://www.researchprotocols.org/2017/7/e140/ %U https://doi.org/10.2196/resprot.8064 %U http://www.ncbi.nlm.nih.gov/pubmed/28716771 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 3 %P e14 %T Rehabilitation-Oriented Serious Game Development and Evaluation Guidelines for Musculoskeletal Disorders %A Idriss,Mohamad %A Tannous,Halim %A Istrate,Dan %A Perrochon,Anaick %A Salle,Jean-Yves %A Ho Ba Tho,Marie-Christine %A Dao,Tien-Tuan %+ Sorbonne University, Université de technologie de Compiègne, CNRS, UMR 7338 Biomechanics and Bioengineering, Centre de recherche Royallieu, Compiègne, CS 60 319, France, 33 0344234334, tien-tuan.dao@utc.fr %K rehabilitation exercise %K virtual rehabilitation %K rehabilitation %K user computer interface %K musculoskeletal diseases %D 2017 %7 04.07.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: The progress in information and communication technology (ICT) led to the development of a new rehabilitation technique called “serious game for functional rehabilitation.” Previous works have shown that serious games can be used for general health and specific disease management. However, there is still lack of consensus on development and evaluation guidelines. It is important to note that the game performance depends on the designed scenario. Objective: The objective of this work was to develop specific game scenarios and evaluate them with a panel of musculoskeletal patients to propose game development and evaluation guidelines. Methods: A two-stage workflow was proposed using determinant framework. The development guideline includes the selection of three-dimensional (3D) computer graphics technologies and tools, the modeling of physical aspects, the design of rehabilitation scenarios, and the implementation of the proposed scenarios. The evaluation guideline consists of the definition of evaluation metrics, the execution of the evaluation campaign, the analysis of user results and feedbacks, and the improvement of the designed game. Results: The case study for musculoskeletal disorders on the healthy control and patient groups showed the usefulness of these guidelines and associated games. All participants enjoyed the 2 developed games (football and object manipulation), and found them challenging and amusing. In particular, some healthy subjects increased their score when enhancing the level of difficulty. Furthermore, there were no risks and accidents associated with the execution of these games. Conclusions: It is expected that with the proven effectiveness of the proposed guidelines and associated games, this new rehabilitation game may be translated into clinical routine practice for the benefit of patients with musculoskeletal disorders. %M 28676468 %R 10.2196/games.7284 %U http://games.jmir.org/2017/3/e14/ %U https://doi.org/10.2196/games.7284 %U http://www.ncbi.nlm.nih.gov/pubmed/28676468 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e13 %T Gamification in Stress Management Apps: A Critical App Review %A Hoffmann,Alexandra %A Christmann,Corinna A %A Bleser,Gabriele %+ Junior research group wearHEALTH, Department of Computer Science, University of Kaiserslautern, Gottlieb-Daimler-Str. 48, Kaiserslautern, 67663, Germany, 49 631 205 3456, hoffmann@cs.uni-kl.de %K game element %K mHealth, motivation %K app %K behavior change %K gamification %D 2017 %7 07.06.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: In today’s society, stress is more and more often a cause of disease. This makes stress management an important target of behavior change programs. Gamification has been suggested as one way to support health behavior change. However, it remains unclear to which extend available gamification techniques are integrated in stress management apps, and if their occurrence is linked to the use of elements from behavior change theory. Objective: The aim of this study was to investigate the use of gamification techniques in stress management apps and the cooccurrence of these techniques with evidence-based stress management methods and behavior change techniques. Methods: A total of 62 stress management apps from the Google Play Store were reviewed on their inclusion of 17 gamification techniques, 15 stress management methods, and 26 behavior change techniques. For this purpose, an extended taxonomy of gamification techniques was constructed and applied by 2 trained, independent raters. Results: Interrater-reliability was high, with agreement coefficient (AC)=.97. Results show an average of 0.5 gamification techniques for the tested apps and reveal no correlations between the use of gamification techniques and behavior change techniques (r=.17, P=.20), or stress management methods (r=.14, P=.26). Conclusions: This leads to the conclusion that designers of stress management apps do not use gamification techniques to influence the user’s behaviors and reactions. Moreover, app designers do not exploit the potential of combining gamification techniques with behavior change theory. %M 28592397 %R 10.2196/games.7216 %U http://games.jmir.org/2017/2/e13/ %U https://doi.org/10.2196/games.7216 %U http://www.ncbi.nlm.nih.gov/pubmed/28592397 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 5 %P e93 %T The Effectiveness of a Computer Game-Based Rehabilitation Platform for Children With Cerebral Palsy: Protocol for a Randomized Clinical Trial %A Kanitkar,Anuprita %A Szturm,Tony %A Parmar,Sanjay %A Gandhi,Dorcas BC %A Rempel,Gina Ruth %A Restall,Gayle %A Sharma,Monika %A Narayan,Amitesh %A Pandian,Jeyaraj %A Naik,Nilashri %A Savadatti,Ravi R %A Kamate,Mahesh Appasaheb %+ College of Rehabilitation Sciences, University of Manitoba, R 106, 771 McDermot Ave, Winnipeg, MB, R3E0T6, Canada, 1 204 787 7747, tony.szturm@umanitoba.ca %K repetitive task practice %K cerebral palsy %K fine motor skills %K game-based exercise %K randomized controlled trial %K upper extremity function %D 2017 %7 18.05.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: It is difficult to engage young children with cerebral palsy (CP) in repetitive, tedious therapy. As such, there is a need for innovative approaches and tools to motivate these children. We developed the low-cost, computer game-based rehabilitation platform CGR that combines fine manipulation and gross movement exercises with attention and planning game activities appropriate for young children with CP. Objective: The objective of this study is to provide evidence of the therapeutic value of CGR to improve upper extremity (UE) motor function for children with CP. Methods: This randomized controlled, single-blind, clinical trial with an active control arm will be conducted at 4 sites. Children diagnosed with CP between the ages of 4 and 10 years old with moderate UE impairments and fine motor control abnormalities will be recruited. Results: We will test the difference between experimental and control groups using the Quality of Upper Extremity Skills Test (QUEST) and Peabody Developmental Motor Scales, Second Edition (PDMS-2) outcome measures. The parents of the children and the therapist experiences with the interventions and tools will be explored using semi-structured interviews using the qualitative description approach. Conclusions: This research protocol, if effective, will provide evidence for the therapeutic value and feasibility of CGR in the pediatric rehabilitation of UE function. Trial Registration: Clinicaltrials.gov NCT02728375; http:https://clinicaltrials.gov/ct2/show/NCT02728375 (Archived by WebCite at http://www.webcitation.org/6qDjvszvh) %M 28526673 %R 10.2196/resprot.6846 %U http://www.researchprotocols.org/2017/5/e93/ %U https://doi.org/10.2196/resprot.6846 %U http://www.ncbi.nlm.nih.gov/pubmed/28526673 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e11 %T Medical Student Evaluation With a Serious Game Compared to Multiple Choice Questions Assessment %A Adjedj,Julien %A Ducrocq,Gregory %A Bouleti,Claire %A Reinhart,Louise %A Fabbro,Eleonora %A Elbez,Yedid %A Fischer,Quentin %A Tesniere,Antoine %A Feldman,Laurent %A Varenne,Olivier %+ AP-HP, Hôpital Cochin, Cardiology, 27 rue du Faubourg Saint Jacques, Paris,, France, 33 158412750, olivier.varenne@aphp.fr %K serious game %K multiple choice questions %K medical student %K student evaluation %D 2017 %7 16.05.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: The gold standard for evaluating medical students’ knowledge is by multiple choice question (MCQs) tests: an objective and effective means of restituting book-based knowledge. However, concerns have been raised regarding their effectiveness to evaluate global medical skills. Furthermore, MCQs of unequal difficulty can generate frustration and may also lead to a sizable proportion of close results with low score variability. Serious games (SG) have recently been introduced to better evaluate students’ medical skills. Objectives: The study aimed to compare MCQs with SG for medical student evaluation. Methods: We designed a cross-over randomized study including volunteer medical students from two medical schools in Paris (France) from January to September 2016. The students were randomized into two groups and evaluated either by the SG first and then the MCQs, or vice-versa, for a cardiology clinical case. The primary endpoint was score variability evaluated by variance comparison. Secondary endpoints were differences in and correlation between the MCQ and SG results, and student satisfaction. Results: A total of 68 medical students were included. The score variability was significantly higher in the SG group (σ2 =265.4) than the MCQs group (σ2=140.2; P=.009). The mean score was significantly lower for the SG than the MCQs at 66.1 (SD 16.3) and 75.7 (SD 11.8) points out of 100, respectively (P<.001). No correlation was found between the two test results (R2=0.04, P=.58). The self-reported satisfaction was significantly higher for SG (P<.001). Conclusions: Our study suggests that SGs are more effective in terms of score variability than MCQs. In addition, they are associated with a higher student satisfaction rate. SGs could represent a new evaluation modality for medical students. %M 28512082 %R 10.2196/games.7033 %U http://games.jmir.org/2017/2/e11/ %U https://doi.org/10.2196/games.7033 %U http://www.ncbi.nlm.nih.gov/pubmed/28512082 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e12 %T Guidelines for the Gamification of Self-Management of Chronic Illnesses: Multimethod Study %A AlMarshedi,Alaa %A Wills,Gary %A Ranchhod,Ashok %+ University of Southampton, School of Electronics and Computer Science, SO17 1BJ, Southampton,, United Kingdom, 44 (0)23 8059 4506, aaa3g12@soton.ac.uk %K gamification %K health care %K behavior change %K self-management %K chronic illnesses %D 2017 %7 12.05.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification is the use of game elements and techniques in nongaming contexts. The use of gamification in health care is receiving a great deal of attention in both academic research and the industry. However, it can be noticed that many gamification apps in health care do not follow any standardized guidelines. Objective: This research aims to (1) present a set of guidelines based on the validated framework the Wheel of Sukr and (2) assess the guidelines through expert interviews and focus group sessions with developers. Methods: Expert interviews (N=6) were conducted to assess the content of the guidelines and that they reflect the Wheel of Sukr. In addition, the guidelines were assessed by developers (N=15) in 5 focus group sessions, where each group had an average of 3 developers. Results: The guidelines received support from the experts. By the end of the sixth interview, it was determined that a saturation point was reached. Experts agreed that the guidelines accurately reflect the framework the Wheel of Sukr and that developers can potentially use them to create gamified self-management apps for chronic illnesses. Moreover, the guidelines were welcomed by developers who participated in the focus group sessions. They found the guidelines to be clear, useful, and implementable. Also, they were able to suggest many ways of gamifying a nongamified self-management app when they were presented with one. Conclusions: The findings suggest that the guidelines introduced in this research are clear, useful, and ready to be implemented for the creation of self-management apps that use the notion of gamification as described in the Wheel of Sukr framework. The guidelines are now ready to be practically tested. Further practical studies of the effectiveness of each element in the guidelines are to be carried out. %M 28500018 %R 10.2196/games.7472 %U http://games.jmir.org/2017/2/e12/ %U https://doi.org/10.2196/games.7472 %U http://www.ncbi.nlm.nih.gov/pubmed/28500018 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e10 %T Development, Usability, and Efficacy of a Serious Game to Help Patients Learn About Pain Management After Surgery: An Evaluation Study %A Ingadottir,Brynja %A Blondal,Katrin %A Thue,David %A Zoega,Sigridur %A Thylen,Ingela %A Jaarsma,Tiny %+ Landspitali - the National University Hospital of Iceland, Surgical Services, 13A Hringbraut, Reykjavik, 101, Iceland, 354 8245884, brynjain@landspitali.is %K evaluation studies %K knowledge %K pain management %K patient education %K self care %K surgical procedures, operative %K video games %D 2017 %7 10.05.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Postoperative pain is a persistent problem after surgery and can delay recovery and develop into chronic pain. Better patient education has been proposed to improve pain management of patients. Serious games have not been previously developed to help patients to learn how to manage their postoperative pain. Objective: The aim of this study was to describe the development of a computer-based game for surgical patients to learn about postoperative pain management and to evaluate the usability, user experience, and efficacy of the game. Methods: A computer game was developed by an interdisciplinary team following a structured approach. The usability, user experience, and efficacy of the game were evaluated using self-reported questionnaires (AttrakDiff2, Postoperative Pain Management Game Survey, Patient Knowledge About Postoperative Pain Management questionnaire), semi-structured interviews, and direct observation in one session with 20 participants recruited from the general public via Facebook (mean age 48 [SD 14]; 11 women). Adjusted Barriers Questionnaire II and 3 questions on health literacy were used to collect background information. Results: Theories of self-care and adult learning, evidence for the educational needs of patients about pain management, and principles of gamification were used to develop the computer game. Ease of use and usefulness received a median score between 2.00 (IQR 1.00) and 5.00 (IQR 2.00) (possible scores 0-5; IQR, interquartile range), and ease of use was further confirmed by observation. Participants expressed satisfaction with this novel method of learning, despite some technological challenges. The attributes of the game, measured with AttrakDiff2, received a median score above 0 in all dimensions; highest for attraction (median 1.43, IQR 0.93) followed by pragmatic quality (median 1.31, IQR 1.04), hedonic quality interaction (median 1.00, IQR 1.04), and hedonic quality stimulation (median 0.57, IQR 0.68). Knowledge of pain medication and pain management strategies improved after playing the game (P=.001). Conclusions: A computer game can be an efficient method of learning about pain management; it has the potential to improve knowledge and is appreciated by users. To assess the game’s usability and efficacy in the context of preparation for surgery, an evaluation with a larger sample, including surgical patients and older people, is required. %M 28490419 %R 10.2196/games.6894 %U http://games.jmir.org/2017/2/e10/ %U https://doi.org/10.2196/games.6894 %U http://www.ncbi.nlm.nih.gov/pubmed/28490419 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e9 %T Using Computer Simulations for Investigating a Sex Education Intervention: An Exploratory Study %A Eleftheriou,Anastasia %A Bullock,Seth %A Graham,Cynthia A %A Ingham,Roger %+ Institute for Complex Systems Simulation, Electronics and Computer Science, University of Southampton, Highfield Campus, Southampton,, United Kingdom, 44 07564035077, eleftheriouanastasia@gmail.com %K sex education %K personality %K STI %K gender %K computer simulation %D 2017 %7 03.05.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sexually transmitted infections (STIs) are ongoing concerns. The best method for preventing the transmission of these infections is the correct and consistent use of condoms. Few studies have explored the use of games in interventions for increasing condom use by challenging the false sense of security associated with judging the presence of an STI based on attractiveness. Objectives: The primary purpose of this study was to explore the potential use of computer simulation as a serious game for sex education. Specific aims were to (1) study the influence of a newly designed serious game on self-rated confidence for assessing STI risk and (2) examine whether this varied by gender, age, and scores on sexuality-related personality trait measures. Methods: This paper undertook a Web-based questionnaire study employing between and within subject analyses. A Web-based platform hosted in the United Kingdom was used to deliver male and female stimuli (facial photographs) and collect data. A convenience sample group of 66 participants (64%, 42/66) male, mean age 22.5 years) completed the Term on the Tides, a computer simulation developed for this study. Participants also completed questionnaires on demographics, sexual preferences, sexual risk evaluations, the Sexual Sensation Seeking Scale (SSS), and the Sexual Inhibition Subscale 2 (SIS2) of the Sexual Inhibition/Sexual Excitation Scales-Short Form (SIS/SES - SF). Results: The overall confidence of participants to evaluate sexual risks reduced after playing the game (P<.005). Age and personality trait measures did not predict the change in confidence of evaluating risk. Women demonstrated larger shifts in confidence than did men (P=.03). Conclusions: This study extends the literature by investigating the potential of computer simulations as a serious game for sex education. Engaging in the Term on the Tides game had an impact on participants’ confidence in evaluating sexual risks. %M 28468747 %R 10.2196/games.6598 %U http://games.jmir.org/2017/2/e9/ %U https://doi.org/10.2196/games.6598 %U http://www.ncbi.nlm.nih.gov/pubmed/28468747 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e128 %T Toward Game-Based Digital Mental Health Interventions: Player Habits and Preferences %A Mandryk,Regan Lee %A Birk,Max Valentin %+ Interaction Lab, Department of Computer Science, University of Saskatchewan, 176 Thorvaldson Bldg, 110 Science Place, Saskatoon, SK, S7N5C9, Canada, 1 3069664888, regan@cs.usask.ca %K computer games %K mental health %K depression %K anxiety %D 2017 %7 20.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Designers of digital interventions for mental health often leverage interactions from games because the intrinsic motivation that results from game-based interventions may increase participation and translate into improved treatment efficacy. However, there are outstanding questions about the suitability (eg, are desktop or mobile interventions more appropriate?) and intervention potential (eg, do people with depression activate enough to play?) of games for mental health. Objective: In this paper, we aimed to describe the presently unknown relationship between gaming activity and indicators of well-being so that designers make informed choices when designing game-based interventions for mental health. Methods: We gathered validated scales of well-being (Beck’s Depression Inventory [BDI-II], Patient Health Questionnaire [PHQ-9], trait anxiety [TA], and basic psychological needs satisfaction [BPNS]), play importance (control over game behavior: control; gamer identity: identity), and play behavior (play frequency, platform preferences, and genre preferences) in a Web-based survey (N=491). Results: The majority of our participants played games a few times a week (45.3%, 222/490) or daily (34.3%, 168/490). In terms of depression, play frequency was associated with PHQ-9 (P=.003); PHQ-9 scores were higher for those who played daily than for those who played a few times a week or less. Similarly, for BDI-II (P=.01), scores were higher for those who played daily than for those who played once a week or less. Genre preferences were not associated with PHQ-9 (P=.32) or BDI-II (P=.68); however, platform preference (ie, mobile, desktop, or console) was associated with PHQ-9 (P=.04); desktop-only players had higher PHQ-9 scores than those who used all platforms. Platform preference was not associated with BDI-II (P=.18). In terms of anxiety, TA was not associated with frequency (P=.23), platform preference (P=.07), or genre preference (P=.99). In terms of needs satisfaction, BPNS was not associated with frequency (P=.25) or genre preference (P=.53), but it was associated with platform preference (P=.01); desktop-only players had lower needs satisfaction than those who used all platforms. As expected, play frequency was associated with identity (P<.001) and control (P<.001); those who played more had identified more as a gamer and had less control over their gameplay. Genre preference was associated with identity (P<.001) and control (P<.001); those who played most common genres had higher control over their play and identified most as gamers. Platform preference was not associated with control (P=.80), but was with identity (P=.001); those who played on all devices identified more as a gamer than those who played on mobiles or consoles only. Conclusions: Our results suggest that games are a suitable approach for mental health interventions as they are played broadly by people across a range of indicators of mental health. We further unpack the platform preferences and genre preferences of players with varying levels of well-being. %M 28428161 %R 10.2196/jmir.6906 %U http://www.jmir.org/2017/4/e128/ %U https://doi.org/10.2196/jmir.6906 %U http://www.ncbi.nlm.nih.gov/pubmed/28428161 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 3 %N 1 %P e7 %T Simulated Conversations With Virtual Humans to Improve Patient-Provider Communication and Reduce Unnecessary Prescriptions for Antibiotics: A Repeated Measure Pilot Study %A Schoenthaler,Antoinette %A Albright,Glenn %A Hibbard,Judith %A Goldman,Ron %+ Center for Healthful Behavior Change, Department of Population Health, NYU School of Medicine, 227 East 30th street, New York, NY, 10016, United States, 1 212 263 4205, antoinette.schoenthaler@nyumc.org %K simulation training %K health communication %K patient activation %K motivational interviewing %K decision making %D 2017 %7 19.04.2017 %9 Original Paper %J JMIR Med Educ %G English %X Background: Despite clear evidence that antibiotics do not cure viral infections, the problem of unnecessary prescribing of antibiotics in ambulatory care persists, and in some cases, prescribing patterns have increased. The overuse of antibiotics for treating viral infections has created numerous economic and clinical consequences including increased medical costs due to unnecessary hospitalizations, antibiotic resistance, disruption of gut bacteria, and obesity. Recent research has underscored the importance of collaborative patient-provider communication as a means to reduce the high rates of unnecessary prescriptions for antibiotics. However, most patients and providers do not feel prepared to engage in such challenging conversations. Objectives: The aim of this pilot study was to assess the ability of a brief 15-min simulated role-play conversation with virtual humans to serve as a preliminary step to help health care providers and patients practice, and learn how to engage in effective conversations about antibiotics overuse. Methods: A total of 69 participants (35 providers and 34 patients) completed the simulation once in one sitting. A pre-post repeated measures design was used to assess changes in patients’ and providers’ self-reported communication behaviors, activation, and preparedness, intention, and confidence to effectively communicate in the patient-provider encounter. Changes in patients’ knowledge and beliefs regarding antibiotic use were also evaluated. Results: Patients experienced a short-term positive improvement in beliefs about appropriate antibiotic use for infection (F1,30=14.10, P=.001). Knowledge scores regarding the correct uses of antibiotics improved immediately postsimulation, but decreased at the 1-month follow-up (F1,30=31.16, P<.001). There was no change in patient activation and shared decision-making (SDM) scores in the total sample of patients (P>.10) Patients with lower levels of activation exhibited positive, short-term benefits in increased intent and confidence to discuss their needs and ask questions in the clinic visit, positive attitudes regarding participation in SDM with their provider, and accurate beliefs about the use of antibiotics (P<.10). The results also suggest small immediate gains in providers’ attitudes about SDM (mean change 0.20; F1,33= 8.03, P=.01). Conclusions: This pilot study provided preliminary evidence on the efficacy of the use of simulated conversations with virtual humans as a tool to improve patient-provider communication (ie, through increasing patient confidence to actively participate in the visit and physician attitudes about SDM) for engaging in conversations about antibiotic use. Future research should explore if repeated opportunities to use the 15-min simulation as well as providing users with several different conversations to practice with would result in sustained improvements in antibiotics beliefs and knowledge and communication behaviors over time. The results of this pilot study offered several opportunities to improve on the simulation in order to bolster communication skills and knowledge retention. %M 28428160 %R 10.2196/mededu.6305 %U http://mededu.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/mededu.6305 %U http://www.ncbi.nlm.nih.gov/pubmed/28428160 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e7 %T Who Is Still Playing Pokémon Go? A Web-Based Survey %A Rasche,Peter %A Schlomann,Anna %A Mertens,Alexander %+ Institute of Industrial Engineering and Ergonomics, Department of Mechanical Engineering, RWTH Aachen University, Bergdriesch 27, Aachen, 52062, Germany, 49 2418099477, p.rasche@iaw.rwth-aachen.de %K games %K recreational %K mobile apps %K cell phones %K Pokémon Go %D 2017 %7 05.04.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Poor physical activity is one of the major health care problems in Western civilizations. Various digital gadgets aiming to increase physical activity, such as activity trackers or fitness apps, have been introduced over recent years. The newest products are serious games that incorporate real-life physical activity into their game concept. Recent studies have shown that such games increase the physical activity of their users over the short term. Objective: In this study, we investigated the motivational effects of the digital game “Pokémon Go” leading to continued use or abandonment of the game. The aim of the study was to determine aspects that motivate individuals to play augmented reality exergames and how this motivation can be used to strengthen the initial interest in physical activity. Methods: A total of 199 participants completed an open self-selected Web-based survey. On the basis of their self-indicated assignment to one of three predefined user groups (active, former, and nonuser of Pokémon Go), participants answered various questions regarding game experience, physical activity, motivation, and personality as measured by the Big Five Inventory. Results: In total, 81 active, 56 former, and 62 nonusers of Pokémon Go were recruited. When asked about the times they perform physical activity, active users stated that they were less physically active in general than former and nonusers. However, based on a subjective rating, active users were more motivated to be physically active due to playing Pokémon Go. Motivational aspects differed for active and former users, whereas fan status was the same within both groups. Active users are more motivated by features directly related to Pokémon, such as catching all possible Pokémon and reaching higher levels, whereas former users stress the importance of general game quality, such as better augmented reality and more challenges in the game. Personality did not affect whether a person started to play Pokémon Go nor their abandonment of the game. Conclusions: The results show various motivating elements that should be incorporated into augmented reality exergames based on the game Pokémon Go. We identified different user types for whom different features of the game contribute to maintained motivation or abandonment. Our results show aspects that augmented reality exergame designers should keep in mind to encourage individuals to start playing their game and facilitate long-term user engagement, resulting in a greater interest in physical activity. %M 28381393 %R 10.2196/games.7197 %U http://games.jmir.org/2017/2/e7/ %U https://doi.org/10.2196/games.7197 %U http://www.ncbi.nlm.nih.gov/pubmed/28381393 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e6 %T A Blended Web-Based Gaming Intervention on Changes in Physical Activity for Overweight and Obese Employees: Influence and Usage in an Experimental Pilot Study %A Kouwenhoven-Pasmooij,Tessa A %A Robroek,Suzan JW %A Ling,Sui Wai %A van Rosmalen,Joost %A van Rossum,Elisabeth FC %A Burdorf,Alex %A Hunink,MG Myriam %+ Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Na2818, Postbus 2040, Rotterdam, 3000CA, Netherlands, 31 107043489, t.kouwenhoven@erasmusmc.nl %K eHealth %K gamification %K physical activity %K fitness tracker %K body mass index %K engagement %K social support %K blended care %D 2017 %7 03.04.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Addressing the obesity epidemic requires the development of effective interventions aimed at increasing physical activity (PA). eHealth interventions with the use of accelerometers and gaming elements, such as rewarding or social bonding, seem promising. These eHealth elements, blended with face-to-face contacts, have the potential to help people adopt and maintain a physically active lifestyle. Objective: The aim of this study was to assess the influence and usage of a blended Web-based gaming intervention on PA, body mass index (BMI), and waist circumference among overweight and obese employees. Methods: In an uncontrolled before-after study, we observed 52 health care employees with BMI more than 25 kg/m2, who were recruited via the company’s intranet and who voluntarily participated in a 23-week Web-based gaming intervention, supplemented (blended) with non-eHealth components. These non-eHealth components were an individual session with an occupational health physician involving motivational interviewing and 5 multidisciplinary group sessions. The game was played by teams in 5 time periods, aiming to gain points by being physically active, as measured by an accelerometer. Data were collected in 2014 and 2015. Primary outcome was PA, defined as length of time at MET (metabolic equivalent task) ≥3, as measured by the accelerometer during the game. Secondary outcomes were reductions in BMI and waist circumference, measured at baseline and 10 and 23 weeks after the start of the program. Gaming elements such as “compliance” with the game (ie, days of accelerometer wear), “engagement” with the game (ie, frequency of reaching a personal monthly target), and “eHealth teams” (ie, social influence of eHealth teams) were measured as potential determinants of the outcomes. Linear mixed models were used to evaluate the effects on all outcome measures. Results: The mean age of participants was 48.1 years; most participants were female (42/51, 82%). The mean PA was 86 minutes per day, ranging from 6.5 to 223 minutes, which was on average 26.2 minutes per day more than self-reported PA at baseline and remained fairly constant during the game. Mean BMI was reduced by 1.87 kg/m2 (5.6%) and waist circumference by 5.6 cm (4.8%). The univariable model showed that compliance, engagement, and eHealth team were significantly associated with more PA, which remained significant for eHealth team in the multivariable model. Conclusions: This blended Web-based gaming intervention was beneficial for overweight workers in becoming physically active above the recommended activity levels during the entire intervention period, and a favorable influence on BMI and waist circumference was observed. Promising components in the intervention, and thus targets for upscaling, are eHealth teams and engagement with the game. Broader implementation and long-term follow-up can provide insights into the sustainable effects on PA and weight loss and into who benefits the most from this approach. %M 28373157 %R 10.2196/games.6421 %U http://games.jmir.org/2017/2/e6/ %U https://doi.org/10.2196/games.6421 %U http://www.ncbi.nlm.nih.gov/pubmed/28373157 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e86 %T Pedestrian Inattention Blindness While Playing Pokémon Go as an Emerging Health-Risk Behavior: A Case Report %A Barbieri,Stefania %A Vettore,Gianna %A Pietrantonio,Vincenzo %A Snenghi,Rossella %A Tredese,Alberto %A Bergamini,Mauro %A Previato,Sara %A Stefanati,Armando %A Gaudio,Rosa Maria %A Feltracco,Paolo %+ Department of Urgent and Emergency Care, University of Padova, Via Giustiniani 2, Padova, Padova,, Italy, 39 0498074414, stefibarbieri118@gmail.com %K Pokémon Go %K videogames %K pedestrians %K multiple trauma %K traffic accidents %K motor vehicle collisions %K road injuries %D 2017 %7 01.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street. Objective: We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage. Methods: We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient’s history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital’s privacy policy. Results: The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game. Conclusions: Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims. %M 28365563 %R 10.2196/jmir.6596 %U http://www.jmir.org/2017/4/e86/ %U https://doi.org/10.2196/jmir.6596 %U http://www.ncbi.nlm.nih.gov/pubmed/28365563 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e5 %T Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach %A Hale,Alexander R %A Young,Vicki Louise %A Grand,Ann %A McNulty,Cliodna Ann Miriam %+ Public Health England, Primary Care Unit, Gloucestershire Royal Hospital, Gloucester, GL1 3NN, United Kingdom, 44 300 422 5062, vicki.young@phe.gov.uk %K antibiotic resistance %K computer games %K children %K education %K e-Bug %D 2017 %7 24.03.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of 3 antibiotic games on the e-Bug student website, exploring children’s views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed. Results: The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game “Body Busters” was the most popular, closely followed by “Doctor Doctor,” and “Microbe Mania” the least popular. Conclusions: This study shows that 2 of the e-Bug antibiotic educational games are valuable. “Body Busters” effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. “Doctor Doctor” also resulted in increased knowledge, but was less enjoyable. “Microbe Mania” had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games. %M 28341618 %R 10.2196/games.6420 %U http://games.jmir.org/2017/1/e5/ %U https://doi.org/10.2196/games.6420 %U http://www.ncbi.nlm.nih.gov/pubmed/28341618 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e79 %T Microsoft Kinect-based Continuous Performance Test: An Objective Attention Deficit Hyperactivity Disorder Assessment %A Delgado-Gomez,David %A Peñuelas-Calvo,Inmaculada %A Masó-Besga,Antonio Eduardo %A Vallejo-Oñate,Silvia %A Baltasar Tello,Itziar %A Arrua Duarte,Elsa %A Vera Varela,María Constanza %A Carballo,Juan %A Baca-García,Enrique %+ Hospital Universitario Fundación Jiménez Díaz, Child and Adolescents Service, Avenida Reyes Católicos, 2, Madrid,, Spain, 34 915417267, inmaculada.penuelas@quironsalud.es %K kinect %K attention deficit hyperactivity disorder %K continuous performance test %K impulsivity %K hyperactivity %D 2017 %7 20.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: One of the major challenges in mental medical care is finding out new instruments for an accurate and objective evaluation of the attention deficit hyperactivity disorder (ADHD). Early ADHD identification, severity assessment, and prompt treatment are essential to avoid the negative effects associated with this mental condition. Objective: The aim of our study was to develop a novel ADHD assessment instrument based on Microsoft Kinect, which identifies ADHD cardinal symptoms in order to provide a more accurate evaluation. Methods: A group of 30 children, aged 8-12 years (10.3 [SD 1.4]; male 70% [21/30]), who were referred to the Child and Adolescent Psychiatry Unit of the Department of Psychiatry at Fundación Jiménez Díaz Hospital (Madrid, Spain), were included in this study. Children were required to meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria of ADHD diagnosis. One of the parents or guardians of the children filled the Spanish version of the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior (SWAN) rating scale used in clinical practice. Each child conducted a Kinect-based continuous performance test (CPT) in which the reaction time (RT), the commission errors, and the time required to complete the reaction (CT) were calculated. The correlations of the 3 predictors, obtained using Kinect methodology, with respect to the scores of the SWAN scale were calculated. Results: The RT achieved a correlation of -.11, -.29, and -.37 with respect to the inattention, hyperactivity, and impulsivity factors of the SWAN scale. The correlations of the commission error with respect to these 3 factors were -.03, .01, and .24, respectively. Conclusions: Our findings show a relation between the Microsoft Kinect-based version of the CPT and ADHD symptomatology assessed through parental report. Results point out the importance of future research on the development of objective measures for the diagnosis of ADHD among children and adolescents. %M 28320691 %R 10.2196/jmir.6985 %U http://www.jmir.org/2017/3/e79/ %U https://doi.org/10.2196/jmir.6985 %U http://www.ncbi.nlm.nih.gov/pubmed/28320691 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e72 %T InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians %A Diehl,Leandro Arthur %A Souza,Rodrigo Martins %A Gordan,Pedro Alejandro %A Esteves,Roberto Zonato %A Coelho,Izabel Cristina Meister %+ Internal Medicine Department, Health Sciences Center, Londrina State University (UEL), Depto Clinica Medica/CCS, Av Robert Koch 60, Londrina PR, 86038350, Brazil, 55 4333712234, drgaucho@yahoo.com %K diabetes mellitus %K insulin %K video games %K medical education %K continuing medical education %K educational technology %D 2017 %7 09.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated. Objective: The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity. Methods: Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively. Results: Subjects’ characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as “fun or pleasant,” “useful,” and “practice-changing.” Conclusions: The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients. Trial Registration: Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf) %M 28279950 %R 10.2196/jmir.6944 %U http://www.jmir.org/2017/3/e72/ %U https://doi.org/10.2196/jmir.6944 %U http://www.ncbi.nlm.nih.gov/pubmed/28279950 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e4 %T A Mobile, Avatar-Based App for Improving Body Perceptions Among Adolescents: A Pilot Test %A Lyles,Annmarie A %A Amresh,Ashish %A Huberty,Jennifer %A Todd,Michael %A Lee,Rebecca E %+ College of Nursing and Health Innovation, Arizona State University, 550 N 3rd St, Phoenix, AZ, 85004, United States, 1 602 496 2196, Annmarie.Lyles@asu.edu %K adolescents %K avatars %K eHealth %K mHealth %K perceptions %K Web-based %K usability testing %D 2017 %7 02.03.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: One barrier to effectively treating weight issues among adolescents is that they tend to use social comparison instead of objective measures to evaluate their own health status. When adolescents correctly perceive themselves as overweight, they are more likely to adopt healthy lifestyle behaviors. Objective: The purpose of this pilot test was to develop and assess acceptability and usability of an avatar-based, theoretically derived mobile app entitled Monitor Your Avatar (MYA). Methods: The MYA app was engineered for high school adolescents to identify, using avatars, what they thought they looked like, what they wanted to look like, and what they actually looked like based on body measurements. Results: The MYA app was pilot-tested with male and female adolescents aged 15-18 years to assess for acceptability and usability. A total of 42 students created and viewed their avatars. The majority of the adolescents were female (28/42, 67%), age 16 years (16/42, 38%), white (35/42, 83%), non-Hispanic (36/42, 86%), in grade 10 (20/42, 48%), healthy weight for females (23/28, 82%), and obese for males (7/14, 50%). The adolescents had positive reactions to the avatar app and being able to view avatars that represented them. All but one student (41/42, 98%) indicated some level of comfort viewing the avatars and would use the app in the future to see how their bodies change over time. Conclusions: Avatar-based mobile apps, such as the MYA app, provide immediate feedback and allow users to engage with images that are personalized to represent their perceptions and actual body images. This pilot study adds to the increasing but limited research of using games to improve health outcomes among high school adolescents. There is a need to further adapt the MYA app and gather feedback from a larger number of high school adolescents, including those from diverse backgrounds. %M 28254737 %R 10.2196/games.6354 %U http://games.jmir.org/2017/1/e4/ %U https://doi.org/10.2196/games.6354 %U http://www.ncbi.nlm.nih.gov/pubmed/28254737 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e3 %T Game-Based Rehabilitation for Myoelectric Prosthesis Control %A Prahm,Cosima %A Vujaklija,Ivan %A Kayali,Fares %A Purgathofer,Peter %A Aszmann,Oskar C %+ Christian Doppler Laboratory for Restoration of Extremity Function, Department of Plastic and Reconstructive Surgery, Medical University of Vienna, University Clinic for Surgery, Währinger Gürtel 18-20, Vienna, 1090, Austria, 43 140400 ext 61098, cosima.prahm@meduniwien.ac.at %K upper limb prosthesis control %K upper extremity amputees %K gaming %K serious games %K neuromuscular rehabilitation %K intrinsic motivation %K EMG control %D 2017 %7 09.02.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: A high number of upper extremity myoelectric prosthesis users abandon their devices due to difficulties in prosthesis control and lack of motivation to train in absence of a physiotherapist. Virtual training systems, in the form of video games, provide patients with an entertaining and intuitive method for improved muscle coordination and improved overall control. Complementary to established rehabilitation protocols, it is highly beneficial for this virtual training process to start even before receiving the final prosthesis, and to be continued at home for as long as needed. Objective: The aim of this study is to evaluate (1) the short-term effects of a commercially available electromyographic (EMG) system on controllability after a simple video game-based rehabilitation protocol, and (2) different input methods, control mechanisms, and games. Methods: Eleven able-bodied participants with no prior experience in EMG control took part in this study. Participants were asked to perform a surface EMG test evaluating their provisional maximum muscle contraction, fine accuracy and isolation of electrode activation, and endurance control over at least 300 seconds. These assessments were carried out (1) in a Pregaming session before interacting with three EMG-controlled computer games, (2) in a Postgaming session after playing the games, and (3) in a Follow-Up session two days after the gaming protocol to evaluate short-term retention rate. After each game, participants were given a user evaluation survey for the assessment of the games and their input mechanisms. Participants also received a questionnaire regarding their intrinsic motivation (Intrinsic Motivation Inventory) at the end of the last game. Results: Results showed a significant improvement in fine accuracy electrode activation (P<.01), electrode separation (P=.02), and endurance control (P<.01) from Pregaming EMG assessments to the Follow-Up measurement. The deviation around the EMG goal value diminished and the opposing electrode was activated less frequently. Participants had the most fun playing the games when collecting items and facing challenging game play. Conclusions: Most upper limb amputees use a 2-channel myoelectric prosthesis control. This study demonstrates that this control can be effectively trained by employing a video game-based rehabilitation protocol. %M 28183689 %R 10.2196/games.6026 %U https://games.jmir.org/2017/1/e3/ %U https://doi.org/10.2196/games.6026 %U http://www.ncbi.nlm.nih.gov/pubmed/28183689 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e2 %T User-Centered Design of Serious Games for Older Adults Following 3 Years of Experience With Exergames for Seniors: A Study Design %A Brox,Ellen %A Konstantinidis,Stathis Th %A Evertsen,Gunn %+ Norut Northern Research Institute, Box 6434, Tromsoe,, Norway, 47 91847928, ellenbrox@gmail.com %K user studies %K usability testing %K gestural input %K user-centred design %K accessibility %K consumer health %K exergames %K participatory design %K lessons learned %D 2017 %7 11.01.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Seniors need sufficient balance and strength to manage in daily life, and sufficient physical activity is required to achieve and maintain these abilities. This can be a challenge, but fun and motivational exergames can be of help. However, most commercial games are not suited for this age group for several reasons. Many usability studies and user-centered design (UCD) protocols have been developed and applied, but to the best of our knowledge none of them are focusing on seniors’ use of games for physical activity. In GameUp, a European cofunded project, some prototype Kinect exergames to enhance the mobility of seniors were developed in a user-centered approach. Objective: In this paper we aim to record lessons learned in 3 years of experience with exergames for seniors, considering both the needs of older adults regarding user-centered development of exergames and participation in UCD. We also provide a UCD protocol for exergames tailored to senior needs. Methods: An initial UCD protocol was formed based on literature of previous research outcomes. Senior users participated in UCD following the initial protocol. The users formed a steady group that met every second week for 3 years to play exergames and participate in the UCD during the 4 phases of the protocol. Several methods were applied in the 4 different phases of the UCD protocol; the most important methods were structured and semistructured interviews, observations, and group discussions. Results: A total of 16 seniors with an average age above 80 years participated for 3 years in UCD in order to develop the GameUp exergames. As a result of the lessons learned by applying the different methodologies of the UCD protocol, we propose an adjusted UCD protocol providing explanations on how it should be applied for seniors as users. Questionnaires should be turned into semistructured and structured interviews while user consultation sessions should be repeated with the same theme to ensure that the UCD methods produce a valid outcome. By first following the initial and gradually the adjusted UCD protocol, the project resulted in exergame functionalities and interface features for seniors. Conclusions: The main lessons learned during 3 years of experience with exergames for seniors applying UCD are that devoting time to seniors is a key element of success so that trust can be gained, communication can be established, and users’ opinions can be recorded. All different game elements should be taken into consideration during the design of exergames for seniors even if they seem obvious. Despite the limitations of this study, one might argue that it provides a best practice guide to the development of serious games for physical activity targeting seniors. %M 28077348 %R 10.2196/games.6254 %U http://games.jmir.org/2017/1/e2/ %U https://doi.org/10.2196/games.6254 %U http://www.ncbi.nlm.nih.gov/pubmed/28077348 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e3 %T The Use of Motion-Based Technology for People Living With Dementia or Mild Cognitive Impairment: A Literature Review %A Dove,Erica %A Astell,Arlene J %+ Research & Academics, Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, ON, L1N 5S9, Canada, 1 905 430 4055 ext 6313, dovee@ontarioshores.ca %K dementia %K mild cognitive impairment %K technology %K review %D 2017 %7 11.01.2017 %9 Review %J J Med Internet Res %G English %X Background: The number of people living with dementia and mild cognitive impairment (MCI) is increasing substantially. Although there are many research efforts directed toward the prevention and treatment of dementia and MCI, it is also important to learn more about supporting people to live well with dementia or MCI through cognitive, physical, and leisure means. While past research suggests that technology can be used to support positive aging for people with dementia or MCI, the use of motion-based technology has not been thoroughly explored with this population. Objective: The aim of this study was to identify and synthesize the current literature involving the use of motion-based technology for people living with dementia or MCI by identifying themes while noting areas requiring further research. Methods: A systematic review of studies involving the use of motion-based technology for human participants living with dementia or MCI was conducted. Results: A total of 31 articles met the inclusion criteria. Five questions are addressed concerning (1) context of use; (2) population included (ie, dementia, MCI, or both); (3) hardware and software selection; (4) use of motion-based technology in a group or individual setting; and (5) details about the introduction, teaching, and support methods applied when using the motion-based technology with people living with dementia or MCI. Conclusions: The findings of this review confirm the potential of motion-based technology to improve the lives of people living with dementia or MCI. The use of this technology also spans across several contexts including cognitive, physical, and leisure; all of which support multidimensional well-being. The literature provides evidence that people living with dementia or MCI can learn how to use this technology and that they enjoy doing so. However, there is a lack of information provided in the literature regarding the introduction, training, and support methods applied when using this form of technology with this population. Future research should address the appropriate introduction, teaching, and support required for people living with dementia or MCI to use the motion-based technology. In addition, it is recommended that the diverse needs of these specific end-users be considered in the design and development of this technology. %M 28077346 %R 10.2196/jmir.6518 %U http://www.jmir.org/2017/1/e3/ %U https://doi.org/10.2196/jmir.6518 %U http://www.ncbi.nlm.nih.gov/pubmed/28077346 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e1 %T Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology %A Paim,Crislaine Pires Padilha %A Goldmeier,Silvia %+ Institute of Cardiology of Rio Grande do Sul, University Foundation of Cardiology, 395 Princesa Isabel Avenue, Porto Alegre, 90620-001, Brazil, 55 51 32303600, sgoldmeier@gmail.com %K nursing education research %K educational technology %K perioperative nursing %D 2017 %7 10.01.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Existing research suggests that digital games can be used effectively for educational purposes at any level of training. Perioperative nursing educators can use games to complement curricula, in guidance and staff development programs, to foster team collaboration, and to give support to critical thinking in nursing practice because it is a complex environment. Objective: To describe the process of developing an educational game to set up surgical instruments on the Mayo stand or back table as a resource to assist the instructor in surgical instrumentation training for students and nursing health professionals in continued education. Methods: The study was characterized by applied research in production technology. It included the phases of analysis and design, development, and evaluation. The objectives of the educational game were developed through Bloom’s taxonomy. Parallel to the physical development of the educational game, a proposed model for the use of digital elements in educational game activities was applied to develop the game content. Results: The development of the game called “Playing with Tweezers” was carried out in 3 phases and was evaluated by 15 participants, comprising students and professional experts in various areas of knowledge such as nursing, information technology, and education. An environment was created with an initial screen, menu buttons containing the rules of the game, and virtual tour modes for learning and assessment. Conclusions: The “digital” nursing student needs engagement, stimulation, reality, and entertainment, not just readings. “Playing with Tweezers” is an example of educational gaming as an innovative teaching strategy in nursing that encourages the strategy of involving the use of educational games to support theoretical or practical classroom teaching. Thus, the teacher does not work with only 1 type of teaching methodology, but with a combination of different methodologies. In addition, we cannot forget that skill training in an educational game does not replace curricular practice, but helps. %M 28073736 %R 10.2196/games.6048 %U http://games.jmir.org/2017/1/e1/ %U https://doi.org/10.2196/games.6048 %U http://www.ncbi.nlm.nih.gov/pubmed/28073736 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e21 %T Design of a Serious Game for Handling Obstetrical Emergencies %A Jean dit Gautier,Estelle %A Bot-Robin,Virginie %A Libessart,Aurélien %A Doucède,Guillaume %A Cosson,Michel %A Rubod,Chrystèle %+ Department of Gynecology Surgery, Hopital Jeanne de Flandre, University of Lille, Rue Eugéne Avinée, Lille cedex, 59037, France, 33 624634623, estelle.jdg@gmail.com %K serious game %K obstetric emergencies %K gynecology %D 2016 %7 21.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game. Objective: Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations. Methods: A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative. Results: Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested. Conclusions: Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development. %M 28003175 %R 10.2196/games.5526 %U http://games.jmir.org/2016/2/e21/ %U https://doi.org/10.2196/games.5526 %U http://www.ncbi.nlm.nih.gov/pubmed/28003175 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e22 %T Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students’ Experiences Using a Multiplayer Virtual World %A Creutzfeldt,Johan %A Hedman,Leif %A Felländer-Tsai,Li %+ Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K32, Karolinska University Hospital, Stockholm, 14186, Sweden, 46 8 585 82102, johan.creutzfeldt@ki.se %K avatars %K cardiopulmonary resuscitation %K educational technology %K medical students %K experiences %K multiplayer virtual worlds %K patient simulation %K virtual learning environments %D 2016 %7 16.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners’ reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students’ perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students’ experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. %M 27986645 %R 10.2196/games.6448 %U http://games.jmir.org/2016/2/e22/ %U https://doi.org/10.2196/games.6448 %U http://www.ncbi.nlm.nih.gov/pubmed/27986645 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 12 %P e315 %T Influence of Pokémon Go on Physical Activity: Study and Implications %A Althoff,Tim %A White,Ryen W %A Horvitz,Eric %+ Computer Science Department, Stanford University, 94 Thoburn Ct., Apt 108, Stanford, CA, 94305, United States, 1 6504850758, althoff@cs.stanford.edu %K physical activity %K Pokémon Go %K mobile health %K mHealth %K wearable devices %K mobile applications %K games %K exergames %K public health %D 2016 %7 06.12.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity helps people maintain a healthy weight and reduces the risk for several chronic diseases. Although this knowledge is widely recognized, adults and children in many countries around the world do not get recommended amounts of physical activity. Although many interventions are found to be ineffective at increasing physical activity or reaching inactive populations, there have been anecdotal reports of increased physical activity due to novel mobile games that embed game play in the physical world. The most recent and salient example of such a game is Pokémon Go, which has reportedly reached tens of millions of users in the United States and worldwide. Objective: The objective of this study was to quantify the impact of Pokémon Go on physical activity. Methods: We study the effect of Pokémon Go on physical activity through a combination of signals from large-scale corpora of wearable sensor data and search engine logs for 32,000 Microsoft Band users over a period of 3 months. Pokémon Go players are identified through search engine queries and physical activity is measured through accelerometers. Results: We find that Pokémon Go leads to significant increases in physical activity over a period of 30 days, with particularly engaged users (ie, those making multiple search queries for details about game usage) increasing their activity by 1473 steps a day on average, a more than 25% increase compared with their prior activity level (P<.001). In the short time span of the study, we estimate that Pokémon Go has added a total of 144 billion steps to US physical activity. Furthermore, Pokémon Go has been able to increase physical activity across men and women of all ages, weight status, and prior activity levels showing this form of game leads to increases in physical activity with significant implications for public health. In particular, we find that Pokémon Go is able to reach low activity populations, whereas all 4 leading mobile health apps studied in this work largely draw from an already very active population. Conclusions: Mobile apps combining game play with physical activity lead to substantial short-term activity increases and, in contrast to many existing interventions and mobile health apps, have the potential to reach activity-poor populations. Future studies are needed to investigate potential long-term effects of these applications. %M 27923778 %R 10.2196/jmir.6759 %U http://www.jmir.org/2016/12/e315/ %U https://doi.org/10.2196/jmir.6759 %U http://www.ncbi.nlm.nih.gov/pubmed/27923778 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e20 %T Attentional Bias Modification With Serious Game Elements: Evaluating the Shots Game %A Boendermaker,Wouter J %A Sanchez Maceiras,Soraya %A Boffo,Marilisa %A Wiers,Reinout W %+ Department of Child and Adolescent Studies, Utrecht University, Heidelberglaan 1, Utrecht, 3584 CS, Netherlands, 31 302534742, w.j.boendermaker@uu.nl %K cognitive training %K cognitive bias modification (CBM) %K attentional bias %K adolescents %K serious games %K motivation %D 2016 %7 06.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Young adults often experiment with heavy use of alcohol, which poses severe health risks and increases the chance of developing addiction problems. In clinical patients, cognitive retraining of automatic appetitive processes, such as selective attention toward alcohol (known as “cognitive bias modification of attention,” or CBM-A), has been shown to be a promising add-on to treatment, helping to prevent relapse. Objective: To prevent escalation of regular use into problematic use in youth, motivation appears to play a pivotal role. As CBM-A is often viewed as long and boring, this paper presents this training with the addition of serious game elements as a novel approach aimed at enhancing motivation to train. Methods: A total of 96 heavy drinking undergraduate students carried out a regular CBM-A training, a gamified version (called “Shots”), or a placebo training version over 4 training sessions. Measures of motivation to change their behavior, motivation to train, drinking behavior, and attentional bias for alcohol were included before and after training. Results: Alcohol attentional bias was reduced after training only in the regular training condition. Self-reported drinking behavior was not affected, but motivation to train decreased in all conditions, suggesting that the motivational features of the Shots game were not enough to fully counteract the tiresome nature of the training. Moreover, some of the motivational aspects decreased slightly more in the game condition, which may indicate potential detrimental effects of disappointing gamification. Conclusions: Gamification is not without its risks. When the motivational value of a training task with serious game elements is less than expected by the adolescent, effects detrimental to their motivation may occur. We therefore advise caution when using gamification, as well as underscore the importance of careful scientific evaluation. %M 27923780 %R 10.2196/games.6464 %U http://games.jmir.org/2016/2/e20/ %U https://doi.org/10.2196/games.6464 %U http://www.ncbi.nlm.nih.gov/pubmed/27923780 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e19 %T Quittr: The Design of a Video Game to Support Smoking Cessation %A Bindoff,Ivan %A de Salas,Kristy %A Peterson,Gregory %A Ling,Tristan %A Lewis,Ian %A Wells,Lindsay %A Gee,Peter %A Ferguson,Stuart G %+ University of Tasmania, Private Bag 87, Hobart, 7001, Australia, 61 3 62266220, Kristy.deSalas@utas.edu.au %K smoking cessation %K video games %K mobile phone %K motivation %D 2016 %7 01.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking is recognized as the largest, single, preventable cause of death and disease in the developed world. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term abstinence. Behavioral support, such as education, advice, goal-setting, and encouragement, is known to be beneficial in improving the likelihood of succeeding in a quit attempt, but it remains difficult to effectively deliver this behavioral support and keep the patient engaged with the process for a sufficient duration. In an attempt to solve this, there have been numerous mobile apps developed, yet engagement and retention have remained key challenges that limit the potential effectiveness of these interventions. Video games have been clearly linked with the effective delivery of health interventions, due to their capacity to increase motivation and engagement of players. Objective: The objective of this study is to describe the design and development of a smartphone app that is theory-driven, and which incorporates gaming characteristics in order to promote engagement with content, and thereby help smokers to quit. Methods: Game design and development was informed by a taxonomy of motivational affordances for meaningful gamified and persuasive technologies. This taxonomy describes a set of design components that is grounded in well-established psychological theories on motivation. Results: This paper reports on the design and development process of Quittr, a mobile app, describing how game design principles, game mechanics, and game elements can be used to embed education and support content, such that the app actually requires the user to access and engage with relevant educational content. The next stage of this research is to conduct a randomized controlled trial to determine whether the additional incentivization game features offer any value in terms of the key metrics of engagement–how much content users are consuming, how many days users are persisting with using the app, and what proportion of users successfully abstain from smoking for 28 days, based on user-reported data and verified against a biochemical baseline using cotinine tests. Conclusions: We describe a novel, and theoretically-informed mobile app design approach that has a broad range of potential applications. By using the virtual currency approach, we remove the need for the game to comprehensively integrate the healthy activity as part of its actual play mechanics. This opens up the potential for a wide variety of health problems to be tackled through games where no obvious play mechanic presents itself. The implications of this app are that similar approaches may be of benefit in areas such as managing chronic conditions (diabetes, heart disease, etc), treating substance abuse (alcohol, illicit drugs, etc), diet and exercise, eating disorders (anorexia, bulimia, and binge eating), and various phobias. %M 27908844 %R 10.2196/games.6258 %U http://games.jmir.org/2016/2/e19/ %U https://doi.org/10.2196/games.6258 %U http://www.ncbi.nlm.nih.gov/pubmed/27908844 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e224 %T Efficacy of Mobile Serious Games in Increasing HIV Risk Perception in Swaziland: A Randomized Control Trial (SGprev Trial) Research Protocol %A Lukhele,Bhekumusa Wellington %A Musumari,Patou %A El-Saaidi,Christina %A Techasrivichien,Teeranee %A Suguimoto,S. Pilar %A Ono Kihara,Masako %A Kihara,Masahiro %+ Department of Global Health and Socio Epidemiology, Frontier Laboratory Bldg, 2nd Fl., Kyoto University School of Public Health Yoshida Konoe-cho, Sakyo-ku, Kyoto, 6068501, Japan, 81 757534350 ext 4350, bhekumusa.lukhele.36x@st.kyoto-u.ac.jp %K eHealth %K mHealth %K gamification %K Internet %K HIV prevention %K innovation %D 2016 %7 22.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: The human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) continue to be a major public health problem in Sub-Saharan Africa (SSA), particularly in Swaziland, which has the highest HIV prevalence in this region. A wide range of strategies and interventions have been used to promote behavior change, though almost all such interventions have involved mass media. Therefore, innovative behavior change strategies beyond mass media communication are urgently needed. Serious games have demonstrated effectiveness in advancing health in the developed world; however, no rigorous serious games interventions have been implemented in HIV prevention in SSA. Objective: We plan to test whether a serious game intervention delivered on mobile phones to increase HIV risk perception, increase intention to reduce sexual partnerships, and increase intention to know own and partners HIV status will be more effective compared with current prevention efforts. Methods: This is a two-arm randomized intervention trial. We will recruit 380 participants who meet the following eligibility criteria: 18-29 years of age, own a smartphone running an Android-based operating system, have the WhatsApp messaging app, live in Swaziland, and can adequately grant informed consent. Participants will be allocated into a smartphone interactive, educational story game, and a wait-list control group in a 1:1 allocation ratio. Subsequently, a self-administered Web-based questionnaire will be issued at baseline and after 4 weeks of exposure to the game. We hypothesize that the change in HIV risk perception between pre- and post-intervention assessment is greater in the intervention group compared with the change in the control group. Our primary hypothesis is based on the assumption that increased perceived risk of HIV provides cues to engage in protective behavior. Our primary outcome measure is HIV risk perceived mean change between pre- and post-intervention compared with the mean change in the wait-list control group at 4-weeks post-intervention. We will use standardized regression coefficients to calculate the effect of the intervention on our primary outcome with P values. We will conduct both intention to treat and as treated analysis. Results: This study is funded by Hayao Nakayama Foundation for Science & Technology and Culture; Grant number H26-A2-41. The research and development approval has been obtained from Kyoto University Graduate School and Faculty of Medicine Ethics Committee, Japan, and Swaziland’s Ministry of Health Ethics and Scientific committee. Results are expected in February 2017. Conclusions: This study will provide evidence on the efficiency of a mobile phone interactive game in increasing HIV risk perception in Swaziland. Our findings may also be generalizable to similar settings in SSA. Trial Registration: University Hospital Medical Information Network Clinical Trial Registry ID number (UMIN-CTR):UMIN000021781; URL:https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000025103 (Archived by WebCite at http://www.webcitation.org/6hOphB11a). %M 27876685 %R 10.2196/resprot.6543 %U http://www.researchprotocols.org/2016/4/e224/ %U https://doi.org/10.2196/resprot.6543 %U http://www.ncbi.nlm.nih.gov/pubmed/27876685 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e18 %T Game On? Smoking Cessation Through the Gamification of mHealth: A Longitudinal Qualitative Study %A El-Hilly,Abdulrahman Abdulla %A Iqbal,Sheeraz Syed %A Ahmed,Maroof %A Sherwani,Yusuf %A Muntasir,Mohammed %A Siddiqui,Sarim %A Al-Fagih,Zaid %A Usmani,Omar %A Eisingerich,Andreas B %+ Airway Disease, National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, Dovehouse Street, London, SW3 6LY, United Kingdom, 44 (0)20 7351 8051, o.usmani@imperial.ac.uk %K gamification %K mhealth %K mobile health %K smoking cessation %K health behavior %K health policy %K public health %K behavioral support %D 2016 %7 24.10.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Finding ways to increase and sustain engagement with mHealth interventions has become a challenge during application development. While gamification shows promise and has proven effective in many fields, critical questions remain concerning how to use gamification to modify health behavior. Objective: The objective of this study is to investigate how the gamification of mHealth interventions leads to a change in health behavior, specifically with respect to smoking cessation. Methods: We conducted a qualitative longitudinal study using a sample of 16 smokers divided into 2 cohorts (one used a gamified intervention and the other used a nongamified intervention). Each participant underwent 4 semistructured interviews over a period of 5 weeks. Semistructured interviews were also conducted with 4 experts in gamification, mHealth, and smoking cessation. Interviews were transcribed verbatim and thematic analysis undertaken. Results: Results indicated perceived behavioral control and intrinsic motivation acted as positive drivers to game engagement and consequently positive health behavior. Importantly, external social influences exerted a negative effect. We identified 3 critical factors, whose presence was necessary for game engagement: purpose (explicit purpose known by the user), user alignment (congruency of game and user objectives), and functional utility (a well-designed game). We summarize these findings in a framework to guide the future development of gamified mHealth interventions. Conclusions: Gamification holds the potential for a low-cost, highly effective mHealth solution that may replace or supplement the behavioral support component found in current smoking cessation programs. The framework reported here has been built on evidence specific to smoking cessation, however it can be adapted to health interventions in other disease categories. Future research is required to evaluate the generalizability and effectiveness of the framework, directly against current behavioral support therapy interventions in smoking cessation and beyond. %M 27777216 %R 10.2196/games.5678 %U http://games.jmir.org/2016/2/e18/ %U https://doi.org/10.2196/games.5678 %U http://www.ncbi.nlm.nih.gov/pubmed/27777216 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e46 %T Evaluation of a Digital Game-Based Learning Program for Enhancing Youth Mental Health: A Structural Equation Modeling of the Program Effectiveness %A Huen,Jenny MY %A Lai,Eliza SY %A Shum,Angie KY %A So,Sam WK %A Chan,Melissa KY %A Wong,Paul WC %A Law,YW %A Yip,Paul SF %+ Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong, China (Hong Kong), 852 39174375, sfpyip@hku.hk %K digital game-based learning %K mental health %K program evaluation %K Internet %D 2016 %7 07.10.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital game-based learning (DGBL) makes use of the entertaining power of digital games for educational purposes. Effectiveness assessment of DGBL programs has been underexplored and no attempt has been made to simultaneously model both important components of DGBL: learning attainment (ie, educational purposes of DGBL) and engagement of users (ie, entertaining power of DGBL) in evaluating program effectiveness. Objective: This study aimed to describe and evaluate an Internet-based DGBL program, Professor Gooley and the Flame of Mind, which promotes mental health to adolescents in a positive youth development approach. In particular, we investigated whether user engagement in the DGBL program could enhance their attainment on each of the learning constructs per DGBL module and subsequently enhance their mental health as measured by psychological well-being. Methods: Users were assessed on their attainment on each learning construct, psychological well-being, and engagement in each of the modules. One structural equation model was constructed for each DGBL module to model the effect of users' engagement and attainment on the learning construct on their psychological well-being. Results: Of the 498 secondary school students that registered and participated from the first module of the DGBL program, 192 completed all 8 modules of the program. Results from structural equation modeling suggested that a higher extent of engagement in the program activities facilitated users’ attainment on the learning constructs on most of the modules and in turn enhanced their psychological well-being after controlling for users’ initial psychological well-being and initial attainment on the constructs. Conclusions: This study provided evidence that Internet intervention for mental health, implemented with the technologies and digital innovations of DGBL, could enhance youth mental health. Structural equation modeling is a promising approach in evaluating the effectiveness of DGBL programs. %M 27717921 %R 10.2196/mental.5656 %U http://mental.jmir.org/2016/4/e46/ %U https://doi.org/10.2196/mental.5656 %U http://www.ncbi.nlm.nih.gov/pubmed/27717921 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e225 %T Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (“Balance It”): A Pilot Study %A Spook,Jorinde %A Paulussen,Theo %A Kok,Gerjo %A van Empelen,Pepijn %+ Wageningen University and Research, Department of Communication, Philosophy and Technology: Centre for Integrative Development, PO Box 8130, 6700 EW, Wageningen,, Netherlands, 31 0317481446, jorinde.spook@wur.nl %K Balance It %K effect evaluation %K serious game %K self-regulation %K prevention and control %K health promotion %K dietary intake %K physical activity %D 2016 %7 26.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA). Objective: We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA. Methods: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. Results: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. Conclusions: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight. %M 27670222 %R 10.2196/jmir.4964 %U http://www.jmir.org/2016/9/e225/ %U https://doi.org/10.2196/jmir.4964 %U http://www.ncbi.nlm.nih.gov/pubmed/27670222 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e15 %T A Study on the Validity of a Computer-Based Game to Assess Cognitive Processes, Reward Mechanisms, and Time Perception in Children Aged 4-8 Years %A Peijnenborgh,Janneke CAW %A Hurks,Petra PM %A Aldenkamp,Albert P %A van der Spek,Erik D %A Rauterberg,GWM %A Vles,Johan SH %A Hendriksen,Jos GM %+ Center for Neurological Learning Disabilities, Kempenhaeghe, P.O. Box 61, Heeze, 5590 AB, Netherlands, 31 (0)40227923, peijnenborghj@kempenhaeghe.nl %K experimental games %K ADHD %K children %K neuropsychological test %D 2016 %7 22.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: A computer-based game, named Timo’s Adventure, was developed to assess specific cognitive functions (eg, attention, planning, and working memory), time perception, and reward mechanisms in young school-aged children. The game consists of 6 mini-games embedded in a story line and includes fantasy elements to enhance motivation. Objective: The aim of this study was to investigate the validity of Timo’s Adventure in normally developing children and in children with attention-deficit/hyperactivity disorder (ADHD). Methods: A total of 96 normally developing children aged 4-8 years and 40 children with ADHD were assessed using the game. Clinical validity was investigated by examining the effects of age on performances within the normally developing children, as well as performance differences between the healthy controls and the ADHD group. Results: Our analyses in the normally developing children showed developmental effects; that is, older children made fewer inhibition mistakes (r=−.33, P=.001), had faster (and therefore better) reaction times (r=−.49, P<.001), and were able to produce time intervals more accurately than younger children (ρ=.35, P<.001). Discriminant analysis showed that Timo’s Adventure was accurate in most classifications whether a child belonged to the ADHD group or the normally developing group: 78% (76/97) of the children were correctly classified as having ADHD or as being in the normally developing group. The classification results showed that 72% (41/57) children in the control group were correctly classified, and 88% (35/40) of the children in the ADHD group were correctly classified as having ADHD. Sensitivity (0.89) and specificity (0.69) of Timo’s Adventure were satisfying. Conclusions: Computer-based games seem to be a valid tool to assess specific strengths and weaknesses in young children with ADHD. %M 27658428 %R 10.2196/games.5997 %U http://games.jmir.org/2016/2/e15/ %U https://doi.org/10.2196/games.5997 %U http://www.ncbi.nlm.nih.gov/pubmed/27658428 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e16 %T Effects of Visual Display on Joint Excursions Used to Play Virtual Dodgeball %A Thomas,James S %A France,Christopher R %A Applegate,Megan E %A Leitkam,Samuel T %A Pidcoe,Peter E %A Walkowski,Stevan %+ School of Rehabilitation and Communication Sciences, Ohio University, W281 Grover Center, Athens, OH, 45701, United States, 1 740 593 4178, thomasj5@ohio.edu %K virtual reality %K avatar presentation %K joint kinematics %D 2016 %7 15.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) interventions hold great potential for rehabilitation as commercial systems are becoming more affordable and can be easily applied to both clinical and home settings. Objective: In this study, we sought to determine how differences in the VR display type can influence motor behavior, cognitive load, and participant engagement. Methods: Movement patterns of 17 healthy young adults (8 female, 9 male) were examined during games of Virtual Dodgeball presented on a three-dimensional television (3DTV) and a head-mounted display (HMD). The participant’s avatar was presented from a third-person perspective on a 3DTV and from a first-person perspective on an HMD. Results: Examination of motor behavior revealed significantly greater excursions of the knee (P=.003), hip (P<.001), spine (P<.001), shoulder (P=.001), and elbow (P=.026) during HMD versus 3DTV gameplay, resulting in significant differences in forward (P=.003) and downward (P<.001) displacement of the whole-body center of mass. Analyses of cognitive load and engagement revealed that relative to 3DTV, participants indicated that HMD gameplay resulted in greater satisfaction with overall performance and was less frustrating (P<.001). There were no significant differences noted for mental demand. Conclusions: Differences in visual display type and participant perspective influence how participants perform in Virtual Dodgeball. Because VR use within rehabilitation settings is often designed to help restore movement following orthopedic or neurologic injury, these findings provide an important caveat regarding the need to consider the potential influence of presentation format and perspective on motor behavior. %M 27634561 %R 10.2196/games.6476 %U http://games.jmir.org/2016/2/e16/ %U https://doi.org/10.2196/games.6476 %U http://www.ncbi.nlm.nih.gov/pubmed/27634561 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e14 %T Gamifying Self-Management of Chronic Illnesses: A Mixed-Methods Study %A AlMarshedi,Alaa %A Wills,Gary %A Ranchhod,Ashok %+ University of Southampton, School of Electronics and Computer Science, aaa3g12@soton.ac.uk, Southampton,, United Kingdom, 44 (0)23 8059 4506, aaa3g12@soton.ac.uk %K gamification %K healthcare %K self-management %K chronic illnesses %K diabetes %K motivation %K behavioral change %D 2016 %7 09.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Self-management of chronic illnesses is an ongoing issue in health care research. Gamification is a concept that arose in the field of computer science and has been borrowed by many other disciplines. It is perceived by many that gamification can improve the self-management experience of people with chronic illnesses. This paper discusses the validation of a framework (called The Wheel of Sukr) that was introduced to achieve this goal. Objective: This research aims to (1) discuss a gamification framework targeting the self-management of chronic illnesses and (2) validate the framework by diabetic patients, medical professionals, and game experts. Methods: A mixed-method approach was used to validate the framework. Expert interviews (N=8) were conducted in order to validate the themes of the framework. Additionally, diabetic participants completed a questionnaire (N=42) in order to measure their attitudes toward the themes of the framework. Results: The results provide a validation of the framework. This indicates that gamification might improve the self-management of chronic illnesses, such as diabetes. Namely, the eight themes in the Wheel of Sukr (fun, esteem, socializing, self-management, self-representation, motivation, growth, sustainability) were perceived positively by 71% (30/42) of the participants with P value <.001. Conclusions: In this research, both the interviews and the questionnaire yielded positive results that validate the framework (The Wheel of Sukr). Generally, this study indicates an overall acceptance of the notion of gamification in the self-management of diabetes. %M 27612632 %R 10.2196/games.5943 %U http://games.jmir.org/2016/2/e14/ %U https://doi.org/10.2196/games.5943 %U http://www.ncbi.nlm.nih.gov/pubmed/27612632 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e39 %T Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review %A Brown,Menna %A O'Neill,Noelle %A van Woerden,Hugo %A Eslambolchilar,Parisa %A Jones,Matt %A John,Ann %+ Swansea University, Medical School, ILS2, Singleton Park, Swansea, SA2 8PP, United Kingdom, 44 179260 ext 6312, menna.brown@swansea.ac.uk %K adherence %K Web-based mental health interventions %K well-being %K gamification %K engagement %K dropout %K patient compliance %K patient nonadherence %D 2016 %7 24.08.2016 %9 Review %J JMIR Ment Health %G English %X Background: Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of “active” technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being. Objective: This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being. Methods: A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched. Results: A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration. Conclusions: Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data. %M 27558893 %R 10.2196/mental.5710 %U http://mental.jmir.org/2016/3/e39/ %U https://doi.org/10.2196/mental.5710 %U http://www.ncbi.nlm.nih.gov/pubmed/27558893 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e13 %T A Video Game Promoting Cancer Risk Perception and Information Seeking Behavior Among Young-Adult College Students: A Randomized Controlled Trial %A Khalil,Georges Elias %A Beale,Ivan L %A Chen,Minxing %A Prokhorov,Alexander V %+ The M.D. Anderson Cancer Center, Department of Behavioral Science, University of Texas, 1155 Pressler St. Unit 1330, Houston, TX,, United States, 1 713 563 2605, gekhalil@mdanderson.org %K cancer %K risk %K information seeking %K perceived risk %K perceived susceptibility %K perceived severity %K cancer prevention %K games for health %K serious games %D 2016 %7 28.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Risky behaviors tend to increase drastically during the transition into young adulthood. This increase may ultimately facilitate the initiation of carcinogenic processes at a young age, highlighting a serious public health problem. By promoting information seeking behavior (ISB), young adults may become aware of cancer risks and potentially take preventive measures. Objective: Based on the protection motivation theory, the current study seeks to evaluate the impact of challenge in a fully automated video game called Re-Mission on young adult college students' tendency to perceive the severity of cancer, feel susceptible to cancer, and engage in ISB. Methods: A total of 216 young adults were recruited from a university campus, consented, screened, and randomized in a single-blinded format to 1 of 3 conditions: an intervention group playing Re-Mission at high challenge (HC; n=85), an intervention group playing Re-Mission at low challenge (LC; n=81), and a control group with no challenge (NC; presented with illustrated pictures of Re-Mission; n=50). Measurement was conducted at baseline, immediate posttest, 10-day follow-up, and 20-day follow-up. Repeated-measures mixed-effect models were conducted for data analysis of the main outcomes. Results: A total of 101 young adults continued until 20-day follow-up. Mixed-effect models showed that participants in the HC and LC groups were more likely to increase in perceived susceptibility to cancer (P=.03), perceived severity of cancer (P=.02), and ISB (P=.01) than participants in the NC group. The LC group took until 10-day follow-up to show increase in perceived susceptibility (B=0.47, standard error (SE) 0.16, P=.005). The HC group showed an immediate increase in perceived susceptibility at posttest (B=0.43, SE 0.14, P=.002). The LC group exhibited no changes in perceived severity (B=0.40, SE 0.33, P=.24). On the other hand, the HC group showed a significant increase from baseline to posttest (B=0.39, SE 0.14, P=.005), maintaining this increase until 20-day follow-up (B=−0.007, SE 0.26, P=.98). Further analyses indicated that perceived threat from virtual cancer cells in the game is related to the increase in perceived severity (B=0.1, SE 0.03, P=.001), and perceived susceptibility is related to changes in ISB at 10-day follow-up (B=0.21, SE 0.08, P=.008). Conclusions: The feature of challenge with cancer cells in a virtual environment has the potential to increase cancer risk perception and ISB. The results are promising considering that the Re-Mission intervention was neither designed for cancer risk communication, nor applied among healthy individuals. Further research is needed to understand the theoretical framework underlying the effects of Re-Mission on ISB. The findings call for the development of a Web-based, game-based intervention for cancer risk communication and information seeking among young adults. ClinicalTrial: International Standard Randomized Controlled Trial Number (ISRCTN): 15789289; http://www.controlled-trials.com/ISRCTN15789289 (Archived by WebCite at http://www.webcitation.org/6jGYZC3lZ) %M 27470927 %R 10.2196/games.5793 %U http://games.jmir.org/2016/2/e13/ %U https://doi.org/10.2196/games.5793 %U http://www.ncbi.nlm.nih.gov/pubmed/27470927 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 7 %P e196 %T Possible Biases of Researchers’ Attitudes Toward Video Games: Publication Trends Analysis of the Medical Literature (1980–2013) %A Segev,Aviv %A Rovner,Mitchell %A Appel,David Ian %A Abrams,Aaron W %A Rotem,Michal %A Bloch,Yuval %+ Shalvata Mental Health Center, 1st Aliyat Hanoar St, POB 94, Hod Hasharon,, Israel, 972 9 7478 554, segev_a@netvision.net.il %K video games %K publication trends %K bias %D 2016 %7 18.07.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The study of video games is expanding, and so is the debate regarding their possible positive and deleterious effects. As controversies continue, several researchers have expressed their concerns about substantial biases existing in the field, which might lead to the creation of a skewed picture, both in the professional and in the lay literature. However, no study has tried to examine this issue quantitatively. Objective: The objective of our study was to examine possible systematic biases in the literature, by analyzing the publication trends of the medical and life sciences literature regarding video games. Methods: We performed a complete and systematic PubMed search up to December 31, 2013. We assessed all 1927 articles deemed relevant for their attitude toward video games according to the focus, hypothesis, and authors’ interpretation of the study results, using a 3-category outcome (positive, negative, and neutral). We assessed the prevalence of different attitudes for possible association with year of publication, location of researchers, academic discipline, methodological research, and centrality of the publishing journals. Results: The attitude toward video games presented in publications varied by year of publication, location, academic discipline, and methodological research applied (P<.001 for all). Moreover, representation of different attitudes differed according to centrality of the journals, as measured by their impact factor (P<.001). Conclusions: The results suggest that context, whether scientific or social, is related to researchers’ attitudes toward video games. Readers, both lay and professional, should weigh these contextual variables when interpreting studies’ results, in light of the possible bias they carry. The results also support a need for a more balanced, open-minded approach toward video games, as it is likely that this complex phenomenon carries novel opportunities as well as new hazards. %M 27430187 %R 10.2196/jmir.5935 %U http://www.jmir.org/2016/7/e196/ %U https://doi.org/10.2196/jmir.5935 %U http://www.ncbi.nlm.nih.gov/pubmed/27430187 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e12 %T Validation of a Computerized, Game-based Assessment Strategy to Measure Training Effects on Motor-Cognitive Functions in People With Dementia %A Wiloth,Stefanie %A Lemke,Nele %A Werner,Christian %A Hauer,Klaus %+ AGAPLESION Bethanien Hospital, Geriatric Centre at the University of Heidelberg, Heidelberg, Germany, Research Department, Rohrbacher Straße 149, Heidelberg, 69126, Germany, 49 1739471446, stefanie.wiloth@gmail.com %K serious games %K computerized assessment %K validation %K motor-cognitive functions %K elderly %K older adults %K cognitive impairment %K dementia %D 2016 %7 18.7.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergames often used for training purpose can also be applied to create assessments based on quantitative data derived from the game. A number of studies relate to these use functionalities developing specific assessment tasks by using the game software and provided good data on psychometric properties. However, (1) assessments often include tasks other than the original game task used for training and therefore relate to similar but not to identical or integrated performances trained, (2) people with diagnosed dementia have insufficiently been addressed in validation studies, and (3) studies did commonly not present validation data such as sensitivity to change, although this is a paramount objective for validation to evaluate responsiveness in intervention studies. Objective: Specific assessment parameters have been developed using quantitative data directly derived from the data stream during the game task of a training device (Physiomat). The aim of this study was to present data on construct validity, test–retest reliability, sensitivity to change, and feasibility of this internal assessment approach, which allows the quantification of Physiomat training effects on motor-cognitive functions in 105 multimorbid patients with mild-to-moderate dementia (mean age 82.7±5.9). Methods: Physiomat assessment includes various tasks at different complexity levels demanding balance and cognitive abilities. For construct validity, motor-cognitive Physiomat assessment tasks were compared with established motor and cognitive tests using Spearman’s rank correlations (rs). For test–retest reliability, we used intra-class correlations (ICC3,1) and focused on all Physiomat tasks. Sensitivity to change of trained Physiomat tasks was tested using Wilcoxon statistic and standardized response means (SRMs). Completion rate and time were calculated for feasibility. Results: Analyses have mostly shown moderate-to-high correlations between established motor as well as cognitive tests and simple (rs=−.22 to .68, P ≤.001-.03), moderate (rs=−.33 to .71, P ≤.001-.004), and complex motor-cognitive Physiomat tasks (rs=−.22 to .83, P ≤.001-.30) indicating a good construct validity. Moderate-to-high correlations between test and retest assessments were found for simple, moderate, and complex motor-cognitive tasks (ICC=.47-.83, P ≤.001) indicating good test–retest reliability. Sensitivity to change was good to excellent for Physiomat assessment as it reproduced significant improvements (P ≤.001) with mostly moderate-to-large effect sizes (SRM=0.5-2.0) regarding all trained tasks. Completion time averaged 25.8 minutes. Completion rate was high for initial Physiomat measures. No adverse events occurred during assessment. Conclusions: Overall, Physiomat proved to have good psychometric qualities in people with mild-to-moderate dementia representing a reliable, valid, responsive, and feasible assessment strategy for multimorbid older adults with or without cognitive impairment, which relates to identical and integrated performances trained by using the game. %M 27432746 %R 10.2196/games.5696 %U http://games.jmir.org/2016/2/e12/ %U https://doi.org/10.2196/games.5696 %U http://www.ncbi.nlm.nih.gov/pubmed/27432746 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e11 %T Gamification of Cognitive Assessment and Cognitive Training: A Systematic Review of Applications and Efficacy %A Lumsden,Jim %A Edwards,Elizabeth A %A Lawrence,Natalia S %A Coyle,David %A Munafò,Marcus R %+ UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, 12a Priory rd, Bristol, BS8 1TU, United Kingdom, 44 117 92 88450, jim.lumsden@bristol.ac.uk %K gamification %K gamelike %K cognition %K computer games %K review %D 2016 %7 15.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive tasks are typically viewed as effortful, frustrating, and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or reduce intervention effects. However, gamification may provide a possible solution. If game design features can be incorporated into cognitive tasks without undermining their scientific value, then data quality, intervention effects, and participant engagement may be improved. Objectives: This systematic review aims to explore and evaluate the ways in which gamification has already been used for cognitive training and assessment purposes. We hope to answer 3 questions: (1) Why have researchers opted to use gamification? (2) What domains has gamification been applied in? (3) How successful has gamification been in cognitive research thus far? Methods: We systematically searched several Web-based databases, searching the titles, abstracts, and keywords of database entries using the search strategy (gamif* OR game OR games) AND (cognit* OR engag* OR behavi* OR health* OR attention OR motiv*). Searches included papers published in English between January 2007 and October 2015. Results: Our review identified 33 relevant studies, covering 31 gamified cognitive tasks used across a range of disorders and cognitive domains. We identified 7 reasons for researchers opting to gamify their cognitive training and testing. We found that working memory and general executive functions were common targets for both gamified assessment and training. Gamified tests were typically validated successfully, although mixed-domain measurement was a problem. Gamified training appears to be highly engaging and does boost participant motivation, but mixed effects of gamification on task performance were reported. Conclusions: Heterogeneous study designs and typically small sample sizes highlight the need for further research in both gamified training and testing. Nevertheless, careful application of gamification can provide a way to develop engaging and yet scientifically valid cognitive assessments, and it is likely worthwhile to continue to develop gamified cognitive tasks in the future. %M 27421244 %R 10.2196/games.5888 %U http://games.jmir.org/2016/2/e11/ %U https://doi.org/10.2196/games.5888 %U http://www.ncbi.nlm.nih.gov/pubmed/27421244 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e10 %T A Serious Game to Increase Healthy Food Consumption in Overweight or Obese Adults: Randomized Controlled Trial %A Blackburne,Tegan %A Rodriguez,Alexandra %A Johnstone,Stuart John %+ Brain and Behaviour Research Institute, School of Psychology, University of Wollongong, Northfields Avenue, Wollongong, 2522, Australia, 61 242214495, sjohnsto@uow.edu.au %K obesity %K inhibition training %K event-related potential %K eating %K mobile apps %D 2016 %7 13.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Obesity is a growing global issue that is linked to cognitive and psychological deficits. Objective: This preliminary study investigated the efficacy of training to improve inhibitory control (IC), a process linked to overeating, on consumption and cognitive control factors. Methods: This study utilized a multisession mobile phone–based intervention to train IC in an overweight and obese population using a randomized waitlist-control design. A combination of self-assessment questionnaires and psychophysiological measures was used to assess the efficacy of the intervention in terms of improved general IC and modified food consumption after training. Attitudes toward food were also assessed to determine their mediating role in food choices. A total of 58 participants (47 female) completed 2 assessment sessions 3 weeks apart, with 2 weeks of intervention training for the training group during this time. The groups did not differ in baseline demographics including age, body mass index, and inhibitory control. Results: Inhibitory control ability improved across the training sessions, with increases in P3 amplitude implying increased cognitive control over responses. Inhibitory control training was associated with increased healthy and reduced unhealthy food consumption in a taste test and in the week following training, as measured by the Healthy Eating Quiz and the food consumption test. Cognitive restraint was enhanced after training for the training but not the waitlist condition in the Three-Factor Eating Questionnaire, implying that attempts to avoid unhealthy foods in the future will be easier for the training group participants. Conclusions: Inhibitory control training delivered via a purpose-designed mobile phone app is easy to complete, is convenient, and can increase cognitive restraint and reduce unhealthy food consumption. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000263493; http://www.ANZCTR.org.au/ACTRN12616000263493.aspx (Archived by WebCite at http://www.webcitation.org/6ioHjGING) %M 27417192 %R 10.2196/games.5708 %U http://games.jmir.org/2016/2/e10/ %U https://doi.org/10.2196/games.5708 %U http://www.ncbi.nlm.nih.gov/pubmed/27417192 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e81 %T Acceptance, Usability and Health Applications of Virtual Worlds by Older Adults: A Feasibility Study %A Cook,Nicole %A Winkler,Sandra L %+ Master of Public Health program, College of Osteopathic Medicine, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, FL, 33314, United States, 1 9542621505, nc570@nova.edu %K Second Life %K virtual worlds %K older adults %K seniors %K health care %K training %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Virtual worlds allow users to communicate and interact across various environments, scenarios, and platforms. Virtual worlds present opportunities in health care to reduce the burden of illness and disability by supporting education, rehabilitation, self-management, and social networking. The application of virtual worlds to older adults who bear the burden and cost of health conditions associated with age has not been evaluated. Objective: The aim of this study is to explore the usability, ease of use, and enjoyment of a virtual world by older adults, the types of virtual world activities that older adults may engage in, and the perceptions of older adults regarding the application of virtual worlds in health care. Methods: This quasi-experimental pre-post design research was guided by the Technology Acceptance Model (TAM). Participants were recruited from a Lifelong Learning Institute (LLI) program at Nova Southeastern University. Participants attended four training sessions over a 5-week period in the Second Life (SL) virtual world. Subjects were surveyed before and after the training on perceived ease of use, attitudes towards technology, behavioral intention to use the system, facilitating conditions, effort expectancy, and self-efficacy. Results: Older adults (N=19) completed the informed consent and attended the first training session, and 11 participants (58%, 11/19) completed the full training and the post survey. Completers (82%, 9/11) were more likely than non-completers (37%, 3/8) to consider themselves technologically savvy (P=.048), and to express confidence in being able to use the virtual world (100%, 11/11 vs 37%, 3/8; P=.002). All completers (100%, 11/11) perceived that SL has application in health behaviors and disease and reducing social isolation among people who are homebound. Of the completers, 10 (91%, 10/11) responded that they enjoyed learning how to use SL. Completers suggested that future trainings include more assistants and smaller groups. Conclusions: This pilot study suggests that virtual worlds can be both a feasible and an applicable method to promote health among some seniors. Future research on virtual worlds with older populations should consider using state-of-the art technology including large monitors, providing a minimum of one trainer for every two to three participants, and distributing a comprehensive training manual at the start of the training to support organization and recall. %M 27256457 %R 10.2196/resprot.5423 %U http://www.researchprotocols.org/2016/2/e81/ %U https://doi.org/10.2196/resprot.5423 %U http://www.ncbi.nlm.nih.gov/pubmed/27256457 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e8 %T Effects of Playing a Serious Computer Game on Body Mass Index and Nutrition Knowledge in Women %A Shiyko,Mariya %A Hallinan,Sean %A Seif El-Nasr,Magy %A Subramanian,Shree %A Castaneda-Sceppa,Carmen %+ Northeastern University, Applied Psychology, 360 Huntington Ave, 404 INV, Boston, MA, 02115, United States, 1 6173737527, m.shiyko@neu.edu %K serious games %K games for health %K weight loss %K body mass index %K nutritional knowledge %K game play %K self-determination theory %K Player Experience of Need Satisfaction (PENS) model %K women %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Obesity and weight gain is a critical public health concern. Serious digital games are gaining popularity in the context of health interventions. They use persuasive and fun design features to engage users in health-related behaviors in a non-game context. As a young field, research about effectiveness and acceptability of such games for weight loss is sparse. Objective: The goal of this study was to evaluate real-world play patterns of SpaPlay and its impact on body mass index (BMI) and nutritional knowledge. SpaPlay is a computer game designed to help women adopt healthier dietary and exercise behaviors, developed based on Self-Determination theory and the Player Experience of Need Satisfaction (PENS) model. Progress in the game is tied to real-life activities (e.g., eating a healthy snack, taking a flight of stairs). Methods: We recruited 47 women to partake in a within-subject 90-day longitudinal study, with assessments taken at baseline, 1-, 2-, and 3- months. Women were on average, 29.8 years old (±7.3), highly educated (80.9% had BA or higher), 39% non-White, baseline BMI 26.98 (±5.6), who reported at least contemplating making changes in their diet and exercise routine based on the Stages of Change Model. We computed 9 indices from game utilization data to evaluate game play. We used general linear models to examine inter-individual differences between levels of play, and multilevel models to assess temporal changes in BMI and nutritional knowledge. Results: Patterns of game play were mixed. Participants who reported being in the preparation or action stages of behavior change exhibited more days of play and more play regularity compared to those who were in the contemplation stage. Additionally, women who reported playing video games 1-2 hours per session demonstrated more sparse game play. Brief activities, such as one-time actions related to physical activity or healthy food, were preferred over activities that require a longer commitment (e.g., taking stairs every day for a week). BMI decreased significantly (P<.001) from baseline to 3-month follow-up, yielding a large effect size of 1.28. Nutritional knowledge increased significantly (P<.001) from first to third month follow-ups, with an effect size of .86. The degree of change in both outcomes was related to game play, baseline readiness to change, and the extent of video game play in general. Conclusions: This work demonstrates initial evidence of success for using a serious game as an intervention for health behavior change in real world settings. Our findings also highlight the need to understand not only game effectiveness but also inter-individual differences. Individualizing content and the intervention medium appears to be necessary for a more personalized and long-lasting impact. %M 27255497 %R 10.2196/games.4977 %U http://games.jmir.org/2016/1/e8/ %U https://doi.org/10.2196/games.4977 %U http://www.ncbi.nlm.nih.gov/pubmed/27255497 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e9 %T Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play %A Levac,Danielle %A Nawrotek,Joanna %A Deschenes,Emilie %A Giguere,Tia %A Serafin,Julie %A Bilodeau,Martin %A Sveistrup,Heidi %+ Northeastern University, Department of Physical Therapy, Movement and Rehabilitation Sciences, 407c Robinson Hall, 360 Huntington Avenue, Boston, MA, 02115, United States, 1 6173735198, d.levac@neu.edu %K active video games, virtual reality, physical therapy, movement, reliability %D 2016 %7 01.06.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality active video games are increasingly popular physical therapy interventions for children with cerebral palsy. However, physical therapists require educational resources to support decision making about game selection to match individual patient goals. Quantifying the movements elicited during virtual reality active video game play can inform individualized game selection in pediatric rehabilitation. Objective: The objectives of this study were to develop and evaluate the feasibility and reliability of the Movement Rating Instrument for Virtual Reality Game Play (MRI-VRGP). Methods: Item generation occurred through an iterative process of literature review and sample videotape viewing. The MRI-VRGP includes 25 items quantifying upper extremity, lower extremity, and total body movements. A total of 176 videotaped 90-second game play sessions involving 7 typically developing children and 4 children with cerebral palsy were rated by 3 raters trained in MRI-VRGP use. Children played 8 games on 2 virtual reality and active video game systems. Intraclass correlation coefficients (ICCs) determined intra-rater and interrater reliability. Results: Excellent intrarater reliability was evidenced by ICCs of >0.75 for 17 of the 25 items across the 3 raters. Interrater reliability estimates were less precise. Excellent interrater reliability was achieved for far reach upper extremity movements (ICC=0.92 [for right and ICC=0.90 for left) and for squat (ICC=0.80) and jump items (ICC=0.99), with 9 items achieving ICCs of >0.70, 12 items achieving ICCs of between 0.40 and 0.70, and 4 items achieving poor reliability (close-reach upper extremity-ICC=0.14 for right and ICC=0.07 for left) and single-leg stance (ICC=0.55 for right and ICC=0.27 for left). Conclusions: Poor video quality, differing item interpretations between raters, and difficulty quantifying the high-speed movements involved in game play affected reliability. With item definition clarification and further psychometric property evaluation, the MRI-VRGP could inform the content of educational resources for therapists by ranking games according to frequency and type of elicited body movements. %M 27251029 %R 10.2196/games.5528 %U http://games.jmir.org/2016/1/e9/ %U https://doi.org/10.2196/games.5528 %U http://www.ncbi.nlm.nih.gov/pubmed/27251029 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e7 %T A Serious Game for Clinical Assessment of Cognitive Status: Validation Study %A Tong,Tiffany %A Chignell,Mark %A Tierney,Mary C. %A Lee,Jacques %+ Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, 5 King's College Road, Toronto, ON,, Canada, 1 416 978 7581, tiffany.tong@mail.utoronto.ca %K cognitive assessments %K cognitive screening tools %K computerized assessments %K games %K human computer interaction %K human factors %K neuropsychological tests %K screening %K serious games %K tablet computers %K technology assessment %K usability %K validation studies %K video games %D 2016 %7 27.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: We propose the use of serious games to screen for abnormal cognitive status in situations where it may be too costly or impractical to use standard cognitive assessments (eg, emergency departments). If validated, serious games in health care could enable broader availability of efficient and engaging cognitive screening. Objective: The objective of this work is to demonstrate the feasibility of a game-based cognitive assessment delivered on tablet technology to a clinical sample and to conduct preliminary validation against standard mental status tools commonly used in elderly populations. Methods: We carried out a feasibility study in a hospital emergency department to evaluate the use of a serious game by elderly adults (N=146; age: mean 80.59, SD 6.00, range 70-94 years). We correlated game performance against a number of standard assessments, including the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). Results: After a series of modifications, the game could be used by a wide range of elderly patients in the emergency department demonstrating its feasibility for use with these users. Of 146 patients, 141 (96.6%) consented to participate and played our serious game. Refusals to play the game were typically due to concerns of family members rather than unwillingness of the patient to play the game. Performance on the serious game correlated significantly with the MoCA (r=–.339, P <.001) and MMSE (r=–.558, P <.001), and correlated (point-biserial correlation) with the CAM (r=.565, P <.001) and with other cognitive assessments. Conclusions: This research demonstrates the feasibility of using serious games in a clinical setting. Further research is required to demonstrate the validity and reliability of game-based assessments for clinical decision making. %M 27234145 %R 10.2196/games.5006 %U http://games.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/games.5006 %U http://www.ncbi.nlm.nih.gov/pubmed/27234145 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e3 %T Crave-Out: A Distraction/Motivation Mobile Game to Assist in Smoking Cessation %A DeLaughter,Kathryn L %A Sadasivam,Rajani S %A Kamberi,Ariana %A English,Thomas M %A Seward,Greg L %A Chan,S Wayne %A Volkman,Julie E %A Amante,Daniel J %A Houston,Thomas K %+ CHOIR ENRM VAMC, 200 Springs Rd., Bedford, MA,, United States, 1 781 687 2559, kathryn.delaughter@va.gov %K smoking cessation %K Internet %K secondary prevention %K health behavior %D 2016 %7 26.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking is still the number one preventable cause of death. Cravings—an intense desire or longing for a cigarette—are a major contributor to quit attempt failure. New tools to help smokers’ manage their cravings are needed. Objective: To present a case study of the development process and testing of a distraction/motivation game (Crave-Out) to help manage cravings. Methods: We used a phased approach: in Phase 1 (alpha testing), we tested and refined the game concept, using a Web-based prototype. In Phase 2 (beta testing), we evaluated the distraction/motivation potential of the mobile game prototype, using a prepost design. After varying duration of abstinence, smokers completed the Questionnaire of Smoking Urge-Brief (QSU-Brief) measurement before and after playing Crave-Out. Paired t tests were used to compare pregame and postgame QSU-Brief levels. To test dissemination potential, we released the game on the Apple iTunes App Store and tracked downloads between December 22, 2011, and May 5, 2014. Results: Our concept refinement resulted in a multilevel, pattern memory challenge game, with each level increasing in difficulty. Smokers could play the game as long as they wanted. At the end of each level, smokers were provided clear goals for the next level and rewards (positive reinforcement using motivational tokens that represented a benefit of quitting smoking). Negative reinforcement was removed in alpha testing as smokers felt it reminded them of smoking. Measurement of QSU-Brief (N=30) resulted in a pregame mean of 3.24 (SD 1.65) and postgame mean of 2.99 (SD 1.40) with an overall decrease of 0.25 in cravings (not statistically significant). In a subset analysis, the QSU-Brief decrease was significant for smokers abstinent for more than 48 hours (N=5) with a pregame mean of 2.84 (SD 1.16) and a postgame mean of 2.0 (SD 0.94; change=0.84; P =.03). Between December 22, 2011, and May 29, 2014, the game was downloaded 3372 times from the App-Store, with 1526 smokers visiting the online resource www.decide2quit.org linked to the game. Conclusions: Overall, playing the game resulted in small, but nonsignificant decreases in cravings, with changes greater for those had already quit for more than 48 hours. Lessons learned can inform further development. Future research could incorporate mHealth games in multicomponent cessation interventions. Trial Registration: Clinicaltrials.gov NCT00797628; https://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/6hbJr6LWG) %M 27229772 %R 10.2196/games.4566 %U http://games.jmir.org/2016/1/e3/ %U https://doi.org/10.2196/games.4566 %U http://www.ncbi.nlm.nih.gov/pubmed/27229772 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e5 %T A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment %A Pasquier,Pierre %A Mérat,Stéphane %A Malgras,Brice %A Petit,Ludovic %A Queran,Xavier %A Bay,Christian %A Boutonnet,Mathieu %A Jault,Patrick %A Ausset,Sylvain %A Auroy,Yves %A Perez,Jean Paul %A Tesnière,Antoine %A Pons,François %A Mignon,Alexandre %+ Percy Military Teaching Hospital, Department of anesthesiology and intensive care, French Military Health Service, 101 avenue Henri Barbusse, Clamart, 92141, France, 33 141466000, pasquier9606@me.com %K serious games %K forward combat casualty care %K care under fire %K interdisciplinary collaboration %K simulation %K medical simulation %K virtual simulation %K training %K education %K assessment %D 2016 %7 18.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: The French Military Health Service has standardized its military prehospital care policy in a ‘‘Sauvetage au Combat’’ (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC. Objectives: The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment. Methods: A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance. Results: The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi–operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months. Conclusions: The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations. %M 27194369 %R 10.2196/games.5340 %U http://games.jmir.org/2016/1/e5/ %U https://doi.org/10.2196/games.5340 %U http://www.ncbi.nlm.nih.gov/pubmed/27194369 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 4 %P e94 %T Is Participatory Design Associated with the Effectiveness of Serious Digital Games for Healthy Lifestyle Promotion? A Meta-Analysis %A DeSmet,Ann %A Thompson,Debbe %A Baranowski,Tom %A Palmeira,Antonio %A Verloigne,Maïté %A De Bourdeaudhuij,Ilse %+ Ghent University, Department of Movement and Sport Sciences, Watersportlaan 2, Ghent, 9000, Belgium, 32 92646311, ilse.debourdeaudhuij@ugent.be %K serious games %K video games %K computer games %K games %K health promotion %K meta-analysis %K review %K design %K community-based participatory research %D 2016 %7 29.04.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious digital games can be effective at changing healthy lifestyles, but large differences in their effectiveness exist. The extent of user involvement in game design may contribute to game effectiveness by creating a better fit with user preferences. Participatory design (PD), which represents active user involvement as informant (ie, users are asked for input and feedback) or codesigner (ie, users as equal partners in the design) early on and throughout the game development, may be associated with higher game effectiveness, as opposed to no user involvement or limited user involvement. Objective: This paper reports the results of a meta-analysis examining the moderating role of PD in the effectiveness of serious digital games for healthy lifestyle promotion. Methods: Four databases were searched for peer-reviewed papers in English that were published or in press before October 2014, using a (group-) randomized controlled trial design. Effectiveness data were derived from another meta-analysis assessing the role of behavior change techniques and game features in serious game effectiveness. Results: A total of 58 games evaluated in 61 studies were included. As previously reported, serious digital games had positive effects on healthy lifestyles and their determinants. Unexpectedly, PD (g=0.075, 95% CI 0.017 to 0.133) throughout game development was related to lower game effectiveness on behavior (Q=6.74, P<.05) than when users were only involved as testers (g=0.520, 95% CI 0.150 to 0.890, P<.01). Games developed with PD (g=0.171, 95% CI 0.061 to 0.281, P<.01) were also related to lower game effectiveness on self-efficacy (Q=7.83, P<.05) than when users were not involved in game design (g=0.384, 95% CI 0.283 to 0.485, P<.001). Some differences were noted depending on age group, publication year of the study, and on the specific role in PD (ie, informant or codesigner), and depending on the game design element. Games developed with PD were more effective in changing behavioral determinants when they included users in design elements on game dynamics (beta=.215, 95% CI .075 to .356, P<.01) and, more specifically, as an informant (beta=.235, 95% CI .079 to .329, P<.01). Involving users as informants in PD to create game levels was also related to higher game effectiveness (Q=7.02, P<.01). Codesign was related to higher effectiveness when used to create the game challenge (Q=11.23, P<.01), but to lower game effectiveness when used to create characters (Q=4.36, P<.05) and the game world (Q=3.99, P<.05). Conclusions: The findings do not support higher effectiveness of games developed with PD. However, significant differences existed among PD games. More support was found for informant roles than for codesign roles. When PD was applied to game dynamics, levels, and game challenge, this was associated with higher effectiveness than when it was applied to game aesthetics. Since user involvement may have an important influence on reach, adoption, and implementation of the intervention, further research and design efforts are needed to enhance effectiveness of serious games developed with PD. %M 27129447 %R 10.2196/jmir.4444 %U http://www.jmir.org/2016/4/e94/ %U https://doi.org/10.2196/jmir.4444 %U http://www.ncbi.nlm.nih.gov/pubmed/27129447 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e4 %T The Relationship Between Engagement and Neurophysiological Measures of Attention in Motion-Controlled Video Games: A Randomized Controlled Trial %A Leiker,Amber M %A Miller,Matthew %A Brewer,Lauren %A Nelson,Monica %A Siow,Maria %A Lohse,Keith %+ Rehabilitation Informatics Lab, School of Kinesiolgy, Auburn University, 301 Wire Road, Auburn, AL, , United States, 1 334 844 1982, rehabinformatics@gmail.com %K games %K engagement %K motivation %K eP3a %K Kinect %K exergame %D 2016 %7 21.04.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Video games and virtual environments continue to be the subject of research in health sciences for their capacity to augment practice through user engagement. Creating game mechanics that increase user engagement may have indirect benefits on learning (ie, engaged learners are likely to practice more) and may also have direct benefits on learning (ie, for a fixed amount of practice, engaged learners show superior retention of information or skills). Objective: To manipulate engagement through the aesthetic features of a motion-controlled video game and measure engagement’s influence on learning. Methods: A group of 40 right-handed participants played the game under two different conditions (game condition or sterile condition). The mechanics of the game and the amount of practice were constant. During practice, event-related potentials (ERPs) to task-irrelevant probe tones were recorded during practice as an index of participants’ attentional reserve. Participants returned for retention and transfer testing one week later. Results: Although both groups improved in the task, there was no difference in the amount of learning between the game and sterile groups, countering previous research. A new finding was a statistically significant relationship between self-reported engagement and the amplitude of the early-P3a (eP3a) component of the ERP waveform, such that participants who reported higher levels of engagement showed a smaller eP3a (beta=−.08, P=.02). Conclusions: This finding provides physiological data showing that engagement elicits increased information processing (reducing attentional reserve), which yields new insight into engagement and its underlying neurophysiological properties. Future studies may objectively index engagement by quantifying ERPs (specifically the eP3a) to task-irrelevant probes. %M 27103052 %R 10.2196/games.5460 %U http://games.jmir.org/2016/1/e4/ %U https://doi.org/10.2196/games.5460 %U http://www.ncbi.nlm.nih.gov/pubmed/27103052 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e2 %T Feasibility of Applied Gaming During Interdisciplinary Rehabilitation for Patients With Complex Chronic Pain and Fatigue Complaints: A Mixed-Methods Study %A Vugts,Miel A P %A Joosen,Margot C W %A van Bergen,Alfonsus H M M %A Vrijhoef,Hubertus J M %+ Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, P.O. Box 90153, Tilburg, 5000 LE, Netherlands, 31 13 466 8271, m.a.p.vugts@tilburguniversity.edu %K behavioral medicine %K therapy %K computer-assisted %K computer games %K mind-body therapies %K patient acceptance of health care %K feasibility studies %K fatigue syndrome, chronic %K fibromyalgia %K musculoskeletal pain %D 2016 %7 01.04.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Applied gaming holds potential as a convenient and engaging means for the delivery of behavioral interventions. For developing and evaluating feasible computer-based interventions, policy makers and designers rely on limited knowledge about what causes variation in usage. Objective: In this study, we looked closely at why and by whom an applied game (LAKA) is demanded and whether it is feasible (with respect to acceptability, demand, practicality, implementation, and efficacy) and devised a complementary intervention during an interdisciplinary rehabilitation program (IRP) for patients with complex chronic pain and fatigue complaints. Methods: A mixed-methods design was used. Quantitative process analyses and assessments of feasibility were carried out with patients of a Dutch rehabilitation center who received access to LAKA without professional support during a 16-week interdisciplinary outpatient program. The quantitative data included records of routinely collected baseline variables (t0), additional surveys to measure technology acceptance before (t1) and after 8 weeks of access to LAKA (t2), and automatic log files of usage behavior (frequency, length, and progress). Subsequently, semistructured interviews were held with purposively selected patients. Interview codes triangulated and illustrated explanations of usage and supplemented quantitative findings on other feasibility domains. Results: Of the 410 eligible patients who started an IRP during the study period, 116 patients participated in additional data collections (108 with problematic fatigue and 47 with moderate or severe pain). Qualitative data verified that hedonic motivation was the most important factor for behavioral intentions to use LAKA (P<.001). Moreover, quotes illustrated a positive association between usage intentions (t1) and baseline level (t0) coping by active engagement (Spearman ρ=0.25; P=.008) and why patients who often respond by seeking social support were represented in a group of 71 patients who accessed the game (P=.034). The median behavioral intention to use LAKA was moderately positive and declined over time. Twenty patients played the game from start to finish. Behavioral change content was recognized and seen as potentially helpful by interview respondents who exposed themselves to the content of LAKA. Conclusions: Variation in the demand for applied gaming is generally explained by perceived enjoyment and effort and by individual differences in coping resources. An applied game can be offered as a feasible complementary intervention for more patients with complex chronic pain or fatigue complaints by embedding and delivering in alignment with patient experiences. Feasibility, effectiveness, and cost-effectiveness can be evaluated in a full-scale evaluation. New observations elicit areas of further research on the usage of computer-based interventions. %M 27036094 %R 10.2196/games.5088 %U http://games.jmir.org/2016/1/e2/ %U https://doi.org/10.2196/games.5088 %U http://www.ncbi.nlm.nih.gov/pubmed/27036094 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e26 %T Behavioral Outcome Effects of Serious Gaming as an Adjunct to Treatment for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial %A Bul,Kim CM %A Kato,Pamela M %A Van der Oord,Saskia %A Danckaerts,Marina %A Vreeke,Leonie J %A Willems,Annik %A van Oers,Helga JJ %A Van Den Heuvel,Ria %A Birnie,Derk %A Van Amelsvoort,Thérèse AMJ %A Franken,Ingmar HA %A Maras,Athanasios %+ Yulius Academy, Yulius Mental Health Care Organization, Dennenhout 1, Barendrecht, 2994 GC, Netherlands, 31 884056990, k.bul@yulius.nl %K attention deficit-hyperactivity disorder %K ADHD %K serious game %K Internet %K children %K treatment %K randomized controlled trial %D 2016 %7 16.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The need for accessible and motivating treatment approaches within mental health has led to the development of an Internet-based serious game intervention (called “Plan-It Commander”) as an adjunct to treatment as usual for children with attention-deficit/hyperactivity disorder (ADHD). Objective: The aim was to determine the effects of Plan-It Commander on daily life skills of children with ADHD in a multisite randomized controlled crossover open-label trial. Methods: Participants (N=170) in this 20-week trial had a diagnosis of ADHD and ranged in age from 8 to 12 years (male: 80.6%, 137/170; female: 19.4%, 33/170). They were randomized to a serious game intervention group (group 1; n=88) or a treatment-as-usual crossover group (group 2; n=82). Participants randomized to group 1 received a serious game intervention in addition to treatment as usual for the first 10 weeks and then received treatment as usual for the next 10 weeks. Participants randomized to group 2 received treatment as usual for the first 10 weeks and crossed over to the serious game intervention in addition to treatment as usual for the subsequent 10 weeks. Primary (parent report) and secondary (parent, teacher, and child self-report) outcome measures were administered at baseline, 10 weeks, and 10-week follow-up. Results: After 10 weeks, participants in group 1 compared to group 2 achieved significantly greater improvements on the primary outcome of time management skills (parent-reported; P=.004) and on secondary outcomes of the social skill of responsibility (parent-reported; P=.04), and working memory (parent-reported; P=.02). Parents and teachers reported that total social skills improved over time within groups, whereas effects on total social skills and teacher-reported planning/organizing skills were nonsignificant between groups. Within group 1, positive effects were maintained or further improved in the last 10 weeks of the study. Participants in group 2, who played the serious game during the second period of the study (weeks 10 to 20), improved on comparable domains of daily life functioning over time. Conclusions: Plan-It Commander offers an effective therapeutic approach as an adjunct intervention to traditional therapeutic ADHD approaches that improve functional outcomes in daily life. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 62056259; http://www.controlled-trials.com/ISRCTN62056259 (Archived by WebCite at http://www.webcitation.org/6eNsiTDJV). %M 26883052 %R 10.2196/jmir.5173 %U http://www.jmir.org/2016/2/e26/ %U https://doi.org/10.2196/jmir.5173 %U http://www.ncbi.nlm.nih.gov/pubmed/26883052 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 1 %P e6 %T Digital Gaming for Improving the Functioning of People With Traumatic Brain Injury: Protocol of a Feasibility Study %A Välimäki,Maritta %A Korkeila,Jyrki %A Kauppi,Kaisa %A Kaakinen,Johanna K %A Holm,Suvi %A Vahlo,Jukka %A Tenovuo,Olli %A Hämäläinen,Heikki %A Sarajuuri,Jaana %A Rantanen,Pekka %A Orenius,Tage %A Koponen,Aki %+ Faculty of Medicine, Department of Nursing Science, Lemminkäisenkatu 1, University of Turku, 20014, Finland, 358 23338495, mava@utu.fi %K digital games %K brain injury %K cognitive rehabilitation %D 2016 %7 09.02.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Traumatic brain injury (TBI) is a critical public health problem. The recovery process for people with TBI is typically slow and dependent on complex and intensive assisted rehabilitation programs. Objective: To evaluate the effects and feasibility of digital games for cognitive functioning and general well-being among people with traumatic brain injury. Methods: This is a single-site feasibility study conducted in Finland, which uses a pragmatic, randomized controlled trial with three arms, and will recruit patients from the Turku University Hospital, Division of Clinical Neurosciences in Finland. Participants must meet the following inclusion criteria: (1) a Finnish speaking adult, aged 18-65 years; (2) diagnosed with a traumatic brain injury (diagnostic criteria ICD-10, S06.X, T90.5) in the University Hospital; (3) access to a TV, a computer, and the Internet at home; (4) not an active digital gamer (5 hours or less a week); (5) willing to participate in the study. Participants must have been discharged from the neurologic treatment period for traumatic brain injury for over 12 months before the commencement of the trial, and they may not have actively participated in cognitive rehabilitation during the 3 months prior to the trial. Written informed consent will be mandatory for acceptance into the trial. Exclusion criteria are as follows: (1) sensory, cognitive, or physical impairment (eg, severe cognitive impairment); (2) a deficiency restricting the use of computers or computer game control system unaided (eg, impairment in vision, severe astigmatism, hemiplegia, disorder in visuospatial perception, dysfunction of the central vestibular system); (3) apathy identified in previous neuropsychological evaluations; (4) diagnosed severe mental disorders (eg, schizophrenia or severe depressive disorders to be identified in medical records as the secondary diagnosis). Results: The preparatory phase for the study is fulfilled. Recruitment started in June 2015 and finished November 2015. Results will be reported in 2016. Conclusions: The specific outcomes such as primary outcome measures were selected because they are widely used psychological tests and thought to be sensitive to changes in the cognitive functions related to TBI. Trial Registration: Clinicaltrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH) %M 26860741 %R 10.2196/resprot.4841 %U http://www.researchprotocols.org/2016/1/e6/ %U https://doi.org/10.2196/resprot.4841 %U http://www.ncbi.nlm.nih.gov/pubmed/26860741 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e29 %T Effects of a Web-Based Computer-Tailored Game to Reduce Binge Drinking Among Dutch Adolescents: A Cluster Randomized Controlled Trial %A Jander,Astrid %A Crutzen,Rik %A Mercken,Liesbeth %A Candel,Math %A de Vries,Hein %+ School for Public Health and Primary Care CAPHRI, Department of Health Promotion, Maastricht University, PO Box 616, Maastricht, 6200 MD, Netherlands, 31 433884279, astrid.jander@maastrichtuniversity.nl %K adolescents %K alcohol drinking %K binge drinking %K cluster randomized controlled trial %K serious games %K computer tailoring %D 2016 %7 03.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Binge drinking among Dutch adolescents is among the highest in Europe. Few interventions so far have focused on adolescents aged 15 to 19 years. Because binge drinking increases significantly during those years, it is important to develop binge drinking prevention programs for this group. Web-based computer-tailored interventions can be an effective tool for reducing this behavior in adolescents. Embedding the computer-tailored intervention in a serious game may make it more attractive to adolescents. Objective: The aim was to assess whether a Web-based computer-tailored intervention is effective in reducing binge drinking in Dutch adolescents aged 15 to 19 years. Secondary outcomes were reduction in excessive drinking and overall consumption during the previous week. Personal characteristics associated with program adherence were also investigated. Methods: A cluster randomized controlled trial was conducted among 34 Dutch schools. Each school was randomized into either an experimental (n=1622) or a control (n=1027) condition. Baseline assessment took place in January and February 2014. At baseline, demographic variables and alcohol use were assessed. Follow-up assessment of alcohol use took place 4 months later (May and June 2014). After the baseline assessment, participants in the experimental condition started with the intervention consisting of a game about alcohol in which computer-tailored feedback regarding motivational characteristics was embedded. Participants in the control condition only received the baseline questionnaire. Both groups received the 4-month follow-up questionnaire. Effects of the intervention were assessed using logistic regression mixed models analyses for binge and excessive drinking and linear regression mixed models analyses for weekly consumption. Factors associated with intervention adherence in the experimental condition were explored by means of a linear regression model. Results: In total, 2649 adolescents participated in the baseline assessment. At follow-up, 824 (31.11%) adolescents returned. The intervention was effective in reducing binge drinking among adolescents aged 15 years (P=.03) and those aged 16 years when they participated in at least 2 intervention sessions (P=.04). Interaction effects between excessive drinking and educational level (P=.08) and between weekly consumption and age (P=.09) were found; however, in-depth analyses revealed no significant subgroup effects for both interaction effects. Additional analyses revealed that prolonged use of the intervention was associated with stronger effects for binge drinking. Yet, overall adherence to the intervention was low. Analyses revealed that being Protestant, female, younger, a nonbinge drinker, and having a higher educational background were associated with adherence. Conclusions: The intervention was effective for adolescents aged 15 and 16 years concerning binge drinking. Prevention messages may be more effective for those at the start of their drinking career, whereas other methods may be needed for those with a longer history of alcohol consumption. Despite using game elements, intervention completion was low. Trial Registration: Dutch Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by WebCite® at http://www.webcitation.org/6eSJD3FiY) %M 26842694 %R 10.2196/jmir.4708 %U http://www.jmir.org/2016/2/e29/ %U https://doi.org/10.2196/jmir.4708 %U http://www.ncbi.nlm.nih.gov/pubmed/26842694 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e1 %T Behavioral Economics, Wearable Devices, and Cooperative Games: Results From a Population-Based Intervention to Increase Physical Activity %A van Mierlo,Trevor %A Hyatt,Douglas %A Ching,Andrew T %A Fournier,Rachel %A Dembo,Ron S %+ Evolution Health Systems Inc., 901 King Street West, Suite 400, Toronto, ON, M5V 3H5, Canada, 1 4166448476, tvanmierlo@evolutionhs.com %K behavioral economics, cooperative games, adherence, compliance, serious games, Superusers, health rewards, internet of things, wearable devices %D 2016 %7 28.01.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Health care literature supports the development of accessible interventions that integrate behavioral economics, wearable devices, principles of evidence-based behavior change, and community support. However, there are limited real-world examples of large scale, population-based, member-driven reward platforms. Subsequently, a paucity of outcome data exists and health economic effects remain largely theoretical. To complicate matters, an emerging area of research is defining the role of Superusers, the small percentage of unusually engaged digital health participants who may influence other members. Objective: The objective of this preliminary study is to analyze descriptive data from GOODcoins, a self-guided, free-to-consumer engagement and rewards platform incentivizing walking, running and cycling. Registered members accessed the GOODcoins platform through PCs, tablets or mobile devices, and had the opportunity to sync wearables to track activity. Following registration, members were encouraged to join gamified group challenges and compare their progress with that of others. As members met challenge targets, they were rewarded with GOODcoins, which could be redeemed for planet- or people-friendly products. Methods: Outcome data were obtained from the GOODcoins custom SQL database. The reporting period was December 1, 2014 to May 1, 2015. Descriptive self-report data were analyzed using MySQL and MS Excel. Results: The study period includes data from 1298 users who were connected to an exercise tracking device. Females consisted of 52.6% (n=683) of the study population, 33.7% (n=438) were between the ages of 20-29, and 24.8% (n=322) were between the ages of 30-39. 77.5% (n=1006) of connected and active members met daily-recommended physical activity guidelines of 30 minutes, with a total daily average activity of 107 minutes (95% CI 90, 124). Of all connected and active users, 96.1% (n=1248) listed walking as their primary activity. For members who exchanged GOODcoins, the mean balance was 4,000 (95% CI 3850, 4150) at time of redemption, and 50.4% (n=61) of exchanges were for fitness or outdoor products, while 4.1% (n=5) were for food-related items. Participants were most likely to complete challenges when rewards were between 201-300 GOODcoins. Conclusions: The purpose of this study is to form a baseline for future research. Overall, results indicate that challenges and incentives may be effective for connected and active members, and may play a role in achieving daily-recommended activity guidelines. Registrants were typically younger, walking was the primary activity, and rewards were mainly exchanged for fitness or outdoor products. Remaining to be determined is whether members were already physically active at time of registration and are representative of healthy adherers, or were previously inactive and were incentivized to change their behavior. As challenges are gamified, there is an opportunity to investigate the role of superusers and healthy adherers, impacts on behavioral norms, and how cooperative games and incentives can be leveraged across stratified populations. Study limitations and future research agendas are discussed. %M 26821955 %R 10.2196/games.5358 %U http://games.jmir.org/2016/1/e1/ %U https://doi.org/10.2196/games.5358 %U http://www.ncbi.nlm.nih.gov/pubmed/26821955 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e8 %T Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study %A Bird,Marie-Louise %A Clark,Brodie %A Millar,Johanna %A Whetton,Sue %A Smith,Stuart %+ Healthy Research Centre, Faculty of Health, University of Tasmania, Locked Bag 1322, Launceston, 7250, Australia, 61 408123433, birdm@utas.edu.au %K health care reform %K postural balance %K pleasure %K exercise %K perception %D 2015 %7 27.11.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (“exergames”), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perceptions of the use of technology to improve health are not known. Objective: The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods: Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (“Your Shape Fitness Evolved 2012”). Games scores, rates of game participation, and enjoyment were also recorded. Results: A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83%-100%) were recorded. Conclusions: Older adults’ have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults. %M 26614263 %R 10.2196/games.4275 %U http://games.jmir.org/2015/2/e8/ %U https://doi.org/10.2196/games.4275 %U http://www.ncbi.nlm.nih.gov/pubmed/26614263 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e130 %T Using an eHealth Intervention to Stimulate Health Behavior for the Prevention of Cognitive Decline in Dutch Adults: A Study Protocol for the Brain Aging Monitor %A Aalbers,Teun %A Baars,Maria AE %A Qin,Li %A de Lange,Annet %A Kessels,Roy PC %A Olde Rikkert,Marcel GM %+ Department of Geriatric Medicine, Radboud University Medical Center, PO Box 9101, Nijmegen, 6500 HB, Netherlands, 31 243619807, teun.aalbers@radboudumc.nl %K cognition %K healthy lifestyle %K eHealth %K internet %K prevention %K applied games %K protocol %D 2015 %7 10.11.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Internet-delivered intervention programs are an effective way of changing health behavior in an aging population. The same population has an increasing number of people with cognitive decline or cognitive impairments. Modifiable lifestyle risk factors such as physical activity, nutrition, smoking, alcohol consumption, sleep, and stress all influence the probability of developing neurodegenerative diseases such as Alzheimer’s disease. Objective: This study aims to answer two questions: (1) Is the use of a self-motivated, complex eHealth intervention effective in changing multiple health behaviors related to cognitive aging in Dutch adults in the work force, especially those aged 40 and over? and (2) Does this health behavior change result in healthier cognitive aging patterns and contribute to preventing or delaying future onset of neurodegenerative syndromes? Methods: The Brain Aging Monitor study uses a quasi-experimental 2-year pre-posttest design. The Brain Aging Monitor is an online, self-motivated lifestyle intervention program. Recruitment is done both in medium to large organizations and in the Dutch general population over the age of 40. The main outcome measure is the relationship between lifestyle change and cognitive aging. The program uses different strategies and modalities such as Web content, email, online newsletters, and online games to aid its users in behavior change. To build self-regulatory skills, the Brain Aging Monitor offers its users goal-setting activities, skill-building activities, and self-monitoring. Results: Study results are expected to be published in early 2016. Conclusions: This study will add to the body of evidence on the effectiveness of eHealth intervention programs with the combined use of state-of-the-art applied games and established behavior change techniques. This will lead to new insights on how to use behavior change techniques and theory in multidimensional lifestyle eHealth research, and how these techniques and theories apply when they are used in a setting where no professional back-end is available. Trial Registration: Nederlands Trial Register: NTR4144; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4144 (Archived by WebCite at http://www.webcitation.org/6cZzwZSg3) %M 26554496 %R 10.2196/resprot.4468 %U http://www.researchprotocols.org/2015/4/e130/ %U https://doi.org/10.2196/resprot.4468 %U http://www.ncbi.nlm.nih.gov/pubmed/26554496 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 10 %P e245 %T Using Videogame Apps to Assess Gains in Adolescents’ Substance Use Knowledge: New Opportunities for Evaluating Intervention Exposure and Content Mastery %A Montanaro,Erika %A Fiellin,Lynn E %A Fakhouri,Tamer %A Kyriakides,Tassos C %A Duncan,Lindsay R %+ Yale University, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT, 06510, United States, 1 203 764 4333, erika.montanaro@yale.edu %K video games %K intervention studies %K substance use %K HIV %K evaluation %K eHealth %D 2015 %7 28.10.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Videogame interventions are becoming increasingly popular as a means to engage people in behavioral interventions; however, strategies for examining data from such interventions have not been developed. Objective: The objective of this study was to describe how a technology-based intervention can yield meaningful, objective evidence of intervention exposure within a behavioral intervention. This study demonstrates the analysis of automatic log files, created by software from a videogame intervention, that catalog game play and, as proof of concept, the association of these data with changes in substance use knowledge as documented with standardized assessments. Methods: We analyzed 3- and 6-month follow-up data from 166 participants enrolled in a randomized controlled trial evaluating a videogame intervention, PlayForward: Elm City Stories (PlayForward). PlayForward is a videogame developed as a risk reduction and prevention program targeting HIV risk behaviors (substance use and sex) in young minority adolescents. Log files were analyzed to extract the total amount of time spent playing the videogame intervention and the total number of game levels completed and beaten by each player. Results: Completing and beating more of the game levels, and not total game play time, was related to higher substance use knowledge scores at the 3- (P=.001) and 6-month (P=.001) follow-ups. Conclusions: Our findings highlight the potential contributions a videogame intervention can make to the study of health behavior change. Specifically, the use of objective data collected during game play can address challenges in traditional human-delivered behavioral interventions. Trial Registration: Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6cV9fxsOg) %M 26510775 %R 10.2196/jmir.4377 %U http://www.jmir.org/2015/10/e245/ %U https://doi.org/10.2196/jmir.4377 %U http://www.ncbi.nlm.nih.gov/pubmed/26510775 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e118 %T Games and Telerehabilitation for Balance Impairments and Gaze Dysfunction: Protocol of a Randomized Controlled Trial %A Szturm,Tony %A Hochman,Jordan %A Wu,Christine %A Lisa,Lix %A Reimer,Karen %A Wonneck,Beth %A Giacobbo,Andrea %+ College of Rehabilitation Sciences, Department of Physical Therapy, University of Manitoba, R106, 771 McDermot Avenue,, Winnipeg, MB, R3E 0T6, Canada, 1 (204) 789 3897, tony.szturm@umanitoba.ca %K balance-exercises %K gaze-exercises %K home therapy %K telerehabilitation %K therapeutic-gaming %K vestibular rehabilitation %D 2015 %7 21.10.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Digital media and gaming have received considerable interest from researchers and clinicians as a model for learning a broad range of complex tasks and facilitating the transfer of skills to daily life. These emerging rehabilitation technologies have the potential to improve clinical outcomes and patient participation because they are engaging, motivating, and accessible. Our research goal is to develop preventative and therapeutic point-of-care eHealth applications that will lead to equivalent or better long-term health outcomes and health care costs than existing programs. We have produced a novel computer-aided tele-rehabilitation platform that combines computer game-based exercises with tele-monitoring. Objective: Compare the therapeutic effectiveness of an in-home, game-based rehabilitation program (GRP) to standard care delivered in an outpatient physical therapy clinic on measures of balance, gaze control, dizziness, and health-related quality of life. Methods: A randomized, controlled, single-blind pilot trial will be conducted. Fifty-six participants with a diagnosis of peripheral vestibular disorder will be randomly assigned to either usual physical therapy (comparator group) or to a game-based intervention (experimental group). Measures to be assessed will include gaze control, dynamic balance, and self-reported measures of dizziness. Results: The project was funded and enrollment was started in August 2014. To date, 36 participants have been enrolled. There have been 6 drop-outs. It is expected that the study will be completed January 2016 and the first results are expected to be submitted for publication in Spring of 2016. Conclusions: A successful application of this rehabilitation program would help streamline rehabilitation services, leverage therapist time spent with clients, and permit regular practice times at the client’s convenience. Trial Registration: Clinicaltrials.gov: NCT02134444; https://clinicaltrials.gov/ct2/show/NCT02134444 (Archived by WebCite at http://www.webcitation.org/6cE18bqqY) %M 26490109 %R 10.2196/resprot.4743 %U http://www.researchprotocols.org/2015/4/e118/ %U https://doi.org/10.2196/resprot.4743 %U http://www.ncbi.nlm.nih.gov/pubmed/26490109 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e7 %T Effects of Social Network Exposure on Nutritional Learning: Development of an Online Educational Platform %A Dagan,Noa %A Beskin,Daniel %A Brezis,Mayer %A Reis,Ben Y %+ Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital and Harvard Medical School, 1 Autumn St Room 540.1, Boston, MA, 02115, United States, 1 857 218 4561, ben.reis@childrens.harvard.edu %K nutrition requirements %K obesity %K public health %K social networking sites %D 2015 %7 05.10.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Social networking sites (SNSs) such as Facebook have the potential to enhance online public health interventions, in part, as they provide social exposure and reinforcement. Objective: The objective of the study was to evaluate whether social exposure provided by SNSs enhances the effects of online public health interventions. Methods: As a sample intervention, we developed Food Hero, an online platform for nutritional education in which players feed a virtual character according to their own nutritional needs and complete a set of virtual sport challenges. The platform was developed in 2 versions: a "private version" in which a user can see only his or her own score, and a "social version" in which a user can see other players’ scores, including preexisting Facebook friends. We assessed changes in participants’ nutritional knowledge using 4 quiz scores and 3 menu-assembly scores. Monitoring feeding and exercising attempts assessed engagement with the platform. Results: The 2 versions of the platform were randomly assigned between a study group (30 members receiving the social version) and a control group (33 members, private version). The study group's performance on the quizzes gradually increased over time, relative to that of the control group, becoming significantly higher by the fourth quiz (P=.02). Furthermore, the study group's menu-assembly scores improved over time compared to the first score, whereas the control group's performance deteriorated. Study group members spent an average of 3:40 minutes assembling each menu compared to 2:50 minutes in the control group, and performed an average of 1.58 daily sport challenges, compared to 1.21 in the control group (P=.03). Conclusions: This work focused on isolating the SNSs' social effects in order to help guide future online interventions. Our results indicate that the social exposure provided by SNSs is associated with increased engagement and learning in an online nutritional educational platform. %M 26441466 %R 10.2196/games.4002 %U http://games.jmir.org/2015/2/e7/ %U https://doi.org/10.2196/games.4002 %U http://www.ncbi.nlm.nih.gov/pubmed/26441466 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 3 %P e114 %T Using Video Games to Enhance Motivation States in Online Education: Protocol for a Team-Based Digital Game %A Janssen,Anna %A Shaw,Tim %A Goodyear,Peter %+ Sydney Medical School, University of Sydney, Level 2, Charles Perkins Centre D17, University of Sydney, Sydney, 2006, Australia, 61 02 9036 9406, anna.janssen@sydney.edu.au %K digital games %K medical education %K online learning %D 2015 %7 28.09.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Video and computer games for education have been of interest to researchers for several decades. Over the last half decade, researchers in the health sector have also begun exploring the value of this medium. However, there are still many gaps in the literature regarding the effective use of video and computer games in medical education, particularly in relation to how learners interact with the platform, and how the games can be used to enhance collaboration. Objective: The objective of the study is to evaluate a team-based digital game as an educational tool for engaging learners and supporting knowledge consolidation in postgraduate medical education. Methods: A mixed methodology will be used in order to establish efficacy and level of motivation provided by a team-based digital game. Second-year medical students will be recruited as participants to complete 3 matches of the game at spaced intervals, in 2 evenly distributed teams. Prior to playing the game, participants will complete an Internet survey to establish baseline data. After playing the game, participants will voluntarily complete a semistructured interview to establish motivation and player engagement. Additionally, metrics collected from the game platform will be analyzed to determine efficacy. Results: The research is in the preliminary stages, but thus far a total of 54 participants have been recruited into the study. Additionally, a content development group has been convened to develop appropriate content for the platform. Conclusions: Video and computer games have been demonstrated to have value for educational purposes. Significantly less research has addressed how the medium can be effectively utilized in the health sector. Preliminary data from this study would suggest there is an interest in games for learning in the medical student body. As such, it is beneficial to undertake further research into how these games teach and engage learners in order to evaluate their role in tertiary and postgraduate medical education in the future. %M 26416522 %R 10.2196/resprot.4016 %U http://www.researchprotocols.org/2002/3/e114/ %U https://doi.org/10.2196/resprot.4016 %U http://www.ncbi.nlm.nih.gov/pubmed/26416522 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 8 %P e210 %T Apps for IMproving FITness and Increasing Physical Activity Among Young People: The AIMFIT Pragmatic Randomized Controlled Trial %A Direito,Artur %A Jiang,Yannan %A Whittaker,Robyn %A Maddison,Ralph %+ Faculty of Medical and Health Sciences, National Institute for Health Innovation, University of Auckland, National Institute for Health Innovation, School of Population Health, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand, 64 9 373 7599 ext 85285, a.direito@auckland.ac.nz %K physical fitness %K motor activity %K exercise %K physical activity %K adolescent %K health promotion %K telemedicine %K mHealth %K mobile applications %K smartphone %D 2015 %7 27.08.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Given the global prevalence of insufficient physical activity (PA), effective interventions that attenuate age-related decline in PA levels are needed. Mobile phone interventions that positively affect health (mHealth) show promise; however, their impact on PA levels and fitness in young people is unclear and little is known about what makes a good mHealth app. Objective: The aim was to determine the effects of two commercially available smartphone apps (Zombies, Run and Get Running) on cardiorespiratory fitness and PA levels in insufficiently active healthy young people. A second aim was to identify the features of the app design that may contribute to improved fitness and PA levels. Methods: Apps for IMproving FITness (AIMFIT) was a 3-arm, parallel, randomized controlled trial conducted in Auckland, New Zealand. Participants were recruited through advertisements in electronic mailing lists, local newspapers, flyers posted in community locations, and presentations at schools. Eligible young people aged 14-17 years were allocated at random to 1 of 3 conditions: (1) use of an immersive app (Zombies, Run), (2) use of a nonimmersive app (Get Running), or (3) usual behavior (control). Both smartphone apps consisted of a fully automated 8-week training program designed to improve fitness and ability to run 5 km; however, the immersive app featured a game-themed design and narrative. Intention-to-treat analysis was performed using data collected face-to-face at baseline and 8 weeks, and all regression models were adjusted for baseline outcome value and gender. The primary outcome was cardiorespiratory fitness, objectively assessed as time to complete the 1-mile run/walk test at 8 weeks. Secondary outcomes were PA levels (accelerometry and self-reported), enjoyment, psychological need satisfaction, self-efficacy, and acceptability and usability of the apps. Results: A total of 51 participants were randomized to the immersive app intervention (n=17), nonimmersive app intervention (n=16), or the control group (n=18). The mean age of participants was 15.7 (SD 1.2) years; participants were mostly NZ Europeans (61%, 31/51) and 57% (29/51) were female. Overall retention rate was 96% (49/51). There was no significant intervention effect on the primary outcome using either of the apps. Compared to the control, time to complete the fitness test was –28.4 seconds shorter (95% CI –66.5 to 9.82, P=.20) for the immersive app group and –24.7 seconds (95% CI –63.5 to 14.2, P=.32) for the nonimmersive app group. No significant intervention effects were found for secondary outcomes. Conclusions: Although apps have the ability to increase reach at a low cost, our pragmatic approach using readily available commercial apps as a stand-alone instrument did not have a significant effect on fitness. However, interest in future use of PA apps is promising and highlights a potentially important role of these tools in a multifaceted approach to increase fitness, promote PA, and consequently reduce the adverse health outcomes associated with insufficient activity. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12613001030763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12613001030763 (Archived by WebCite at http://www.webcitation.org/6aasfJVTJ). %M 26316499 %R 10.2196/jmir.4568 %U http://www.jmir.org/2015/8/e210/ %U https://doi.org/10.2196/jmir.4568 %U http://www.ncbi.nlm.nih.gov/pubmed/26316499 %0 Journal Article %@ 2369-2529 %I JMIR Publications Inc. %V 2 %N 2 %P e8 %T Interchangeability of the Wii Balance Board for Bipedal Balance Assessment %A Bonnechère,Bruno %A Jansen,Bart %A Omelina,Lubos %A Rooze,Marcel %A Van Sint Jan,Serge %+ Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculty of Medicine, Université Libre de Bruxelles, Lennik Street 808, Brussels, 1070, Belgium, 32 25556262, bbonnech@ulb.ac.be %K force plate %K balance board %K balance performance %K validity %K repeatability %D 2015 %7 27.08.2015 %9 Short Paper %J JMIR Rehabil Assist Technol %G English %X Background: Since 2010, an increasing interest in more portable and flexible hardware for balance and posture assessment led to previously published studies determining whether or not the Wii Balance Board could be used to assess balance and posture, both scientifically and clinically. However, no previous studies aimed at comparing results from different Wii Balance Boards for clinical balance evaluation exist. Objective: The objective of this crossover study is to assess the interchangeability of the Wii Balance Board. Methods: A total of 6 subjects participated in the study and their balance was assessed using 4 different Wii Balance Boards. Trials were recorded simultaneously with Wii Balance Boards and with a laboratory force plate. Nine relevant clinical parameters were derived from center of pressure displacement data obtained from Wii Balance Board and force plate systems. Intraclass correlation coefficients (ICC), F tests, and Friedman tests were computed to assess the agreement between trials and to compare the Wii Balance Board and force plate results. Results: Excellent correlations were found between the Wii Balance Board and force plate (mean ρ =.83). With the exception of 2 parameters, strong to excellent agreements were found for the 7 remaining parameters (ICC=.96). No significant differences were found between trials recorded with different Wii Balance Boards. Conclusions: Our results indicate that for most of the parameters analyzed, balance and posture assessed with one Wii Balance Board were statistically similar to results obtained from another. Furthermore, the good correlation between the Wii Balance Board and force plate results shows that Wii Balance Boards can be reliably used for scientific assessment using most of the parameters analyzed in this study. These results also suggest that the Wii Balance Board could be used in multicenter studies and therefore, would allow for the creation of larger populations for clinical studies. Trial Registration: Ethical Committee of the Erasme Hospital (CCB B406201215142). %M 28582237 %R 10.2196/rehab.3832 %U http://rehab.jmir.org/2015/2/e8/ %U https://doi.org/10.2196/rehab.3832 %U http://www.ncbi.nlm.nih.gov/pubmed/28582237 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e6 %T Training Vegetable Parenting Practices Through a Mobile Game: Iterative Qualitative Alpha Test %A Brand,Leah %A Beltran,Alicia %A Buday,Richard %A Hughes,Sheryl %A O'Connor,Teresia %A Baranowski,Janice %A Dadabhoy,Hafza R %A Diep,Cassandra S %A Baranowski,Tom %+ Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St, Houston, TX, 77030, United States, 1 713 798 9319, lbrand@bcm.edu %K mobile games %K games for health %K serious games %K pediatric nutrition %K parenting %D 2015 %7 24.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Vegetable consumption protects against chronic diseases, but many young children do not eat vegetables. One quest within the mobile application Mommio was developed to train mothers of preschoolers in effective vegetable parenting practices, or ways to approach getting their child to eat and enjoy vegetables. A much earlier version of the game, then called Kiddio, was alpha tested previously, but the game has since evolved in key ways. Objective: The purpose of this research was to alpha test the first quest, substantiate earlier findings and obtain feedback on new game features to develop an effective, compelling parenting game. Methods: Mothers of preschool children (n=20) played a single quest of Mommio 2 to 4 times, immediately after which a semi-structured interview about their experience was completed. Interviews were transcribed and double coded using thematic analysis methods. Results: Mothers generally liked the game, finding it realistic and engaging. Some participants had difficulties with mechanics for moving around the 3-D environment. Tips and hints were well received, and further expansion and customization were desired. Conclusions: Earlier findings were supported, though Mommio players reported more enjoyment than Kiddio players. Continued development will include more user-friendly mechanics, customization, opportunities for environment interaction, and food parenting scenarios. %M 26208899 %R 10.2196/games.4081 %U http://games.jmir.org/2015/2/e6/ %U https://doi.org/10.2196/games.4081 %U http://www.ncbi.nlm.nih.gov/pubmed/26208899 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e5 %T Using a Virtual Environment to Deliver Evidence-Based Interventions: The Facilitator's Experience %A Aebersold,Michelle %A Villarruel,Antonia %A Tschannen,Dana %A Valladares,Angel %A Yaksich,Joseph %A Yeagley,Emily %A Hawes,Armani %+ University of Michigan, School of Nursing, 400 North Ingalls, Ann Arbor, MI, , United States, 1 734 615 8498, mabersol@umich.edu %K Second Life %K multi-user virtual environments %K evidence-based interventions %K community-based organizations %D 2015 %7 21.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Evidence-based interventions (EBIs) have the potential to maximize positive impact on communities. However, despite the quantity and quality of EBIs for prevention, the need for formalized training and associated training-related expenses, such as travel costs, program materials, and input of personnel hours, pose implementation challenges for many community-based organizations. In this study, the community of inquiry (CoI) framework was used to develop the virtual learning environment to support the adaptation of the ¡Cuídate! (Take Care of Yourself!) Training of Facilitators curriculum (an EBI) to train facilitators from community-based organizations. Objective: The purpose of this study was to examine the feasibility of adapting a traditional face-to-face facilitator training program for ¡Cuídate!, a sexual risk reduction EBI for Latino youth, for use in a multi-user virtual environment (MUVE). Additionally, two aims of the study were explored: the acceptability of the facilitator training and the level of the facilitators’ knowledge and self-efficacy to implement the training. Methods: A total of 35 facilitators were trained in the virtual environment. We evaluated the facilitators' experience in the virtual training environment and determined if the learning environment was acceptable and supported the acquisition of learning outcomes. To this end, the facilitators were surveyed using a modified community of inquiry survey, with questions specific to the Second Life environment and an open-ended questionnaire. In addition, a comparison to face-to-face training was conducted using survey methods. Results: Results of the community of inquiry survey demonstrated a subscale mean of 23.11 (SD 4.12) out of a possible 30 on social presence, a subscale mean of 8.74 (SD 1.01) out of a possible 10 on teaching presence, and a subscale mean of 16.69 (SD 1.97) out of a possible 20 on cognitive presence. The comparison to face-to-face training showed no significant differences in participants' ability to respond to challenging or sensitive questions (P=.50) or their ability to help participants recognize how Latino culture supports safer sex (P=.32). There was a significant difference in their knowledge of core elements and modules (P<.001). A total of 74% (26/35) of the Second Life participants did agree/strongly agree that they had the skills to deliver the ¡Cuídate! program. Conclusions: The results showed that participants found the Second Life environment to be acceptable to the learners and supported an experience in which learners were able to acquire the knowledge and skills needed to deliver the curriculum. %M 26199045 %R 10.2196/games.4293 %U http://games.jmir.org/2015/2/e5/ %U https://doi.org/10.2196/games.4293 %U http://www.ncbi.nlm.nih.gov/pubmed/26199045 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e4 %T Health Behavior Theory in Physical Activity Game Apps: A Content Analysis %A Payne,Hannah E %A Moxley,Victor BA %A MacDonald,Elizabeth %+ Computational Health Science Research Group, Department of Health Science, Brigham Young University, 3024 LSB, Provo, UT, 84604, United States, 1 530 919 5100, hannahp413@gmail.com %K health and fitness apps %K mobile phone %K behavioral health %K theory %K content analysis %K physical activity %D 2015 %7 13.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Physical activity games developed for a mobile phone platform are becoming increasingly popular, yet little is known about their content or inclusion of health behavior theory (HBT). Objective: The objective of our study was to quantify elements of HBT in physical activity games developed for mobile phones and to assess the relationship between theoretical constructs and various app features. Methods: We conducted an analysis of exercise and physical activity game apps in the Apple App Store in the fall of 2014. A total of 52 apps were identified and rated for inclusion of health behavior theoretical constructs using an established theory-based rubric. Each app was coded for 100 theoretical items, containing 5 questions for 20 different constructs. Possible total theory scores ranged from 0 to 100. Descriptive statistics and Spearman correlations were used to describe the HBT score and association with selected app features, respectively. Results: The average HBT score in the sample was 14.98 out of 100. One outlier, SuperBetter, scored higher than the other apps with a score of 76. Goal setting, self-monitoring, and self-reward were the most-reported constructs found in the sample. There was no association between either app price and theory score (P=.5074), or number of gamification elements and theory score (P=.5010). However, Superbetter, with the highest HBT score, was also the most expensive app. Conclusions: There are few content analyses of serious games for health, but a comparison between these findings and previous content analyses of non-game health apps indicates that physical activity mobile phone games demonstrate higher levels of behavior theory. The most common theoretical constructs found in this sample are known to be efficacious elements in physical activity interventions. It is unclear, however, whether app designers consciously design physical activity mobile phone games with specific constructs in mind; it may be that games lend themselves well to inclusion of theory and any constructs found in significant levels are coincidental. Health games developed for mobile phones could be potentially used in health interventions, but collaboration between app designers and behavioral specialists is crucial. Additionally, further research is needed to better characterize mobile phone health games and the relative importance of educational elements versus gamification elements in long-term behavior change. %M 26168926 %R 10.2196/games.4187 %U http://games.jmir.org/2015/2/e4/ %U https://doi.org/10.2196/games.4187 %U http://www.ncbi.nlm.nih.gov/pubmed/26168926 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 6 %P e150 %T A Virtual Emergency Telemedicine Serious Game in Medical Training: A Quantitative, Professional Feedback-Informed Evaluation Study %A Nicolaidou,Iolie %A Antoniades,Athos %A Constantinou,Riana %A Marangos,Charis %A Kyriacou,Efthyvoulos %A Bamidis,Panagiotis %A Dafli,Eleni %A Pattichis,Constantinos S %+ Department of Communication and Internet Studies, Cyprus University of Technology, P.O. Box 50329, Limassol, 3603, Cyprus, 357 99329897, iolie.nicolaidou@cut.ac.cy %K telemedicine %K emergency telemedicine %K serious games %K virtual patients %K medical education %K professional feedback-informed evaluation %K emergency assessment and management %D 2015 %7 17.06.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious games involving virtual patients in medical education can provide a controlled setting within which players can learn in an engaging way, while avoiding the risks associated with real patients. Moreover, serious games align with medical students’ preferred learning styles. The Virtual Emergency TeleMedicine (VETM) game is a simulation-based game that was developed in collaboration with the mEducator Best Practice network in response to calls to integrate serious games in medical education and training. The VETM game makes use of data from an electrocardiogram to train practicing doctors, nurses, or medical students for problem-solving in real-life clinical scenarios through a telemedicine system and virtual patients. The study responds to two gaps: the limited number of games in emergency cardiology and the lack of evaluations by professionals. Objective: The objective of this study is a quantitative, professional feedback-informed evaluation of one scenario of VETM, involving cardiovascular complications. The study has the following research question: “What are professionals’ perceptions of the potential of the Virtual Emergency Telemedicine game for training people involved in the assessment and management of emergency cases?” Methods: The evaluation of the VETM game was conducted with 90 professional ambulance crew nursing personnel specializing in the assessment and management of emergency cases. After collaboratively trying out one VETM scenario, participants individually completed an evaluation of the game (36 questions on a 5-point Likert scale) and provided written and verbal comments. The instrument assessed six dimensions of the game: (1) user interface, (2) difficulty level, (3) feedback, (4) educational value, (5) user engagement, and (6) terminology. Data sources of the study were 90 questionnaires, including written comments from 51 participants, 24 interviews with 55 participants, and 379 log files of their interaction with the game. Results: Overall, the results were positive in all dimensions of the game that were assessed as means ranged from 3.2 to 3.99 out of 5, with user engagement receiving the highest score (mean 3.99, SD 0.87). Users’ perceived difficulty level received the lowest score (mean 3.20, SD 0.65), a finding which agrees with the analysis of log files that showed a rather low success rate (20.6%). Even though professionals saw the educational value and usefulness of the tool for pre-hospital emergency training (mean 3.83, SD 1.05), they identified confusing features and provided input for improving them. Conclusions: Overall, the results of the professional feedback-informed evaluation of the game provide a strong indication of its potential as an educational tool for emergency training. Professionals’ input will serve to improve the game. Further research will aim to validate VETM, in a randomized pre-test, post-test control group study to examine possible learning gains in participants’ problem-solving skills in treating a patient’s symptoms in an emergency situation. %M 26084866 %R 10.2196/jmir.3667 %U http://www.jmir.org/2015/6/e150/ %U https://doi.org/10.2196/jmir.3667 %U http://www.ncbi.nlm.nih.gov/pubmed/26084866 %0 Journal Article %@ 2369-3762 %I JMIR Publications Inc. %V 1 %N 1 %P e2 %T Student Preferences on Gaming Aspects for a Serious Game in Pharmacy Practice Education: A Cross-Sectional Study %A Chang,Huan Ying %A Poh,David Yan Hong %A Wong,Li Lian %A Yap,John Yin Gwee %A Yap,Kevin Yi-Lwern %+ National University of Singapore, Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, 18 Science Drive 4, Singapore, , Singapore, 65 6601 3253, kevinyap.ehealth@gmail.com %K gaming aspects %K pharmacy-related serious game %K pharmacy practice education %K reward systems %K game settings %K storylines %K viewing perspectives %K gaming styles %D 2015 %7 11.05.2015 %9 Original Paper %J JMIR Medical Education %G English %X Background: Serious games are motivating and provide a safe environment for students to learn from their mistakes without experiencing any negative consequences from their actions. However, little is known about students’ gaming preferences and the types of serious games they like to play for education. Objective: This study aims to determine the types of gaming aspects that students would like to play in a pharmacy-related serious game. Methods: A cross-sectional study was conducted using a self-administered survey, which obtained students’ responses on their preferences regarding various gaming aspects (reward systems, game settings, storylines, viewing perspectives, and gaming styles) and for a hypothetical gaming scenario (authentic simulation or post-apocalyptic fantasy). Descriptive statistics, chi-square, and Fisher’s exact tests were used for statistical analyses. Results: Response rate was 72.7% (497/684 undergraduates). The most popular game reward systems were unlocking mechanisms (112/497, 22.5%) and experience points (90/497, 18.1%). Most students preferred fantasy/medieval/mythic (253/497, 50.9%) and modern (117/497, 23.5%) settings, but lower year undergraduates preferred modern settings less than upper year seniors (47/236, 19.9% vs 70/242, 28.9%, P=.022). Almost one-third (147/497, 29.6%) preferred an adventurer storyline or an authentic pharmacy-related plot (119/497, 23.9%), and a collaborative game style was most preferred by the students (182/497, 36.6%). Three-dimensional game perspectives (270/497, 54.3%) were more popular than two-dimensional perspectives (221/497, 44.5%), especially among males than females (126/185, 68.1% vs 142/303, 46.9%, P<.001). In terms of choice for a pharmacy-related serious game, a post-apocalyptic fantasy game (scenario B, 287/497, 57.7%) was more popular than an authentic simulation game (scenario A, 209/497, 42.1%). More males preferred the post-apocalyptic fantasy scenario than females (129/187, 69.0% vs 155/306, 50.7%, P<.001). Conclusions: In general, students want a three-dimensional, fantasy/medieval/mythic post-apocalyptic game, based on an adventurer storyline with an unlocking mechanism reward system. A balance between real-life and fantasy elements needs to be struck in order for the game to cater students towards health care practices. %M 27731304 %R 10.2196/mededu.3754 %U http://mededu.jmir.org/2015/1/e2/ %U https://doi.org/10.2196/mededu.3754 %U http://www.ncbi.nlm.nih.gov/pubmed/27731304 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 2 %P e11 %T Integrating Health Behavior Theory and Design Elements in Serious Games %A Cheek,Colleen %A Fleming,Theresa %A Lucassen,Mathijs FG %A Bridgman,Heather %A Stasiak,Karolina %A Shepherd,Matthew %A Orpin,Peter %+ Rural Clinical School, School of Medicine, University of Tasmania, Private Bag 3513, Burnie, , Australia, 61 3 6430 5922, Colleen.Cheek@utas.edu.au %K depression %K adolescent %K cognitive behavior therapy %K online intervention %K user-centered %K self-efficacy %K motivation %K adherence %K SPARX %D 2015 %7 21.04.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games. Objective: To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective. Methods: We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework. Results: A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model. Conclusions: This study’s method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user’s sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose. %M 26543916 %R 10.2196/mental.4133 %U http://mental.jmir.org/2015/2/e11/ %U https://doi.org/10.2196/mental.4133 %U http://www.ncbi.nlm.nih.gov/pubmed/26543916 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e3 %T Digital Games for Type 1 and Type 2 Diabetes: Underpinning Theory With Three Illustrative Examples %A Kamel Boulos,Maged N %A Gammon,Shauna %A Dixon,Mavis C %A MacRury,Sandra M %A Fergusson,Michael J %A Miranda Rodrigues,Francisco %A Mourinho Baptista,Telmo %A Yang,Stephen P %+ The Alexander Graham Bell Centre for Digital Health, Moray College UHI, University of the Highlands and Islands, AGBC210, Moray College UHI, Moray Street, Elgin, IV30 1JJ, United Kingdom, 44 1343576830, maged.kamelboulos@uhi.ac.uk %K diabetes mellitus %K video games %K self-care %D 2015 %7 18.03.2015 %9 Viewpoint %J JMIR Serious Games %G English %X Digital games are an important class of eHealth interventions in diabetes, made possible by the Internet and a good range of affordable mobile devices (eg, mobile phones and tablets) available to consumers these days. Gamifying disease management can help children, adolescents, and adults with diabetes to better cope with their lifelong condition. Gamification and social in-game components are used to motivate players/patients and positively change their behavior and lifestyle. In this paper, we start by presenting the main challenges facing people with diabetes—children/adolescents and adults—from a clinical perspective, followed by three short illustrative examples of mobile and desktop game apps and platforms designed by Ayogo Health, Inc. (Vancouver, BC, Canada) for type 1 diabetes (one example) and type 2 diabetes (two examples). The games target different age groups with different needs—children with type 1 diabetes versus adults with type 2 diabetes. The paper is not meant to be an exhaustive review of all digital game offerings available for people with type 1 and type 2 diabetes, but rather to serve as a taster of a few of the game genres on offer today for both types of diabetes, with a brief discussion of (1) some of the underpinning psychological mechanisms of gamified digital interventions and platforms as self-management adherence tools, and more, in diabetes, and (2) some of the hypothesized potential benefits that might be gained from their routine use by people with diabetes. More research evidence from full-scale evaluation studies is needed and expected in the near future that will quantify, qualify, and establish the evidence base concerning this gamification potential, such as what works in each age group/patient type, what does not, and under which settings and criteria. %M 25791276 %R 10.2196/games.3930 %U http://games.jmir.org/2015/1/e3/ %U https://doi.org/10.2196/games.3930 %U http://www.ncbi.nlm.nih.gov/pubmed/25791276 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e2 %T Therapists’ Perceptions of Social Media and Video Game Technologies in Upper Limb Rehabilitation %A Tatla,Sandy K %A Shirzad,Navid %A Lohse,Keith R %A Virji-Babul,Naznin %A Hoens,Alison M %A Holsti,Liisa %A Li,Linda C %A Miller,Kimberly J %A Lam,Melanie Y %A Van der Loos,HF Machiel %+ Sunny Hill Health Centre for Children, 3644 Slocan Avenue, Vancouver, BC, V5M 3E8, Canada, 1 604 453 8300, statla2@cw.bc.ca %K virtual reality %K technology adoption %K rehabilitation %K therapy %K social media %K gaming %K stroke %K cerebral palsy %K hemiplegia %D 2015 %7 10.03.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: The application of technologies, such as video gaming and social media for rehabilitation, is garnering interest in the medical field. However, little research has examined clinicians’ perspectives regarding technology adoption by their clients. Objective: The objective of our study was to explore therapists’ perceptions of how young people and adults with hemiplegia use gaming and social media technologies in daily life and in rehabilitation, and to identify barriers to using these technologies in rehabilitation. Methods: We conducted two focus groups comprised of ten occupational therapists/physiotherapists who provide neurorehabilitation to individuals with hemiplegia secondary to stroke or cerebral palsy. Data was analyzed using inductive thematic analysis. The diffusion of innovations theory provided a framework to interpret emerging themes. Results: Therapists were using technology in a limited capacity. They identified barriers to using social media and gaming technology with their clients, including a lack of age appropriateness, privacy issues with social media, limited transfer of training, and a lack of accessibility of current systems. Therapists also questioned their role in the context of technology-based interventions. The opportunity for social interaction was perceived as a major benefit of integrated gaming and social media. Conclusions: This study reveals the complexities associated with adopting new technologies in clinical practice, including the need to consider both client and clinician factors. Despite reporting several challenges with applying gaming and social media technology with clinical populations, therapists identified opportunities for increased social interactions and were willing to help shape the development of an upper limb training system that could more readily meet the needs of clients with hemiplegia. By considering the needs of both therapists and clients, technology developers may increase the likelihood that clinicians will adopt innovative technologies. %M 25759148 %R 10.2196/games.3401 %U http://games.jmir.org/2015/1/e2/ %U https://doi.org/10.2196/games.3401 %U http://www.ncbi.nlm.nih.gov/pubmed/25759148 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e1 %T The Design and Relevance of a Computerized Gamified Depression Therapy Program for Indigenous Māori Adolescents %A Shepherd,Matthew %A Fleming,Theresa %A Lucassen,Mathijs %A Stasiak,Karolina %A Lambie,Ian %A Merry,Sally N %+ School of Counselling, Human Services and Social Work, Department of Education, University of Auckland, 5th floor, N Building, Epsom Campus, Epsom, Auckland, Private Bag 92601, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K computerized cognitive behavioral therapy %K Māori %K indigenous populations %K depression %K consumer opinions %K participatory design %D 2015 %7 03.03.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression. Objective: The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach. Methods: There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data. Results: SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery. Conclusions: SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people. Trial Registration: The New Zealand Northern Y Regional Ethics Committee; http://ethics.health.govt.nz/home; NTY/09/003; (Archived by WebCite at http://www.webcitation/6VYgHXKaR). %M 25736225 %R 10.2196/games.3804 %U http://games.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/games.3804 %U http://www.ncbi.nlm.nih.gov/pubmed/25736225 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e13 %T Active Fantasy Sports: Rationale and Feasibility of Leveraging Online Fantasy Sports to Promote Physical Activity %A Moller,Arlen C %A Majewski,Sara %A Standish,Melanie %A Agarwal,Pooja %A Podowski,Aleksandra %A Carson,Rebecca %A Eyesus,Biruk %A Shah,Aakash %A Schneider,Kristin L %+ Department of Psychology, Illinois Institute of Technology, Suite 252, 3105 S Dearborn, Chicago, IL, 60616, United States, 1 312 567 3505, amoller@iit.edu %K physical activity %K games for health %K active video game %K exergame %K asynchronous %K social support %K multiplayer %K enjoyment %K intrinsic motivation %K sports %D 2014 %7 25.11.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: The popularity of active video games (AVGs) has skyrocketed over the last decade. However, research suggests that the most popular AVGs, which rely on synchronous integration between players’ activity and game features, fail to promote physical activity outside of the game or for extended periods of engagement. This limitation has led researchers to consider AVGs that involve asynchronous integration of players’ ongoing physical activity with game features. Rather than build an AVG de novo, we selected an established sedentary video game uniquely well suited for the incorporation of asynchronous activity: online fantasy sports. Objective: The primary aim of this study was to explore the feasibility of a new asynchronous AVG—active fantasy sports—designed to promote physical activity. Methods: We conducted two pilot studies of an active fantasy sports game designed to promote physical activity. Participants wore a low cost triaxial accelerometer and participated in an online fantasy baseball (Study 1, n=9, 13-weeks) or fantasy basketball (Study 2, n=10, 17-weeks) league. Privileges within the game were made contingent on meeting weekly physical activity goals (eg, averaging 10,000 steps/day). Results: Across the two studies, the feasibility of integrating physical activity contingent features and privileges into online fantasy sports games was supported. Participants found the active fantasy sports game enjoyable, as or more enjoyable than traditional (sedentary) online fantasy sports (Study 1: t8=4.43, P<.01; Study 2: t9=2.09, P=.07). Participants in Study 1 increased their average steps/day, t8=2.63, P<.05, while participants in Study 2 maintained (ie, did not change) their activity, t9=1.57, P=.15). In postassessment interviews, social support within the game was cited as a key motivating factor for increasing physical activity. Conclusions: Preliminary evidence supports potential for the active fantasy sports system as a sustainable and scalable intervention for promoting adult physical activity. %M 25654304 %R 10.2196/games.3691 %U http://games.jmir.org/2014/2/e13/ %U https://doi.org/10.2196/games.3691 %U http://www.ncbi.nlm.nih.gov/pubmed/25654304 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e11 %T How to Systematically Assess Serious Games Applied to Health Care %A Graafland,Maurits %A Dankbaar,Mary %A Mert,Agali %A Lagro,Joep %A De Wit-Zuurendonk,Laura %A Schuit,Stephanie %A Schaafstal,Alma %A Schijven,Marlies %+ Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, 1100DD, Netherlands, 31 20 566 4207, m.p.schijven@amc.uva.nl %K consensus %K serious game %K applied game %K telehealth %K mobile health %K video game %D 2014 %7 11.11.2014 %9 Viewpoint %J JMIR Serious Games %G English %X The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game’s rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games. %M 25654163 %R 10.2196/games.3825 %U http://games.jmir.org/2014/2/e11/ %U https://doi.org/10.2196/games.3825 %U http://www.ncbi.nlm.nih.gov/pubmed/25654163 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 8 %P e183 %T Physiological and Brain Activity After a Combined Cognitive Behavioral Treatment Plus Video Game Therapy for Emotional Regulation in Bulimia Nervosa: A Case Report %A Fagundo,Ana Beatriz %A Via,Esther %A Sánchez,Isabel %A Jiménez-Murcia,Susana %A Forcano,Laura %A Soriano-Mas,Carles %A Giner-Bartolomé,Cristina %A Santamaría,Juan J %A Ben-Moussa,Maher %A Konstantas,Dimitri %A Lam,Tony %A Lucas,Mikkel %A Nielsen,Jeppe %A Lems,Peter %A Cardoner,Narcís %A Menchón,Jose M %A de la Torre,Rafael %A Fernandez-Aranda,Fernando %+ University Hospital of Bellvitge-IDIBELL, Department of Psychiatry, Feixa Llarga s/n, Barcelona, 08907, Spain, 34 93 2607227, ffernandez@bellvitgehospital.cat %K eating disorders %K bulimia nervosa %K emotional regulation %K impulsivity %K video game therapy %K neuroimaging %K fMRI %D 2014 %7 12.08.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: PlayMancer is a video game designed to increase emotional regulation and reduce general impulsive behaviors, by training to decrease arousal and improve decision-making and planning. We have previously demonstrated the usefulness of PlayMancer in reducing impulsivity and improving emotional regulation in bulimia nervosa (BN) patients. However, whether these improvements are actually translated into brain changes remains unclear. Objective: The aim of this case study was to report on a 28-year-old Spanish woman with BN, and to examine changes in physiological variables and brain activity after a combined treatment of video game therapy (VGT) and cognitive behavioral therapy (CBT). Methods: Ten VGT sessions were carried out on a weekly basis. Anxiety, physiological, and impulsivity measurements were recorded. The patient was scanned in a 1.5-T magnetic resonance scanner, prior to and after the 10-week VGT/CBT combined treatment, using two paradigms: (1) an emotional face-matching task, and (2) a multi-source interference task (MSIT). Results: Upon completing the treatment, a decrease in average heart rate was observed. The functional magnetic resonance imaging (fMRI) results indicated a post-treatment reduction in reaction time along with high accuracy. The patient engaged areas typically active in healthy controls, although the cluster extension of the active areas decreased after the combined treatment. Conclusions: These results suggest a global improvement in emotional regulation and impulsivity control after the VGT therapy in BN, demonstrated by both physiological and neural changes. These promising results suggest that a combined treatment of CBT and VGT might lead to functional cerebral changes that ultimately translate into better cognitive and emotional performances. %M 25116416 %R 10.2196/jmir.3243 %U http://www.jmir.org/2014/8/e183/ %U https://doi.org/10.2196/jmir.3243 %U http://www.ncbi.nlm.nih.gov/pubmed/25116416 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e10 %T Diabetes Island: Preliminary Impact of a Virtual World Self-Care Educational Intervention for African Americans With Type 2 Diabetes %A Ruggiero,Laurie %A Moadsiri,Ada %A Quinn,Lauretta T %A Riley,Barth B %A Danielson,Kirstie K %A Monahan,Colleen %A Bangs,Valerie A %A Gerber,Ben S %+ Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road (MC 275), Chicago, IL, 60608, United States, 1 312 413 9825, lruggier@uic.edu %K minority group %K type 2 diabetes mellitus %K self-management %D 2014 %7 08.08.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Diabetes is a serious worldwide public health challenge. The burden of diabetes, including prevalence and risk of complications, is greater for minorities, particularly African Americans. Internet-based immersive virtual worlds offer a unique opportunity to reach large and diverse populations with diabetes for self-management education and support. Objective: The objective of the study was to examine the acceptability, usage, and preliminary outcome of a virtual world intervention, Diabetes Island, in low-income African Americans with type 2 diabetes. The main hypotheses were that the intervention would: (1) be perceived as acceptable and useful; and (2) improve diabetes self-care (eg, behaviors and barriers) and self-care related outcomes, including glycemic control (A1C), body mass index (BMI), and psychosocial factors (ie, empowerment and distress) over six months. Methods: The evaluation of the intervention impact used a single-group repeated measures design, including three assessment time points: (1) baseline, (2) 3 month (mid intervention), and (3) 6 month (immediate post intervention). Participants were recruited from a university primary care clinic. A total of 41 participants enrolled in the 6 month intervention study. The intervention components included: (1) a study website for communication, feedback, and tracking; and (2) access to an immersive virtual world (Diabetes Island) through Second Life, where a variety of diabetes self-care education activities and resources were available. Outcome measures included A1C, BMI, self-care behaviors, barriers to adherence, eating habits, empowerment, and distress. In addition, acceptability and usage were examined. A series of mixed-effects analyses, with time as a single repeated measures factor, were performed to examine preliminary outcomes. Results: The intervention study sample (N=41) characteristics were: (1) mean age of 55 years, (2) 71% (29/41) female, (3) 100% (41/41) African American, and (4) 76% (31/41) reported annual incomes below US $20,000. Significant changes over time in the expected direction were observed for BMI (P<.02); diabetes-related distress (P<.02); global (P<.01) and dietary (P<.01) environmental barriers to self-care; one physical activity subscale (P<.04); and one dietary intake (P<.01) subscale. The participant feedback regarding the intervention (eg, ease of use, interest, and perceived impact) was consistently positive. The usage patterns showed that the majority of participants logged in regularly during the first two months, and around half logged in each week on average across the six month period. Conclusions: This study demonstrated promising initial results of an immersive virtual world approach to reaching underserved individuals with diabetes to deliver diabetes self-management education. This intervention model and method show promise and could be tailored for other populations. A large scale controlled trial is needed to further examine efficacy. %M 25584346 %R 10.2196/games.3260 %U http://games.jmir.org/2014/2/e10/ %U https://doi.org/10.2196/games.3260 %U http://www.ncbi.nlm.nih.gov/pubmed/25584346 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e5 %T Assessing Video Games to Improve Driving Skills: A Literature Review and Observational Study %A Sue,Damian %A Ray,Pradeep %A Talaei-Khoei,Amir %A Jonnagaddala,Jitendra %A Vichitvanichphong,Suchada %+ Lab for Agile Information Systems, School of Systems, Management, and Leadership, University of Technology, Sydney, CB10.04.346, PO Box 123, Broadway, Ultimo NSW 2007, Sydney, , Australia, 61 (02) 9514 3, amir.talaei@uts.edu.au %K video games %K driving %K motor skills %K health %K coordination %D 2014 %7 07.08.2014 %9 Review %J JMIR Serious Games %G English %X Background: For individuals, especially older adults, playing video games is a promising tool for improving their driving skills. The ease of use, wide availability, and interactivity of gaming consoles make them an attractive simulation tool. Objective: The objective of this study was to look at the feasibility and effects of installing video game consoles in the homes of individuals looking to improve their driving skills. Methods: A systematic literature review was conducted to assess the effect of playing video games on improving driving skills. An observatory study was performed to evaluate the feasibility of using an Xbox 360 Kinect console for improving driving skills. Results: Twenty–nine articles, which discuss the implementation of video games in improving driving skills were found in literature. On our study, it was found the Xbox 360 with Kinect is capable of improving physical and mental activities. Xbox Video games were introduced to engage players in physical, visual and cognitive activities including endurance, postural sway, reaction time, eyesight, eye movement, attention and concentration, difficulties with orientation, and semantic fluency. However, manual dexterity, visuo-spatial perception and binocular vision could not be addressed by these games. It was observed that Xbox Kinect (by incorporating Kinect sensor facilities) combines physical, visual and cognitive engagement of players. These results were consistent with those from the literature review. Conclusions: From the research that has been carried out, we can conclude that video game consoles are a viable solution for improving user’s physical and mental state. In future we propose to carry a thorough evaluation of the effects of video games on driving skills in elderly people. %M 25654355 %R 10.2196/games.3274 %U http://games.jmir.org/2014/2/e5/ %U https://doi.org/10.2196/games.3274 %U http://www.ncbi.nlm.nih.gov/pubmed/25654355 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e9 %T Just a Fad? Gamification in Health and Fitness Apps %A Lister,Cameron %A West,Joshua H %A Cannon,Ben %A Sax,Tyler %A Brodegard,David %+ LaughModel Health Communication Research Group, Department of Health Science, Brigham Young University, 213 RB, Provo, UT, 84604, United States, 1 9702316755, cameron@laughmodel.com %K gamification %K mobile phone %K behavioral health %K health and fitness apps %D 2014 %7 04.08.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification has been a predominant focus of the health app industry in recent years. However, to our knowledge, there has yet to be a review of gamification elements in relation to health behavior constructs, or insight into the true proliferation of gamification in health apps. Objective: The objective of this study was to identify the extent to which gamification is used in health apps, and analyze gamification of health and fitness apps as a potential component of influence on a consumer’s health behavior. Methods: An analysis of health and fitness apps related to physical activity and diet was conducted among apps in the Apple App Store in the winter of 2014. This analysis reviewed a sample of 132 apps for the 10 effective game elements, the 6 core components of health gamification, and 13 core health behavior constructs. A regression analysis was conducted in order to measure the correlation between health behavior constructs, gamification components, and effective game elements. Results: This review of the most popular apps showed widespread use of gamification principles, but low adherence to any professional guidelines or industry standard. Regression analysis showed that game elements were associated with gamification (P<.001). Behavioral theory was associated with gamification (P<.05), but not game elements, and upon further analysis gamification was only associated with composite motivational behavior scores (P<.001), and not capacity or opportunity/trigger. Conclusions: This research, to our knowledge, represents the first comprehensive review of gamification use in health and fitness apps, and the potential to impact health behavior. The results show that use of gamification in health and fitness apps has become immensely popular, as evidenced by the number of apps found in the Apple App Store containing at least some components of gamification. This shows a lack of integrating important elements of behavioral theory from the app industry, which can potentially impact the efficacy of gamification apps to change behavior. Apps represent a very promising, burgeoning market and landscape in which to disseminate health behavior change interventions. Initial results show an abundant use of gamification in health and fitness apps, which necessitates the in-depth study and evaluation of the potential of gamification to change health behaviors. %M 25654660 %R 10.2196/games.3413 %U http://games.jmir.org/2014/2/e9/ %U https://doi.org/10.2196/games.3413 %U http://www.ncbi.nlm.nih.gov/pubmed/25654660 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e7 %T The Cure: Design and Evaluation of a Crowdsourcing Game for Gene Selection for Breast Cancer Survival Prediction %A Good,Benjamin M %A Loguercio,Salvatore %A Griffith,Obi L %A Nanis,Max %A Wu,Chunlei %A Su,Andrew I %+ The Scripps Research Institute, Department of Molecular and Experimental Medicine, MEM-216, 10550 North Torrey Pines Road, La Jolla, CA, 92037, United States, 1 619 261 2046, bgood@scripps.edu %K breast neoplasms %K gene expression %K artificial intelligence %K survival analysis %K crowdsourcing %K Web applications %K computer games %K collaborative and social computing systems and tools %K supervised learning %K feature selection %D 2014 %7 29.07.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Molecular signatures for predicting breast cancer prognosis could greatly improve care through personalization of treatment. Computational analyses of genome-wide expression datasets have identified such signatures, but these signatures leave much to be desired in terms of accuracy, reproducibility, and biological interpretability. Methods that take advantage of structured prior knowledge (eg, protein interaction networks) show promise in helping to define better signatures, but most knowledge remains unstructured. Crowdsourcing via scientific discovery games is an emerging methodology that has the potential to tap into human intelligence at scales and in modes unheard of before. Objective: The main objective of this study was to test the hypothesis that knowledge linking expression patterns of specific genes to breast cancer outcomes could be captured from players of an open, Web-based game. We envisioned capturing knowledge both from the player’s prior experience and from their ability to interpret text related to candidate genes presented to them in the context of the game. Methods: We developed and evaluated an online game called The Cure that captured information from players regarding genes for use as predictors of breast cancer survival. Information gathered from game play was aggregated using a voting approach, and used to create rankings of genes. The top genes from these rankings were evaluated using annotation enrichment analysis, comparison to prior predictor gene sets, and by using them to train and test machine learning systems for predicting 10 year survival. Results: Between its launch in September 2012 and September 2013, The Cure attracted more than 1000 registered players, who collectively played nearly 10,000 games. Gene sets assembled through aggregation of the collected data showed significant enrichment for genes known to be related to key concepts such as cancer, disease progression, and recurrence. In terms of the predictive accuracy of models trained using this information, these gene sets provided comparable performance to gene sets generated using other methods, including those used in commercial tests. The Cure is available on the Internet. Conclusions: The principal contribution of this work is to show that crowdsourcing games can be developed as a means to address problems involving domain knowledge. While most prior work on scientific discovery games and crowdsourcing in general takes as a premise that contributors have little or no expertise, here we demonstrated a crowdsourcing system that succeeded in capturing expert knowledge. %M 25654473 %R 10.2196/games.3350 %U http://games.jmir.org/2014/2/e7/ %U https://doi.org/10.2196/games.3350 %U http://www.ncbi.nlm.nih.gov/pubmed/25654473 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e8 %T What Serious Video Games Can Offer Child Obesity Prevention %A Thompson,Debbe %+ USDA/ARS Children's Nutrition Research Center, Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston, TX, 77030, United States, 1 713 798 7076, dit@bcm.edu %K serious video games %K children %K teenagers %K obesity prevention %K formative research, qualitative research %D 2014 %7 16.07.2014 %9 Viewpoint %J JMIR Serious Games %G English %X Childhood obesity is a worldwide issue, and effective methods encouraging children to adopt healthy diet and physical activity behaviors are needed. This viewpoint addresses the promise of serious video games, and why they may offer one method for helping children eat healthier and become more physically active. Lessons learned are provided, as well as examples gleaned from personal experiences. %M 25654589 %R 10.2196/games.3480 %U http://games.jmir.org/2014/2/e8/ %U https://doi.org/10.2196/games.3480 %U http://www.ncbi.nlm.nih.gov/pubmed/25654589 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e6 %T A Functional Magnetic Resonance Imaging Assessment of Small Animals’ Phobia Using Virtual Reality as a Stimulus %A Clemente,Miriam %A Rey,Beatriz %A Rodriguez-Pujadas,Aina %A Breton-Lopez,Juani %A Barros-Loscertales,Alfonso %A Baños,Rosa M %A Botella,Cristina %A Alcañiz,Mariano %A Avila,Cesar %+ LabHuman, I3BH, Universitat Politecnica de Valencia, Ciudad Politécnica de la Innovación - Cubo Azul - Edif 8B - Acceso N, Camino de Vera s/n, Valencia, 46022, Spain, 34 96 387 75 18 ext 67042, yavanna12@gmail.com %K neuroimaging %K patient assessment %K virtual reality %K phobia %D 2014 %7 27.06.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: To date, still images or videos of real animals have been used in functional magnetic resonance imaging protocols to evaluate the brain activations associated with small animals’ phobia. Objective: The objective of our study was to evaluate the brain activations associated with small animals’ phobia through the use of virtual environments. This context will have the added benefit of allowing the subject to move and interact with the environment, giving the subject the illusion of being there. Methods: We have analyzed the brain activation in a group of phobic people while they navigated in a virtual environment that included the small animals that were the object of their phobia. Results: We have found brain activation mainly in the left occipital inferior lobe (P<.05 corrected, cluster size=36), related to the enhanced visual attention to the phobic stimuli; and in the superior frontal gyrus (P<.005 uncorrected, cluster size=13), which is an area that has been previously related to the feeling of self-awareness. Conclusions: In our opinion, these results demonstrate that virtual stimulus can enhance brain activations consistent with previous studies with still images, but in an environment closer to the real situation the subject would face in their daily lives. %M 25654753 %R 10.2196/games.2836 %U http://games.jmir.org/2014/1/e6/ %U https://doi.org/10.2196/games.2836 %U http://www.ncbi.nlm.nih.gov/pubmed/25654753 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 6 %P e151 %T Exploring Design Requirements for Repurposing Dental Virtual Patients From the Web to Second Life: A Focus Group Study %A Antoniou,Panagiotis E %A Athanasopoulou,Christina A %A Dafli,Eleni %A Bamidis,Panagiotis D %+ Medical School, Faculty of Health Sciences, Aritstotle University of Thessaloniki, PO Box 376, Thessaloniki, 54124, Greece, 30 2310 999310, bamidis@med.auth.gr %K education %K medical %K dental %K focus groups %K patient simulation %K problem-based learning %K video games %D 2014 %7 13.06.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Since their inception, virtual patients have provided health care educators with a way to engage learners in an experience simulating the clinician’s environment without danger to learners and patients. This has led this learning modality to be accepted as an essential component of medical education. With the advent of the visually and audio-rich 3-dimensional multi-user virtual environment (MUVE), a new deployment platform has emerged for educational content. Immersive, highly interactive, multimedia-rich, MUVEs that seamlessly foster collaboration provide a new hotbed for the deployment of medical education content. Objective: This work aims to assess the suitability of the Second Life MUVE as a virtual patient deployment platform for undergraduate dental education, and to explore the requirements and specifications needed to meaningfully repurpose Web-based virtual patients in MUVEs. Methods: Through the scripting capabilities and available art assets in Second Life, we repurposed an existing Web-based periodontology virtual patient into Second Life. Through a series of point-and-click interactions and multiple-choice queries, the user experienced a specific periodontology case and was asked to provide the optimal responses for each of the challenges of the case. A focus group of 9 undergraduate dentistry students experienced both the Web-based and the Second Life version of this virtual patient. The group convened 3 times and discussed relevant issues such as the group’s computer literacy, the assessment of Second Life as a virtual patient deployment platform, and compared the Web-based and MUVE-deployed virtual patients. Results: A comparison between the Web-based and the Second Life virtual patient revealed the inherent advantages of the more experiential and immersive Second Life virtual environment. However, several challenges for the successful repurposing of virtual patients from the Web to the MUVE were identified. The identified challenges for repurposing of Web virtual patients to the MUVE platform from the focus group study were (1) increased case complexity to facilitate the user’s gaming preconception in a MUVE, (2) necessity to decrease textual narration and provide the pertinent information in a more immersive sensory way, and (3) requirement to allow the user to actuate the solutions of problems instead of describing them through narration. Conclusions: For a successful systematic repurposing effort of virtual patients to MUVEs such as Second Life, the best practices of experiential and immersive game design should be organically incorporated in the repurposing workflow (automated or not). These findings are pivotal in an era in which open educational content is transferred to and shared among users, learners, and educators of various open repositories/environments. %M 24927470 %R 10.2196/jmir.3343 %U http://www.jmir.org/2014/6/e151/ %U https://doi.org/10.2196/jmir.3343 %U http://www.ncbi.nlm.nih.gov/pubmed/24927470 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e4 %T Personal, Social, and Game-Related Correlates of Active and Non-Active Gaming Among Dutch Gaming Adolescents: Survey-Based Multivariable, Multilevel Logistic Regression Analyses %A Simons,Monique %A de Vet,Emely %A Chinapaw,Mai JM %A de Boer,Michiel %A Seidell,Jacob C %A Brug,Johannes %+ EMGO Institute for Health and Care Research, Department of Health Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands, Amsterdam, , Netherlands, 31 205983670, m.simons@vu.nl %K video games %K interactive games %K active games %K adolescent %K sedentary lifestyle %K physical activity %K determinants %D 2014 %7 04.04.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Playing video games contributes substantially to sedentary behavior in youth. A new generation of video games—active games—seems to be a promising alternative to sedentary games to promote physical activity and reduce sedentary behavior. At this time, little is known about correlates of active and non-active gaming among adolescents. Objective: The objective of this study was to examine potential personal, social, and game-related correlates of both active and non-active gaming in adolescents. Methods: A survey assessing game behavior and potential personal, social, and game-related correlates was conducted among adolescents (12-16 years, N=353) recruited via schools. Multivariable, multilevel logistic regression analyses, adjusted for demographics (age, sex and educational level of adolescents), were conducted to examine personal, social, and game-related correlates of active gaming ≥1 hour per week (h/wk) and non-active gaming >7 h/wk. Results: Active gaming ≥1 h/wk was significantly associated with a more positive attitude toward active gaming (OR 5.3, CI 2.4-11.8; P<.001), a less positive attitude toward non-active games (OR 0.30, CI 0.1-0.6; P=.002), a higher score on habit strength regarding gaming (OR 1.9, CI 1.2-3.2; P=.008) and having brothers/sisters (OR 6.7, CI 2.6-17.1; P<.001) and friends (OR 3.4, CI 1.4-8.4; P=.009) who spend more time on active gaming and a little bit lower score on game engagement (OR 0.95, CI 0.91-0.997; P=.04). Non-active gaming >7 h/wk was significantly associated with a more positive attitude toward non-active gaming (OR 2.6, CI 1.1-6.3; P=.035), a stronger habit regarding gaming (OR 3.0, CI 1.7-5.3; P<.001), having friends who spend more time on non-active gaming (OR 3.3, CI 1.46-7.53; P=.004), and a more positive image of a non-active gamer (OR 2, CI 1.07–3.75; P=.03). Conclusions: Various factors were significantly associated with active gaming ≥1 h/wk and non-active gaming >7 h/wk. Active gaming is most strongly (negatively) associated with attitude with respect to non-active games, followed by observed active game behavior of brothers and sisters and attitude with respect to active gaming (positive associations). On the other hand, non-active gaming is most strongly associated with observed non-active game behavior of friends, habit strength regarding gaming and attitude toward non-active gaming (positive associations). Habit strength was a correlate of both active and non-active gaming, indicating that both types of gaming are habitual behaviors. Although these results should be interpreted with caution because of the limitations of the study, they do provide preliminary insights into potential correlates of active and non-active gaming that can be used for further research as well as preliminary direction for the development of effective intervention strategies for replacing non-active gaming by active gaming among adolescents. %M 25654657 %R 10.2196/games.3092 %U http://games.jmir.org/2014/1/e4/ %U https://doi.org/10.2196/games.3092 %U http://www.ncbi.nlm.nih.gov/pubmed/25654657 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 2 %P e61 %T Effect of a Kinect-Based Exercise Game on Improving Executive Cognitive Performance in Community-Dwelling Elderly: Case Control Study %A Kayama,Hiroki %A Okamoto,Kazuya %A Nishiguchi,Shu %A Yamada,Minoru %A Kuroda,Tomohiro %A Aoyama,Tomoki %+ Human Health Sciences, Graduate School of Medicine, Kyoto University, 53, Kawaharcho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan, 81 75 751 3909, kayama.hiroki.37r@st.kyoto-u.ac.jp %K fall prevention %K cognitive function %K dual-task %K training %K elderly %D 2014 %7 24.02.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Decrease of dual-task (DT) ability is known to be one of the risk factors for falls. We developed a new game concept, Dual-Task Tai Chi (DTTC), using Microsoft’s motion-capture device Kinect, and demonstrated that the DTTC test can quantitatively evaluate various functions that are known risk factors for falling in elderly adults. Moreover, DT training has been attracting attention as a way to improve balance and DT ability. However, only a few studies have reported that it improves cognitive performance. Objective: The purpose of this study was to demonstrate whether or not a 12-week program of DTTC training would effectively improve cognitive functions. Methods: This study examined cognitive functions in community-dwelling older adults before and after 12 weeks of DTTC training (training group [TG]) or standardized training (control group [CG]). Primary end points were based on the difference in cognitive functions between the TG and the CG. Cognitive functions were evaluated using the trail-making test (part A and part B) and verbal fluency test. Results: A total of 41 elderly individuals (TG: n=26, CG: n=15) participated in this study and their cognitive functions were assessed before and after DTTC training. Significant differences were observed between the two groups with significant group × time interactions for the executive cognitive function measure, the delta-trail-making test (part B−part A; F1,36=4.94, P=.03; TG: pre mean 48.8 [SD 43.9], post mean 42.2 [SD 29.0]; CG: pre mean 49.5 [SD 51.8], post mean 64.9 [SD 54.7]). Conclusions: The results suggest that DTTC training is effective for improving executive cognitive functions. Trial Registration: Japan Medical Association Clinical Trial Registration Number: JMA-IIA00092; https://dbcentre3.jmacct.med.or.jp/jmactr/App/JMACTRS06/JMACTRS06.aspx?seqno=2682 (Archived by WebCite at http://www.webcitation.org/6NRtOkZFh). %M 24565806 %R 10.2196/jmir.3108 %U http://www.jmir.org/2014/2/e61/ %U https://doi.org/10.2196/jmir.3108 %U http://www.ncbi.nlm.nih.gov/pubmed/24565806 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e3 %T Views of Young People in Rural Australia on SPARX, a Fantasy World Developed for New Zealand Youth With Depression %A Cheek,Colleen %A Bridgman,Heather %A Fleming,Theresa %A Cummings,Elizabeth %A Ellis,Leonie %A Lucassen,Mathijs FG %A Shepherd,Matthew %A Skinner,Timothy %+ Rural Clinical School, University of Tasmania, Private Bag 3513, Burnie, 7320, Australia, 61 364305922, Colleen.Cheek@utas.edu.au %K mental health %K stigma %K computer games %K youth %K rural health, computerized CBT %D 2014 %7 18.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: A randomized control trial demonstrated that a computerized cognitive behavioral therapy (cCBT) program (Smart, Positive, Active, Realistic, X-factor thoughts [SPARX]) was an appealing and efficacious treatment for depression for adolescents in New Zealand. Little is known about the acceptability of computerized therapy programs for rural Australians and the suitability of computerized programs developed in one cultural context when used in another country. Issues such as accents and local differences in health care access might mean adjustments to programs are required. Objective: This study sought to explore the acceptability of SPARX by youth in rural Australia and to explore whether and how young people would wish to access such a program. Methods: Focus groups and semistructured interviews were conducted with 16 young people attending two youth-focused community services in a small, rural Tasmanian town. An inductive data-driven approach was used to identify themes using the interview transcripts as the primary data source. Interpretation was supported by demographic data, observer notes, and content analysis. Results: Participants reported that young people want help for mental health issues but they have an even stronger need for controlling how they access services. In particular, they considered protecting their privacy in their small community to be paramount. Participants thought computerized therapy was a promising way to increase access to treatment for youth in rural and remote areas if offered with or without therapist support and via settings other than school. The design features of SPARX that were perceived to be useful, included the narrative structure of the program, the use of different characters, the personalization of an avatar, “socialization” with the Guide character, optional journaling, and the use of encouraging feedback. Participants did not consider (New Zealand) accents off-putting. Young people believed the SPARX program would appeal to those who play computer games generally, but may be less appealing for those who do not. Conclusions: The findings suggest that computerized therapy offered in ways that support privacy and choice can improve access to treatment for rural youth. Foreign accents and style may not be off-putting to teenage users when the program uses a playful fantasy genre, as it is consistent with their expectation of fantasy worlds, and it is in a medium with which they already have a level of competence. Rather, issues of engaging design and confidential access appeared to be more important. These findings suggest a proven tool once formally assessed at a local level can be adopted cross-nationally. %M 25659116 %R 10.2196/games.3183 %U http://games.jmir.org/2014/1/e3/ %U https://doi.org/10.2196/games.3183 %U http://www.ncbi.nlm.nih.gov/pubmed/25659116 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 2 %P e47 %T A Decade of Research on the Use of Three-Dimensional Virtual Worlds in Health Care: A Systematic Literature Review %A Ghanbarzadeh,Reza %A Ghapanchi,Amir Hossein %A Blumenstein,Michael %A Talaei-Khoei,Amir %+ School of Information and Communication Technology, Griffith University, G23 2.32, Gold Coast Campus, Gold Coast, Queensland, 4222, Australia, 61 7 555 28502, reza.ghanbarzadeh@griffithuni.edu.au %K 3D virtual worlds %K 3DVW %K health care %D 2014 %7 18.02.2014 %9 Review %J J Med Internet Res %G English %X Background: A three-dimensional virtual world (3DVW) is a computer-simulated electronic 3D virtual environment that users can explore, inhabit, communicate, and interact with via avatars, which are graphical representations of the users. Since the early 2000s, 3DVWs have emerged as a technology that has much to offer the health care sector. Objective: The purpose of this study was to characterize different application areas of various 3DVWs in health and medical context and categorize them into meaningful categories. Methods: This study employs a systematic literature review on the application areas of 3DVWs in health care. Our search resulted in 62 papers from five top-ranking scientific databases published from 1990 to 2013 that describe the use of 3DVWs for health care specific purposes. We noted a growth in the number of academic studies on the topic since 2006. Results: We found a wide range of application areas for 3DVWs in health care and classified them into the following six categories: academic education, professional education, treatment, evaluation, lifestyle, and modeling. The education category, including professional and academic education, contains the largest number of papers (n=34), of which 23 are related to the academic education category and 11 to the professional education category. Nine papers are allocated to treatment category, and 8 papers have contents related to evaluation. In 4 of the papers, the authors used 3DVWs for modeling, and 3 papers targeted lifestyle purposes. The results indicate that most of the research to date has focused on education in health care. We also found that most studies were undertaken in just two countries, the United States and the United Kingdom. Conclusions: 3D virtual worlds present several innovative ways to carry out a wide variety of health-related activities. The big picture of application areas of 3DVWs presented in this review could be of value and offer insights to both the health care community and researchers. %M 24550130 %R 10.2196/jmir.3097 %U http://www.jmir.org/2014/2/e47/ %U https://doi.org/10.2196/jmir.3097 %U http://www.ncbi.nlm.nih.gov/pubmed/24550130 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e2 %T DietBet: A Web-Based Program that Uses Social Gaming and Financial Incentives to Promote Weight Loss %A Leahey,Tricia %A Rosen,Jamie %+ Brown Medical School, Department of Psychiatry and Human Behavior, The Miriam Hospital's Weight Control and Diabetes Research Center, 196 Richmond Street, Providence, RI, 02903, United States, 1 4017938947, tleahey@lifespan.org %K commercial weight loss %K Web-based intervention %K social gaming %K financial incentives %D 2014 %7 07.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Web-based commercial weight loss programs are increasing in popularity. Despite their significant public health potential, there is limited research on the effectiveness of such programs. Objective: The objective of our study was to examine weight losses produced by DietBet and explore whether baseline and engagement variables predict weight outcomes. Methods: DietBet is a social gaming website that uses financial incentives and social influence to promote weight loss. Players bet money and join a game. All players have 4 weeks to lose 4% of their initial body weight. At enrollment, players can choose to share their participation on Facebook. During the game, players interact with one another and report their weight loss on the DietBet platform. At week 4, all players within each game who lose at least 4% of initial body weight are declared winners and split the pool of money bet at the start of the game. Official weigh-in procedures are used to verify weights at the start of the game and at the end. Results: From December 2012 to July 2013, 39,387 players (84.04% female, 33,101/39,387; mean weight 87.8kg, SD 22.6kg) competed in 1934 games. The average amount bet was US $27 (SD US $22). A total of 65.63% (25,849/39,387) provided a verified weight at the end of the 4-week competition. The average intention-to-treat weight loss was 2.6% (SD 2.3%). Winners (n=17,171) won an average of US $59 (SD US $35) and lost 4.9% (SD 1.0%) of initial body weight, with 30.68% (5268/17,171) losing 5% or more of their initial weight. Betting more money at game entry, sharing on Facebook, completing more weigh-ins, and having more social interactions during the game predicted greater weight loss and greater likelihood of winning (Ps<.001). In addition, weight loss clustered within games (P<.001), suggesting that players influenced each others’ weight outcomes. Conclusions: DietBet, a social gaming website, reached nearly 40,000 individuals in just 7 months and produced excellent 4-week weight loss results. Given its reach and potential public health impact, future research may consider examining whether a longer program promotes additional weight loss. %M 25658966 %R 10.2196/games.2987 %U http://games.jmir.org/2014/1/e2/ %U https://doi.org/10.2196/games.2987 %U http://www.ncbi.nlm.nih.gov/pubmed/25658966 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e1 %T Evaluating the Benefits of Collaboration in Simulation Games: The Case of Health Care %A Leung,Ricky %+ School of Public Health, Department of Health Policy, Management & Behavior, SUNY-Albany, One University Place, Room 181, University at Albany, One University Drive, Rensselaer, NY, 12144-3456, United States, 1 6083348781, rleung@albany.edu %K simulation games %K health policy %K social networks %D 2014 %7 28.01.2014 %9 Viewpoint %J JMIR Serious Games %G English %X Background: Organizations have used simulation games for health promotion and communication. To evaluate how simulation games can foster collaboration among stakeholders, this paper develops two social network measures. Objective: The paper aims to initiate two specific measures that facilitate organizations and researchers to evaluate the effectiveness of Web-based simulation games in fostering collaboration. Methods: The two measures are: (1) network density and (2) network diversity. They measure the level of connectedness and communication evenness within social networks. To illustrate how these measures may be used, a hypothetical game about health policy is outlined. Results: Web-based games can serve as an effective platform to engage stakeholders because interaction among them is quite convenient. Yet, systematic evaluation and planning are necessary to realize the benefits of these games. The paper suggests directions for testing how the social network dimension of Web-based games can augment individual-level benefits that stakeholders can obtain from playing simulation games. Conclusions: While this paper focuses on measuring the structural properties of social networks in Web-based games, further research should focus more attention on the appropriateness of game contents. In addition, empirical research should cover different geographical areas, such as East Asian countries where video games are very popular. %M 25658851 %R 10.2196/games.3178 %U http://games.jmir.org/2014/1/e1/ %U https://doi.org/10.2196/games.3178 %U http://www.ncbi.nlm.nih.gov/pubmed/25658851 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 1 %N 1 %P e3 %T Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers %A Cugelman,Brian %+ AlterSpark Corp., 730 Dovercourt Road, #1909, Toronto, ON, M6H 2W9, Canada, 1 416 921 2055, brian@alterspark.com %K behavioral medicine %K behaviour and behavior mechanisms %K behavioral research %K behavioral sciences %K persuasive communication %K health psychology %K psychology %K experimental game %K interactive games %K computer games %D 2013 %7 12.12.2013 %9 Editorial %J JMIR Serious Games %G English %X This editorial provides a behavioral science view on gamification and health behavior change, describes its principles and mechanisms, and reviews some of the evidence for its efficacy. Furthermore, this editorial explores the relation between gamification and behavior change frameworks used in the health sciences and shows how gamification principles are closely related to principles that have been proven to work in health behavior change technology. Finally, this editorial provides criteria that can be used to assess when gamification provides a potentially promising framework for digital health interventions. %M 25658754 %R 10.2196/games.3139 %U http://games.jmir.org/2013/1/e3/ %U https://doi.org/10.2196/games.3139 %U http://www.ncbi.nlm.nih.gov/pubmed/25658754 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 12 %P e270 %T Puzzling With Online Games (BAM-COG): Reliability, Validity, and Feasibility of an Online Self-Monitor for Cognitive Performance in Aging Adults %A Aalbers,Teun %A Baars,Maria A E %A Olde Rikkert,Marcel G M %A Kessels,Roy P C %+ Radboud University Medical Center, Department of Geriatric Medicine, Reinier Postlaan 4, Nijmegen, 6500 HB, Netherlands, 31 243619807, teun.aalbers@radboudumc.nl %K cognitive testing %K brain aging %K games %K validity %K reliability %K self-monitoring %K Internet %K eHealth %D 2013 %7 03.12.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Online interventions are aiming increasingly at cognitive outcome measures but so far no easy and fast self-monitors for cognition have been validated or proven reliable and feasible. Objective: This study examines a new instrument called the Brain Aging Monitor–Cognitive Assessment Battery (BAM-COG) for its alternate forms reliability, face and content validity, and convergent and divergent validity. Also, reference values are provided. Methods: The BAM-COG consists of four easily accessible, short, yet challenging puzzle games that have been developed to measure working memory (“Conveyer Belt”), visuospatial short-term memory (“Sunshine”), episodic recognition memory (“Viewpoint”), and planning (“Papyrinth”). A total of 641 participants were recruited for this study. Of these, 397 adults, 40 years and older (mean 54.9, SD 9.6), were eligible for analysis. Study participants played all games three times with 14 days in between sets. Face and content validity were based on expert opinion. Alternate forms reliability (AFR) was measured by comparing scores on different versions of the BAM-COG and expressed with an intraclass correlation (ICC: two-way mixed; consistency at 95%). Convergent validity (CV) was provided by comparing BAM-COG scores to gold-standard paper-and-pencil and computer-assisted cognitive assessment. Divergent validity (DV) was measured by comparing BAM-COG scores to the National Adult Reading Test IQ (NART-IQ) estimate. Both CV and DV are expressed as Spearman rho correlation coefficients. Results: Three out of four games showed adequate results on AFR, CV, and DV measures. The games Conveyer Belt, Sunshine, and Papyrinth have AFR ICCs of .420, .426, and .645 respectively. Also, these games had good to very good CV correlations: rho=.577 (P=.001), rho=.669 (P<.001), and rho=.400 (P=.04), respectively. Last, as expected, DV correlations were low: rho=−.029 (P=.44), rho=−.029 (P=.45), and rho=−.134 (P=.28) respectively. The game Viewpoint provided less desirable results with an AFR ICC of .167, CV rho=.202 (P=.15), and DV rho=−.162 (P=.21). Conclusions: This study provides evidence for the use of the BAM-COG test battery as a feasible, reliable, and valid tool to monitor cognitive performance in healthy adults in an online setting. Three out of four games have good psychometric characteristics to measure working memory, visuospatial short-term memory, and planning capacity. %M 24300212 %R 10.2196/jmir.2860 %U http://www.jmir.org/2013/12/e270/ %U https://doi.org/10.2196/jmir.2860 %U http://www.ncbi.nlm.nih.gov/pubmed/24300212 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 10 %P e240 %T Design and Evaluation of a Simulation for Pediatric Dentistry in Virtual Worlds %A Papadopoulos,Lazaros %A Pentzou,Afroditi-Evaggelia %A Louloudiadis,Konstantinos %A Tsiatsos,Thrasyvoulos-Konstantinos %+ Laboratory of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Panepistimioupoli, Thessaloniki, 54124, Greece, 30 2310999272, lazapap@hotmail.gr %K virtual patient %K virtual world %K pediatric dentistry %K simulation %K Second Life %K OpenSim %K communication %K tell-show-do %K behavior management %D 2013 %7 29.10.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Three-dimensional virtual worlds are becoming very popular among educators in the medical field. Virtual clinics and patients are already used for case study and role play in both undergraduate and continuing education levels. Dental education can also take advantage of the virtual world’s pedagogical features in order to give students the opportunity to interact with virtual patients (VPs) and practice in treatment planning. Objective: The objective of this study was to design and evaluate a virtual patient as a supplemental teaching tool for pediatric dentistry. Methods: A child VP, called Erietta, was created by utilizing the programming and building tools that online virtual worlds offer. The case is about an eight-year old girl visiting the dentist with her mother for the first time. Communication techniques such as Tell-Show-Do and parents’ interference management were the basic elements of the educational scenario on which the VP was based. An evaluation of the simulation was made by 103 dental students in their fourth year of study. Two groups were formed: an experimental group which was exposed to the simulation (n=52) and a control group which did not receive the simulation (n=51). At the end, both groups were asked to complete a knowledge questionnaire and the results were compared. Results: A statistically significant difference between the two groups was found by applying a t test for independent samples (P<.001), showing a positive learning effect from the VP. The majority of the participants evaluated the aspects of the simulation very positively while 69% (36/52) of the simulation group expressed their preference for using this module as an additional teaching tool. Conclusions: This study demonstrated that a pediatric dentistry VP built in a virtual world offers significant learning potential when used as a supplement to the traditional teaching techniques. %R 10.2196/jmir.2651 %U http://www.jmir.org/2013/10/e240/ %U https://doi.org/10.2196/jmir.2651 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 1 %N 1 %P e2 %T Surgical Trainee Opinions in the United Kingdom Regarding a Three-Dimensional Virtual Mentoring Environment (MentorSL) in Second Life: Pilot Study %A Jaffer,Usman %A John,Nigel W %A Standfield,Nigel %+ Imperial College Healthcare Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom, 44 (0)7968872992, usman.jaffer@doctors.org.uk %K education %K Internet %K training %D 2013 %7 20.09.2013 %9 Original Paper %J JMIR Serious Games %G English %X Background: Medical mentoring is becoming increasingly complex with the evolving needs of trainees and the complexities of their personal and social lives. The Internet is an enabling technology, which increasingly facilitates interaction with multiple people at a distance. Web 2.0 and 3.0 technology shows promise in furthering this facilitation. Objective: The objective of our study was to establish opinions among doctors in postgraduate surgical training regarding mentoring and whether these doctors would readily accept virtual mentoring following a brief experience. Methods: On the 12th of February 2012, an introductory teaching class was arranged by The London Postgraduate School of Surgery for doctors in training. Participants were introduced to a novel virtual mentoring system and asked to complete a questionnaire regarding their opinions before and after the demonstration. Results: A total of 57 junior doctors attended. Among them, 35 completed questionnaires pre- and postdemonstration. Regarding usefulness of a 3D virtual environment for mentoring, 6/35 (17%) agreed or strongly agreed and 20/35 (57%) were unsure prior to the session. Following 20 minutes using MentorSL, this significantly increased to 14/35 (40%) agreeing or strongly agreeing with 11/35 (31%) unsure (P<.001). Prior to using MentorSL, regarding usefulness of voice communication for virtual mentoring, 11/35 (31%) agreed or strongly agreed and 18/35 (51%) were unsure. Following 20 minutes using MentorSL, 19/35 (54%) agreed or strongly agreed and 10/35 (29%) were unsure of usefulness. Regarding ease of use of navigation, search mentor, meeting scheduling, and voice communication features, 17/35 (49%), 13/35 (37%), 15/35 (43%), and 16/35 (46%) participants agreed or strongly agreed, respectively. Regarding usefulness of telementoring, 24/35 (69%) agreed or strongly agreed, increasing to 28/35 (80%) following the introduction. For usefulness of multiple mentors, initially 24/35 (69%) agreed or strongly agreed increasing to 29/35 (83%). For overall satisfaction, 30/35 (86%) reported good or adequate and 19/35 (54%) agreed or strongly agreed with using the system again. Conclusions: These data suggest that a short introduction on how to use virtual systems may result in significant participation and use of virtual mentoring systems. %M 25658652 %R 10.2196/games.2822 %U http://games.jmir.org/2013/1/e2/ %U https://doi.org/10.2196/games.2822 %U http://www.ncbi.nlm.nih.gov/pubmed/25658652 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 2 %N 2 %P e35 %T Development and Alpha Testing of QuitIT: An Interactive Video Game to Enhance Skills for Coping With Smoking Urges %A Krebs,Paul %A Burkhalter,Jack E %A Snow,Bert %A Fiske,Jeff %A Ostroff,Jamie S %+ Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, 641 Lexington Ave, 7th Floor, New York, NY, 10022, United States, 1 646 888 0041, ostroffj@mskcc.org %K smoking cessation %K health promotion game %K tobacco, quitting self efficacy %K behavioral medicine %K virtual reality %D 2013 %7 11.09.2013 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Despite many efforts at developing relapse prevention interventions, most smokers relapse to tobacco use within a few months after quitting. Interactive games offer a novel strategy for helping people develop the skills required for successful tobacco cessation. Objective: The objective of our study was to develop a video game that enables smokers to practice strategies for coping with smoking urges and maintaining smoking abstinence. Our team of game designers and clinical psychologists are creating a video game that integrates the principles of smoking behavior change and relapse prevention. We have reported the results of expert and end-user feedback on an alpha version of the game. Methods: The alpha version of the game consisted of a smoking cue scenario often encountered by smokers. We recruited 5 experts in tobacco cessation research and 20 current and former smokers, who each played through the scenario. Mixed methods were used to gather feedback on the relevance of cessation content and usability of the game modality. Results: End-users rated the interface from 3.0 to 4.6/5 in terms of ease of use and from 2.9 to 4.1/5 in terms of helpfulness of cessation content. Qualitative themes showed several user suggestions for improving the user interface, pacing, and diversity of the game characters. In addition, the users confirmed a high degree of game immersion, identification with the characters and situations, and appreciation for the multiple opportunities to practice coping strategies. Conclusions: This study highlights the procedures for translating behavioral principles into a game dynamic and shows that our prototype has a strong potential for engaging smokers. A video game modality exemplifies problem-based learning strategies for tobacco cessation and is an innovative step in behavioral management of tobacco use. %M 24025236 %R 10.2196/resprot.2416 %U http://www.researchprotocols.org/2013/2/e35/ %U https://doi.org/10.2196/resprot.2416 %U http://www.ncbi.nlm.nih.gov/pubmed/24025236 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 1 %N 1 %P e1 %T Ecological Validity of Virtual Reality Daily Living Activities Screening for Early Dementia: Longitudinal Study %A Tarnanas,Ioannis %A Schlee,Winfried %A Tsolaki,Magda %A Müri,René %A Mosimann,Urs %A Nef,Tobias %+ Gerontechnology and Rehabilitation Group, University of Bern, Murtenstrasse 50, Bern, 3010, Switzerland, 41 31 632 7582, ioannis.tarnanas@artorg.unibe.ch %D 2013 %7 06.08.2013 %9 Original Paper %J JMIR Serious Games %G English %X Background: Dementia is a multifaceted disorder that impairs cognitive functions, such as memory, language, and executive functions necessary to plan, organize, and prioritize tasks required for goal-directed behaviors. In most cases, individuals with dementia experience difficulties interacting with physical and social environments. The purpose of this study was to establish ecological validity and initial construct validity of a fire evacuation Virtual Reality Day-Out Task (VR-DOT) environment based on performance profiles as a screening tool for early dementia. Objective: The objectives were (1) to examine the relationships among the performances of 3 groups of participants in the VR-DOT and traditional neuropsychological tests employed to assess executive functions, and (2) to compare the performance of participants with mild Alzheimer’s-type dementia (AD) to those with amnestic single-domain mild cognitive impairment (MCI) and healthy controls in the VR-DOT and traditional neuropsychological tests used to assess executive functions. We hypothesized that the 2 cognitively impaired groups would have distinct performance profiles and show significantly impaired independent functioning in ADL compared to the healthy controls. Methods: The study population included 3 groups: 72 healthy control elderly participants, 65 amnestic MCI participants, and 68 mild AD participants. A natural user interface framework based on a fire evacuation VR-DOT environment was used for assessing physical and cognitive abilities of seniors over 3 years. VR-DOT focuses on the subtle errors and patterns in performing everyday activities and has the advantage of not depending on a subjective rating of an individual person. We further assessed functional capacity by both neuropsychological tests (including measures of attention, memory, working memory, executive functions, language, and depression). We also evaluated performance in finger tapping, grip strength, stride length, gait speed, and chair stands separately and while performing VR-DOTs in order to correlate performance in these measures with VR-DOTs because performance while navigating a virtual environment is a valid and reliable indicator of cognitive decline in elderly persons. Results: The mild AD group was more impaired than the amnestic MCI group, and both were more impaired than healthy controls. The novel VR-DOT functional index correlated strongly with standard cognitive and functional measurements, such as mini-mental state examination (MMSE; rho=0.26, P=.01) and Bristol Activities of Daily Living (ADL) scale scores (rho=0.32, P=.001). Conclusions: Functional impairment is a defining characteristic of predementia and is partly dependent on the degree of cognitive impairment. The novel virtual reality measures of functional ability seem more sensitive to functional impairment than qualitative measures in predementia, thus accurately differentiating from healthy controls. We conclude that VR-DOT is an effective tool for discriminating predementia and mild AD from controls by detecting differences in terms of errors, omissions, and perseverations while measuring ADL functional ability. %M 25658491 %R 10.2196/games.2778 %U http://games.jmir.org/2013/1/e1/ %U https://doi.org/10.2196/games.2778 %U http://www.ncbi.nlm.nih.gov/pubmed/25658491 %0 Journal Article %@ 1923-2195 %I Gunther Eysenbach %V 2 %N 1 %P e1 %T InSpire to Promote Lung Assessment in Youth: Evolving the Self-Management Paradigms of Young People With Asthma %A Elias,Pierre %A Rajan,Nithin O %A McArthur,Kara %A Dacso,Clifford C %+ The Abramson Center for the Future of Health, The Methodist Hospital Research Institute, 6565 Fannin, MGJ 3012, Houston, TX, 77030, United States, 1 713 202 2462, kmcarthur@tmhs.org %K pediatric asthma %K chronic disease management %K mobile phones %K spirometry %K gamification %D 2013 %7 21.05.2013 %9 Original Paper %J Med 2.0 %G English %X Background: Asthma is the most common chronic disease in childhood, disproportionately affecting urban, minority, and disadvantaged children. Individualized care plans supported by daily lung-function monitoring can reduce morbidity and mortality. However, despite 20 years of interventions to increase adherence, only 50% of US youth accurately follow their care plans, which leads to millions of preventable hospitalizations, emergency room visits, and sick days every year. We present a feasibility study of a novel, user-centered approach to increasing young people’s lung-function monitoring and asthma self-care. Promoting Lung Assessment in Youth (PLAY) helps young people become active managers of their asthma through the Web 2.0 principles of participation, cocreation, and information sharing. Specifically, PLAY combines an inexpensive, portable spirometer with the motivational power and convenience of mobile phones and virtual-community gaming. Objective: The objective of this study was to develop and pilot test InSpire, a fully functional interface between a handheld spirometer and an interactive game and individualized asthma-care instant-messaging system housed on a mobile phone. Methods: InSpire is an application for mobile smartphones that creates a compelling world in which youth collaborate with their physicians on managing their asthma. Drawing from design-theory on global timer mechanics and role playing, we incentivized completing spirometry maneuvers by making them an engaging part of a game young people would want to play. The data can be sent wirelessly to health specialists and return care recommendations to patients in real-time. By making it portable and similar to applications normally desired by the target demographic, InSpire is able to seamlessly incorporate asthma management into their lifestyle. Results: We describe the development process of building and testing the InSpire prototype. To our knowledge, the prototype is a first-of-its kind mobile one-stop shop for asthma management. Feasibility testing in children aged 7 to 14 with asthma assessed likability of the graphical user interface as well as young people’s interest in our incentivizing system. Nearly 100% of children surveyed said they would play games like those in PLAY if they involved breathing into a spirometer. Two-thirds said they would prefer PLAY over the spirometer alone, whereas 1/3 would prefer having both. No children said they would prefer the spirometer over PLAY. Conclusions: Previous efforts at home-monitoring of asthma in children have experienced rapid decline in adherence. An inexpensive monitoring technology combined with the computation, interactive communication, and display ability of a mobile phone is a promising approach to sustainable adherence to lung-function monitoring and care plans. An exciting game that redefines the way youth conduct health management by inviting them to collaborate in their health better can be an incentive and a catalyst for more far-reaching goals. %M 25075232 %R 10.2196/med20.2014 %U http://www.medicine20.com/2013/1/e1/ %U https://doi.org/10.2196/med20.2014 %U http://www.ncbi.nlm.nih.gov/pubmed/25075232 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 5 %P e81 %T Prevalence of Behavior Changing Strategies in Fitness Video Games: Theory-Based Content Analysis %A Lyons,Elizabeth Jane %A Hatkevich,Claire %+ Institute for Translational Sciences, School of Medicine, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0342, United States, 1 409 772 1917, ellyons@utmb.edu %K video game %K theory %K content analysis %K fitness %K physical activity %K exergame %D 2013 %7 07.05.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Fitness video games are popular, but little is known about their content. Because many contain interactive tools that mimic behavioral strategies from weight loss intervention programs, it is possible that differences in content could affect player physical activity and/or weight outcomes. There is a need for a better understanding of what behavioral strategies are currently available in fitness games and how they are implemented. Objective: The purpose of this study was to investigate the prevalence of evidence-based behavioral strategies across fitness video games available for home use. Games available for consoles that used camera-based controllers were also contrasted with games available for a console that used handheld motion controllers. Methods: Fitness games (N=18) available for three home consoles were systematically identified and play-tested by 2 trained coders for at least 3 hours each. In cases of multiple games from one series, only the most recently released game was included. The Sony PlayStation 3 and Microsoft Xbox360 were the two camera-based consoles, and the Nintendo Wii was the handheld motion controller console. A coding list based on a taxonomy of behavioral strategies was used to begin coding. Codes were refined in an iterative process based on data found during play-testing. Results: The most prevalent behavioral strategies were modeling (17/18), specific performance feedback (17/18), reinforcement (16/18), caloric expenditure feedback (15/18), and guided practice (15/18). All games included some kind of feedback on performance accuracy, exercise frequency, and/or fitness progress. Action planning (scheduling future workouts) was the least prevalent of the included strategies (4/18). Twelve games included some kind of social integration, with nine of them providing options for real-time multiplayer sessions. Only two games did not feature any kind of reward. Games for the camera-based consoles (mean 12.89, SD 2.71) included a greater number of strategies than those for the handheld motion controller console (mean 10.00, SD 2.74, P=.04). Conclusions: Behavioral strategies for increasing self-efficacy and self-regulation are common in home console fitness video games. Social support and reinforcement occurred in approximately half of the studied games. Strategy prevalence varies by console type, partially due to greater feedback afforded by camera-based controllers. Experimental studies are required to test the effects of these strategies when delivered as interactive tools, as this medium may represent an innovative platform for disseminating evidence-based behavioral weight loss intervention components. %M 23651701 %R 10.2196/jmir.2403 %U http://www.jmir.org/2013/5/e81/ %U https://doi.org/10.2196/jmir.2403 %U http://www.ncbi.nlm.nih.gov/pubmed/23651701 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 15 %N 3 %P e51 %T Development and Testing of a Multidimensional iPhone Pain Assessment Application for Adolescents with Cancer %A Stinson,Jennifer N %A Jibb,Lindsay A %A Nguyen,Cynthia %A Nathan,Paul C %A Maloney,Anne Marie %A Dupuis,L Lee %A Gerstle,J Ted %A Alman,Benjamin %A Hopyan,Sevan %A Strahlendorf,Caron %A Portwine,Carol %A Johnston,Donna L %A Orr,Mike %+ The Hospital for Sick Children, 555 University Ave, Toronto, ON, , Canada, 1 416 813 8501 ext 4514, jennifer.stinson@sickkids.ca %K neoplasms %K pain %K child %K adolescent %K youth %K cellular phone %K game %D 2013 %7 08.03.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary. Objective: Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer. Methods: We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app. Results: Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete. Conclusions: A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing. %M 23475457 %R 10.2196/jmir.2350 %U http://www.jmir.org/2013/3/e51/ %U https://doi.org/10.2196/jmir.2350 %U http://www.ncbi.nlm.nih.gov/pubmed/23475457