%0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e63491 %T Encouraging the Voluntary Mobilization of Mental Resources by Manipulating Task Design: Explorative Study %A Louis,Lina-Estelle %A Moussaoui,Saïd %A Ravoux,Sébastien %A Milleville-Pennel,Isabelle %K visual game-like elements %K gamification %K multiplicity of cognitive functions %K cognitive tasks %K perceived playfulness %K mental workload %K performance %K cognitive training %K aging %K mental effort %K cognitive function %K cognitive skills %K cognitive tests %D 2025 %7 10.4.2025 %9 %J JMIR Form Res %G English %X Background: Cognitive training is increasingly being considered and proposed as a solution for several pathologies, particularly those associated with aging. However, trainees need to be willing to invest enough mental effort to succeed and make progress. Objective: In this study, we explore how gamification in a narrative context (ie, the addition of visual game-like elements [GLEs] embedded in real-world contexts) could contribute increase in perceived playfulness (PP) and voluntary mental effort allocated to a cognitive task. In such context, narrative elements and GLEs can be designed to align with a commonly relatable scenario (like simulating fishing or gardening activity) to ground the task in familiar, real-world contexts. We also consider if the supposed effect of GLEs on PP and voluntary mental effort could endure while manipulating an intrinsic variable of the task (ie, by increasing cognitive solicitation). Methods: In total, 20 participants (average age 33.6, SD 8.6 y) took part in 3 cognitive tasks proposed in a numerical format: a classic version of the Corsi test (Classic Corsi, a spatial memory task), a playful version of the Classic Corsi test (Playful Corsi), with added visual GLEs in a narrative context, and a playful version of the Classic Corsi test with added cognitive solicitation, that is, mental motor inhibition (Playful Corsi Multi). We assessed the impact of visual GLEs and cognitive solicitation on PP (1 question) and mental workload (MWL) using NASA-Task Load Index (NASA-TLX) and workload profile (WP) questionnaires. Results: Results showed that PP was not influenced by interface’s playful characteristics (Classic Corsi [mean 62.4, SD 8.8] vs Playful Corsi [mean 66, SD 8.8]; W=77; P=.30) but decreased the time necessary to complete the task (Classic Corsi [mean 10.7, SD 2.1 s] vs Playful Corsi [mean 6.8, SD 1.6 s]; W=209; P<.001) as well as performance (Classic Corsi [mean 92.4, SD 9.1] vs Playful Corsi [mean 88.2, SD 11.3]; W=140.5; P=.02). So, possibly, visual GLEs could raise the stakes of the task slightly and implicitly encourage people to go a bit faster. Furthermore, visual GLEs increased MWL regarding attentional resources (assessed by WP: Classic Corsi [mean 52.4, SD 10.9] vs Playful Corsi [mean 65.8, SD 10.9]; W=27.5; P=.04), while manipulating cognitive solicitation impacted MWL when linked to task requirements (assessed by NASA-TLX: Playful Corsi [mean 54.2, SD 9.4] vs Playful Corsi Multi [mean 67.5, SD 9.4]; W=35.5; P=.01) without impacting the performance to the task (Playful Corsi [mean 83.8, SD 13.9] vs Playful Corsi Multi [mean 94, SD 5.5]; W=27; P=.007). Thus, working on the way cognitive functions are solicited would be wiser than adding visual GLEs to improve users’ voluntary mental effort while preserving performance. Conclusion: These results offer valuable insights to improve users’ experience during gamified cognitive tasks and serious games. %R 10.2196/63491 %U https://formative.jmir.org/2025/1/e63491 %U https://doi.org/10.2196/63491 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50992 %T Electrophysiological Insights in Exergaming—Electroencephalography Data Recording and Movement Artifact Detection: Systematic Review %A Rico-Olarte,Carolina %A Lopez,Diego M %A Eskofier,Bjoern M %A Becker,Linda %+ Machine Learning and Data Analytics Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Carl-Thiersch-Straße 2b, Erlangen, 91052, Germany, 49 9131 85 28990, carolinarico@unicauca.edu.co %K exergaming %K EEG %K brain activity %K motion artifact %K artifact removal %D 2025 %7 7.4.2025 %9 Review %J JMIR Serious Games %G English %X Background: Exergames are interactive solutions that require physical activity and are commonly used in learning or rehabilitation settings. For cognitive rehabilitation with exergames, the assessment of the intervention progress can be conducted by verifying the changes in brain activity. Electroencephalography (EEG) is a well-known method for this evaluation. However, motion artifacts due to large body movements can impede signal quality. No comprehensive guide on the artifact removal methods in the context of exergaming has been found. Objective: This paper aimed to identify studies that have assessed EEG signals while a user interacts with an exergame and the applied methods for data handling and analysis with a focus on dealing with movement artifacts. Methods: This review included studies on human participants while engaging in exergames, where the primary outcome was brain activity measured by EEG. A total of 5 databases were searched at 3 time points: March 2021, October 2022, and February 2024. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies assessed methodological quality, rating studies as “good,” “fair,” or “poor.” Data were synthesized quantitatively to identify characteristics across studies, including sample demographics and intervention details, and basic statistics (mean [SD]) were calculated. Results: A total of 494 papers were screened, resulting in 17 studies having been included. All studies carried out EEG recordings during exergame interactions, primarily assessing attention and concentration, with the alpha wave being the most analyzed EEG band. Common motion artifact removal methods included visual inspection and independent component analysis. The review identified significant risks of bias, with 2 studies rated as “good,” 7 as “fair,” and 8 as “poor.” Due to the small number of studies and their heterogeneity, a meta-analysis was not feasible. Conclusions: The study successfully identifies the feasibility of recording electrophysiological brain activity during exergaming and provides insights into EEG devices, analysis methods, and exergaming systems used in previous studies. However, limitations, such as the lack of sufficient detail on motion artifact removal and a focus on short-term effects, underscore the need for improved methodologies and reporting standards, with recommendations for enhancing reliability in cognitive rehabilitation with exergames. %M 40194274 %R 10.2196/50992 %U https://games.jmir.org/2025/1/e50992 %U https://doi.org/10.2196/50992 %U http://www.ncbi.nlm.nih.gov/pubmed/40194274 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e59514 %T Considering Theory-Based Gamification in the Co-Design and Development of a Virtual Reality Cognitive Remediation Intervention for Depression (bWell-D): Mixed Methods Study %A Hewko,Mark %A Gagnon Shaigetz,Vincent %A Smith,Michael S %A Kohlenberg,Elicia %A Ahmadi,Pooria %A Hernandez Hernandez,Maria Elena %A Proulx,Catherine %A Cabral,Anne %A Segado,Melanie %A Chakrabarty,Trisha %A Choudhury,Nusrat %+ National Research Council, 435 Ellice Avenue, Winnipeg, MB, R3B 1Y6, Canada, 1 204 984 4625, mark.hewko@nrc-cnrc.gc.ca %K virtual reality %K clinical psychology %K cognitive assessment %K neuropsychology %K mental health %K cognitive training %K cognitive remediation %K cognitive rehabilitation %K digital therapeutics %D 2025 %7 31.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically. Objective: We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies. Methods: In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials. Results: The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program. Conclusions: In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains. %M 40163852 %R 10.2196/59514 %U https://games.jmir.org/2025/1/e59514 %U https://doi.org/10.2196/59514 %U http://www.ncbi.nlm.nih.gov/pubmed/40163852 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e56978 %T Gamified Adaptive Approach Bias Modification in Individuals With Methamphetamine Use History From Communities in Sichuan: Pilot Randomized Controlled Trial %A Shen,Danlin %A Jiao,Jianping %A Zhang,Liqun %A Liu,Yanru %A Liu,Xiang %A Li,Yuanhui %A Zhang,Tianjiao %A Li,Dai %A Hao,Wei %K digital therapeutics %K substance use disorder %K game %K pilot RCT %K randomized controlled trial %K methamphetamine %K psychiatric %K gamified design %K engagement %K effectiveness %K smartphone app %K cognitive bias modification %D 2025 %7 10.3.2025 %9 %J JMIR Serious Games %G English %X Background: Cognitive bias modification (CBM) programs have shown promise in treating psychiatric conditions, but they can be perceived as boring and repetitive. Incorporating gamified designs and adaptive algorithms in CBM training may address this issue and enhance engagement and effectiveness. Objectives: This study aims to gather preliminary data and assess the preliminary efficacy of an adaptive approach bias modification (A-ApBM) paradigm in reducing cue-induced craving in individuals with methamphetamine use history. Methods: A randomized controlled trial with 3 arms was conducted. Individuals aged 18‐60 years with methamphetamine dependence and at least 1 year of methamphetamine use were recruited from 12 community-based rehabilitation centers in Sichuan, China. Individuals with the inability to fluently operate a smartphone and the presence of mental health conditions other than methamphetamine use disorder were excluded. The A-ApBM group engaged in ApBM training using a smartphone app for 4 weeks. The A-ApBM used an adaptive algorithm to dynamically adjust the difficulty level based on individual performance. Cue-induced craving scores and relapses were assessed using a visual analogue scale at baseline, postintervention, and at week-16 follow-up. Results: A total of 136 participants were recruited and randomized: 48 were randomized to the A-ApBM group, 48 were randomized to the static approach bias modification (S-ApBM) group, and 40 were randomized to the no-intervention control group. The A-ApBM group showed a significant reduction in cue-induced craving scores at postintervention compared with baseline (Cohen d=0.34; P<.01; 95% CI 0.03-0.54). The reduction remained significant at the week-16 follow-up (Cohen d=0.40; P=.01; 95% CI 0.18-0.57). No significant changes were observed in the S-ApBM and control groups. Conclusions: The A-ApBM paradigm with gamified designs and dynamic difficulty adjustments may be an effective intervention for reducing cue-induced craving in individuals with methamphetamine use history. This approach improves engagement and personalization, potentially enhancing the effectiveness of CBM programs. Further research is needed to validate these findings and explore the application of A-ApBM in other psychiatric conditions. Trial Registration: ClinicalTrials.gov NCT05794438; https://clinicaltrials.gov/study/NCT05794438 %R 10.2196/56978 %U https://games.jmir.org/2025/1/e56978 %U https://doi.org/10.2196/56978 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e54075 %T Identifying Key Principles and Commonalities in Digital Serious Game Design Frameworks: Scoping Review %A Maxim,Raluca Ionela %A Arnedo-Moreno,Joan %+ , Universitat Oberta de Catalunya, Rambla del Poblenou, 154-156, Sant Martí, Barcelona, 08018, Spain, 34 724346819, rmaxim@uoc.edu %K entertainment game design frameworks %K serious game design frameworks %K design principles %K empathic design thinking %K artificial intelligence %D 2025 %7 5.3.2025 %9 Review %J JMIR Serious Games %G English %X Background: Digital serious games (DSGs), designed for purposes beyond entertainment and consumed via electronic devices, have garnered attention for their potential to enhance learning and promote behavior change. Their effectiveness depends on the quality of their design. Frameworks for DSG design can guide the creation of engaging games tailored to objectives such as education, health, and social impact. Objective: This study aims to review, analyze, and synthesize the literature on digital entertainment game design frameworks and DSG design frameworks (DSGDFWs). The focus is on conceptual frameworks offering high-level guidance for the game creation process rather than component-specific tools. We explore how these frameworks can be applied to create impactful serious games in fields such as health care and education. Key goals include identifying design principles, commonalities, dependencies, gaps, and opportunities in the literature. Suggestions for future research include empathic design thinking, artificial intelligence integration, and iterative improvements. The findings culminate in a synthesized 4-phase design process, offering generic guidelines for designers and developers to create effective serious games that benefit society. Methods: A 2-phase methodology was used: a scoping literature review and cluster analysis. A targeted search across 7 databases (ACM, Scopus, Springer, IEEE, Elsevier, JMIR Publications, and SAGE) was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Studies included academic or industry papers evaluating digital game design frameworks. Cluster analysis was applied to categorize the data, revealing trends and correlations among frameworks. Results: Of 987 papers initially identified, 25 (2.5%) met the inclusion criteria, with an additional 22 identified through snowballing, resulting in 47 papers. These papers presented 47 frameworks, including 16 (34%) digital entertainment game design frameworks and 31 (66%) DSGDFWs. Thematic analysis grouped frameworks into categories, identifying patterns and relationships between design elements. Commonalities, dependencies, and gaps were analyzed, highlighting opportunities for empathic design thinking and artificial intelligence applications. Key considerations in DSG design were identified and presented in a 4-phase design baseline with the outcome of a list of design guidelines that might, according to the literature, be applied to an end-to-end process of designing and building future innovative solutions. Conclusions: The main benefits of using DSGDFWs seem to be related to enhancing the effectiveness of serious games in achieving their intended objectives, such as learning, behavior change, and social impact. Limitations primarily seem to be related to constraints associated with the specific contexts in which the serious games are developed and used. Approaches in the future should be aimed at refining and adapting existing frameworks to different contexts and purposes, as well as exploring new frameworks that incorporate emerging technologies and design principles. %M 40053743 %R 10.2196/54075 %U https://games.jmir.org/2025/1/e54075 %U https://doi.org/10.2196/54075 %U http://www.ncbi.nlm.nih.gov/pubmed/40053743 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e64004 %T A Self-Adaptive Serious Game to Improve Motor Learning Among Older Adults in Immersive Virtual Reality: Short-Term Longitudinal Pre-Post Study on Retention and Transfer %A Everard,Gauthier %A Declerck,Louise %A Lejeune,Thierry %A Edwards,Martin Gareth %A Bogacki,Justine %A Reiprich,Cléo %A Delvigne,Kelly %A Legrain,Nicolas %A Batcho,Charles Sebiyo %+ School of Rehabilitation Sciences, Faculty of Medicine, Laval University, 2325 Rue de l'Université, Québec, QC, G1V0A6, Canada, 1 4185299141 ext 46914, gauthier.everard@uclouvain.be %K virtual reality %K aged %K learning %K upper extremity %K video games %K kinematics %D 2025 %7 3.3.2025 %9 Original Paper %J JMIR Aging %G English %X Background: Despite their potential, the use of serious games within immersive virtual reality (iVR) for enhancing motor skills in older adults remains relatively unexplored. In this study, we developed a self-adaptive serious game in iVR called REAsmash-iVR. This game involves swiftly locating and striking a digital mole presented with various distractors. Objective: This short-term longitudinal pre-post study aims to evaluate REAsmash-iVR’s efficacy in promoting motor learning in older adults. Specifically, we seek to determine the transfer and retention of motor learning achieved through REAsmash-iVR to other iVR tasks. Methods: A total of 20 older adults participated in the study, engaging with REAsmash-iVR over 7 consecutive days. The evaluation included iVR tests such as KinematicsVR and a VR adaptation of the Box and Block Test (BBT-VR). KinematicsVR tasks included drawing straight lines and circles as fast and as accurately as possible, while BBT-VR required participants to move digital cubes as quickly as possible within 60 seconds. Assessments were conducted before and after the intervention, with a follow-up at 1 week post intervention. The primary outcome focused on evaluating the impact of REAsmash-iVR on speed-accuracy trade-off during KinematicsVR tasks. Secondary outcomes included analyzing movement smoothness, measured by spectral arc length, and BBT-VR scores. Results: Results revealed significant improvements in speed-accuracy trade-off post intervention compared to that before the intervention, with notable retention of skills for straight lines (t19=5.46; P<.001; Cohen d=1.13) and circle drawing (t19=3.84; P=.001; Cohen d=0.787). Likewise, there was a significant enhancement in spectral arc length, particularly for circle drawing (χ²2=11.2; P=.004; ε2=0.23), but not for straight-line drawing (χ²2=2.1; P=.35; ε2=0.003). Additionally, participants demonstrated transfer with significant improvement (q=5.26; P<.001; Cohen r=0.678) and retention (q=6.82; P<.001; Cohen r=0.880) in BBT-VR skills. Conclusions: These findings provide perspectives for the use of iVR to improve motor learning in older adults through delivering self-adaptive serious games targeting motor and cognitive functions. Trial Registration: ClinicalTrials.gov NCT04694833; https://clinicaltrials.gov/study/NCT04694833 %M 40053708 %R 10.2196/64004 %U https://aging.jmir.org/2025/1/e64004 %U https://doi.org/10.2196/64004 %U http://www.ncbi.nlm.nih.gov/pubmed/40053708 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e60755 %T Evaluating the Efficacy of a Serious Game to Deliver Health Education About Invasive Meningococcal Disease: Clustered Randomized Controlled Equivalence Trial %A Bloomfield,Lauren %A Boston,Julie %A Masek,Martin %A Andrew,Lesley %A Barwood,Donna %A Devine,Amanda %+ Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027, Australia, 61 0863045702, julie.boston@ecu.edu.au %K serious games %K meningococcal disease %K immersive digital applications %K health promotion %K gaming %K meningitis %K infection %K bacteria %K contagious %K infectious %K immersive %K education %K mHealth %K mobile health %K applications %K youth %K adolescents %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Invasive meningococcal disease (IMD) is a serious, vaccine-preventable infectious disease that can be life-threatening. Teaching adolescents about the early detection and prevention of IMD can be challenging in a school environment, with educators reporting they lack confidence or expertise to cover this in the classroom environment. Professional guest educators are an alternative to cover specialist topics such as IMD; however, time and resourcing constraints can mean that these educators are not always available. Serious games may be an alternative to face-to-face education, where complex health information may be delivered via self-directed gameplay. Objective: This study aims to develop a serious game that can replace a face-to-face educator in a classroom setting to educate adolescents aged 12 years to 15 years. This study evaluates the efficacy of the Meningococcal Immunisation Awareness, Prevention and Protection app (MIApp), a serious game designed to replicate the information provided in a 30-minute face-to-face presentation provided by a trained educator. Methods: This clustered, randomized controlled equivalence trial involved students (Years 7-10) from 6 secondary schools across metropolitan Western Australia who completed pre- and postintervention questionnaires with a follow-up at 3 months postintervention to measure the primary outcome of IMD knowledge acquisition following this self-guided intervention. The findings were compared with changes in an active control (comparison) group who received an in-class educational presentation about IMD transmission and protection. A questionnaire was developed to assess 9 key areas of knowledge. Median scores for knowledge pre- and postintervention were collected from a self-administered assessment of this questionnaire and, at 3 months postintervention, were compared between groups. A knowledge score of +/–2/16 was determined a priori to meet the criteria for equivalence. Participants who used MIApp were also asked a series of questions to assess the enjoyment of and engagement with the game. Results: Of the 788 participating students, the median postintervention correct score in both the MIApp and control cohorts was 14/16 (87.5% correct responses), compared with the median pre-intervention correct score of 6/16 (37.5% correct responses), representing a significant (P<.001) increase in IMD knowledge in both groups. Improvements were retained in both groups 3 months after the initial intervention (median correct score: 11/16 in the intervention group; 12/16 in the control group; P=.86), demonstrating the efficacy of MIApp to deliver health education about IMD transmission and protection, although response rates in the follow-up cohort were low (255/788, 32.4%). Conclusions: MIApp met the predetermined threshold for equivalence, demonstrating similar improvements in knowledge posttrial and at the 3-month follow-up. Participating adolescents considered the MIApp game more enjoyable than a presentation, with equivalent improvements in knowledge. Serious games could represent a constructive tool to help teachers impart specialized health education. %M 39932769 %R 10.2196/60755 %U https://games.jmir.org/2025/1/e60755 %U https://doi.org/10.2196/60755 %U http://www.ncbi.nlm.nih.gov/pubmed/39932769 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69080 %T Digital Gaming and Subsequent Health and Well-Being Among Older Adults: Longitudinal Outcome-Wide Analysis %A Nakagomi,Atsushi %A Ide,Kazushige %A Kondo,Katsunori %A Shiba,Koichiro %+ Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba, 2638522, Japan, 81 432903177 ext 3177, anakagomi0211@gmail.com %K digital gaming %K older adults %K flourishing %K well-being %K physical activity %K social engagement %K mobile phone %D 2025 %7 27.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital gaming has become increasingly popular among older adults, potentially offering cognitive, social, and physical benefits. However, its broader impact on health and well-being, particularly in real-world settings, remains unclear. Objective: This study aimed to evaluate the multidimensional effects of digital gaming on health and well-being among older adults, using data from the Japan Gerontological Evaluation Study conducted in Matsudo City, Chiba, Japan. Methods: Data were drawn from 3 survey waves (2020 prebaseline, 2021 baseline, and 2022 follow-up) of the Japan Gerontological Evaluation Study, which targets functionally independent older adults. The exposure variable, digital gaming, was defined as regular video game play and was assessed in 2021. In total, 18 outcomes across 6 domains were evaluated in 2022; domain 1—happiness and life satisfaction, domain 2—physical and mental health, domain 3—meaning and purpose, domain 4—character and virtue, domain 5—close social relationships, and domain 6—health behavior. Furthermore, 10 items from the Human Flourishing Index were included in domains 1-5, with 2 items for each domain. Overall flourishing was defined as the average of the means across these 5 domains. In addition, 7 items related to domains 2, 5, and 6 were assessed. The final sample consisted of 2504 participants aged 65 years or older, with questionnaires containing the Human Flourishing Index randomly distributed to approximately half of the respondents (submodule: n=1243). Consequently, we used 2 datasets for analysis. We applied targeted maximum likelihood estimation to estimate the population average treatment effects, with Bonferroni correction used to adjust for multiple testing. Results: Digital gaming was not significantly associated with overall flourishing or with any of the 5 domains from the Human Flourishing Index. Although initial analyses indicated associations between digital gaming and participation in hobby groups (mean difference=0.12, P=.005) as well as meeting with friends (mean difference=0.076, P=.02), these associations did not remain significant after applying the Bonferroni correction for multiple testing. In addition, digital gaming was not associated with increased sedentary behavior or reduced outdoor activities. Conclusions: This study provides valuable insights into the impact of digital gaming on the health and well-being of older adults in a real-world context. Although digital gaming did not show a significant association with improvements in flourishing or in the individual items across the 5 domains, it was also not associated with increased sedentary behavior or reduced outdoor activities. These findings suggest that digital gaming can be part of a balanced lifestyle for older adults, offering opportunities for social engagement, particularly through hobby groups. Considering the solitary nature of gaming, promoting social gaming opportunities may be a promising approach to enhance the positive effects of digital gaming on well-being. %M 39869904 %R 10.2196/69080 %U https://www.jmir.org/2025/1/e69080 %U https://doi.org/10.2196/69080 %U http://www.ncbi.nlm.nih.gov/pubmed/39869904 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e58912 %T Pervasive Games for Sexual Health Promotion: Scoping Literature Review %A Rubio,Claudio %A Besoain,Felipe %+ Department of Interactive Visualization and Virtual Reality, Faculty of Engineering, University of Talca, 2 norte #685, Talca, 3460000, Chile, 56 2201687 ext 2687, fbesoain@utalca.cl %K serious games %K promotion %K ubiquitous technologies %K healthy behaviors %K HIV %K sexually transmitted infection %K STI %K scoping review %K mobile phone %D 2025 %7 15.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: Serious games play a fundamental role in promoting safe sexual behaviors. This medium has great potential for promoting healthy behaviors that prevent potential risk factors, such as sexually transmitted infections, and promote adherence to sexual health treatments, such as antiretroviral therapy. The ubiquity of mobile devices enhances access to such tools, increasing the effectiveness of video games as agents of change. Objective: In this scoping review, we aimed to (1) identify the extent to which pervasive games have been used in the field of sexual health, (2) determine the theories used in the design and evaluation of pervasive games for sexual health, (3) identify the methods used to evaluate pervasive games for sexual health, and (4) explore the reported benefits of using pervasive games for sexual health. Methods: Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology, we conducted a comprehensive literature search in the Web of Science, Scopus, IEEE Xplore, and ACM databases for articles published between January 1, 2000, and August 4, 2024. Included articles were published in English between 2000 and 2024 and involved the design, implementation, or evaluation of a ubiquitous video game focused on promoting safe sexual behaviors, with qualitative and/or quantitative results based on theory-based techniques and ubiquitous technologies. Review articles, conference papers, or books without available data or quantitative or qualitative results were excluded. Results: We screened 521 of 612 articles (85.1%) after removing duplicates. After the title and abstract review, 51 (9.8%) articles were assessed for eligibility, and 30 (5.8%) articles meeting the criteria were studied and evaluated in depth. The results suggested that the use of pervasive video games has a positive impact on promoting safe sexual behaviors. This is enhanced by the effectiveness of theory-based techniques and the use of mobile technologies as developmental factors that drive the gaming experience. The results indicated that this domain is a growing field that should not be ignored. Conclusions: The literature showed that pervasive video games have been effective in promoting safe sexual behaviors. Substantial growth has been seen in scientific community interest in researching this domain; nevertheless, there is still much to work on. In this context, we advocate for the standardization of design, implementation, and experimentation as essential phases in creating video game experiences. These 3 fundamental aspects are critical in the development of video game–based studies to ensure the reproducibility of experiments. %M 39813670 %R 10.2196/58912 %U https://games.jmir.org/2025/1/e58912 %U https://doi.org/10.2196/58912 %U http://www.ncbi.nlm.nih.gov/pubmed/39813670 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e63143 %T Optimizing a Novel Smartphone App to Prevent Postpartum Depression Adapted From an Evidence-Based Cognitive Behavioral Therapy Program: Qualitative Study %A Lewkowitz,Adam K %A Guillen,Melissa %A Ursino,Katrina %A Baker,Rackeem %A Lum,Liana %A Battle,Cynthia L %A Ware,Crystal %A Ayala,Nina K %A Clark,Melissa %A Ranney,Megan L %A Miller,Emily S %A Guthrie,Kate M %K cognitive behavioral therapy %K mothers and babies program %K digital health %K postpartum depression %K smartphone application %K FRAME for intervention adaptation %K Framework for Modification and Adaptation %K behavioral therapy %K mental health apps %D 2024 %7 9.12.2024 %9 %J JMIR Hum Factors %G English %X Background: Low-income pregnant patients are at high risk of postpartum depression (PPD). Mothers and Babies (MB) is a cognitive behavioral therapy–based program that prevents up to 50% of de novo PPD when provided in person to low-income Spanish- and English-speaking people who are pregnant without depression. MB is limited by the need for trained personnel to support it. Transforming MB into a smartphone app may mitigate this key barrier. Objective: We aimed to use qualitative data from target end users to create and optimize MBapp, a novel app centered on the MB program. Methods: Draft wireframes of MBapp were created in English and Spanish with cognitive behavioral therapy–based modules adapted from MB. These wireframes included several features shown previously to sustain app engagement: (1) push notifications delivered at participant-preferred times; (2) text-, graphic-, and video-based content; and (3) gamification with digital rewards for app engagement. English- or Spanish-speaking individuals with public health insurance who were between 32 weeks gestation and 6 months post partum and owned smartphones were eligible to consent for individual in-depth interviews. Individuals with prior or current depression were excluded. Interviews were recorded, transcribed, and analyzed using deductive and inductive codes to characterize opinions about MBapp and perceptions of challenges and facilitators of use of MBapp or other perinatal or mental health apps. End user feedback led to major modifications to the wireframes. Each of these changes was categorized according to the FRAME (Framework for Modification and Adaptation), an established method of systematically reporting adaptations and modifications to evidence-based interventions via end user feedback. Recruitment ceased with content saturation, defined as 3 successive participants providing only positive feedback on MBapp’s wireframe, without further suggestions for improvement. Results: A total of 25 interviews were completed. Participants were racially and ethnically diverse, generally representing our target end user population, and 48% (n=12) of interviews were conducted in Spanish. Participants’ suggestions to improve MBapp were categorized within the FRAME as adaptations that improved either content or context to optimize reach, retention, engagement, and fit for end users. Specifically, the following features were added to MBapp secondary to end user feedback: (1) audio narration; (2) “ask a clinician” nonurgent questions; (3) on-demand module summaries accessible upon module completion; and (4) choice to defer assessments and start the next module. Participants also provided insights into features of perinatal or mental health apps they found appealing or unappealing to understand preferences, challenges, and negotiables or nonnegotiables for MBapp. Conclusions: Adapting MBapp to incorporate end users’ perspectives optimized our digital PPD prevention intervention, ideally increasing its appeal to future users. Our team’s next steps will confirm that MBapp is a feasible, acceptable intervention among English- and Spanish-speaking perinatal people at risk of PPD. %R 10.2196/63143 %U https://humanfactors.jmir.org/2024/1/e63143 %U https://doi.org/10.2196/63143 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e59047 %T Electronic Feedback Alone Versus Electronic Feedback Plus in-Person Debriefing for a Serious Game Designed to Teach Novice Anesthesiology Residents to Perform General Anesthesia for Cesarean Delivery: Randomized Controlled Trial %A Lee,Allison %A Goodman,Stephanie %A Chen,Chen Miao %A Landau,Ruth %A Chatterji,Madhabi %K general anesthesia %K cesarean delivery %K multiple choice questions %K serious game %K debriefing %K feedback %K anesthesia %K anesthesiology %K anesthesiologist %K anesthetist %K cesarean %K EmergenCSim %K randomized controlled trial %D 2024 %7 19.11.2024 %9 %J JMIR Serious Games %G English %X Background: EmergenCSim is a novel researcher-developed serious game (SG) with an embedded scoring and feedback tool that reproduces an obstetric operating room environment. The learner must perform general anesthesia for emergent cesarean delivery for umbilical cord prolapse. The game was developed as an alternative teaching tool because of diminishing real-world exposure of anesthesiology trainees to this clinical scenario. Traditional debriefing (facilitator-guided reflection) is considered to be integral to experiential learning but requires the participation of an instructor. The optimal debriefing methods for SGs have not been well studied. Electronic feedback is commonly provided at the conclusion of SGs, so we aimed to compare the effectiveness of learning when an in-person debrief is added to electronic feedback compared with using electronic feedback alone. Objective: We hypothesized that an in-person debriefing in addition to the SG-embedded electronic feedback will provide superior learning than electronic feedback alone. Methods: Novice first-year anesthesiology residents (CA-1; n=51) (1) watched a recorded lecture on general anesthesia for emergent cesarean delivery, (2) took a 26-item multiple-choice question pretest, and (3) played EmergenCSim (maximum score of 196.5). They were randomized to either the control group that experienced the electronic feedback alone (group EF, n=26) or the intervention group that experienced the SG-embedded electronic feedback and an in-person debriefing (group IPD+EF, n=25). All participants played the SG a second time, with instructions to try to increase their score, and then they took a 26-item multiple-choice question posttest. Pre- and posttests (maximum score of 26 points each) were validated parallel forms. Results: For groups EF and IPD+EF, respectively, mean pretest scores were 18.6 (SD 2.5) and 19.4 (SD 2.3), and mean posttest scores were 22.6 (SD 2.2) and 22.1 (SD 1.6; F1,49=1.8, P=.19). SG scores for groups EF and IPD+EF, respectively, were—mean first play SG scores of 135 (SE 4.4) and 141 (SE 4.5), and mean second play SG scores of 163.1 (SE 2.9) and 173.3 (SE 2.9; F1,49=137.7, P<.001). Conclusions: Adding an in-person debriefing experience led to greater improvement in SG scores, emphasizing the learning benefits of this practice. Improved SG performance in both groups suggests that SGs have a role as independent, less resource-intensive educational tools. %R 10.2196/59047 %U https://games.jmir.org/2024/1/e59047 %U https://doi.org/10.2196/59047 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e13723 %T Developing Game-Based Design for eHealth in Practice: 4-Phase Game Design Process %A de Vette,Frederiek %A Ruiz-Rodriguez,Aurora %A Tabak,Monique %A Oude Nijeweme-d'Hollosy,Wendy %A Hermens,Hermie %A Vollenbroek-Hutten,Miriam %+ Biomechanical Engineering Group, Faculty of Engineering Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 53 489 5798, a.ruizrodriguez@utwente.nl %K game based %K gamification %K game %K eHealth %K telemedicine %K development %K design %K engagement %K game preferences %K older adults %K self-management %K prototyping %K evaluations %K creative %D 2024 %7 8.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Games are increasingly used in eHealth as a strategy for user engagement. There is an enormous diversity of end users and objectives targeted by eHealth. Hence, identifying game content that drives and sustains engagement is challenging. More openness in the game design process and motivational strategies could aid researchers and designers of future game-based apps. Objective: This study aims to provide insights into our approach to develop game-based eHealth in practice with a case study (Personalised ICT Supported Services for Independent Living and Active Ageing [PERSSILAA]). PERSSILAA is a self-management platform that aims to counter frailty by offering training modules to older adults in the domains of healthy nutrition and physical and cognitive training to maintain a healthy lifestyle. We elaborate on the entire game design process and show the motivational strategies applied. Methods: We introduce four game design phases in the process toward game-based eHealth: (1) end-user research, (2) conceptualization, (3) creative design, and (4) refinement (ie, prototyping and evaluations). Results: First, 168 participants participated in end-user research, resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include focusing game concepts on thinking, problem-solving, variation, discovery, and achievement and using high-quality aesthetics. Second, stakeholder sessions with development partners resulted in strategies for long-term engagement using indicators of user performance on the platform’s training modules. These performance indicators, for example, completed training sessions or exercises, form the basis for game progression. Third, results from prior phases were used in creative design to create the game “Stranded!” The user plays a person who is shipwrecked who must gather parts for a life raft by completing in-game objectives. Finally, iterative prototyping resulted in the final prototype of the game-based app. A total of 35 older adults participated using simulated training modules. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the app (75/100), and intended future use (66/100), which implies that the app is ready for use by a larger population. Conclusions: The study resulted in a game-based app for which the entire game design process within eHealth was transparently documented and where engagement strategies were based on extensive user research. Our user evaluations indicate that the strategies for long-term engagement led to game content that was perceived as engaging by older adults. As a next step, research is needed on the user experience and actual engagement with the game to support the self-management of older adults, followed by clinical studies on its added value. %M 39514861 %R 10.2196/13723 %U https://formative.jmir.org/2024/1/e13723 %U https://doi.org/10.2196/13723 %U http://www.ncbi.nlm.nih.gov/pubmed/39514861 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e63296 %T Risk Perception and Knowledge Following a Social Game–Based Tobacco Prevention Program for Adolescents: Pilot Randomized Comparative Trial %A Khalil,Georges %A Ramirez,Erica %A Khan,Meerah %A Zhao,Bairu %A Ribeiro,Nuno %A Balian,Patrick %+ Department of Health Outcomes and Biomedical Informatics, University of Florida, Malachowsky Hall for Data Science and Information Technology, 1889 Museum Rd, Suite 7000, Gainesville, FL, 32603, United States, 1 3526279467, gkhalil@ufl.edu %K tobacco prevention %K vaping %K combustible tobacco %K risk perception %K adolescent %K games %K social interaction %D 2024 %7 5.11.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescence is a critical developmental stage that is particularly vulnerable to the initiation of tobacco use. Despite the well-documented health risks associated with tobacco use, it remains prevalent among adolescents. Games for health are a promising strategy for tobacco prevention, using experiential and social learning theories to enhance engagement and improve behavior change. Objective: This pilot study aims to (1) compare the social game–based program Storm-Heroes to a nonsocial program regarding adolescents’ personal and social experiences and (2) examine how these experiences predict higher tobacco knowledge and perceived risks of vaping and conventional tobacco use. Methods: In a cluster-randomized comparative design, 4 after-school sites (N=79 adolescents) were recruited in person and randomized in a single-blinded format to 1 of 2 interventions: the social game Storm-Heroes (44/79, 56%) or the nonsocial program A Smoking Prevention Interactive Experience (ASPIRE; 35/79, 44%). A study team member supervised both interventions. Data were collected at baseline, immediate follow-up, and a 1.5-month follow-up (45/74, 61% retained). Repeated measures mixed effects models were conducted. Results: A total of 45 participants continued until the 1.5-month follow-up. Participants in the Strom-Heroes group were more likely to increase their perceived risk of vaping (B=0.40; P<.001), perceived risk of conventional tobacco use (B=0.35; P=.046), and tobacco knowledge (B=1.63; P<.001) than those in the control condition. The usability level of the program was related to a higher perceived risk of vaping (B=0.16; P=.003) and conventional tobacco use (B=0.16; P=.02) by follow-up. Attention to the program was also related to higher perceived risk of vaping (B=0.12; P=.002) and conventional tobacco use (B=0.14; P<.001). Distraction was not related to either perceived risk of vaping (P=.15) or perceived risk of conventional tobacco use (P=.71). In contrast, both more attention (B=0.60; P<.001) and less distraction (B=–0.37; P<.001) were related to higher tobacco knowledge. Conclusions: The increased perceived risk of vaping and conventional tobacco among Storm-Heroes participants aligns with the program’s goals of improving participants’ awareness of the risks associated with tobacco use and their tobacco knowledge. However, distraction weakened the effect of the program on tobacco knowledge, indicating that emphasis needs to be placed on minimizing distraction for better outcomes. With the results of this study, researchers can work to advance the current version of Storm-Heroes and amplify engagement in the program to improve its potential for preventing adolescents’ initiation of tobacco use. Trial Registration: ClinicalTrials.gov NCT02703597; https://clinicaltrials.gov/study/NCT02703597 %M 39499912 %R 10.2196/63296 %U https://games.jmir.org/2024/1/e63296 %U https://doi.org/10.2196/63296 %U http://www.ncbi.nlm.nih.gov/pubmed/39499912 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e55034 %T Game-Based eHealth Interventions for the Reduction of Fatigue in People With Chronic Diseases: Systematic Review and Meta-Analysis %A Warlo,Leonie S %A El Bardai,Souraya %A de Vries,Andrica %A van Veelen,Marie-Lise %A Moors,Suzan %A Rings,Edmond HHM %A Legerstee,Jeroen S %A Dierckx,Bram %+ Department of Child and Adolescent Psychiatry/Psychology, Sophia Children’s Hospital, Erasmus Medical Center, Wytemaweg 80, Rotterdam, 3015 CN, Netherlands, 31 630403394, s.elbardai@erasmusmc.nl %K fatigue %K chronic disease %K eHealth %K serious games %K exergames %D 2024 %7 17.10.2024 %9 Review %J JMIR Serious Games %G English %X Background: Fatigue is a common and debilitating side effect of chronic diseases, significantly impacting patients’ quality of life. While physical exercise and psychological treatments have been shown to reduce fatigue, patients often struggle with adherence to these interventions in clinical practice. Game-based eHealth interventions are believed to address adherence issues by making the intervention more accessible and engaging. Objective: This study aims to compile empirical evidence on game-based eHealth interventions for fatigue in individuals with chronic diseases and to evaluate their effectiveness in alleviating fatigue. Methods: A comprehensive literature search was performed across Embase, MEDLINE ALL, PsycINFO, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar in August 2021. Study characteristics and outcomes from the included studies were extracted, and a random-effects meta-analysis was conducted. Sensitivity and subgroup analyses were performed to identify sources of heterogeneity. Results: Of 1742 studies identified, 17 were included in the meta-analysis. These studies covered 5 different chronic diseases: multiple sclerosis (n=10), cancer (n=3), renal disease (n=2), stroke (n=1), and Parkinson disease (n=1). All but 1 study used exergaming interventions. The meta-analysis revealed a significant moderate effect size in reducing fatigue favoring the experimental interventions (standardized mean difference [SMD] –0.65, 95% CI –1.09 to –0.21, P=.003) compared with control conditions consisting of conventional care and no care. However, heterogeneity was high (I2=85.87%). Subgroup analyses were conducted for the 2 most prevalent diseases. The effect size for the multiple sclerosis subgroup showed a trend in favor of eHealth interventions (SMD –0.47, 95% CI –0.95 to 0.01, P=.05, I2=63.10%), but was not significant for the cancer group (SMD 0.61, 95% CI –0.36 to 1.58, P=.22). Balance exercises appeared particularly effective in reducing fatigue (SMD –1.19, 95% CI –1.95 to –0.42, P=.002). Conclusions: Game-based eHealth interventions appear effective in reducing fatigue in individuals with chronic diseases. Further research is needed to reinforce these findings and explore their impact on specific diseases. Additionally, there is a lack of investigation into interventions beyond exergaming within the field of game-based learning. %M 39419502 %R 10.2196/55034 %U https://games.jmir.org/2024/1/e55034 %U https://doi.org/10.2196/55034 %U http://www.ncbi.nlm.nih.gov/pubmed/39419502 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e55333 %T Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale %A Flato,Uri Adrian Prync %A Beffa dos Santos,Emilio José %A Bispo Diaz T Martins,Isabella %A Rossignoli,Vinicius Gazin %A Dias Midega,Thais %A Kallas-Silva,Lucas %A Ferreira Mendes de Oliveira,Ricardo %A do Socorro Lima Figueiredo Flato,Adriana %A Vicente Guimarães,Mario %A Penna Guimarães,Hélio %K cardiopulmonary resuscitation %K basic life support %K serious game %K CPR training %K usability %K cardiopulmonary %K emergency %K life support %K CPR %K training %K education %K game %K gaming %K educational %K resuscitation %K survey %K satisfaction %K SUS %K user experience %K System Usability Scale %D 2024 %7 9.10.2024 %9 %J JMIR Serious Games %G English %X %R 10.2196/55333 %U https://games.jmir.org/2024/1/e55333 %U https://doi.org/10.2196/55333 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e64673 %T Serious Gaming for Chemotherapy-Induced Nausea and Vomiting in Older Adults With Cancer: Protocol for a Randomized Clinical Trial %A Loerzel,Victoria %A Alamian,Arsham %A Clochesy,John %A Geddie,Patricia I %+ College of Nursing, University of Central Florida, 12201 Research Parkway, Suite 300, Orlando, FL, 32826-3265, United States, 1 4078230762, victoria.loerzel@ucf.edu %K chemotherapy-induced nausea and vomiting %K aged %K serious game %K symptom self-management %K mobile phone %K neoplasms %K self-care %D 2024 %7 2.10.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Older adults are at high risk for toxicity due to cancer treatment and increased risk for adverse events related to chemotherapy-induced nausea and vomiting (CINV). Unfortunately, older adults report multiple treatment-related symptoms but use few strategies to self-manage these symptoms due to erroneous beliefs related to the effectiveness of commonly taught self-management strategies. We developed a novel serious game, Managing at Home (MAH), to help older adults learn how to effectively self-manage CINV at home. Objective: This study has 2 aims. Aim 1 is to examine changes in CINV severity, self-management behaviors, functioning, quality of life, cognitive representation, and health care use within the intervention group from baseline (T1) to completion of the study (T6). Aim 2 is to determine the efficacy of the MAH intervention by comparing differences in primary outcomes (CINV severity and health care use) and secondary outcomes (self-management behaviors, functioning, and quality of life) between the intervention and control groups at each follow-up visit (T2-T6) and completion of the study (T6). Methods: This is a longitudinal randomized clinical trial. We will collect data from 500 older adults receiving cancer-related chemotherapy at baseline (T1) and at each treatment cycle until cycle 6 (T6). Participants will be enrolled if they are 60 years or older of age, are newly diagnosed with cancer, being treated with any chemotherapy agent with moderate or high emetic potential, are on a 2-, 3-, or 4-week treatment cycle, are proficient in English, and have a telephone. Previous diagnosis or treatment for cancer, end-stage disease with less than 6 months to live, and uncorrected visual or hearing impairment are exclusion criteria. Results: This study was funded in September 2022 and received institutional review board approval in October 2022. As of July 2023, the enrollment of participants is ongoing and currently has 130 enrolled participants. Data collection and analysis will be complete in 2027. Conclusions: This study addresses self-management of CINV in older adults using an innovative serious game. The MAH intervention uses simulation and gaming technology to engage older adults in active learning in order to reframe erroneous perceptions about symptom self-management. If shown to be effective, it can easily be adapted to include other cancer-related symptoms or other chronic illnesses. Trial Registration: ClinicalTrials.gov NCT05838638; https://clinicaltrials.gov/study/NCT05838638 International Registered Report Identifier (IRRID): DERR1-10.2196/64673 %M 39357051 %R 10.2196/64673 %U https://www.researchprotocols.org/2024/1/e64673 %U https://doi.org/10.2196/64673 %U http://www.ncbi.nlm.nih.gov/pubmed/39357051 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47141 %T Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation %A Taj,Umar %A Grimani,Aikaterini %A Read,Daniel %A Vlaev,Ivo %K behavior change %K experimental modeling %K gamification %K medication adherence %K antibiotics %K games %K medication %K testing behavior %K clinical outcome %K simulate %K diagnosis %K devices %K symptoms %K tool %D 2024 %7 24.9.2024 %9 %J JMIR Serious Games %G English %X Background: Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach “gamified behavioral simulation.” In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions. Objective: This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence. Methods: A laboratory experiment was conducted using a modified popular and addictive open-source video game called “2048,” which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups (“incentive” group, “reminder” group, “commitment device” group, and “elongated duration for symptoms” group). Results: The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI −33.97% to −11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen. Conclusions: Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial. %R 10.2196/47141 %U https://games.jmir.org/2024/1/e47141 %U https://doi.org/10.2196/47141 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e63505 %T Effectiveness of an mHealth App That Uses Financial Incentives and Gamification to Promote Health Behavior Change in Adolescents and Caregivers: Protocol for a Clinic-Based Randomized Controlled Trial %A Braddock,Amy %A Ghosh,Parijat %A Montgomery,Emma %A Lim,Crystal %A Ghosh,Jaya %A Henry,Nicole %A Popescu,Mihail %A Kimchi,Kimberly %A Guo,Congyu %A Bosworth,K Taylor %A Koopman,Richelle J %+ Family and Community Medicine, University of Missouri, Columbia, MA306, 1 Hospital Drive, Columbia, MO, 65212, United States, 1 5738847733, williamsamy@health.missouri.edu %K mHealth %K adolescents %K apps %K caregivers %K obesity %K healthy lifestyle %K CommitFit %K mobile health %D 2024 %7 10.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers. Objective: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel “CommitFit” mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers. Methods: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates “CommitFit,” which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit$, where adolescents were paid US $0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits. Results: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025. Conclusions: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit. International Registered Report Identifier (IRRID): DERR1-10.2196/63505 %M 39255473 %R 10.2196/63505 %U https://www.researchprotocols.org/2024/1/e63505 %U https://doi.org/10.2196/63505 %U http://www.ncbi.nlm.nih.gov/pubmed/39255473 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49029 %T Gamification in Mobile Apps for Children With Disabilities: Scoping Review %A Mahmoudi,Ebrahim %A Yejong Yoo,Paul %A Chandra,Ananya %A Cardoso,Roberta %A Denner Dos Santos,Carlos %A Majnemer,Annette %A Shikako,Keiko %+ School of Physical and Occupational Therapy, McGill University, 3654 Prom Sir-William-Osler, Montreal, QC, H3G 1Y5, Canada, 1 514 488 5552 ext 1141, keiko.thomas@mcgill.ca %K mobile health %K mHealth %K gamification %K children with disabilities %K mobile phone %D 2024 %7 6.9.2024 %9 Review %J JMIR Serious Games %G English %X Background: Children with disabilities face numerous challenges in accessing health services. Mobile health is an emerging field that could significantly reduce health inequities by providing more accessible services. Many mobile apps incorporate gamification elements such as feedback, points, and stories to increase engagement and motivation; however, little is known about how gamification has been incorporated in mobile apps for children with disabilities. Objective: This scoping review aims to identify and synthesize the existing research evidence on the use of gamification in mobile apps for children with disabilities. Specifically, the objectives were to (1) identify the categories of these mobile apps (eg, treatment and educational) (2), describe the health-related outcomes they target, (3) assess the types and levels of gamification elements used within these apps, and (4) determine the reasons for incorporating gamification elements into mobile apps. Methods: We searched MEDLINE, PsycINFO, CINAHL, Embase, the ACM Digital Library, and IEEE Xplore databases to identify papers published between 2008 and 2023. Original empirical research studies reporting on gamified mobile apps for children with disabilities that implemented at least 1 gamification strategy or tactic were included. Studies investigating serious games or full-fledged games were excluded. Results: A total of 38 studies reporting on 32 unique gamified mobile apps were included. Findings showed that gamified apps focus on communication skills and oral health in children with autism spectrum disorder while also addressing self-management and academic skills for other disability groups. Gamified mobile apps have demonstrated potential benefits across different populations and conditions; however, there were mixed results regarding their impact. The gamification strategies included fun and playfulness (23/32, 72%), feedback on performance (17/32, 53%), and reinforcement (17/32, 53%) in more than half of apps, whereas social connectivity was used as a gamification strategy in only 4 (12%) mobile apps. There were 2 main reasons for integrating gamification elements into mobile apps described in 16 (42%) studies: increasing user engagement and motivation and enhancing intervention effects. Conclusions: This scoping review offers researchers a comprehensive review of the gamification elements currently used in mobile apps for the purposes of treatment, education, symptom management, and assessment for children with disabilities. In addition, it indicates that studies on certain disability groups and examinations of health-related outcomes have been neglected, highlighting the need for further investigations in these areas. Furthermore, research is needed to investigate the effectiveness of mobile-based gamification elements on health and health behavior outcomes, as well as the healthy development of children with disabilities. %M 39240675 %R 10.2196/49029 %U https://games.jmir.org/2024/1/e49029 %U https://doi.org/10.2196/49029 %U http://www.ncbi.nlm.nih.gov/pubmed/39240675 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52017 %T The Impact and Acceptance of Gamification by Learners in a Digital Literacy Course at the Undergraduate Level: Randomized Controlled Trial %A Alnuaim,Abeer %K gamification %K games %K technology integration %K information literacy %K technology acceptance %D 2024 %7 23.8.2024 %9 %J JMIR Serious Games %G English %X Background: In recent years, the integration of technology in education has revolutionized traditional learning paradigms. Digital literacy, a crucial skill in the 21st century, has become a vital aspect of modern education, enabling students to navigate, critically assess, and effectively use digital tools. As educators strive to boost engagement and learning outcomes, gamification has appeared as an auspicious pedagogical approach. By applying game mechanics to nongame contexts, gamification seeks to create a more immersive and digital learning experience. Objective: This research paper aims to investigate the impact and acceptance of gamification by learners in a digital literacy course at the undergraduate level. Methods: In a pre-post intervention study, 168 undergraduate students were randomly assigned either to the experimental group (gamification based) or control group (conventional) learning condition. Both groups of participants learned the same topics in digital literacy. Results: Empirical findings showed that participants from the experimental group had better academic performance in digital literacy than those who were not exposed to the game-based learning environment. The participants’ prior experience with gamification was not found to be a significant predictor of their acceptance of gamification in a digital literacy course. Conclusions: The study provides evidence supporting the potential benefits of gamification in enhancing digital literacy education and opens the door for further exploration and implementation of gamified learning approaches in higher education settings. %R 10.2196/52017 %U https://games.jmir.org/2024/1/e52017 %U https://doi.org/10.2196/52017 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e54684 %T Feasibility and Acceptability of a Mobile Game to Support Smoking Cessation: Repeated Measures Study %A Goodwin,Shelby %A Nastasi,Jessica A %A Newman,Schyler T %A Rapoza,Darion %A Raiff,Bethany R %+ Department of Psychology, College of Science and Mathematics, Rowan University, 201 Mullica Hill Road, Glassboro, NJ, 08028, United States, 1 856 256 4500 ext 53782, raiff@rowan.edu %K mHealth %K mobile health %K smoking cessation %K video game intervention %K mobile phone %D 2024 %7 21.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Approximately half of smokers attempt to quit, but 90% of these attempts fail. Video game–based interventions have the potential to address common barriers to evidence-based smoking cessation treatment, including high cost, lack of health care access, and low engagement. Objective: The purpose of this study was to evaluate the feasibility and acceptability of a video game–based smoking cessation intervention called Inspired and its impact on the 7-day smoking point prevalence at the 30-day follow-up. Methods: US adults (n=48) were recruited via the web to use Inspired on their smartphones for 7 weeks. The object of the game was to defend a healing tree against attackers. Levels of the game were unlocked twice daily when participants self-reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which could strengthen in-game abilities. Participants received additional in-game rewards to aid gameplay by submitting either smoking self-reports only or self-reports indicating abstinence, determined through random assignment. In addition, participants completed a web-based survey at intake, week 4, week 7, and the 30-day follow-up. Results: Of the 48 participants, who had an average age of 39.8 (SD 10.7) years, 27 (56%) were female, 4 (8%) Hispanic, 37 (77%) White, and 27 (56%) employed; 26 (54%) earned .11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P≥.17 in all cases). Conclusions: Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective. Trial Registration: Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8 %M 38517466 %R 10.2196/43078 %U https://games.jmir.org/2024/1/e43078 %U https://doi.org/10.2196/43078 %U http://www.ncbi.nlm.nih.gov/pubmed/38517466 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48080 %T Improving Behavioral-Based Safety Training in Using Verbal Commands Through a Theory-Driven and Feedback-Based Nonimmersive Virtual Reality Game: Development and Usability Study %A Atagbuzia,Chukwudiebube %A Ng,Ean H %A Natarajan,Ganapathy %+ Oregon State University, 204 Rogers Hall, Oregon State University, Corvallis, OR, 97331, United States, 1 15417370570, ean.ng@oregonstate.edu %K behavioral safety training %K SERES framework %K Reflection, Engagement, Choice, Information, Play, Exposition framework %K gamification %K gestalt laws of perception %D 2024 %7 12.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The construction, chemical, aviation, medical, and health care industries have used serious games for safety training. To our knowledge, serious games have not been developed focusing on behavioral change to improve safety through the use of verbal commands and instilling players with heightened awareness of their spatial proximity to other people in their surroundings. Objective: We aimed to develop a theory-driven serious game for improving safety behavior using verbal commands and validate the implementation of the theoretical frameworks used for game development. The game developed, KitchenSpeak, was a first-person character (FPC) game where users respond to in-game prompts to use loud verbal commands when they are approaching another employee’s blind spot. Methods: In addition to using the SERES framework in guiding the general game design and development, and the Reflection, Engagement, Choice, Information, Play, Exposition (RECIPE) framework to inform the design of the game mechanics, we also applied gestalt laws of perception for graphic design to guide the design of the game’s user interface. We conducted 2 evaluative tests (alpha and beta) to collect end user and stakeholder feedback on the implementation of the theoretical frameworks, as well as to collect relevant information for full-scale implementation and a future validation study. Results: The alpha and beta tests had 8 and 40 participants, respectively. The alpha test results revealed that the theoretical frameworks were adequately applied; however, suggestions were also made to modify and improve the game. The beta test results suggested further improvements for the game design and found no differences in the perception of ease of play between participants with and without previous FPC gaming experience (P=.47; Kruskal-Wallis). Results suggested that the game met its design and theoretical requirements, and it would be easily playable by all players regardless of their previous experience in FPC games. Conclusions: A theory-driven and evidence-based FPC game titled KitchenSpeak was developed to teach the use of kitchen-speak terms in commercial kitchens. Evaluative tests were conducted to validate the implementation of the theoretical frameworks. Our main contributions are creating and validating game-based training to improve behavioral-based safety in the workplace and the incorporation of gestalt laws of perception for graphic design in the game’s user interface. %M 38470470 %R 10.2196/48080 %U https://formative.jmir.org/2024/1/e48080 %U https://doi.org/10.2196/48080 %U http://www.ncbi.nlm.nih.gov/pubmed/38470470 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47257 %T Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review %A Hakim,Hina %A Driedger,S Michelle %A Gagnon,Dominique %A Chevrier,Julien %A Roch,Geneviève %A Dubé,Eve %A Witteman,Holly O %+ Department of Family and Emergency Medicine, Université Laval, 1050 avenue de la Médecine, Pavillon Ferdinand-Vandry, Québec City, QC, G1V 0A6, Canada, 1 418 656 2131, hina.hakim.1@ulaval.ca %K digital gamified tools %K digital game %K vaccination %K gamification %K vaccine uptake %K scoping review %K review method %K vaccine %K gamified %K COVID-19 %K COVID %K SARS-CoV-2 %K health behaviour %K health behavior %K health promotion %K behavior change %K behaviour change %D 2024 %7 29.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health. Objective: In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools. Methods: We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively. Results: Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature. Conclusions: Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts. %M 38421688 %R 10.2196/47257 %U https://games.jmir.org/2024/1/e47257 %U https://doi.org/10.2196/47257 %U http://www.ncbi.nlm.nih.gov/pubmed/38421688 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52990 %T The Effects of Serious Games on Cardiopulmonary Resuscitation Training and Education: Systematic Review With Meta-Analysis of Randomized Controlled Trials %A Cheng,Pengfei %A Huang,Yangxi %A Yang,Pengyu %A Wang,Haizhen %A Xu,Baichao %A Qu,Chaoran %A Zhang,Hua %+ International Nursing School, Hainan Medical University, Number 3, Xueyuan Road., Haikou, 571199, China, 86 13698954876, zhanghuashelley@hotmail.com %K CPR %K education %K meta-analysis %K serious game %K training %D 2024 %7 6.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Serious games have emerged as an innovative educational strategy with the potential to significantly enhance the quality and effectiveness of cardiopulmonary resuscitation (CPR) training. Despite their promise, there remains a degree of controversy when comparing the advantages of serious games with traditional CPR training methods. This study seeks to provide a comprehensive assessment of the impact of serious games on CPR training and education by systematically analyzing the results of previous research. Objective: This study aimed to assess the effect of serious games on CPR training and education by summarizing and pooling the results of previous studies. Methods: We conducted a thorough and systematic search across 9 prominent web-based databases, encompassing the period from the inception of these databases until April 1, 2023. The databases included in our search were PubMed, Cochrane Library, Wiley Online Library, EBSCO (PsycInfo), SpringerLink, Chinese Biology Medicine Disc, Vip Journal Integration Platform, Wanfang Database, and Chinese National Knowledge Infrastructure. The studies selected adhered to the following criteria: (1) being a randomized controlled trial comparing serious games and traditional methods for CPR training; (2) having participants aged 12 years or older in CPR; (3) having an experimental group using serious games and a control group using nongame methods for CPR instruction; and (4) having outcomes including theoretical and skill assessments, compression depth, and rate. The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Data analysis was performed using RevMan (version 5.3; Cochrane Training), and mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables. Results: A total of 9 articles were included, involving 791 study participants, of whom 395 in the experimental group taught CPR training using serious games and 396 in the control group taught CPR training using traditional methods. The results of our meta-analysis indicate that the use of serious games in CPR training yields outcomes that are comparable in effectiveness to traditional training methods across several key areas. Specifically, serious games demonstrated equivalence to traditional formats in theory assessment (SMD –0.22, 95% CI – 0.96 to 0.51; P=.55), skill assessment (SMD –0.49, 95% CI –1.52 to 0.55; P=.36), compression depth (MD –3.17, 95% CI –0.18 to 6.53; P=.06), and compression rate (MD –0.20, 95% CI –7.29 to 6.89; P=.96). Conclusions: In summary, serious games offer a viable and effective CPR education approach, yielding results comparable to traditional formats. This modality is a valuable addition to CPR training methodologies. However, caution is warranted in interpreting these findings due to limited controlled trials, small sample sizes, and low-quality meta-analyzed evidence. %M 38319697 %R 10.2196/52990 %U https://games.jmir.org/2024/1/e52990 %U https://doi.org/10.2196/52990 %U http://www.ncbi.nlm.nih.gov/pubmed/38319697 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39019 %T The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review %A Huang,Xiting %A Xiang,Xinyue %A Liu,Yang %A Wang,Zhiqian %A Jiang,Zhili %A Huang,Lihua %+ Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Building 17, 3rd Floor, 79 Qingchun Road, Hangzhou, 310003, China, 86 13867129329, lihuahuang818@zju.edu.cn %K gamification %K chronic diseases %K self-management %K scoping review %K mobile phone %D 2023 %7 22.12.2023 %9 Review %J JMIR Serious Games %G English %X Background: Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients’ participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases. Objective: This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population. Methods: We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis. Results: We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard. Conclusions: This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification. %M 38133907 %R 10.2196/39019 %U https://games.jmir.org/2023/1/e39019 %U https://doi.org/10.2196/39019 %U http://www.ncbi.nlm.nih.gov/pubmed/38133907 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51812 %T Assessing the Impact of a Serious Game (MedSMARxT: Adventures in PharmaCity) in Improving Opioid Safety Awareness Among Adolescents and Parents: Quantitative Study %A Abraham,Olufunmilola %A McCarthy,Tyler James %A Zaborek,Jen %+ 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 adolescent %K opioid %K medication safety %K serious games %K gamification %K health behavior %D 2023 %7 7.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: The opioid crisis continues to worsen across the United States, affecting people of all demographics. Few evidence-based interventions exist for educating families, particularly those with adolescents, about opioid prescription safety. Serious games have demonstrated impacts in improving medication-related outcomes for various health conditions. The characterizing goal of this serious game is to improve opioid safety knowledge and awareness among adolescents and their families. Objective: This study evaluated the impact of a serious game, MedSMARxT: Adventures in PharmaCity, designed to foster opioid safety awareness among adolescents and their parents. Methods: A national sample of parents and their adolescent children was recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Eligible participants were adolescents aged between 12 and 18 years and their parents. Study participants were required to reside in the United States; speak, read, and understand English; and have access to a computer with a webcam. Parent-child dyads completed pregame and postgame surveys and participated in gameplay for up to 30 minutes. Primary outcome scales have been previously evaluated by the study team. Results: A total of 60 adolescent participants and 68 parent participants met full attention criteria for inclusion in this study. Statistical analysis confirmed that both adolescents’ and parents’ concept scores improved from baseline regarding opioid safety self-efficacy (adolescent: mean 0.35, SD 0.60; P<.001; parent: mean 0.28, SD 0.42; P<.001), perceived knowledge (adolescent: mean 1.08, SD 1.04; P<.001; parent: mean 0.56, SD 0.55; P<.001), behavioral intent (adolescent: mean 0.26, SD 0.39; P<.001; parent: mean 0.25, SD 0.32; P<.001), safe storage (adolescent: mean 0.12, SD 0.27; P<.001; parent: mean 0.03, SD 0.11; P=.03), disposal knowledge (adolescent: mean 0.10, SD 0.27; P=.006; parent: mean 0.07, SD 0.16; P<.001), and knowledge about misuse behavior (adolescent: mean 0.05, SD 0.14; P=.002; parent: mean 0.04, SD 0.10; P<.001). Participant groups, stratified by who completed and who did not complete gameplay, improved their knowledge and awareness, with no significant differences between subgroups. Conclusions: The use of this serious game to improve opioid prescription safety practices among parents and adolescents was supported by the study findings. MedSMARxT: Adventures in PharmaCity is an intervention with the capability of teaching parents and adolescents about safe opioid prescription practices. Further studies and game refinement are needed to demonstrate the effectiveness of a game-based intervention in clinical settings and community pharmacies. %M 38060287 %R 10.2196/51812 %U https://formative.jmir.org/2023/1/e51812 %U https://doi.org/10.2196/51812 %U http://www.ncbi.nlm.nih.gov/pubmed/38060287 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e48063 %T Effects of a Gamified Agent-Based System for Personalized Elderly Care: Pilot Usability Study %A Martinho,Diogo %A Crista,Vítor %A Carneiro,João %A Matsui,Kenji %A Corchado,Juan Manuel %A Marreiros,Goreti %+ Research Group on Intelligent Engineering and Computing for Advanced Innovation and Development, Polytechnic of Porto - School of Engineering (ISEP), R. Dr. António Bernardino de Almeida 431, Porto, 4249-015, Portugal, 351 911007406, diepm@isep.ipp.pt %K gamification %K cognitive assistants %K elderly care %K coaching system %K older people %K technology %K virtual assistant %K cognitive %K usability %K intervention %K physical activity %K agent-based system %D 2023 %7 23.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The global percentage of older people has increased significantly over the last decades. Information and communication technologies have become essential to develop and motivate them to pursue healthier ways of living. This paper examines a personalized coaching health care service designed to maintain living conditions and active aging among older people. Among the technologies the service includes, we highlight the use of both gamification and cognitive assistant technologies designed to support older people and an application combining a cognitive virtual assistant to directly interact with the older person and provide feedback on their current health condition and several gamification techniques to motivate the older person to stay engaged with the application and pursuit of healthier daily habits. Objective: This pilot study aimed to investigate the feasibility and usability of a gamified agent-based system for older people and obtain preliminary results on the effectiveness of the intervention regarding physical activity health outcomes. Methods: The study was designed as an intervention study comparing pre- and posttest results. The proposed gamified agent-based system was used by 12 participants over 7 days (1 week), and step count data were collected with access to the Google Fit application programming interface. Step count data after the intervention were compared with average step count data before the intervention (average daily values over a period of 4 weeks before the intervention). A　1-tailed Student t test was used to determine the relationship between the dependent and independent variables. Usability was measured using the System Usability Scale questionnaire, which was answered by 8 of the 12 participants in the study. Results: The posttest results showed significant pre- to posttest changes (P=.30; 1-tailed Student t test) with a moderate effect size (Cohen d=0.65). The application obtained an average usability score of 78. Conclusions: The presented pilot was validated, showing the positive health effects of using gamification techniques and a virtual cognitive assistant. Additionally, usability metrics considered for this study confirmed high adherence and interest from most participants in the pilot. %M 37995116 %R 10.2196/48063 %U https://games.jmir.org/2023/1/e48063 %U https://doi.org/10.2196/48063 %U http://www.ncbi.nlm.nih.gov/pubmed/37995116 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e49019 %T Influence of Pokémon GO on Physical Activity and Psychosocial Well-Being in Children and Adolescents: Systematic Review %A Liang,Haiyan %A Wang,Xi %A An,Ruopeng %+ School of Sport Business, Guangzhou Sport University, 1268, Guangzhou Avenue Middle, Tianhe District,, Guangzhou, 510500, China, 86 20 38024301, 2405753573@qq.com %K Pokémon GO %K artificial intelligence %K physical activity %K psychosocial well-being %K children %K adolescent %D 2023 %7 13.11.2023 %9 Review %J J Med Internet Res %G English %X Background: Pokémon GO, an augmented reality game with widespread popularity, can potentially influence players’ physical activity (PA) levels and psychosocial well-being. Objective: This review aims to systematically examine the scientific evidence regarding the impact of Pokémon GO on PA and psychosocial well-being in children and adolescents. Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework, we conducted keyword and reference searches in the PubMed, CINAHL, Web of Science, and Scopus databases. We performed title and abstract screening, full-text review, evidence synthesis, and identified research gaps. Results: Our review included 10 studies that explored the effect of Pokémon GO on PA or psychosocial well-being among children and adolescents. These studies used diverse designs across multiple countries and regions. Pokémon GO use measures encompassed frequency, experience, adherence, and motivation. PA assessment methods ranged from self-reported questionnaires to technology-based evaluations and qualitative approaches. Psychosocial well-being measures included emotional intelligence, personal well-being, self-control, emotionality, and sociability. In general, the estimated impact of Pokémon GO on PA was positive, with gaming elements and engagement correlating with increased PA levels. However, the effect on psychosocial well-being presented mixed results, with positive associations for sociability but a complex relationship involving well-being and internet gaming disorder. The limitations of these studies comprised the absence of randomized controlled trials, heterogeneity in study designs and outcome measures, and potential confounding bias. Conclusions: Overall, Pokémon GO tends to positively affect PA levels, while the impact on psychosocial well-being remains complex and requires further investigation. Future research should investigate the mechanisms connecting Pokémon GO use with PA and psychosocial well-being and the potential risks of excessive gameplay. These findings can help inform public health interventions to harness gaming technologies for promoting PA and enhancing well-being among the younger generation. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42023412032; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=412032 %M 37955949 %R 10.2196/49019 %U https://www.jmir.org/2023/1/e49019 %U https://doi.org/10.2196/49019 %U http://www.ncbi.nlm.nih.gov/pubmed/37955949 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44708 %T Case-Based Serious Gaming for Complication Management in Colorectal and Pancreatic Surgery: Prospective Observational Study %A Schwarzkopf,Sophie-Caroline %A Distler,Marius %A Welsch,Thilo %A Krause-Jüttler,Grit %A Weitz,Jürgen %A Kolbinger,Fiona R %+ Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, TUD Dresden University of Technology, Fetscherstrasse 74, Dresden, 01307, Germany, 49 351 458 ext 19624, fiona.kolbinger@uniklinikum-dresden.de %K Serious game %K surgical education %K clinical reasoning %K medical education %K postoperative complications %K educational games %K computer-based learning %K colorectal surgery %K decision-making %K pancreatic surgery %D 2023 %7 9.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The potential risk and subsequent impact of serious complications after pancreatic and colorectal surgery can be significantly reduced through early recognition, correct assessment, and timely initiation of appropriate therapy. Serious gaming (SG) is an innovative teaching method that combines play with knowledge acquisition, increased concentration, and quick decision-making and could therefore be used for clinically oriented education. Objective: This study aims to develop a case-based SG platform for complication management in pancreatic and colorectal surgery, validate the application by comparing game courses of various professional groups in the health care sector, and test the acceptance of the developed platform in the context of clinical education by measuring levels of usability and applicability within the framework of a validity and usefulness analysis. Methods: In this observational trial, a novel SG for management of postoperative complications was developed and prospectively validated in a cohort of 131 human caregivers with varying experience in abdominal surgery. A total of 6 realistic patient cases were implemented, representing common complications after pancreatic and colorectal surgery. Cases were developed and illustrated using anonymized images, data, and histories of postoperative patients. In the prospective section of this study, following a brief case presentation, participants were asked to triage the virtual patient, make an initial suspected diagnosis, and design a 3-step management plan, throughout which the results of selected diagnostic and therapeutic actions were presented. Participants’ proposed case management was compared to ideal case management according to clinical guidelines. Usability, applicability, validity, and acceptance of the application were assessed using the Trier Teaching Evaluation Inventory as part of a noncomparative analysis. In addition, a comparative analysis of conventional teaching and learning formats was carried out. Results: A total of 131 cases were answered. Physicians selected more appropriate therapeutic measures than nonphysicians. In the Trier Teaching Evaluation Inventory, design, structure, relevance, timeliness, and interest promotion were predominantly rated positively. Most participants perceived the application to be superior to conventional lecture-based formats (training courses, lectures, and seminars) in terms of problem-solving skills (102/131, 77.9%), self-reflection (102/131, 77.9%), and usability and applicability (104/131, 79.4%). Conclusions: Case-based SG has educational potential for complication management in surgery and could thereby contribute to improvements in postoperative patient care. %M 37943588 %R 10.2196/44708 %U https://games.jmir.org/2023/1/e44708 %U https://doi.org/10.2196/44708 %U http://www.ncbi.nlm.nih.gov/pubmed/37943588 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e40190 %T The Relationship Between Lockdowns and Video Game Playtime: Multilevel Time-Series Analysis Using Massive-Scale Data Telemetry %A Zendle,David %A Flick,Catherine %A Halgarth,Darel %A Ballou,Nick %A Cutting,Joe %A Drachen,Anders %+ Department of Computer Science, University of York, Heslington Way, York, YO10 5GH, United Kingdom, 44 1904320000, david.zendle@york.ac.uk %K COVID-19 %K lockdown policy %K disordered gaming %K big data %K playtime %K policy %K lockdown %K public health %K side effects %K pandemic %K video games %K playing %K gaming %K time %K disordered %D 2023 %7 8.11.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 led governments worldwide to enact a variety of containment and closure policies. Substantial attention has been directed toward the idea that these public health measures may have unanticipated negative side effects. One proposed effect relates to video games. There is a nascent evidence base suggesting that individuals played video games for longer and in a more disordered manner during lockdowns and school closures specifically. These increases are commonly framed as a potential health concern in relation to disordered gaming. However, the evidence base regarding changes in gaming during the COVID-19 pandemic is based on self-report and, thus, is susceptible to bias. Therefore, it is unclear what the true consequences of lockdowns were for gaming behavior worldwide. Objective: The primary objective of this study was to estimate whether any specific lockdown policy led to meaningful increases in the amount of time individuals spent playing video games. Methods: Rather than relying on self-report, we used >251 billion hours of raw gameplay telemetry data from 184 separate countries to assess the behavioral correlates of COVID-19–related policy decisions. A multilevel model estimated the impact of varying enforcement levels of 8 containment and closure policies on the amount of time that individual users spent in-game. Similar models estimated the impact of policy on overall playtime and the number of users within a country. Results: No lockdown policy can explain substantial variance in playtime per gamer. School closures were uniquely associated with meaningful increases in total playtime within a country (r2=0.048). However, this was associated with increases in the number of unique individuals playing games (r2=0.057) rather than increases in playtime per gamer (r2<0.001). Conclusions: Previous work using self-report data has suggested that important increases in heavy gaming may occur during pandemics because of containment and closure (“lockdown”) procedures. This study contrasts with the previous evidence base and finds no evidence of such a relationship. It suggests that significant further work is needed before increases in disordered or heavy gaming are considered when planning public health policies for pandemic preparedness. %M 37938889 %R 10.2196/40190 %U https://www.jmir.org/2023/1/e40190 %U https://doi.org/10.2196/40190 %U http://www.ncbi.nlm.nih.gov/pubmed/37938889 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42117 %T Using Augmented Reality Toward Improving Social Skills: Scoping Review %A Mittmann,Gloria %A Zehetner,Vanessa %A Hoehl,Stefanie %A Schrank,Beate %A Barnard,Adam %A Woodcock,Kate %+ School of Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2SA, United Kingdom, 44 121 414 6036, papers@katewoodcock.com %K virtual reality %K serious games %K autism spectrum disorder %K social learning %K communication %K cooperation %K mobile phone %D 2023 %7 20.9.2023 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR) has emerged as a promising technology in educational settings owing to its engaging nature. However, apart from applications aimed at the autism spectrum disorder population, the potential of AR in social-emotional learning has received less attention. Objective: This scoping review aims to map the range of AR applications that improve social skills and map the characteristics of such applications. Methods: In total, 2 independent researchers screened 2748 records derived from 3 databases in December 2021—PubMed, IEEE Xplore, and ACM Guide to Computing Literature. In addition, the reference lists of all the included records and existing reviews were screened. Records that had developed a prototype with the main outcome of improving social skills were included in the scoping review. Included records were narratively described for their content regarding AR and social skills, their target populations, and their outcomes. Evaluation studies were assessed for methodological quality. Results: A total of 17 records met the inclusion criteria for this study. Overall, 10 records describe applications for children with autism, primarily teaching about reading emotions in facial expressions; 7 records describe applications for a general population, targeting both children and adults, with a diverse range of outcome goals. The methodological quality of evaluation studies was found to be weak. Conclusions: Most applications are designed to be used alone, although AR is well suited to facilitating real-world interactions during a digital experience, including interactions with other people. Therefore, future AR applications could endorse social skills in a general population in more complex group settings. %M 37728971 %R 10.2196/42117 %U https://games.jmir.org/2023/1/e42117 %U https://doi.org/10.2196/42117 %U http://www.ncbi.nlm.nih.gov/pubmed/37728971 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e49382 %T Parents’ Perceptions of a Serious Game for Educating Families on Prescription Opioid Safety: Qualitative Pilot Study of MedSMARxT: Adventures in PharmaCity %A Abraham,Olufunmilola %A Nixon,Grace Ann %A Seitz,Laura Louise %+ 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 6082634498, olufunmilola.abraham@wisc.edu %K opioids %K opioid %K parents %K adolescents %K medication safety %K family health %K serious games %K parent %K adolescent %K youths %K gaming %K game %K games %K teenager %K teenagers %K acceptance %K perception %K perceptions %K patient education %K pharmacy %K pharmaceutic %K pharmaceutics %K pharmaceutical %K drug %K safety %D 2023 %7 12.9.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Opioid misuse is a pervasive, worsening problem that affects the health of people throughout the United States, including adolescents. There are few adolescent-focused interventions designed to educate them about opioid medication safety. The MedSMARxT: Adventures in PharmaCity, is a serious educational video game that teaches parents and their youths about safe opioid practices. Objective: This study aimed to elucidate parent’s perceptions of MedSMARxT: Adventures in PharmaCity and its potential use by parents and their adolescents. Methods: Parents of adolescents aged 12 to 18 years who live in the United States were recruited from April to October 2021 via Qualtrics research panels, social media, email listserves, and snowball sampling. The study participants played MedSMARxT: Adventures in PharmaCity for 30 minutes and then participated in a 30-minute postgame interview via WebEx (Cisco). Questions were developed and piloted to examine adults’ perceptions of the game. Participants were asked three sets of open-ended questions: (1) questions about the game and elements of the game, (2) what they learned from the game, and (3) questions about their experience with games. Audio recordings were transcribed verbatim. Interview transcripts were coded using content and thematic analysis by study team members to identify major themes and subthemes from the data. Results: Parent participants (N=67) played MedSMARxT: Adventures in PharmaCity and completed a postgame interview. Analysis extrapolated four primary themes from the data: (1) participant gaming experience, (2) perception of game features, (3) educational purpose of the game, and (4) future use of the game. Most participants (n=56, 84%), had at least some experience with video games. More than half of the participants (n=35, 52%) participants, had positive reactions to the game characters and scenes depicted in MedSMARxT: Adventures in PharmaCity and stated they were realistic for adolescents. Most participants (n=39, 58%), would recommend the game to others. Significant difficulties with gameplay navigation were reported by 38 (57%) participants, as well as a slow game pace. All participants were able to accurately identify the overarching goal of the game: opioid or medication safety. The game reinforced existing knowledge for participants, though many (n=15, 22%), reported a new awareness of the need to store opioid medications in a locked area and the availability of medication disposal drop boxes at pharmacies. Participants stated that they would recommend the game for future use by families and youths in various health care and non–health care settings. Conclusions: The use of a tailored serious game is a novel, engaging tool to educate adolescents on opioid safety. MedSMARxT: Adventures in PharmaCity can be used as a tool for parents and adolescents to facilitate meaningful dialogue about safe and appropriate opioid use. %M 37698899 %R 10.2196/49382 %U https://games.jmir.org/2023/1/e49382 %U https://doi.org/10.2196/49382 %U http://www.ncbi.nlm.nih.gov/pubmed/37698899 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e51772 %T The Effectiveness of Video-Based Game Exercise Therapy Applications in Pes Planus Rehabilitation: Protocol for a Randomized Controlled Trial %A Erten,Ayşe Büşra %A Tarakçı,Devrim %A Çaçan,Mehmet Akif %+ Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Istanbul Medipol University, Kavacık South Campus, Göztepe Mahallesi Atatürk Caddesi No: 40/16, Beykoz, Istanbul, 34815, Turkey, 90 0216 681 51 00, abertenn@gmail.com %K exergame %K pes planus %K rehabilitation %K serious game %K video-based game therapy %D 2023 %7 11.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Pes planus is one of the most common foot deformities. Although there are many studies on the effectiveness of various exercise methods in pes planus rehabilitation, the number of studies on video-based game exercise therapy applications is very limited. Objective: This study aims to evaluate the effectiveness of 2 video-based game exercise therapies and structured exercise practices in pes planus rehabilitation. Methods: This study is a 3-arm, parallel-group, single-blinded randomized controlled trial. The study will include 69 patients with flexible pes planus aged between 18 and 25 years who attend the orthopedics and traumatology clinic and meet the inclusion criteria. The primary outcomes are measures of navicular drop and pedobarographic analysis before and after the intervention, and the secondary outcomes include balance, femoral anteversion, and lower extremity muscle strength. Participants will be evaluated with a navicular drop test for medial longitudinal arch height, a pedobarographic analysis system for plantar pressure analysis, a Craig test for femoral anteversion, the Becure Balance System for balance measurement, and a myometer device for lower extremity muscle strength measurement. Participants will be randomly assigned to a structured exercise group, an exergame group, or a serious game group according to their order of arrival. The structured exercise group will use a short foot exercise, a towel-picking exercise, and various walking and balance exercises. Patients in the serious play group will play the lower extremity games in the Becure Balance System. Patients in the exergame group will play balance games on the Nintendo Wii game console. All participants will participate in 18 exercise sessions (3 days a week for 6 weeks). After the treatment, the initial measurements will be repeated. Results: The study started in January 2023. It is expected to be completed in June 2024. Conclusions: This study will be the first randomized controlled study to evaluate the effectiveness of 2 different video-based game exercise therapy applications in pes planus rehabilitation. Through this study, the use of video-based game exercise therapy in pes planus rehabilitation, together with the developing technology, will be a guide. In addition, a new exercise protocol, including serious game exercises, will be added to the literature. In the future, it is expected that our study on the development of different game systems, especially for the ankle, will provide pioneering feedback. Trial Registration: ClinicalTrials.gov NCT05679219; https://clinicaltrials.gov/study/NCT05679219 International Registered Report Identifier (IRRID): DERR1-10.2196/51772 %M 37695657 %R 10.2196/51772 %U https://www.researchprotocols.org/2023/1/e51772 %U https://doi.org/10.2196/51772 %U http://www.ncbi.nlm.nih.gov/pubmed/37695657 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45969 %T Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review %A Stathakarou,Natalia %A Kononowicz,Andrzej A %A Swain,Cara %A Karlgren,Klas %+ Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, Solna, Stockholm, 171 77, Sweden, 46 8 524 852 98, natalia.stathakarou@ki.se %K gamification %K game elements %K military medicine %K trauma %K medical education %K military training %K systematic review %K game %K gaming %K simulation %D 2023 %7 8.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. Objective: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. Methods: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. Results: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20% (126/630) of the identified abstracts in groups of 2 reviewers. Conclusions: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. International Registered Report Identifier (IRRID): DERR1-10.2196/45969 %M 37682596 %R 10.2196/45969 %U https://www.researchprotocols.org/2023/1/e45969 %U https://doi.org/10.2196/45969 %U http://www.ncbi.nlm.nih.gov/pubmed/37682596 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39915 %T The Success of Serious Games and Gamified Systems in HIV Prevention and Care: Scoping Review %A Jitmun,Waritsara %A Palee,Patison %A Choosri,Noppon %A Surapunt,Tisinee %+ Data Analytics and Knowledge Synthesis for Healthcare (DAKSH) Research Group, College of Arts, Media, and Technology, Chiang Mai University, 239 Huay Kaew Rd, Su Thep Road, Mueang, Chiang Mai, 50200, Thailand, 66 918592114, noppon.c@cmu.ac.th %K HIV %K serious game %K gamification %K public health %K primary health care %K patient care %K behavioral health %D 2023 %7 5.9.2023 %9 Review %J JMIR Serious Games %G English %X Background: AIDS, which is caused by HIV, has long been one of the most significant global public health issues. Since the beginning of the HIV epidemic, various types of nonelectronic communication tools have been commonly used in HIV/AIDS prevention and care, but studies that apply the potential of electronic games are still limited. Objective: We aimed to identify, compare, and describe serious games and gamified systems currently used in HIV/AIDS prevention and care that were studied over a specific period of time. Methods: A scoping review was conducted into serious games and gamified systems used in HIV prevention and care in various well-known digital libraries from January 2010 to July 2021. Results: After identifying research papers and completing the article selection process, 49 of the 496 publications met the inclusion criteria and were examined. A total of 32 articles described 22 different serious games, while 17 articles described 13 gamified systems for HIV prevention and care. Conclusions: Most of the studies described in the publications were conducted in the United States, while only a few studies were performed in sub-Saharan African countries, which have the highest global HIV/AIDS infection rates. Regarding the development platform, the vast majority of HIV/AIDS gaming systems were typically deployed on mobile devices. This study demonstrates the effectiveness of using serious games and gamified systems. Both can improve the efficacy of HIV/AIDS prevention strategies, particularly those that encourage behavior change. %M 37669098 %R 10.2196/39915 %U https://games.jmir.org/2023/1/e39915 %U https://doi.org/10.2196/39915 %U http://www.ncbi.nlm.nih.gov/pubmed/37669098 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44414 %T A Novel, Expert-Endorsed, Neurocognitive Digital Assessment Tool for Addictive Disorders: Development and Validation Study %A Lee,Rico S C %A Albertella,Lucy %A Christensen,Erynn %A Suo,Chao %A Segrave,Rebecca A %A Brydevall,Maja %A Kirkham,Rebecca %A Liu,Chang %A Fontenelle,Leonardo F %A Chamberlain,Samuel R %A Rotaru,Kristian %A Yücel,Murat %+ QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, 4006, Australia, 61 412494834, muratyucel40@gmail.com %K cognitive neuroscience %K addictive behaviors %K mental health %K gaming %K gamified %K gamification %K development %K assessment %K software %K addiction %K mental disorder %K neurocognition %K neurocognitive %K brain health %K gamified task %K psychometric %K game developer %K game development %K validation %K validate %K validity %D 2023 %7 25.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Many people with harmful addictive behaviors may not meet formal diagnostic thresholds for a disorder. A dimensional approach, by contrast, including clinical and community samples, is potentially key to early detection, prevention, and intervention. Importantly, while neurocognitive dysfunction underpins addictive behaviors, established assessment tools for neurocognitive assessment are lengthy and unengaging, difficult to administer at scale, and not suited to clinical or community needs. The BrainPark Assessment of Cognition (BrainPAC) Project sought to develop and validate an engaging and user-friendly digital assessment tool purpose-built to comprehensively assess the main consensus-driven constructs underpinning addictive behaviors. Objective: The purpose of this study was to psychometrically validate a gamified battery of consensus-based neurocognitive tasks against standard laboratory paradigms, ascertain test-retest reliability, and determine their sensitivity to addictive behaviors (eg, alcohol use) and other risk factors (eg, trait impulsivity). Methods: Gold standard laboratory paradigms were selected to measure key neurocognitive constructs (Balloon Analogue Risk Task [BART], Stop Signal Task [SST], Delay Discounting Task [DDT], Value-Modulated Attentional Capture [VMAC] Task, and Sequential Decision-Making Task [SDT]), as endorsed by an international panel of addiction experts; namely, response selection and inhibition, reward valuation, action selection, reward learning, expectancy and reward prediction error, habit, and compulsivity. Working with game developers, BrainPAC tasks were developed and validated in 3 successive cohorts (total N=600) and a separate test-retest cohort (N=50) via Mechanical Turk using a cross-sectional design. Results: BrainPAC tasks were significantly correlated with the original laboratory paradigms on most metrics (r=0.18-0.63, P<.05). With the exception of the DDT k function and VMAC total points, all other task metrics across the 5 tasks did not differ between the gamified and nongamified versions (P>.05). Out of 5 tasks, 4 demonstrated adequate to excellent test-retest reliability (intraclass correlation coefficient 0.72-0.91, P<.001; except SDT). Gamified metrics were significantly associated with addictive behaviors on behavioral inventories, though largely independent of trait-based scales known to predict addiction risk. Conclusions: A purpose-built battery of digitally gamified tasks is sufficiently valid for the scalable assessment of key neurocognitive processes underpinning addictive behaviors. This validation provides evidence that a novel approach, purported to enhance task engagement, in the assessment of addiction-related neurocognition is feasible and empirically defensible. These findings have significant implications for risk detection and the successful deployment of next-generation assessment tools for substance use or misuse and other mental disorders characterized by neurocognitive anomalies related to motivation and self-regulation. Future development and validation of the BrainPAC tool should consider further enhancing convergence with established measures as well as collecting population-representative data to use clinically as normative comparisons. %M 37624635 %R 10.2196/44414 %U https://www.jmir.org/2023/1/e44414 %U https://doi.org/10.2196/44414 %U http://www.ncbi.nlm.nih.gov/pubmed/37624635 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46602 %T Developing a Game (Inner Dragon) Within a Leading Smartphone App for Smoking Cessation: Design and Feasibility Evaluation Study %A White,Justin S %A Salem,Marie K %A Toussaert,Séverine %A Westmaas,J Lee %A Raiff,Bethany R %A Crane,David %A Warrender,Edward %A Lyles,Courtney %A Abroms,Lorien %A Thrul,Johannes %+ Philip R Lee Institute for Health Policy Studies, University of California, 490 Illinois Street, Box 0936, San Francisco, CA, 94158, United States, 1 415 476 8045, Justin.White@ucsf.edu %K smoking cessation %K mobile app %K games for health %K gamification %K software design %K feasibility %K mobile phone %D 2023 %7 11.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. Objective: The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation. Methods: In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. Results: Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users’ progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants. Conclusions: Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app. %M 37566442 %R 10.2196/46602 %U https://games.jmir.org/2023/1/e46602 %U https://doi.org/10.2196/46602 %U http://www.ncbi.nlm.nih.gov/pubmed/37566442 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45541 %T Usability and Satisfaction Testing of Game-Based Learning Avatar-Navigated Mobile (GLAm), an App for Cervical Cancer Screening: Mixed Methods Study %A Wanberg,Lindsey J %A Kim,Angela %A Vogel,Rachel I %A Sadak,Karim Thomas %A Teoh,Deanna %+ Division of Gynecologic Oncology, Masonic Cancer Center, University of Minnesota, 420 Delaware Street SE, MMC 395, Minneapolis, MN, 55455, United States, 1 612 625 6503, dkteoh@umn.edu %K cancer screening %K cervical cancer screening %K cervical cancer %K Game-based Learning Avatar-navigated mobile %K health care app %K mixed methods study %K mobile health %K mobile technology %K Pap test %K usability testing %K young adult health care %D 2023 %7 8.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Barriers to cervical cancer screening in young adults include a lack of knowledge and negative perceptions of testing. Evidence shows that mobile technology reduces these barriers; thus, we developed a web app, Game-based Learning Avatar-navigated mobile (GLAm), to educate and motivate cervical cancer screening using the Fogg Behavioral Model as a theoretic guide. Users create avatars to navigate the app, answer short quizzes with education about cervical cancer and screening, watch videos of the screening process, and earn digital trophies. Objective: We tested ease of use, usefulness, and satisfaction with the GLAm app among young adults. Methods: This mixed methods study comprised a qualitative think-aloud play interview session and a quantitative survey study. Participants were cervical cancer screening–eligible US residents aged 21 to 29 years recruited through social media. Qualitative study participants explored the app in a think-aloud play session conducted through videoconference. Data were analyzed using directed content analysis to identify themes of ease of use, usefulness, and content satisfaction. Qualitative study participants and additional participants then used the app independently for 1 week and completed a web-based survey (the quantitative study). Ease of use, usefulness, and satisfaction were assessed using the validated Technology Acceptance Model and Computer System Usability Questionnaire adapted to use of an app. Mean (SD) scores (range 1-7) are presented. Results: A total of 23 individuals participated in one or both study components. The mean age was 25.6 years. A majority were cisgender women (21/23, 91%) and White (18/23, 78%), and 83% (19/23) had at least some secondary education. Nine participants completed the think-aloud play session. Direct content analysis showed desire for content that is concise, eases anxiety around screenings, and uses game features (avatars and rewards). Twenty-three individuals completed the quantitative survey study. Mean scores showed the app was perceived to be easy to use (mean score 6.17, SD 0.27) and moderately useful to increase cervical cancer screening knowledge and uptake (mean score 4.94, SD 0.27). Participants were highly satisfied with the app (mean score 6.21, SD 1.20). Conclusions: Survey results showed participants were satisfied with the app format and found it easy to use. The app was perceived to be moderately useful to inform and motivate cervical cancer screening; notably, the screening reminder function was not tested in this study. Qualitative study results demonstrated the app’s ability to ease anxiety about screening through demonstration of the screening process, and brevity of app components was favored. Interpretation of results is limited by the predominantly cisgender, White, and educated study population; additional testing in populations which historically have lower cervical cancer screening uptake is needed. A modified version of the app is undergoing efficacy testing in a randomized clinical trial. %M 37552527 %R 10.2196/45541 %U https://formative.jmir.org/2023/1/e45541 %U https://doi.org/10.2196/45541 %U http://www.ncbi.nlm.nih.gov/pubmed/37552527 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45436 %T Gamification and Soft Skills Assessment in the Development of a Serious Game: Design and Feasibility Pilot Study %A Altomari,Luca %A Altomari,Natalia %A Iazzolino,Gianpaolo %+ Department of Mechanical, Energy and Management Engineering, University of Calabria, Ponte Pietro Bucci, Rende, 87036, Italy, 39 3932671847, luca.altomari@gmail.com %K gamification %K soft skills %K recruitment %K serious games %K assessment %K process mining %K work-life skills %D 2023 %7 26.7.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The advent of new technologies has had a profound impact on the labor market, transforming the way we work and interact with each other. With the rise of digital tools and platforms, gamification has emerged as a powerful technique for enhancing productivity and engagement in various fields, including human resource management. In particular, gamification has been found to be effective in developing and assessing soft skills, which play a critical role in determining the success of individuals, teams, and organizations. Objective: We present a serious game that identifies the most sought-after skills in the job market and offers feedback, and we provide a set of guidelines for the creation of serious games. Methods: We present the serious game Among the Office Criticality (AOC). The AOC game structure involves a set of sequence analysis techniques, which is known as process mining. Results: The pilot study findings indicate that the game is both engaging and beneficial to subjects, suggesting that the results align with current theoretical perspectives. Furthermore, the study suggests that the obtained data can be extended to the broader population. Conclusions: This study illustrates a serious game structured according to the needs of the labor market and developed to put the user at the center, using evaluation techniques consistent with the literature, with the aim of constituting an interdisciplinary approach suitable for adequately assessing users and creating value for them. %M 37494078 %R 10.2196/45436 %U https://games.jmir.org/2023/1/e45436 %U https://doi.org/10.2196/45436 %U http://www.ncbi.nlm.nih.gov/pubmed/37494078 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44429 %T A Gamified Mobile App That Helps People Develop the Metacognitive Skills to Cope With Stressful Situations and Difficult Emotions: Formative Assessment of the InsightApp %A Amo,Victoria %A Prentice,Mike %A Lieder,Falk %+ Max Planck Institute for Intelligent Systems, Max Planck Ring 4, Tübingen, 72076, Germany, 49 15730645508, victoria.amo@tuebingen.mpg.de %K ecological momentary interventions %K serious games %K mindfulness-based interventions %K acceptance and commitment therapy %K cognitive behavioral therapy %K mobile phone %D 2023 %7 16.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Ecological momentary interventions open up new and exciting possibilities for delivering mental health interventions and conducting research in real-life environments via smartphones. This makes designing psychotherapeutic ecological momentary interventions a promising step toward cost-effective and scalable digital solutions for improving mental health and understanding the effects and mechanisms of psychotherapy. Objective: The first objective of this study was to formatively assess and improve the usability and efficacy of a gamified mobile app, the InsightApp, for helping people learn some of the metacognitive skills taught in cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based interventions. The app aims to help people constructively cope with stressful situations and difficult emotions in everyday life. The second objective of this study was to test the feasibility of using the InsightApp as a research tool for investigating the efficacy of psychological interventions and their underlying mechanisms. Methods: We conducted 2 experiments. In experiment 1 (n=65; completion rate: 63/65, 97%), participants (mean age 27, SD 14.9; range 19-55 years; 41/60, 68% female) completed a single session with the InsightApp. The intervention effects on affect, belief endorsement, and propensity for action were measured immediately before and after the intervention. Experiment 2 (n=200; completion rate: 142/200, 71%) assessed the feasibility of conducting a randomized controlled trial using the InsightApp. We randomly assigned participants to an experimental or a control condition, and they interacted with the InsightApp for 2 weeks (mean age 37, SD 12.16; range 20-78 years; 78/142, 55% female). Experiment 2 included all the outcome measures of experiment 1 except for the self-reported propensity to engage in predefined adaptive and maladaptive behaviors. Both experiments included user experience surveys. Results: In experiment 1, a single session with the app seemed to decrease participants’ emotional struggle, the intensity of their negative emotions, their endorsement of negative beliefs, and their self-reported propensity to engage in maladaptive coping behaviors (P<.001 in all cases; average effect size=−0.82). Conversely, participants’ endorsement of adaptive beliefs and their self-reported propensity to act in accordance with their values significantly increased (P<.001 in all cases; average effect size=0.48). Experiment 2 replicated the findings of experiment 1 (P<.001 in all cases; average effect size=0.55). Moreover, experiment 2 identified a critical obstacle to conducting a randomized controlled trial (ie, asymmetric attrition) and how it might be overcome. User experience surveys suggested that the app’s design is suitable for helping people apply psychotherapeutic techniques to cope with everyday stress and anxiety. User feedback provided valuable information on how to further improve app usability. Conclusions: In this study, we tested the first prototype of the InsightApp. Our encouraging preliminary results show that it is worthwhile to continue developing the InsightApp and further evaluate it in a randomized controlled trial. %M 37327040 %R 10.2196/44429 %U https://formative.jmir.org/2023/1/e44429 %U https://doi.org/10.2196/44429 %U http://www.ncbi.nlm.nih.gov/pubmed/37327040 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39874 %T Effectiveness of a Personalized, Chess-Based Training Serious Video Game in the Treatment of Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial %A Rodrigo-Yanguas,María %A Martín-Moratinos,Marina %A González-Tardón,Carlos %A Sanchez-Sanchez,Fernando %A Royuela,Ana %A Bella-Fernández,Marcos %A Blasco-Fontecilla,Hilario %+ Servicio de Psiquiatría, Hospital Universitario Puerta de Hierro Majadahonda, C/ Manuel de Falla s/n, Majadahonda, 28222, Spain, 34 911911690, hmblasco@yahoo.es %K attention-deficit hyperactivity disorder %K ADHD %K serious video games %K cognitive training %K chess %K video game %K teen %K young adult %K game %K intervention %K treatment %K emotional %K control %K regulation %K attention %K school %K function %K symptom %D 2023 %7 24.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Compared with traditional approaches, gaming strategies are promising interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). We developed a serious game, The Secret Trail of Moon (TSTM), for ADHD treatment. Objective: The main objective of this clinical trial was to demonstrate the effectiveness of an add-on, either TSTM or Therapeutic Chess (TC), in previously optimally drug-titrated, clinically stable patients with ADHD. Methods: This study is a prospective, unicentric, randomized clinical trial in clinically stable patients with ADHD, aged 12 to 22 years. The TSTM (n=35) and TC groups (n=34) performed 12 weekly sessions of their respective treatments. The control group (CG) patients (n=35) were called by phone every week, but they received no cognitive intervention. The primary end point was the change from baseline to end point in the parent “Behavior Rating Inventory of Executive Function-2” (BRIEF-2; patients’ parents) in the per-protocol population (31 serious videogame: 24 TC and 34 CG). Results: Our study failed to probe clear-cut improvements in the global score of the BRIEF-2. However, the TC group showed improvements in measures of emotional control, emotional regulation, and inattention. The TSTM group showed improvements in measures of emotional regulation, inattention, and school context. Conclusions: TSTM and TC did not improve executive function symptoms, but they improved ADHD symptomatology related to emotional regulation. Further studies with bigger samples are required to confirm these preliminary findings. Trial Registration: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065 %M 37093628 %R 10.2196/39874 %U https://games.jmir.org/2023/1/e39874 %U https://doi.org/10.2196/39874 %U http://www.ncbi.nlm.nih.gov/pubmed/37093628 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43047 %T A Gamified Real-time Video Observed Therapies (GRVOTS) Mobile App via the Modified Nominal Group Technique: Development and Validation Study %A Abas,Siti Aishah %A Ismail,Nurhuda %A Zakaria,Yuslina %A Ismail,Ismassabah %A Mat Zain,Nurul Hidayah %A Yasin,Siti Munira %A Ibrahim,Khalid %A Razali,Asmah %A Mohd Yusoff,Mas Ahmad Sherzkawee %A Ahmad,Norliza %A Chinnayah,Thilaka %+ Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Sungai Buloh, 47000, Malaysia, 60 361267174, yuda@uitm.edu.my %K video directly observed therapy %K VDOT %K mobile health %K mHealth %K tuberculosis %K medication adherence %K directly observed therapy %K video-observed therapy %K mobile app %K mobile health app %K gamification %D 2023 %7 7.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The success rate of tuberculosis (TB) treatment in Malaysia remains below the recommended World Health Organization target of 90% despite the implementation of directly observed therapy, short-course, a physical drug monitoring system, since 1994. With increasing numbers of patients with TB in Malaysia defaulting on treatment, exploring another method to improve TB treatment adherence is vital. The use of gamification and real-time elements via video-observed therapies in mobile apps is one such method expected to induce motivation toward TB treatment adherence. Objective: This study aimed to document the process of designing, developing, and validating the gamification, motivation, and real-time elements in the Gamified Real-time Video Observed Therapies (GRVOTS) mobile app. Methods: The modified nominal group technique via a panel of 11 experts was used to validate the presence of the gamification and motivation elements inside the app, which were assessed based on the percentage of agreement among the experts. Results: The GRVOTS mobile app, which can be used by patients, supervisors, and administrators, was successfully developed. For validation purposes, the gamification and motivation features of the app were validated as they achieved a total mean percentage of agreement of 97.95% (SD 2.51%), which was significantly higher than the minimum agreement score of 70% (P<.001). Further, each component of gamification, motivation, and technology was also rated at 70% or more. Among the gamification elements, fun received the lowest scores, possibly because the nature of serious games does not prioritize the fun element and because the perception of fun varies by personality. The least popular element in motivation was relatedness, as stigma and discrimination hinder interaction features, such as leaderboards and chats, in the mobile app. Conclusions: It has been validated that the GRVOTS mobile app contains gamification and motivation elements, which are intended to encourage medication adherence to TB treatment. %M 36881449 %R 10.2196/43047 %U https://games.jmir.org/2023/1/e43047 %U https://doi.org/10.2196/43047 %U http://www.ncbi.nlm.nih.gov/pubmed/36881449 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e35756 %T Impact of Gamification on Consumers’ Favorability in Cause-Related Marketing Programs: Between-Subjects Experiments %A Li,Yanhe %A Li,Yanchen %A Zhou,Xiu %A Ma,Kunshu %+ School of Business, Macau University of Science and Technology, Avenida Wai Long, Taipa, Macau S.A.R, 999078, China, 86 88972037, ycli@must.edu.mo %K cause-related marketing %K gamification %K enjoyment %K favorability %K business %K marketing %K gamified %D 2023 %7 10.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Successful cause-related marketing (CRM) campaigns can help companies stand out from their competitors; however, CRM may not have pleasant outcomes, even if it receives substantial investment. Objective: This research aimed to investigate how gamified CRM projects influence consumers’ favorability. Methods: We introduced 3 different CRM projects in 3 different studies. Every project had 2 versions according to the level of gamification, and participants were randomly assigned into these 2 groups. Additionally, we used a 2 (gamification: lower, higher) 2 (rules presentation: without visual cues, with visual cues) between-subjects design to test the moderation role of rules presentation in gamified CRM projects. Results: In Study 1, we identified that the highly gamified CRM program induces more enjoyment (F1,139=21.11, P<.001) and higher favorability (F1,139=14.57, P<.001). Moreover, we found that enjoyment played a mediation role between gamification and favorability (P<.001) in Study 2. In addition, the results of Study 3 indicated rules presentation in a gamified CRM program can moderate the indirect effect of gamification on favorability via enjoyment (index of the moderated mediation: 95% CI –1.12 to –0.10; for rules presentation with visual cues: 95% CI 0.69 to 1.40; for rules presentation without visual cues: 95% CI 0.08 to 0.83). Conclusions: Overall, this research contributes to the CRM literature and suggests gamification is an effective way of managing CRM campaigns. %M 36626196 %R 10.2196/35756 %U https://games.jmir.org/2023/1/e35756 %U https://doi.org/10.2196/35756 %U http://www.ncbi.nlm.nih.gov/pubmed/36626196 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e36390 %T An Emotional Bias Modification for Children With Attention-Deficit/Hyperactivity Disorder: Co-design Study %A Zhang,Melvyn %A Ranganath,Vallabhajosyula %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 11, Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 98556631, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K attention-deficit/hyperactivity disorder %K ADHD %K child psychiatry %D 2022 %7 9.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the common neurodevelopment disorders. Children with ADHD typically have difficulties with emotional regulation. Previous studies have investigated the assessment for underlying emotional biases using the visual probe task. However, one of the significant limitations of the visual probe task is that it is demanding and repetitive over time. Previous studies have examined the use of gamification methods in addressing the limitations of the emotional bias visual probe task. There has also been increased recognition of the potential of participatory action research methods and how it could help to make the conceptualized interventions more relevant. Objective: The primary aim of this study was to collate health care professionals’ perspectives on the limitations of the existing visual probe task and to determine if gamification elements were viable to be incorporated into an emotional bias modification task. Methods: A co-design workshop was conducted. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore, were invited to participate. Considering the COVID-19 pandemic and the restrictions, a web-based workshop was conducted. There were 3 main phases in the workshops. First, participants were asked to identify limitations and suggest potential methods to overcome some of the identified limitations. Second, participants were shown examples of existing gaming interventions in published literature and commercial stores. They were also asked to comment on the advantages and limitations of these interventions. Finally, participants were asked if gamification techniques would be appropriate. Results: Overall, 4 health care professionals consented and participated. Several limitations were identified regarding the conventional emotional bias intervention. These included the nature of the task parameters, included stimulus set, and factors that could have an impact on the accuracy of responding to the task. After examining the existing ADHD games, participants raised concerns about the evidence base of some of the apps. They articulated that any developed ADHD game ought to identify the specific skill set that was targeted clearly. Regarding gamification strategies, participants preferred economic and performance-based gamification approaches. Conclusions: This study has managed to elucidate health care professionals’ perspectives toward refining a conventional emotional bias intervention for children with ADHD. In view of the repetitiveness of the conventional task, the suggested gamification techniques might help in influencing task adherence and reduce the attrition rates. %M 36485019 %R 10.2196/36390 %U https://formative.jmir.org/2022/12/e36390 %U https://doi.org/10.2196/36390 %U http://www.ncbi.nlm.nih.gov/pubmed/36485019 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e35907 %T Points and the Delivery of Gameful Experiences in a Gamified Environment: Framework Development and Case Analysis %A Park,Sungjin %A Kim,Sangkyun %+ Graduate School of Business, Kyung Hee University, 506, Orbis Hall, 24, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea, 82 02 961 0448, saviour@khu.ac.kr %K point %K design framework %K gamification %K gameful experience %K pointsification %K overjustification effect %D 2022 %7 29.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Points represent one of the most widely used game mechanics in gamification. They have been used as a means to provide feedback to users. They visually show user performance and are used along with other game mechanics to produce synergy effects. However, using points without analyzing the application environment and targets adversely affects users. Objective: This study aims to identify the problems that users encounter when points are applied improperly, to solve problems based on an analysis of previous studies and actual point use cases, and to develop a point design framework to deliver gameful experiences. Methods: Three problems were identified by analyzing previous studies. The first problem is points that only accumulate. The second is points that emphasize a user’s difference from other people. The third pertains to the reward distribution problem that occurs when points are used as rewards. Results: We developed a framework by deriving 3 criteria for applying points. The first criterion is based on the passive acquisition approach and the active use approach. The second criterion is used to classify points as “high/low” and “many/few” types. The third criterion is the classification of personal reward points and group reward points based on segmentation of the reward criteria. We developed 8 types of points based on the derived point design framework. Conclusions: We expect that some of the problems that users experience when using points can be solved. Furthermore, we expect that some of the problems that arise when points are used as rewards, such as pointsification and the overjustification effect, can be solved. By solving such problems, we suggest a direction that enables a gameful experience for point users and improves the core value delivery through gameful experiences. We also suggest a gameful experience delivery method in the context of the ongoing COVID-19 pandemic. %M 36173674 %R 10.2196/35907 %U https://games.jmir.org/2022/3/e35907 %U https://doi.org/10.2196/35907 %U http://www.ncbi.nlm.nih.gov/pubmed/36173674 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 9 %P e40189 %T Information System for Symptom Diagnosis and Improvement of Attention Deficit Hyperactivity Disorder: Protocol for a Nonrandomized Controlled Pilot Study %A Pandria,Niki %A Petronikolou,Vasileia %A Lazaridis,Aristotelis %A Karapiperis,Christos %A Kouloumpris,Eleftherios %A Spachos,Dimitris %A Fachantidis,Anestis %A Vasiliou,Dimitris %A Vlahavas,Ioannis %A Bamidis,Panagiotis %+ Medical Physics and Digital Innovation Lab, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Building D, Entrance 8, 3rd floor, Campus of Aristotle University of Thessaloniki, Thessaloniki, 54124, Greece, 30 2310999310, bamidis@auth.gr %K attention deficit hyperactivity disorder (ADHD) %K machine learning %K web health %K serious games %K ADHD monitoring %D 2022 %7 28.9.2022 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders during childhood; however, the diagnosis procedure remains challenging, as it is nonstandardized, multiparametric, and highly dependent on subjective evaluation of the perceived behavior. Objective: To address the challenges of existing procedures for ADHD diagnosis, the ADHD360 project aims to develop a platform for (1) early detection of ADHD by assessing the user’s likelihood of having ADHD characteristics and (2) providing complementary training for ADHD management. Methods: A 2-phase nonrandomized controlled pilot study was designed to evaluate the ADHD360 platform, including ADHD and non-ADHD participants aged 7 to 16 years. At the first stage, an initial neuropsychological evaluation along with an interaction with the serious game developed (“Pizza on Time”) for approximately 30-45 minutes is performed. Subsequently, a 2-week behavior monitoring of the participants through the mADHD360 app is planned after a telephone conversation between the participants’ parents and the psychologist, where the existence of any behaviors characteristic of ADHD that affect daily functioning is assessed. Once behavior monitoring is complete, the research team invites the participants to the second stage, where they play the game for a mean duration of 10 weeks (2 times per week). Once the serious game is finished, a second round of behavior monitoring is performed following the same procedures as the initial one. During the study, gameplay data were collected and preprocessed. The protocol of the pilot trials was initially designed for in-person participation, but after the COVID-19 outbreak, it was adjusted for remote participation. State-of-the-art machine learning (ML) algorithms were used to analyze labeled gameplay data aiming to detect discriminative gameplay patterns among the 2 groups (ADHD and non-ADHD) and estimate a player’s likelihood of having ADHD characteristics. A schema including a train-test splitting with a 75:25 split ratio, k-fold cross-validation with k=3, an ML pipeline, and data evaluation were designed. Results: A total of 43 participants were recruited for this study, where 18 were diagnosed with ADHD and the remaining 25 were controls. Initial neuropsychological assessment confirmed that the participants in the ADHD group showed a deviation from the participants without ADHD characteristics. A preliminary analysis of collected data consisting of 30 gameplay sessions showed that the trained ML models achieve high performance (ie, accuracy up to 0.85) in correctly predicting the users’ labels (ADHD or non-ADHD) from their gameplay session on the ADHD360 platform. Conclusions: ADHD360 is characterized by its notable capacity to discriminate player gameplay behavior as either ADHD or non-ADHD. Therefore, the ADHD360 platform could be a valuable complementary tool for early ADHD detection. Trial Registration: ClinicalTrials.gov NCT04362982; https://clinicaltrials.gov/ct2/show/NCT04362982 International Registered Report Identifier (IRRID): RR1-10.2196/40189 %M 36169998 %R 10.2196/40189 %U https://www.researchprotocols.org/2022/9/e40189 %U https://doi.org/10.2196/40189 %U http://www.ncbi.nlm.nih.gov/pubmed/36169998 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e31456 %T Digital Interventions for Emotion Regulation in Children and Early Adolescents: Systematic Review and Meta-analysis %A Reynard,Sally %A Dias,Joao %A Mitic,Marija %A Schrank,Beate %A Woodcock,Kate Anne %+ Centre for Applied Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2SA, United Kingdom, 44 0121 414 6036, sallyreynard1@gmail.com %K emotion regulation %K digital interventions %K youth %K systematic review %K meta-analysis %K children %K early adolescents %K serious games %K training %K biofeedback %K mobile phone %D 2022 %7 19.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Difficulties in emotion regulation are common in adolescence and are associated with poor social and mental health outcomes. However, psychological therapies that promote adaptive emotion regulation may be inaccessible and unattractive to youth. Digital interventions may help address this need. Objective: The aim of this systematic review and meta-analysis was to synthesize evidence on the efficacy, feasibility, and acceptability of emotion regulation digital interventions in children and early adolescents aged 8 to 14 years. Methods: Systematic searches of Web of Science, MEDLINE, PsycINFO, EMBASE, Education Resources Information Centre, ACM Digital Library, and IEEE Xplore up to July 2020 identified 39 studies, of which 11 (28%) were included in the meta-analyses (n=2476 participants). A bespoke tool was used to assess risk of bias. Results: The studies evaluated digital games (27/39, 69%), biofeedback (4/39, 10%), virtual or augmented reality (4/39, 10%), and program or multimedia (4/39, 10%) digital interventions in samples classified as diagnosed, at risk, healthy, and universal. The most consistent evidence came from digital games, which reduced negative emotional experience with a small significant effect, largely in youth at risk of anxiety (Hedges g=–0.19, 95% CI –0.34 to –0.04). In general, digital interventions tended to improve emotion regulation, but this effect was not significant (Hedges g=0.19, 95% CI –0.16 to 0.54). Conclusions: Most feasibility issues were identified in diagnosed youth, and acceptability was generally high across intervention types and samples. Although there is cause to be optimistic about digital interventions supporting the difficulties that youth experience in emotion regulation, the predominance of early-stage development studies highlights the need for more work in this area. %M 35984681 %R 10.2196/31456 %U https://games.jmir.org/2022/3/e31456 %U https://doi.org/10.2196/31456 %U http://www.ncbi.nlm.nih.gov/pubmed/35984681 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e35202 %T The Effectiveness of Serious Games in Improving Memory Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Alhuwail,Dari %A Al-Jafar,Eiman %A Ahmed,Arfan %A Shuweihdi,Farag %A Reagu,Shuja Mohd %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K memory %K systematic reviews %K meta-analysis %K mobile phone %D 2022 %7 9.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Memory, one of the main cognitive functions, is known to decline with age. Serious games have been used for improving memory in older adults. The effectiveness of serious games in improving memory has been assessed by many studies. To draw definitive conclusions about the effectiveness of serious games, the findings of these studies need to be pooled and aggregated. Objective: This study aimed to assess the effectiveness of serious games in improving memory in older adults with cognitive impairment. Methods: A systematic review of randomized controlled trials was carried out. The search sources included 8 databases, the reference lists of the included studies and relevant reviews, and the studies that cited the included studies. In total, 2 reviewers (AA and MH) independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Extracted data were synthesized using a narrative approach and a statistical approach (ie, multilevel meta-analysis), as appropriate. Results: Of the 618 citations retrieved, 18 (2.9%) met the eligibility criteria for this review. Of these 18 studies, 15 (83%) randomized controlled trials were included in 10 multilevel meta-analyses. We found that serious games were more effective than no or passive interventions in improving nonverbal memory (P=.02; standardized mean difference [SMD]=0.46, 95% CI 0.09-0.83) and working memory (P=.04; SMD=0.31, 95% CI 0.01-0.60) but not verbal memory (P=.13; SMD=0.39, 95% CI −0.11 to 0.89). The review also showed that serious games were more effective than conventional exercises in improving verbal memory (P=.003; SMD=0.46, 95% CI 0.16-0.77) but not nonverbal memory (P=.30; SMD=−0.19, 95% CI −0.54 to 0.17) or working memory (P=.99; SMD=0.00, 95% CI −0.45 to 0.45). Serious games were as effective as conventional cognitive activities in improving verbal memory (P=.14; SMD=0.66, 95% CI −0.21 to 1.54), nonverbal memory (P=.94; SMD=−0.01, 95% CI −0.32 to 0.30), and working memory (P=.08; SMD=0.37, 95% CI −0.05 to 0.78) among older adults with cognitive impairment. Finally, the effect of adaptive serious games on working memory was comparable with that of nonadaptive serious games (P=.08; SMD=0.18, 95% CI −0.02 to 0.37). Conclusions: Serious games have the potential to improve verbal, nonverbal, and working memory in older adults with cognitive impairment. However, our findings should be interpreted cautiously given that most meta-analyses were based on a few studies (≤3) and judged to have a low quality of evidence. Therefore, serious games should be offered as a supplement to existing proven and safe interventions rather than as a complete substitute until further, more robust evidence is available. Future studies should investigate the short- and long-term effects of serious games on memory and other cognitive abilities among people of different age groups with or without cognitive impairment. %M 35943792 %R 10.2196/35202 %U https://games.jmir.org/2022/3/e35202 %U https://doi.org/10.2196/35202 %U http://www.ncbi.nlm.nih.gov/pubmed/35943792 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e29830 %T Virtual Reality Training Using Nintendo Wii Games for Patients With Stroke: Randomized Controlled Trial %A Anwar,Naveed %A Karimi,Hossein %A Ahmad,Ashfaq %A Gilani,Syed Amir %A Khalid,Kehkshan %A Aslam,Ahmed Sohaib %A Hanif,Asif %+ University Institute of Physical Therapy, University of Lahore, 1-Km, Defence Road, Bhupatian Chowk, Off Raiwind Road, Lahore, Pakistan, 92 3336140916, dr.hossein.karimi@gmail.com %K stroke %K virtual reality %K Fugl-Meyer score %K rehabilitation %K training %K physical therapy %K therapy %K balance %K function %K randomized controlled trial %D 2022 %7 13.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial. Objective: The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke. Methods: It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22. Results: The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted. Conclusions: VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability. Trial Registration: Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view %M 35699989 %R 10.2196/29830 %U https://games.jmir.org/2022/2/e29830 %U https://doi.org/10.2196/29830 %U http://www.ncbi.nlm.nih.gov/pubmed/35699989 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34884 %T Effects of Virtual Reality–Based Multimodal Audio-Tactile Cueing in Patients With Spatial Attention Deficits: Pilot Usability Study %A Knobel,Samuel Elia Johannes %A Kaufmann,Brigitte Charlotte %A Geiser,Nora %A Gerber,Stephan Moreno %A Müri,René M %A Nef,Tobias %A Nyffeler,Thomas %A Cazzoli,Dario %+ Neurocenter, Luzerner Kantonsspital, Spitalstrasse, Luzern, 6004, Switzerland, 41 205 56 86, dario.cazzoli@luks.ch %K virtual reality %K search task %K stroke %K neglect, multimodal cueing %K bird search task %D 2022 %7 25.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) devices are increasingly being used in medicine and other areas for a broad spectrum of applications. One of the possible applications of VR involves the creation of an environment manipulated in a way that helps patients with disturbances in the spatial allocation of visual attention (so-called hemispatial neglect). One approach to ameliorate neglect is to apply cross-modal cues (ie, cues in sensory modalities other than the visual one, eg, auditory and tactile) to guide visual attention toward the neglected space. So far, no study has investigated the effects of audio-tactile cues in VR on the spatial deployment of visual attention in neglect patients. Objective: This pilot study aimed to investigate the feasibility and usability of multimodal (audio-tactile) cueing, as implemented in a 3D VR setting, in patients with neglect, and obtain preliminary results concerning the effects of different types of cues on visual attention allocation compared with noncued conditions. Methods: Patients were placed in a virtual environment using a head-mounted display (HMD). The inlay of the HMD was equipped to deliver tactile feedback to the forehead. The task was to find and flag appearing birds. The birds could appear at 4 different presentation angles (lateral and paracentral on the left and right sides), and with (auditory, tactile, or audio-tactile cue) or without (no cue) a spatially meaningful cue. The task usability and feasibility, and 2 simple in-task measures (performance and early orientation) were assessed in 12 right-hemispheric stroke patients with neglect (5 with and 7 without additional somatosensory impairment). Results: The new VR setup showed high usability (mean score 10.2, SD 1.85; maximum score 12) and no relevant side effects (mean score 0.833, SD 0.834; maximum score 21). A repeated measures ANOVA on task performance data, with presentation angle, cue type, and group as factors, revealed a significant main effect of cue type (F30,3=9.863; P<.001) and a significant 3-way interaction (F90,9=2.057; P=.04). Post-hoc analyses revealed that among patients without somatosensory impairment, any cue led to better performance compared with no cue, for targets on the left side, and audio-tactile cues did not seem to have additive effects. Among patients with somatosensory impairment, performance was better with both auditory and audio-tactile cueing than with no cue, at every presentation angle; conversely, tactile cueing alone had no significant effect at any presentation angle. Analysis of early orientation data showed that any type of cue triggered better orientation in both groups for lateral presentation angles, possibly reflecting an early alerting effect. Conclusions: Overall, audio-tactile cueing seems to be a promising method to guide patient attention. For instance, in the future, it could be used as an add-on method that supports attentional orientation during established therapeutic approaches. %M 35612894 %R 10.2196/34884 %U https://games.jmir.org/2022/2/e34884 %U https://doi.org/10.2196/34884 %U http://www.ncbi.nlm.nih.gov/pubmed/35612894 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e38212 %T Authors’ Reply to: Learning More About the Effects of Gamification on Physical Activity. Comment on “Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials” %A Mazeas,Alexandre %A Duclos,Martine %A Pereira,Bruno %A Chalabaev,Aïna %+ Univ Grenoble Alpes, SENS, 1741 rue de la Piscine, 38000 Grenoble, France, 33 476635081, alexandre.mazeas@univ-grenoble-alpes.fr %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %K elderly %K old adults %D 2022 %7 3.5.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 35503414 %R 10.2196/38212 %U https://www.jmir.org/2022/5/e38212 %U https://doi.org/10.2196/38212 %U http://www.ncbi.nlm.nih.gov/pubmed/35503414 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e36396 %T Learning More About the Effects of Gamification on Physical Activity. Comment on “Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials” %A Hung,Cheng-Hsien %A Kao,Yung-Shuo %+ Department of Pharmacy, Chang Bing Show Chwan Memorial Hospital, No 6, Lugong Rd, Lukang Township, Changhua County, 50544, Taiwan, 886 4 7813888 ext 71255, chenghsien823@gmail.com %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %K elderly %K old adults %D 2022 %7 3.5.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 35503654 %R 10.2196/36396 %U https://www.jmir.org/2022/5/e36396 %U https://doi.org/10.2196/36396 %U http://www.ncbi.nlm.nih.gov/pubmed/35503654 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35295 %T Impact of Visual Game-Like Features on Cognitive Performance in a Virtual Reality Working Memory Task: Within-Subjects Experiment %A Redlinger,Eric %A Glas,Bernhard %A Rong,Yang %+ Tokyo Institute of Technology, Institute of Innovative Research / Koike & Yoshimura Lab, 2-12-1-I3-20 Ookayama Campus, Tokyo, 152-8552, Japan, 81 3 5734 362, redlinger.e.aa@m.titech.ac.jp %K HMD %K working memory %K gamification %K cognitive training %K serious game %K game %K cognitive activity %K user performance %K visual memory %K cognitive %K user performance %K mobile phone %D 2022 %7 28.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although the pursuit of improved cognitive function through working memory training has been the subject of decades of research, the recent growth in commercial adaptations of classic working memory tasks in the form of gamified apps warrants additional scrutiny. In particular, the emergence of virtual reality as a platform for cognitive training presents opportunities for the use of novel visual features. Objective: This study aimed to add to the body of knowledge regarding the use of game-like visual design elements by specifically examining the application of two particular visual features common to virtual reality environments: immersive, colorful backgrounds and the use of 3D depth. In addition, electroencephalography (EEG) data were collected to identify potential neural correlates of any observed changes in performance. Methods: A simple visual working memory task was presented to participants in several game-like adaptations, including the use of colorful, immersive backgrounds and 3D depth. The impact of each adaptation was separately assessed using both EEG and performance assessment outcomes and compared with an unmodified version of the task. Results: Results suggest that although accuracy and reaction time may be slightly affected by the introduction of such game elements, the effects were small and not statistically significant. Changes in EEG power, particularly in the beta and theta rhythms, were significant but failed to correlate with any corresponding changes in performance. Therefore, they may only reflect cognitive changes at the perceptual level. Conclusions: Overall, the data suggest that the addition of these specific visual features to simple cognitive tasks does not appear to significantly affect performance or task-dependent cognitive load. %M 35482373 %R 10.2196/35295 %U https://games.jmir.org/2022/2/e35295 %U https://doi.org/10.2196/35295 %U http://www.ncbi.nlm.nih.gov/pubmed/35482373 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e32996 %T Gamification in Diplomacy Studies as an Effective Tool for Knowledge Transfer: Questionnaire Study %A Cercel,Mihai Ovidiu %+ Department of International Relations and European Integration, National University of Political Studies and Public Administration, 30A, Expozitiei Boulevard, Bucharest, 012104, Romania, 40 371 445 076, mihai.cercel@dri.snspa.ro %K modern diplomacy %K international relations %K innovations in learning experience %K gamification %K serious games %K role play design %K knowledge transfer %K competency development %D 2022 %7 25.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Graduate education in modern diplomacy poses several challenges, as it requires several competencies to be developed before diplomatic service is joined. Incorporation of simulation games can have a positive impact on the design of international relations and diplomacy learning process. We have designed a novel role play game (MAEDRI) to simulate part of the activities of a typical Ministry of Foreign Affairs. Objective: This study aims to evaluate the effectiveness of MAEDRI in transferring knowledge in international relations education programs at the National University of Political Studies and Public Administration, Bucharest, Romania, across a 4-year period. Methods: The game enrolled master’s level graduate students. The data were collected through a voluntary and anonymous questionnaire between 2017 and 2020. At the end of each of the 4 editions we organized debriefing sessions that gave students the opportunity to provide feedback on their experience with this exercise, level of collaboration within the team, lessons learned, and to make suggestions for improvements. Using an online questionnaire, we measured the participants’ perception regarding the level of effectiveness in increasing knowledge transfer, motivation, and engagement. Questionnaire data were consolidated in percentages for each item. Results: A total of 49 participants completed the study. A total of 24 skills (13 professional and 11 social skills) were assessed. We identified a strong positive correlation between stress management and conflict management (r=.86; P<.001) as well as significantly positive correlations between building relations within the team and the ability to dialog and be persuasive (r=.7; P<.001), between procedure compliance and planning and organizing the work (r=.69; P<.001), and between analysis capacity and decision based on data received (r=.68; P<.001). Among social skills, self-control, confidence, and flexibility were the most substantially improved. Conclusions: We describe several benefits of a novel game, used as an education tool to enhance a series of competencies necessary in international relations studies. Our results demonstrate a significant level of student engagement and motivation while playing MAEDRI, improvement of several essential skills, and enhanced knowledge transfer to real-life situations. While the data are encouraging, further research is needed to evaluate the full impact of role play as an effective experiential learning method. %M 35468081 %R 10.2196/32996 %U https://games.jmir.org/2022/2/e32996 %U https://doi.org/10.2196/32996 %U http://www.ncbi.nlm.nih.gov/pubmed/35468081 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e30464 %T Identifying Player Types to Tailor Game-Based Learning Design to Learners: Cross-sectional Survey using Q Methodology %A Van Gaalen,A E J %A Schönrock-Adema,J %A Renken,R J %A Jaarsma,A D C %A Georgiadis,J R %+ Anatomy & Medical Physiology Section, Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University Groningen, Antonius Deusinglaan 1, Groningen, 9713AV, Netherlands, 31 648527717, j.r.georgiadis@umcg.nl %K gamification %K serious games %K game-based learning %K medical education %K computers %K new technology %K focus group %K play %K qualitative %K player types %K taxonomy %K theory %K framework %D 2022 %7 4.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Game-based learning appears to be a promising instructional method because of its engaging properties and positive effects on motivation and learning. There are numerous options to design game-based learning; however, there is little data-informed knowledge to guide the choice of the most effective game-based learning design for a given educational context. The effectiveness of game-based learning appears to be dependent on the degree to which players like the game. Hence, individual differences in game preferences should be taken into account when selecting a specific game-based learning design. Objective: We aimed to identify patterns in students’ perceptions of play and games—player types and their most important characteristics. Methods: We used Q methodology to identify patterns in opinions on game preferences. We recruited undergraduate medical and dental students to participate in our study and asked participants to sort and rank 49 statements on game preferences. These statements were derived from a prior focus group study and literature on game preferences. We used by-person factor analysis and varimax rotation to identify common viewpoints. Both factors and participants’ comments were used to interpret and describe patterns in game preferences. Results: From participants’ (n=102) responses, we identified 5 distinct patterns in game preferences: the social achiever, the explorer, the socializer, the competitor, and the troll. These patterns revolved around 2 salient themes: sociability and achievement. The 5 patterns differed regarding cheating, playing alone, story-telling, and the complexity of winning. Conclusions: The patterns were clearly interpretable, distinct, and showed that medical and dental students ranged widely in how they perceive play. Such patterns may suggest that it is important to take students’ game preferences into account when designing game-based learning and demonstrate that not every game-based learning-strategy fits all students. To the best of our knowledge, this study is the first to use a scientifically sound approach to identify player types. This can help future researchers and educators select effective game-based learning game elements purposefully and in a student-centered way. %M 35377333 %R 10.2196/30464 %U https://games.jmir.org/2022/2/e30464 %U https://doi.org/10.2196/30464 %U http://www.ncbi.nlm.nih.gov/pubmed/35377333 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30949 %T Identifying Video Game Preferences Among Adults Interested in Quitting Smoking Cigarettes: Survey Study %A Upton,Caitlyn R %A Nastasi,Jessica A %A Raiff,Bethany R %+ Department of Psychology, College of Science and Mathematics, Rowan University, 201 Mullica Hill Road, Glassboro, NJ, 08028, United States, 1 (856) 256 4500 ext 5, raiff@rowan.edu %K genres %K popular games %K smoking cessation %K video games %K smartphone %K mobile phone %D 2022 %7 24.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking is the most prevalent cause of morbidity and mortality in the United States. Although most individuals who smoke express a desire to quit smoking, only a small percentage are successful. Serious games have become popular in health sectors as a potential avenue for delivering a scalable treatment that is both accessible and engaging for the smoking population. Several smoking cessation games have already been developed, but these games feature a broad range of gameplay elements and are not necessarily based on existing video game preferences in the general or smoking population. Objective: To better inform treatment development, this study aims to evaluate video game genre preferences among treatment-seeking individuals who smoke (N=473). Methods: Participants responded to a screening survey to enroll in a larger, serious game intervention for smoking cessation. During this screening survey, participants were asked to disclose their favorite video games, which resulted in 277 unique game titles. These titles were coded for genre categories based on publisher listings and game features. The genres were then analyzed for the frequency of reporting overall and across age groups. Results: Action, Role-Playing, and Action-Adventure were the most reported genres among adults aged ≤34 years; Action, Action-Adventure, and Logic were the most reported genres among adults aged 35-44 years; and Logic and Action were the most reported genres among adults aged ≥45 years. Conclusions: These data indicate that treatment-seeking individuals who smoke have different game preferences across age groups, and the data provide novel information to inform the development of future serious games targeting the smoking population that are tailored to the preferences of their age group. Trial Registration: ClinicalTrials.gov NCT03929003; https://clinicaltrials.gov/ct2/show/NCT03929003 %M 35323116 %R 10.2196/30949 %U https://games.jmir.org/2022/1/e30949 %U https://doi.org/10.2196/30949 %U http://www.ncbi.nlm.nih.gov/pubmed/35323116 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e34592 %T The Effectiveness and Safety of Serious Games for Improving Cognitive Abilities Among Elderly People With Cognitive Impairment: Systematic Review and Meta-Analysis %A Abd-alrazaq,Alaa %A Alajlani,Mohannad %A Alhuwail,Dari %A Toro,Carla T %A Giannicchi,Anna %A Ahmed,Arfan %A Makhlouf,Ahmed %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 5825, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K global cognition %K systematic review %K meta-analysis %D 2022 %7 10.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Cognitive impairment is a mental disorder that commonly affects elderly people. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological intervention for improving cognitive abilities. The effectiveness and safety of serious games for improving cognitive abilities have been investigated by several systematic reviews; however, they are limited by design and methodological weaknesses. Objective: This study aims to assess the effectiveness and safety of serious games for improving cognitive abilities among elderly people with cognitive impairment. Methods: A systematic review of randomized controlled trials (RCTs) was conducted. The following 8 electronic databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also screened reference lists of the included studies and relevant reviews, as well as checked studies citing our included studies. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies. Results: Fifteen studies met the eligibility criteria among 466 citations retrieved. Of those, 14 RCTs were eventually included in the meta-analysis. We found that, regardless of their type, serious games were more effective than no intervention (P=.04) and conventional exercises (P=.002) for improving global cognition among elderly people with cognitive impairment. Further, a subgroup analysis showed that cognitive training games were more effective than no intervention (P=.05) and conventional exercises (P<.001) for improving global cognition among elderly people with cognitive impairment. Another subgroup analysis demonstrated that exergames (a category of serious games that includes physical exercises) are as effective as no intervention and conventional exercises (P=.38) for improving global cognition among elderly people with cognitive impairment. Although some studies found adverse events from using serious games, the number of adverse events (ie, falls and exacerbations of pre-existing arthritis symptoms) was comparable between the serious game and control groups. Conclusions: Serious games and specifically cognitive training games have the potential to improve global cognition among elderly people with cognitive impairment. However, our findings remain inconclusive because the quality of evidence in all meta-analyses was very low, mainly due to the risk of bias raised in the majority of the included studies, high heterogeneity of the evidence, and imprecision of total effect sizes. Therefore, psychologists, psychiatrists, and patients should consider offering serious games as a complement and not a substitute to existing interventions until further more robust evidence is available. Further studies are needed to assess the effect of exergames, the safety of serious games, and their long-term effects. %M 35266877 %R 10.2196/34592 %U https://games.jmir.org/2022/1/e34592 %U https://doi.org/10.2196/34592 %U http://www.ncbi.nlm.nih.gov/pubmed/35266877 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31395 %T The Effectiveness of Virtual Reality–Based Interventions in Rehabilitation Management of Breast Cancer Survivors: Systematic Review and Meta-analysis %A Bu,Xiaofan %A Ng,Peter H F %A Xu,Wenjing %A Cheng,Qinqin %A Chen,Peter Q %A Cheng,Andy S K %A Liu,Xiangyu %+ Department of Health Service Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Number 283, Tongzi Road, Changsha, 410013, China, 86 18674869736, 979596459@qq.com %K virtual reality %K rehabilitation management %K symptom %K motor function %K systematic review %K meta-analysis %D 2022 %7 28.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Breast cancer survivors (BCSs) can present with various physical and psychological symptoms and functional deficits that impact their quality of life. Virtual reality (VR) technology is being used in breast cancer rehabilitation management to improve the emotional, cognitive, and physical well-being of BCSs. Objective: This systematic review aimed to examine the effectiveness of VR-based interventions on health-related outcomes in BCSs. A meta-analysis was conducted to evaluate the effectiveness of VR-based interventions in the rehabilitation management of BCSs. Methods: A systematic search was conducted on PubMed, Web of Science, EMBASE, CINAHL with Full Text, the Cochrane Central Register of Controlled Trials, CNKI, WanFang, VIP, and CBM, from inception to May 25, 2021. The inclusion criteria of the selected studies were as follows: (1) adults diagnosed with breast cancer; (2) any type of VR-based interventions (immersive and nonimmersive virtual environment); (3) comparison of traditional rehabilitation methods; (4) outcomes including pain, depression, anxiety, fatigue, cognitive function, shoulder range of motion (ROM), hand grip strength, lymphedema, cybersickness symptoms, fear of movement, bleeding, effusion, and flap necrosis, both during and after treatment; and (5) randomized controlled trials (RCTs), case-controlled trials, and quasi-experimental studies. The Cochrane Collaboration Tool was used to evaluate the risk of bias. Review Manager version 5.3 (Cochrane Collaboration) was used to conduct the meta-analysis. The mean difference (MD) and SDs with 95% CIs were used to calculate continuous variables. Results: Twelve articles were included in this systematic review, of which 10 contributed information to the meta-analysis. A total of 604 participants were analyzed. The statistical analysis showed significant results for flexion (standard mean difference [SMD] 1.79; 95% CI 0.55 to 3.03; P=.005), extension (SMD 1.54; 95% CI 0.83 to 2.25; P<.001), abduction (MD 17.53; 95% CI 14.33 to 20.72; P<.001), adduction (MD 15.98; 95% CI 14.02 to 17.94; P<.001), internal rotation (MD 7.12; 95% CI 5.54 to 8.70; P<.001), external rotation (SMD 0.96; 95% CI 0.62 to 1.29; P<.001), anxiety (MD −6.47; 95% CI −7.21 to −5.73; P<.001), depression (MD −4.27; 95% CI −4.64 to −3.91; P<.001), pain (MD −1.32; 95% CI −2.56 to −0.09; P=.04), and cognitive function (MD 8.80; 95% CI 8.24 to 9.36; P<.001). The meta-analysis indicated little to no difference in hand grip strength (MD 1.96; 95% CI –0.93 to 4.85; P=.18). Conclusions: Findings of this review noted a weak but consistent positive association between VR-based interventions and outcomes. However, these results must be interpreted with caution due to the limited number of controlled trials analyzed, small sample sizes, and poor methodological quality. Well‐designed, large, high‐quality trials may have a significant impact on our confidence in the results. Future studies should identify specific aspects that improve the clinical impact of VR-based interventions on major outcomes in BCSs in the clinical setting. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021250727; https://tinyurl.com/2p89rmnk %M 35225817 %R 10.2196/31395 %U https://games.jmir.org/2022/1/e31395 %U https://doi.org/10.2196/31395 %U http://www.ncbi.nlm.nih.gov/pubmed/35225817 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e27597 %T Data-Driven Classification of Human Movements in Virtual Reality–Based Serious Games: Preclinical Rehabilitation Study in Citizen Science %A Barak Ventura,Roni %A Stewart Hughes,Kora %A Nov,Oded %A Raghavan,Preeti %A Ruiz Marín,Manuel %A Porfiri,Maurizio %+ Center for Urban Science and Progress, New York University, 370 Jay Street, Brooklyn, NY, 11201, United States, 1 646 997 3681, mporfiri@nyu.edu %K motion analysis %K principal component analysis %K telerehabilitation %K virtual reality %D 2022 %7 10.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients’ lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science–based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users’ range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software’s response to their movements. During calibration, the time series of the users’ movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation. %M 35142629 %R 10.2196/27597 %U https://games.jmir.org/2022/1/e27597 %U https://doi.org/10.2196/27597 %U http://www.ncbi.nlm.nih.gov/pubmed/35142629 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 2 %P e27794 %T The Effects of mHealth-Based Gamification Interventions on Participation in Physical Activity: Systematic Review %A Xu,Linqi %A Shi,Hongyu %A Shen,Meidi %A Ni,Yuanyuan %A Zhang,Xin %A Pang,Yue %A Yu,Tianzhuo %A Lian,Xiaoqian %A Yu,Tianyue %A Yang,Xige %A Li,Feng %+ School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, 130012, China, 86 1 779 008 9009, fli@jlu.edu.cn %K mobile health %K gamification %K physical activity %K systematic review %K mobile phone %D 2022 %7 3.2.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: It is well known that regular physical exercise has associated benefits; yet, participation remains suboptimal. Mobile health (mHealth) has become an indispensable medium to deliver behavior change interventions, and there is a growing interest in the gamification apps in mHealth to promote physical activity (PA) participation. Gamification could use game design elements (such as points, leaderboards, and progress bars), and it has the potential to increase motivation for PA and engagement. However, mHealth-based gamification interventions are still emerging, and little is known about the application status and efficacy of such interventions. Objective: This systematic review aims to investigate gamification apps in mHealth for improving PA levels and simultaneously summarize the impact of gamification interventions on PA participation. Methods: We searched PubMed, Scopus, Web of Science, Embase, CINAHL (EBSCO host), and IEEE Xplore from inception to December 20, 2020. Original empirical research exploring the effects of gamification interventions on PA participation was included. The papers described at least one outcome regarding exercise or PA participation, which could be subjective self-report or objective indicator measurement. Of note, we excluded studies about serious games or full-fledged games. Results: Of 2944 studies identified from the database search, 50 (1.69%) were included, and the information was synthesized. The review revealed that gamification of PA had been applied to various population groups and broadly distributed among young people but less distributed among older adults and patients with a disease. Most of the studies (30/50, 60%) combined gamification with wearable devices to improve PA behavior change, and 50% (25/50) of the studies used theories or principles for designing gamified PA interventions. The most frequently used game elements were goal-setting, followed by progress bars, rewards, points, and feedback. This review demonstrated that gamification interventions could increase PA participation; however, the results were mixed, and modest changes were attained, which could be attributed to the heterogeneity across studies. Conclusions: Overall, this study provides an overview of the existing empirical research in PA gamification interventions and provides evidence for the efficacy of gamification in enhancing PA participation. High-quality empirical studies are needed in the future to assess the efficacy of a combination of gamification and wearable activity devices to promote PA, and further exploration is needed to investigate the optimal implementation of these features of game elements and theories to enhance PA participation. %M 35113034 %R 10.2196/27794 %U https://mhealth.jmir.org/2022/2/e27794 %U https://doi.org/10.2196/27794 %U http://www.ncbi.nlm.nih.gov/pubmed/35113034 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31747 %T Development and Evaluation of a Virtual Reality Puzzle Game to Decrease Food Intake: Randomized Controlled Trial %A Liu,Yunxin %A Stamos,Angelos %A Dewitte,Siegfried %A van Berlo,Zeph M C %A van der Laan,Laura N %+ Department of Communication and Cognition, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 (0)134664811, L.N.vdLaan@tilburguniversity.edu %K virtual reality %K pre-exposure %K self-control %K hedonic consumption %K food cravings %D 2022 %7 3.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has gained popularity in daily life, and VR food cues seem to elicit food cravings, similar to real food cues. However, little is known about the impact of VR food cues on actual food intake. Objective: In real life (RL), exposure to food cues in a situation in which the desire to eat food interferes with the completion of a food-related task reduces the subsequent food intake (ie, the pre-exposure effect). In this study, we examine, on the one hand, whether the pre-exposure effect could be replicated in RL and, on the other hand, whether this effect could be extended to VR contexts. Methods: The study used a 2 (stimulus type: food vs nonfood) × 2 (mode: VR vs RL) between-subject design (n=175). Participants were randomly assigned to 1 of the 4 conditions. Results: We found the main effect of mode on food intake, with a higher food intake after both VR conditions than after RL conditions (P=.02). In addition, among female participants, we found that exposure to both food cues (ie, VR and RL) resulted in lower food intake than exposure to both nonfood cues (P=.05). In contrast, this effect was not observed among male participants (P=.34). Additionally, VR and RL cues generated similar emotional and behavioral responses (eg, arousal and game difficulty). Conclusions: We were unable to replicate the exposure effect in our complete sample. Subgroup analyses, however, showed that for women, exposure to food cues (either in VR or in RL) reduces food intake, indicating that a VR pre-exposure procedure may effectively be applied exclusively for women. Trial Registration: ClinicalTrials.gov NCT05169996; https://clinicaltrials.gov/ct2/show/NCT05169996 %M 35113028 %R 10.2196/31747 %U https://games.jmir.org/2022/1/e31747 %U https://doi.org/10.2196/31747 %U http://www.ncbi.nlm.nih.gov/pubmed/35113028 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30526 %T An Evidence Map on Serious Games in Preventing Sexually Transmitted Infections Among Adolescents: Systematic Review About Outcome Categories Investigated in Primary Studies %A Ilskens,Karina %A Wrona,Kamil J %A Dockweiler,Christoph %A Fischer,Florian %+ School of Public Health, Bielefeld University, Universitätsstr. 25, Bielefeld, 33615, Germany, 49 5211065160, kamil.wrona@uni-bielefeld.de %K serious games %K entertainment education %K STI %K STD %K sexual health %K effect %K impact %K sexually transmitted infections %K adolescents %K adolescent sexual health %D 2022 %7 2.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Sexually transmitted infections (STIs) represent a global health risk. Adolescents are at increased risk of infection for several reasons such as lack of knowledge, risky sexual behaviors, and lack of behavioral sills (eg, to negotiate safer sex). Given the fact that adolescents often use digital media and that serious games are considered to have the potential to change knowledge, attitudes and behavior, serious games represent an opportunity for the prevention of STIs. Objective: The aim of this systematic review was to identify and systematically summarize the dimensions that have been investigated in primary studies on serious games targeting STI prevention among adolescents. Methods: A systematic review was conducted in PubMed and Web of Science. Studies published from 2009 to 2021 were included that assessed the effectiveness of serious games on adolescent sexual health. A total of 18 studies met the inclusion criteria and were categorized according to dimensions of effectiveness and user experience. Results: Various dimensions of effectiveness and aspects of user experience were investigated in the primary studies. In total, 9 dimensions of effectiveness were observed: sexual behavior, behavioral intentions, knowledge, attitudes and beliefs, self-efficacy and personal limitations, character traits and future orientation, environmental and individual risk factors, risk perception and risk assessment, as well as normative beliefs and (social) norms. Furthermore, several dimensions related to user experience were investigated in primary studies, that is, motivation, acceptability, trustworthiness, comprehensibility, handling and control, perceived effectiveness, as well as satisfaction. Conclusions: This review provides an overview of serious games interventions that are vastly different in approach, content, and even platform. In previous studies, knowledge has already been comprehensively assessed, and a positive influence of serious games on knowledge about sexual topics is evident. The results clearly show that adolescents’ sexual knowledge has been increased by the serious games interventions. However, methodological and content differences in the surveys make it difficult to draw conclusions about the effectiveness related to changes in attitudes and behavior. %M 35107438 %R 10.2196/30526 %U https://games.jmir.org/2022/1/e30526 %U https://doi.org/10.2196/30526 %U http://www.ncbi.nlm.nih.gov/pubmed/35107438 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e32359 %T Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial %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, Faculty of Health, Queensland University of Technology, 170 Victoria Park Road, Brisbane, 4059, Australia, 61 731384714, julie.vermeir@hdr.qut.edu.au %K chronic pain %K cognition %K attentional bias %K gamification %K motivation %K randomized controlled trial %K web-based intervention %K pain management %K digital intervention %K digital health %D 2022 %7 27.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits. Objective: The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial. Methods: A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement. Results: The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively. Conclusions: This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx International Registered Report Identifier (IRRID): PRR1-10.2196/32359 %M 35084344 %R 10.2196/32359 %U https://www.researchprotocols.org/2022/1/e32359 %U https://doi.org/10.2196/32359 %U http://www.ncbi.nlm.nih.gov/pubmed/35084344 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e26779 %T Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials %A Mazeas,Alexandre %A Duclos,Martine %A Pereira,Bruno %A Chalabaev,Aïna %+ Univ. Grenoble Alpes, SENS, 1741 rue de la Piscine, 38000 Grenoble, France, 33 4 76 63 50 81, alexandre.mazeas@univ-grenoble-alpes.fr %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %D 2022 %7 4.1.2022 %9 Review %J J Med Internet Res %G English %X Background: Gamification refers to the use of game elements in nongame contexts. The use of gamification to change behaviors and promote physical activity (PA) is a promising avenue for tackling the global physical inactivity pandemic and the current prevalence of chronic diseases. However, there is no evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature. Objective: The aim of this systematic review and meta-analysis is to evaluate the effectiveness of gamified interventions and their health care potential by testing the generalizability and sustainability of their influence on PA and sedentary behavior. Methods: A total of 5 electronic databases (PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials published in English from 2010 to 2020. Eligibility criteria were based on the components of the participants, interventions, comparators, and outcomes framework. Studies were included when they used gamified interventions in daily life with an active or inactive control group and when they assessed a PA or sedentary behavior outcome. We conducted meta-analyses using a random-effects model approach. Sensitivity analyses, influence analyses, and publication bias analyses were performed to examine the robustness of our results. Results: The main meta-analysis performed on 16 studies and 2407 participants revealed a small to medium summary effect of gamified interventions on PA behavior (Hedges g=0.42, 95% CI 0.14-0.69). No statistical difference among different subgroups (adults vs adolescents and healthy participants vs adults with chronic diseases) and no interaction effects with moderators such as age, gender, or BMI were found, suggesting good generalizability of gamified interventions to different user populations. The effect was statistically significant when gamified interventions were compared with inactive control groups, such as waiting lists (Hedges g=0.58, 95% CI 0.08-1.07), and active control groups that included a nongamified PA intervention (Hedges g=0.23, 95% CI 0.05-0.41). This suggests that gamified interventions are not only efficient in changing behavior but also more effective compared with other behavioral interventions. The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) was weaker, with a very small to small effect (Hedges g=0.15, 95% CI 0.07-0.23). Conclusions: This meta-analysis confirms that gamified interventions are promising for promoting PA in various populations. Additional analyses revealed that this effect persists after the follow-up period, suggesting that it is not just a novelty effect caused by the playful nature of gamification, and that gamified products appear effective compared with equivalent nongamified PA interventions. Future rigorous trials are required to confirm these findings. %M 34982715 %R 10.2196/26779 %U https://www.jmir.org/2022/1/e26779 %U https://doi.org/10.2196/26779 %U http://www.ncbi.nlm.nih.gov/pubmed/34982715 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e33975 %T Investigating the Use of a Serious Game to Improve Opioid Safety Awareness Among Adolescents: Quantitative Study %A Abraham,Olufunmilola %A Rosenberger,Claire %A Tierney,Kathleen %A Birstler,Jen %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin–Madison, 777 Highland Ave, Madison, WI, 53705, United States, 1 6082634498, olufunmilola.abraham@wisc.edu %K opioids %K adolescents %K opioid safety %K medication safety %K opioid knowledge %K serious games %K naloxone %K Narcan %K youth %K technology %K safety %K gaming %K addiction %K drug %K young adult %K teenager %K survey %K awareness %D 2021 %7 23.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The misuse of opioid medications among adolescents is a serious problem in the United States. Serious games (SGs) are a novel way to promote the safe and responsible management of opioid medications among adolescents, thereby reducing the number of adolescent opioid misuse cases reported annually. Objective: This study aimed to examine the effect of the SG MedSMART: Adventures in PharmaCity on adolescents’ opioid safety knowledge, awareness, behavioral intent, and self-efficacy. Methods: A nationally representative sample of adolescents aged 12 to 18 years were recruited online through Qualtrics panels from October to November 2020. Data collection consisted of a pregame survey, 30 minutes of gameplay, and a postgame survey. The pregame and postgame surveys included 66 items examining the participants’ baseline opioid knowledge, safety, use, and demographic information. The postgame survey had 25 additional questions regarding the MedSMART game. Gameplay scenarios included 5 levels intended to mimic adolescents’ daily life while educating the players about appropriate opioid storage and disposable practices, negative consequences of sharing opioid medications, and the use of Narcan. Survey questions were divided into 10 categories to represent key concepts and were summarized into concept scores. Differences in concept scores were described by overall mean (SD) when stratified by gender, race, school, grade, and age. Differences of change in concept score were analyzed using the Kruskal-Wallis and correlation tests. Results: A total of 117 responses were analyzed. The results showed significant improvement on all concept scores except for Narcan knowledge (mean change -0.04, SD 0.29; P=.60) and safe storage (mean change 0.03, SD 0.20; P=.09). Female participants had greater improvement than males for safe disposal (female mean 0.12, SD 0.25 vs male mean 0.04, SD 0.17; P=.05). Male participants had higher improvement than female participants for misuse behavior (female mean 0.05, SD 0.28 vs male mean 0.14, SD 0.27; P=.04). Perceived knowledge for participants who had non-White or Hispanic racial backgrounds had higher improvement than for non-Hispanic White participants (non-White mean 1.10, SD 1.06 vs White mean 0.75, SD 0.91; P=.03). Older grades were associated with greater improvement in opioid knowledge (correlation coefficient -0.23, 95% CI -0.40 to -0.05; P=.01). There were 28 (23.9%) participants who played all 5 levels of the game and had better improvement in opioid use self-efficacy. Conclusions: Our findings suggest MedSMART: Adventures in PharmaCity can be used as an effective tool to educate adolescents on the safe and responsible use of prescribed opioid medications. Future testing of the effectiveness of this SG should involve a randomized controlled trial. Additionally, the feasibility of implementing and disseminating MedSMART: Adventures in PharmaCity in schools and health care settings such as adolescent health or primary care clinics, emergency departments, and pharmacies should be investigated. %M 34747712 %R 10.2196/33975 %U https://games.jmir.org/2021/4/e33975 %U https://doi.org/10.2196/33975 %U http://www.ncbi.nlm.nih.gov/pubmed/34747712 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e28896 %T Team Building Through Team Video Games: Randomized Controlled Trial %A Keith,Mark J %A Dean,Douglas L %A Gaskin,James %A Anderson,Greg %+ Information Systems Department, Marriott School of Business, Brigham Young University, Campus Dr, Provo, UT, 84602, United States, 1 801 674 5159, mark.keith@gmail.com %K team video gaming %K team building %K flow %K team cohesion %K video games %K gamification %K team %K teamwork %K cohesion %K theory %K framework %K performance %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Organizations of all types require the use of teams. Poor team member engagement costs billions of US dollars annually. Objective: This study aimed to explain how team building can be accomplished with team video gaming based on a team cohesion model enhanced by team flow theory. Methods: In this controlled experiment, teams were randomly assigned to a team video gaming treatment or a control treatment. Team productivity was measured during both pretreatment and posttreatment team tasks. After the pretest, teams who were involved in the team video gaming treatment competed against other teams by playing the Halo or Rock Band video game for 45 minutes. After the pretest, teams in the control treatment worked alone for 45 minutes. Then, all teams completed the posttest team activity. This same experimental protocol was conducted on 2 different team tasks. Results: For both tasks, teams in the team video gaming treatment increased their productivity significantly more (F1=8.760, P=.004) on the posttest task than teams in the control treatment. Our flow-based theoretical model explained team performance improvement more than twice as well (R2=40.6%) than prior related research (R2=18.5%). Conclusions: The focused immersion caused by team video gaming increased team performance while the enjoyment component of flow decreased team performance on the posttest. Both flow and team cohesion contributed to team performance, with flow contributing more than cohesion. Team video gaming did not increase team cohesion, so team video gaming effects are independent of cohesion. Team video gaming is a valid practical method for developing and improving newly formed teams. %M 34904954 %R 10.2196/28896 %U https://games.jmir.org/2021/4/e28896 %U https://doi.org/10.2196/28896 %U http://www.ncbi.nlm.nih.gov/pubmed/34904954 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e27953 %T Game Design in Mental Health Care: Case Study–Based Framework for Integrating Game Design Into Therapeutic Content %A Siriaraya,Panote %A Visch,Valentijn %A Boffo,Marilisa %A Spijkerman,Renske %A Wiers,Reinout %A Korrelboom,Kees %A Hendriks,Vincent %A Salemink,Elske %A van Dooren,Marierose %A Bas,Michael %A Goossens,Richard %+ Faculty of Industrial Design Engineering, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, Netherlands, 31 152789111, spanote@gmail.com %K design models %K gamification %K case studies %K mental health %K eHealth %D 2021 %7 1.12.2021 %9 Viewpoint %J JMIR Serious Games %G English %X While there has been increasing interest in the use of gamification in mental health care, there is a lack of design knowledge on how elements from games could be integrated into existing therapeutic treatment activities in a manner that is balanced and effective. To help address this issue, we propose a design process framework to support the development of mental health gamification. Based on the concept of experienced game versus therapy worlds, we highlight 4 different therapeutic components that could be gamified to increase user engagement. By means of a Dual-Loop model, designers can balance the therapeutic and game design components and design the core elements of a mental health care gamification. To support the proposed framework, 4 cases of game design in mental health care (eg, therapeutic protocols for addiction, anxiety, and low self-esteem) are presented. %M 34855611 %R 10.2196/27953 %U https://games.jmir.org/2021/4/e27953 %U https://doi.org/10.2196/27953 %U http://www.ncbi.nlm.nih.gov/pubmed/34855611 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e30572 %T Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial %A Jessen,Stian %A Mirkovic,Jelena %A Halvorsen Brendmo,Elanor %A Solberg Nes,Lise %+ Department of Digital Health Research, Division of Medicine, Oslo University Hospital HF, Aker Sykehus, Trondheimsveien 23, Oslo, 0586, Norway, 47 9804 9759, stian.jessen@rr-research.no %K mHealth %K personal strengths %K gameful design %K gamification %K user engagement %K explorative %K feasibility %K usefulness %K usability %K design %K self-management %K chronic illness %D 2021 %7 17.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life. Objective: The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes. Methods: A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre– and post–psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data. Results: In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received. Conclusions: Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life. %M 34787580 %R 10.2196/30572 %U https://formative.jmir.org/2021/11/e30572 %U https://doi.org/10.2196/30572 %U http://www.ncbi.nlm.nih.gov/pubmed/34787580 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e19614 %T Gamifying Sexual Education for Adolescents in a Low-Tech Setting: Quasi-Experimental Design Study %A Haruna,Hussein %A Okoye,Kingsley %A Zainuddin,Zamzami %A Hu,Xiao %A Chu,Samuel %A Hosseini,Samira %+ Writing Lab, Institute for the Future of Education, Tecnologico de Monterrey, Avenida Eugenio Garza Sada 2501 Sur, Monterrey, 64849, Mexico, 52 18134162370, harunahussein@gmail.com %K gamified instruction %K serious gaming %K gamification %K educational innovation %K teenage students %K digital generation %K e-learning %K low-tech setting %D 2021 %7 12.10.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sexual education has become increasingly important as unhealthy sexual practices and subsequent health risks become more prevalent during adolescence. Traditional sex education teaching methodologies are limiting for digital natives exposed to various digital technologies. Harnessing the power of technology applications attractive to the younger generation may be a useful approach for teaching sex education. Objective: The aim of this study was to improve sexual health knowledge and understanding of the problems associated with unhealthy sexual practices and address sexual and reproductive health challenges experienced in a low-tech setting. Methods: A participatory design approach was used to develop the digital gamified methodology. A sample of 120 secondary school students aged 11-15 were randomly assigned to either experimental or control group for each of the 3 teaching approaches: (1) gamified instruction (actual serious games [SG] in teaching); (2) gamification (GM; making nongames, such as game-like learning); and (3) traditional teaching (TT) methods. Results: The SG and GM approaches were more effective than TT methods in teaching sexual health education. Specifically, the average scores across groups demonstrated an increase of mean scores from the pre- to posttest (25.10 [SD 5.50] versus 75.86 [SD 13.16]; t119=41.252; P<.001 [2 tailed]). Analysis of variance indicated no significant differences across groups for pretest scores (F2,117=1.048, P=.35). Significant differences across groups were evident in the posttest scores. Students in the SG and GM groups had higher average scores than the TT group (F2,117=83.98; P<.001). Students reported increased learning motivation, attitude, know-how, and participation in learning (P<.001) when using SG and GM approaches. Conclusions: Digital health technologies (particularly teaching and learning through gamified instruction and other novel approaches) may improve sexual health education. These findings may also be applied by practitioners in health care settings and by researchers wishing to further the development of sex education. %M 34636739 %R 10.2196/19614 %U https://games.jmir.org/2021/4/e19614 %U https://doi.org/10.2196/19614 %U http://www.ncbi.nlm.nih.gov/pubmed/34636739 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e20066 %T Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review %A Vieira,Catarina %A Ferreira da Silva Pais-Vieira,Carla %A Novais,João %A Perrotta,André %+ Research Centre for Informatics and Systems, Informatics Engineering Department, Universidade de Coimbra, Pólo II - Pinhal de Marrocos, Coimbra, 3030-290, Portugal, 351 239790000, avperrotta@dei.uc.pt %K serious games %K physical rehabilitation %K systematic review %K physical impairment %K game design %K game characteristics %K stroke %K multiple sclerosis %K cerebral palsy %D 2021 %7 23.9.2021 %9 Review %J JMIR Serious Games %G English %X Background: Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes. Objective: This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation. Methods: We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases. Results: We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs. Conclusions: Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging. %M 34554102 %R 10.2196/20066 %U https://games.jmir.org/2021/3/e20066 %U https://doi.org/10.2196/20066 %U http://www.ncbi.nlm.nih.gov/pubmed/34554102 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e22803 %T The Impact of a Gameful Breathing Training Visualization on Intrinsic Experiential Value, Perceived Effectiveness, and Engagement Intentions: Between-Subject Online Experiment %A Lukic,Yanick Xavier %A Klein,Shari Shirin %A Brügger,Victoria %A Keller,Olivia Clare %A Fleisch,Elgar %A Kowatsch,Tobias %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 446328638, ylukic@ethz.ch %K breathing training %K serious game %K digital health %K mobile health %K mHealth %K mobile phone %K experiential value %K instrumental value %K online experiment %D 2021 %7 14.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Slow-paced breathing has been shown to be positively associated with psychological and physiological health. In practice, however, there is little long-term engagement with breathing training, as shown by the usage statistics of breathing training apps. New research suggests that gameful smartphone-delivered breathing training may address this challenge. Objective: This study assesses the impact of breathing training, guided by a gameful visualization, on perceived experiential and instrumental values and the intention to engage in such training. Methods: A between-subject online experiment with 170 participants was conducted, and one-way multiple analysis of variance and two-tailed t test analyses were used to test for any difference in intrinsic experiential value, perceived effectiveness, and the intention to engage in either a breathing training with a gameful or a nongameful guidance visualization. Moreover, prior experience in gaming and meditation practices were assessed as moderator variables for a preliminary analysis. Results: The intrinsic experiential value for the gameful visualization was found to be significantly higher compared to the nongameful visualization (P=.001), but there was no difference in either perceived effectiveness (P=.50) or the intention to engage (P=.44). The preliminary analysis of the influence of meditation and gaming experience on the outcomes indicates that people with more meditation experience yielded higher intrinsic experiential values from using the gameful visualization than people with no or little meditation experience (P=.03). This analysis did not find any additional evidence of gaming time or meditation experience impacting the outcomes. Conclusions: The gameful visualization was found to increase the intrinsic experiential value of the breathing training without decreasing the perceived effectiveness. However, there were no differences in intentions to engage in both breathing training conditions. Furthermore, gaming and meditation experiences seem to have no or only a small positive moderating effect on the relationship between the gameful visualization and the intrinsic experiential value. Future longitudinal field studies are required to assess the impact of gameful breathing training on actual behavior, that is, long-term engagement and outcomes. %M 34519662 %R 10.2196/22803 %U https://games.jmir.org/2021/3/e22803 %U https://doi.org/10.2196/22803 %U http://www.ncbi.nlm.nih.gov/pubmed/34519662 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e30390 %T Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING) %A Warsinsky,Simon %A Schmidt-Kraepelin,Manuel %A Rank,Sascha %A Thiebes,Scott %A Sunyaev,Ali %+ Department of Economics and Management, Karlsruhe Institute of Technology, Kaiserstr. 89, Karlsruhe, 76133, Germany, 49 72160846037, sunyaev@kit.edu %K game-based interventions %K gamification %K serious games %K literature review %K reporting guidelines %K conceptual ambiguity %D 2021 %7 10.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so. Objective: This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions. Methods: We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field. Results: Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions. Conclusions: Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions. %M 34505840 %R 10.2196/30390 %U https://www.jmir.org/2021/9/e30390 %U https://doi.org/10.2196/30390 %U http://www.ncbi.nlm.nih.gov/pubmed/34505840 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26824 %T A Virtual Reality Game (The Secret Trail of Moon) for Treating Attention-Deficit/Hyperactivity Disorder: Development and Usability Study %A Rodrigo-Yanguas,Maria %A Martin-Moratinos,Marina %A Menendez-Garcia,Angela %A Gonzalez-Tardon,Carlos %A Royuela,Ana %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana-Puerta de Hierro University Hospital, Avenida, Manuel de Falla 1, Majadahonda, 28222, Spain, 34 655214857, hmblasco@yahoo.es %K attention-deficit/hyperactivity disorder %K chess %K virtual reality %K serious video game %K psychotherapy %K cognitive training %K usability %K new technologies %K transfer %K randomized controlled trial %D 2021 %7 1.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed for cognitive training related to core ADHD symptoms and executive dysfunction. Objective: We aimed to describe the development and usability of TSTM. Methods: The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion) of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation). Results: A total of 31/37 (86%) and 30/37 (83%) of participants liked playing TSTM and wanted to continue playing TSTM, respectively. Further, 5/37 (14%) of participants reported that they experienced either perceived dizziness or virtual reality motion sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype and frequent video game players to infrequent video game players. Conclusions: Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD. Trial Registration: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065 %M 34468332 %R 10.2196/26824 %U https://games.jmir.org/2021/3/e26824 %U https://doi.org/10.2196/26824 %U http://www.ncbi.nlm.nih.gov/pubmed/34468332 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e27291 %T A Didactic Escape Game for Emergency Medicine Aimed at Learning to Work as a Team and Making Diagnoses: Methodology for Game Development %A Abensur Vuillaume,Laure %A Laudren,Garry %A Bosio,Alexandre %A Thévenot,Pauline %A Pelaccia,Thierry %A Chauvin,Anthony %+ Emergency Department, CHR Metz-Thionville, 1 Allée du Château, Metz, 57000, France, 33 3 87 55 36 05, l.abensurvuillaume@chr-metz-thionville.fr %K training techniques %K educational technique %K game theories %K emergency medicine %K games %K education %K escape game %K simulation-based training %K pedagogical %K serious games %K emergency medicine training %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the health care environment, teamwork is paramount, especially when referring to patient safety. We are interested in recent and innovative solutions such as escape games, which is a type of adventure game that may be highly useful as an educational tool, potentially combining good communication skills with successful gamification. They involve teams of 5 to 10 individuals who are “locked” in the same room and must collaborate to solve puzzles while under pressure from a timer. Objective: The purpose of this paper was to describe the steps involved in creating and implementing an educational escape game. This tool can then be put into service or further developed by trainers who wish to use it for learning interprofessional collaboration. Therefore, we started with an experience of creating an educational escape game for emergency medicine teams. Methods: We chose to develop an educational escape game by using 6 successive steps. First, we built a team. Second, we chose the pedagogical objectives. Third, we gamified (switched from objectives to scenario). Next, we found the human and material resources needed. Thereafter, we designed briefing and debriefing. Lastly, we tested the game. Results: By following these 6 steps, we created the first ambulant educational escape game that teaches people, or nurses, doctors, and paramedics, working in emergency medicine to work as a team. Conclusions: From a pedagogic point of view, this game may be a good tool for helping people in multidisciplinary fields (medical and paramedical teams) to learn how to work collaboratively and to communicate as a group. Above all, it seems to be an innovative tool that complements medical simulation–based learning and thus consolidates traditional education. %M 34463628 %R 10.2196/27291 %U https://games.jmir.org/2021/3/e27291 %U https://doi.org/10.2196/27291 %U http://www.ncbi.nlm.nih.gov/pubmed/34463628 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26153 %T A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study %A Allegue,Dorra Rakia %A Kairy,Dahlia %A Higgins,Johanne %A Archambault,Philippe S %A Michaud,Francois %A Miller,William C %A Sweet,Shane N %A Tousignant,Michel %+ The Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, 6363 Chemin Hudson (fifth floor), Montreal, QC, H3S1M9, Canada, 1 4389901309, dorra.rakia.allegue@umontreal.ca %K stroke %K rehabilitation %K virtual reality %K video games %K telerehabilitation %K upper extremity %K motivation %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment–upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID): RR2-10.2196/14629 %M 34132649 %R 10.2196/26153 %U https://games.jmir.org/2021/3/e26153 %U https://doi.org/10.2196/26153 %U http://www.ncbi.nlm.nih.gov/pubmed/34132649 %0 Journal Article %@ 2562-0959 %I JMIR Publications %V 4 %N 2 %P e30325 %T Gamification and Game-Based Strategies for Dermatology Education: Narrative Review %A Szeto,Mindy D %A Strock,Daniel %A Anderson,Jarett %A Sivesind,Torunn E %A Vorwald,Victoria M %A Rietcheck,Hope R %A Weintraub,Gil S %A Dellavalle,Robert P %+ Department of Dermatology, University of Colorado Anschutz Medical Campus, 1665 Aurora Court, 3rd Floor, Mailstop F703, Aurora, CO, 80045, United States, 1 7208480500, mindy.szeto@cuanschutz.edu %K games %K game-playing %K gamification %K serious games %K simulations %K education %K medical education %K dermatology education %K patient education %K review %D 2021 %7 30.8.2021 %9 Review %J JMIR Dermatol %G English %X Background: Game-based approaches, or gamification, are popular learning strategies in medical education for health care providers and patients alike. Gamification has taken the form of serious educational games and simulations to enable learners to rehearse skills and knowledge in a safe environment. Dermatology learners in particular may benefit from gamification methods, given the visual and procedural nature of the field. Objective: This narrative review surveys current applications of gamification within general medical training, in the education of dermatology students, and in dermatology patient outreach. Methods: A literature search was performed using PubMed, Google Scholar, and ResearchGate to access and review relevant medical education- and dermatology-related gamification studies published in peer-reviewed journals. Two independent researchers with education and experience in dermatology screened publications to select studies featuring a diversity of gamification approaches and study subjects for in-depth examination. Results: A total of 6 general medical education–related and 7 dermatology-specific gamification studies were selected. Gamification generally increased motivation and engagement, improved reinforcement of learning objectives, and contributed to more enjoyable and positive educational experiences compared to traditional modes of instruction. Enhancing examination scores, building confidence, and developing stronger team dynamics were additional benefits for medical trainees. Despite the abundance of gamification studies in general medical education, comparatively few instances were specific to dermatology learning, although large organizations such as the American Academy of Dermatology have begun to implement these strategies nationally. Gamification may also a provide promising alternative means of diversifying patient education and outreach methods, especially for self-identification of malignant melanoma. Conclusions: Serious games and simulations in general medical education have successfully increased learner motivation, enjoyment, and performance. In limited preliminary studies, gamified approaches to dermatology-specific medical education enhanced diagnostic accuracy and interest in the field. Game-based interventions in patient-focused educational pilot studies surrounding melanoma detection demonstrated similar efficacy and knowledge benefits. However, small study participant numbers and large variability in outcome measures may indicate decreased generalizability of findings regarding the current impact of gamification approaches, and further investigation in this area is warranted. Additionally, some relevant studies may have been omitted by the simplified literature search strategy of this narrative review. This could be expanded upon in a secondary systematic review of gamified educational platforms. %M 37632819 %R 10.2196/30325 %U https://derma.jmir.org/2021/2/e30325 %U https://doi.org/10.2196/30325 %U http://www.ncbi.nlm.nih.gov/pubmed/37632819 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e27195 %T Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach %A McClincy,Michael %A Seabol,Liliana G %A Riffitts,Michelle %A Ruh,Ethan %A Novak,Natalie E %A Wasilko,Rachel %A Hamm,Megan E %A Bell,Kevin M %+ Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA, 15224, United States, 1 412 692 5530, mcclincymp@upmc.edu %K IHT %K pediatric %K sports medicine %K ACL %K orthopaedics %K rehabilitation %K health technology %K gamification %D 2021 %7 27.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements. Objective: This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior. Methods: In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post–ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants. Results: The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity. Conclusions: The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting. %M 34448715 %R 10.2196/27195 %U https://games.jmir.org/2021/3/e27195 %U https://doi.org/10.2196/27195 %U http://www.ncbi.nlm.nih.gov/pubmed/34448715 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e24546 %T The Impact of Gamification-Induced Users' Feelings on the Continued Use of mHealth Apps: A Structural Equation Model With the Self-Determination Theory Approach %A Wang,Tong %A Fan,Lingye %A Zheng,Xu %A Wang,Wei %A Liang,Jun %A An,Kai %A Ju,Mei %A Lei,Jianbo %+ Institute of Medical Technology, Health Science Center, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, China, 86 82805901, jblei@hsc.pku.edu.cn %K mHealth app %K continued use %K continuance intention %K gamification %K self-determination theory (SDT) %K expectation confirmation model of information system continuance (ECM-ISC) %K PLS-SEM %D 2021 %7 12.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Continued use of mHealth apps can achieve better effects in health management. Gamification is an important factor in promoting users’ intention to continue using mHealth apps. Past research has rarely explored the factors underlying the continued use of mobile health (mHealth) apps and gamification’s impact mechanism or path on continued use. Objective: This study aimed to explore the factors influencing mHealth app users’ intention to continue using mHealth apps and the impact mechanism and path of users’ feelings induced by gamification on continued mHealth app use. Methods: First, based on the expectation confirmation model of information system continuance, we built a theoretical model for continued use of mHealth apps based on users’ feelings toward gamification. We used self-determination theory to analyze gamification’s impact on user perceptions and set the resulting feelings (competence, autonomy, and relatedness) as constructs in the model. Second, we used the survey method to validate the research model, and we used partial least squares to analyze the data. Results: A total of 2988 responses were collected from mHealth app users, and 307 responses were included in the structural equation model after passing the acceptance criteria. The intrinsic motivation for using mHealth apps is significantly affected by autonomy (β=.312; P<.001), competence (β=.346; P<.001), and relatedness (β=.165; P=.004) induced by gamification. The intrinsic motivation for using mHealth apps has a significant impact on satisfaction (β=.311, P<.001) and continuance intention (β=.142; P=.045); furthermore, satisfaction impacts continuance intention significantly (β=.415; P<.001). Confirmation has a significant impact on perceived usefulness (β=.859; P<.001) and satisfaction (β=.391; P<.001), and perceived usefulness has a significant impact on satisfaction (β=.269; P<.001) and continuance intention (β=.273; P=.001). The mediating effect analysis showed that in the impact path of the intrinsic motivation for using the mHealth apps on continuance intention, satisfaction plays a partial mediating role (β=.129; P<.001), with a variance accounted for of 0.466. Conclusions: This study explored the impact path of users’ feelings induced by gamification on the intention of continued mHealth app use. We confirmed that perceived usefulness, confirmation, and satisfaction in the classical continued use theory for nonmedical information systems positively affect continuance intention. We also found that the path and mechanism of users' feelings regarding autonomy, competence, and relatedness generated during interactions with different gamification elements promote the continued use of mHealth apps. %M 34387550 %R 10.2196/24546 %U https://www.jmir.org/2021/8/e24546 %U https://doi.org/10.2196/24546 %U http://www.ncbi.nlm.nih.gov/pubmed/34387550 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26449 %T The Making and Evaluation of Digital Games Used for the Assessment of Attention: Systematic Review %A Wiley,Katelyn %A Robinson,Raquel %A Mandryk,Regan L %+ Department of Computer Science, University of Saskatchewan, Room 373, Thorvaldson Bldg, University of Saskatchewan, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 306 966 5186, katelyn.wiley@usask.ca %K cognitive assessment %K attention %K serious games %K gamification %K systematic review %K mobile phone %D 2021 %7 9.8.2021 %9 Review %J JMIR Serious Games %G English %X Background: Serious games are now widely used in many contexts, including psychological research and clinical use. One area of growing interest is that of cognitive assessment, which seeks to measure different cognitive functions such as memory, attention, and perception. Measuring these functions at both the population and individual levels can inform research and indicate health issues. Attention is an important function to assess, as an accurate measure of attention can help diagnose many common disorders, such as attention-deficit/hyperactivity disorder and dementia. However, using games to assess attention poses unique problems, as games inherently manipulate attention through elements such as sound effects, graphics, and rewards, and research on adding game elements to assessments (ie, gamification) has shown mixed results. The process for developing cognitive tasks is robust, with high psychometric standards that must be met before these tasks are used for assessment. Although games offer more diverse approaches for assessment, there is no standard for how they should be developed or evaluated. Objective: To better understand the field and provide guidance to interdisciplinary researchers, we aim to answer the question: How are digital games used for the cognitive assessment of attention made and measured? Methods: We searched several databases for papers that described a digital game used to assess attention that could be deployed remotely without specialized hardware. We used Rayyan, a systematic review software, to screen the records before conducting a systematic review. Results: The initial database search returned 49,365 papers. Our screening process resulted in a total of 74 papers that used a digital game to measure cognitive functions related to attention. Across the studies in our review, we found three approaches to making assessment games: gamifying cognitive tasks, creating custom games based on theories of cognition, and exploring potential assessment properties of commercial games. With regard to measuring the assessment properties of these games (eg, how accurately they assess attention), we found three approaches: comparison to a traditional cognitive task, comparison to a clinical diagnosis, and comparison to knowledge of cognition; however, most studies in our review did not evaluate the game’s properties (eg, if participants enjoyed the game). Conclusions: Our review provides an overview of how games used for the assessment of attention are developed and evaluated. We further identified three barriers to advancing the field: reliance on assumptions, lack of evaluation, and lack of integration and standardization. We then recommend the best practices to address these barriers. Our review can act as a resource to help guide the field toward more standardized approaches and rigorous evaluation required for the widespread adoption of assessment games. %M 34383674 %R 10.2196/26449 %U https://games.jmir.org/2021/3/e26449 %U https://doi.org/10.2196/26449 %U http://www.ncbi.nlm.nih.gov/pubmed/34383674 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28400 %T Feasibility and Effects of Virtual Reality Motor-Cognitive Training in Community-Dwelling Older People With Cognitive Frailty: Pilot Randomized Controlled Trial %A Kwan,Rick Yiu Cho %A Liu,Justina Yat Wa %A Fong,Kenneth Nai Kuen %A Qin,Jing %A Leung,Philip Kwok-Yuen %A Sin,Olive Suk Kan %A Hon,Pik Yuen %A Suen,Lydia W %A Tse,Man-Kei %A Lai,Claudia KY %+ Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, GH502, Hung Hom, Kowloon, Hong Kong, , China (Hong Kong), 852 2766 6546, rick.kwan@polyu.edu.hk %K virtual reality %K motor-cognitive training %K cognitive frailty %K game %K feasibility %K VR %K training %K older adults %K frail %K pilot study %K randomized controlled trial %D 2021 %7 6.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive frailty refers to the coexistence of physical frailty and cognitive impairment, and is associated with many adverse health outcomes. Although cognitive frailty is prevalent in older people, motor-cognitive training is effective at enhancing cognitive and physical function. We proposed a virtual reality (VR) simultaneous motor-cognitive training program, which allowed older people to perform daily activities in a virtual space mimicking real environments. Objective: We aimed to (1) explore the feasibility of offering VR simultaneous motor-cognitive training to older people with cognitive frailty and (2) compare its effects with an existing motor-cognitive training program in the community on the cognitive function and physical function of older people with cognitive frailty. Methods: A two-arm (1:1), assessor-blinded, parallel design, randomized controlled trial was employed. The eligibility criteria for participants were: (1) aged ≥60 years, (2) community dwelling, and (3) with cognitive frailty. Those in the intervention group received cognitive training (ie, cognitive games) and motor training (ie, cycling on an ergometer) simultaneously on a VR platform, mimicking the daily living activities of older people. Those in the control group received cognitive training (ie, cognitive games) on tablet computers and motor training (ie, cycling on the ergometer) sequentially on a non-VR platform. Both groups received a 30-minute session twice a week for 8 weeks. Feasibility was measured by adherence, adverse outcomes, and successful learning. The outcomes were cognitive function, physical frailty level, and walking speed. Results: Seventeen participants were recruited and randomized to either the control group (n=8) or intervention group (n=9). At baseline, the median age was 74.0 years (IQR 9.5) and the median Montreal Cognitive Assessment score was 20.0 (IQR 4.0). No significant between-group differences were found in baseline characteristics except in the number of chronic illnesses (P=.04). At postintervention, the intervention group (Z=–2.67, P=.01) showed a significantly larger improvement in cognitive function than the control group (Z=–1.19, P=.24). The reduction in physical frailty in the intervention group (Z=–1.73, P=.08) was similar to that in the control group (Z=–1.89, P=.06). Improvement in walking speed based on the Timed Up-and-Go test was moderate in the intervention group (Z=–0.16, P=.11) and greater in the control group (Z=–2.52, P=.01). The recruitment rate was acceptable (17/33, 52%). Both groups had a 100% attendance rate. The intervention group had a higher completion rate than the control group. Training was terminated for one participant (1/9, 11%) due to minimal VR sickness (Virtual Reality Sickness Questionnaire score=18.3/100). Two participants (2/8, 25%) in the control group withdrew due to moderate leg pain. No injuries were observed in either group. Conclusions: This study provides preliminary evidence that the VR simultaneous motor-cognitive training is effective at enhancing the cognitive function of older people with cognitive frailty. The effect size on frailty was close to reaching a level of significance and was similar to that observed in the control group. VR training is feasible and safe for older people with cognitive frailty. Trial Registration: ClinicalTrials.gov NCT04467216; https://clinicaltrials.gov/ct2/show/NCT04467216 %M 34383662 %R 10.2196/28400 %U https://games.jmir.org/2021/3/e28400 %U https://doi.org/10.2196/28400 %U http://www.ncbi.nlm.nih.gov/pubmed/34383662 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e24112 %T Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study %A Derksen,Marloes E %A Jaspers,Monique WM %A van Strijp,Sander %A Fransen,Mirjam P %+ Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 20 5664494, m.e.derksen@amsterdamumc.nl %K think aloud %K heuristic evaluation %K usability %K mHealth %K game elements %K smoking prevention %K user-centered design %K mobile phone %D 2021 %7 4.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation. Objective: This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation. Methods: Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society. Results: Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon). Conclusions: The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing. %M 34346895 %R 10.2196/24112 %U https://formative.jmir.org/2021/8/e24112 %U https://doi.org/10.2196/24112 %U http://www.ncbi.nlm.nih.gov/pubmed/34346895 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e25637 %T Medical Students’ Perceptions of Play and Learning: Qualitative Study With Focus Groups and Thematic Analysis %A Van Gaalen,A E J %A Jaarsma,A D C %A Georgiadis,J R %+ Department of Biomedical Sciences of Cells and Systems, Section Anatomy & Medical Physiology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, Groningen, 9713AV, Netherlands, 31 640994891, a.e.j.van.gaalen@umcg.nl %K gamification %K serious games %K game-based learning %K medical education %K computers %K new technology %K focus group %K play %K qualitative %D 2021 %7 28.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In times where distance learning is becoming the norm, game-based learning (GBL) is increasingly applied to health profession education. Yet, decisions for if, when, how, and for whom GBL should be designed cannot be made on a solid empirical basis. Though the act of play seems to be intertwined with GBL, it is generally ignored in the current scientific literature. Objective: The objective of our study was to explore students’ perceptions of play in leisure time and of GBL as part of a mechanistic, bottom-up approach towards evidence-informed design and implementation of GBL in health profession education. Methods: We conducted 6 focus group discussions with medical and dentistry students, which were analyzed using thematic analysis. Results: A total of 58 students participated. We identified 4 major themes based on the students’ perception of play in leisure time and on the combination of play and learning. Our results indicate that, while play preferences were highly various in our health profession student cohort, pleasure was the common ground reported for playing. Crucially, play and the serious act of learning seemed paradoxical, indicating that the value and meaning of play are strongly context-dependent for students. Conclusions: Four key points can be constructed from our study. First, students play for pleasure. Perceptions of pleasure vary considerably among students. Second, students consider play as inefficient. Inefficiency will only be justified when it increases learning. Third, play should be balanced with the serious and only be used for difficult or tedious courses. Fourth, GBL activities should not be made compulsory for students. We provide practical implications and directions for future research. %M 34319237 %R 10.2196/25637 %U https://games.jmir.org/2021/3/e25637 %U https://doi.org/10.2196/25637 %U http://www.ncbi.nlm.nih.gov/pubmed/34319237 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e25437 %T Evaluating Quality, Usability, Evidence-Based Content, and Gamification Features in Mobile Learning Apps Designed to Teach Children Basic Life Support: Systematic Search in App Stores and Content Analysis %A Fijačko,Nino %A Masterson Creber,Ruth %A Gosak,Lucija %A Štiglic,Gregor %A Egan,Dominic %A Chaka,Brian %A Debeljak,Nika %A Strnad,Matej %A Skok,Pavel %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, 2000, Slovenia, 386 23004764, nino.fijacko@um.si %K cardiopulmonary resuscitation %K basic life support %K mobile learning %K mobile phone %K gamification %K schoolchildren %D 2021 %7 20.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the Kids Save Lives statements, initiatives to train school-age children in basic life support (BLS) have been widespread. Mobile phone apps, combined with gamification, represent an opportunity for including mobile learning (m-learning) in teaching schoolchildren BLS as an additional teaching method; however, the quality of these apps is questionable. Objective: This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children. Methods: We searched the Google Play Store and Apple iOS App Store using multiple terms (eg, cardiopulmonary resuscitation [CPR] or BLS). Apps meeting the inclusion criteria were evaluated by 15 emergency health care professionals using the user version of the Mobile Application Rating Scale and System Usability Scale. We modified a five-finger mnemonic for teaching schoolchildren BLS and reviewed the apps’ BLS content using standardized criteria based on three CPR guidelines. GFs in the apps were evaluated using a gamification taxonomy. Results: Of the 1207 potentially relevant apps, only 6 (0.49%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95% CI 3.0-3.4) and 47.1/100 points (95% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the personal and fictional, educational, and performance gamification groups represented most GFs. Conclusions: Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills. %M 34283034 %R 10.2196/25437 %U https://mhealth.jmir.org/2021/7/e25437 %U https://doi.org/10.2196/25437 %U http://www.ncbi.nlm.nih.gov/pubmed/34283034 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e29080 %T Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review %A Barteit,Sandra %A Lanfermann,Lucia %A Bärnighausen,Till %A Neuhann,Florian %A Beiersmann,Claudia %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 62215634030, barteit@uni-heidelberg.de %K virtual reality %K augmented reality %K global health %K income-limited countries %K medical education %D 2021 %7 8.7.2021 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment. Objective: We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs). Methods: We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD). Results: A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs. Conclusions: The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education. %M 34255668 %R 10.2196/29080 %U https://games.jmir.org/2021/3/e29080 %U https://doi.org/10.2196/29080 %U http://www.ncbi.nlm.nih.gov/pubmed/34255668 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25151 %T Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study %A Maharaj,Alita %A Lim,David %A Murphy,Rinki %A Serlachius,Anna %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand, 64 9 923 3073, a.serlachius@auckland.ac.nz %K type 2 diabetes %K mobile apps %K diabetes %K self-management %K user engagement %K app %K mHealth %K randomized controlled trial %K intervention %K efficacy %D 2021 %7 16.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Diabetes apps represent a promising addition to face-to-face self-management interventions, which can be time and resource intensive. However, few randomized controlled trials have evaluated the efficacy of diabetes apps, in particular as a stand-alone intervention without additional clinical support. Objective: We used a feasibility randomized trial design to investigate differences in user engagement between 2 commercially available apps (free versions of Glucose Buddy and mySugr) over 2 weeks in adults with type 2 diabetes. Feasibility was assessed based on recruitment uptake, adherence to the diabetes apps, and follow-up rates. We also hypothesized that the diabetes app mySugr would demonstrate higher user engagement at follow-up due to its use of gamification. We also predicted higher user engagement would be associated with improved self-care behaviors and illness beliefs. Methods: Adults with type 2 diabetes attending outpatient diabetes clinics in Auckland were recruited and randomized (1:1 without blinding) to use either the Glucose Buddy or mySugr diabetes apps. User engagement, self-care behaviors, and illness beliefs were measured 2 weeks after baseline. Spearman rank correlations, Mann-Whitney tests, and Wilcoxon signed-rank tests were used to explore associations between the outcome measures and to investigate possible changes between and within groups. Six participants were interviewed to further explore acceptability and usability. Results: In total, 58 participants (29 per group) completed the 2-week follow-up, of whom only 38 reported using the apps (Glucose Buddy: n=20; mySugr: n=18). Both groups reported low engagement (Glucose Buddy: median 4 days; mySugr: median 6.5 days; P=.06; use for both groups: median 10 minutes). No changes were observed in self-care or illness beliefs in either group. Out of the self-care behaviors, only blood glucose testing was significantly associated with minutes of app use (P=.02). The interviews suggested that although both apps were deemed acceptable, they were generally viewed as time-consuming and too complicated to use. Conclusions: Low engagement with both Glucose Buddy and mySugr reflect the challenges associated with engaging users with diabetes apps. Due to low engagement and loss to follow-up, the changes in outcome measures should be interpreted with caution. The results highlight the need for more clinical support as well as involvement from end users and behavior change specialists in order to incorporate evidence-based behavior change techniques to motivate and provide value to users. Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12618000424202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374671 %M 34132640 %R 10.2196/25151 %U https://formative.jmir.org/2021/6/e25151 %U https://doi.org/10.2196/25151 %U http://www.ncbi.nlm.nih.gov/pubmed/34132640 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 2 %P e24337 %T Parents' Perspectives on a Computer Game–Assisted Rehabilitation Program for Manual Dexterity in Children With Cerebral Palsy: Qualitative Analysis of Expectations, Child Engagement, and Benefits %A Kanitkar,Anuprita %A Parmar,Sanjay Tejraj %A Szturm,Tony J %A Restall,Gayle %A Rempel,Gina %A Sepehri,Nariman %+ University of Manitoba, 800 Sherbrook Street, RR327, Winnipeg, MB, Canada, 1 2048813112, anuprita.kan@gmail.com %K cerebral palsy %K parents' expectations %K fine motor function %K object manipulation %K computer game–based treatment protocol %K parents %K motor function %K computer games, rehabilitation %K game-based rehabilitation %K gross movement %K children %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Children with motor impairments affecting the upper extremity benefit from task-specific therapy, such as constraint-induced movement therapy. However, there is a need to improve engagement and compliance with task-specific exercise programs that target manual dexterity for children with cerebral palsy (CP). A computer game–based rehabilitation (GRP) platform was developed that combines fine manipulation and gross movement exercises with engaging game activities appropriate for young children with CP. Objective: The objectives of this qualitative analysis were to compare parents’ perspectives and opinions about expectations, challenges, and benefits between 2 interventions. Methods: A mixed methods, randomized controlled trial (RCT) was conducted to examine the feasibility and estimate the effect size of 2 exercise programs for rehabilitation of manual dexterity of children with CP using either GRP or conventional therapy. Parents of 26 of the children who completed the GRP program (n=33) and parents of 15 of the children who completed the conventional therapy program (n=27) participated in the interviews. A general conductive approach was used to analyze the data recorded during the parents’ interviews. Results: Five themes captured the range of the parent’s experiences, viewpoints, and ideas: (1) parents’ expectations, (2) child’s engagement with therapy, (3) positive effects of the interventions, (4) challenges, and (5) improving the protocol. Conclusions: Parents from both groups recognized that their expectations related to improving children’s object handling and manipulation skills including participation in activities of daily life were addressed during the 16-week therapy program. Parents perceived a change in the children’s level of independence in their daily tasks at home, school, and leisure activities. Trial Registration: ClinicalTrials.gov NCT02728375; https://clinicaltrials.gov/ct2/show/NCT02728375 %M 34057424 %R 10.2196/24337 %U https://rehab.jmir.org/2021/2/e24337 %U https://doi.org/10.2196/24337 %U http://www.ncbi.nlm.nih.gov/pubmed/34057424 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e21900 %T A Gamification Framework for Cognitive Assessment and Cognitive Training: Qualitative Study %A Khaleghi,Ali %A Aghaei,Zahra %A Mahdavi,Mohammad Amin %+ Department of Computer Engineering, Imam Khomeini International University, Norouzian Boulevard, Qazvin, Iran, 98 9121003006, ali.khaleghi.ir@gmail.com %K cognitive tasks %K boredom %K motivation %K gamification %K game elements %K framework %K process %K gamification design %K cognitive training %K cognitive assessment %D 2021 %7 18.5.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive tasks designed to measure or train cognition are often repetitive and presented in a monotonous manner, features that lead to participant boredom and disengagement. In this situation, participants do not put forth their best effort to do these tasks well. As a result, neuropsychologists cannot draw accurate conclusions about the data collected, and intervention effects are reduced. It is assumed that greater engagement and motivation will manifest as improved data quality. Gamification, the use of game elements in nongame settings, has been heralded as a potential mechanism for increasing participant engagement in cognitive tasks. Some studies have reported a positive effect of gamification on participant performance, although most studies have shown mixed results. One reason for these contrasting findings is that most studies have applied poor and heterogeneous design techniques to gamify cognitive tasks. Therefore, an appropriate gamification design framework is needed in these tasks. Objective: This study aimed to propose a framework to guide the design of gamification in cognitive tasks. Methods: We employed a design science research (DSR) approach to provide a framework for gamifying cognitive assessments and training by synthesizing current gamification design frameworks and gamification works in cognitive assessment and training, as well as incorporating field experiences. The prototypes of the framework were iteratively evaluated with 17 relevant experts. Results: We proposed a framework consisting of 7 phases: (1) preparation; (2) knowing users; (3) exploring existing tools for assessing or training a targeted cognitive context and determining the suitability of game-up and mapping techniques; (4) ideation; (5) prototyping using the Objects, Mechanics, Dynamics, Emotions (OMDE) design guideline; (6) development; and (7) disseminating and monitoring. Conclusions: We found that (1) an intermediate design framework is needed to gamify cognitive tasks, which means that game elements should be selected by considering current cognitive assessment or training context characteristics since game elements may impose an irrelevant cognitive load that, in turn, can jeopardize data quality; (2) in addition to developing a new gamified cognitive task from scratch, 2 gamification techniques are widely used (first, adding game elements to an existing cognitive task and second, mapping an existing game to a cognitive function or impairment to assess or train it); and (3) further research is required to investigate the interplay of cognitive processes and game mechanics. %M 33819164 %R 10.2196/21900 %U https://games.jmir.org/2021/2/e21900 %U https://doi.org/10.2196/21900 %U http://www.ncbi.nlm.nih.gov/pubmed/33819164 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e27290 %T Impact of Gamification on the Self-Efficacy and Motivation to Quit of Smokers: Observational Study of Two Gamified Smoking Cessation Mobile Apps %A Rajani,Nikita B %A Mastellos,Nikolaos %A Filippidis,Filippos T %+ Department of Primary Care and Public Health, Imperial College London, School of Public Health, St. Dunstan's Road, London, W6 8RP, United Kingdom, 44 7427615928, nikita.rajani14@imperial.ac.uk %K gamification %K smoking cessation %K mobile applications %K self-efficacy %K motivation to quit %K mHealth %K mobile phone %D 2021 %7 27.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The proportion of smokers making quit attempts and the proportion of smokers successfully quitting have been decreasing over the past few years. Previous studies have shown that smokers with high self-efficacy and motivation to quit have an increased likelihood of quitting and staying quit. Consequently, further research on strategies that can improve the self-efficacy and motivation of smokers seeking to quit could lead to substantially higher cessation rates. Some studies have found that gamification can positively impact the cognitive components of behavioral change, including self-efficacy and motivation. However, the impact of gamification in the context of smoking cessation and mobile health has been sparsely investigated. Objective: This study aims to examine the association between perceived usefulness, perceived ease of use, and frequency of use of gamification features embedded in smoking cessation apps on self-efficacy and motivation to quit smoking. Methods: Participants were assigned to use 1 of the 2 mobile apps for a duration of 4 weeks. App-based questionnaires were provided to participants before app use and 2 weeks and 4 weeks after they started using the app. Gamification was quantitatively operationalized based on the Cugelman gamification framework and concepts from the technology acceptance model. The mean values of perceived frequency, ease of use, and usefulness of gamification features were calculated at midstudy and end-study. Two linear regression models were used to investigate the impact of gamification on self-efficacy and motivation to quit. Results: A total of 116 participants completed the study. The mean self-efficacy increased from 37.38 (SD 13.3) to 42.47 (SD 11.5) points and motivation to quit increased from 5.94 (SD 1.4) to 6.32 (SD 1.7) points after app use. Goal setting was perceived to be the most useful gamification feature, whereas sharing was perceived to be the least useful. Participants self-reported that they used the progress dashboards the most often, whereas they used the sharing feature the least often. The average perceived frequency of gamification features was statistically significantly associated with change in self-efficacy (β=3.35; 95% CI 0.31-6.40) and change in motivation to quit (β=.54; 95% CI 0.15-0.94) between baseline and end-study. Conclusions: Gamification embedded in mobile apps can have positive effects on self-efficacy and motivation to quit smoking. The findings of this study can provide important insights for tobacco control policy makers, mobile app developers, and smokers seeking to quit. %M 33904824 %R 10.2196/27290 %U https://games.jmir.org/2021/2/e27290 %U https://doi.org/10.2196/27290 %U http://www.ncbi.nlm.nih.gov/pubmed/33904824 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e14746 %T Leaderboard Design Principles to Enhance Learning and Motivation in a Gamified Educational Environment: Development Study %A Park,Sungjin %A Kim,Sangkyun %+ Department of Industrial Engineering, Kangwon National University, 417, Engineering Building, Kangwon Deahak Gil 1, Chuncheon, KS007, Republic of Korea, 82 033 250 6287, saviour@kangwon.ac.kr %K leaderboard design %K gamification %K learning motivation %K affordance %D 2021 %7 20.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification in education enhances learners’ motivation, problem-solving abilities, decision-making abilities, and social skills such as communication. Numerous ongoing studies are examining the application of gamification design methodology and game mechanics to a learning environment. Leaderboards are a type of game mechanic that assist learners in goal setting and unleash the motivation for learning. Objective: The aim of this study was to develop leaderboard design principles to assist learners in efficient goal setting, improve learning motivation, and promote learning in gamified learning environments. Methods: This study implemented 2 different strategies. First, we analyzed previous research on leaderboards that focus on educational efficacy and influence on social interactions. Second, we collected and analyzed data related to cases of leaderboards being used in educational and sport environments. Results: This study determined 4 leaderboard design objectives from previous studies. Based on these objectives, we developed 3 leaderboard design principles. First, macro leaderboards and micro leaderboards should be designed and used together. Second, all the elements used to measure learners’ achievements in an educational environment should be incorporated into the micro leaderboard. Third, leaderboards should be designed and considered for application in contexts other than learning environments. This study further analyzes best practices considering the 3 leaderboard design principles. Conclusions: This study contributes toward resolving problems associated with leaderboard design for the application of gamification in educational environments. Based upon our results, we strongly suggest that when teachers consider applying gamification in classrooms, the leaderboard design principles suggested in this research should be incorporated. %M 33877049 %R 10.2196/14746 %U https://games.jmir.org/2021/2/e14746 %U https://doi.org/10.2196/14746 %U http://www.ncbi.nlm.nih.gov/pubmed/33877049 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e24647 %T A Gamified, Social Media–Inspired, Web-Based Personalized Normative Feedback Alcohol Intervention for Lesbian, Bisexual, and Queer-Identified Women: Protocol for a Hybrid Trial %A Boyle,Sarah C %A LaBrie,Joseph W %+ HeadsUp Labs, Department of Psychology, Loyola Marymount University, 1 LMU Drive, Suite 3787, Los Angeles, CA, 90045, United States, 1 8182909940, sarah.boyle@lmu.edu %K sexual minority women %K alcohol %K intervention %K social norms %K gamification %K protocol %K mobile phone %D 2021 %7 16.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sexual minority women are more likely to drink alcohol, engage in heavy drinking, and experience alcohol-related problems than heterosexual women. However, culturally tailored interventions for this population have been slow to emerge. Objective: This type 1 effectiveness-implementation trial examines the feasibility and efficacy of a gamified, culturally tailored, personalized normative feedback (PNF) alcohol intervention for sexual minority women who psychologically identify as lesbian, bisexual, or queer (LBQ). Methods: The core components of a PNF intervention were delivered within LezParlay, a fun, social media–inspired, digital competition designed to challenge negative stereotypes about LBQ women and increase visibility. The competition was advertised on the web through social media platforms and collaboration with LBQ community organizations. After 2 rounds of play by a large cohort of LBQ women, a subsample of 500 drinkers already taking part in the competition were invited to participate in the evaluation study. Study participants were randomized to receive 1 of 3 unique sequences of PNF (ie, alcohol and stigma coping, alcohol and control, or control topics only) over 2 intervention rounds. Randomization was fully automated by the web app, and both researchers and participants were blinded. Results: Analyses will evaluate whether PNF on alcohol use reduces participants’ drinking and negative consequences at 2 and 4 months postintervention; examine whether providing PNF on stigma-coping behaviors, in addition to alcohol use, further reduces alcohol use and consequences beyond PNF on alcohol alone; identify mediators and moderators of intervention efficacy; and examine broader LezParlay app engagement, acceptability, and perceived benefits. Conclusions: This incognito intervention approach is uniquely oriented toward engaging and preventing alcohol-related risks among community populations of LBQ women who may view their heavy drinking as normative and not in need of change because of the visibility of alcohol use in sexual minority community spaces. Thus, this intervention strategy diverges from, and is intended to complement, more intensive programs being developed to meet the needs of LBQ women already motivated to reduce their consumption. Trial Registration: ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478 International Registered Report Identifier (IRRID): DERR1-10.2196/24647 %M 33861212 %R 10.2196/24647 %U https://www.researchprotocols.org/2021/4/e24647 %U https://doi.org/10.2196/24647 %U http://www.ncbi.nlm.nih.gov/pubmed/33861212 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e23822 %T Integration of Motor Learning Principles Into Virtual Reality Interventions for Individuals With Cerebral Palsy: Systematic Review %A Demers,Marika %A Fung,Karen %A Subramanian,Sandeep K %A Lemay,Martin %A Robert,Maxime T %+ Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Department of Rehabilitation, Faculty of Medicine, Université Laval, 525 boul Hamel, Quebec, QC, G1M 2S8, Canada, 1 418 529 9141 ext 6121, maxime.robert@fmed.ulaval.ca %K virtual rehabilitation %K upper limb %K brain damage %K feedback %K active video games %K learning %D 2021 %7 7.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Increasing evidence supports the use of virtual reality systems to improve upper limb motor functions in individuals with cerebral palsy. While virtual reality offers the possibility to include key components to promote motor learning, it remains unclear if and how motor learning principles are incorporated into the development of rehabilitation interventions using virtual reality. Objective: The objective of this study was to determine the extent to which motor learning principles are integrated into virtual reality interventions targeting upper limb function in individuals with cerebral palsy. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed in 10 databases using a combination of keywords related to cerebral palsy, virtual reality, video games, and rehabilitation. Studies were divided into 2 categories: commercial video game platforms and devices and custom virtual reality systems. Study quality was assessed using the modified Downs and Black checklist. Results: The initial search yielded 1497 publications. A total of 26 studies from 30 publications were included, with most studies classified as “fair” according to the modified Downs and Black checklist. The majority of studies provided enhanced feedback and variable practice and used functionally relevant and motivating virtual tasks. The dosage varied greatly (total training time ranged from 300 to 3360 minutes), with only 6 studies reporting the number of movement repetitions per session. The difficulty progression and the assessment of skills retention and transfer were poorly incorporated, especially for the commercial video games. Conclusions: Motor learning principles should be better integrated into the development of future virtual reality systems for optimal upper limb motor recovery in individuals with cerebral palsy. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020151982; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151982 %M 33825690 %R 10.2196/23822 %U https://games.jmir.org/2021/2/e23822 %U https://doi.org/10.2196/23822 %U http://www.ncbi.nlm.nih.gov/pubmed/33825690 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e23302 %T Tabletop Board Game Elements and Gamification Interventions for Health Behavior Change: Realist Review and Proposal of a Game Design Framework %A Epstein,Daniel S %A Zemski,Adam %A Enticott,Joanne %A Barton,Christopher %+ Department of General Practice, Monash University, Ferntree Gully Road, Notting Hill, Australia, 61 408578964, dan.epstein@monash.edu %K behavior change %K games %K serious games %K board games %K behavior interventions %K health interventions %K health games %K game design %K tabletop games %D 2021 %7 31.3.2021 %9 Review %J JMIR Serious Games %G English %X Background: Games, when used as interventional tools, can influence behavior change by incentivizing, reinforcing, educating, providing feedback loops, prompting, persuading, or providing meaning, fun, and community. However, not all game elements will appeal to all consumers equally, and different elements might work for different people and in different contexts. Objective: The aim of this study was to conduct a realist review of tabletop games targeting behavior change and to propose a framework for designing effective behavior change games. Methods: A realist review was conducted to inform program theory in the development of tabletop games for health behavior change. The context, mechanisms used to change behavior, and outcomes of included studies were reviewed through a realist lens. Results: Thirty-one papers met the eligibility criteria and were included in the review. Several design methods were identified that enhanced the efficacy of the games to change behavior. These included design by local teams, pilot testing, clearly defined targets of behavior change, conscious attention to all aspects of game design, including game mechanics, dynamics, aesthetics, and the elicitation of emotions. Delivery with other mediums, leveraging behavioral insights, prior training for delivery, and repeated play were also important. Some design elements that were found to reduce efficacy included limited replayability or lack of fun for immersive engagement. Conclusions: Game designers need to consider all aspects of the context and the mechanisms to achieve the desired behavior change outcomes. Careful design thinking should include consideration of the game mechanics, dynamics, aesthetics, emotions, and contexts of the game and the players. People who know the players and the contexts well should design the games or have significant input. Testing in real-world settings is likely to lead to better outcomes. Careful selection and purposeful design of the behavior change mechanisms at play is essential. Fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect. %M 33787502 %R 10.2196/23302 %U https://games.jmir.org/2021/1/e23302 %U https://doi.org/10.2196/23302 %U http://www.ncbi.nlm.nih.gov/pubmed/33787502 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e26007 %T Game-Based Learning Outcomes Among Physiotherapy Students: Comparative Study %A Molina-Torres,Guadalupe %A Rodriguez-Arrastia,Miguel %A Alarcón,Raquel %A Sánchez-Labraca,Nuria %A Sánchez-Joya,María %A Roman,Pablo %A Requena,Mar %+ Department of Nursing, Physical Therapy and Medicine, University of Almeria, Carretera de Sacramento s/n, Almeria, 04120, Spain, 34 950 21 45 63, pablo.roman@ual.es %K gamification %K board game–based approach %K health sciences %K physiotherapy %K teaching innovation %D 2021 %7 24.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: University teaching methods are changing, and in response to a classical teacher-centered approach, new methods continue to strengthen knowledge acquisition by involving students more actively in their learning, thus achieving greater motivation and commitment. Objective: This study aimed to analyze the degree of satisfaction of physiotherapy students who used a board game–based approach, as well as to compare the difference between traditional and gamification teaching methods and their influence on the final evaluation of these students. Methods: A comparative study was conducted. Participants were physiotherapy students who were enrolled in the subject of “physiotherapy in geriatric and adult psychomotricity” (n=59). They were divided into two groups (experimental [n=29] and control [n=30] groups) through convenience sampling. The experimental group received gamification lessons, where the students performed different tests adapted from Party&Co, and the control group received traditional lessons. A total of 16 theoretical lessons were received in both groups. Results: The scores in the final examination of the subject were higher in the experimental group (mean 7.53, SD 0.95) than in the control group (mean 6.24, SD 1.34), showing a statistically significant difference between the two groups (P=.001). Conclusions: Overall, the “Physiotherapy Party” game not only stimulated learning and motivated students, but also improved learning outcomes among participants, and the improvements were greater than those among students who received traditional teaching. %M 33759800 %R 10.2196/26007 %U https://games.jmir.org/2021/1/e26007 %U https://doi.org/10.2196/26007 %U http://www.ncbi.nlm.nih.gov/pubmed/33759800 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e24151 %T Application of Eye Tracking in Puzzle Games for Adjunct Cognitive Markers: Pilot Observational Study in Older Adults %A Krebs,Christine %A Falkner,Michael %A Niklaus,Joel %A Persello,Luca %A Klöppel,Stefan %A Nef,Tobias %A Urwyler,Prabitha %+ Gerontechnology & Rehabilitation group, University of Bern, Murtenstrasse 50, Bern, 3008, Switzerland, 41 316327607, prabitha.urwyler@artorg.unibe.ch %K eye tracking %K puzzle games %K aging %K cognitive assessment %K cognition, attention, executive functions, visual search, fixations %D 2021 %7 22.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Recent studies suggest that computerized puzzle games are enjoyable, easy to play, and engage attentional, visuospatial, and executive functions. They may help mediate impairments seen in cognitive decline in addition to being an assessment tool. Eye tracking provides a quantitative and qualitative analysis of gaze, which is highly useful in understanding visual search behavior. Objective: The goal of the research was to test the feasibility of eye tracking during a puzzle game and develop adjunct markers for cognitive performance using eye-tracking metrics. Methods: A desktop version of the Match-3 puzzle game with 15 difficulty levels was developed using Unity 3D (Unity Technologies). The goal of the Match-3 puzzle was to find configurations (target patterns) that could be turned into a row of 3 identical game objects (tiles) by swapping 2 adjacent tiles. Difficulty levels were created by manipulating the puzzle board size (all combinations of width and height from 4 to 8) and the number of unique tiles on the puzzle board (from 4 to 8). Each level consisted of 4 boards (ie, target patterns to match) with one target pattern each. In this study, the desktop version was presented on a laptop computer setup with eye tracking. Healthy older subjects were recruited to play a full set of 15 puzzle levels. A paper-pencil–based assessment battery was administered prior to the Match-3 game. The gaze behavior of all participants was recorded during the game. Correlation analyses were performed on eye-tracking data correcting for age to examine if gaze behavior pertains to target patterns and distractor patterns and changes with puzzle board size (set size). Additionally, correlations between cognitive performance and eye movement metrics were calculated. Results: A total of 13 healthy older subjects (mean age 70.67 [SD 4.75] years; range 63 to 80 years) participated in this study. In total, 3 training and 12 test levels were played by the participants. Eye tracking recorded 672 fixations in total, 525 fixations on distractor patterns and 99 fixations on target patterns. Significant correlations were found between executive functions (Trail Making Test B) and number of fixations on distractor patterns (P=.01) and average fixations (P=.005). Conclusions: Overall, this study shows that eye tracking in puzzle games can act as a supplemental source of data for cognitive performance. The relationship between a paper-pencil test for executive functions and fixations confirms that both are related to the same cognitive processes. Therefore, eye movement metrics might be used as an adjunct marker for cognitive abilities like executive functions. However, further research is needed to evaluate the potential of the various eye movement metrics in combination with puzzle games as visual search and attentional marker. %M 33749607 %R 10.2196/24151 %U https://games.jmir.org/2021/1/e24151 %U https://doi.org/10.2196/24151 %U http://www.ncbi.nlm.nih.gov/pubmed/33749607 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e25063 %T Preserved Inhibitory Control Deficits of Overweight Participants in a Gamified Stop-Signal Task: Experimental Study of Validity %A Schroeder,Philipp Alexander %A Lohmann,Johannes %A Ninaus,Manuel %+ Department of Psychology, Clinical Psychology and Psychotherapy, University of Tübingen, Schleichstr 4, Tübingen, , Germany, 49 07071 297 7435, philipp.schroeder@uni-tuebingen.de %K gamification %K inhibitory control %K response inhibition %K overweight %K BMI %K stop-signal task %K mental health %K games %K overweight %D 2021 %7 12.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification in mental health could increase training adherence, motivation, and transfer effects, but the external validity of gamified tasks is unclear. This study documents that gamified task variants can show preserved associations between markers of behavioral deficits and health-related variables. We draw on the inhibitory control deficit in overweight populations to investigate effects of gamification on performance measures in a web-based experimental task. Objective: This study tested whether associations between inhibitory control and overweight were preserved in a gamified stop-signal task (SST). Methods: Two versions of an adaptive SST were developed and tested in an online experiment. Participants (n=111) were randomized to 1 of the 2 task variants and completed a series of questionnaires along with either the gamified SST or a conventional SST. To maximize its possible effects on participants’ inhibitory control, the gamified SST included multiple game elements in addition to the task itself and the stimuli. Both variants drew on the identical core mechanics, but the gamified variant included an additional narrative, graphical theme, scoring system with visual and emotional feedback, and the presence of a companion character. In both tasks, food and neutral low-poly stimuli were classified based on their color tone (go trials), but responses were withheld in 25% of the trials (stop trials). Mean go reaction times and stop-signal reaction times (SSRT) were analyzed as measures of performance and inhibitory control. Results: Participants in the gamified SST had longer reaction times (803 [SD 179] ms vs 607 [SD 90] ms) and worse inhibitory control (SSRT 383 [SD 109] ms vs 297 [SD 45] ms). The association of BMI with inhibitory control was relatively small (r=.155, 95% CI .013-.290). Overweight participants had longer reaction times (752 [SD 217] ms vs 672 [SD 137] ms) and SSRTs (363 [SD 116] ms vs 326 [SD 77] ms). Gamification did not interact with the effect of overweight on mean performance or inhibitory control. There were no effects of gamification on mood and user experience, despite a negative effect on perceived efficiency. Conclusions: The detrimental effects of heightened BMI on inhibitory control were preserved in a gamified version of the SST. Overall, the effects of overweight were smaller than in previously published web-based and laboratory studies. Gamification elements can impact behavioral performance, but gamified tasks can still assess inhibitory control deficits. Although our results are promising, according validations may differ for other types of behavior, gamification, and health variables. %M 33709936 %R 10.2196/25063 %U https://games.jmir.org/2021/1/e25063 %U https://doi.org/10.2196/25063 %U http://www.ncbi.nlm.nih.gov/pubmed/33709936 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20537 %T Defining Digital Game-Based Learning for Science, Technology, Engineering, and Mathematics: A New Perspective on Design and Developmental Research %A Ishak,Shahrul Affendi %A Din,Rosseni %A Hasran,Umi Azmah %+ Science, Technology, Engineering, and Mathematics Enculturation Research Centre, Faculty of Education, Universiti Kebangsaan Malaysia, 43600 UKM, Bangi, 43600, Malaysia, 60 166656420, rosseni@ukm.edu.my %K digital game-based learning %K STEM digital game %K game development model %K game design %K design and developmental research %D 2021 %7 19.2.2021 %9 Viewpoint %J J Med Internet Res %G English %X In the modern age, digital games are widely used as informal media for Science, Technology, Engineering, and Mathematics (STEM) education and medical therapy for game-based learning. Digital games provide learners with a graphical system of interaction that enhances scientific concepts within an enjoyable environment. The vastly increasing number of digital games produced in the market affects the quality of STEM digital games while requiring multidisciplinary expertise. This paper proposes a framework for STEM digital game-based learning encompassing input-process-output stages. Several studies from the early 2000s onward were reviewed to discuss and present a new perspective on a framework for the design and development of digital games, particularly for STEM. This proposed framework consists of digital game development as input, experience as a process, and constructs as output. This simple and precise framework will generate a universal product for various types of learners. It can thus be used as a guideline for game designers, developers, and experts to develop STEM digital games and achieve better learning outcomes. %M 33605885 %R 10.2196/20537 %U http://www.jmir.org/2021/2/e20537/ %U https://doi.org/10.2196/20537 %U http://www.ncbi.nlm.nih.gov/pubmed/33605885 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e23710 %T Perception of Game-Based Rehabilitation in Upper Limb Prosthetic Training: Survey of Users and Researchers %A Garske,Christian Alexander %A Dyson,Matthew %A Dupan,Sigrid %A Nazarpour,Kianoush %+ Intelligent Sensing Laboratory, School of Engineering, Newcastle University, Merz Court, Newcastle upon Tyne, NE1 7RU, United Kingdom, 44 191 20 86682, c.a.garske2@ncl.ac.uk %K upper limb %K rehabilitation %K arm prosthesis %K serious games %K engagement %K transfer %D 2021 %7 1.2.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have been investigated for their use in multiple forms of rehabilitation for decades. The rising trend to use games for physical fitness in more recent years has also provided more options and garnered more interest for their use in physical rehabilitation and motor learning. In this study, we report the results of an opinion survey of serious games in upper limb prosthetic training. Objective: This study investigates and contrasts the expectations and preferences for game-based prosthetic rehabilitation of people with limb difference and researchers. Methods: Both participant groups answered open and closed questions as well as a questionnaire to assess their user types. The distribution of the user types was compared with a Pearson chi-square test against a sample population. The data were analyzed using the thematic framework method; answers fell within the themes of usability, training, and game design. Researchers shared their views on current challenges and what could be done to tackle these. Results: A total of 14 people with limb difference and 12 researchers participated in this survey. The open questions resulted in an overview of the different views on prosthetic training games between the groups. The user types of people with limb difference and researchers were both significantly different from the sample population, with χ25=12.3 and χ25=26.5, respectively. Conclusions: We found that the respondents not only showed a general willingness and tentative optimism toward the topic but also acknowledged hurdles limiting the adoption of these games by both clinics and users. The results indicate a noteworthy difference between researchers and people with limb difference in their game preferences, which could lead to design choices that do not represent the target audience. Furthermore, focus on long-term in-home experiments is expected to shed more light on the validity of games in upper limb prosthetic rehabilitation. %M 33522975 %R 10.2196/23710 %U http://games.jmir.org/2021/1/e23710/ %U https://doi.org/10.2196/23710 %U http://www.ncbi.nlm.nih.gov/pubmed/33522975 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e21303 %T Utilizing Theories and Evaluation in Digital Gaming Interventions to Increase Human Papillomavirus Vaccination Among Young Males: Qualitative Study %A Darville,Gabrielle %A Burns,Jade %A Chavanduka,Tanaka %A Anderson-Lewis,Charkarra %+ Department of Public Health, College of Health Professions, Mercer University, 1501 Mercer University Drive, Macon, GA, 31207, United States, 1 478 301 5129, darville_gc@mercer.edu %K digital games %K behavior change %K theory %K evaluation %K game design %K health care providers %D 2021 %7 22.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV attributes to most cancers including anal, oral, cervical, and penile. Despite infection rates in the United States, recommendations and communication campaigns have traditionally focused on females. Because of this, males lack knowledge about reasons for vaccination, the benefits of being vaccinated, and their HPV risk, overall. Gaming as a health education strategy can be beneficial as mechanism that can promote behavior change for this key demographic because of the popularity of gaming. Objective: We sought to explore the relationship between gamification and HPV vaccine uptake. Methods: Interviews were conducted with experts (n=22) in the fields of cancer prevention, sexual and reproductive health, public health, game design, technology, and health communication on how a game should be developed to increase HPV vaccination rates among males. Results: Overwhelmingly, theoretical models such as the health belief model were identified with key constructs such as self-efficacy and risk perception. Experts also suggested using intervention mapping and logic models as planning tools for health promotion interventions utilizing a digital game as a medium. In game and out of game measures were discussed as assessments for quality and impact by our expert panel. Conclusions: This study shows that interventions should focus on whether greater utilization of serious games, and the incorporation of theory and standardized methods, can encourage young men to get vaccinated and to complete the series of HPV vaccinations. %M 33480856 %R 10.2196/21303 %U http://games.jmir.org/2021/1/e21303/ %U https://doi.org/10.2196/21303 %U http://www.ncbi.nlm.nih.gov/pubmed/33480856 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e24078 %T Emotional Bias Modification for Individuals With Attention Deficit Hyperactivity Disorder: Protocol for a Co-Design Study %A Zhang,Melvyn %A Vallabhajosyula,Ranganath %A Fung,Daniel %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Level 18 Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 63892000, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K ADHD %K child psychiatry %D 2020 %7 23.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a worldwide prevalence rate of 5%. Individuals with ADHD often tend to have difficulties with emotional regulation. The advances in experimental psychology have led to the discovery of emotional biases. Targeting emotional biases could potentially help improve the core symptoms of irritability and short-temperedness among these individuals. Emotional biases refer to the preferential allocation of attention toward emotional stimuli. A recent study reported the presence of emotional biases among individuals with ADHD when they compared individuals with ADHD with those without. Gamification technologies have been explored to help diminish the repetitiveness of the task and increase the intrinsic motivation to train. These inconsistent findings of the impact of gaming on the effectiveness of mobile interventions call for further work to better understand the needs of patients (users) and health care professionals. Objective: The aim of this research study is to collate health care professionals’ perspectives on the limitations of the existing task, and to determine if gamification elements could be incorporated, to refine the conventional intervention. Methods: A qualitative research approach, that of a focus group, will be used. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore will be invited to participate in this qualitative research. During the focus group, participants are to comment on the limitations of the existing emotional bias intervention; recommend strategies to improve the intervention; and provide their perspectives pertaining to the use of gamification to improve the intervention. Results: We expect that the study will be completed in 12 months from the publication of this protocol. Conclusions: To our best knowledge, this is perhaps one of the only few studies that have attempted to explore emotional biases among adolescents with ADHD. International Registered Report Identifier (IRRID): PRR1-10.2196/24078 %M 33355536 %R 10.2196/24078 %U http://www.researchprotocols.org/2020/12/e24078/ %U https://doi.org/10.2196/24078 %U http://www.ncbi.nlm.nih.gov/pubmed/33355536 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 11 %P e23626 %T Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study %A Rantala,Arja %A Jansson,Miia M %A Helve,Otto %A Lahdenne,Pekka %A Pikkarainen,Minna %A Pölkki,Tarja %+ Research Group of Medical Imaging, Physics and Technology, Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Pentti Kaiteran katu 1, Oulu, FI-90014, Finland, 358 504340424, arja.rantala@oulu.fi %K anxiety %K children %K day surgery %K delivery of health care %K digital solution %K gamification %K nursing %K pain %K qualitative study %K technology %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative pain relief, and postoperative guidance. Parents’ experiences help care providers to provide effective, family-centered care that responds to parents’ needs throughout the day surgery pathway. Objective: The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs for a digital gaming solution in order to facilitate the digitalization of these pathways. Methods: This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to the hospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: Parental experiences of the children’s day surgery pathway included 3 main categories: (1) needs for parental guidance, (2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparation of child for treatment). The needs for a digital gaming solution were identified as 1 main category—the digital gaming solution for children and families to support care. This main category included 3 upper categories: (1) preparing children and families for the day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution. Conclusions: Parents need guidance and support for their children’s day surgery care pathways. A digital gaming solution may be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to digital gaming solutions that provide support and guidance and engage children in the day surgery pathways. %M 33185556 %R 10.2196/23626 %U http://medinform.jmir.org/2020/11/e23626/ %U https://doi.org/10.2196/23626 %U http://www.ncbi.nlm.nih.gov/pubmed/33185556 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e14322 %T Use of a Smartphone App to Increase Physical Activity Levels in Insufficiently Active Adults: Feasibility Sequential Multiple Assignment Randomized Trial (SMART) %A Gonze,Bárbara De Barros %A Padovani,Ricardo Da Costa %A Simoes,Maria Do Socorro %A Lauria,Vinicius %A Proença,Neli Leite %A Sperandio,Evandro Fornias %A Ostolin,Thatiane Lopes Valentim Di Paschoale %A Gomes,Grace Angélica De Oliveira %A Castro,Paula Costa %A Romiti,Marcello %A Gagliardi,Antonio %A Arantes,Rodolfo Leite %A Dourado,Victor Zuniga %+ Laboratory of Epidemiology and Human Movement (EPIMOV), Department of Human Movement Sciences, Federal University of São Paulo, Rua Silva Jardim 136, Vila Mathias, Santos, 11015-020, Brazil, 55 1332290203, victor.dourado@unifesp.br %K tailored messages %K gamification %K steps per day %D 2020 %7 23.10.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The sequential multiple assignment randomized trial (SMART) design allows for changes in the intervention during the trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has not been utilized in a smartphone/gamified intervention for physical activity. Objective: We aimed to investigate the feasibility of the SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively. Methods: We conducted a feasibility 24-week/two-stage SMART in which 18 insufficiently active participants (<10,000 steps/day) were first randomized to group 1 (smartphone app only), group 2 (smartphone app + tailored messages), and a control group (usual routine during the protocol). Participants were motivated to increase their step count by at least 2000 steps/day each week. Based on the 12-week intermediate outcome, responders continued the intervention and nonresponders were rerandomized to subsequent treatment, including a new group 3 (smartphone app + tailored messages + gamification) in which they were instructed to form groups to use several game elements available in the chosen app (Pacer). We considered responders as those with any positive slope in the linear relationship between weeks and steps per day at the end of the first stage of the intervention. We compared the accelerometer-based steps per day before and after the intervention, as well as the slopes of the app-based steps per day between the first and second stages of the intervention. Results: Twelve participants, including five controls, finished the intervention. We identified two responders in group 1. We did not observe relevant changes in the steps per day either throughout the intervention or compared with the control group. However, the rerandomization of five nonresponders led to a change in the slope of the steps per day (median −198 steps/day [IQR −279 to −103] to 20 steps/day [IQR −204 to 145]; P=.08). Finally, in three participants from group 2, we observed an increase in the number of steps per day up to the sixth week, followed by an inflection to baseline values or even lower (ie, a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into the following: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals. Conclusions: The SMART design was feasible and changed the behavior of steps per day after rerandomization. Rerandomization should be implemented earlier to take advantage of tailored messages. Additionally, difficulties with technology and realistic and individualized goals should be considered in interventions for physical activity using smartphones. Trial Registration: Brazilian Registry of Clinical Trials RBR-8xtc9c; http://www.ensaiosclinicos.gov.br/rg/RBR-8xtc9c/. %M 33094733 %R 10.2196/14322 %U https://www.researchprotocols.org/2020/10/e14322 %U https://doi.org/10.2196/14322 %U http://www.ncbi.nlm.nih.gov/pubmed/33094733 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19280 %T Archetypes of Gamification: Analysis of mHealth Apps %A Schmidt-Kraepelin,Manuel %A Toussaint,Philipp A %A Thiebes,Scott %A Hamari,Juho %A Sunyaev,Ali %+ Department of Economics and Management, Karlsruhe Institute of Technology, Kaiserstraße 89, Karlsruhe, D-76133, Germany, 49 72160846037, sunyaev@kit.edu %K mHealth %K smartphones %K mobile phones %K gamification %K quantified-self %K exergames, persuasive technology %D 2020 %7 19.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Nowadays, numerous health-related mobile apps implement gamification in an attempt to draw on the motivational potential of video games and thereby increase user engagement or foster certain health behaviors. However, research on effective gamification is still in its infancy and researchers increasingly recognize methodological shortcomings of existing studies. What we actually know about the phenomenon today stems from fragmented pieces of knowledge, and a variety of different perspectives. Existing research primarily draws on conceptual knowledge that is gained from research prototypes, and isolated from industry best practices. We still lack knowledge on how gamification has been successfully designed and implemented within the industry and whether certain gamification approaches have shown to be particularly suitable for certain health behaviors. Objective: We address this lack of knowledge concerning best practices in the design and implementation of gamification for health-related mobile apps by identifying archetypes of gamification approaches that have emerged in pertinent health-related mobile apps and analyzing to what extent those gamification approaches are influenced by the underlying desired health-related outcomes. Methods: A 3-step research approach is employed. As a first step, a database of 143 pertinent gamified health-related mobile apps from the Apple App Store and Google Play Store is set up. Second, the gamification approach of each app within the database is classified based on an established taxonomy for gamification in health-related apps. Finally, a 2-step cluster analysis is conducted in order to identify archetypes of the most dominant gamification approaches in pertinent gamified health-related mobile apps. Results: Eight archetypes of gamification emerged from the analysis of health-related mobile apps: (1) competition and collaboration, (2) pursuing self-set goals without rewards, (3) episodical compliance tracking, (4) inherent gamification for external goals, (5) internal rewards for self-set goals, (6) continuous assistance through positive reinforcement, (7) positive and negative reinforcement without rewards, and (8) progressive gamification for health professionals. The results indicate a close relationship between the identified archetypes and the actual health behavior that is being targeted. Conclusions: By unveiling salient best practices and discussing their relationship to targeted health behaviors, this study contributes to a more profound understanding of gamification in mobile health. The results can serve as a foundation for future research that advances the knowledge on how gamification may positively influence health behavior change and guide practitioners in the design and development of highly motivating and effective health-related mobile health apps. %M 33074155 %R 10.2196/19280 %U https://mhealth.jmir.org/2020/10/e19280 %U https://doi.org/10.2196/19280 %U http://www.ncbi.nlm.nih.gov/pubmed/33074155 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17810 %T Effective Gamification of the Stop-Signal Task: Two Controlled Laboratory Experiments %A Friehs,Maximilian Achim %A Dechant,Martin %A Vedress,Sarah %A Frings,Christian %A Mandryk,Regan Lee %+ Department of Cognitive Psychology and Methodology, Trier University, Universitätsring 15, Trier, 54292, Germany, 49 651201 ext 3250, friehs@uni-trier.de %K video games %K games, experimental %K proof of concept study %K cognition %K psychology %K motivation %D 2020 %7 8.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: A lack of ability to inhibit prepotent responses, or more generally a lack of impulse control, is associated with several disorders such as attention-deficit/hyperactivity disorder and schizophrenia as well as general damage to the prefrontal cortex. A stop-signal task (SST) is a reliable and established measure of response inhibition. However, using the SST as an objective assessment in diagnostic or research-focused settings places significant stress on participants as the task itself requires concentration and cognitive effort and is not particularly engaging. This can lead to decreased motivation to follow task instructions and poor data quality, which can affect assessment efficacy and might increase drop-out rates. Gamification—the application of game-based elements in nongame settings—has shown to improve engaged attention to a cognitive task, thus increasing participant motivation and data quality. Objective: This study aims to design a gamified SST that improves participants’ engagement and validate this gamified SST against a standard SST. Methods: We described the design of our gamified SST and reported on 2 separate studies that aim to validate the gamified SST relative to a standard SST. In study 1, a within-subject design was used to compare the performance of the SST and a stop-signal game (SSG). In study 2, we added eye tracking to the procedure to determine if overt attention was affected and aimed to replicate the findings from study 1 in a between-subjects design. Furthermore, in both studies, flow and motivational experiences were measured. Results: In contrast, the behavioral performance was comparable between the tasks (P<.87; BF01=2.87), and the experience of flow and intrinsic motivation were rated higher in the SSG group, although this difference was not significant. Conclusions: Overall, our findings provide evidence that the gamification of SST is possible and that the SSG is enjoyed more. Thus, when participant engagement is critical, we recommend using the SSG instead of the SST. %M 32897233 %R 10.2196/17810 %U https://games.jmir.org/2020/3/e17810 %U https://doi.org/10.2196/17810 %U http://www.ncbi.nlm.nih.gov/pubmed/32897233 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e20667 %T Feasibility of a Commercially Available Virtual Reality System to Achieve Exercise Guidelines in Youth With Spina Bifida: Mixed Methods Case Study %A Lai,Byron %A Davis,Drew %A Narasaki-Jara,Mai %A Hopson,Betsy %A Powell,Danielle %A Gowey,Marissa %A Rocque,Brandon G %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, School of Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 2052001724, byronlai@uab.edu %K physical activity %K active video gaming %K exergaming %K disability %K Oculus Quest %D 2020 %7 3.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Access to physical activity among youth with spina bifida (SB) is much lower than it is for children without disability. Enjoyable home-based exercise programs are greatly needed. Objective: Our objective is to examine the feasibility of a virtual reality (VR) active video gaming system (ie, bundle of consumer-available equipment) to meet US physical activity guidelines in two youth with SB. Methods: Two youth with SB—a 12-year-old female and a 13-year-old male; both full-time wheelchair users—participated in a brief, 4-week exercise program using a popular VR head-mounted display: Oculus Quest (Facebook Technologies). The system included a Polar H10 (Polar Canada) Bluetooth heart rate monitor, a no-cost mobile phone app (VR Health Exercise Tracker [Virtual Reality Institute of Health and Exercise]), and 13 games. The intervention protocol was conducted entirely in the homes of the participants due to the coronavirus disease 2019 (COVID-19) pandemic. The VR system was shipped to participants and they were instructed to do their best to complete 60 minutes of moderate-intensity VR exercise per day. Exercise duration, intensity, and calories expended were objectively monitored and recorded during exercise using the heart rate monitor and a mobile app. Fatigue and depression were measured via self-report questionnaires at pre- and postintervention. Participants underwent a semistructured interview with research staff at postintervention. Results: Across the intervention period, the total average minutes of all exercise performed each week for participants 1 and 2 were 281 (SD 93) and 262 (SD 55) minutes, respectively. The total average minutes of moderate-intensity exercise performed per week for participants 1 and 2 were 184 (SD 103) (184/281, 65.4%) and 215 (SD 90) (215/262, 82.1%) minutes, respectively. One participant had a reduction in their depression score, using the Quality of Life in Neurological Disorders (Neuro-QoL) test, from baseline to postintervention, but no other changes were observed for fatigue and depression scores. Participants reported that the amount of exercise they completed was far higher than what was objectively recorded, due to usability issues with the chest-worn heart rate monitor. Participants noted that they were motivated to exercise due to the enjoyment of the games and VR headset as well as support from a caregiver. Conclusions: This study demonstrated that two youth with SB who used wheelchairs could use a VR system to independently and safely achieve exercise guidelines at home. Study findings identified a promising protocol for promoting exercise in this population and this warrants further examination in future studies with larger samples. %M 32880577 %R 10.2196/20667 %U http://games.jmir.org/2020/3/e20667/ %U https://doi.org/10.2196/20667 %U http://www.ncbi.nlm.nih.gov/pubmed/32880577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e21265 %T Effect of an E-Learning Module on Personal Protective Equipment Proficiency Among Prehospital Personnel: Web-Based Randomized Controlled Trial %A Suppan,Laurent %A Abbas,Mohamed %A Stuby,Loric %A Cottet,Philippe %A Larribau,Robert %A Golay,Eric %A Iten,Anne %A Harbarth,Stephan %A Gartner,Birgit %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 789151845, laurent.suppan@hcuge.ch %K personal protective equipment %K COVID-19 %K electronic learning %K prehospital %K randomized controlled trial %K protection %K equipment %K safety %K gamified %K online learning %K communication %D 2020 %7 21.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: To avoid misuse of personal protective equipment (PPE), ensure health care workers’ safety, and avoid shortages, effective communication of up-to-date infection control guidelines is essential. As prehospital teams are particularly at risk of contamination given their challenging work environment, a specific gamified electronic learning (e-learning) module targeting this audience might provide significant advantages as it requires neither the presence of learners nor the repetitive use of equipment for demonstration. Objective: The aim of this study was to evaluate whether a gamified e-learning module could improve the rate of adequate PPE choice by prehospital personnel in the context of the coronavirus disease (COVID-19) pandemic. Methods: This was an individual-level randomized, controlled, quadruple-blind (investigators, participants, outcome assessors, and data analysts) closed web-based trial. All emergency prehospital personnel working in Geneva, Switzerland, were eligible for inclusion, and were invited to participate by email in April 2020. Participants were informed that the study aim was to assess their knowledge regarding PPE, and that they would be presented with both the guidelines and the e-learning module, though they were unaware that there were two different study paths. All participants first answered a preintervention quiz designed to establish their profile and baseline knowledge. The control group then accessed the guidelines before answering a second set of questions, and were then granted access to the e-learning module. The e-learning group was shown the e-learning module right after the guidelines and before answering the second set of questions. Results: Of the 291 randomized participants, 176 (60.5%) completed the trial. There was no significant difference in baseline knowledge between groups. Though the baseline proportion of adequate PPE choice was high (75%, IQR 50%-75%), participants’ description of the donning sequence was in most cases incorrect. After either intervention, adequate choice of PPE increased significantly in both groups (P<.001). Though the median of the difference in the proportion of correct answers was slightly higher in the e-learning group (17%, IQR 8%-33% versus 8%, IQR 8%-33%), the difference was not statistically significant (P=.27). Confidence in the ability to use PPE was maintained in the e-learning group (P=.27) but significantly decreased in the control group (P=.04). Conclusions: Among prehospital personnel with an already relatively high knowledge of and experience with PPE use, both web-based study paths increased the rate of adequate choice of PPE. There was no major added value of the gamified e-learning module apart from preserving participants' confidence in their ability to correctly use PPE. %M 32747329 %R 10.2196/21265 %U http://www.jmir.org/2020/8/e21265/ %U https://doi.org/10.2196/21265 %U http://www.ncbi.nlm.nih.gov/pubmed/32747329 %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 %@ 2291-5222 %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 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 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 %@ 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 %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e15164 %T Gamified Mobile Computerized Cognitive Behavioral Therapy for Japanese University Students With Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Yokomitsu,Kengo %A Irie,Tomonari %A Sekiguchi,Mayu %A Shimizu,Ayako %A Matsuoka,Hirofumi %A Merry,Sally Nicola %A Stasiak,Karolina %+ College of Comprehensive Psychology, Ritsumeikan University, 2-150 Iwakura-cho, Ibaraki, Osaka, 567-8570, Japan, 81 72 665 2490, k-yoko@fc.ritsumei.ac.jp %K SPARX %K Japan %K university students %K depressive symptoms %D 2020 %7 7.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence shows that computerized self-help interventions are effective for reducing symptoms of depression. One such intervention, SPARX, is a gamified mobile computerized cognitive behavioral therapy (cCBT) developed for adolescents in New Zealand, which was shown to be as effective as usual care for young people with mild-to-moderate symptoms of depression. However, gamified cCBT has not yet been tested in Japan. Objective: This trial is designed to investigate whether a Japanese-adapted version of SPARX improves depressive symptoms in Japanese university students with mild-to-moderate depressive symptoms. Methods: In this 7-week, multicenter, stratified, parallel-group, superiority randomized trial, participants will be allocated to either a treatment condition (SPARX) or a wait-list control condition. SPARX is a fully automated program, which will be delivered to the mobile phone or tablet device of the participants. SPARX is designed as an interactive fantasy game to guide the user through seven modules that teach key CBT strategies. All participants will be recruited from universities via advertisements on online bulletin boards, the campus newspaper, and posters. Participants in the treatment condition will use the SPARX program weekly. The primary outcome is the reduction of depressive symptoms (using Patient Health Questionnaires-9) measured at baseline and weekly: once after the 7-week intervention and once at a 1-month follow-up. Secondary outcomes include satisfaction with the program and satisfaction with life, measured by the Satisfaction With Life Scale; positive and negative moods, measured by the Profile of Mood States Second Edition; social functioning, measured by the EuroQol Instrument; rumination, measured by the Ruminative Responses Scale; and coping, measured by the Brief Coping Orientation to Problem Experienced Inventory. Results: This study received funding from The Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, and obtained institutional review board approval in September 2019. Data collection began in April 2019. Conclusions: Results of this trial may provide further evidence for the efficacy of gamified cCBT for the treatment of depression and, specifically, provide support for using SPARX with Japanese university students. Trial Registration: Japan Primary Registries Network UMIN000034354; https://tinyurl.com/uu7xd77 International Registered Report Identifier (IRRID): DERR1-10.2196/15164 %M 32254045 %R 10.2196/15164 %U https://www.researchprotocols.org/2020/4/e15164 %U https://doi.org/10.2196/15164 %U http://www.ncbi.nlm.nih.gov/pubmed/32254045 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 9 %N 1 %P e13684 %T Improving Patient Preference Elicitation by Applying Concepts From the Consumer Research Field: Narrative Literature Review %A Ver Donck,Niki %A Vander Stichele,Geert %A Huys,Isabelle %+ Health Economics Consultancy, ISMS, Campus Blairon 477, Turnhout, 2300, Belgium, 32 14 701 930, niki.verdonck@student.kuleuven.be %K preference elicitation methods %K decision making %K consumer research methods %D 2020 %7 31.3.2020 %9 Review %J Interact J Med Res %G English %X Background: Although preference research finds its origins in consumer research, preference elicitation methods have increasingly attracted attention in different decision-making contexts in health care. Simulating real-life decision making is believed to be important during consumer preference elicitation. Objective: The aims of this study were to compare the process of decision making between patients and consumers and to identify methods from the consumer research field that could be applied in patient preference elicitation. Methods: A narrative literature review was performed to identify preference elicitation concepts from a consumer context that could offer improvements in health care. Results: The process of decision making between patients and consumers was highly comparable. The following five concepts from the consumer research field that could effectively simulate a real-life decision-making process for applications in health care were identified: simulating alternatives, self-reflection, feedback-driven exploration, separated (adaptive) dual response, and arranging profiles in blocks. Conclusions: Owing to similarities in the decision-making process, patients could be considered as a subgroup of consumers, suggesting that preference elicitation concepts from the consumer field may be relevant in health care. Five concepts that help to simulate real-life decision making have the potential to improve patient preference elicitation. However, the extent to which real decision-making contexts can be mimicked in health care remains unknown. %M 32229460 %R 10.2196/13684 %U http://www.i-jmr.org/2020/1/e13684/ %U https://doi.org/10.2196/13684 %U http://www.ncbi.nlm.nih.gov/pubmed/32229460 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e14568 %T Prevention of HIV and Other Sexually Transmitted Infections by Geofencing and Contextualized Messages With a Gamified App, UBESAFE: Design and Creation Study %A Besoain,Felipe %A Perez-Navarro,Antoni %A Jacques Aviñó,Constanza %A Caylà,Joan A %A Barriga,Nicolas A %A Garcia de Olalla,Patricia %+ Faculty of Computer Sciences, Multimedia and Telecommunication, Universitat Oberta de Catalunya, Rambla del Poblenou, 156, Barcelona, 08018, Spain, 34 619963691, aperezn@uoc.edu %K human immunodeficiency virus %K mobile apps %K sexually transmitted infection %K recreational games %D 2020 %7 17.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Advances in the development of information and communication technologies have facilitated social and sexual interrelationships, thanks to the websites and apps created to this end. However, these resources can also encourage sexual contacts without appropriate preventive measures in relation to HIV and other sexually transmitted infections (STIs). How can users be helped to benefit from the advantages of these apps while keeping in mind those preventive measures? Objective: This study aimed to prevent STIs by helping users to remember preventive measures in the risky situations. Methods: We have used the design and creation methodology and have developed a software system. This system has two parts: an Android operating system app with emphasis on ubiquitous computing and gamification as well as a server with a webpage. First, a functional test with 5 men who have sex with men (MSM) allowed us to test the app with end users. In addition, a feasibility test with 4 MSM for a month allowed us to try the UBESAFE system with all its functionalities. Results: The main output is a system called UBESAFE that is addressed to MSM. The system has two main parts: (1) an app that sends preventive contextualized messages to users when they use a contact app or when they are near a point where sexual contacts are likely and (2) a server part that was managed by the public health agency of Barcelona (ASPB), which preserves the quality and pertinence of messages and places and offers instant help to users. To increase users’ adherence, UBESAFE uses a gamified system to engage users in the creation of preventive messages. Users increased the initial pool of messages by more than 100% (34/30) and created more than 56% (9/16) of places (named hot zones). Conclusions: The system helped MSM who used it to become conscious about HIV and other STIs. The system also helped the ASPB to stay in contact with MSM and to detect behaviors that could benefit from preventive measures. All functions were performed in a nonintrusive manner because users used the app privately. Furthermore, the system has shown how important it is to make users a part of the creation process as well as to develop apps that work by themselves and thus become useful to the users. %M 32181752 %R 10.2196/14568 %U http://mhealth.jmir.org/2020/3/e14568/ %U https://doi.org/10.2196/14568 %U http://www.ncbi.nlm.nih.gov/pubmed/32181752 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e12884 %T Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and Feasibility Testing of the Precious App %A Nurmi,Johanna %A Knittle,Keegan %A Ginchev,Todor %A Khattak,Fida %A Helf,Christopher %A Zwickl,Patrick %A Castellano-Tejedor,Carmina %A Lusilla-Palacios,Pilar %A Costa-Requena,Jose %A Ravaja,Niklas %A Haukkala,Ari %+ Discipline of Social Psychology, Faculty of Social Sciences, University of Helsinki, Unioninkatu 37, PO Box 54, Helsinki, 00014, Finland, 358 44 504484297, johanna.nurmi@helsinki.fi %K health app %K mHealth %K human-computer interaction %K prevention %K service design %K usability design %K intrinsic motivation %K reflective processes %K spontaneous processes %K engagement %K self-determination theory %K autonomous motivation %K gamification %K physical activity %D 2020 %7 30.1.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Most adults do not engage in sufficient physical activity to maintain good health. Smartphone apps are increasingly used to support physical activity but typically focus on tracking behaviors with no support for the complex process of behavior change. Tracking features do not engage all users, and apps could better reach their targets by engaging users in reflecting their reasons, capabilities, and opportunities to change. Motivational interviewing supports this active engagement in self-reflection and self-regulation by fostering psychological needs proposed by the self-determination theory (ie, autonomy, competence, and relatedness). However, it is unknown whether digitalized motivational interviewing in a smartphone app engages users in this process. Objective: This study aimed to describe the theory- and evidence-based development of the Precious app and to examine how digitalized motivational interviewing using a smartphone app engages users in the behavior change process. Specifically, we aimed to determine if use of the Precious app elicits change talk in participants and how they perceive autonomy support in the app. Methods: A multidisciplinary team built the Precious app to support engagement in the behavior change process. The Precious app targets reflective processes with motivational interviewing and spontaneous processes with gamified tools, and builds on the principles of self-determination theory and control theory by using 7 relational techniques and 12 behavior change techniques. The feasibility of the app was tested among 12 adults, who were asked to interact with the prototype and think aloud. Semistructured interviews allowed participants to extend their statements. Participants’ interactions with the app were video recorded, transcribed, and analyzed with deductive thematic analysis to identify the theoretical themes related to autonomy support and change talk. Results: Participants valued the autonomy supportive features in the Precious app (eg, freedom to pursue personally relevant goals and receive tailored feedback). We identified the following five themes based on the theory-based theme autonomy support: valuing the chance to choose, concern about lack of autonomy, expecting controlling features, autonomous goals, and autonomy supportive feedback. The motivational interviewing features actively engaged participants in reflecting their outcome goals and reasons for activity, producing several types of change talk and very little sustain talk. The types of change talk identified were desire, need, reasons, ability, commitment, and taking steps toward change. Conclusions: The Precious app takes a unique approach to engage users in the behavior change process by targeting both reflective and spontaneous processes. It allows motivational interviewing in a mobile form, supports psychological needs with relational techniques, and targets intrinsic motivation with gamified elements. The motivational interviewing approach shows promise, but the impact of its interactive features and tailored feedback needs to be studied over time. The Precious app is undergoing testing in a series of n-of-1 randomized controlled trials. %M 32003750 %R 10.2196/12884 %U https://mhealth.jmir.org/2020/1/e12884 %U https://doi.org/10.2196/12884 %U http://www.ncbi.nlm.nih.gov/pubmed/32003750 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15597 %T Analysis of Collective Human Intelligence for Diagnosis of Pigmented Skin Lesions Harnessed by Gamification Via a Web-Based Training Platform: Simulation Reader Study %A Rinner,Christoph %A Kittler,Harald %A Rosendahl,Cliff %A Tschandl,Philipp %+ Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria, 43 40400 ext 77000, philipp.tschandl@meduniwien.ac.at %K skin cancer %K crowdsourcing %K games, experimental %K diagnosis %K melanoma %K nevi %K skin pigmentation %K basal cell carcinoma %K dermatoscopy %D 2020 %7 24.1.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The diagnosis of pigmented skin lesion is error prone and requires domain-specific expertise, which is not readily available in many parts of the world. Collective intelligence could potentially decrease the error rates of nonexperts. Objective: The aim of this study was to evaluate the feasibility and impact of collective intelligence for the detection of skin cancer. Methods: We created a gamified study platform on a stack of established Web technologies and presented 4216 dermatoscopic images of the most common benign and malignant pigmented skin lesions to 1245 human raters with different levels of experience. Raters were recruited via scientific meetings, mailing lists, and social media posts. Education was self-declared, and domain-specific experience was tested by screening tests. In the target test, the readers had to assign 30 dermatoscopic images to 1 of the 7 disease categories. The readers could repeat the test with different lesions at their own discretion. Collective human intelligence was achieved by sampling answers from multiple readers. The disease category with most votes was regarded as the collective vote per image. Results: We collected 111,019 single ratings, with a mean of 25.2 (SD 18.5) ratings per image. As single raters, nonexperts achieved a lower mean accuracy (58.6%) than experts (68.4%; mean difference=−9.4%; 95% CI −10.74% to −8.1%; P<.001). Collectives of nonexperts achieved higher accuracies than single raters, and the improvement increased with the size of the collective. A collective of 4 nonexperts surpassed single nonexperts in accuracy by 6.3% (95% CI 6.1% to 6.6%; P<.001). The accuracy of a collective of 8 nonexperts was 9.7% higher (95% CI 9.5% to 10.29%; P<.001) than that of single nonexperts, an improvement similar to single experts (P=.73). The sensitivity for malignant images increased for nonexperts (66.3% to 77.6%) and experts (64.6% to 79.4%) for answers given faster than the intrarater mean. Conclusions: A high number of raters can be attracted by elements of gamification and Web-based marketing via mailing lists and social media. Nonexperts increase their accuracy to expert level when acting as a collective, and faster answers correspond to higher accuracy. This information could be useful in a teledermatology setting. %M 32012058 %R 10.2196/15597 %U http://www.jmir.org/2020/1/e15597/ %U https://doi.org/10.2196/15597 %U http://www.ncbi.nlm.nih.gov/pubmed/32012058 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 11 %P e14180 %T Remotely Monitored Gamification and Social Incentives to Improve Glycemic Control Among Adults With Uncontrolled Type 2 Diabetes (iDiabetes): Protocol for a Randomized Controlled Trial %A Fortunato,Michael %A Harrison,Joseph %A Oon,Ai Leen %A Small,Dylan %A Hilbert,Victoria %A Rareshide,Charles %A Patel,Mitesh %+ University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19103, United States, 1 12158983367, mpatel@pennmedicine.upenn.edu %K behavioral economics %K gamification %K social incentives %K diabetes %K glycemic control weight %K physical activity %K remote monitoring %K wearable devices %D 2019 %7 20.11.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Type 2 diabetes is a significant cause of morbidity and mortality in the United States. Lifestyle modifications including increasing physical activity and losing weight have been demonstrated to improve glycemic control. However, most patients struggle to make these changes. Many stakeholders are interested in using gamification and social incentives to increase engagement in healthy behaviors. However, these approaches often do not appropriately leverage insights from behavioral economics that could be used to address predictable barriers to behavior change. Objective: This study aimed to describe the protocol for the Influencing DIabetics to Adapt Behaviors related to Exercise and weighT by Enhancing Social incentives (iDiabetes) trial, which aimed to evaluate the effectiveness of gamification interventions that leverage insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives to improve glycemic control, promote weight loss, and increase physical activity among overweight and obese adults with type 2 diabetes. Methods: We are conducting a one-year four-arm randomized controlled trial of 361 overweight and obese patients with type 2 diabetes and a glycated hemoglobin (HbA1c) level ≥8.0. Wireless weight scales and wearable devices are provided to remotely monitor weight and physical activity and transmit data to the study team. Patients are recruited by email, following which they establish a baseline measure of weight, daily step count, HbA1c level, and low-density lipoprotein cholesterol level and then repeat these measures at 6 and 12 months. The control arm receives no other interventions. Patients randomized to one of the three intervention arms are entered into a game designed using insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives. To examine predictors of strong or poor performance, participants completed validated questionnaires on a range of areas including their personality, risk preferences, and social network. Results: Enrollment of 361 patients was completed in January 2019. Results are expected in 2020. Conclusions: The iDiabetes trial represents a scalable model to remotely monitor the daily health behaviors of adults with type 2 diabetes. Results from this trial will help provide insights into how to improve management of patients with type 2 diabetes. Trial Registration: ClinicalTrials.gov NCT02961192; https://clinicaltrials.gov/ct2/show/NCT02961192 International Registered Report Identifier (IRRID): DERR1-10.2196/14180 %M 31746765 %R 10.2196/14180 %U http://www.researchprotocols.org/2019/11/e14180/ %U https://doi.org/10.2196/14180 %U http://www.ncbi.nlm.nih.gov/pubmed/31746765 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 6 %N 2 %P e12010 %T Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review %A Mubin,Omar %A Alnajjar,Fady %A Jishtu,Nalini %A Alsinglawi,Belal %A Al Mahmud,Abdullah %+ College of Information Technology, United Arab Emirates University, PO Box 15551, Al Ain, Abu Dhabi, United Arab Emirates, 971 37673333, fady.alnajjar@uaeu.ac.ae %K stroke %K robot %K exoskeleton %K virtual reality %K augmented reality %K gamification %K rehabilitation %D 2019 %7 8.9.2019 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications. Objective: The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors. Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients’ condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients. Results: Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation. Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies. %M 31586360 %R 10.2196/12010 %U https://rehab.jmir.org/2019/2/e12010 %U https://doi.org/10.2196/12010 %U http://www.ncbi.nlm.nih.gov/pubmed/31586360 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e13717 %T Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review %A Cheng,Vanessa Wan Sze %A Davenport,Tracey %A Johnson,Daniel %A Vella,Kellie %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, Sydney,, Australia, 61 286276941, vanessa.cheng@sydney.edu.au %K well-being %K video games %K gamification %K mental health %K health behavior %K systematic review %K eHealth %K mHealth %K health informatics %D 2019 %7 26.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators. Objective: This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions. Methods: We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3. Results: The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers’ justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention’s intended effects. Conclusions: Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields. %M 31244479 %R 10.2196/13717 %U http://mental.jmir.org/2019/6/e13717/ %U https://doi.org/10.2196/13717 %U http://www.ncbi.nlm.nih.gov/pubmed/31244479 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12157 %T Gamifying Breastfeeding for Fathers: Process Evaluation of the Milk Man Mobile App %A White,Becky %A Giglia,Roslyn C %A White,James A %A Dhaliwal,Satvinder %A Burns,Sharyn K %A Scott,Jane A %+ School of Public Health, Curtin University, GPO Box U1987, Bentley, Perth, 6845, Australia, 61 8 9266 9050, jane.scott@curtin.edu.au %K mHealth %K app %K breastfeeding %K fathers %K gamification %K socially connected %K push notifications %D 2019 %7 20.06.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Mobile technology offers unique opportunities to reach people with health promotion interventions. Breastfeeding is an important public health issue, and fathers are a key support. Milk Man is a father-focused breastfeeding app that sought to engage fathers with information and conversation about breastfeeding, with the goal to impact positively on breastfeeding duration. Objective: The study aimed to describe the process evaluation of the Milk Man app that was trialed in the Parent Infant Feeding Initiative randomized controlled trial. Methods: The app used an information library, gamification, push notifications, and social connectivity via a Web-based conversation forum, which included polls and conversation starters, to engage fathers with breastfeeding information. Fathers had access to the app from approximately 32 weeks of gestation to 6 months postpartum. Process evaluation data were collected from a self-completed questionnaire administered via a Web-based link sent to participants at 6 weeks postpartum, and app analytics data were collected directly from the app. Quantitative data from both sources and qualitative responses to open-ended questions were used to triangulate findings to investigate patterns of usage and the effectiveness of each app engagement strategy to motivate and engage users. Results: A total of 80.3% (586/730) of participants, who were randomized to receive the app, downloaded Milk Man. Push notifications and interest in what other fathers had posted in the forum were the 2 main motivators to app use. Fathers used the app most while their partners were still pregnant and in the weeks immediately after the birth of their baby. Perspectives on the gamification strategy were varied. However, at 6 weeks postpartum, approximately one-third of fathers still using the app said that the gamification elements were encouraging the app use. The ease of use of the app and the design were important elements that were rated positively. The conversation forum emerged as the hub of app activity; all but 1 of the most accessed library articles and external organization links had been prompted as part of a conversation starter. Fathers posted comments in the conversation forum 1126 times (average of 2.21 per user) and voted in polls 3096 times (average of 6 per user). Conclusions: These results demonstrate that the Milk Man app was an acceptable source of breastfeeding information and support that fathers and fathers-to-be are prepared to use throughout the perinatal period. The app showed encouraging results with facilitating conversation between partners. The conversation forum was clearly central to the success of the app, and fathers provided suggestions for improvement. Gamification results were varied, yet it was a key motivator for some users. These results provide valuable insight into the acceptability of the engagement strategies, including motivations for use and user perspectives on the app. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000605695; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?ACTRN=12614000605695  %M 31518324 %R 10.2196/12157 %U http://pediatrics.jmir.org/2019/1/e12157/ %U https://doi.org/10.2196/12157 %U http://www.ncbi.nlm.nih.gov/pubmed/31518324 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e13051 %T Effects of the FIT Game on Physical Activity in Sixth Graders: A Pilot Reversal Design Intervention Study %A Joyner,Damon %A Wengreen,Heidi %A Aguilar,Sheryl %A Madden,Gregory %+ Utah State University, 8700 Old Main Hill, Logan, UT,, United States, 1 435 797 1806, heidi.wengreen@usu.edu %K children %K accelerometer %K step count %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: The FIT Game is a low-cost intervention that increases fruit and vegetable consumption in elementary school children. For this study, the FIT Game was adapted into an intervention designed to increase children’s physical activity at school. Objective: We aimed to evaluate if the FIT Game could increase children’s physical activity relative to their baseline levels. Methods: A total of 29 participants were recruited from a sixth-grade classroom. An ABAB reversal design was used. Participants wore an accelerometer while at school during pre/postintervention baseline (A) and intervention (B) phases. During the FIT Game intervention, daily physical activity goals encouraged the class to increase their median daily step count above the 60th percentile of the previous 10 days. When daily goals were met, game-based accomplishments were realized. Results: Children met their activity goals 80% of the time during the intervention phases. Physical activity at school increased from a median of 3331 steps per day during the baseline to 4102 steps during the FIT Game phases (P<.001, Friedman test). Conclusions: Preliminary evidence showed that playing the FIT Game could positively influence children’s physical activity at school. %M 31215508 %R 10.2196/13051 %U http://games.jmir.org/2019/2/e13051/ %U https://doi.org/10.2196/13051 %U http://www.ncbi.nlm.nih.gov/pubmed/31215508 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e13303 %T Affective Game Planning for Health Applications: Quantitative Extension of Gerontoludic Design Based on the Appraisal Theory of Stress and Coping %A Khalili-Mahani,Najmeh %A De Schutter,Bob %+ PERFORM Centre, Concordia University, PC 2 207, 7200 Sherbrooke O, Montreal, QC, H4B 1R6, Canada, 1 514 848 2424 ext 5370, najmeh.khalili-mahani@concordia.ca %K games %K user acceptance of health care %K psychology %K informatics %K aging %K adaptation %K rehabilitation %D 2019 %7 06.06.2019 %9 Viewpoint %J JMIR Serious Games %G English %X User retention is the first challenge in introducing any information and communication technologies (ICT) for health applications, particularly for seniors who are increasingly targeted as beneficiaries of such technologies. Interaction with digital technologies may be too stressful to older adults to guarantee their adoption in their routine selfcare. The second challenge, which also relates to adoption, is to supply empirical evidence that support the expectations of their beneficial outcomes. To address the first challenge, persuasive technologies such as serious games (SGs) are increasingly promoted as ludic approaches to deliver assistive care to older adults. However, there are no standards yet to assess the efficacy of different genres of games across populations, or compare and contrast variations in health outcomes arising from user interface design and user experience. For the past 3 decades, research has focused either on qualitative assessment of the appeal of digital games for seniors (by game designers) or on the quantitative evaluation of their clinical efficacy (by clinical researchers). The consensus is that interindividual differences play a key role in whether games can be useful or not for different individuals. Our challenge is to design SGs that retain their users long enough to sustain beneficial transfer effects. We propose to add a neuropsychological experimental framework (based on the appraisal theory of stress and coping) to a Gerontoludic design framework (that emphasizes designing positive and meaningful gaming experience over benefit-centric ones) in order to capture data to guide SG game development. Affective Game Planning for Health Applications (AGPHA) adds a model-driven mixed-methods experimental stage to a user-centered mechanics-dynamics-aesthetics game-design cycle. This intersectoral framework is inspired by latest trends in the fields of neuroimaging and neuroinformatics that grapple with similar challenges related to the psychobiological context of an individual's behaviors. AGPHA aims to bring users, designers, clinicians, and researchers together to generate a common data repository that consists of 4 components to define, design, evaluate, and document SGs. By unifying efforts under a standard approach, we will accelerate innovations in persuasive and efficacious ICTs for the aging population. %M 31172966 %R 10.2196/13303 %U http://games.jmir.org/2019/2/e13303/ %U https://doi.org/10.2196/13303 %U http://www.ncbi.nlm.nih.gov/pubmed/31172966 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e10071 %T The QuitIT Coping Skills Game for Promoting Tobacco Cessation Among Smokers Diagnosed With Cancer: Pilot Randomized Controlled Trial %A Krebs,Paul %A Burkhalter,Jack %A Fiske,Jeffrey %A Snow,Herbert %A Schofield,Elizabeth %A Iocolano,Michelle %A Borderud,Sarah %A Ostroff,Jamie S %+ Department of Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, United States, 1 6465012637, Paul.Krebs@nyumc.org %K tobacco %K cancer %K mHealth %K app %K mobile phone %D 2019 %7 10.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although smoking cessation apps have become popular, few have been tested in randomized clinical trials or undergone formative evaluation with target users. Objective: We developed a cessation app targeting tobacco-dependent cancer patients. Game design and behavioral rehearsal principles were incorporated to help smokers identify, model, and practice coping strategies to avoid relapse to smoking. In this randomized pilot trial, we examined feasibility (recruitment and retention rates), acceptability (patient satisfaction), quitting self-confidence, and other cessation-related indices to guide the development of a larger trial. Methods: We randomized 42 English-speaking cancer patients scheduled for surgical treatment to either the Standard Care (SC; telecounseling and cessation pharmacotherapies) or the experimental QuitIT study arm (SC and QuitIT game). Gameplay parameters were captured in-game; satisfaction with the game was assessed at 1-month follow-up. We report study screening, exclusion, and refusal reasons; compare refusal and attrition by key demographic and clinical variables; and report tobacco-related outcomes. Results: Follow-up data were collected from 65% (13/20) patients in the QuitIT and 61% (11/18) in SC arms. Study enrollees were 71% (27/38) females, 92% (35/38) white people, and 95% (36/38) non-Hispanic people. Most had either lung (12/38, 32%) or gastrointestinal (9/38, 24%) cancer. Those dropping out were less likely than completers to have used a tablet (P<.01) and have played the game at all (P=.02) and more likely to be older (P=.05). Of 20 patients in the QuitIT arm, 40% (8/20) played the game (system data). There were no differences between those who played and did not play by demographic, clinical, technology use, and tobacco-related variables. Users completed an average of 2.5 (SD 4.0) episodes out of 10. A nonsignificant trend was found for increased confidence to quit in the QuitIT arm (d=0.25, 95% CI −0.56 to 1.06), and more participants were abstinent in the QuitIT group than in the SC arm (4/13, 30%, vs 2/11, 18%). Satisfaction with gameplay was largely positive, with most respondents enjoying use, relating to the characters, and endorsing that gameplay helped them cope with actual smoking urges. Conclusions: Recruitment and retention difficulties suggest that the perihospitalization period may be a less than ideal time for delivering a smoking cessation app intervention. Framing of the app as a “game” may have decreased receptivity as participants may have been preoccupied with hospitalization demands and illness concerns. Less tablet experience and older age were associated with participant dropout. Although satisfaction with the gameplay was high, 60% (12/20) of QuitIT participants did not play the game. Paying more attention to patient engagement, changing the intervention delivery period, providing additional reward and support for use, and improving cessation app training may bolster feasibility for a larger trial. Trial Registration: ClinicalTrials.gov NCT01915836; https://clinicaltrials.gov/ct2/show/NCT01915836 (Archived by WebCite at http://www.webcitation.org/73vGsjG0Y) %M 30632971 %R 10.2196/10071 %U http://mhealth.jmir.org/2019/1/e10071/ %U https://doi.org/10.2196/10071 %U http://www.ncbi.nlm.nih.gov/pubmed/30632971 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10133 %T Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions Through Avatar Customization: Crowdsourced Quasi-Experimental Study %A Birk,Max Valentin %A Mandryk,Regan Lee %+ University of Saskatchewan, Department of Computer Science, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 3069662327, max.birk@usask.ca %K cognitive therapy %K computer-assisted therapy %K video games %K attentional bias %K cognitive bias %K motivation %D 2019 %7 08.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The success of internet-based mental health interventions in practice—that is, in the wild—depends on the uptake and retention of the application and the user’s focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in the wild has been shown to increase uptake and retention in internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use and the effect on intervention efficacy. Objective: Designers of internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve digital interventions. The aim of this study was to investigate the effects of 1 motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification). Methods: We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state anxiety (State-Trait Anxiety Inventory), we randomly assigned half of the participants in each condition to either an attentional retraining condition (Attention Bias Modification Training) or a control condition. After training, participants were exposed to a negative mood induction using images with strong negative valance (International Affective Picture System), after which we measured state anxiety again. Results: Avatar customization decreased posttraining state anxiety when controlling for baseline state anxiety for those in the attentional retraining condition; however, those who did not train experienced decreased resilience to the negative mood induction (F1,252=6.86, P=.009, ηp2=.027). This interaction effect suggests that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F5,252=12.46, P<.001, R2=.23), regardless of condition (F1,252=.79, P=.38). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training but increased poststimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F1,252=6.19, P=.01). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F10,248=18.5, P<.001, R2=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health. Conclusions: Our results suggest that applying motivational design—specifically avatar customization—is a viable strategy to increase engagement and subsequently training efficacy in a computerized cognitive task. %M 30622095 %R 10.2196/10133 %U https://www.jmir.org/2019/1/e10133/ %U https://doi.org/10.2196/10133 %U http://www.ncbi.nlm.nih.gov/pubmed/30622095 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11683 %T Use of In-Game Rewards to Motivate Daily Self-Report Compliance: Randomized Controlled Trial %A Taylor,Sara %A Ferguson,Craig %A Peng,Fengjiao %A Schoeneich,Magdalena %A Picard,Rosalind W %+ Affective Computing Group, Department of Media Arts and Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, E14-348V, Cambridge, MA, 02142, United States, 1 6128608622, sataylor@mit.edu %K self-reports %K protocol compliance %K recreational games %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Encouraging individuals to report daily information such as unpleasant disease symptoms, daily activities and behaviors, or aspects of their physical and emotional state is difficult but necessary for many studies and clinical trials that rely on patient-reported data as primary outcomes. Use of paper diaries is the traditional method of completing daily diaries, but digital surveys are becoming the new standard because of their increased compliance; however, they still fall short of desired compliance levels. Objective: Mobile games using in-game rewards offer the opportunity to increase compliance above the rates of digital diaries and paper diaries. We conducted a 5-week randomized control trial to compare the completion rates of a daily diary across 3 conditions: a paper-based participant-reported outcome diary (Paper PRO), an electronic-based participant-reported outcome diary (ePRO), and a novel ePRO diary with in-game rewards (Game-Motivated ePRO). Methods: We developed a novel mobile game that is a combination of the idle and pet collection genres to reward individuals who complete a daily diary with an in-game reward. Overall, 197 individuals aged 6 to 24 years (male: 100 and female: 97) were enrolled in a 5-week study after being randomized into 1 of the 3 methods of daily diary completion. Moreover, 157 participants (male: 84 and female: 69) completed at least one diary and were subsequently included in analysis of compliance rates. Results: We observed a significant difference (F2,124=6.341; P=.002) in compliance to filling out daily diaries, with the Game-Motivated ePRO group having the highest compliance (mean completion 86.4%, SD 19.6%), followed by the ePRO group (mean completion 77.7%, SD 24.1%), and finally, the Paper PRO group (mean completion 70.6%, SD 23.4%). The Game-Motivated ePRO (P=.002) significantly improved compliance rates above the Paper PRO. In addition, the Game-Motivated ePRO resulted in higher compliance rates than the rates of ePRO alone (P=.09). Equally important, even though we observed significant differences in completion of daily diaries between groups, we did not observe any statistically significant differences in association between the responses to a daily mood question and study group, the average diary completion time (P=.52), or the System Usability Scale score (P=.88). Conclusions: The Game-Motivated ePRO system encouraged individuals to complete the daily diaries above the compliance rates of the Paper PRO and ePRO without altering the participants’ responses. Trial Registration: ClinicalTrials.gov NCT03738254; http://clinicaltrials.gov/ct2/show/NCT03738254 (Archived by WebCite at http://www.webcitation.org/74T1p8u52) %M 30609986 %R 10.2196/11683 %U https://www.jmir.org/2019/1/e11683/ %U https://doi.org/10.2196/11683 %U http://www.ncbi.nlm.nih.gov/pubmed/30609986 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10252 %T Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game %A Edwards,Elizabeth A %A Caton,Hope %A Lumsden,Jim %A Rivas,Carol %A Steed,Liz %A Pirunsarn,Yutthana %A Jumbe,Sandra %A Newby,Chris %A Shenvi,Aditi %A Mazumdar,Samaresh %A Smith,Jim Q %A Greenhill,Darrel %A Griffiths,Chris J %A Walton,Robert T %+ Centre for Primary Care and Public Health, Blizard Institute, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB, United Kingdom, 44 020 7882 2498, dr.elizabeth.ann.edwards@gmail.com %K smoking cessation %K health behaviors %K behavioral medicine %K games for health %K mHealth %K eHealth %D 2018 %7 29.11.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps. Objective: This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app. Methods: A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers. Results: Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend. Conclusions: A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings. %M 30497994 %R 10.2196/10252 %U http://games.jmir.org/2018/4/e10252/ %U https://doi.org/10.2196/10252 %U http://www.ncbi.nlm.nih.gov/pubmed/30497994