%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e16458 %T Promoting Physical Activity in Japanese Older Adults Using a Social Pervasive Game: Randomized Controlled Trial %A Santos,Luciano Henrique De Oliveira %A Okamoto,Kazuya %A Otsuki,Ryo %A Hiragi,Shusuke %A Yamamoto,Goshiro %A Sugiyama,Osamu %A Aoyama,Tomoki %A Kuroda,Tomohiro %+ Department of Social Informatics, Graduate School of Informatics, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan, 81 75 366 7701, lhsantos@kuhp.kyoto-u.ac.jp %K aged %K physical activity %K pervasive games %K social interaction %D 2021 %7 6.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pervasive games aim to create more fun and engaging experiences by mixing elements from the real world into the game world. Because they intermingle with players’ lives and naturally promote more casual gameplay, they could be a powerful strategy to stimulate physical activity among older adults. However, to use these games more effectively, it is necessary to understand how design elements of the game affect player behavior. Objective: The aim of this study was to evaluate how the presence of a specific design element, namely social interaction, would affect levels of physical activity. Methods: Participants were recruited offline and randomly assigned to control and intervention groups in a single-blind design. Over 4 weeks, two variations of the same pervasive game were compared: with social interaction (intervention group) and with no social interaction (control group). In both versions, players had to walk to physical locations and collect virtual cards, but the social interaction version allowed people to collaborate to obtain more cards. Changes in the weekly step counts were used to evaluate the effect on each group, and the number of places visited was used as an indicator of play activity. Results: A total of 20 participants were recruited (no social interaction group, n=10; social interaction group, n=10); 18 participants remained active until the end of the study (no social interaction group, n=9; social interaction group, n=9). Step counts during the first week were used as the baseline level of physical activity (no social interaction group: mean 46,697.2, SE 7905.4; social interaction group: mean 45,967.3, SE 8260.7). For the subsequent weeks, changes to individual baseline values (absolute/proportional) for the no social interaction group were as follows: 1583.3 (SE 3108.3)/4.6% (SE 7.2%) (week 2), 591.5 (SE 2414.5)/2.4% (SE 4.7%) (week 3), and −1041.8 (SE 1992.7)/0.6% (SE 4.4%) (week 4). For the social interaction group, changes to individual baseline values were as follows: 11520.0 (SE 3941.5)/28.0% (SE 8.7%) (week 2), 9567.3 (SE 2631.5)/23.0% (SE 5.1%) (week 3), and 7648.7 (SE 3900.9)/13.9% (SE 8.0%) (week 4). The result of the analysis of the group effect was significant (absolute change: η2=0.31, P=.04; proportional change: η2=0.30, P=.03). Correlations between both absolute and proportional change and the play activity were significant (absolute change: r=0.59, 95% CI 0.32 to 0.77; proportional change: r=0.39, 95% CI 0.08 to 0.64). Conclusions: The presence of social interaction design elements in pervasive games appears to have a positive effect on levels of physical activity. Trial Registration: Japan Medical Association Clinical Trial Registration Number JMA-IIA00314; https://tinyurl.com/y5nh6ylr (Archived by WebCite at http://www.webcitation.org/761a6MVAy) %M 33404507 %R 10.2196/16458 %U https://games.jmir.org/2021/1/e16458 %U https://doi.org/10.2196/16458 %U http://www.ncbi.nlm.nih.gov/pubmed/33404507 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e25226 %T A Mobile Serious Game About the Pandemic (COVID-19 - Did You Know?): Design and Evaluation Study %A Gaspar,Juliano De Souza %A Lage,Eura Martins %A Silva,Fernando José Da %A Mineiro,Érico %A Oliveira,Isaias José Ramos De %A Oliveira,Igor %A Souza,Rayner Guilherme De %A Gusmão,Juan Rodrigues Oliveira %A De Souza,Camila Fernanda Donadoni %A Reis,Zilma Silveira Nogueira %+ Faculdade de Medicina, Universidade Federal de Minas Gerais, Rua Alfredo Balena, 190, Belo Horizonte, 30130-100, Brazil, 55 313409 0000, julianogaspar@gmail.com %K coronavirus %K COVID-19 %K e-learning %K mHealth %K digital health %K gamification %K serious game %K mobile apps %K public health %K informatics %D 2020 %7 22.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: No treatment for COVID-19 is yet available; therefore, providing access to information about SARS-CoV-2, the transmission route of the virus, and ways to prevent the spread of infection is a critical sanitary measure worldwide. Serious games have advantages in the dissemination of reliable information during the pandemic; they can provide qualified content while offering interactivity to the user, and they have great reach over the internet. Objective: This study aimed to develop a serious game with the purpose of providing science-based information on the prevention of COVID-19 and personal care during the pandemic while assessing players’ knowledge about COVID-19–related topics. Methods: The study was conducted with the interdisciplinary collaboration of specialists in health sciences, computing, and design at the Federal University of Minas Gerais, Brazil. The health recommendations were grouped into six thematic blocks, presented in a quiz format. The software languages were based on the progressive web app development methodology with the Ionic framework, JavaScript, HTML5, cascading style sheets, and TypeScript (Angular). Open data reports of how users interact with the serious game were obtained using the Google Analytics application programming interface. The visual identity, logo, infographics, and icons were carefully developed by considering a selection of colors, typography, sounds, and images that are suitable for young audiences. Cards with cartoon characters were introduced at the end of each thematic topic to interact with the player, reinforcing their correct answers or alerting them to the need to learn more about the disease. The players’ performance was assessed by the rate of incorrect and correct answers and analyzed by linear correlation coefficient over 7 weeks. The agile SCRUM development methodology enabled quick and daily interactions of developers through a webchat and sequential team meetings. Results: The game “COVID-19–Did You Know?” was made available for free on a public university website on April 1, 2020. The game had been accessed 17,571 times as of September 2020. Dissemination actions such as reports on social media and television showed a temporal correspondence with the access number. The players’ error rate in the topic “Mask” showed a negative trend (r=–.83; P=.01) over the weeks of follow-up. The other topics showed no significant trend over the weeks. Conclusions: The gamification strategy for health education content on the theme of COVID-19 reached a young audience, which is considered to be a priority in the strategy of orientation toward social distancing. Specific educational reinforcement measures were proposed and implemented based on the players’ performance. The improvement in the users’ performance on the topic about the use of masks may reflect an increase in information about or adherence to mask use over time. %M 33301416 %R 10.2196/25226 %U http://games.jmir.org/2020/4/e25226/ %U https://doi.org/10.2196/25226 %U http://www.ncbi.nlm.nih.gov/pubmed/33301416 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e21855 %T Health Care Providers’ Performance, Mindset, and Attitudes Toward a Neonatal Resuscitation Computer-Based Simulator: Empirical Study %A Cutumisu,Maria %A Ghoman,Simran K %A Lu,Chang %A Patel,Siddhi D %A Garcia-Hidalgo,Catalina %A Fray,Caroline %A Brown,Matthew R G %A Greiner,Russell %A Schmölzer,Georg M %+ Department of Educational Psychology, Faculty of Education, University of Alberta, 6-102 Education North, Edmonton, AB, T6G2G5, Canada, 1 7804925211, cutumisu@ualberta.ca %K infant %K newborn %K delivery room %K neonatal resuscitation %K performance %K neonatal resuscitation program %K serious games %K computer-based game simulation %K mindset %D 2020 %7 21.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neonatal resuscitation involves a complex sequence of actions to establish an infant’s cardiorespiratory function at birth. Many of these responses, which identify the best action sequence in each situation, are taught as part of the recurrent Neonatal Resuscitation Program training, but they have a low incidence in practice, which leaves health care providers (HCPs) less prepared to respond appropriately and efficiently when they do occur. Computer-based simulators are increasingly used to complement traditional training in medical education, especially in the COVID-19 pandemic era of mass transition to digital education. However, it is not known how learners’ attitudes toward computer-based learning and assessment environments influence their performance. Objective: This study explores the relation between HCPs’ attitudes toward a computer-based simulator and their performance in the computer-based simulator, RETAIN (REsuscitation TrAINing), to uncover the predictors of performance in computer-based simulation environments for neonatal resuscitation. Methods: Participants were 50 neonatal HCPs (45 females, 4 males, 1 not reported; 16 respiratory therapists, 33 registered nurses and nurse practitioners, and 1 physician) affiliated with a large university hospital. Participants completed a demographic presurvey before playing the game and an attitudinal postsurvey after completing the RETAIN game. Participants’ survey responses were collected to measure attitudes toward the computer-based simulator, among other factors. Knowledge on neonatal resuscitation was assessed in each round of the game through increasingly difficult neonatal resuscitation scenarios. This study investigated the moderating role of mindset on the association between the perceived benefits of understanding the terminology used in the computer-based simulator, RETAIN, and their performance on the neonatal resuscitation tasks covered by RETAIN. Results: The results revealed that mindset moderated the relation between participants’ perceived terminology used in RETAIN and their actual performance in the game (F3,44=4.56, R2=0.24, adjusted R2=0.19; P=.007; estimate=–1.19, SE=0.38, t44=–3.12, 95% CI –1.96 to –0.42; P=.003). Specifically, participants who perceived the terminology useful also performed better but only when endorsing more of a growth mindset; they also performed worse when endorsing more of a fixed mindset. Most participants reported that they enjoyed playing the game. The more the HCPs agreed that the terminology in the tutorial and in the game was accessible, the better they performed in the game, but only when they reported endorsing a growth mindset exceeding the average mindset of all the participants (F3,44=6.31, R2=0.30, adjusted R2=0.25; P=.001; estimate=–1.21, SE=0.38, t44=−3.16, 95% CI –1.99 to –0.44; P=.003). Conclusions: Mindset moderates the strength of the relationship between HCPs’ perception of the role that the terminology employed in a game simulator has on their performance and their actual performance in a computer-based simulator designed for neonatal resuscitation training. Implications of this research include the design and development of interactive learning environments that can support HCPs in performing better on neonatal resuscitation tasks. %M 33346741 %R 10.2196/21855 %U http://games.jmir.org/2020/4/e21855/ %U https://doi.org/10.2196/21855 %U http://www.ncbi.nlm.nih.gov/pubmed/33346741 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19580 %T Use of Virtual Reality to Assess Dynamic Posturography and Sensory Organization: Instrument Validation Study %A Wittstein,Matthew William %A Crider,Anthony %A Mastrocola,Samantha %A Guerena Gonzalez,Mariana %+ Department of Exercise Science, Elon University, 2525 Campus Box, Elon, NC, 27244, United States, 1 336 278 6693, mwittstein@elon.edu %K postural control %K virtual reality %K sensory organization test %K intraclass correlations %D 2020 %7 16.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The Equitest system (Neurocom) is a computerized dynamic posturography device used by health care providers and clinical researchers to safely test an individual’s postural control. While the Equitest system has evaluative and rehabilitative value, it may be limited owing to its cost, lack of portability, and reliance on only sagittal plane movements. Virtual reality (VR) provides an opportunity to reduce these limitations by providing more mobile and cost-effective tools while also observing a wider array of postural characteristics. Objective: This study aimed to test the plausibility of using VR as a feasible alternative to the Equitest system for conducting a sensory organization test. Methods: A convenience sample of 20 college-aged healthy individuals participated in the study. Participants completed the sensory organization test using the Equitest system as well as using a VR environment while standing atop a force plate (Bertec Inc). The Equitest system measures the equilibrium index. During VR trials, the estimated equilibrium index, 95% ellipse area, path length, and anterior-posterior detrended fluctuation analysis scaling exponent alpha were calculated from center of pressure data. Pearson correlation coefficients were used to assess the relationship between the equilibrium index and center of pressure–derived balance measures. Intraclass correlations for absolute agreement and consistency were calculated to compare the equilibrium index and estimated equilibrium index. Results: Intraclass correlations demonstrated moderate consistency and absolute agreement (0.5 < intraclass correlation coefficient < 0.75) between the equilibrium index and estimated equilibrium index from the Equitest and VR sensory organization test (SOT), respectively, in four of six tested conditions. Additionally, weak to moderate correlations between force plate measurements and the equilibrium index were noted in several of the conditions. Conclusions: This research demonstrated the plausibility of using VR as an alternative method to conduct the SOT. Ongoing development and testing of virtual environments are necessary before employing the technology as a replacement to current clinical tests. %M 33325830 %R 10.2196/19580 %U http://games.jmir.org/2020/4/e19580/ %U https://doi.org/10.2196/19580 %U http://www.ncbi.nlm.nih.gov/pubmed/33325830 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e25595 %T Impact of a Serious Game on the Intention to Change Infection Prevention and Control Practices in Nursing Homes During the COVID-19 Pandemic: Protocol for a Web-Based Randomized Controlled Trial %A Suppan,Laurent %A Abbas,Mohamed %A Catho,Gaud %A Stuby,Loric %A Regard,Simon %A Harbarth,Stephan %A Achab,Sophia %A Suppan,Mélanie %+ Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, Geneva, 1211, Switzerland, 41 223723311, laurent.suppan@hcuge.ch %K COVID-19 %K transmission %K serious game %K infection prevention %K health care worker %K SARS-COV-2 %K nursing home %K randomized controlled trial %K elderly %K older adult %K infection control %K infectious disease %D 2020 %7 15.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Nursing home residents are at high risk of complications and death due to COVID-19. Lack of resources, both human and material, amplifies the likelihood of contamination in these facilities where a single employee can contaminate dozens of residents and colleagues. Improving the dissemination of and adhesion to infection prevention and control (IPC) guidelines is therefore essential. Serious games have been shown to be effective in developing knowledge and in increasing engagement, and could motivate nursing home employees to change their IPC practices. Objective: Our aim is to assess the impact of “Escape COVID-19,” a serious game designed to enhance knowledge and application of IPC procedures, on the intention of nursing home employees to change their IPC practices. Methods: We will carry out a web-based randomized controlled trial following the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) guidelines and incorporating relevant elements of CHERRIES (Checklist for Reporting Results of Internet E-Surveys). Participants will be randomized to either the control or the serious game (intervention) group. First, both groups will be asked to answer a questionnaire designed to gather demographic data and assess baseline knowledge. The control group will then receive a quick reminder of the current national guidelines and links to IPC guidelines for health care professionals, while the other group will play the game. Both groups will then have to answer a second questionnaire designed to assess their willingness to change their IPC practices after having followed their respective material. After completing this questionnaire, they will be granted access to the material presented to the group they were not assigned to and receive a course completion certificate. The primary outcome will be the proportion of participants willing to change their IPC practices according to group. Secondary outcomes will include the analysis of specific questions detailing the exact changes considered by the participants. Factors associated with participant willingness or reluctance to change behavior will also be assessed. Attrition will also be assessed at each stage of the study. Results: The study protocol has been presented to our regional ethics committee (Req-2020-01262), which issued a declaration of no objection as such projects do not fall within the scope of the Swiss federal law on human research. Data collection began on November 5, 2020, and should be completed by December 4, 2020. Conclusions: This study should determine whether “Escape COVID-19,” a serious game designed to improve compliance with COVID-19 safe practices, modifies the intention to follow IPC guidelines among nursing home employees. International Registered Report Identifier (IRRID): DERR1-10.2196/25595 %M 33296329 %R 10.2196/25595 %U http://www.researchprotocols.org/2020/12/e25595/ %U https://doi.org/10.2196/25595 %U http://www.ncbi.nlm.nih.gov/pubmed/33296329 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e23734 %T Effects of a Mobile App Called Quittr, Which Utilizes Premium Currency and Games Features, on Improving Engagement With Smoking Cessation Intervention: Pilot Randomized Controlled Trial %A Bindoff,Ivan %A Ling,Tristan R %A Gee,Peter %A Geelan,Benjamin %A Ferguson,Stuart G %A Peterson,Gregory M %+ School of Pharmacy and Pharmacology, University of Tasmania, 1 Churchill Ave, Sandy Bay, 7005, Australia, 61 408528276, Ivan.Bindoff@utas.edu.au %K smoking %K cessation %K Quittr %K engagement %K retention %K churn %K cigarette %K mHealth %K game %D 2020 %7 14.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Numerous mobile health (mHealth) apps have been developed to support smokers attempting to quit smoking. Although these apps have been reported to be successful, only modest improvements in the quit rate have been measured. It has been proposed that efforts to improve user engagement and retention may improve the quit rate further. Owing to the high cost of smoking-related disease, it is considered worthwhile to pursue even small improvements. Objective: The aim of this study was to test a novel smartphone app that leverages premium currency strategies developed by the mobile games industry in an attempt to improve engagement and retention with a smoking cessation intervention. Methods: We designed and developed a smoking cessation app called “Quittr” in line with previously developed smoking cessation mHealth apps. In addition to this established framework, we added a stand-alone fully featured city-building clicker-style game called “Tappy Town,” and a premium virtual currency called “QuitCoins.” The user earns QuitCoins for using the app in a way that contributes positively toward their quit attempt, and they can redeem these coins in Tappy Town for bonuses. To establish whether these features improved engagement and retention, we ran a 5-month randomized controlled trial where the intervention group had the full app with the extra games features, while the control group had the standard app only. Recruitment was performed via web-based advertising. Participants (N=175) had no direct contact with the researchers or other support staff. Results: No significant differences in terms of engagement, retention, or smoking outcomes were found between the control and intervention groups. However, survey data indicated that the majority of the participants valued Tappy Town (10/17, 59%) and the QuitCoins rewards system (13/17, 77%). Usage data also suggested that Tappy Town was widely played and was generally appealing to users (mean total time spent in app, control group: 797 seconds vs intervention group: 3502 seconds, P<.001). Analysis of the results suggests that users in the intervention group may have been negatively affected by the aspects of the chosen design, and some theories were explored to explain this unexpected outcome. Conclusions: Although the novel features of the Quittr app failed to improve the key outcomes measured in this study, there were enough positive indications to warrant further exploration of the concept. Additional research will be required to identify and correct any design flaws that may have adversely affected our participants before a follow-up study can be completed. Trial Registration: Australian and New Zealand Clinical Trials Register ACTRN12617000491369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372661&isReview=true %M 33315016 %R 10.2196/23734 %U http://games.jmir.org/2020/4/e23734/ %U https://doi.org/10.2196/23734 %U http://www.ncbi.nlm.nih.gov/pubmed/33315016 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e22007 %T A Cognitive-Based Board Game With Augmented Reality for Older Adults: Development and Usability Study %A Chen,Yen-Fu %A Janicki,Sylvia %+ Department of Media Design, Tatung University, 40, Sec 3, Zhongshan N Rd, Taipei, 104, Taiwan, 886 221822928 ext 6732, yfchen@gm.ttu.edu.tw %K cognitive-based %K augmented reality %K board game %K older adults %K cognitive health %K serious game %D 2020 %7 14.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Older adults in Taiwan are advised to adopt regular physical and social activities for the maintenance of their cognitive and physical health. Games offer a means of engaging older individuals in these activities. For this study, a collaborative cognitive-based board game, Nostalgic Seekers, was designed and developed with augmented reality technology to support cognitive engagement in older adults. Objective: A user study of the board game was conducted to understand how the game facilitates communication, problem solving, and emotional response in older players and whether augmented reality is a suitable technology in game design for these players. Methods: A total of 23 participants aged 50 to 59 years were recruited to play and evaluate the game. In each session, participants’ interactions were observed and recorded, then analyzed through Bales’ interaction process analysis. Following each session, participants were interviewed to provide feedback on their experience. Results: The quantitative analysis results showed that the participants engaged in task-oriented communication more frequently than social-emotional communication during the game. In particular, there was a high number of answers relative to questions. The analysis also showed a significant positive correlation between task-oriented acts and the game score. Qualitative analysis indicated that participants found the experience of playing the game enjoyable, nostalgic objects triggered positive emotional responses, and augmented reality technology was widely accepted by participants and provided effective engagement in the game. Conclusions: Nostalgic Seekers provided cognitive exercise and social engagement to players and demonstrated the positive potential of integrating augmented reality technology into cognitive-based games for older adults. Future game designs could explore strategies for regular and continuous engagement. %M 33315015 %R 10.2196/22007 %U http://games.jmir.org/2020/4/e22007/ %U https://doi.org/10.2196/22007 %U http://www.ncbi.nlm.nih.gov/pubmed/33315015 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18473 %T Choice of Leisure Activities by Adolescents and Adults With Internet Gaming Disorder: Development and Feasibility Study of a Virtual Reality Program %A Lee,Narae %A Kim,Jae-Jin %A Shin,Yu-Bin %A Eom,Hyojung %A Kim,Min-Kyeong %A Kyeong,Sunghyon %A Jung,Young Hoon %A Min,Sarang %A Kwon,Joon Hee %A Kim,Eunjoo %+ Department of Psychiatry, Yonsei University Gangnam Severance Hospital, Eonju-ro 211, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3345, ejkim96@yuhs.ac %K virtual reality %K VR %K internet game disorder %K IGD %K cognitive behavioral therapy %K CBT %K motivation %D 2020 %7 11.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Excessive internet game use frequently leads to various physical, psychological, and social problems, and internet gaming disorder (IGD) has become a serious public health issue worldwide. Recently, virtual reality (VR) therapy has emerged as a promising method to increase psychological treatment motivation and accessibility. However, few studies have examined the potential of VR technology for the management of IGD, and VR content tailored to IGD characteristics remains scarce. Objective: This preliminary study aimed to examine the potential of a VR-based program that was designed to help users identify their leisure time use patterns, especially those related to gaming, and to modify their gaming overuse by alternative activities provided in the VR content. Moreover, to investigate whether users’ VR activities reflect various clinical variables of IGD in youth, we examined the relationships among the leisure time activity selection pattern, built-in response, and speech data obtained from the VR program, as well as symptom severity of internet gaming, psychiatric comorbidities, and motivation of participants reported through relevant questionnaire data. Methods: Three types of VR content (understanding my daily activities at home, finding an alternative activity to internet gaming at home, expressing contradictory opinions toward a friend’s gaming beliefs) were developed by simulating the daily situations in which patients with IGD can select alternative free-time leisure activities. We examined internet addiction, mental health problems, and motivation for 23 IGD and 29 control participants. Behavioral and self-rated responses from VR, such as alternative activity selection data and speech patterns (speech time, speech satisfaction, and speech accordance), and results from various questionnaires were compared between groups. The correlations between IGD behaviors in VR and real-life behaviors assessed by questionnaire measures were analyzed. Results: Significant correlations were found between internet gaming behavior and user activity data, such as speech and activity selection pattern, in our VR program. Our results showed that the IGD group had fewer leisure activities and preferred game or digital activities to other types of activities compared to controls, even in VR. There was a positive relationship between the viability of alternative leisure activities the participants selected in VR and the amount of perceived satisfaction from that activity (r=.748, P<.001). Speech accordance in the IGD group was lower than in the control group and was correlated negatively with Internet Addiction Test and Internet Addiction Test–gaming scores (r=.300, P=.03) but positively with users’ motivation (r=.312, P=.02). Conclusions: The results from our VR program can provide information about daily activity patterns of youths with IGD and the relationship between user VR activities and IGD symptoms, which can be useful in applying VR technology to IGD management. %M 33306033 %R 10.2196/18473 %U http://games.jmir.org/2020/4/e18473/ %U https://doi.org/10.2196/18473 %U http://www.ncbi.nlm.nih.gov/pubmed/33306033 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19036 %T Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study %A Roche,Tadzio Raoul %A Said,Sadiq %A Rössler,Julian %A Gozdzik,Malgorzata %A Meybohm,Patrick %A Zacharowski,Kai %A Spahn,Donat R %A Nöthiger,Christoph B %A Tscholl,David W %+ Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, Zürich, 8091, Switzerland, 41 44 253 94 51, david.tscholl@usz.ch %K blood coagulation %K hemostasis %K blood coagulation test %K point of care %K rotational thromboelastometry %K Visual Clot %K decision making %K survey and questionnaires %K situation awareness %K user-centered design %K qualitative research %K visualization %K avatar %D 2020 %7 4.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers’ confidence. Objective: This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management. Methods: This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study. Results: A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were “positive design features” (29/36, 81%), “facilitates decision making” (17/36, 47%), and “quantification not made” (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly. Conclusions: A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test–based coagulation management. %M 33172834 %R 10.2196/19036 %U http://games.jmir.org/2020/4/e19036/ %U https://doi.org/10.2196/19036 %U http://www.ncbi.nlm.nih.gov/pubmed/33172834 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e24986 %T A Serious Game Designed to Promote Safe Behaviors Among Health Care Workers During the COVID-19 Pandemic: Development of “Escape COVID-19” %A Suppan,Mélanie %A Catho,Gaud %A Robalo Nunes,Tomás %A Sauvan,Valérie %A Perez,Monique %A Graf,Christophe %A Pittet,Didier %A Harbarth,Stephan %A Abbas,Mohamed %A Suppan,Laurent %+ Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, Geneva, 1211, Switzerland, 41 223723311, melanie.bochet@hcuge.ch %K COVID-19 %K transmission %K serious games %K infection prevention %K health care workers %K SARS-COV-2 %K infectious disease %K safety %K behavior %K hospital %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: As many countries fear and even experience the emergence of a second wave of COVID-19, reminding health care workers (HCWs) and other hospital employees of the critical role they play in preventing SARS-CoV-2 transmission is more important than ever. Building and strengthening the intrinsic motivation of HCWs to apply infection prevention and control (IPC) guidelines to avoid contaminating their colleagues, patients, friends, and relatives is a goal that must be energetically pursued. A high rate of nosocomial infections during the first COVID-19 wave was detected by IPC specialists and further cemented their belief in the need for an engaging intervention that could improve compliance with COVID-19 safe behaviors. Objective: Our aim was to develop a serious game that would promote IPC practices with a specific focus on COVID-19 among HCWs and other hospital employees. Methods: The first 3 stages of the SERES framework were used to develop this serious game. A brainswarming session between developers and IPC specialists was used to identify the target audience and acquisition objectives. Nicholson’s RECIPE mnemonic (reflection, engagement, choice, information, play, exposition) for meaningful gamification was used to guide the general design. A common and simple terminology was used to suit the broad target audience. The game was tested on various platforms (smartphones, tablets, laptops, desktop computers) by different users during each development loop and before its final release. Results: The game was designed to target all hospital staff who could be in direct contact with patients within the Geneva University Hospitals. In total, 10 acquisition objectives were defined by IPC specialists and implemented into the game according to the principles of meaningful gamification. A simple storyboard was first created using Microsoft PowerPoint and was progressively refined through multiple iteration loops. Articulate Storyline was then used to create two successive versions of the actual game. In the final version, a unique graphic atmosphere was created with help from a professional graphic designer. Feedback mechanisms were used extensively throughout the game to strengthen key IPC messages. Conclusions: The SERES framework was successfully used to create “Escape COVID-19,” a serious game designed to promote safe IPC practices among HCWs and other hospital employees during the COVID-19 pandemic. This game can be obtained free of charge for research and educational purposes. A SCORM (shareable content object reference model) package is available to facilitate results and completion tracking on most current learning management systems. %M 33242312 %R 10.2196/24986 %U http://games.jmir.org/2020/4/e24986/ %U https://doi.org/10.2196/24986 %U http://www.ncbi.nlm.nih.gov/pubmed/33242312 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e16883 %T Evaluation of a Serious Video Game to Facilitate Conversations About Human Papillomavirus Vaccination for Preteens: Pilot Randomized Controlled Trial %A Cates,Joan R %A Fuemmeler,Bernard F %A Stockton,Laurie L %A Diehl,Sandra J %A Crandell,Jamie L %A Coyne-Beasley,Tamera %+ Massey Cancer Center, Virginia Commonwealth University, 830 E. Main St., Rm 4-128, P.O. Box 980149, Richmond, VA, 23219, United States, 1 804 828 8892, Bernard.Fuemmeler@vcuhealth.org %K video games %K papillomavirus vaccines %K adolescent health %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the United States, the most common sexually transmitted infection, human papillomavirus (HPV), causes genital warts and is associated with an estimated 33,700 newly diagnosed cancer cases annually. HPV vaccination, especially for preteens aged 11 to 12 years, is effective in preventing the acquisition of HPV and HPV-associated cancers. However, as of 2018, completion of the 2- or 3-dose HPV vaccination series increased only from 48.6% to 51.1% in teens aged 13 to 17 years, and this increase was observed only in boys. By comparison, 88.7% of teens had more than one dose of the recommended vaccine against tetanus, diphtheria, and acellular pertussis (Tdap), and 85.1% of teens had more than one dose of meningococcal vaccine. Immunizations for Tdap, meningococcal disease, and HPV can occur at the same clinical visit but often do not. Objective: Vaccination against HPV is recommended for routine use in those aged 11 to 12 years in the United States, yet it is underutilized. We aimed to develop an educational video game to engage preteens in the decision to vaccinate. Methods: Land of Secret Gardens is a metaphor for protecting seedlings (body) with a potion (vaccine). We screened 131 dyads of parents and preteens from 18 primary practices in North Carolina who had not initiated HPV vaccination. We measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. A total of 55 dyads were enrolled, and we randomly assigned 28 (21 completed) to play the game and 27 (26 completed) to the comparison group. Results: In total, 18 preteens reported playing the game. The vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant.. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant. Conclusions: Video games help preteens in the decision to pursue HPV vaccination. A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification is effective in increasing preteen interest in HPV vaccination, as game features support decision making for HPV vaccination. Trial Registration: ClinicalTrials.gov NCT04627298; https://www.clinicaltrials.gov/ct2/show/NCT04627298 %M 33270028 %R 10.2196/16883 %U https://games.jmir.org/2020/4/e16883 %U https://doi.org/10.2196/16883 %U http://www.ncbi.nlm.nih.gov/pubmed/33270028 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18528 %T Using Serious Games for Antismoking Health Campaigns: Experimental Study %A Kim,Jihyun %A Song,Hayeon %A Merrill Jr,Kelly %A Jung,Younbo %A Kwon,Remi Junghuem %+ Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul, 03063, Republic of Korea, 82 2 740 1870, Hayeon.song@gmail.com %K fear appeals %K serious games %K smoking %K entertainment education %K susceptibility %D 2020 %7 2.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games for health have been gaining in popularity among scholars and practitioners. However, there remain a few questions to be addressed. Objective: This study tests the effects of a serious game and fear appeals on smoking-related outcomes. More specifically, this research aims to understand how serious games function as a more effective vehicle for a health campaign than a traditional medium, such as a print-based pamphlet. Further, while serious games utilize a variety of persuasive strategies in the game’s content, it is not clear whether fear appeals, which are widely used persuasive-message strategies for health, can be an effective strategy in serious games. Thus, we are testing the effect of fear appeals in a serious game. Methods: We created a computer game and a print brochure to educate participants about the risks of smoking. More specifically, a flash-based single-player game was developed in which players were asked to avoid cigarettes in the gameplay context. We also developed an online brochure based on existing smoking-related brochures at a university health center; antismoking messages on the computer game and in the brochure were comparable. Then, an experiment using a 2 (media type: game vs. print) x 2 (fearful image: fear vs. no-fear) between-subjects design was conducted. The study recruitment was announced to undergraduate students enrolled in a large, public Midwestern university in the United States. After a screening test, a total of 72 smokers, who reported smoking in the past 30 days, participated in the experiment. Results: Overall, gameplay, when compared to print-based pamphlets, had greater impacts on attitudes toward smoking and the intention to quit smoking. Further, the game’s persuasive effects were especially pronounced when messages contained fear appeals. When fearful images were presented, participants in the game condition reported significantly more negative attitudes toward social smoking than those in the print condition [F(1,67)=7.28; P=.009; ηp2=0.10]. However, in the no-fear condition, there was no significant difference between the conditions [F(1,67)=0.25; P=.620]. Similarly, the intention to quit smoking [F(1,67)=4.64; P=.035; ηp2=0.07] and susceptibility [F(1,67)=6.92; P=.011; ηp2=0.09] were also significantly different between the conditions, but only when fear appeals were used. Conclusions: This study extends fear appeal research by investigating the effects of different media types. It offers empirical evidence that a serious game can be an effective vehicle for fear appeals. %M 33263549 %R 10.2196/18528 %U http://games.jmir.org/2020/4/e18528/ %U https://doi.org/10.2196/18528 %U http://www.ncbi.nlm.nih.gov/pubmed/33263549 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e21652 %T The Role of Enjoyment in a Serious Game for Binge Drinking Prevention: Pretest-Posttest Quasi-Experimental Study %A Hong,Traci %A Cabrera,Joshua %A Beaudoin,Christopher E %+ College of Communication, Boston University, 640 Commonwealth Ave, Boston, MA, 02215, United States, 1 6173533450, tjhong@bu.edu %K alcohol prevention %K binge drinking %K serious game %D 2020 %7 30.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although binge drinking peaks at age 21 to 25 years, there is limited research on the effects of serious games in this population, as well as on the process by which playing serious games impacts alcohol-related outcomes. Designed with both health behavioral theory and game theory, One Shot is an online serious game that aims to prevent binge drinking. Objective: This study utilized a conceptual model for serious video game processes. Using One Shot, the model assessed the following process stages: (1) Alcohol Use Disorders Identification Test-Concise (AUDIT-C); (2) in-game factors of game time and risky alcohol decisions; (3) game enjoyment; and (4) postgame outcomes of intention to drink less and drinking refusal self-efficacy. Methods: In a one-group pretest-posttest quasi-experimental design, a sample (N=550) of young adults (age 21-25 years) who reported recent binge drinking played the One Shot game. Intention to drink less and drinking refusal self-efficacy were measured at pregame and postgame, with their effects lagged in statistical analysis. Participants were presented with various scenarios in the game that pertained to risky alcohol decisions, which, along with game time, were unobtrusively recorded by the server. A structural equation model (SEM) was used to test the conceptual model, with assessments made to determine if enjoyment mediated the effects of game time and risky alcohol decisions on the 2 postgame alcohol-related outcomes. Results: A well-fitting SEM demonstrated support for the multistep model, with AUDIT-C predicting risky alcohol decisions (β=.30). Risky alcohol decisions (β=−.22) and game time (β=.18) predicted enjoyment, which, in turn, predicted intention to drink less (β=.21) and drinking refusal self-efficacy (β=.16). Enjoyment significantly (P<.001) mediated the effects of game time and risky alcohol decision on intention to drink less and drinking refusal self-efficacy. Conclusions: The results support a conceptual model in which staggered individual and in-game factors influence alcohol-related outcomes. Enjoyment is important for participants’ intentions to drink less and beliefs that they can refuse alcohol. %M 33252348 %R 10.2196/21652 %U http://www.jmir.org/2020/11/e21652/ %U https://doi.org/10.2196/21652 %U http://www.ncbi.nlm.nih.gov/pubmed/33252348 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19723 %T Use of a Low-Cost Portable 3D Virtual Reality Simulator for Psychomotor Skill Training in Minimally Invasive Surgery: Task Metrics and Score Validity %A Alvarez-Lopez,Fernando %A Maina,Marcelo Fabián %A Arango,Fernando %A Saigí-Rubió,Francesc %+ Faculty of Health Sciences, Universitat Oberta de Catalunya, Avinguda Tibidabo, 39-43, Barcelona, 08035, Spain, 34 933 263 622, fsaigi@uoc.edu %K simulation training %K minimally invasive surgical procedures %K medical education %K user-computer interface %K computer-assisted surgery %K Leap Motion Controller %D 2020 %7 27.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery. Objective: The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality). Methods: In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability. Results: Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures. Conclusions: The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery. %M 33107833 %R 10.2196/19723 %U http://games.jmir.org/2020/4/e19723/ %U https://doi.org/10.2196/19723 %U http://www.ncbi.nlm.nih.gov/pubmed/33107833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e19840 %T Exergaming With Beat Saber: An Investigation of Virtual Reality Aftereffects %A Szpak,Ancret %A Michalski,Stefan Carlo %A Loetscher,Tobias %+ University of South Australia, St Bernards Road, Magill, South Australia, Adelaide, 5072, Australia, 61 08 8302 ext 4336, ancret.szpak@unisa.edu.au %K virtual reality %K motion sickness %K exercise %K sedentary behavior %K depth perception %D 2020 %7 23.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) exergaming has the potential to target sedentary behavior. Immersive environments can distract users from the physical exertion of exercise and can motivate them to continue exergaming. Despite the recent surge in VR popularity, numerous users still experience VR sickness from using head-mounted displays (HMDs). Apart from the commonly assessed self-reported symptoms, depth perception and cognition may also be affected. Considering the potential benefits of VR exergaming, it is crucial to identify the adverse effects limiting its potential and continued uptake. Objective: This study aims to investigate the consequences of playing one of the most popular VR exergames for 10 and 50 min on aspects of vision, cognition, and self-reported VR sickness. Methods: A total of 36 participants played an exergame, called Beat Saber, using an HMD. A repeated measures within-subject design was conducted to assess changes in vision, cognition, and well-being after short (10 min) and long (50 min) durations of VR exposure. We measured accommodation, convergence, decision speed, movement speed, and self-reported sickness at 3 test periods—before VR, immediately after VR, and 40 min after VR (late). Results: Beat Saber was well tolerated, as there were no dropouts due to sickness. For most participants, any immediate aftereffects were short-lived and returned to baseline levels after 40 min of exiting VR. For both short and long exposures, there were changes in accommodation (F1,35=8.424; P=.006) and convergence (F1,35=7.826; P=.008); however, in the late test period, participants returned to baseline levels. Measures on cognition revealed no concern. The total simulator sickness questionnaire (SSQ) scores increased immediately after VR (F1,35=26.515; P<.001) and were significantly higher for long compared with short exposures (t35=2.807; P=.03), but there were no differences in exposure duration in the late test period, with scores returning to baseline levels. Although at a group level, participants’ sickness levels returned to baseline 40 min after VR exposure, approximately 14% of the participants still reported high levels of sickness in the late test period after playing 50 min of Beat Saber. We also showed that the participants who experienced a high level of sickness after a short exposure were almost certain to experience a high level of symptoms after a longer exposure. Conclusions: Irrespective of the duration of exposure, this study found no strong evidence for adverse symptoms 40 min after exiting VR; however, some individuals still reported high levels of VR sickness at this stage. We recommend that users commit to a waiting period after exiting VR to ensure that any aftereffects have deteriorated. Exergames in HMDs have the potential to encourage people to exercise but are understudied, and the aftereffects of exergaming need to be closely monitored to ensure that VR exergames can reach their full potential. %M 33095182 %R 10.2196/19840 %U http://www.jmir.org/2020/10/e19840/ %U https://doi.org/10.2196/19840 %U http://www.ncbi.nlm.nih.gov/pubmed/33095182 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e20126 %T A Tablet App for Handwriting Skill Screening at the Preliteracy Stage: Instrument Validation Study %A Dui,Linda Greta %A Lunardini,Francesca %A Termine,Cristiano %A Matteucci,Matteo %A Stucchi,Natale Adolfo %A Borghese,Nunzio Alberto %A Ferrante,Simona %+ Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Colombo 40, Milan, 20133, Italy, 39 0223999690, lindagreta.dui@polimi.it %K serious game %K tablet %K isochrony %K homothety %K speed-accuracy tradeoff %K steering law %K writing %K prevention %D 2020 %7 22.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Difficulties in handwriting, such as dysgraphia, impact several aspects of a child’s everyday life. Current methodologies for the detection of such difficulties in children have the following three main weaknesses: (1) they are prone to subjective evaluation; (2) they can be administered only when handwriting is mastered, thus delaying the diagnosis and the possible adoption of countermeasures; and (3) they are not always easily accessible to the entire community. Objective: This work aims at developing a solution able to: (1) quantitatively measure handwriting features whose alteration is typically seen in children with dysgraphia; (2) enable their study in a preliteracy population; and (3) leverage a standard consumer technology to increase the accessibility of both early screening and longitudinal monitoring of handwriting difficulties. Methods: We designed and developed a novel tablet-based app Play Draw Write to assess potential markers of dysgraphia through the quantification of the following three key handwriting laws: isochrony, homothety, and speed-accuracy tradeoff. To extend such an approach to a preliteracy age, the app includes the study of the laws in terms of both word writing and symbol drawing. The app was tested among healthy children with mastered handwriting (third graders) and those at a preliterate age (kindergartners). Results: App testing in 15 primary school children confirmed that the three laws hold on the tablet surface when both writing words and drawing symbols. We found significant speed modulation according to size (P<.001), no relevant changes to fraction time for 67 out of 70 comparisons, and significant regression between movement time and index of difficulty for 44 out of 45 comparisons (P<.05, R2>0.28, 12 degrees of freedom). Importantly, the three laws were verified on symbols among 19 kindergartners. Results from the speed-accuracy exercise showed a significant evolution with age of the global movement time (circle: P=.003, square: P<.001, word: P=.001), the goodness of fit of the regression between movement time and accuracy constraints (square: P<.001, circle: P=.02), and the index of performance (square: P<.001). Our findings show that homothety, isochrony, and speed-accuracy tradeoff principles are present in children even before handwriting acquisition; however, some handwriting-related skills are partially refined with age. Conclusions: The designed app represents a promising solution for the screening of handwriting difficulties, since it allows (1) anticipation of the detection of alteration of handwriting principles at a preliteracy age and (2) provision of broader access to the monitoring of handwriting principles. Such a solution potentially enables the selective strengthening of lacking abilities before they exacerbate and affect the child’s whole life. %M 33090110 %R 10.2196/20126 %U http://games.jmir.org/2020/4/e20126/ %U https://doi.org/10.2196/20126 %U http://www.ncbi.nlm.nih.gov/pubmed/33090110 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e21123 %T Lessons Learned From an Evaluation of Serious Gaming as an Alternative to Mannequin-Based Simulation Technology: Randomized Controlled Trial %A Benda,Natalie C %A Kellogg,Kathryn M %A Hoffman,Daniel J %A Fairbanks,Rollin J %A Auguste,Tamika %+ Women’s and Infants’ Services, MedStar Washington Hospital Center, 110 Irving St. NW, 5B-41, Washington, DC, 20010, United States, 1 202 877 8177, tamika.c.auguste@medstar.net %K simulation training %K continuing medical education %K obstetrics %D 2020 %7 28.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of new technology like virtual reality, e-learning, and serious gaming can offer novel, more accessible options that have been demonstrated to improve learning outcomes. Objective: The aim of this study was to compare the educational effectiveness of serious game–based simulation training to traditional mannequin-based simulation training and to determine the perceptions of physicians and nurses. We used an obstetric use case, namely electronic fetal monitoring interpretation and decision making, for our assessment. Methods: This study utilized a mixed methods approach to evaluate the effectiveness of the new, serious game–based training method and assess participants’ perceptions of the training. Participants were randomized to traditional simulation training in a center with mannequins or serious game training. They then participated in an obstetrical in-situ simulation scenario to assess their learning. Participants also completed a posttraining perceptions questionnaire. Results: The primary outcome measure for this study was the participants’ performance in an in-situ mannequin-based simulation scenario, which occurred posttraining following a washout period. No significant statistical differences were detected between the mannequin-based and serious game–based groups in overall performance, although the study was not sufficiently powered to conclude noninferiority. The survey questions were tested for significant differences in participant perceptions of the educational method, but none were found. Qualitative participant feedback revealed important areas for improvement, with a focus on game realism. Conclusions: The serious game training tool developed has potential utility in providing education to those without access to large simulation centers; however, further validation is needed to demonstrate if this tool is as effective as mannequin-based simulation. %M 32985993 %R 10.2196/21123 %U http://games.jmir.org/2020/3/e21123/ %U https://doi.org/10.2196/21123 %U http://www.ncbi.nlm.nih.gov/pubmed/32985993 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e21879 %T Controlling the Sense of Embodiment for Virtual Avatar Applications: Methods and Empirical Study %A Kim,Chang-Seop %A Jung,Myeongul %A Kim,So-Yeon %A Kim,Kwanguk %+ Department of Computer Science, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea, 82 2 2220 2319, kenny@hanyang.ac.kr %K embodiment %K virtual avatar %K full-body illusion %K motion capture %K virtual reality %D 2020 %7 22.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The sense of embodiment (SoE) is the feeling of one’s own body, and research on the SoE extends from the rubber hand illusion to the full-body ownership illusion with a virtual avatar. Objective: The key to utilizing a virtual avatar is understanding and controlling the SoE, and it can be extended to several medical applications. In this study, we aimed to clarify these aspects by considering the following three subcomponents of SoE: sense of agency, ownership, and self-location. Methods: We defined a human avatar (HA), point light avatar (PLA), and out-of-body point light avatar (OBPLA) and compared them in three user studies. In study 1, 28 participants were recruited and the three avatar conditions (HA, PLA, and OBPLA) were compared. In study 2, 29 new participants were recruited, and there were two avatar conditions (HA ad PLA) and two motion synchrony conditions (synchrony and asynchrony). In study 3, 29 other participants were recruited, and there were two avatar conditions (PLA and OBPLA) and two motion synchrony conditions (synchrony and asynchrony). Dependent measures included sense of agency, ownership, and self-location; emotional response; presence; and simulator sickness. Results: The findings of study 1 showed that the three avatar generation methodologies can control the sense of ownership and self-location in a stepwise manner while maintaining a high sense of agency. In studies 2 and 3, we found dependencies among the three subcomponents of SoE and observed that they affected users’ subjective experiences. Conclusions: Our findings may have implications for boosting the effects of virtual avatar applications in medical areas, by understanding and controlling the SoE with a full-body illusion. %M 32960174 %R 10.2196/21879 %U http://games.jmir.org/2020/3/e21879/ %U https://doi.org/10.2196/21879 %U http://www.ncbi.nlm.nih.gov/pubmed/32960174 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17979 %T Serious Game on a Smartphone for Adolescents Undergoing Hemodialysis: Development and Evaluation %A Santana,Cristina Célia De Almeida Pereira %A Freitas,Ana Tereza Vaz De Souza %A Oliveira Barreto,Gilson %A Sousa De Avelar,Igor %A Mazaro-Costa,Renata %A Bueno,Gina Nolêto %A Ribeiro,Diuly Caroline %A Damasceno Silva,Gabriela %A Naghettini,Alessandra Vitorino %+ Hospital das Clínicas, Postgraduate Program Teaching in Health, Goias Federal University, Primeira Avenida, S/nº, Setor Universitário, Goiânia, 74605-020, Brazil, 55 62991507049, ccaps44@gmail.com %K adolescent %K hemodialysis %K serious game %K operability %D 2020 %7 14.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescents with chronic kidney disease have a hard time adhering to hemodialysis as a therapy, indicating a need to establish new alternatives for motivation and adherence to treatment. Objective: The objective of this study was to develop and evaluate a serious game to stimulate and motivate adolescents undergoing hemodialysis. Methods: We describe the technological production followed by a qualitative analysis. We invited 8 adolescents undergoing hemodialysis in the city Goiânia, located in the midwest of Brazil, to participate. The final convenience sample included 7 (87.5% of the target population) adolescents. The process was conducted in 3 phases: creation of a serious game, evaluation of its use, and observation of its motivating effect on behavioral modification with a focus on acquiring the necessary competence for self-care. Results: An app (Bim) in the modality of a serious game was developed to be used during hemodialysis; the player was encouraged to take care of a character with daily actions during his or her treatment. The game was made available to adolescents aged 10-14 years. Mobile devices were offered during the hemodialysis treatment for a period of 30-40 minutes, 3 times a week for 60 days. The usage definitions of the game were freely chosen by the participants. The qualitative evaluation of the use of the Bim app showed that it encompasses scenarios and activities that enable the exercise of daily actions for the treatment of patients. The behavioral evaluation showed that the Bim app worked as a motivating stimulus for behavioral adherence to hemodialysis requirements. Conclusions: The easy-to-access app interface showed good operability for its users. The description of the character and proposed activities contributed to motivation and ability to cope with hemodialysis care. %M 32924950 %R 10.2196/17979 %U http://games.jmir.org/2020/3/e17979/ %U https://doi.org/10.2196/17979 %U http://www.ncbi.nlm.nih.gov/pubmed/32924950 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17823 %T Biosensor Real-Time Affective Analytics in Virtual and Mixed Reality Medical Education Serious Games: Cohort Study %A Antoniou,Panagiotis E %A Arfaras,George %A Pandria,Niki %A Athanasiou,Alkinoos %A Ntakakis,George %A Babatsikos,Emmanouil %A Nigdelis,Vasilis %A Bamidis,Panagiotis %+ Lab of Medical Physics, The Medical School, Aristotle University of Thessaloniki, PO Box 376, Thessaloniki, 54124, Greece, 30 2310 999310, bamidis@auth.gr %K virtual patients %K affective learning %K electroencephalography %K medical education %K virtual reality %K wearable sensors %K serious medical games %D 2020 %7 2.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The role of emotion is crucial to the learning process, as it is linked to motivation, interest, and attention. Affective states are expressed in the brain and in overall biological activity. Biosignals, like heart rate (HR), electrodermal activity (EDA), and electroencephalography (EEG) are physiological expressions affected by emotional state. Analyzing these biosignal recordings can point to a person’s emotional state. Contemporary medical education has progressed extensively towards diverse learning resources using virtual reality (VR) and mixed reality (MR) applications. Objective: This paper aims to study the efficacy of wearable biosensors for affect detection in a learning process involving a serious game in the Microsoft HoloLens VR/MR platform. Methods: A wearable array of sensors recording HR, EDA, and EEG signals was deployed during 2 educational activities conducted by 11 participants of diverse educational level (undergraduate, postgraduate, and specialist neurosurgeon doctors). The first scenario was a conventional virtual patient case used for establishing the personal biosignal baselines for the participant. The second was a case in a VR/MR environment regarding neuroanatomy. The affective measures that we recorded were EEG (theta/beta ratio and alpha rhythm), HR, and EDA. Results: Results were recorded and aggregated across all 3 groups. Average EEG ratios of the virtual patient (VP) versus the MR serious game cases were recorded at 3.49 (SD 0.82) versus 3.23 (SD 0.94) for students, 2.59 (SD 0.96) versus 2.90 (SD 1.78) for neurosurgeons, and 2.33 (SD 0.26) versus 2.56 (SD 0.62) for postgraduate medical students. Average alpha rhythm of the VP versus the MR serious game cases were recorded at 7.77 (SD 1.62) μV versus 8.42 (SD 2.56) μV for students, 7.03 (SD 2.19) μV versus 7.15 (SD 1.86) μV for neurosurgeons, and 11.84 (SD 6.15) μV versus 9.55 (SD 3.12) μV for postgraduate medical students. Average HR of the VP versus the MR serious game cases were recorded at 87 (SD 13) versus 86 (SD 12) bpm for students, 81 (SD 7) versus 83 (SD 7) bpm for neurosurgeons, and 81 (SD 7) versus 77 (SD 6) bpm for postgraduate medical students. Average EDA of the VP versus the MR serious game cases were recorded at 1.198 (SD 1.467) μS versus 4.097 (SD 2.79) μS for students, 1.890 (SD 2.269) μS versus 5.407 (SD 5.391) μS for neurosurgeons, and 0.739 (SD 0.509) μS versus 2.498 (SD 1.72) μS for postgraduate medical students. The variations of these metrics have been correlated with existing theoretical interpretations regarding educationally relevant affective analytics, such as engagement and educational focus. Conclusions: These results demonstrate that this novel sensor configuration can lead to credible affective state detection and can be used in platforms like intelligent tutoring systems for providing real-time, evidence-based, affective learning analytics using VR/MR-deployed medical education resources. %M 32876575 %R 10.2196/17823 %U http://games.jmir.org/2020/3/e17823/ %U https://doi.org/10.2196/17823 %U http://www.ncbi.nlm.nih.gov/pubmed/32876575 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e20249 %T Learning With Virtual Reality in Nursing Education: Qualitative Interview Study Among Nursing Students Using the Unified Theory of Acceptance and Use of Technology Model %A Lange,Ann-Kathrin %A Koch,Jana %A Beck,Anastasia %A Neugebauer,Till %A Watzema,Frauke %A Wrona,Kamil J %A Dockweiler,Christoph %+ University of Bielefeld, Universitätsstr 25, Bielefeld, 33615, Germany, 49 521106 ext 5160, ann-kathrin.lange@uni-bielefeld.de %K virtual reality %K edutainment %K serious games %K education %K health care %K gamification %K anatomy %K digital game–based learning %K nursing %K nursing informatics %D 2020 %7 1.9.2020 %9 Original Paper %J JMIR Nursing %G English %X Background: Digital games–based learning is a method of using digital games to impart knowledge. Virtual reality (VR) programs are a practical application of this method. Due to demographic changes, the nursing profession will become increasingly important. These VR applications can be of use in training nurses for future professional challenges they may encounter. The continuous development of VR applications enables trainees to encounter simulated real life effectively and to experience increasingly concrete situations. This can be of great importance in nursing education, since 3-dimensionality enables a better visualization of many fields of activity and can prevent potential future errors. In addition to this learning effect, VR applications also bring an element of fun to learning. Objective: The aim of this qualitative research effort is to observe the degree of acceptance of VR applications by nursing students in Germany. Various factors, including social influences, performance expectations, and effort expectations, are taken into consideration. Methods: With a qualitative cohort study, the acceptance of nursing students towards VR applications in anatomy teaching was determined. The 12 participants were first asked to fill out a quantitative questionnaire on their sociodemographic characteristics and the extent to which they valued and liked using technology. The participants were then allowed to test the VR application themselves and were finally asked about their experience in a qualitative interview. For the collection of data and the analysis of results, the unified theory of acceptance and use of technology was used in this study. Results: Overall, the study shows that the interviewed persons rated the VR application quite positively. The greatest influence in this was the personal attitude towards technology; the higher this affinity is, the more useful the VR application appears. Social influences can also increase the participant’s own acceptance if peers have a positive attitude towards such applications. The study shows that the trainees' motivation to learn was increased by using VR. We believe this is because each trainee could learn individually and the VR application was perceived as an enjoyable activity. Nevertheless, the cost factor of implementing VR applications in nursing training is currently still an obstacle, as not every institution has such financial capacities. Conclusions: The extent to which the use of VR applications in the training of nursing staff is justified depends on the degree of personal acceptance. The collected results give good practice-oriented insight into the attitude of trainees towards VR. Many of the interviewed persons saw benefits in the use of VR technologies. As VR applications are constantly developing, it is necessary to conduct further studies on VR applications in nursing education and to include other possible disciplines in which these applications can be helpful. %R 10.2196/20249 %U https://nursing.jmir.org/2020/1/e20249/ %U https://doi.org/10.2196/20249 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e16655 %T A Serious Game on the First-Aid Procedure in Choking Scenarios: Design and Evaluation Study %A Boada,Imma %A Rodriguez Benitez,Antonio %A Thió-Henestrosa,Santiago %A Soler,Josep %+ Graphics and Imaging Laboratory, Escola Politècnica Superior, Edifici Politècnica IV, C/ de la Universitat de Girona, 6, Campus Montilivi, 17003 Girona, Spain, 34 618334786, imma.boada@udg.edu %K choking %K prevention %K first-aid procedure %K first-aid education %D 2020 %7 19.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Choking is one of the causes of unintentional injury death. Gaining the knowledge of the first-aid procedure that has to be applied in case of choking can increase the chances of survival of persons with choking. Serious games can be a good channel for educating people about choking scenarios and the actions to be taken to save the persons with choking. Objective: The objective of this study is to present and evaluate the effectiveness of a serious game designed to prevent choking and to promote the first-aid procedure that needs to be applied in case of choking. Methods: In this study, we present a serious game as a set of minigames that reproduces the main steps of the protocol for the first-aid performed in choking. In the proposed game, the player acquires the role of a helper who has to save the person in a choking emergency by applying the main steps of the protocol. Time and score restrictions are imposed to pass each minigame. To test this game, we performed a pilot study with 48 high school students. Different tests were performed to assess the students’ preferences and their knowledge on choking before and after playing the proposed game. The obtained results were analyzed using Mann-Whitney U test when a grade variable was involved and by using Fisher exact test when 2 categorical variables were involved. Results: The findings of our study showed that the players enjoyed the game. No statistical differences were detected when considering the gender of the player, their preferences for video games, or their previous experience in choking emergencies. By comparing the knowledge of these students before and after playing the game, we found that all the indicators of the knowledge about how to act in case of a choking emergency were improved through this serious game. Conclusions: The findings of our study show that the proposed game is a good strategy for promoting and teaching first-aid procedures in choking emergencies to nonexperts in this field. %M 32812882 %R 10.2196/16655 %U http://games.jmir.org/2020/3/e16655/ %U https://doi.org/10.2196/16655 %U http://www.ncbi.nlm.nih.gov/pubmed/32812882 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17367 %T The Acceptability and Impact of the Xploro Digital Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study %A Bray,Lucy %A Sharpe,Ashley %A Gichuru,Phillip %A Fortune,Peter-Marc %A Blake,Lucy %A Appleton,Victoria %+ Faculty of Health, Social Care and Medicine, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, United Kingdom, 44 01695 657231, brayl@edgehill.ac.uk %K health literacy %K augmented reality %K children %K procedure %K health %K artificial intelligence %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. Objective: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent’s procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. Methods: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children’s hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. Results: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=−2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=−4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. Conclusions: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use. %M 32780025 %R 10.2196/17367 %U http://www.jmir.org/2020/8/e17367/ %U https://doi.org/10.2196/17367 %U http://www.ncbi.nlm.nih.gov/pubmed/32780025 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17799 %T A Graded Exposure, Locomotion-Enabled Virtual Reality App During Walking and Reaching for Individuals With Chronic Low Back Pain: Cohort Gaming Design %A Hennessy,Rebecca White %A Rumble,Deanna %A Christian,Mike %A Brown,David A %A Trost,Zina %+ PhD Program in Rehabilitation Science, School of Health Professions, University of Alabama at Birmingham, 1716 9th Avenue South, Birmingham, AL, United States, 1 205 975 3592, rwhite31@uab.edu %K virtual reality %K chronic low back pain %K walking %K rehabilitation %K virtual reality exposure therapy %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Chronic low back pain (cLBP) can interfere with daily activities, and individuals with elevated pain-related fear (also known as kinesiophobia or the fear of injury due to movement) can develop worse long-term disability. Graded exposure (GEXP) protocols use successive participation in avoided activities to help individuals overcome fearful movement appraisals and encourage activity. We sought to develop a series of GEXP virtual reality (VR) walking and reaching scenarios to increase the exposure and engagement of people with high kinesiophobia and cLBP. Objective: This study aims to (1) determine GEXP content validity of the VR application and (2) determine the feasibility of individuals with cLBP performing locomotion-enabled physical activities. Methods: We recruited 13 individuals with cLBP and high pain-related fear to experience six VR modules, which provide progressive movement exposure over three sessions in a 1 week period. At session 1, participants ranked each module by likelihood to avoid and assigned an expected pain and concern for harming their back rating to each module. Participants provided a rating of perceived exertion (RPE) after experiencing each module. To test feasibility, we administered the system usability scale (SUS) and treatment evaluation inventory (TEI) following the final session. In addition, we measured pain and pain-related fear at baseline and follow-up. Results: The 12 participants who completed the study period assigned higher avoidance (P=.002), expected pain (P=.002), and expected concern (P=.002) for session 3 modules compared with session 1 modules. RPE significantly increased from session 1 (mean 14.8, SD 2.3) to session 3 (mean 16.8, SD 2.2; P=.009). The VR application showed positive feasibility for individuals with cLBP through acceptable SUS (mean 76.7, SD 13.0) and TEI (mean 32.5, SD 4.9) scores. Neither pain (P=.20) nor pain-related fear (P=.58) changed significantly across sessions. Conclusions: The GEXP VR modules provided progressive exposure to physical challenges, and participants found the VR application acceptable and usable as a potential treatment option. Furthermore, the lack of significant change for pain and pain-related fear reflects that participants were able to complete the modules safely. %M 32773381 %R 10.2196/17799 %U http://games.jmir.org/2020/3/e17799/ %U https://doi.org/10.2196/17799 %U http://www.ncbi.nlm.nih.gov/pubmed/32773381 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18644 %T The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis %A Vermeir,Julie F %A White,Melanie J %A Johnson,Daniel %A Crombez,Geert %A Van Ryckeghem,Dimitri M L %+ School of Psychology and Counselling, Institute of Health and Biomedical Innovation, Queensland University of Technology, 170 Victoria Park Road, Brisbane, 4059, Australia, 61 731384714, julie.vermeir@hdr.qut.edu.au %K gamification %K cognition %K health %K systematic review %K meta-analysis %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: There has been a growing interest in the application of gamification (ie, the use of game elements) to computerized cognitive training. The introduction of targeted gamification features to such tasks may increase motivation and engagement as well as improve intervention effects. However, it is possible that game elements can also have adverse effects on cognitive training (eg, be a distraction), which can outweigh their potential motivational benefits. So far, little is known about the effectiveness of such applications. Objective: This study aims to conduct a systematic review and meta-analysis to investigate the effect of gamification on process outcomes (eg, motivation) and on changes in the training domain (eg, cognition), as well as to explore the role of potential moderators. Methods: We searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ProQuest Psychology, Web of Science, Scopus, PubMed, Science Direct, Excerpta Medica dataBASE, Institute of Electrical and Electronics Engineers Xplore, Association for Computing Machinery, and a range of gray-area literature databases. The searches included papers published between 2008 and 2018. Meta-analyses were performed using a random-effects model. Results: The systematic review identified 49 studies, of which 9 randomized controlled trials were included in the meta-analysis. The results of the review indicated that research in this context is still developing and lacks well-controlled empirical studies. Gamification in cognitive training is applied to a large range of age groups and audiences and is mostly delivered at a research site through computers. Rewards and feedback continue to dominate the gamification landscape, whereas social-oriented features (eg, competition) are underused. The meta-analyses showed that gamified training tasks were more motivating/engaging (Hedges g=0.72) and more demanding/difficult (Hedges g=–0.52) than non- or less-gamified tasks, whereas no effects on the training domain were found. Furthermore, no variables moderated the impact of gamified training tasks. However, meta-analytic findings were limited due to a small number of studies. Conclusions: Overall, this review provides an overview of the existing research in the domain and provides evidence for the effectiveness of gamification in improving motivation/engagement in the context of cognitive training. We discuss the shortcomings in the current literature and provide recommendations for future research. %M 32773374 %R 10.2196/18644 %U https://games.jmir.org/2020/3/e18644 %U https://doi.org/10.2196/18644 %U http://www.ncbi.nlm.nih.gov/pubmed/32773374 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18247 %T Assessing Ethoshunt as a Gamification-Based Mobile App in Ethics Education: Pilot Mixed-Methods Study %A Zakaria,Noor Syamilah %A Saripan,M Iqbal %A Subarimaniam,Neerushah %A Ismail,Alyani %+ Department of Counselor Education and Counseling Psychology, Faculty of Educational Studies, Universiti Putra Malaysia, UPM Serdang, Selangor Darul Ehsan, 43400, Malaysia, 60 127849776, syamilah@upm.edu.my %K gamification %K ethics %K education %K ethics education %K ethical competency %K mobile app %K mobile app usability %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification has remarkable potential in the learning space. The process of creating a gamified system and its influence on human behavior reflect the interaction between educators and machines. Objective: The purpose of this pilot study was to present Ethoshunt as a gamification-based mobile app that can be used in teaching and learning ethics. Methods: This study involved a mixed-methods research design. The researchers surveyed 39 undergraduate students who were introduced to Ethoshunt in order to examine the relationships between mobile app usability and positive emotions, ethical competency, and user experience. Affinity diagramming was used as a tool to organize the opinions and experiences of participants using featured gamification elements. Results: Game dynamics and game mechanics explained the functionality of Ethoshunt. In addition, the learning flow through Ethoshunt was discussed. Overall, the findings were positive, and mobile app usability had the strongest relationship with positive emotions (r=0.744, P<.001), followed by ethical competency (r=0.686, P<.001) and user experience (r=0.614, P<.001). Conclusions: Positive emotions could be perceived as an important dimension in the development and usability of Ethoshunt. The researchers suggest that the gamification-based mobile app advocated in this study may provide ideas for ethics educators who wish to develop a technology-mediated learning environment. %M 32663153 %R 10.2196/18247 %U http://games.jmir.org/2020/3/e18247/ %U https://doi.org/10.2196/18247 %U http://www.ncbi.nlm.nih.gov/pubmed/32663153 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e20797 %T Exploring User Needs in the Development of a Virtual Reality–Based Advanced Life Support Training Platform: Exploratory Usability Study %A Moore,Nathan %A Yoo,Soojeong %A Poronnik,Philip %A Brown,Martin %A Ahmadpour,Naseem %+ Research and Education Network, Western Sydney Local Health District, Post Graduate Medical Education Centre Lvl 3 Education Block, Westmead Hospital, Cnr Hawkesbury Rd and Darcy Rd, Westmead, 2145, Australia, 61 427850889, nathan.moore@health.nsw.gov.au %K virtual reality %K Advanced Life Support %K Advanced Cardiac Life Support %K clinical training %K education %K serious games %D 2020 %7 7.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Traditional methods of delivering Advanced Life Support (ALS) training and reaccreditation are resource-intensive and costly. Interactive simulations and gameplay using virtual reality (VR) technology can complement traditional training processes as a cost-effective, engaging, and flexible training tool. Objective: This exploratory study aimed to determine the specific user needs of clinicians engaging with a new interactive VR ALS simulation (ALS-SimVR) application to inform the ongoing development of such training platforms. Methods: Semistructured interviews were conducted with experienced clinicians (n=10, median age=40.9 years) following a single playthrough of the application. All clinicians have been directly involved in the delivery of ALS training in both clinical and educational settings (median years of ALS experience=12.4; all had minimal or no VR experience). Interviews were supplemented with an assessment of usability (using heuristic evaluation) and presence. Results: The ALS-SimVR training app was well received. Thematic analysis of the interviews revealed five main areas of user needs that can inform future design efforts for creating engaging VR training apps: affordances, agency, diverse input modalities, mental models, and advanced roles. Conclusions: This study was conducted to identify the needs of clinicians engaging with ALS-SimVR. However, our findings revealed broader design considerations that will be crucial in guiding future work in this area. Although aligning the training scenarios with accepted teaching algorithms is important, our findings reveal that improving user experience and engagement requires careful attention to technology-specific issues such as input modalities. %M 32763877 %R 10.2196/20797 %U http://games.jmir.org/2020/3/e20797/ %U https://doi.org/10.2196/20797 %U http://www.ncbi.nlm.nih.gov/pubmed/32763877 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17565 %T User Experience of Interactive Technologies for People With Dementia: Comparative Observational Study %A Andrade Ferreira,Luis Duarte %A Ferreira,Henrique %A Cavaco,Sofia %A Cameirão,Mónica %A i Badia,Sergi Bermúdez %+ NOVA LINCS, Dep de Informática, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, Campus de Caparica, Caparica, Lisboa, 2829-516, Portugal, 351 21 294 8300, luis.d.ferreira@m-iti.org %K dementia %K technology %K interaction %K psychomotor performance %K equipment safety %K costs and cost analysis %K user-computer interface %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games (SGs) are used as complementary approaches to stimulate patients with dementia. However, many of the SGs use out-of-the-shelf technologies that may not always be suitable for such populations, as they can lead to negative behaviors, such as anxiety, fatigue, and even cybersickness. Objective: This study aims to evaluate how patients with dementia interact and accept 5 out-of-the-shelf technologies while completing 10 virtual reality tasks. Methods: A total of 12 participants diagnosed with dementia (mean age 75.08 [SD 8.07] years, mean Mini-Mental State Examination score 17.33 [SD 5.79], and mean schooling 5.55 [SD 3.30]) at a health care center in Portugal were invited to participate in this study. A within-subject experimental design was used to allow all participants to interact with all technologies, such as HTC VIVE, head-mounted display (HMD), tablet, mouse, augmented reality (AR), leap motion (LM), and a combination of HMD with LM. Participants’ performance was quantified through behavioral and verbal responses, which were captured through video recordings and written notes. Results: The findings of this study revealed that the user experience using technology was dependent on the patient profile; the patients had a better user experience when they use technologies with direct interaction configuration as opposed to indirect interaction configuration in terms of assistance required (P=.01) and comprehension (P=.01); the participants did not trigger any emotional responses when using any of the technologies; the participants’ performance was task-dependent; the most cost-effective technology was the mouse, whereas the least cost-effective was AR; and all the technologies, except for one (HMD with LM), were not exposed to external hazards. Conclusions: Most participants were able to perform tasks using out-of-the-shelf technologies. However, there is no perfect technology, as they are not explicitly designed to address the needs and skills of people with dementia. Here, we propose a set of guidelines that aim to help health professionals and engineers maximize user experience when using such technologies for the population with dementia. %M 32755894 %R 10.2196/17565 %U http://games.jmir.org/2020/3/e17565/ %U https://doi.org/10.2196/17565 %U http://www.ncbi.nlm.nih.gov/pubmed/32755894 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18687 %T Mapping Behavioral Health Serious Game Interventions for Adults With Chronic Illness: Scoping Review %A Thomas,Teresa Hagan %A Sivakumar,Varshini %A Babichenko,Dmitriy %A Grieve,Victoria L B %A Klem,Mary Lou %+ School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, United States, 1 4126243799, t.thomas@pitt.edu %K review %K chronic disease %K behavioral sciences %K video games %D 2020 %7 30.7.2020 %9 Review %J JMIR Serious Games %G English %X Background: Serious games for health are increasingly being used to address health outcomes in patients with chronic illnesses. These studies vary in their study designs, patient populations, frameworks, outcome variables, and degree of specificity of the serious game intervention. Objective: This scoping review aims to clarify the conceptual features of the existing research related to serious games designed to improve cognitive and behavioral outcomes in adults with chronic illness. Methods: We applied the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for scoping reviews (PRISMA-ScR) methodology, including an a priori research question. We searched 4 electronic databases to identify articles published through November 2019. Inclusion criteria encompassed (1) adults 18 years or older; (2) patients with a diagnosis of chronic illness; (3) a serious game intervention; and (4) defined patient outcomes that assess patients’ behavioral, cognitive, or health outcomes. Results: Of the 3305 articles identified, 38 were included in the review. We charted and analyzed the theoretical frameworks, key concepts, and outcome variables of these studies with summaries of features across articles. The majority of studies used a randomized controlled trial design (23/38, 61%), included a custom serious game intervention (22/38, 58%), and lacked a theoretical framework (25/38, 66%). Common outcome variables included quality of life (16/38, 42%), mood (15/38, 39%), cognitive function (13/38, 34%), symptoms (12/38, 32%), and physical activity (9/38, 24%). Key differences between studies included whether or not serious games aimed to train versus teach patients, be widely accessible versus tailored interventions, or replace versus complement current treatments. Conclusions: This scoping review defines the current landscape of research in serious games for health research targeting behavioral and cognitive outcomes in adults with chronic disease. Studies have addressed a variety of patient populations and diverse patient outcomes. Researchers wanting to build on the current research should integrate theoretical frameworks into the design of the intervention and trial to more clearly articulate the active ingredients and mechanisms of serious games. %M 32729836 %R 10.2196/18687 %U http://games.jmir.org/2020/3/e18687/ %U https://doi.org/10.2196/18687 %U http://www.ncbi.nlm.nih.gov/pubmed/32729836 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18479 %T Reasons to Engage in and Learning Experiences From Different Play Strategies in a Web-Based Serious Game on Delirium for Medical Students: Mixed Methods Design %A Buijs-Spanjers,Kiki R %A Hegge,Harianne HM %A Cnossen,Fokie %A Jaarsma,Debbie ADC %A de Rooij,Sophia E %+ Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P O Box 30.001 HP AA43, Groningen, 9700 RB, Netherlands, 31 503613464, k.r.spanjers@umcg.nl %K dark play %K serious games %K medical education %K medical students %K delirium %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although many studies have recently been published on the value of serious games for medical education, little attention has been given to the role of dark play (choosing unacceptable actions in games). Objective: This study aimed to investigate potential differences in the characteristics of medical students who have the opportunity to choose normal or dark play in a serious game. This study also aimed to compare their reasons for choosing a play strategy and their perceptions of what they learned from their game play. Methods: We asked undergraduate medical students to play a serious game in which they had to take care of a patient with delirium (The Delirium Experience). After getting acquainted with the game, students could opt for normal or dark play. Student characteristics (age, gender, experience with caring for older or delirious patients, and number of completed clerkships) were collected, and the Delirium Attitude Scale and Learning Motivation and Engagement Questionnaire were administered. Reasons for choosing normal or dark play were evaluated with an open-ended question. Information on lessons they had learned from the game was collected using an open-ended question and self-reported knowledge on delirium. Results: This study had 160 participants (89 normal play, 71 dark play). Male students (26/160, 56.5%) chose dark play significantly more often than female students (45/160, 39.5%; P=.049). We did not find significant differences in student characteristics or measurement outcomes between play strategies. Participants’ main reason for choosing normal play was to learn how to provide care to delirious patients, and the main reason for dark play was to gain insight into what a delirious patient has to endure during delirious episodes. All participants learned what to do when taking care of a delirious patient and gained insight into how a patient experiences delirium. We found no differences in self-reported knowledge. Conclusions: When medical students have the opportunity to choose dark play in a serious game, half of them will probably choose this play strategy. Male students will more likely opt for dark play than female students. Choice of play strategy is not affected by any other student characteristic or measurement outcome. All students learned the same lessons from playing the game, irrespective of their learning strategy. %M 32723710 %R 10.2196/18479 %U http://games.jmir.org/2020/3/e18479/ %U https://doi.org/10.2196/18479 %U http://www.ncbi.nlm.nih.gov/pubmed/32723710 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17096 %T Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults’ Psychological Health: Quasi-Experimental Study %A Cheng,Vivian Ya-Wen %A Huang,Chiu-Mieh %A Liao,Jung-Yu %A Hsu,Hsiao-Pei %A Wang,Shih-Wen %A Huang,Su-Fei %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, 162, Section 1, He-ping East Road, Taipei, 10610, Taiwan, 886 277493705, jonglong@ntnu.edu.tw %K three-dimensional %K virtual reality %K aromatherapy %K older adult %K happiness %K stress %K sleep quality %K meditation %K life satisfaction %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown. Objective: A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan. Methods: A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention. Results: Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all P<.001). Another GEE analysis showed that the significant improvements in the 5 outcome variables persisted in participants aged 80 years and older (n=35; all P<.001). Conclusions: This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults’ psychological health. The results are promising for the promotion of psychological health in institutionalized older adults. Trial Registration: ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216. %M 32706660 %R 10.2196/17096 %U http://www.jmir.org/2020/7/e17096/ %U https://doi.org/10.2196/17096 %U http://www.ncbi.nlm.nih.gov/pubmed/32706660 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14865 %T Habits and Attitudes of Video Gaming and Information Technology Use in People with Schizophrenia: Cross-Sectional Survey %A Choi,William TH %A Yu,Dan KS %A Wong,Terry %A Lantta,Tella %A Yang,Min %A Välimäki,Maritta %+ Department of Nursing Science, Faculty of Medicine, University of Turku, ICT-City, A-wing, 5th floor, Joukahaisenkatu 3–5, Turku, 20520, Finland, 358 29 450 236, maritta.valimaki@polyu.edu.hk %K video gaming %K internet %K information technology %K schizophrenia %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information technology and video gaming have potential advantages in the treatment of schizophrenia. However, information regarding the habits and attitudes related to internet use and video gaming in people with schizophrenia is limited. Objective: The aim of this study was to explore the habits and attitudes regarding video gaming and information technology usage and their associated factors in people with schizophrenia in Hong Kong. Methods: In this cross-sectional survey, service users with schizophrenia were recruited from 6 halfway hostels and 7 integrated centers for mental wellness in Hong Kong. A 79-item self-report questionnaire was utilized to explore the habits of internet use and video gaming in these people with schizophrenia. The attitude toward video gaming was assessed using the Gaming Attitudes, Motivations, and Experiences Scales. Of the 148 individuals in a convenience sample who were invited to participate in this study, 110 willingly participated (a response rate of 74.3%). The data were analyzed using descriptive statistics, a two-tailed independent t test, Pearson correlation, and principal analysis with 3 methods of rotation (varimax, equimax, and promax). Results: Most participants (100/110, 90.9%) had access to the internet and half of them (54/110, 49.1%) used the internet daily mostly to watch videos (66/110, 60.0%) or read news or books, etc (42/110, 38.2%). One-third of the participants (36/110, 32.7%) used the internet to play web-based games, and most of them (88/110, 80.0%) had played a video game in the past year. The most favorable gaming platforms were cellular phones (43/88, 49%) followed by computers (19/88, 22%) and arcade cabinets (6/88, 7%). The most favorable game genre was action games (34/145, 23.4%). Those who had a bachelor’s degree or higher scored lower in social interaction than those with a lower education level (P=.03). Those who played video games daily scored higher in the category of story than those who did not play daily (t86=2.03, P=.05). The most popular gaming category was autonomy and the least popular categories were violent catharsis and violent reward. Two motives, “social playing” and “evasive playing,” were formed to describe the characteristics of playing video games. Conclusions: Our data showed a high internet utilization rate among people with schizophrenia in Hong Kong. Only a few of them used the internet to search for health-related information. Our study also exemplified the unique habits of gaming among the participants. Health care professionals could utilize video games to engage people with schizophrenia and promote coping with stress and provide social skills training to such people with schizophrenia. Identification of the gaming attitudes can contribute to the development of serious games for the schizophrenic population. Further investigation is vital for the promotion of mental health through web-based platforms. %M 32459646 %R 10.2196/14865 %U http://www.jmir.org/2020/7/e14865/ %U https://doi.org/10.2196/14865 %U http://www.ncbi.nlm.nih.gov/pubmed/32459646 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18313 %T Immersive Virtual Reality for the Reduction of State Anxiety in Clinical Interview Exams: Prospective Cohort Study %A Concannon,Brendan Joseph %A Esmail,Shaniff %A Roduta Roberts,Mary %+ Department of Occupational Therapy, University of Alberta, 8205 - 114 St 2-64 Corbett Hall, Edmonton, AB, T6G 2G4, Canada, 1 780 492 2499, mroberts@ualberta.ca %K virtual reality %K VR %K head-mounted display %K HMD %K immersive technology %K occupational therapy %K OSCE %K simulation %K psychology %K anxiety %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (VR) with head-mounted display was used to determine if clinical interview simulation could reduce the anxiety levels of first-year occupational therapy (OT) students as they prepared for upcoming Objective Structured Clinical Examinations (OSCEs). Anxiety among health science students is a potential problem that may diminish their performance during OSCEs. This investigation aimed to fill the gap in the literature regarding the effectiveness of VR to reduce anxiety in OT students. Objective: This investigation aimed to uncover the effectiveness of immersive VR in reducing state anxiety in OT students who were preparing for OSCEs. Methods: A prospective, experimental, nonrandomized controlled trial compared levels of state anxiety, test anxiety, and academic self-efficacy in two groups of first-year OT students; these levels were measured at four different time points by self-reported psychometric scales, analyzed with a mixed factorial analysis of variance (ANOVA). Members of Phase 1 (NoVR) were not exposed to the VR simulation and acted as a control group for members of Phase 2 (YesVR), who were exposed to the VR simulation. VR simulation featured a virtual clinic and a standardized patient who students could interview in natural language. Measures of student study strategies and previous experience with VR were also recorded. Results: A total of 49 participants—29 in the NoVR group and 20 in the YesVR group—showed that state anxiety had a rise-then-fall trend, peaking at the time point just before the OSCE. At that point, the YesVR students showed significantly less state anxiety than did the NoVR students (t46.19=2.34, P=.02, Cohen d=0.65, ηp2=0.105). The mean difference was 6.78 units (95% CI 0.96-12.61). In similar trends for both groups, student test anxiety remained relatively static across the time points, while academic self-efficacy continually increased. A moderate positive correlation was found for total time spent studying and peak state anxiety (NoVR r=.46, n=28, P=.01; YesVR r=.52, n=19, P=.02). Conclusions: This investigation shows evidence of immersive VR’s capability to reduce state anxiety in OT students preparing for clinical practical exams. Immersive VR simulation, used for the reduction of anxiety in health science students, can potentially lead to a future of positive mental health change from the virtual to the real world. %M 32673223 %R 10.2196/18313 %U http://games.jmir.org/2020/3/e18313/ %U https://doi.org/10.2196/18313 %U http://www.ncbi.nlm.nih.gov/pubmed/32673223 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16365 %T The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps %A Fijačko,Nino %A Gosak,Lucija %A Cilar,Leona %A Novšak,Alenka %A Creber,Ruth Masterson %A Skok,Pavel %A Štiglic,Gregor %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, Slovenia, 386 23004764, nino.fijacko@um.si %K mobile health %K oral health care %K gamification %K mobile store %K evidence-based dentistry %K behavior change technique %K Mobile Application Rating Scale user version %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches. Objective: The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene. Methods: We searched six online app stores using four search terms (“oral hygiene game,” “oral hygiene gamification,” “oral hygiene brush game,” and “oral hygiene brush gamification”). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change. Results: Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94%), virtual characters (14/17, 82%), and fantasy (13/17, 76%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app. Conclusions: The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement. %M 32673235 %R 10.2196/16365 %U https://mhealth.jmir.org/2020/7/e16365 %U https://doi.org/10.2196/16365 %U http://www.ncbi.nlm.nih.gov/pubmed/32673235 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18207 %T Developing a Theory-Driven Serious Game to Promote Prescription Opioid Safety Among Adolescents: Mixed Methods Study %A Abraham,Olufunmilola %A Thakur,Tanvee %A Brown,Randall %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Room 2515 Rennebohm Hall, 777 Highland Avenue, Madison, WI, 53705, United States, 1 608 263 4498, olufunmilola.abraham@wisc.edu %K opioid %K medication adherence %K adolescents %K youth %K video games %K games %K mobile phone %K educational technology %D 2020 %7 3.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescents in North America are severely affected by the opioid crisis, yet there are limited educational resources for educating teens about prescription opioid safety and misuse. Empirical literature lacks evidence regarding teen education about prescription opioid safety through serious games and lacks conceptual models and frameworks to guide the process of game development for this purpose. Objective: This study aims to conceptualize and design a serious game prototype to teach teens about prescription opioid safety and propose a conceptual framework for developing a serious game to educate youth about safe and responsible use of prescription opioids. Methods: The initial steps of the project comprised of the formulation of an integrated conceptual framework that included factors from health behavior models and game development models. This was followed by the formal process of serious game development, which resulted in a game prototype. The assessment of the game prototype was done through group discussions, individual interviews, and questionnaires with adolescents following gameplay. Field notes were used to keep track of the responses from the group discussions. Content and thematic analyses were used to analyze field notes and responses to the open-ended questionnaire, which were then used to refine the game prototype. Results: A total of 10 playtests with over 319 adolescents and emerging young adults (AYAs) in community settings such as middle schools, high schools, and colleges were conducted by the project team between March and June 2019. The AYAs provided feedback on the initial game prototype using questionnaires administered through Qualtrics or in-person on paper. Preliminary feedback suggested that the teens found the game objectives, outcomes, and design appealing. Overall, the game was perceived as realistic, and learning outcomes seemed achievable. Suggestions for improvement included the need for additional direction on gameplay, clearer instructions, concise dialog, and reduced technical problems in the gameplay. Conclusions: We propose a conceptual framework for developing a serious game prototype to educate youth about prescription opioid safety. The project used a theory-driven conceptual framework for the development of a serious game targeting the prevention of adolescent opioid misuse and garnered preliminary feedback on the game to improve the quality of gameplay and the prototype. Feedback through informal assessments in community settings suggests that the youth and their families are interested in a game-based approach to learn about prescription opioid safety in homes and schools. The next steps include modifications to the game prototype based on feedback from the community, integration of learning analytics to track the in-game behaviors of players, and formal testing of the final prototype. %M 32618571 %R 10.2196/18207 %U https://games.jmir.org/2020/3/e18207 %U https://doi.org/10.2196/18207 %U http://www.ncbi.nlm.nih.gov/pubmed/32618571 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18781 %T A Web-Based Mobile App (INTERACCT App) for Adolescents Undergoing Cancer and Hematopoietic Stem Cell Transplantation Aftercare to Improve the Quality of Medical Information for Clinicians: Observational Study %A Lawitschka,Anita %A Buehrer,Stephanie %A Bauer,Dorothea %A Peters,Konrad %A Silbernagl,Marisa %A Zubarovskaya,Natalia %A Brunmair,Barbara %A Kayali,Fares %A Hlavacs,Helmut %A Mateus-Berr,Ruth %A Riedl,David %A Rumpold,Gerhard %A Peters,Christina %+ Stem Cell Transplantation-Outpatient and Aftercare Clinic, St. Anna Children’s Hospital, Medical University Vienna, Kinderspitalgasse 15, 1090 Vienna, Vienna, Austria, 43 1 40 170 ext 2900, anita.lawitschka@stanna.at %K mobile app %K adolescents %K cancer %K stem cell transplant %K self-reported heath status %K medical information exchange %K mobile phone %D 2020 %7 30.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A growing number of cancer and hematopoietic stem cell transplant (HSCT) survivors require long-term follow-up with optimal communication schemes, and patients' compliance is crucial. Adolescents have various unmet needs. Regarding self-report of symptoms and health status, users of mobile apps showed enhanced compliance. Currently, HSCT aftercare at the HSCT outpatient clinic of the St. Anna Children’s Hospital in Vienna, Austria, is based on handwritten diaries, carrying various disadvantages. Recently, we developed the prototype of a web-based, self-monitoring gamified mobile app tailored for adolescents: the INTERACCT (Integrating Entertainment and Reaction Assessment into Child Cancer Therapy) app. Objective: This observational, prospective study evaluated the usability of the INTERACCT app for tracking real-time self-reported symptoms and health status data in adolescent HSCT patients and a healthy matched control group. The primary outcome of the study was the quality of the self-reported medical information. We hypothesized that the mobile app would provide superior medical information for the clinicians than would the handwritten diaries. Methods: Health data were reported via paper diary and mobile app for 5 consecutive days each. The quality of medical information was rated on a 5-point scale independently and blinded by two HSCT clinicians, and the duration of use was evaluated. A total of 52 participant questionnaires were assessed for gaming patterns and device preferences, self-efficacy, users’ satisfaction, acceptability, and suggestions for improvement of the mobile app. Interrater reliability was calculated with the intraclass correlation coefficient, based on a two-way mixed model; one-way repeated-measures analysis of variance and t tests were conducted post hoc. Descriptive methods were used for correlation with participants’ demographics. For users’ satisfaction and acceptability of the mobile app, the median and the IQR were calculated. Results: Data from 42 participants—15 patients and 27 healthy students—with comparable demographics were evaluated. The results of our study indicated a superiority of the quality of self-reported medical data in the INTERACCT app over traditional paper-and-pencil assessment (mobile app: 4.14 points, vs paper-based diary: 3.77 points, P=.02). The mobile app outperformed paper-and-pencil assessments mainly among the patients, in particular among patients with treatment-associated complications (mobile app: 4.43 points, vs paper-based diary: 3.73 points, P=.01). The mobile app was used significantly longer by adolescents (≥14 years: 4.57 days, vs ≤13 years: 3.14 days, P=.03) and females (4.76 days for females vs 2.95 days for males, P=.004). This corresponds with a longer duration of use among impaired patients with comorbidities. User satisfaction and acceptability ratings for the mobile app were high across all groups, but adherence to entering a large amount of data decreased over time. Based on our results, we developed a case vignette of the target group. Conclusions: Our study was the first to show that the quality of patient-reported medical information submitted via the INTERACCT app embedded in a serious game is superior to that submitted via a handwritten diary. In light of these results, a refinement of the mobile app supported by a machine learning approach is planned within an international research project. %M 32602847 %R 10.2196/18781 %U http://mhealth.jmir.org/2020/6/e18781/ %U https://doi.org/10.2196/18781 %U http://www.ncbi.nlm.nih.gov/pubmed/32602847 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15635 %T Virtual Reality Games and the Role of Body Involvement in Enhancing Positive Emotions and Decreasing Anxiety: Within-Subjects Pilot Study %A Pallavicini,Federica %A Pepe,Alessandro %+ Department of Human Sciences for Education, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milan, 20100, Italy, 39 0264484903, federica.pallavicini@gmail.com %K virtual reality %K virtual reality gaming %K video games %K emotions %K positive emotions %K anxiety %K state anxiety %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the last few years, the introduction of immersive technologies, especially virtual reality, into the gaming market has dramatically altered the traditional concept of video games. Given the unique features of virtual reality in terms of interaction and its ability to completely immerse the individual into the game, this technology should increase the propensity for video games to effectively elicit positive emotions and decrease negative emotions and anxiety in the players. However, to date, few studies have investigated the ability of virtual reality games to induce positive emotions, and the possible effect of this new type of video game in diminishing negative emotions and anxiety has not yet been tested. Furthermore, given the critical role of body movement in individuals’ well-being and in emotional responses to video games, it seems critical to investigate how body involvement can be exploited to modulate the psychological benefits of virtual reality games in terms of enhancing players’ positive emotions and decreasing negative emotions and anxiety. Objective: This within-subjects study aimed to explore the ability of commercial virtual reality games to induce positive emotions and diminish negative emotions and state anxiety of the players, investigating the effects of the level of body involvement requested by the game (ie, high vs low). Methods: A total of 36 young adults played a low body-involvement (ie, Fruit Ninja VR) and a high body-involvement (ie, Audioshield) video game in virtual reality. The Visual Analogue Scale (VAS) and the State-Trait Anxiety Inventory, Form-Y1 (STAI-Y1) were used to assess positive and negative emotions and state anxiety. Results: Results of the generalized linear model (GLM) for repeated-measures multivariate analysis of variance (MANOVA) revealed a statistically significant increase in the intensity of happiness (P<.001) and surprise (P=.003) and, in parallel, a significant decrease in fear (P=.01) and sadness (P<.001) reported by the users. Regarding the ability to improve anxiety in the players, the results showed a significant decrease in perceived state anxiety after game play, assessed with both the STAI-Y1 (P=.003) and the VAS-anxiety (P=.002). Finally, the results of the GLM MANOVA showed a greater efficacy of the high body-involvement game (ie, Audioshield) compared to the low body-involvement game (ie, Fruit Ninja VR), both for eliciting positive emotions (happiness, P<.001; and surprise, P=.01) and in reducing negative emotions (fear, P=.05; and sadness, P=.05) and state anxiety, as measured by the STAI-Y1 (P=.05). Conclusions: The two main principal findings of this study are as follows: (1) virtual reality video games appear to be effective tools to elicit positive emotions and to decrease negative emotions and state anxiety in individuals and (2) the level of body involvement of the virtual video game has an important effect in determining the ability of the game to improve positive emotions and decrease negative emotions and state anxiety of the players. %M 32554371 %R 10.2196/15635 %U http://games.jmir.org/2020/2/e15635/ %U https://doi.org/10.2196/15635 %U http://www.ncbi.nlm.nih.gov/pubmed/32554371 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16261 %T Development and Validation of the Reasons to Exergame (RTEX) Scale in Young Adults: Exploratory Factors Analysis %A O'Loughlin,Erin %A Sabiston,Catherine M %A Kakinami,Lisa %A McGrath,Jennifer J %A Consalvo,Mia %A O'Loughlin,Jennifer L %A Barnett,Tracie A %+ Centre de Recherche du CHUM, Concordia University, 850 rue Saint-Denis, Bureau S02-370, Montreal, QC, H2X 0A9, Canada, 1 514 890 8000 ext 15853, erin_oloughlin@hotmail.com %K exergaming %K youth %K young adults %K motivation %K scale %D 2020 %7 15.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergaming is associated with positive health benefits; however, little is known about what motivates young people to exergame. Objective: This study aimed to develop a new Reasons to Exergame (RTEX) scale and describe its psychometric properties (Study 1) including test-retest reliability (Study 2). We also examined the test-retest reliability of self-report exergaming behavior measures (Study 2). Methods: We identified scale items in consultation with experts. In Study 1, we conducted an Exploratory Factor Analysis of RTEX and examined how the factors identified relate to exergaming frequency and intensity in a population-based sample of 272 young adults. In Study 2, we examined the test-retest reliability of RTEX factors and self-report measures of past-week exergaming frequency and intensity among 147 college students. Results: We identified four factors in RTEX: exergaming for fitness, exergaming for enjoyment, preferring exergaming over other gaming options, and choosing exergaming over competing interests (eg, sports). Test-retest reliability of RTEX factors (ICC 0.7-0.8) and self-report exergaming frequency (ICC 0.4-0.9) was adequate. Exergaming for fitness and enjoyment were positively associated with the frequency of exergaming with friends and family, and with exergaming intensity. Preferring exergaming over other gaming options and choosing exergaming over competing interests (eg, sports) were not related to exergaming behavior. Conclusions: RTEX is a psychometrically sound scale with four factors that measure reasons to exergame. Replication of these findings is needed in larger, more diverse samples. %M 32538792 %R 10.2196/16261 %U http://games.jmir.org/2020/2/e16261/ %U https://doi.org/10.2196/16261 %U http://www.ncbi.nlm.nih.gov/pubmed/32538792 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17112 %T Effect of Pokémon Go on Self-Harm Using Population-Based Interrupted Time-Series Analysis: Quasi-Experimental Study %A Wong,Rosa Sze Man %A Ho,Frederick Ka Wing %A Tung,Keith Tsz Suen %A Fu,King-Wa %A Ip,Patrick %+ Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Room 123, 1/F, New Clinical Building, Queen Mary Hospital, Pokfulam, Hong Kong, , China (Hong Kong), 852 22554090, patricip@hku.hk %K Pokémon Go %K self-harm %K mobile game %K injury %K mHealth interventions %K interrupted time-series analysis %D 2020 %7 12.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pokémon Go is a very popular location-based augmented reality game with widespread influences over the world. An emerging body of research demonstrates that playing Pokémon Go can lead to improvements in physical activity and psychosocial well-being; however, whether Pokémon Go reduces self-harm incidence at the population-level is still questionable. Objective: This study aimed to quantify how the launch of Pokémon Go in Hong Kong affected the incidence of self-harm using a quasi-experimental design. Methods: An interrupted time-series design with Poisson segmented regression adjusted for time and seasonality trends was used on data from 2012 to 2018 to detect any changes in the number of accident and emergency attendances due to self-harm, after Pokémon Go was launched. The findings were validated using a baseline control period and using other intentional injuries and minor noninjuries as control outcomes. We also assessed intervention effects by age group. Results: From January 1, 2012 to July 31, 2018, there were 13,463 accident and emergency attendances due to self-harm in Hong Kong. During the period after launching Pokémon Go, self-harm attendances dropped by 34% (adjusted incidence rate ratio: 0.66, 95% CI 0.61-0.73). When analyzed by age group, a reduction in self-harm incidence was only apparent in adults (18 to 24 years of age: adjusted incidence rate ratio: 0.78, P=.02; 25 to 39 years of age: adjusted incidence rate ratio: 0.75, P<.001; 40 years of age and older: adjusted incidence rate ratio: 0.57, P<.001). Conclusions: Self-harm incidence in the population, particularly in adults, showed a significant decline in the period after Pokémon Go was launched. Augmented reality games such as Pokémon Go show great promise as a tool to enhance psychosocial well-being and improve mental health. %M 32530429 %R 10.2196/17112 %U http://games.jmir.org/2020/2/e17112/ %U https://doi.org/10.2196/17112 %U http://www.ncbi.nlm.nih.gov/pubmed/32530429 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e17756 %T A Mobile Game (Safe City) Designed to Promote Children’s Safety Knowledge and Behaviors: Protocol for a Randomized Controlled Trial %A Wong,Rosa S %A Tung,Keith TS %A Wong,Hiu Tung %A Ho,Frederick KW %A Wong,Hing Sang %A Fu,King-Wa %A Pong,Ting Chuen %A Chan,Ko Ling %A Chow,Chun Bong %A Ip,Patrick %+ Department of Paediatrics & Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, China (Hong Kong), 852 2255 4090, patricip@hku.hk %K serious game %K safety training %K mobile game %K mobile phone %K injury prevention %K randomized controlled trial %K game-based intervention %D 2020 %7 12.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Children have high levels of curiosity and eagerness to explore. This makes them more vulnerable to danger and hazards, and they thus have a higher risk of injury. Safety education such as teaching safety rules and tips is vital to prevent children from injuries. Although game-based approaches have the potential to capture children’s attention and sustain their interest in learning, whether these new instructional approaches are more effective than traditional approaches in delivering safety messages to children remains uncertain. Objective: The aim of this study is to test the effectiveness of a game-based intervention in promoting safety knowledge and behaviors among Hong Kong school children in Grades 4-6. It will also examine the potential effect of the game-based intervention on these children’s functioning and psychosocial difficulties. Methods: This study comprises the development of a city-based role-playing game Safe City, where players are immersed as safety inspectors to prevent dangerous situations and promote safety behavior in a virtual city environment. The usability and acceptability tests will be conducted with children in Grades 4-6 who will trial the gameplay on a mobile phone. Adjustments will be made based on their feedback. A 4-week randomized controlled trial with children studying in Grades 4-6 in Hong Kong elementary schools will be conducted to assess the effectiveness of the Safe City game–based intervention. In this trial, 504 children will play Safe City, and 504 children will receive traditional instructional materials (electronic and printed safety information). The evaluation will be conducted using both child self-report and parent proxy-report data. Specifically, child safety knowledge and behaviors will be assessed by a questionnaire involving items on knowledge and behaviors, respectively, for home safety, road safety, and sport-related safety; child functioning will be assessed by PedsQL Generic Core Scales; and psychosocial difficulties will be assessed by the Strength and Difficulties Questionnaire. These questionnaires will be administered at 3 time points: before, 1 month, and 3 months after the intervention. Game usage statistics will also be reviewed. Results: This project was funded in September 2019. The design and development of the Safe City game are currently under way. Recruitment and data collection will begin from September 2020 and will continue up to March 1, 2021. Full analysis will be conducted after the end of the data collection period. Conclusions: If the Safe City game is found to be an effective tool to deliver safety education, it could be used to promote safety in children in the community and upgraded to incorporate more health-related topics to support education and empowerment for the larger public. Trial Registration: ClinicalTrials.gov NCT04096196; https://clinicaltrials.gov/ct2/show/NCT04096196 International Registered Report Identifier (IRRID): PRR1-10.2196/17756 %M 32530436 %R 10.2196/17756 %U http://www.researchprotocols.org/2020/6/e17756/ %U https://doi.org/10.2196/17756 %U http://www.ncbi.nlm.nih.gov/pubmed/32530436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15339 %T Using Geocaching to Promote Active Aging: Qualitative Study %A Fornasini,Silvia %A Dianti,Marco %A Bacchiega,Alessandro %A Forti,Stefano %A Conforti,Diego %+ Fondazione Bruno Kessler, Via Sommarive 18, Trento, 38123, Italy, 39 0461 314140, s.fornasini@fbk.eu %K geocaching %K active ageing %K elderly empowerment %K qualitative methods %D 2020 %7 11.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the past few years, the development of technologies supporting active aging has been increasing. Among the activities that promote physical exercise by using technologies is geocaching—a treasure hunt of sorts in which participants use a receiver GPS to hide or find real or virtual objects. Although this activity is particularly suited to the promotion of healthy lifestyles in older people, geocaching remains to be unexplored in this area. Objective: This study aimed to investigate the effectiveness of activities combining geocaching and self-tracking technologies to promote active aging, evaluate the usability of technologies, and explore the ways in which technologies have been integrated in the organizational context under examination to determine the user experience of participants. Methods: A group of individuals aged 65 years and older (N=14) attending a senior center managed by a social cooperative was involved in the study. Some of them created the geocaching contents, and others, split into 2 teams, participated in the game. Each participant was given a pedometer bracelet and the geocaching app. The steps taken by individual participants along with the number of caches found by each group translated into team scores. Results: The main results of the study were as follows: (1) activities in favor of active aging that involve the use of new technologies can foster the participation of elderly people; in particular, adding gamification to self-tracking can be a valid strategy to promote physical exercise among the elderly; (2) for this to happen, involvement of older people firsthand is crucial, and there must be a focus on their active involvement and empowerment in every phase of the project; and (3) the mediation of conflicts and competition that arise from the gamification could only take place because of the strong support of the organization in the form of social workers. Conclusions: The results show that promoting active aging through technologies requires more effort than simply using these tools; it requires a wider process that involves an articulated organizational network with heterogeneous actors, technologies, and relations. %M 32525486 %R 10.2196/15339 %U http://www.jmir.org/2020/6/e15339/ %U https://doi.org/10.2196/15339 %U http://www.ncbi.nlm.nih.gov/pubmed/32525486 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e16506 %T The Model of Gamification Principles for Digital Health Interventions: Evaluation of Validity and Potential Utility %A Floryan,Mark %A Chow,Philip I %A Schueller,Stephen M %A Ritterband,Lee M %+ Department of Computer Science, University of Virginia, 85 Engineer's Way, Charlottesville, VA, 22904, United States, 1 4342433087, mrf8t@virginia.edu %K gamification %K internet interventions %K eHealth %K mHealth %K digital health %D 2020 %7 10.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although gamification continues to be a popular approach to increase engagement, motivation, and adherence to behavioral interventions, empirical studies have rarely focused on this topic. There is a need to empirically evaluate gamification models to increase the understanding of how to integrate gamification into interventions. Objective: The model of gamification principles for digital health interventions proposes a set of five independent yet interrelated gamification principles. This study aimed to examine the validity and reliability of this model to inform its use in Web- and mobile-based apps. Methods: A total of 17 digital health interventions were selected from a curated website of mobile- and Web-based apps (PsyberGuide), which makes independent and unbiased ratings on various metrics. A total of 133 independent raters trained in gamification evaluation techniques were instructed to evaluate the apps and rate the degree to which gamification principles are present. Multiple ratings (n≥20) were collected for each of the five gamification principles within each app. Existing measures, including the PsyberGuide credibility score, mobile app rating scale (MARS), and the app store rating of each app were collected, and their relationship with the gamification principle scores was investigated. Results: Apps varied widely in the degree of gamification implemented (ie, the mean gamification rating ranged from 0.17≤m≤4.65 out of 5). Inter-rater reliability of gamification scores for each app was acceptable (κ≥0.5). There was no significant correlation between any of the five gamification principles and the PsyberGuide credibility score (P≥.49 in all cases). Three gamification principles (supporting player archetypes, feedback, and visibility) were significantly correlated with the MARS score, whereas three principles (meaningful purpose, meaningful choice, and supporting player archetypes) were significantly correlated with the app store rating. One gamification principle was statistically significant with both the MARS and the app store rating (supporting player archetypes). Conclusions: Overall, the results support the validity and potential utility of the model of gamification principles for digital health interventions. As expected, there was some overlap between several gamification principles and existing app measures (eg, MARS). However, the results indicate that the gamification principles are not redundant with existing measures and highlight the potential utility of a 5-factor gamification model structure in digital behavioral health interventions. These gamification principles may be used to improve user experience and enhance engagement with digital health programs. %M 32519965 %R 10.2196/16506 %U https://www.jmir.org/2020/6/e16506 %U https://doi.org/10.2196/16506 %U http://www.ncbi.nlm.nih.gov/pubmed/32519965 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15647 %T Gamifying Parenting Education Using an App Developed for Pacific and Other New Zealand Families (Play Kindly): Qualitative Study %A Mairs,Rebecca A %A Bekker,Marthinus J %A Patolo,Tony %A Hopkins,Sarah A %A Cowley-Malcolm,Esther T %A Perese,Lana M %A Sundborn,Gerhard B %A Merry,Sally N %+ Department of Psychological Medicine, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand, 64 9 373 7599 ext 92019, marthinus.bekker@auckland.ac.nz %K parenting %K mHealth %K Pacific peoples %D 2020 %7 10.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Play Kindly is a gamified animated app designed to address common behavioral problems in childhood. The interface is designed to appeal to Pacific people, a population group with a higher risk of developing clinically significant behavioral problems than most other ethnic groups in New Zealand. Objective: The aim of this study is to explore the opinions of parents and professionals about the acceptability, usability, and content of Play Kindly. Methods: We used qualitative and Pacific and Māori research methodologies. A total of five focus groups with 45 parents and 12 individual interviews with professionals were conducted. The five focus groups consisted of 2 pan-Pacific groups, 1 Māori group, 1 open group, and 1 group of young Pacific adults or prospective parents. The professionals were from a range of disciplines, and the majority had expertise in early childhood, parenting interventions, or research in this field. Results: Play Kindly appealed to both parents and professionals. Participants related to the scenarios, which were created in collaboration with a playwright and animator. Although most participants liked the Pacific feel, there was some disagreement about how culturally specific the app should be. A range of issues with usability and gamification techniques were highlighted, likely attributed to the low budget and lack of initial co-design with parents as well as professionals with specific expertise in parenting. A number of parents and professionals felt that the parenting strategies were overly simplified and did not take into account the context in which the behavior occurred. Professionals suggested narrowing the focus of the app to deliver two important parenting messages: playing with your child and positively reinforcing desired behaviors. Conclusions: Play Kindly is the first culturally adapted parenting app of its kind designed for Pacific parents and other New Zealanders with children 2-5 years of age. This app has potential in Pacific communities where there are limited culturally specific parenting resources. The results of this study will guide improvements of the app prior to testing it in an open trial. %M 32519973 %R 10.2196/15647 %U http://games.jmir.org/2020/2/e15647/ %U https://doi.org/10.2196/15647 %U http://www.ncbi.nlm.nih.gov/pubmed/32519973 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16216 %T Serious Games for Nutritional Education: Online Survey on Preferences, Motives, and Behaviors Among Young Adults at University %A Holzmann,Sophie Laura %A Schäfer,Hanna %A Plecher,David Alexander %A Stecher,Lynne %A Klinker,Gudrun Johanna %A Groh,Georg %A Hauner,Hans %A Holzapfel,Christina %+ Institute for Nutritional Medicine, Else Kröner-Fresenius-Center for Nutritional Medicine, School of Medicine, Technical University of Munich, Georg-Brauchle-Ring 62, Munich, , Germany, 49 89 289 249 23, christina.holzapfel@tum.de %K nutrition %K information sources %K serious games %K digital gameplay %K preferences %K motives %K behavior %K university students %K survey %D 2020 %7 3.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Data on nutritional information and digital gameplay are limited among young adults in Germany. Objective: This survey aimed to gather data on nutritional information sources and digital games for nutritional education (preferences, motives, and behaviors) among young adults at both Munich universities in Germany. Methods: An online survey was developed by an multidisciplinary research group using EvaSys, an in-house survey software. The questionnaire (47 items) covered questions about baseline characteristics (eg, housing situation and weight), nutrition (eg, nutritional information sources), and digital (nutritional) gameplay (eg, preferences, motives, and behaviors). A feedback field was also provided. This publication is based on a selection of 20 questions (7 baseline characteristics, 2 nutrition, 11 gameplay). Young adults, primarily Munich university students aged from 18 to 24 years, were invited to participate by digital and nondigital communication channels between 2016 and 2017. Statistical analyses were performed using Excel 2013 (Microsoft Corp) and R version 3.1.3 (R Foundation for Statistical Computing). Results: In total, 468 young adults (342/468, 73.1% women; 379/468, 81.0% university students) participated. Most of the participants (269/468, 57.5%) were aged 18 to 24 years with a BMI in the normal weight range (346/447, 77.4%). Mean body weight was 65.5 [SD 14.0] kg. Most participants reported getting nutritional information from the internet (372/467, 79.7%) and printed media (298/467, 63.8%), less than 1.0% (2/467, 0.4%) named digital games. Apps (100/461, 21.7%) and university/workplace (146/461, 31.7%) were the most desired sources for additional information about nutrition, while 10.0% (46/461, 10.0%) of participants stated wanting digital games. Almost two-thirds (293/468, 62.6%) of participants played digital games, while one-fifth (97/456, 21.3%) played digital games daily using smartphones or tablets. Finally, most respondents (343/468, 73.3%), mainly women, expressed interest in obtaining nutritional information during digital gameplay. However, significant gender differences were shown for nutritional acquisition behaviors and digital gameplay preferences, motives, and behaviors. Conclusions: Our survey population reported playing digital games (especially men) and wanting nutritional information during digital gameplay (especially women). Furthermore, university or workplace are named as preferred settings for nutritional information. Therefore, a digital game app might have the potential to be a tool for nutritional education among young adults within the university or workplace environment. %M 32490847 %R 10.2196/16216 %U https://games.jmir.org/2020/2/e16216 %U https://doi.org/10.2196/16216 %U http://www.ncbi.nlm.nih.gov/pubmed/32490847 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16983 %T Digital Gamification to Enhance Vaccine Knowledge and Uptake: Scoping Review %A Montagni,Ilaria %A Mabchour,Inass %A Tzourio,Christophe %+ Bordeaux Population Health U1219, Inserm-University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 0547304281, ilaria.montagni@u-bordeaux.fr %K gamification %K vaccination %K vaccine hesitancy %K digital tools %K scoping review %D 2020 %7 18.5.2020 %9 Review %J JMIR Serious Games %G English %X Background: Vaccine hesitancy is a growing threat to population health, and effective interventions are needed to reduce its frequency. Digital gamification is a promising new approach to tackle this public health issue. Objective: The purpose of this scoping review was to assess the amount and quality of outcomes in studies evaluating gamified digital tools created to increase vaccine knowledge and uptake. Methods: We searched for peer-reviewed articles published between July 2009 and August 2019 in PubMed, Google Scholar, Journal of Medical Internet Research, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, and SocINDEX. Studies were coded by author, year of publication, country, journal, research design, sample size and characteristics, type of vaccine, theory used, game content, game modality, gamification element(s), data analysis, type of outcomes, and mean quality score. Outcomes were synthesized through the textual narrative synthesis method. Results: A total of 7 articles met the inclusion criteria and were critically reviewed. Game modalities and gamification elements were diverse, but role play and a reward system were present in all studies. These articles included a mixture of randomized controlled trials, quasi-experimental studies, and studies comprising quantitative and qualitative measures. The majority of the studies were theory-driven. All the identified gamified digital tools were highly appreciated for their usability and were effective in increasing awareness of vaccine benefits and motivation for vaccine uptake. Conclusions: Despite the relative paucity of studies on this topic, this scoping review suggests that digital gamification has strong potential for increasing vaccination knowledge and, eventually, vaccination coverage. %M 32348271 %R 10.2196/16983 %U http://games.jmir.org/2020/2/e16983/ %U https://doi.org/10.2196/16983 %U http://www.ncbi.nlm.nih.gov/pubmed/32348271 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14369 %T Can Social Communication Skills for Children Diagnosed With Autism Spectrum Disorder Rehearsed Inside the Video Game Environment of Minecraft Generalize to the Real World? %A Cadieux,Lee %A Keenan,Mickey %+ School of Arts and Humanities, Ulster University, MA205 Magee Campus, Northland Road, Londonderry, BT48 7JL, United Kingdom, 44 2871675025, l.cadieux@ulster.ac.uk %K autism %K behavior analysis %K serious games %K social skills %K gamification %K Lego %K neurodiversity %K Minecraft %K virtual worlds %K virtual reality %D 2020 %7 12.5.2020 %9 Viewpoint %J JMIR Serious Games %G English %X In this paper, we outline opportunities within the video game environment for building skills applicable to real-world issues faced by some children. The game Minecraft is extremely popular and of particular interest to children diagnosed with autism spectrum disorder. Although the game has been used by support communities to facilitate the social interaction of children and peer support for their parents, little has been done to examine how social skills developed within the game environment generalize to the real world. Social Craft aims to establish a framework in which key social communication skills would be rehearsed in-game with a view to facilitating their replication in a similarly contained real-world environment. Central to this approach is an understanding of the basic principles of behavior and the engagement of a sound methodology for the collection of data inside and outside the respective environments. %M 32396129 %R 10.2196/14369 %U http://games.jmir.org/2020/2/e14369/ %U https://doi.org/10.2196/14369 %U http://www.ncbi.nlm.nih.gov/pubmed/32396129 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17295 %T Development and Feasibility Testing of a Video Game to Reduce High-Risk Heterosexual Behavior in Spanish-Speaking Latinx Adolescents: Mixed Methods Study %A Pensak,Meredith J %A Lundsberg,Lisbet S %A Stanwood,Nancy L %A Cutler,Abigail S %A Gariepy,Aileen M %+ Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0526, Cincinnati, OH, 45219, United States, 1 5135097246, pensakmj@ucmail.uc.edu %K adolescent %K Latino %K Latina %K sexual activity %K video game %D 2020 %7 4.5.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Similar to broader health disparities, Latinx adolescents have higher rates of high-risk sexual behavior resulting in pregnancy rates that are 2 times higher and sexually transmitted infection rates that are 5 to 8 times higher than non-Hispanic, white adolescents. Novel approaches are needed to reduce high-risk sexual behavior among Spanish-speaking Latinx adolescents who represent the fastest-growing group of US immigrants. Objective: This study aimed to partner with Spanish-speaking Latinx adolescents in a participatory design process to develop and test a Spanish-language video game intervention to decrease high-risk heterosexual behavior. Methods: This is an iterative, two-phase, mixed methods study. In phase 1, we conducted focus groups with Spanish-speaking Latinx adolescents to elicit feedback on the content and format of an existing English-language video game. Feedback was then incorporated into an expanded and culturally adapted Spanish-language video game. In phase 2, we pilot tested the feasibility, acceptability, and preliminary efficacy of the new Spanish-language video game intervention by measuring known antecedents to sexual behavior (intentions, self-efficacy, risk perception, and knowledge) assessed at enrollment and 12-week follow-up. We applied a thematic analysis to examine focus group feedback and a bivariate analysis to analyze pre- and postquantitative data. Results: In phase 1, 15 Spanish-speaking Latinx adolescents provided feedback for further video game development. A Spanish-language video game was then produced and tested in phase 2. We recruited and enrolled 24 Spanish-speaking Latinx adolescents aged 15 to 17 years. Participants played the video game for an average of 4.2 hours during monitored sessions. Pilot testing demonstrated feasibility and acceptability; 65% (3/20) of participants stated that they would play it again, and 65% (3/20) said they would recommend it to friends. Condom-specific knowledge did significantly increase between baseline and follow-up (P=.007). Other variables of sexual behavior antecedents did not differ significantly between baseline and 12-week follow-up. Conclusions: An iterative participatory design process in partnership with Spanish-speaking adolescents produced an innovative and acceptable Spanish-language video game intervention aimed at decreasing high-risk sexual behavior in adolescents. Pilot testing demonstrated preliminary feasibility and yielded essential information for further video game development. %M 32364507 %R 10.2196/17295 %U http://games.jmir.org/2020/2/e17295/ %U https://doi.org/10.2196/17295 %U http://www.ncbi.nlm.nih.gov/pubmed/32364507 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17807 %T Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia: Qualitative Study %A Lindner,Philip %A Rozental,Alexander %A Jurell,Alice %A Reuterskiöld,Lena %A Andersson,Gerhard %A Hamilton,William %A Miloff,Alexander %A Carlbring,Per %+ Department of Psychology, Stockholm University, Frescati hagväg 8, 104 05, Stockholm, , Sweden, 46 704522587, philip.lindner@ki.se %K virtual reality %K gamification %K serious game %K exposure therapy %K phobia %K user experience %D 2020 %7 29.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention. Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods. Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis. Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal. Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences. %M 32347803 %R 10.2196/17807 %U http://games.jmir.org/2020/2/e17807/ %U https://doi.org/10.2196/17807 %U http://www.ncbi.nlm.nih.gov/pubmed/32347803 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16096 %T Investigating Serious Games That Incorporate Medication Use for Patients: Systematic Literature Review %A Abraham,Olufunmilola %A LeMay,Sarah %A Bittner,Sarah %A Thakur,Tanvee %A Stafford,Haley %A Brown,Randall %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin–Madison, 777 Highland Ave, 2515 Rennebohm Hall, Madison, WI, 53705, United States, 1 6082634498, olufunmilola.abraham@wisc.edu %K games %K medication adherence %K patient safety %K video games %K systematic review %D 2020 %7 29.4.2020 %9 Review %J JMIR Serious Games %G English %X Background: The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use. Objective: This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use. Methods: PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection. Results: Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies. Conclusions: Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives. %M 32347811 %R 10.2196/16096 %U http://games.jmir.org/2020/2/e16096/ %U https://doi.org/10.2196/16096 %U http://www.ncbi.nlm.nih.gov/pubmed/32347811 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16724 %T Multidimensional Evaluation of Virtual Reality Paradigms in Clinical Neuropsychology: Application of the VR-Check Framework %A Krohn,Stephan %A Tromp,Johanne %A Quinque,Eva M %A Belger,Julia %A Klotzsche,Felix %A Rekers,Sophia %A Chojecki,Paul %A de Mooij,Jeroen %A Akbal,Mert %A McCall,Cade %A Villringer,Arno %A Gaebler,Michael %A Finke,Carsten %A Thöne-Otto,Angelika %+ Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany, 49 30 45050, stephan.krohn@charite.de %K virtual reality %K neuropsychology %K cognition %K research design %D 2020 %7 27.4.2020 %9 Viewpoint %J J Med Internet Res %G English %X Virtual reality (VR) represents a key technology of the 21st century, attracting substantial interest from a wide range of scientific disciplines. With regard to clinical neuropsychology, a multitude of new VR applications are being developed to overcome the limitations of classical paradigms. Consequently, researchers increasingly face the challenge of systematically evaluating the characteristics and quality of VR applications to design the optimal paradigm for their specific research question and study population. However, the multifaceted character of contemporary VR is not adequately captured by the traditional quality criteria (ie, objectivity, reliability, validity), highlighting the need for an extended paradigm evaluation framework. To address this gap, we propose a multidimensional evaluation framework for VR applications in clinical neuropsychology, summarized as an easy-to-use checklist (VR-Check). This framework rests on 10 main evaluation dimensions encompassing cognitive domain specificity, ecological relevance, technical feasibility, user feasibility, user motivation, task adaptability, performance quantification, immersive capacities, training feasibility, and predictable pitfalls. We show how VR-Check enables systematic and comparative paradigm optimization by illustrating its application in an exemplary research project on the assessment of spatial cognition and executive functions with immersive VR. This application furthermore demonstrates how the framework allows researchers to identify across-domain trade-offs, makes deliberate design decisions explicit, and optimizes the allocation of study resources. Complementing recent approaches to standardize clinical VR studies, the VR-Check framework enables systematic and project-specific paradigm optimization for behavioral and cognitive research in neuropsychology. %M 32338614 %R 10.2196/16724 %U https://www.jmir.org/2020/4/e16724 %U https://doi.org/10.2196/16724 %U http://www.ncbi.nlm.nih.gov/pubmed/32338614 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e15725 %T The Kids Obesity Prevention Program: Cluster Randomized Controlled Trial to Evaluate a Serious Game for the Prevention and Treatment of Childhood Obesity %A Mack,Isabelle %A Reiband,Nadine %A Etges,Carolin %A Eichhorn,Sabrina %A Schaeffeler,Norbert %A Zurstiege,Guido %A Gawrilow,Caterina %A Weimer,Katja %A Peeraully,Riyad %A Teufel,Martin %A Blumenstock,Gunnar %A Giel,Katrin Elisabeth %A Junne,Florian %A Zipfel,Stephan %+ Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Osianderstraße 5, Tübingen, 72076, Germany, 49 70712985614, isabelle.mack@uni-tuebingen.de %K children %K serious game %K nutrition %K stress %K energy density %D 2020 %7 24.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Health games provide opportunities for the treatment and prevention of childhood obesity. We developed a motion-controlled serious game for children that addresses 3 core topics of nutrition, physical activity, and stress coping. It is the first serious game that extensively targets the dietary energy density principle (DED-P) in relation to nutrition. The game is intended to provide an additional educational component for the prevention and treatment of obesity in children. Objective: The Kids Obesity Prevention study aimed to evaluate the newly developed game and to evaluate how well children are able to understand and apply the DED-P. Methods: This cluster randomized controlled trial collected data from 82 primary school children aged 9 to 12 years and their parents at baseline (T0), at 2 weeks after study commencement (T1), and at the 4-week follow-up (T2). The dropout rate was 3.6%. The intervention group (IG) played the game within 2 weeks (2 sessions with different game modules). One part of the game involves selection of food with the lower energy density when presented with a pair of foods. This allows assessment of whether the children have understood the DED-P and whether they can apply it to unknown foods under time pressure. The control group (CG) received a brochure about the food pyramid concept and physical activity. The primary outcome was the gain in knowledge (nutrition and stress coping) and measured with a pretested questionnaire. The secondary outcomes were the maintenance of knowledge, application of the DED-P, feelings during game play, game acceptance, and behavioral measures (physical activity, media consumption, and dietary intake). Results: The knowledge score ranging from 0 to 100 increased from T0 (IG: 53 [SD 10], CG: 50 [SD 11]) to T1 (IG: 69 [SD 11], CG: 52 [SD 12]) in IG versus CG (P<.001). At T2, the knowledge score of IG remained at the same level as that of T1. Game data showed that after DED-P education, the classification under time pressure of unknown versus known food pairs according to their DED category was similar (hit rate around 70%). Overall, 95% of the children liked the game very much or much. No group changes were observed at the behavioral level. Conclusions: The Kids Obesity Prevention program sustainably increased knowledge in the areas of nutrition and stress coping, and children were able to apply the DED-P. Trial Registration: ClinicalTrials.gov NCT02551978; https://clinicaltrials.gov/ct2/show/NCT02551978 %M 32329742 %R 10.2196/15725 %U https://www.jmir.org/2020/4/e15725 %U https://doi.org/10.2196/15725 %U http://www.ncbi.nlm.nih.gov/pubmed/32329742 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 4 %P e15534 %T Optimizing Child Nutrition Education With the Foodbot Factory Mobile Health App: Formative Evaluation and Analysis %A Brown,Jacqueline Marie %A Savaglio,Robert %A Watson,Graham %A Kaplansky,Allison %A LeSage,Ann %A Hughes,Janette %A Kapralos,Bill %A Arcand,JoAnne %+ Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science Building Rm 3016, Oshawa, ON, L1G 0C5, Canada, 1 (905) 7218668 ext 3796, joanne.arcand@uoit.ca %K mHealth %K children %K child nutrition sciences %K mobile apps %K health education %D 2020 %7 17.4.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Early nutrition interventions to improve food knowledge and skills are critical in enhancing the diet quality of children and reducing the lifelong risk of chronic disease. Despite the rise of mobile health (mHealth) apps and their known effectiveness for improving health behaviors, few evidence-based apps exist to help engage children in learning about nutrition and healthy eating. Objective: This study aimed to describe the iterative development and user testing of Foodbot Factory, a novel nutrition education gamified app for children to use at home or in the classroom and to present data from user testing experiments conducted to evaluate the app. Methods: An interdisciplinary team of experts in nutrition, education (pedagogy), and game design led to the creation of Foodbot Factory. First, a literature review and an environmental scan of the app marketplace were conducted, and stakeholders were consulted to define the key objectives and content of Foodbot Factory. Dietitian and teacher stakeholders identified priority age groups and learning objectives. Using a quasi-experimental mixed method design guided by the Iterative Convergent Design for Mobile Health Usability Testing approach, five app user testing sessions were conducted among students (ages 9-12 years). During gameplay, engagement and usability were assessed via direct observations with a semistructured form. After gameplay, qualitative interviews and questionnaires were used to assess user satisfaction, engagement, usability, and knowledge gained. Results: The environmental scan data revealed that few evidence-based nutrition education apps existed for children. A literature search identified key nutrients of concern for Canadian children and techniques that could be incorporated into the app to engage users in learning. Foodbot Factory included characters (2 scientists and Foodbots) who initiate fun and engaging dialogue and challenges (minigames), with storylines incorporating healthy eating messages that align with the established learning objectives. A total of five modules were developed: drinks, vegetables and fruit, grain foods, animal protein foods, and plant protein foods. Seven behavior change techniques and three unique gamified components were integrated into the app. Data from each user testing session were used to inform and optimize the next app iteration. The final user testing session demonstrated that participants agreed that they wanted to play Foodbot Factory again (12/17, 71%), that the app is easy to use (12/17, 71%) and fun (14/17, 88%), and that the app goals were clearly presented (15/17, 94%). Conclusions: Foodbot Factory is an engaging and educational mHealth intervention for the Canadian public that is grounded in evidence and developed by an interdisciplinary team of experts. The use of an iterative development approach is a demonstrated method to improve engagement, satisfaction, and usability with each iteration. Children find Foodbot Factory to be fun and easy to use, and can engage children in learning about nutrition. %M 32301743 %R 10.2196/15534 %U http://formative.jmir.org/2020/4/e15534/ %U https://doi.org/10.2196/15534 %U http://www.ncbi.nlm.nih.gov/pubmed/32301743 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e13190 %T Development and Evaluation of Intelligent Serious Games for Children With Learning Difficulties: Observational Study %A Flogie,Andrej %A Aberšek,Boris %A Kordigel Aberšek,Metka %A Sik Lanyi,Cecilia %A Pesek,Igor %+ Faculty of Natural Sciences and Mathematics, University of Maribor, Koroska cesta 160, Maribor, 2000, Slovenia, 386 22293879, igor.pesek@um.si %K serious games, experimental %K social skills %K cognitive competence %K intellectual disability %K learning disabilities %D 2020 %7 16.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Positive results can be obtained through game-based learning, but children with physical disabilities have fewer opportunities to participate in enjoyable physical activity. Because intelligent serious games can provide personalized learning opportunities, motivate the learner, teach 21st-century skills, and provide an environment for authentic and relevant assessment, they may be used to help children and adolescents with different kinds of learning disabilities to develop social and cognitive competences. Objective: The aim of the study was to produce and evaluate a suite of intelligent serious games based on accessible learning objectives for improving key skills, personal development, and work sustainability among children with learning difficulties. Methods: We conducted this research between 2016 and 2018, with pupils aged 11 to 12 years with learning disabilities who were integrated into the mainstream educational system. We used a 4-step methodology to develop learner creativity and social competences: (1) needs analysis, (2) development of learning content, (3) development of intelligent serious games, and (4) a usability evaluation focusing on the research questions and hypothesis. This was based on an initial teachers’ evaluation, using a survey, of students using 2 of the games, where the main goal was to determine user motivation and initiative and to improve the games and the evaluation process. The initial evaluation was followed by a pilot evaluation, which was performed for all proposed games, in all partner countries. Results: In an initial evaluation with 51 participants from Slovenia consisting of a pretest, followed by intelligent serious game intervention and concluding with a posttest, we observed statistically significant improvement in social and cognitive competences measured by tests. Based on these findings and observations, we improved the games and evaluation process. In the pilot test, conducted in all participating countries on a sample of 93 participants, the mean score on the teachers’ observation form on the pretest (before students began using the intelligent serious games) was 3.9. In the posttest, after students had used intelligent serious games, the mean score was 4.1. Conclusions: We focused on developing and evaluating intelligent serious games for persons with learning disabilities, particularly for students with disabilities who are integrated into the mainstream educational system. Such games provide an opportunity for personalized learning and should be tailored to ensure that every learner can achieve the highest standard possible. However, we recommend that the games be adapted based on the students’ needs and capabilities and a specially developed curriculum. The collected feedback showed that (1) children with learning disabilities need appropriately developed intelligent serious games, and (2) intelligent serious games, and the pertaining didactic methodology, should be based on an interoperable curriculum, so that teachers and trainers can use them. The student survey confirmed improvements in all aspects. %M 32297864 %R 10.2196/13190 %U https://games.jmir.org/2020/2/e13190 %U https://doi.org/10.2196/13190 %U http://www.ncbi.nlm.nih.gov/pubmed/32297864 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16431 %T Nutritional Education and Promotion of Healthy Eating Behaviors Among Mexican Children Through Video Games: Design and Pilot Test of FoodRateMaster %A Espinosa-Curiel,Ismael Edrein %A Pozas-Bogarin,Edgar Efrén %A Lozano-Salas,Jorge Luis %A Martínez-Miranda,Juan %A Delgado-Pérez,Edwin Emeth %A Estrada-Zamarron,Lizeth Stefania %+ Centro de Investigación Científica y de Educación Superior de Ensenada, Unidad de Transferencia Tecnológica Tepic, Andador 10, entre calles 3 y 4, Ciudad del Conocimiento, Tepic, Nayarit, 63173, Mexico, 52 3111295930 ext 28607, ecuriel@cicese.edu.mx %K childhood obesity %K serious game %K game design %K nutritional education %K dietary intake %K healthy eating behaviors %D 2020 %7 13.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Childhood obesity has risen dramatically in recent decades, reaching epidemic levels. Children need guidance on and support for maintaining a healthy diet and physical activity to ensure that they grow appropriately and develop healthy eating habits. Serious video games have shown positive effects on promoting the nutritional knowledge, and eating attitudes and behaviors of children; however, research about the usefulness of such games with younger children (8-10 years old) is sparse. Objective: The objective of this study was to design and test the serious video game FoodRateMaster targeting children between 8 and 10 years old. The game includes nutritional information and behavior change techniques to help children improve their knowledge of healthy and unhealthy foods, increase their intake of healthy food, and reduce their intake of ultraprocessed food. In addition, FoodRateMaster was designed as an active game to promote physical activity. Methods: An interdisciplinary team developed FoodRateMaster following an iterative methodology based on a user-centered design. A total of 60 participants (mean age 9 years, SD 0.8; 53% male) completed 12 individual gaming sessions in 6 weeks. A food knowledge questionnaire and a food frequency questionnaire were completed before and after game play. In addition, 39 of the participants’ parents answered a parent perception questionnaire after the game play. Results: Participants showed increased food knowledge from pregame (mean 56.9, SD 10.7) to postgame play (mean 67.8, SD 10.7; P<.001). In addition, there was a greater self-reported frequency in the consumption of cauliflower and broccoli (P<.001) and corn quesadillas (P<.001). They also indicated a lower self-reported intake of 10 unhealthy foods, including french fries (P=.003), candy and chocolate (P<.001), sweet soft cakes (P=.009), and soft drinks (P=.03). Moreover, most of the parents who answered the parent perception questionnaire agreed that their children showed greater interest in explaining why they should avoid some unhealthy foods (67%, 26/39), in distinguishing between healthy and unhealthy foods (64%, 25/39), and in the intake of fruits (64%, 25/39) and vegetables (59%, 23/39). Finally, 14 parents stated that they introduced some changes in their children's diet based on the comments and suggestions they received from their children. Conclusions: In an initial evaluation, children between 8 and 10 years old indicated an increased level in nutritional knowledge and their self-reported frequency intake of two healthy foods, and a decreased level in their self-reported intake of 10 unhealthy foods after playing FoodRateMaster. Moreover, the participants’ parents agreed that FoodRateMaster positively influenced their children’s attitudes toward several healthy eating behaviors. These results support that health games such as FoodRateMaster are viable tools to help young children increase their food knowledge and improve dietary behaviors. A follow-up randomized controlled trial will be conducted to assess the medium- and long-term effects of FoodRateMaster. %M 32281539 %R 10.2196/16431 %U http://games.jmir.org/2020/2/e16431/ %U https://doi.org/10.2196/16431 %U http://www.ncbi.nlm.nih.gov/pubmed/32281539 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e14549 %T Effectiveness of Serious Games to Increase Physical Activity in Children With a Chronic Disease: Systematic Review With Meta-Analysis %A Bossen,Daniël %A Broekema,Aline %A Visser,Bart %A Brons,Annette %A Timmerman,Annieck %A van Etten-Jamaludin,Faridi %A Braam,Katja %A Engelbert,Raoul %+ ACHIEVE Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Tafelbergweg 51, Amsterdam, 1105 BD, Netherlands, 31 621156637, d.bossen@hva.nl %K video games %K computer games %K pediatrics %K chronic disease %K exercise therapy %K health education %D 2020 %7 1.4.2020 %9 Review %J J Med Internet Res %G English %X Background: Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. Objective: The primary purpose of this systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease. Methods: PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library, and CINAHL were systematically searched for articles published from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included to examine the effects of serious games on PA levels in children with a chronic disease. Two investigators independently assessed the intervention, methods, and methodological quality in all articles using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed. Results: This systematic review included 9 randomized controlled trials (886 participants). In 2 of the studies, significant between-group differences in PA levels in favor of the intervention group were reported. The meta-analysis on PA levels showed a nonsignificant effect on moderate to vigorous PA (measured in minutes per day) between the intervention and control groups (standardized mean difference 0.30, 95% CI –0.15 to 0.75, P=.19). The analysis of body composition resulted in significantly greater reductions in BMI in the intervention group (standardized mean difference –0.24, 95% CI –0.45 to 0.04, P=.02). Conclusions: This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects with significantly greater reductions in BMI in favor of the intervention group. A high percentage of nonuse was identified in the study of serious games, and little attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs, and limited details about the interventions were the main limitations. Future research should determine which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques. %M 32234697 %R 10.2196/14549 %U https://www.jmir.org/2020/4/e14549 %U https://doi.org/10.2196/14549 %U http://www.ncbi.nlm.nih.gov/pubmed/32234697 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14182 %T Serious Motion-Based Exercise Games for Older Adults: Evaluation of Usability, Performance, and Pain Mitigation %A Brauner,Philipp %A Ziefle,Martina %+ Human-Computer-Interaction Center, RWTH Aachen University, Campus Boulevard 57, Aachen, 52074, Germany, 49 02418049237, brauner@comm.rwth-aachen.de %K serious games %K exercise game %K health care %K pain %K ambient assisted living %K technology acceptance %D 2020 %7 1.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many societies are facing demographic changes that challenge the viability of health and welfare systems. Serious games for health care and ambient assisted living (AAL) offer health benefits and support for older adults and may mitigate some of the negative effects of the demographic shift. Objective: This study aimed to examine the acceptance of serious games to promote physical health in AAL environments. Since AAL environments are designed specifically to support independent living in older adults, we studied the relationship among age and user diversity, performance in the game, and overall usability and acceptance evaluation. Methods: We developed a motion-based serious exercise game for prototypical AAL environments. In two evaluations, outside (n=71) and within (n=64) the AAL environment, we investigated the influence of age, gender, self-efficacy in interacting with technology, need for achievement on performance, effect of the game, usability evaluation of the game, and overall acceptance. Results: Both games were evaluated as easy to use and fun to play. Both game interventions had a strong pain-mitigating effect in older adults (game 1: −55%, P=.002; game 2: −66%, P=.01). Conclusions: Serious exercise games outside and inside AAL environments can contribute to individuals’ health and well-being and to the stability of health care systems. %M 32234703 %R 10.2196/14182 %U https://games.jmir.org/2020/2/e14182 %U https://doi.org/10.2196/14182 %U http://www.ncbi.nlm.nih.gov/pubmed/32234703 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e12388 %T Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study %A Khalili-Mahani,Najmeh %A Assadi,Atousa %A Li,Kate %A Mirgholami,Mahsa %A Rivard,Marie-Eve %A Benali,Habib %A Sawchuk,Kim %A De Schutter,Bob %+ PERFORM Centre, Concordia University, , Montreal, QC, , Canada, 1 5148482424 ext 5370, najmeh.khalili-mahani@concordia.ca %K silver gaming %K serious games %K stress %K cognitive training %K brain training games %K exercise games %K ICT %D 2020 %7 26.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants’ motivations to adopt these technologies. Objective: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. Methods: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S1-BrainGame, S2-CarRace, and S3-Exergame). Each session included an identical sequence of activities (t1-Baseline, t2-Picture encode, t3-Play, t4-Stroop test, t5-Play, and t6-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire. Results: Session×activity effects were significant on all ambulatory measures (χ210>20; P<.001) other than cortisol (P=.37). Compared with S1 and S2, S3 was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S1, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S3. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (χ21>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. Conclusions: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed. %M 32213474 %R 10.2196/12388 %U http://mental.jmir.org/2020/3/e12388/ %U https://doi.org/10.2196/12388 %U http://www.ncbi.nlm.nih.gov/pubmed/32213474 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e16066 %T Efficacy of a Virtual Reality Biofeedback Game (DEEP) to Reduce Anxiety and Disruptive Classroom Behavior: Single-Case Study %A Bossenbroek,Rineke %A Wols,Aniek %A Weerdmeester,Joanneke %A Lichtwarck-Aschoff,Anna %A Granic,Isabela %A van Rooij,Marieke M J W %+ Behavioural Science Institute, Radboud University, PO Box 9104, Nijmegen, 6500 HE, Netherlands, 31 243612638, r.bossenbroek@pwo.ru.nl %K anxiety %K disruptive behavior %K single-case study %K applied game %K serious games %K special education %K attention-deficit/hyperactivity disorder (ADHD) %K autism spectrum disorder (ASD) %K adolescents %D 2020 %7 24.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many adolescents in special education are affected by anxiety in addition to their behavioral problems. Anxiety leads to substantial long-term problems and may underlie disruptive behaviors in the classroom as a result of the individual’s inability to tolerate anxiety-provoking situations. Thus, interventions in special needs schools that help adolescents cope with anxiety and, in turn, diminish disruptive classroom behaviors are needed. Objective: This study aimed to evaluate the effect of a virtual reality biofeedback game, DEEP, on daily levels of state-anxiety and disruptive classroom behavior in a clinical sample. In addition, the study also aimed to examine the duration of the calm or relaxed state after playing DEEP. Methods: A total of 8 adolescents attending a special secondary school for students with behavioral and psychiatric problems participated in a single-case experimental ABAB study. Over a 4-week period, participants completed 6 DEEP sessions. In addition, momentary assessments (ie, 3 times a day) of self-reported state-anxiety and teacher-reported classroom behavior were collected throughout all A and B phases. Results: From analyzing the individual profiles, it was found that 6 participants showed reductions in anxiety, and 5 participants showed reductions in disruptive classroom behaviors after the introduction of DEEP. On a group level, results showed a small but significant reduction of anxiety (d=–0.29) and a small, nonsignificant reduction of disruptive classroom behavior (d=−0.16) on days when participants played DEEP. Moreover, it was found that the calm or relaxed state of participants after playing DEEP lasted for about 2 hours on average. Conclusions: This study demonstrates the potential of the game, DEEP, as an intervention for anxiety and disruptive classroom behavior in a special school setting. Future research is needed to fully optimize and personalize DEEP as an intervention for the heterogeneous special school population. %M 32207697 %R 10.2196/16066 %U http://mental.jmir.org/2020/3/e16066/ %U https://doi.org/10.2196/16066 %U http://www.ncbi.nlm.nih.gov/pubmed/32207697 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17425 %T Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study %A Katz,Daniel %A Shah,Ronak %A Kim,Elizabeth %A Park,Chang %A Shah,Anjan %A Levine,Adam %A Burnett,Garrett %+ Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, , New York, NY, United States, 1 7323226675, dkatz621@gmail.com %K video game %K experimental game %K virtual reality %K advanced cardiac life support %D 2020 %7 12.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale. %M 32163038 %R 10.2196/17425 %U http://www.jmir.org/2020/3/e17425/ %U https://doi.org/10.2196/17425 %U http://www.ncbi.nlm.nih.gov/pubmed/32163038 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e14766 %T Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation %A Vugts,Miel AP %A Zedlitz,Aglaia MEE %A Joosen,Margot CW %A Vrijhoef,Hubertus JM %+ Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 134664294, m.a.p.vugts@uvt.nl %K serious gaming %K eHealth %K chronic pain %K medically unexplained symptoms %K implementation %K realist evaluation %D 2020 %7 9.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens. Objective: To realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances. Methods: Following a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing—with regression models—routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results. Results: Qualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a “confrontation with yourself,” which reflected self-discrepancies. Important characteristics of serious gaming in the study’s context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07.10) 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