%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 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 %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67000 %T Diaphragmatic Breathing Interfaces to Promote Relaxation for Mitigating Insomnia: Pilot Study %A Lai,Yi-Jen %A Chiu,Hsiao-Yean %A Wu,Ko-Chiu %A Chang,Chun-Wei %+ , Department of Interaction Design, National Taipei University of Technology, Rm. 701-4, Design Building,, No.1 Sec.3 Zhongxiao E Rd, Da'an District, Taipei, 10608, Taiwan, 886 02 2771 2171 ext 4574, kochiuwu@mail.ntut.edu.tw %K brief behavioral treatment for insomnia %K sleep self-efficacy %K mobile health %K mHealth %K breathing training cognitive load %K attention %K gamification %K diaphragmatic breathing %K insomnia %K sleep %K games %K relaxation %K breathing %K breathing guidance %K questionnaire %K mental %K cognition %D 2025 %7 4.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Brief behavioral treatment for insomnia is an effective short-term therapy focusing on stimulus control and sleep restriction to enhance sleep quality. As a crucial part of this therapy, diaphragmatic breathing is often recommended when patients fail to fall asleep within 30 minutes. With the rise of health apps and gamification, these tools are increasingly seen as effective ways to boost self-efficacy and user engagement; however, traditional games tend to increase attention, which can negatively impact sleep and contradicts the aim of sleep therapy. This study thus explored the potential for gamification techniques to promote relaxation without disrupting sleep processes. Objective: The study developed 4 breathing guidance mechanisms, ranging from concrete to abstract: number countdown, zoom-in/out, up/down, and color gradients. The objective was to explore the relationship between game mechanics, cognitive load, relaxation effects, and attention as well as to understand how different designs impact users with varying levels of insomnia. Methods: The study was conducted in 2 phases. The first phase involved a questionnaire on the 4 guidance mechanisms. In the second phase, 33 participants classified by insomnia severity completed a Sleep Self-Efficacy Scale. They then engaged in 5 minutes of diaphragmatic breathing using each of the 4 interfaces. Relaxation effects were measured using heart rate variability via a smartwatch, attention and relaxation levels via an electroencephalogram device, and respiratory rate via a smartphone. Participants also completed the Game Experience Questionnaire and NASA Task Load Index, followed by user interviews. Results: The results indicated that competence, immersion, and challenge significantly influenced cognitive load. Specifically, competence and immersion reduced cognitive load, while challenge, negative affect, and positive affect were correlated with relaxation. Negative affect showed a positive correlation with the mean root mean square of successive differences, while positive affect exhibited a negative correlation with the mean root mean square of successive differences. Cognitive load was found to affect both relaxation and attention, with a negative correlation between mental demand and attention and a positive correlation between temporal demand and respiratory rate. Sleep self-efficacy was negatively correlated with temporal demand and negative affect and positively correlated with competence and immersion. Conclusions: Interfaces offering moderate variability and neither overly abstract nor too concrete guidance are preferable. The up/down interface was most effective, showing the best overall relaxation effect. Conversely, the number countdown interface was stress-inducing, while the zoom-in/out interface had a significant impact on insomnia-related issues, making them less suitable for insomnia-related breathing exercises. Participants showed considerable variability in their response to the color gradient interface. These findings underscore the importance of carefully considering game design elements in relaxation training. It is essential that breathing guidance designs account for the impact of the game experience to effectively promote relaxation in users. %M 40053714 %R 10.2196/67000 %U https://games.jmir.org/2025/1/e67000 %U https://doi.org/10.2196/67000 %U http://www.ncbi.nlm.nih.gov/pubmed/40053714 %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 12 %N %P e58452 %T Game-Based Promotion of Assertiveness to Mitigate the Effects of Bullying in High School Students: Development and Evaluation Study %A Lepe-Salazar,Francisco %A Mejía-Romero,Fernando %A Benicio-Rodríguez,Dámaso %A Hernández-Reyes,Aylin %A Nakajima,Tatsuo %A Salgado-Torres,Sarita %+ Ludolab, Nigromante 89, Centro, Colima, 28030, Mexico, 52 3121100163, flepe@ludolab.org %K serious games %K bullying %K assertiveness %K multiple composite scenarios %K scenario %K cognitive behavioral therapy %K gaming %K design %K development %K bully %K assertive %K feasibility %D 2024 %7 24.12.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: For years, Mexico has reported the highest global incidence of school bullying, with approximately 19% of students going through some form of hostile peer interactions. Despite numerous interventions, these harmful conducts remain deeply entrenched in educational environments. Objective: To address this issue, we developed Bernstein, a serious game that promotes assertiveness—an essential protective factor that reduces the negative effects of bullying. Methods: Bernstein was designed using multiple composite scenarios, a methodology grounded in cognitive behavioral therapy. To evaluate the game’s effectiveness, we conducted an exploratory trial using the Rathus Assertiveness Schedule to assess assertiveness levels before and after the intervention. Participants were high school students who met the inclusion criteria of being open to playing a serious game (with no prior gaming experience required) and having access to a computer with internet connectivity for remote participation. A total of 100 students (65 boys and 35 girls) enrolled in the intervention; however, only 46 participants in the treatment group and 46 in the control group completed the study, resulting in a dropout rate of 8% (8/100). A paired 1-tailed t test was used to compare pre- and postintervention scores within each group, and a one-way ANOVA was conducted to compare the average score improvements between the 2 groups. Results: The treatment group showed a pretest mean Rathus Assertiveness Schedule score of –2.78 (SD 25.93) and a posttest mean of 1.69 (SD 29.48), with a paired 1-tailed t test yielding a P value of .01. The control group had a pretest mean of 2.07 (SD 25.69) and a posttest mean of –2.39 (SD 32.98), with a paired 1-tailed t test yielding a P value of .04. The one-way ANOVA (between groups) yielded a P value of .006, indicating a statistically significant difference, favoring Bernstein over the alternative protocol. Participant feedback highlighted the game’s engaging narrative and character design, although usability issues, such as navigation challenges, were noted as areas for improvement. Conclusions: The results suggest that Bernstein is a promising tool for promoting assertiveness in high school students, providing a potential strategy for addressing bullying-related issues. The study underscores the value of integrating Bernstein into educational programs, offering students a safe and interactive environment to develop resilience. As an exploratory trial, this study faced limitations affecting the generalizability of findings, including the remote format’s impact on facilitator guidance and a relatively small sample size. Further trials with larger, more diverse groups are recommended to validate these early results and enhance Bernstein’s scalability as part of a comprehensive antibullying strategy. %M 39718822 %R 10.2196/58452 %U https://games.jmir.org/2024/1/e58452 %U https://doi.org/10.2196/58452 %U http://www.ncbi.nlm.nih.gov/pubmed/39718822 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e51771 %T Real-Time Digitized Visual Feedback in Exercise Therapy for Lower Extremity Functional Deficits: Qualitative Study of Usability Factors During Prototype Testing %A Widhalm,Klaus %A Maul,Lukas %A Durstberger,Sebastian %A Putz,Peter %A Klupper,Carissa %A Werner,Franz %+ Research Center Digital Health and Care, FH Campus Wien, University of Applied Sciences, Favoritenstraße 232, Vienna, 1100, Austria, 43 1 606 68 77 ext 4387, lukas.maul@fh-campuswien.ac.at %K visualization %K lower extremity %K digitized visual feedback %K exercise therapy %K functional deficit %K serious game %K rehabilitation %K osteoarthritis %K usability %K physiotherapy %K mobile phone %D 2024 %7 10.12.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Osteoarthritis is one of the most common degenerative diseases of the musculoskeletal system and can ultimately lead to the need for surgery, such as total knee or hip arthroplasty. Functional movement deficits can be a prognostic factor for osteoarthritis in the lower extremities. Thus, training physiological movement patterns may help in the treatment of such functional deficits. Motivation to exercise frequently is of utmost importance and can be promoted by using digital real-time feedback. Objective: This qualitative study aims to gather user recommendations for prototype feedback visualizations in a real-time exercise-feedback system called homeSETT for the treatment of functional deficits. The system provides real-time feedback to participants while performing exercises that focus on functional deficits, such as lateral trunk lean, pelvic drop, and valgus thrust. The findings of this study should help to optimize the prototype feedback visualizations. Thus, the main research questions were how patients, physiotherapists, and physicians evaluate the presented, current state of prototype feedback visualizations for selected functional exercises, and what improvements and variations would be recommended. Methods: Testing of the prototype feedback visualizations took place at a movement laboratory using a 3D optoelectronic movement analysis system. Data on usability factors were acquired using the thinking aloud method during and semistructured interviews after prototype testing. Transcribed audio recordings of semistructured interviews as well as scribing logs of the thinking aloud method were examined using qualitative content analysis. Results: Data were analyzed from 9 participants, comprising 2 (22%) patients, 2 (22%) physicians, and 5 (56%) physiotherapists. The mean age of the participants was 45 (SD 9) years and the mean work experience among the participating physiotherapists and physicians was 22 (SD 5) years. Each participant tested 11 different exercise-feedback combinations. Overall, results indicated that participants enjoyed the prototype feedback visualizations and believed that they could be used in therapeutic settings. Participants appreciated the simplicity, clarity, and self-explanatory nature of the feedback visualizations. While most participants quickly familiarized themselves, some struggled to recognize the feedback goals and connect the visualizations to their movements. Recommendations for improvement included optimizing color schemes, sensitivity, and difficulty adjustments. Adding instructional information and game design elements, such as repetition counting and reward systems, was deemed useful. The main study limitations were the small sample size and the use of feedback on performance as the sole feedback modality. Conclusions: The prototype feedback visualizations were positively perceived by the participants and were considered applicable in therapy settings. Insights were gathered on improving the color scheme, sensitivity, and recognizability of the feedback visualizations. The implementation of additional gamification and instructional elements was emphasized. Future work will optimize the prototype feedback visualizations based on study results and evaluate the homeSETT system’s efficacy in eligible patient populations. %R 10.2196/51771 %U https://games.jmir.org/2024/1/e51771 %U https://doi.org/10.2196/51771 %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 %@ 2561-326X %I JMIR Publications %V 8 %N %P e56704 %T Influence of Avatar Identification on the Attraction of Virtual Reality Games: Survey Study %A Li,PengFei %A Qi,Fa %A Ye,Zhihai %+ Art College, Jinan University, No. 601 Huangpu Avenue West, Tianhe District, Guangzhou City, Guangdong Province, Guangzhou, 510632, China, 86 198 3289 9510, tlipengfei@jnu.edu.cn %K avatar identification %K self-differentiation theory %K immersion %K attractiveness %K virtual reality games %D 2024 %7 22.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: In gaming, the embodied interaction experience of avatars serves as a key to emotional sublimation in artistic creation. This presents the emotional expression of art in a more vivid form, which is a critical factor in the high attractiveness of virtual reality (VR) games to players. Intertwined with players’ physiological and psychological responses, immersion is an essential element for enhancing gaming attractiveness. Objective: This study aims to explore how to help players establish a sense of identity with their embodied avatars in VR game environments and enhance the attractiveness of games to players through the mediating effect of immersion. Methods: We conducted a structured questionnaire survey refined through repeated validation. A total of 402 VR users were publicly recruited through the internet from March 22, 2024, to April 13, 2024. Statistical analysis was conducted using the SPSS and Amos tools, including correlation analysis, regression analysis, and mediation effect verification. We divided the self-differentiation theory into 4 dimensions to validate their impact on avatar identification. Subsequently, we correlated the effects of avatar identification, game immersion, and game attractiveness and proposed a hypothetical mediating model. Results: Regression analysis of the predictor variables and the dependent variable indicated a significant positive predictive effect (P<.001); the variance inflation factor values for each independent variable were all <5. In the hypothesis testing of the mediating effect, the total mediating effect was significant (P<.001). Regarding the direct impact, both the effect of avatar identification on immersion and the effect of immersion on game attractiveness were significant (P<.001). However, the direct effect of avatar identification on game attractiveness was not significant (P=.28). Regarding the indirect impact, the effect of avatar identification on game attractiveness was significant (P<.001). The results indicate a significant positive correlation between different dimensions of the self-differentiation theory and identification with avatars. Moreover, immersion in the game fully mediated the relationship between identification with avatars and game attractiveness. Conclusions: This study underscores that the embodiment of avatar identification is influenced by dimensions of self-differentiation, and the impact of identification with avatars on game attractiveness is contingent upon full mediation by immersion. These findings deepen our understanding of the role of avatar identification in VR gaming. %M 39437383 %R 10.2196/56704 %U https://formative.jmir.org/2024/1/e56704 %U https://doi.org/10.2196/56704 %U http://www.ncbi.nlm.nih.gov/pubmed/39437383 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52640 %T Social Gaming to Decrease Loneliness in Older Adults: Recruitment Challenges and Attrition Analysis in a Digital Mixed Methods Feasibility Study %A Châtel,Bas D L %A Janssen,Jeroen H M %A Peeters,Geeske M E E %A Corten,Rense %A Tieben,Rob %A Deen,Menno %A Hendriks,Elmy J M %A Olde Rikkert,Marcel G M %+ Department of Geriatric Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, 6500 HB, Netherlands, 31 0243616772, bastiaan.chatel@gmail.com %K loneliness %K digital health %K serious gaming %K older adults %K recruitment %K feasibility study %D 2024 %7 16.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital mental health interventions could sustainably and scalably prevent and reduce loneliness in older adults. We designed an app containing 29 text-based games and a questionnaire-administering chatbot to stimulate intergenerational contact. Objective: This study aims to evaluate the feasibility of a social gaming app in reducing loneliness among older adults by evaluating recruitment strategies, data collection procedures, and gameplay activity. Methods: This mixed methods study recruited participants via newsletters, articles, and a social media campaign. We used semistructured interviews and descriptive analysis of questionnaire answers and game data to assess feasibility. Key measures included recruitment reach and efficiency, participant demographics, in-app activity, and app usability and engagement feedback. Results: The social media campaign reached 192,641 potential participants, resulting in 1363 game downloads. A total of 155 participants (aged 65 years and older: n=34, 21.9% and aged less than 65 years: n=121, 78.1%) provided informed consent, yielding a conversion rate of 0.08%. The recruitment campaign focusing on distanced playful interaction had a significantly (P<.001) higher click-through rate (1.98%) than a campaign focusing on research participation (click-through rate=0.51%; P<.001). The overall conversion rate from advertisement exposure to research participation was 0.08%. Participants had a mean age of 48 (SD 16) years. The 65 years and older group averaged 70 (SD 5) years, while the less 65 years group averaged 42 (SD 12) years. Additionally, 45.2% (57/126) reported at least moderate levels of loneliness at baseline. Of the initial 554 players, 91 (16.4%) remained active after the first week, and 32 (5.8%) remained active for more than 90 days. Active participants tended to interact with those within their own age group, as indicated by a Pearson correlation of r=0.31 between the ages of the message sender and receiver. Interviews with 12 (48%) participants (aged 65-79 years; female: n=12, 83%) revealed barriers such as excessive chatbot questions and a mismatch between the target group and app design focus. Questionnaire completion rates dropped from 46% at baseline to 10% at follow-up. Conclusions: These findings underscore the challenges of recruitment and retention for older adults in a fully digital social gaming intervention. Effective recruitment strategies and targeted app design are crucial for engagement. Based on these insights, future interventions should focus on simplified interfaces, clear guidance for gameplay, and addressing the specific needs and preferences of older adults, thereby enhancing the effectiveness of digital mental health interventions. %M 39412863 %R 10.2196/52640 %U https://games.jmir.org/2024/1/e52640 %U https://doi.org/10.2196/52640 %U http://www.ncbi.nlm.nih.gov/pubmed/39412863 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e64063 %T The Role of Relevance in Shaping Perceptions of Sleep Hygiene Games Among University Students: Mixed Methods Study %A Liang,Zilu %A Melcer,Edward %A Khotchasing,Kingkarn %A Chen,Samantha %A Hwang,Daeun %A Hoang,Nhung Huyen %+ Ubiquitous and Personal Computing Lab, Kyoto University of Advanced Science, 18 Yamanouchi Gotanda-cho, Ukyo-ku, Kyoto, 615-8577, Japan, 81 754966510, liang.zilu@kuas.ac.jp %K serious games %K sleep hygiene %K sleep technologies %K co-design %K relevance %K self-determination theory %K digital health %K persuasive technology %K behavior change %D 2024 %7 8.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sleep games are an emerging topic in the realm of serious health game research. However, designing features that are both enjoyable and effective at engaging users, particularly university students, to develop healthy sleep habits remains a challenge. Objective: This study aims to investigate user preferences for 3 sleep game prototypes, that is, Hero’s Sleep Journey, Sleep Tamagotchi, and Sleepland, and to explore their popularity and perceived utility in promoting sleep health. Methods: A mixed methods approach was used in this study. Quantitative and qualitative data were collected through a co-design workshop involving 47 university students. Participants were presented with storyboard cards of game features and were asked to provide an overall rating on each game, as well as ratings for individual features. They were also encouraged to provide free-form comments on the features and suggest improvements. In addition, participants were asked to express their preferences among the 3 games regarding which game they would most like to play and which one they found most useful for promoting sleep health. Results: Surprisingly, while Hero’s Sleep Journey was the most popular choice among participants, Sleep Tamagotchi was perceived as the most beneficial for improving sleep health. Relevance emerged as an overarching theme in the qualitative data analysis, with 3 interconnected dimensions: psychological relevance to users’ personal lives, logical relevance to sleep health, and situational relevance to users’ circumstantial context. We discussed how the 3 dimensions of relevance address the autonomy and relatedness constructs outlined in the self-determination theory and proposed 3 design recommendations. Conclusions: Our serious sleep game prototypes demonstrated the potential to engage university students to develop healthy sleep hygiene. Future sleep game designs should aim to create a sense of relevance to users’ personal lives, sleep health goals, and situational contexts. Rather than a one-size-fits-all approach, it is essential to develop a wide range of game genres and features to cater to diverse users. Aligning game features with sleep health goals and educating users on the design rationale through sleep knowledge are also important aspects. Furthermore, allowing users to customize their game experience and manage technology boundaries is necessary to nurture a sense of control and autonomy in the process of forming good sleep hygiene. %M 39378422 %R 10.2196/64063 %U https://games.jmir.org/2024/1/e64063 %U https://doi.org/10.2196/64063 %U http://www.ncbi.nlm.nih.gov/pubmed/39378422 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 7 %N %P e56033 %T Gamified Mobile App (MobERAS) for Telemonitoring Patients in the Postoperative Period Based on the Enhanced Recovery after Surgery Program: Development and Validation Study %A Santiago,Aline Evangelista %A Cruz,Victor Pezzi Gazzinelli %A Furtado,Rafaela Souza %A Cândido,Eduardo Batista %A Brandão,Wladmir Cardoso %A Silva Filho,Agnaldo Lopes %+ Department of Gynecology, Obstetrics and Mastology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Avenue Professor Mário Rubens Guimarães Montenegro, Botucatu, 18618-687, Brazil, 55 11975998003, alinevajf@gmail.com %K handheld computer %K mobile phone %K postoperative period %K mHealth %K mobile health %K telemedicine %K postoperative %K perioperative %K recovery %K surgery %K surgical %K gamify %K gamified %K gamification %K app %K apps %K application %K applications %K design %K develop %K development %K gynecology %K gynecological %K oncology %K oncological %K women’s health %K usability %D 2024 %7 14.8.2024 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Digital technology and gamified apps can be useful in the health care context. Gamification uses technology to influence users’ actions and motivations through experiences that resemble games. Patient adherence to the enhanced recovery after surgery (ERAS) program is crucial for achieving early recovery after surgery and continuous monitoring is essential for obtaining good results. Objective: This study aimed to describe the development and validation of a mobile app for enhanced recovery after surgery (MobERAS), a gamified mobile health app for telemonitoring patients in the postoperative period based on the ERAS program, and to evaluate its functionality and usability and the experience of patients, health care professionals, and computer professionals with its use. Methods: We developed MobERAS for postoperative telemonitoring, with active participation of patients in the process, and offering availability of real-time information for the health team. The app development process included idealization, interdisciplinary team formation, potential needs assessment, and product deployment. Usability tests were conducted throughout the development process with improvements, technical adjustments, and updates. After finalization, comprehensive verification tests were performed. The parameters evaluated are those that can influence the length of hospital stay, such as nausea, vomiting, pain scales, return to normal gastrointestinal function, and thromboembolic events. MobERAS was designed to be downloaded by users on their phones, tablets, or other mobile devices and to provide postoperative data. The app has a GPS that monitors the patient’s walking time and distance and is connected to a virtual database that stores the collected data. Results: Women undergoing medium and major gynecologic oncologic surgeries were included. We included 65 patients with an average age of 53.2 (SD 7.4, range 18-85) years. The time of use ranged from 23.4 to 70 hours (mean 45.1, SD 19.2 hours). Regarding adherence to the use of MobERAS, the mean fill rate was 56.3% (SD 12.1%, range 41.7%-100%), and ambulation data were obtained for 60 (92.3%) of the 65 patients. The researcher had access to the data filled out by the patients in real time. There was good acceptance of the use of MobERAS by the patients, with good evaluation of the app’s usability. MobERAS was easy to use and considered attractive because of its gamified design. The app was rated as good or very good in all items by health care professionals (n=20) and professionals specializing in technological innovation (n=10). Conclusions: MobERAS is easy to use, safe, well accepted by patients, and well evaluated by experts. It can be of great use in clinical surgical practice and an important tool for greater engagement of patients and health care professionals with the ERAS program. %M 39141909 %R 10.2196/56033 %U https://periop.jmir.org/2024/1/e56033 %U https://doi.org/10.2196/56033 %U http://www.ncbi.nlm.nih.gov/pubmed/39141909 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48099 %T Enhancing Serious Game Design: Expert-Reviewed, Stakeholder-Centered Framework %A Bunt,Lance %A Greeff,Japie %A Taylor,Estelle %+ Unit for Data Science and Computing, North-West University, 1174 Hendrick Van Eck Boulevard, Vanderbijlpark, 1900, South Africa, 27 720880188, Lance.Bunt@nwu.ac.za %K serious games %K stakeholder theory %K enterprise architecture %K serious game development %K design framework %D 2024 %7 31.5.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Traditional serious game design methods often overlook stakeholder needs. This study integrates stakeholder theory and enterprise architecture (EA), along with the Architecture Development Method, to propose a novel framework for serious game design. Crafted to aid practitioners, researchers, and specialists in leveraging resources more effectively, the framework is validated through a design science research methodology. Expert reviews have further refined its features, making it a robust tool for enhancing serious game design and implementation. Objective: This paper introduces a framework for designing serious games, covering stakeholder analysis, requirements gathering, and design implementation planning. It highlights the importance of expert review in validating and refining the framework, ensuring its effectiveness and reliability for use in serious game design. Through critical assessment by experts, the framework is optimized for practical application by practitioners, researchers, and specialists in the field, ensuring its utility in enhancing serious game development. The next step will be to validate the framework empirically by applying it to a serious game development project. Methods: We developed and validated a conceptual framework for serious game design by synthesizing stakeholder theory and EA through literature review, concept mapping, and theory development by way of a design science research approach. The framework is iteratively refined and validated via expert review, drawing on insights from professionals experienced in serious games, stakeholder theory, and EA. This method ensures the framework’s practical relevance and effectiveness in addressing real-world design challenges. Results: An expert review by 29 serious game practitioners validated the framework’s success in stakeholder management, confirming its stakeholder-centered effectiveness. Although the experts praised its structured approach, they suggested clearer guidance for game design elements. In addition, the experts, while acknowledging the framework’s complexity, saw its depth as valuable for efficient management. The consensus calls for a refined balance between detailed functionality and user-friendly design, with the framework’s impact on stakeholder capabilities revealing a spectrum of professional needs. Conclusions: This paper presents a framework for creating effective and organizationally aligned serious games. Evaluated across execution, practical, and EA levels, it is logical but varies in ease of understanding, with experts calling for more accessibility at the EA level. It enhances stakeholder efficiency and management but is criticized for rigidity and a need for flexibility. Recommendations include streamlining the framework, enhancing clarity, reducing administrative tasks, and incorporating clear guidelines on technology use, motivational elements, and operational tools. This aims to help stakeholders produce more targeted and adaptable game designs. The next iteration will be developed after application to a project and team feedback. %M 38820585 %R 10.2196/48099 %U https://games.jmir.org/2024/1/e48099 %U https://doi.org/10.2196/48099 %U http://www.ncbi.nlm.nih.gov/pubmed/38820585 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e52275 %T The Effect of a Novel Video Game on Young Soccer Players' Sports Performance and Attention: Randomized Controlled Trial %A Feria-Madueño,Adrian %A Monterrubio-Fernández,Germán %A Mateo Cortes,Jesus %A Carnero-Diaz,Angel %K reaction time %K serious games %K executive function %K decision making %K game %K games %K gaming %K sport %K sports %K soccer %K football %K athlete %K athletes %K athletic %K training %K performance %K physiological %K muscle %K muscular %K sweat %K sweating %K attention training %K attentional %K ball %K exercise %K physical activity %K exergame %K exergames %K interview %K interviews %D 2024 %7 27.5.2024 %9 %J JMIR Serious Games %G English %X Background: Currently, the fusion of technology and sports is inevitable. The integration of various systems and devices has brought about significant transformations in established sports practices, impacting not only the rules but also physiological, biomechanical, and even psychological aspects. Objective: The purpose of this study was to analyze the effect of an attention intervention through a video game on young soccer players. Methods: Twelve young male soccer players (age: mean 8.5, SD 1 years) were divided into 2 groups: a control group (CG; n=10) and an experimental group (EG; n=10). During the 6-week training program, the EG received attention training through a video game twice a week for 15 minutes per session. Pre- and postintervention measurements included a specific decision-making soccer test and interviews with coaching staff. Additionally, success in the video game, muscular activity, and sweat levels were monitored. Results: The EG demonstrated a significant improvement in video game success following the intervention program, as indicated by the achieved level (P<.001). However, no significant differences were found between groups regarding electromyographic (EMG) activity (P=.21) and sweating (P=.20). Prior to implementing the attention training program, both groups exhibited similar data for variables related to decision-making and execution mechanisms (≤10%). Only 2 decision-making variables exceeded 10% but remained below 15% (Shot_D=13.35%; Marking_with_Ball_D=−12.64%). Furthermore, changes in attacking action variables were more pronounced in execution-related variables, except for dribbling and fixing. Conversely, in defensive action variables, changes were greater in decision-related variables, except for marking with the ball and marking without the ball. Conclusions: Our findings reveal that incorporating a specific attentional video game into a soccer training program enhances decision-making compared to a program without the video game. Therefore, it is advisable for practitioners to consider using this tool due to its high efficiency in terms of economic and temporal costs, particularly in improving a key psychological variable. Trial Registration: ISRCTN Registry ISRCTN12742775; https://www.isrctn.com/ISRCTN12742775 %R 10.2196/52275 %U https://games.jmir.org/2024/1/e52275 %U https://doi.org/10.2196/52275 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49478 %T A Serious Game (MyDiabetic) to Support Children’s Education in Type 1 Diabetes Mellitus: Iterative Participatory Co-Design and Feasibility Study %A Novak,Daniel %+ Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Technicka 1902, Prague, 16627, Czech Republic, 420 224357314, xnovakd1@fel.cvut.cz %K diabetes mellitus %K serious games %K mobile app %K co-design %K user-centered design %K serious game %K gaming %K diabetes %K child with diabetes %K child %K children %K insulin %K glucometer %K glucose %K patient education %K insulin %K mobile phone %D 2024 %7 7.5.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games, which are gaming applications used for purposes beyond entertainment to educate users on, and address, specific issues, may present a timely approach to promote healthy diabetes management behaviors among children with type 1 diabetes mellitus (T1DM). The lasting benefits associated with these serious games encompass improved patient education; enhanced glycemic control; the reinforcement of bonds within the community of people with diabetes; the facilitation of meaningful dialogues with caregivers, especially within the familial setting; and a significant reduction in the economic burdens associated with subsequent complications. Objective: This paper primarily aims to provide a detailed overview of the iterative design process and the associated evaluation methods used in the development of the educational game. Furthermore, this study aims to enhance motivation for sustained and extended engagement with the game over time. The MyDiabetic game design aims to educate children on various aspects, including the connections among food, insulin, and physical activity. Furthermore, it seeks to impart knowledge related to the operation of a glucometer and an insulin pen, as well as more advanced technologies such as administering glucagon, measuring ketoacidosis, and continuous glucose monitoring. Methods: The co-design methodology was applied, involving interviews, design workshops, and prototype feedback sessions. A combination of several approaches, such as tailoring, observational learning, social and family support, decision-making practice, and reward systems, was used to support children’s compliance. Moreover, incorporating the literature, guidelines, and current practices into the design ensured that the game was aligned with established health care pathways and included relevant information and best practices for diabetes management. Results: The game was tested on 32 children in 3 iterations. Positive responses were received from children who tested the game as well as their parents. The game was also presented to 5 schoolmates of children with T1DM who appreciated a better understanding of the disease and the opportunity to support their friends more efficiently in T1DM compensation. The involvement of children and clinicians in participatory co-design contributed to to the game's high acceptance. With regard to the game’s impact on education, 1 week of testing revealed an enhancement in educational outcomes. Conclusions: The game is especially suitable for children newly diagnosed with T1DM because it acquaints them in a fun way with new terminology; for example, they can try to measure glycemia levels in an interactive way. The game also caters to children who still need to develop reading skills by including an audio guide. The guide ensures that children of all literacy levels can benefit from the game’s educational content and interactive experiences. The game is available for download on Google Play and the Apple App Store. %M 38713496 %R 10.2196/49478 %U https://games.jmir.org/2024/1/e49478 %U https://doi.org/10.2196/49478 %U http://www.ncbi.nlm.nih.gov/pubmed/38713496 %0 Journal Article %@ 2291-9279 %I JMIR Serious Games %V 12 %N %P e46789 %T Efficacy of a Virtual 3D Simulation–Based Digital Training Module for Building Dental Technology Students’ Long-Term Competency in Removable Partial Denture Design: Prospective Cohort Study %A Liu,KeXin %A Xu,YaQian %A Ma,ChaoYi %A Yu,Na %A Tan,FaBing %A Li,Yi %A Bai,YaXin %A Fu,XiaoMing %A Wan,JiaWu %A Fan,DongQi %A Yin,HuBin %A Chen,MeiXi %A Chen,HongJi %A Jiang,Lin %A Song,JinLin %A Ji,Ping %A Zhao,XiaoHan %A Pang,MengWei %K removable partial denture %K RPD %K virtual simulation %K dental technology %K computer-aided design %K CAD %K clinical practice %K efficacy %K cohort study %K digital training %K training %K dentistry %K treatment %K design %K virtual %K assessment %D 2024 %7 5.4.2024 %9 %J JMIR Serious Games %G English %X Background: Removable partial denture (RPD) design is crucial to long-term success in dental treatment, but shortcomings in RPD design training and competency acquisition among dental students have persisted for decades. Digital production is increasing in prevalence in stomatology, and a digital RPD (D-RPD) module, under the framework of the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT) system reported in our previous work, may improve on existing RPD training models for students. Objective: We aimed to determine the efficacy of a virtual 3D simulation–based progressive digital training module for RPD design compared to traditional training. Methods: We developed a prospective cohort study including dental technology students at the Stomatology College of Chongqing Medical University. Cohort 1 received traditional RPD design training (7 wk). Cohort 2 received D-RPD module training based on text and 2D sketches (7 wk). Cohort 3 received D-RPD module pilot training based on text and 2D sketches (4 wk) and continued to receive training based on 3D virtual casts of real patients (3 wk). RPD design tests based on virtual casts were conducted at 1 month and 1 year after training. We collected RPD design scores and the time spent to perform each assessment. Results: We collected the RPD design scores and the time spent to perform each assessment at 1 month and 1 year after training. The study recruited 109 students, including 58 (53.2%) female and 51 male (56.8%) students. Cohort 1 scored the lowest and cohort 3 scored the highest in both tests (cohorts 1-3 at 1 mo: mean score 65.8, SD 21.5; mean score 81.9, SD 6.88; and mean score 85.3, SD 8.55, respectively; P<.001; cohorts 1-3 at 1 y: mean score 60.3, SD 16.7; mean score 75.5, SD 3.90; and mean score 90.9, SD 4.3, respectively; P<.001). The difference between cohorts in the time spent was not statistically significant at 1 month (cohorts 1-3: mean 2407.8, SD 1370.3 s; mean 1835.0, SD 1329.2 s; and mean 1790.3, SD 1195.5 s, respectively; P=.06) but was statistically significant at 1 year (cohorts 1-3: mean 2049.16, SD 1099.0 s; mean 1857.33, SD 587.39 s; and mean 2524.3, SD 566.37 s, respectively; P<.001). Intracohort comparisons indicated that the differences in scores at 1 month and 1 year were not statistically significant for cohort 1 (95% CI –2.1 to 13.0; P=.16), while cohort 3 obtained significantly higher scores 1 year later (95% CI 2.5-8.7; P=.001), and cohort 2 obtained significantly lower scores 1 year later (95% CI –8.8 to –3.9; P<.001). Conclusions: Cohort 3 obtained the highest score at both time points with retention of competency at 1 year, indicating that progressive D-RPD training including virtual 3D simulation facilitated improved competency in RPD design. The adoption of D-RPD training may benefit learning outcomes. %R 10.2196/46789 %U https://games.jmir.org/2024/1/e46789 %U https://doi.org/10.2196/46789 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e36154 %T Understanding Senior Adults’ Needs, Preferences, and Experiences of Commercial Exergames for Health: Usability Study %A Wang,Yu-Han %+ Department of Multimedia Design, National Taichung University of Science and Technology, No 129, Section 3, Sanmin Road, North District, Taichung City, 404336, Taiwan, 886 422196699, han@gm.nutc.edu.tw %K exergame %K senior user experience %K senior technology acceptance %K game technology %K psychological perception %K serious games %K exercise %K aging %K older adults %K physical activity %D 2024 %7 5.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many senior adults are at risk of mental and physical disorders due to a lack of sufficient exercise. Therefore, adherent exercise should be urgently promoted to improve senior adults’ muscle strength, preventing falls and conditions caused by physical and cognitive decline. However, off-the-shelf exercise games, so-called exergames, are mainly targeted at the younger generation or children, while senior adults are neglected, when this age group strongly needs exercise. Exergames could serve as a health intervention for promoting exercise. Objective: This study aimed to investigate senior adults’ experience, perceptions, and acceptance of game technology to promote exercise in order to suggest game design guidelines. Methods: In this usability study, participants engaged in playing Nintendo Switch and Xbox Kinect games, after which semistructured interviews were conducted. Before the gameplay, the participants provided their background information, exercise habits, and use of technology products. Next, all participants completed a workshop including 3 activities (brief instructions on how to play the games: 20 minutes; playing the selected exergames: 80 minutes; semistructured interviews: 20 minutes) for 2 hours a day for 3 days each. The participants played the latest Nintendo Switch games (eg, Just Dance, Boxing, Ring Fit Adventure) and Xbox Kinect games (eg, Kinect Adventures!, Mini Games). Just Dance, Zumba, and Boxing were played in activity 1; Ring Fit Adventure and Mini Games in activity 2; and Kinect Adventures! in activity 3. Reflexive thematic analysis was applied to identify the relative themes generated from the interviews. Results: In total, 22 participants (mean age 70.4, SD 6.1 years) were enrolled in the workshop in May 2021. The results of the generated themes included incomprehension of game instructions, psychological perception of game technology, and game art preferences. The subthemes generated from game art preferences included favorite game genres, characters, and scenes. Conclusions: There is a significant need for customized game tutorials considering senior adults’ cognitive and physical aging. Furthermore, the adventure game genre is preferable to other games. Humanlike game characters are preferable, especially those with a fit and healthy body shape. Nature scenes are more enjoyable than indoor stages or rooms. Furthermore, the game intensity design and playing time should be carefully planned to meet the World Health Organization’s criteria for physical activity in older adults. Intelligent recommendation systems might be helpful to support older adults with various health conditions. The guidelines suggested in this study might be beneficial for game design, exercise training, and game technology adoption of exergames for older adults to improve health. %M 38578674 %R 10.2196/36154 %U https://games.jmir.org/2024/1/e36154 %U https://doi.org/10.2196/36154 %U http://www.ncbi.nlm.nih.gov/pubmed/38578674 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e44423 %T Exploring a Gaming-Based Intervention for Unemployed Young Adults: Thematic Analysis %A Straand,Ingjerd Jevnaker %A Følstad,Asbjørn %A Bjørnestad,Jone Ravndal %+ Department of Social Work, University of Stavanger, Kjell Arholms hus, Stavanger, 4021, Norway, 47 93 22 22 89, ingjerd.j.straand@uis.no %K positive psychology intervention %K digital mental health %K serious gaming %K intervention design %K research through design %K gaming-based intervention %D 2024 %7 18.1.2024 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Promoting positive psychologies that promote resilience such as a growth mindset could be beneficial for young, unemployed adults, as many lack the self-esteem and self-efficacy to cope with job search adversity. These young people may be reached at scale through the web-based delivery of self-administered positive psychology interventions. However, past studies report unsatisfying user experiences and a lack of user engagement. A gaming-based experience could be an approach to overcoming these challenges. Objective: Our research objective was to explore how young, unemployed adults experience a positive psychology intervention designed as a game to extract learning and principles for future intervention research and development. Methods: To respond to the research question, a team of researchers at the University of Stavanger worked with designers and developers to conceptualize and build a gaming-based intervention. Feedback from the users was collected through formative usability testing with 18 young adults in the target group. Retrospectively, recordings and notes were transcribed and subjected to thematic analysis to extract learnings for the purposes of this paper. Results: A total of 3 themes were identified that pinpoint what we consider to be key priorities for future gaming interventions for unemployed young adults: adaptation to user preferences (eg, need for responding to user preferences), empathic player interaction (eg, need for responsiveness to user inputs and a diverse set of interaction modes), and sensemaking of experience and context (eg, need for explicit presentation of game objectives and need for management of user expectations related to genre). Conclusions: Feedback from end users in usability-testing sessions was vital to understanding user preferences and needs, as well as to inform ongoing intervention design and development. Our study also shows that game design could make interventions more entertaining and engaging but may distort the intervention if the game narrative is not properly aligned with the intervention intent and objectives. By contrast, a lack of adaptation to user needs may cause a less motivating user experience. Thus, we propose a structured approach to promote alignment between user preferences and needs, intervention objectives, and gameplay. %M 38236624 %R 10.2196/44423 %U https://humanfactors.jmir.org/2024/1/e44423 %U https://doi.org/10.2196/44423 %U http://www.ncbi.nlm.nih.gov/pubmed/38236624 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e51719 %T Co-Design of a Virtual Reality Multiplayer Adventure Game for Adolescents With Autism Spectrum Disorder: Mixed Methods Study %A Gabrielli,Silvia %A Cristofolini,Melanie %A Dianti,Marco %A Alvari,Gianpaolo %A Vallefuoco,Ersilia %A Bentenuto,Arianna %A Venuti,Paola %A Mayora Ibarra,Oscar %A Salvadori,Elio %+ Digital Health Research, Fondazione Bruno Kessler, Via Sommarive 18, Trento, 38123, Italy, 39 0461 312 477, sgabrielli@fbk.eu %K co-design %K virtual reality environments %K autism %K social skills interventions %K multiplayer game design %K serious games %D 2023 %7 8.12.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) adventure games can offer ideal technological solutions for training social skills in adolescents with autism spectrum disorder (ASD), leveraging their support for multisensory and multiplayer interactions over distance, which may lower barriers to training access and increase user motivation. However, the design of VR-based game environments for social skills training is still understudied and deserves the deployment of an inclusive design approach to ensure its acceptability by target users. Objective: We aimed to present the inclusive design process that we had followed to develop the Zentastic VR adventure game to foster social skills training in adolescents with ASD and to investigate its feasibility as a training environment for adolescents. Methods: The VR game supports multiplayer training sessions involving small groups of adolescents and their therapists, who act as facilitators. Adolescents with ASD and their therapists were involved in the design and in an explorative acceptability study of an initial prototype of the gaming environment, as well as in a later feasibility multisession evaluation of the VR game final release. Results: The feasibility study demonstrated good acceptability of the VR game by adolescents and an enhancement of their social skills from baseline to posttraining. Conclusions: The findings provide preliminary evidence of the benefits that VR-based games can bring to the training of adolescents with ASD and, potentially, other neurodevelopmental disorders. %M 38064258 %R 10.2196/51719 %U https://games.jmir.org/2023/1/e51719 %U https://doi.org/10.2196/51719 %U http://www.ncbi.nlm.nih.gov/pubmed/38064258 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46990 %T Identifying Game-Based Digital Biomarkers of Cognitive Risk for Adolescent Substance Misuse: Protocol for a Proof-of-Concept Study %A Aneni,Kammarauche %A Chen,Ching-Hua %A Meyer,Jenny %A Cho,Youngsun T %A Lipton,Zachary Chase %A Kher,Saatvik %A Jiao,Megan G %A Gomati de la Vega,Isabella %A Umutoni,Feza Anaise %A McDougal,Robert A %A Fiellin,Lynn E %+ Child Study Center, Yale School of Medicine, 230 S Frontage Road, New Haven, CT, 06519, United States, 1 844 362 9272, uche.aneni@yale.edu %K game-based digital biomarkers %K cognition %K adolescent substance misuse %K cognitive risk factors %K game-based measurement of cognitive function %K biomarker %K adolescent %K screening %K game %K barrier %K digital %K substance %K use %K misuse %D 2023 %7 23.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents at risk for substance misuse are rarely identified early due to existing barriers to screening that include the lack of time and privacy in clinic settings. Games can be used for screening and thus mitigate these barriers. Performance in a game is influenced by cognitive processes such as working memory and inhibitory control. Deficits in these cognitive processes can increase the risk of substance use. Further, substance misuse affects these cognitive processes and may influence game performance, captured by in-game metrics such as reaction time or time for task completion. Digital biomarkers are measures generated from digital tools that explain underlying health processes and can be used to predict, identify, and monitor health outcomes. As such, in-game performance metrics may represent digital biomarkers of cognitive processes that can offer an objective method for assessing underlying risk for substance misuse. Objective: This is a protocol for a proof-of-concept study to investigate the utility of in-game performance metrics as digital biomarkers of cognitive processes implicated in the development of substance misuse. Methods: This study has 2 aims. In aim 1, using previously collected data from 166 adolescents aged 11-14 years, we extracted in-game performance metrics from a video game and are using machine learning methods to determine whether these metrics predict substance misuse. The extraction of in-game performance metrics was guided by literature review of in-game performance metrics and gameplay guidebooks provided by the game developers. In aim 2, using data from a new sample of 30 adolescents playing the same video game, we will test if metrics identified in aim 1 correlate with cognitive processes. Our hypothesis is that in-game performance metrics that are predictive of substance misuse in aim 1 will correlate with poor cognitive function in our second sample. Results: This study was funded by National Institute on Drug Abuse through the Center for Technology and Behavioral Health Pilot Core in May 2022. To date, we have extracted 285 in-game performance metrics. We obtained institutional review board approval on October 11, 2022. Data collection for aim 2 is ongoing and projected to end in February 2024. Currently, we have enrolled 12 participants. Data analysis for aim 2 will begin once data collection is completed. The results from both aims will be reported in a subsequent publication, expected to be published in late 2024. Conclusions: Screening adolescents for substance use is not consistently done due to barriers that include the lack of time. Using games that provide an objective measure to identify adolescents at risk for substance misuse can increase screening rates, early identification, and intervention. The results will inform the utility of in-game performance metrics as digital biomarkers for identifying adolescents at high risk for substance misuse. International Registered Report Identifier (IRRID): DERR1-10.2196/46990 %M 37995115 %R 10.2196/46990 %U https://www.researchprotocols.org/2023/1/e46990 %U https://doi.org/10.2196/46990 %U http://www.ncbi.nlm.nih.gov/pubmed/37995115 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42878 %T Dimensions of Interactive Pervasive Game Design: Systematic Review %A Kai,Liu %A Tan,Wee Hoe %A Saari,Erni Marlina %+ School of Art and Design, Henan University of Engineering, No. 1, Xianghe Road, Xinzheng, Zhengzhou, 451191, China, 86 13298339393, liukai@haue.edu.cn %K interactive %K pervasive game %K systematic review %K design %K mobile phone %D 2023 %7 22.8.2023 %9 Review %J JMIR Serious Games %G English %X Background: As the gaming industry grows around the world, playing pervasive games is becoming an important mode of entertainment. A pervasive game is one in which the game experience extends into the actual world or where the fictive world of the game merges with the physical world. How pervasive games can adapt to the ever-changing nature of technology and design in current society requires a comprehensive review. Objective: In this systematic review, we aimed to measure and analyze 4 dimensions of pervasive games through development, technology, experience, and evaluation. Moreover, we also aimed to discover and interpret their relationship with game, interaction, experience, and service design. Methods: We first chose 3 well-known databases, Web of Science, Scopus, and EBSCO, and searched from 2013 to April 2022. A strictly thorough Boolean search for research keywords such as “pervasive game,” “design,” and “interactive” resulted in 394 relevant articles. These articles were identified, screened, and checked for eligibility to find valid and useful articles, which were then categorized and analyzed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) method. Results: The systematic selection was finally left with 40 valid and valuable articles. After categorization and analysis, all articles were classified according to 4 main themes, which were design and development (11/40, 28%), interaction and technology (15/40, 38%), users and experience (9/40, 23%), and evaluation and service (5/40, 13%). These 4 main areas can be subdivided into several smaller areas. Conclusions: In the 4 areas of game design, interaction design, experience design, and service design, many scholars have studied pervasive games and made contributions. Although the development and technology of pervasive games have evolved with the times, there is still a need to strengthen emerging design concepts within pervasive games. %M 37463860 %R 10.2196/42878 %U https://games.jmir.org/2023/1/e42878 %U https://doi.org/10.2196/42878 %U http://www.ncbi.nlm.nih.gov/pubmed/37463860 %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 %@ 2291-9279 %I JMIR Publications %V 11 %N %P e37105 %T Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study %A Ghosh,Arka %A Agnihotri,Jagriti %A Bhalotia,Sradha %A Sati,Bharat Kumar %A Agarwal,Latika %A A,Akash %A Tandon,Swastika %A Meena,Komal %A Raj,Shreyash %A Azad,Yatin %A Gupta,Silky %A Gupta,Nitin %+ Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kalyanpur, Kanpur, 208016, India, 91 5122594384, guptan@iitk.ac.in %K serious games %K cognitive bias modification %K learned helplessness %K depression %K digital intervention %K mobile phone %D 2023 %7 3.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy–based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring. Objective: In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm. Methods: We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged. Results: We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users. Conclusions: These games may help improve the effectiveness and engagement levels of computerized interventions for depression. %M 37133923 %R 10.2196/37105 %U https://games.jmir.org/2023/1/e37105 %U https://doi.org/10.2196/37105 %U http://www.ncbi.nlm.nih.gov/pubmed/37133923 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41824 %T A Conceptual Framework (2D-ME) for Explaining Self–first and Self–third Person Views of Prototyping Dynamics in Serious Games Design: Experimental Case Study %A Hadjileontiadou,Sofia %A Dias,Sofia B %A Hadjileontiadis,Leontios %+ Department of Primary Education, Democritus University of Thrace, Alexandroupolis-Komotini Rd./New Chili, Alexandroupolis, 68131, Greece, 30 2551030103, schatzil@eled.duth.gr %K 2D-ME conceptual framework %K Technological-Pedagogical-Content Knowledge %K TPACK %K activity theory %K AT %K self–first and self–third person %K Games TPACK %K GTPACK %K internal Activity Interview Script %K iAIS %K serious games prototyping %D 2023 %7 24.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Design dynamics that evolve during a designer’s prototyping process encapsulate important insights about the way the designer is using his or her knowledge, creativity, and reflective thinking. Nevertheless, the capturing of such dynamics is not always an easy task, as they are built through alternations between the self–first and self–third person views. Objective: This study aimed at introducing a conceptual framework, namely 2D-ME, to provide an explainable domain that could express the dynamics across the design timeline during a prototyping process of serious games. Methods: Within the 2D-ME framework, the Technological-Pedagogical-Content Knowledge (TPACK), its adaptation to the serious games (TPACK-Game), and the activity theory frameworks were combined to produce dynamic constructs that incorporate self–first and self–third person extension of the TPACK-Game to Games TPACK, rules, division of labor, and object. The dynamic interplay between such constructs was used as an adaptation engine within an optimization prototype process, so each sequential version of the latter could converge to the designer’s initial idea of the serious game. Moreover, higher-order thinking is scaffolded with the internal Activity Interview Script proposed in this paper. Results: An experimental case study of the application of the 2D-ME conceptual framework in the design of a light reflection game was showcased, revealing all the designer’s dynamics, both from internal (via a diary) and external (via the prototype version) views. The findings of this case study exemplified the convergence of the prototyping process to an optimized output, by minimizing the mean square error between the conceptual (initial and updated) idea of the prototype, following explainable and tangible constructs within the 2D-ME framework. Conclusions: The generic structure of the proposed 2D-ME framework allows its transferability to various levels of expertise in serious games mastering, and it is used both for the designer’s process exploration and training of the novice ones. %M 37093627 %R 10.2196/41824 %U https://games.jmir.org/2023/1/e41824 %U https://doi.org/10.2196/41824 %U http://www.ncbi.nlm.nih.gov/pubmed/37093627 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45467 %T Design Preferences for a Serious Game–Based Cognitive Assessment of Older Adults in Prison: Thematic Analysis %A Mantell,Rhys %A Withall,Adrienne %A Radford,Kylie %A Kasumovic,Michael %A Monds,Lauren %A Hwang,Ye In Jane %+ School of Population Health, University of New South Wales, Samuels Building, F25, Samuel Terry Avenue, Kensington, Sydney, 2052, Australia, 61 0427161651, r.mantell@unsw.edu.au %K serious game %K gamification %K cognitive assessment %K prison %K older adults %K older prisoners %K game design %K self-determination theory %D 2023 %7 17.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have the potential to transform the field of cognitive assessment. The use of serious game–based cognitive assessments in prison environments is particularly exciting. This is because interventions are urgently needed to address the rapid increase in the number of currently incarcerated older adults globally and because of the heightened risks of dementia and cognitive decline present in this population. Game-based assessments are assumed to be fun, engaging, and suitable alternatives to traditional cognitive testing, but these assumptions remain mostly untested in older adults. This is especially true for older adults in prison, whose preferences and needs are seldom heard and may deviate from those previously captured in studies on cognition and serious games. Objective: This study aimed to understand the design preferences of older adults in prison for a game-based cognitive assessment. Methods: This study used reflexive thematic analysis, underpinned by critical realism, and applied the technique of abduction. Overall, 4 focus groups with a total of 20 participants were conducted with older adults (aged ≥50 years; aged ≥45 years for Aboriginal and Torres Strait Islander people) across 3 distinct prison environments in Australia. Results: Self-determination theory was used as a theoretical foundation to interpret the results. Overall, 3 themes were generated: Goldilocks—getting gameplay difficulty just right through optimal challenge (the first theme emphasizes the participants’ collective desire for an individualized optimal level of difficulty in serious gameplay), Avoiding Childish Graphics—gimmicky gameplay can be condescending (the second theme raises the importance of avoiding immature and childlike gameplay features, as some older end users in prison felt that these can be condescending), and A Balanced Diet—meaningful choice and variety keeps game-based assessments fun (the third theme highlights the strong user preference for meaningful choice and variety in any serious game–based cognitive assessment to maximize in-game autonomy). Conclusions: The collection of these themes provides novel insights into key game design preferences of marginalized older adults. %M 37067850 %R 10.2196/45467 %U https://games.jmir.org/2023/1/e45467 %U https://doi.org/10.2196/45467 %U http://www.ncbi.nlm.nih.gov/pubmed/37067850 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42680 %T Children and Young People’s Involvement in Designing Applied Games: Scoping Review %A Saiger,Michael John %A Deterding,Sebastian %A Gega,Lina %+ Dyson School of Design Engineering, Imperial College London, 25 Exhibition Road, South Kensington, London, SW7 2DB, United Kingdom, 44 020 7594 8888, s.deterding@imperial.ac.uk %K serious game %K game design %K end user %K participatory design %K co-design %K user involvement method %K interventions %K game development %K children %K pediatric %K young people %K child %K youth %K review method %K scoping %K applied game %D 2023 %7 16.3.2023 %9 Review %J JMIR Serious Games %G English %X Background: User involvement is widely accepted as key for designing effective applied games for health. This especially holds true for children and young people as target audiences, whose abilities, needs, and preferences can diverge substantially from those of adult designers and players. Nevertheless, there is little shared knowledge about how concretely children and young people have been involved in the design of applied games, let alone consensus guidance on how to do so effectively. Objective: The aim of this scoping review was to describe which user involvement methods have been used in the design of applied games with children and young people, how these methods were implemented, and in what roles children and young people were involved as well as what factors affected their involvement. Methods: We conducted a systematic literature search and selection across the ACM Digital Library, IEEE Xplore, Scopus, and Web of Science databases using State of the Art through Systematic Review software for screening, selection, and data extraction. We then conducted a qualitative content analysis on the extracted data using NVivo. Results: We retrieved 1085 records, of which 47 (4.33%) met the eligibility criteria. The chief involvement methods were participatory design (20/47, 43%) and co-design (16/47, 37%), spanning a wide range of 45 concrete activities with paper prototyping, group discussions, and playtesting being the most frequent. In only half of the studies (24/47, 51%), children and young people participated as true design partners. Our qualitative content analysis suggested 5 factors that affect their successful involvement: comprehension, cohesion, confidence, accessibility, and time constraints. Conclusions: Co-design, participatory design, and similar high-level labels that are currently used in the field gloss over very uneven degrees of participation in design and a wide variety of implementations that greatly affect actual user involvement. This field would benefit from more careful consideration and documentation of the reason of user involvement. Future research should explore concrete activities and configurations that can address the common challenges of involving children and young people, such as comprehension, cohesion, confidence, and accessibility. %M 36928258 %R 10.2196/42680 %U https://games.jmir.org/2023/1/e42680 %U https://doi.org/10.2196/42680 %U http://www.ncbi.nlm.nih.gov/pubmed/36928258 %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 e41766 %T Games in Times of a Pandemic: Structured Overview of COVID-19 Serious Games %A Kermavnar,Tjaša %A Visch,Valentijn T %A Desmet,Pieter M A %+ Human-Centered Design, Industrial Design Engineering, Delft University of Technology, Landbergstraat 15, Delft, 2628 CE, Netherlands, 31 648921936, T.Kermavnar@tudelft.nl %K COVID-19 %K serious game %K game-based intervention %D 2023 %7 7.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The COVID-19 pandemic introduced an urgent need for effective strategies to disseminate crucial knowledge and improve people’s subjective well-being. Complementing more conventional approaches to knowledge dissemination, game-based interventions were developed to create awareness and educate people about the pandemic, hoping to change their attitudes and behavior. Objective: This study provided an overview and analysis of digital and analog game-based interventions in the context of the COVID-19 pandemic. As major pandemics and other large-scale disruptive events are expected to increase in frequency in the coming decades, this analysis aimed to inform the design, uptake, and effects of similar future interventions. Methods: From November 2021 to April 2022, Scopus, Google, and YouTube were searched for articles and videos describing COVID-19–themed game-based interventions. Information regarding authorship, year of development or launch, country of origin, license, deployment, genre or type, target audience, player interaction, in-game goal, and intended transfer effects was extracted. Information regarding intervention effectiveness was retrieved where possible. Results: A diverse assortment of 23 analog and 43 digital serious games was identified, approximately one-third of them (25/66, 38%) through scientific articles. Most of these games were developed by research institutions in 2020 (13/66, 20%) and originated in Europe and North America (38/66, 58%). A limited number (20/66, 30%) were tested on relatively small samples, using a diversity of research methods to assess the potential changes in participants’ knowledge, attitudes, and behaviors as well as their gameplay experience. Although most of the evaluated games (11/20, 55%) effectively engaged and motivated the players, increased awareness, and improved their understanding of COVID-19–related issues, the games’ success in influencing people’s behavior was often unclear or limited. Conclusions: To increase the impact of similar future interventions aimed at disseminating knowledge and influencing people’s attitudes and behaviors during a large-scale crisis, some considerations are suggested. On the basis of the study results and informed by existing game theories, recommendations are made in relation to game development, deployment, and distribution; game users, design, and use; game design terminology; and effectiveness testing for serious games. %M 36634265 %R 10.2196/41766 %U https://games.jmir.org/2023/1/e41766 %U https://doi.org/10.2196/41766 %U http://www.ncbi.nlm.nih.gov/pubmed/36634265 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e40119 %T Impact of Personalized Avatars and Motion Synchrony on Embodiment and Users’ Subjective Experience: Empirical Study %A Jung,Myeongul %A Sim,Sangyong %A Kim,Jejoong %A Kim,Kwanguk %+ Department of Computer Science, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea, 82 222202319, kenny@hanyang.ac.kr %K embodiment %K virtual reality %K virtual avatar %K personalization %K personalized %K body motion %K presence %K simulator sickness %K simulator %K simulation %K avatar %K motion %K body ownership %K self location %K agency %K experience %K virtual world %K immersive %D 2022 %7 8.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Embodiment through a virtual avatar is a key element for people to feel that they are in the virtual world. Objective: This study aimed to elucidate the interaction between 2 methods of eliciting embodiment through a virtual avatar: motion synchronization and appearance similarity between a human and avatar, to understand embodiment (agency, body ownership, and self-location) and subjective experience (presence, simulator sickness, and emotion) in virtual reality. Methods: Using a full-body motion capture system, 24 participants experienced their virtual avatars with a 3D-scanned face and size-matched body from a first-person perspective. This study used a 2 (motion; sync and async) × 2 (appearance; personalized and generic) within-subject design. Results: The results indicated that agency and body ownership increased when motion and appearance were matched, whereas self-location, presence, and emotion were affected by motion only. Interestingly, if the avatar’s appearance was similar to the participants (personalized avatar), they formed an agency toward the avatar’s motion that was not performed by themselves. Conclusions: Our findings would be applicable in the field of behavioral therapy, rehabilitation, and entertainment applications, by eliciting higher agency with a personalized avatar. %M 36346658 %R 10.2196/40119 %U https://games.jmir.org/2022/4/e40119 %U https://doi.org/10.2196/40119 %U http://www.ncbi.nlm.nih.gov/pubmed/36346658 %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 %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36397 %T A New Approach for Reducing Virtual Reality Sickness in Real Time: Design and Validation Study %A Won,JuHye %A Kim,Yoon Sang %+ BioComputing Lab, Institute for Bio-engineering Application Technology, Department of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 0415601496, yoonsang@koreatech.ac.kr %K virtual reality %K VR %K VR sickness %K VR sickness reduction method %K simulator sickness questionnaire %K SSQ, visual guide %K field of view %K serious game %K VR sickness reduction %K VR content %K technology %K digital health %D 2022 %7 27.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Recently, technology that provides virtual reality (VR) content based on streaming services has been rapidly developed. However, there have been few studies to reduce VR sickness that occurs while the user watches VR content while wearing a head-mounted display (HMD) in real time. Objective: Based on this background, we propose a new approach to measure and reduce VR sickness that occurs while the user watches VR content while wearing an HMD in real time. Methods: The proposed approach is to apply VR sickness reduction methods in accordance with the user’s real-time VR sickness level. Three methods that are known to be effective in reducing VR sickness and a single type of VR content were used to examine the effectiveness of the proposed approach, which was confirmed by the experimental results. Results: Our results show that VR sickness significantly decreased when a new approach was applied to VR content (in all cases, P<.05). Conclusions: From our results, it was confirmed that VR sickness could be measured without wearing additional equipment, and its reduction method could be applied in real time in accordance with the user’s condition by the proposed approach in this paper. %M 36166294 %R 10.2196/36397 %U https://games.jmir.org/2022/3/e36397 %U https://doi.org/10.2196/36397 %U http://www.ncbi.nlm.nih.gov/pubmed/36166294 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e39186 %T Breathing as an Input Modality in a Gameful Breathing Training App (Breeze 2): Development and Evaluation Study %A Lukic,Yanick Xavier %A Teepe,Gisbert Wilhelm %A Fleisch,Elgar %A Kowatsch,Tobias %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, , Switzerland, 41 446328638, ylukic@ethz.ch %K breathing training %K serious game %K biofeedback %K digital health %K mobile health %K mHealth %K mobile phone %K machine learning %K deep learning %K transfer learning %K neural networks %D 2022 %7 16.8.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Slow-paced breathing training can have positive effects on physiological and psychological well-being. Unfortunately, use statistics indicate that adherence to breathing training apps is low. Recent work suggests that gameful breathing training may help overcome this challenge. Objective: This study aimed to introduce and evaluate the gameful breathing training app Breeze 2 and its novel real-time breathing detection algorithm that enables the interactive components of the app. Methods: We developed the breathing detection algorithm by using deep transfer learning to detect inhalation, exhalation, and nonbreathing sounds (including silence). An additional heuristic prolongs detected exhalations to stabilize the algorithm’s predictions. We evaluated Breeze 2 with 30 participants (women: n=14, 47%; age: mean 29.77, SD 7.33 years). Participants performed breathing training with Breeze 2 in 2 sessions with and without headphones. They answered questions regarding user engagement (User Engagement Scale Short Form [UES-SF]), perceived effectiveness (PE), perceived relaxation effectiveness, and perceived breathing detection accuracy. We used Wilcoxon signed-rank tests to compare the UES-SF, PE, and perceived relaxation effectiveness scores with neutral scores. Furthermore, we correlated perceived breathing detection accuracy with actual multi-class balanced accuracy to determine whether participants could perceive the actual breathing detection performance. We also conducted a repeated-measure ANOVA to investigate breathing detection differences in balanced accuracy with and without the heuristic and when classifying data captured from headphones and smartphone microphones. The analysis controlled for potential between-subject effects of the participants’ sex. Results: Our results show scores that were significantly higher than neutral scores for the UES-SF (W=459; P<.001), PE (W=465; P<.001), and perceived relaxation effectiveness (W=358; P<.001). Perceived breathing detection accuracy correlated significantly with the actual multi-class balanced accuracy (r=0.51; P<.001). Furthermore, we found that the heuristic significantly improved the breathing detection balanced accuracy (F1,25=6.23; P=.02) and that detection performed better on data captured from smartphone microphones than than on data from headphones (F1,25=17.61; P<.001). We did not observe any significant between-subject effects of sex. Breathing detection without the heuristic reached a multi-class balanced accuracy of 74% on the collected audio recordings. Conclusions: Most participants (28/30, 93%) perceived Breeze 2 as engaging and effective. Furthermore, breathing detection worked well for most participants, as indicated by the perceived detection accuracy and actual detection accuracy. In future work, we aim to use the collected breathing sounds to improve breathing detection with regard to its stability and performance. We also plan to use Breeze 2 as an intervention tool in various studies targeting the prevention and management of noncommunicable diseases. %M 35972793 %R 10.2196/39186 %U https://games.jmir.org/2022/3/e39186 %U https://doi.org/10.2196/39186 %U http://www.ncbi.nlm.nih.gov/pubmed/35972793 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36936 %T A Biofeedback-Based Mobile App With Serious Games for Young Adults With Anxiety in the United Arab Emirates: Development and Usability Study %A Almeqbaali,Mariam %A Ouhbi,Sofia %A Serhani,Mohamed Adel %A Amiri,Leena %A Jan,Reem K %A Zaki,Nazar %A Sharaf,Ayman %A Al Helali,Abdulla %A Almheiri,Eisa %+ Department of Information Systems and Security, College of Information Technology, United Arab Emirates University, Sheik Khalifa Bin Zayed St, Al Ain, Abu Dhabi, United Arab Emirates, 971 3 7135572, serhanim@uaeu.ac.ae %K connected mental health %K mental health %K anxiety %K digital game %K biofeedback %K app %K serious game %K gaming %K gamification %K young adult %K user-centered design %K stress %K stress relief %K user-centred design %K youth %K user feedback %K user experience %K usability %K user need %K development %K mHealth %K mobile health %D 2022 %7 2.8.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Following the outbreak of COVID-19, several studies have reported that young adults encountered a rise in anxiety symptoms, which could negatively affect their quality of life. Promising evidence suggests that mobile apps with biofeedback, serious games, breathing exercises, and positive messaging, among other features, are useful for anxiety self-management and treatment. Objective: This study aimed to develop and evaluate the usability of a biofeedback-based app with serious games for young adults with anxiety in the United Arab Emirates (UAE). Methods: This study consists of two phases: Phase I describes the design and development of the app, while Phase II presents the results of a usability evaluation by experts. To elicit the app’s requirements during Phase I, we conducted (1) a survey to investigate preferences of young adults in the UAE for mobile games for stress relief; (2) an analysis of serious games for anxiety; and (3) interviews with mental health professionals and young adults in the UAE. In Phase II, five experts tested the usability of the developed app using a set of Nielsen’s usability heuristics. Results: A fully functional biofeedback-based app with serious games was co-designed with mental health professionals. The app included 4 games (ie, a biofeedback game, card game, arcade game, and memory game), 2 relaxation techniques (ie, a breathing exercise and yoga videos), and 2 additional features (ie, positive messaging and a mood tracking calendar). The results of Phase II showed that the developed app is efficient, simple, and easy to use. Overall, the app design scored an average of 4 out of 5. Conclusions: The elicitation techniques used in Phase I resulted in the development of an easy-to-use app for the self-management of anxiety. Further research is required to determine the app’s usability and effectiveness in the target population. %M 35916692 %R 10.2196/36936 %U https://games.jmir.org/2022/3/e36936 %U https://doi.org/10.2196/36936 %U http://www.ncbi.nlm.nih.gov/pubmed/35916692 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e34700 %T Design of a Game-Based Training Environment to Enhance Mental Health Care Professionals’ Skills in Using e–Mental Health: Multiple Methods User Requirements Analysis %A Bierbooms,Joyce %A Feijt,Milou A %A IJsselsteijn,Wijnand A %A Bongers,Inge M B %+ Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, P.O. box 90153, Tilburg, 5000 LE, Netherlands, 31 48354735, J.J.P.A.Bierbooms@tilburguniversity.edu %K serious gaming %K e–mental health %K mental health care %K skill development %K game design %K user requirements %K mobile phone %D 2022 %7 27.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: A major factor hampering the adoption of technology in mental health care is a lack of knowledge and skills. Serious gaming offers a potentially effective strategy to enhance the skills needed through experiencing and learning-by-doing in a playful way. However, serious gaming solutions are not widely available for mental health care. Therefore, the development of a game-based training environment in mental health care was pursued in a design project. The first step in such a design project is to identify user requirements that should be met. Objective: This study aims to deliver user requirements that inform the design of a game-based training environment for mental health care professionals. This environment aims to support mental health care professionals’ knowledge and skill enhancement regarding the use of e–mental health (eMH); for example, video calling, mobile apps, web-based treatment modules, and techniques such as virtual or augmented reality. Methods: We used an exploratory multiple methods design consisting of a web-based questionnaire, co-design sessions, and interviews. To ensure a good representation of the target user group, professionals from various disciplines within mental health care were included in the research. The multiple methods design facilitates a broad view of user needs and in-depth knowledge of specific design requirements. We describe the protocol for this research project in a protocol paper published in the JMIR Research Protocols in February 2021. Results: The user requirements analysis revealed three types of users for the envisioned game-based training environment: mental health care professionals who want to learn about the basic possibilities of eMH, mental health care professionals who want to develop their eMH skills to the next level, and mental health care professionals who want to experiment with new technologies. This reflects the diversity of needs that were identified, as well as the need to develop a diversity of suitable scenarios in the environment. User requirements analysis shows that the focus of a training environment should be on increasing knowledge about the possibilities of eMH, focusing on experiencing the benefits in particular situations, and building confidence in using eMH in a therapeutic setting. This requires careful consideration of the suitable game characteristics. Conclusions: Improvement of mental health care professionals’ skills in eMH requires an environment that is user driven and flexible, and simultaneously incorporates contextual factors that are relevant for its implementation in practice. This user requirements analysis contributes to the understanding of the issues that should be considered in the development of a game-based training environment. This shows that there are multiple and diverse learning needs among mental health care professionals. Various client populations, services, and situations demand various options for training. International Registered Report Identifier (IRRID): RR2-10.2196/18815 %M 35896032 %R 10.2196/34700 %U https://games.jmir.org/2022/3/e34700 %U https://doi.org/10.2196/34700 %U http://www.ncbi.nlm.nih.gov/pubmed/35896032 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38465 %T Interactive Somatosensory Games in Rehabilitation Training for Older Adults With Mild Cognitive Impairment: Usability Study %A Chang,Chien-Hsiang %A Yeh,Chung-Hsing %A Chang,Chien-Cheng %A Lin,Yang-Cheng %+ Department of Industrial Design, National Cheng Kung University, Number 1, University Road, Tainan City, 701, Taiwan, 886 62757575 ext 54343, lyc0914@mail.ncku.edu.tw %K dementia %K elderly %K usability %K gesture recognition %K card recognition rehabilitation %K interactive somatosensory game %D 2022 %7 14.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In aging societies, dementia risk increases with advancing age, increasing the incidence of dementia-related degenerative diseases and other complications, especially fall risk. Dementia also escalates the care burden, impacting patients, their families, social welfare institutions, and the social structure and medical system. Objective: In elderly dementia, traditional card recognition rehabilitation (TCRR) does not effectively increase one’s autonomy. Therefore, from the usability perspective, we used the Tetris game as a reference to develop an interactive somatosensory game rehabilitation (ISGR) with nostalgic style for elders with mild cognitive impairment (MCI). Through intuitive gesture-controlled interactive games, we evaluated subjective feelings concerning somatosensory game integration into rehabilitation to explore whether the ISGR could improve the willingness to use and motivation for rehabilitation among elders with MCI. Methods: A total of 15 elders with MCI (7 males and 8 females with an average age of 78.4 years) underwent 2 experiments for 15 minutes. During experiment 1, TCRR was performed, followed by completing the questionnaire of the System Usability Scale (SUS). After 3-5 minutes, the second experiment (the ISGR) was conducted, followed by completing another SUS. We used SUS to explore differences in impacts of TCRR and ISGR on willingness to use among elders with MCI. In addition, we further investigated whether the factor of gender or prior rehabilitation experience would affect the rehabilitation willingness or not. Results: The novel ISGR made the elderly feel interested and improved their willingness for continuous rehabilitation. According to the overall SUS score, the ISGR had better overall usability performance (73.7) than the TCRR (58.0) (t28=–4.62, P<.001). Furthermore, the ISGR individual item scores of “Willingness to Use” (t28=–8.27, P<.001), “Easy to Use” (t28=–3.17, P<.001), “System Integration” (t28=–5.07, P<.001), and “Easy to Learn” (t28=–2.81, P<.001) were better than TCRR. The somatosensory game was easier to learn and master for females than for males (t13=2.71, P=.02). Besides, the ISGR was easier to use (t12=–2.50, P=.02) and learn (t14=–3.33, P<.001) for those without prior rehabilitation experience. The result indicates that for elders with no rehabilitation experience ISGR was easier to use and simpler to learn than TCRR. Conclusions: Regardless of prior rehabilitation experience, the ISGR developed in this study was easy to learn and effective in continuously improving willingness to use. Furthermore, the adoption of a nostalgic game design style served the function of cognitive training and escalated interest in rehabilitation. The ISGR also improved user stickiness by introducing different game scenarios and difficulties, increasing long-term interest and motivation for rehabilitation. For future research on the adoption of interactive somatosensory games in rehabilitation, additional rehabilitation movements can be developed to benefit the elderly with MCI. %M 35834303 %R 10.2196/38465 %U https://games.jmir.org/2022/3/e38465 %U https://doi.org/10.2196/38465 %U http://www.ncbi.nlm.nih.gov/pubmed/35834303 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e32489 %T Perceptions of Cognitive Training Games and Assessment Technologies for Dementia: Acceptability Study With Patient and Public Involvement Workshops %A Harrington,Kyle %A Craven,Michael P %A Wilson,Max L %A Landowska,Aleksandra %+ NIHR MindTech MedTech Co-operative, Institute of Mental Health, University of Nottingham Innovation Park, Nottingham, NG7 2TU, United Kingdom, 44 115 823 1294, kyle.harrington@nottingham.ac.uk %K dementia %K cognitive assessment %K cognitive training %K serious games %K patient and public involvement %D 2022 %7 20.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive training and assessment technologies offer the promise of dementia risk reduction and a more timely diagnosis of dementia, respectively. Cognitive training games may help reduce the lifetime risk of dementia by helping to build cognitive reserve, whereas cognitive assessment technologies offer the opportunity for a more convenient approach to early detection or screening. Objective: This study aims to elicit perspectives of potential end users on factors related to the acceptability of cognitive training games and assessment technologies, including their opinions on the meaningfulness of measurement of cognition, barriers to and facilitators of adoption, motivations to use games, and interrelationships with existing health care infrastructure. Methods: Four linked workshops were conducted with the same group, each focusing on a specific topic: meaningful improvement, learning and motivation, trust in digital diagnosis, and barriers to technology adoption. Participants in the workshops included local involvement team members acting as facilitators and those recruited via Join Dementia Research through a purposive selection and volunteer sampling method. Group activities were recorded, and transcripts were analyzed using thematic analysis with a combination of a priori and data-driven themes. Using a mixed methods approach, we investigated the relationships between the categories of the Capability, Opportunity, and Motivation–Behavior change model along with data-driven themes by measuring the φ coefficient between coded excerpts and ensuring the reliability of our coding scheme by using independent reviewers and assessing interrater reliability. Finally, we explored these themes and their relationships to address our research objectives. Results: In addition to discussions around the capability, motivation, and opportunity categories, several important themes emerged during the workshops: family and friends, cognition and mood, work and hobbies, and technology. Group participants mentioned the importance of functional and objective measures of cognitive change, the social aspect of activities as a motivating factor, and the opportunities and potential shortcomings of digital health care provision. Our quantitative results indicated at least moderate agreement on all but one of the coding schemes and good independence of our coding categories. Positive and statistically significant φ coefficients were observed between several coding themes between categories, including a relatively strong positive φ coefficient between capability and cognition (0.468; P<.001). Conclusions: The implications for researchers and technology developers include assessing how cognitive training and screening pathways would integrate into existing health care systems; however, further work needs to be undertaken to address barriers to adoption and the potential real-world impact of cognitive training and screening technologies. International Registered Report Identifier (IRRID): RR2-10.1007/978-3-030-49065-2_4 %M 35723912 %R 10.2196/32489 %U https://games.jmir.org/2022/2/e32489 %U https://doi.org/10.2196/32489 %U http://www.ncbi.nlm.nih.gov/pubmed/35723912 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 2 %P e34476 %T Co-creation of a Serious Game About Radiotherapy: Participatory Action Research Study With Children Treated for Cancer %A Cederved,Catarina %A Back,Jon %A Ångström-Brännström,Charlotte %A Ljungman,Gustaf %A Engvall,Gunn %+ Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, Uppsala, 75185, Sweden, 46 734697207, catarina.cederved@kbh.uu.se %K children %K participatory action research %K game design %K radiotherapy %K education %K supportive care %K oncology %D 2022 %7 31.5.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Children with cancer who have to undergo radiotherapy can experience fear, because they have no prior knowledge of the treatment. One way of teaching children about the treatment and reducing their fear is to prepare them for it through serious games. Involvement of the end user in the design process within medicine is a way of ensuring that the product being developed will fit the intended user. Objective: The aim was to outline the contributions made by children and their parents through participatory action research when designing a serious game about radiotherapy. Methods: By means of participatory action research, children and their parents participated in the development of a serious game about radiotherapy. Nine children (7-10 years old) were included, each with an accompanying parent. A qualitative approach was used that included interviews and participant observation. Six rounds of iterative development process were used with the children and their parents. Meetings with the children were held either face-to-face or online. Each round resulted in a list of suggestions for changes to the game. A thematic analysis was performed based on the list of proposed changes, underpinned by all gathered data, to highlight how the children’s participation changed the game. Results: Two main themes were identified. The first theme was “The children’s participation was affected by their health and treatment” and included the following subthemes: “an opportunity to share emotions and perceptions of radiotherapy” and “the possibility to participate was affected by the severity of the disease.” The second theme was “participation allowed becoming an active part of game development” and included the following subthemes: “the opportunity to express sentiments about the game,” “the emergence of a playable game through the children’s contributions,” and “the necessity of understanding the text.” Conclusions: The method used in this study made the children active participants, and our results suggest that this method can be used by health care researchers to cocreate serious games with children. It is necessary to inform the children involved that the process takes time, and that the process can be altered to allow as much participation as possible without placing a burden on them. The children’s illness affected their possibility to take part; thus, it is crucial to accommodate the children’s needs when conducting similar studies. The parents’ participation facilitated the meetings for their children, even though their involvement in the game design was negligible. %M 35639467 %R 10.2196/34476 %U https://humanfactors.jmir.org/2022/2/e34476/ %U https://doi.org/10.2196/34476 %U http://www.ncbi.nlm.nih.gov/pubmed/35639467 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e21376 %T Designing a Serious Game (Above Water) for Stigma Reduction Surrounding Mental Health: Semistructured Interview Study With Expert Participants %A Wehbe,Rina R %A Whaley,Colin %A Eskandari,Yasaman %A Suarez,Ally %A Nacke,Lennart E %A Hammer,Jessica %A Lank,Edward %+ Human Computer Interaction for Social Good (HCI4GOOD), Faculty of Computer Science, Dalhousie University, 6299 South Street, Halifax, NS, B3H4R2, Canada, 1 902 494 2211, rina.wehbe@dal.ca %K human–computer interaction %K games for change %K games for mental health %K sensitive topics %K game design %K empirical analysis %K expert participants %D 2022 %7 19.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although in many contexts unsuccessful games targeting learning, social interaction, or behavioral change have few downsides, when covering a sensitive domain such as mental health (MH), care must be taken to avoid harm and stigmatization of people who live with MH conditions. As a result, evaluation of the game to identify benefits and risks is crucial in understanding the game’s success; however, assessment of these apps is often compared with the nongame control condition, resulting in findings specifically regarding entertainment value and user preferences. Research exploring the design process, integrating field experts, and guidelines for designing a successful serious game for sensitive topics is limited. Objective: The aim of this study is to understand which elements of game design can guide a designer when designing a game for sensitive topics. Methods: To carefully probe the design space of serious games for MH, we present Above Water (AbW), a game targeting the reduction of stigma surrounding MH, now in its second iteration. The game, AbW, serves as a consistent research probe to solicit expert feedback. Experts were recruited from a range of topic domains related to MH and wellness, game design, and user experience. Results: By using this deployment as a research probe, this study demonstrates how to synthesize gained insights from multiple expert perspectives and create actionable guidelines for successful design of serious games targeting sensitive topics. Conclusions: Our work contributes to a better understanding of how to design specialized games to address sensitive topics. We present a set of guidelines for designing games for sensitive subjects, and for each guideline, we present an example of how to apply the finding to the sample game (AbW). Furthermore, we demonstrate the generalizability to other sensitive topics by providing an additional example of a game that could be designed with the presented guidelines. %M 35588056 %R 10.2196/21376 %U https://games.jmir.org/2022/2/e21376 %U https://doi.org/10.2196/21376 %U http://www.ncbi.nlm.nih.gov/pubmed/35588056 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e33412 %T HelperFriend, a Serious Game for Promoting Healthy Lifestyle Behaviors in Children: Design and Pilot Study %A Espinosa-Curiel,Ismael Edrein %A Pozas-Bogarin,Edgar Efrén %A Hernández-Arvizu,Maryleidi %A Navarro-Jiménez,Maria Elena %A Delgado-Pérez,Edwin Emeth %A Martínez-Miranda,Juan %A Pérez-Espinosa,Humberto %+ 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.mx %K serious game %K children %K education and behavior change %K healthy lifestyle behaviors %K physical activity %K healthy eating %K socioemotional wellness %D 2022 %7 6.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children. Objective: We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness. Methods: Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction. Results: Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (t14=2.01, P=.03), healthy eating (t14=3.14, P=.003), and socioemotional wellness (t14=2.75, P=.008). In addition, from T0 to T1, the intervention group improved their intention to perform physical activity (t14=2.82, P=.006), healthy eating (t14=3.44, P=.002), and socioemotional wellness (t14=2.65, P=.009); and there was a reduction in their intake of 13 unhealthy foods. HelperFriend was well received by intervention group. Conclusions: HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend. %M 35522474 %R 10.2196/33412 %U https://games.jmir.org/2022/2/e33412 %U https://doi.org/10.2196/33412 %U http://www.ncbi.nlm.nih.gov/pubmed/35522474 %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 1 %P e33955 %T Using Distance Communication for the User-Centered Development of a Smartphone-Based Serious Game for Children With Type 1 Diabetes: Participatory Design Approach %A Nørlev,Jannie %A Derosche,Christina %A Sondrup,Katrine %A Hejlesen,Ole %A Hangaard,Stine %+ Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7E, Aalborg Øst, 9220, Denmark, 45 99409940, jannienoerlev@gmail.com %K type 1 diabetes %K children %K serious game %K distance communication %K user-centered approach %K evaluation %K playtest %K mobile phone %D 2022 %7 29.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The complications of type 1 diabetes (T1D) can be delayed or prevented in children with T1D who receive proper self-management education. Smartphone-based serious games are increasingly being used as an effective tool for teaching self-management. When developing a serious game, it is important that the development process be user-centered. Traditionally, different face-to-face methods have been used when children participate in the development process. However, face-to-face data collection is not always feasible. In such situations, distance communication can be used when developing a serious game. Objective: The objective of this study is to develop a user-centered smartphone-based serious game that teaches self-management focused on carbohydrate intake in children aged 8-14 years with T1D using distance communication in both the development and evaluation of the game. Methods: The development and evaluation of a smartphone-based serious game prototype was inspired by the Lean principles, and a user-centered approach was applied. The development process included 1 expert interview and design workshops with children with T1D. On the basis of the interview and design workshop results, a serious game prototype was developed using Microsoft PowerPoint. The evaluation of the serious game prototype included an interview with a dietitian and a playtest with children with T1D. All data were collected using distance communication. Results: A user-centered smartphone-based serious game prototype was developed and evaluated. The expert interview with the dietitian formed the basis for the learning outcomes in the game. Four children and their parents contributed to the preferences, needs, requirements, and ideas for selected parts of the game design. The dietitian evaluated the prototype positively and validated its content and accuracy. The serious game prototype was well-received by the children and their parents during the playtest. The serious game prototype was perceived as a useful and engaging way to learn. However, the difficulty level was not appropriate, and the information was too basic for participants who had been diagnosed over a year ago. The use of digital communication platforms did not cause any problems. Conclusions: The smartphone-based serious game prototype has the potential to be a useful and attractive tool for teaching disease self-management. The use of distance communication proved to be a useful approach in the development of a serious game. %M 35348466 %R 10.2196/33955 %U https://games.jmir.org/2022/1/e33955 %U https://doi.org/10.2196/33955 %U http://www.ncbi.nlm.nih.gov/pubmed/35348466 %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 e34698 %T Feasibility, Enjoyment, and Language Comprehension Impact of a Tablet- and GameFlow-Based Story-Listening Game for Kindergarteners: Methodological and Mixed Methods Study %A Vanden Bempt,Femke %A Economou,Maria %A Dehairs,Ward %A Vandermosten,Maaike %A Wouters,Jan %A Ghesquière,Pol %A Vanderauwera,Jolijn %+ Parenting and Special Education Research Unit, Faculty of Psychology and Educational Sciences, KU Leuven, Leopold Vanderkelenstraat 32/3765, Leuven, 3000, Belgium, 32 16376202, femke.vandenbempt@kuleuven.be %K serious gaming %K language comprehension %K enjoyment %K feasibility %K GameFlow %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Enjoyment plays a key role in the success and feasibility of serious gaming interventions. Unenjoyable games will not be played, and in the case of serious gaming, learning will not occur. Therefore, a so-called GameFlow model has been developed, which intends to guide (serious) game developers in the process of creating and evaluating enjoyment in digital (serious) games. Regarding language learning, a variety of serious games targeting specific language components exist in the market, albeit often without available assessments of enjoyment or feasibility. Objective: This study evaluates the enjoyment and feasibility of a tablet-based, serious story-listening game for kindergarteners, developed based on the principles of the GameFlow model. This study also preliminarily explores the possibility of using the game to foster language comprehension. Methods: Within the framework of a broader preventive reading intervention, 91 kindergarteners aged 5 years with a cognitive risk for dyslexia were asked to play the story game for 12 weeks, 6 days per week, either combined with a tablet-based phonics intervention or control games. The story game involved listening to and rating stories and responding to content-related questions. Game enjoyment was assessed through postintervention questionnaires, a GameFlow-based evaluation, and in-game story rating data. Feasibility was determined based on in-game general question response accuracy (QRA), reflecting the difficulty level, attrition rate, and final game exposure and training duration. Moreover, to investigate whether game enjoyment and difficulty influenced feasibility, final game exposure and training duration were predicted based on the in-game initial story ratings and initial QRA. Possible growth in language comprehension was explored by analyzing in-game QRA as a function of the game phase and baseline language skills. Results: Eventually, data from 82 participants were analyzed. The questionnaire and in-game data suggested an overall enjoyable game experience. However, the GameFlow-based evaluation implied room for game design improvement. The general QRA confirmed a well-adapted level of difficulty for the target sample. Moreover, despite the overall attrition rate of 39% (32/82), 90% (74/82) of the participants still completed 80% of the game, albeit with a large variation in training days. Higher initial QRA significantly increased game exposure (β=.35; P<.001), and lower initial story ratings significantly slackened the training duration (β=−0.16; P=.003). In-game QRA was positively predicted by game phase (β=1.44; P=.004), baseline listening comprehension (β=1.56; P=.002), and vocabulary (β=.16; P=.01), with larger QRA growth over game phases in children with lower baseline listening comprehension skills (β=−0.08; P=.04). Conclusions: Generally, the story game seemed enjoyable and feasible. However, the GameFlow model evaluation and predictive relationships imply room for further game design improvements. Furthermore, our results cautiously suggest the potential of the game to foster language comprehension; however, future randomized controlled trials should further elucidate the impact on language comprehension. %M 35319480 %R 10.2196/34698 %U https://games.jmir.org/2022/1/e34698 %U https://doi.org/10.2196/34698 %U http://www.ncbi.nlm.nih.gov/pubmed/35319480 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32027 %T A Virtual Reality Game Suite for Graded Rehabilitation in Patients With Low Back Pain and a High Fear of Movement: Within-Subject Comparative Study %A Peebles,Alexander T %A van der Veen,Susanne %A Stamenkovic,Alexander %A France,Christopher R %A Pidcoe,Peter E %A Thomas,James S %+ Department of Physical Therapy, Virginia Commonwealth University, 900 E. Leigh St, 4th Floor, Richmond, VA, 23298, United States, 1 740 541 6324, jthomas32@vcu.edu %K virtual reality %K reaching %K intervention %K rehabilitation %K exergaming %K biomechanics %K serious games %K gamification %K movement %K physiotherapy %K lumbar %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Complex movement pathologies that are biopsychosocial in nature (eg, back pain) require a multidimensional approach for effective treatment. Virtual reality is a promising tool for rehabilitation, where therapeutic interventions can be gamified to promote and train specific movement behaviors while increasing enjoyment, engagement, and retention. We have previously created virtual reality–based tools to assess and promote lumbar excursion during reaching and functional gameplay tasks by manipulating the position of static and dynamic contact targets. Based on the framework of graded exposure rehabilitation, we have created a new virtual reality therapy aimed to alter movement speed while retaining the movement-promoting features of our other developments. Objective: This study aims to compare lumbar flexion excursion and velocity across our previous and newly developed virtual reality tools in a healthy control cohort. Methods: A total of 31 healthy participants (16 males, 15 females) took part in 3 gamified virtual reality therapies (ie, Reachality, Fishality, and Dodgeality), while whole-body 3D kinematics were collected at 100 Hz using a 14-camera motion capture system. Lumbar excursion, lumbar flexion velocity, and actual target impact location in the anterior and vertical direction were compared across each virtual reality task and between the 4 anthropometrically defined intended target impact locations using separate 2-way repeated measures analysis of variance models. Results: There was an interaction between game and impact height for each outcome (all P<.001). Post-hoc simple effects models revealed that lumbar excursion was reduced during Reachality and Fishality relative to that during Dodgeality for the 2 higher impact heights but was greater during Reachality than during Fishality and Dodgeality for the lowest impact height. Peak lumbar flexion velocity was greater during Dodgeality than during Fishality and Reachality across heights. Actual target impact locations during Dodgeality and Fishality were lower relative to those during Reachality at higher intended impact locations but higher at lower intended impact locations. Finally, actual target impact location was further in the anterior direction for Reachality compared to that for Fishality and for Fishality relative to that for Dodgeality. Conclusions: Lumbar flexion velocity was reduced during Fishality relative to that during Dodgeality and resembled velocity demands more similar to those for a self-paced reaching task (ie, Reachality). Additionally, lumbar motion and target impact location during Fishality were more similar to those during Reachality than to those during Dodgeality, which suggests that this new virtual reality game is an effective tool for shaping movement. These findings are encouraging for future research aimed at developing an individualized and graded virtual reality intervention for patients with low back pain and a high fear of movement. %M 35319471 %R 10.2196/32027 %U https://games.jmir.org/2022/1/e32027 %U https://doi.org/10.2196/32027 %U http://www.ncbi.nlm.nih.gov/pubmed/35319471 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e28982 %T Serious Game for Change in Behavioral Intention Toward Lifestyle-Related Diseases: Experimental Study With Structural Equation Modeling Using the Theory of Planned Behavior %A Egashira,Mahiro %A Son,Daisuke %A Ema,Arisa %+ Department of Community-Based Family Medicine, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, 683-8503, Japan, 81 859 38 6661, sondtky@gmail.com %K lifestyle-related disease %K mechanism of behavior change %K serious game %K theory of planned behavior %D 2022 %7 21.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Health activities should be tailored to individual lifestyles and values. To raise awareness of health behaviors, various practices related to health education, such as interactive activities among individuals with different backgrounds, have been developed. Moreover, serious games have been used as a tool for facilitating communication. However, there have been few investigations that are based on the framework of the theory of planned behavior on the mechanisms of health-related behavioral intention change from playing serious games. Objective: We aimed to investigate the mechanisms of behavioral intention change among various age groups after an intervention using a serious game to increase awareness of lifestyle-related diseases. Methods: Adults, undergraduates, and high school students played a serious game, called Negotiation Battle, and answered a questionnaire—Gaming Event Assessment Form for Lifestyle-related Diseases—before, immediately after, and 2-4 weeks after the game. The questionnaire was composed of 16 items based on the theory of planned behavior. We used structural equation modeling to compare responses from the 3 groups. Results: For all 3 age groups (adults: mean 43.4 years, range 23-67 years; undergraduates: mean 20.9 years, range 19-34 years; high school students: mean 17.9 years, 17-18 years), perceived behavior control was the key factor of behavioral intention change. Immediately after the game, causal relationships between perceived behavioral control and behavioral intention were enhanced or maintained for all groups—adults (before: path coefficient 1.030, P<.001; after: path coefficient 2.045, P=.01), undergraduates (before: path coefficient 0.568, P=.004; after: path coefficient 0.737, P=.001), and high school students (before: path coefficient 14.543, P=.97; after: path coefficient 0.791, P<.001). Analysis of free descriptions after intervention suggested that experiencing dilemma is related to learning and behavioral intention. Conclusions: The study revealed that the serious game changed the behavioral intention of adolescents and adults regarding lifestyle-related diseases, and changes in perceived behavioral control mediated the alteration mechanism. %M 35188465 %R 10.2196/28982 %U https://games.jmir.org/2022/1/e28982 %U https://doi.org/10.2196/28982 %U http://www.ncbi.nlm.nih.gov/pubmed/35188465 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31570 %T A Serious Puzzle Game to Enhance Adherence to Antirheumatic Drugs in Patients With Rheumatoid Arthritis: Systematic Development Using Intervention Mapping %A Pouls,Bart PH %A Bekker,Charlotte L %A van Dulmen,Sandra %A Vriezekolk,Johanna E %A van den Bemt,Bart JF %+ Department of Rheumatology Research, Sint Maartenskliniek, Hengstdal 3, Nijmegen, 6574NA, Netherlands, 31 612502678, b.pouls@maartenskliniek.nl %K medication adherence %K serious game %K eHealth %K rheumatoid arthritis %K intervention mapping %K intervention development %D 2022 %7 18.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Patients’ implicit attitudes toward medication need and concerns may influence their adherence. Targeting these implicit attitudes by combining game-entertainment with medication-related triggers might improve medication adherence in patients with rheumatoid arthritis (RA). Objective: The aim of this study was to describe the systematic development of a serious game to enhance adherence to antirheumatic drugs by using intervention mapping. Methods: A serious game was developed using the intervention mapping framework guided by a multidisciplinary expert group, which proceeded along 6 steps: (1) exploring the problem by assessing the relationship between medication adherence and implicit attitudes, (2) defining change objectives, (3) selecting evidence-based behavior change techniques that focused on adjusting implicit attitudes, (4) designing the intervention, (5) guaranteeing implementation by focusing on intrinsic motivation, and (6) planning a scientific evaluation. Results: Based on the problem assessment and guided by the Dual-Attitude Model, implicit negative and illness-related attitudes of patients with RA were defined as the main target for the intervention. Consequently, the change objective was “after the intervention, participants have a more positive attitude toward antirheumatic drugs.” Attention bias modification, evaluative conditioning, and goal priming were the techniques chosen to implicitly target medication needs. These techniques were redesigned into medication-related triggers and built in the serious puzzle game. Thirty-seven patients with RA tested the game at several stages. Intrinsic motivation was led by the self-determination theory and addressed the 3 needs, that is, competence, autonomy, and relatedness. The intervention will be evaluated in a randomized clinical trial that assesses the effect of playing the serious game on antirheumatic drug adherence. Conclusions: We systematically developed a serious game app to enhance adherence to antirheumatic drugs among patients with RA by using the intervention mapping framework. This paper could serve as a guideline for other health care providers when developing similar interventions. %M 35179510 %R 10.2196/31570 %U https://games.jmir.org/2022/1/e31570 %U https://doi.org/10.2196/31570 %U http://www.ncbi.nlm.nih.gov/pubmed/35179510 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e33459 %T Teaching Students About Plagiarism Using a Serious Game (Plagi-Warfare): Design and Evaluation Study %A Ade-Ibijola,Abejide %A Young,Keagan %A Sivparsad,Nashik %A Seforo,Mpho %A Ally,Suhail %A Olowolafe,Adebola %A Frahm-Arp,Maria %+ Johannesburg Business School, University of Johannesburg, Barry Hertzog Ave &, Empire Rd, Milpark, Johannesburg, 2092, South Africa, 27 11 559 1774, abejideai@uj.ac.za %K serious games %K educational games %K plagiarism %K library games %K game mechanics %K education %K teaching %D 2022 %7 16.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Educational games have been proven to support the teaching of various concepts across disciplines. Plagiarism is a major problem among undergraduate and postgraduate students at universities. Objective: In this paper, we propose a game called Plagi-Warfare that attempts to teach students about plagiarism. Methods: To do this at a level that is beyond quizzes, we proposed a game storyline and mechanics that allow the player (or student) to play as a mafia member or a detective. This either demonstrated their knowledge by plagiarizing within the game as a mafia member or catching plagiarists within the game as a detective. The game plays out in a 3D environment representing the major libraries of the University of Johannesburg, South Africa. In total, 30 students were selected to evaluate the game. Results: Evaluation of the game mechanics and storyline showed that the student gamers enjoyed the game and learned about plagiarism. Conclusions: In this paper, we presented a new educational game that teaches students about plagiarism by using a new crime story and an immersive 3D gaming environment representing the libraries of the University of Johannesburg. %M 35171103 %R 10.2196/33459 %U https://games.jmir.org/2022/1/e33459 %U https://doi.org/10.2196/33459 %U http://www.ncbi.nlm.nih.gov/pubmed/35171103 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e29137 %T The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Alajlani,Mohannad %A Alhuwail,Dari %A Schneider,Jens %A Akhu-Zaheya,Laila %A Ahmed,Arfan %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar, 974 55708566, mhouseh@hbku.edu.qa %K serious games %K exergames %K anxiety %K computerized cognitive behavioral therapy games %K biofeedback games %K systematic reviews %K meta-analysis %K mobile phone %D 2022 %7 14.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses. Objective: This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review. Methods: We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. 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: Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low–quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (P=.70) and no intervention (P=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (P=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (P=.03). Conclusions: This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety. %M 35156932 %R 10.2196/29137 %U https://games.jmir.org/2022/1/e29137 %U https://doi.org/10.2196/29137 %U http://www.ncbi.nlm.nih.gov/pubmed/35156932 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e34656 %T Serious Games Without Screens. Comment on “Involvement of End Users in the Development of Serious Games for Health Care Professions Education: Systematic Descriptive Review” %A Cosimini,Michael Joseph %A Watsjold,Bjorn %A Chan,Teresa M %+ Oregon Health Sciences University, 707 S Gaines St, Portland, OR, 97239, United States, 1 503 494 7993 ext 47993, cosimini@ohsu.edu %K game-based learning %K health professions education %K participatory design %K systematic review %K user-centered design %K serious games %K game development %K end users %K education %D 2022 %7 9.2.2022 %9 Letter to the Editor %J JMIR Serious Games %G English %X %M 35138255 %R 10.2196/34656 %U https://games.jmir.org/2022/1/e34656 %U https://doi.org/10.2196/34656 %U http://www.ncbi.nlm.nih.gov/pubmed/35138255 %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 e31172 %T Exploring Middle School Students’ Perspectives on Using Serious Games for Cancer Prevention Education: Focus Group Study %A Abraham,Olufunmilola %A Szela,Lisa %A Khan,Mahnoor %A Geddam,Amrita %+ Social & Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, 777 Highland Ave, Madison, WI, 53705, United States, 1 608 263 4498, olufunmilola.abraham@wisc.edu %K adolescents %K adolescent education %K adolescent health %K older children %K middle school students %K cancer awareness %K cancer education %K cancer prevention %K health education %K serious games %D 2022 %7 24.1.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cancer in the United States is a leading cause of mortality. Educating adolescents about cancer risks can improve awareness and introduce healthy lifestyle habits. Public health efforts have made significant progress in easing the burden of cancer through the promotion of early screening and healthy lifestyle advocacy. However, there are limited interventions that educate the adolescent population about cancer prevention. Previous studies have demonstrated the effectiveness of serious games (SGs) to teach adolescents about healthy lifestyle choices, but few research efforts have examined the utility of using SGs to educate youth specifically on cancer prevention. Objective: This study aimed to investigate middle school students’ preferences for the use of SGs for cancer prevention education. The study also characterized the students’ perceptions of desired game design features for a cancer prevention SG. Methods: Focus groups were held to allow adolescents to review a game playbook and discuss gaming behaviors and preferences for an SG for cancer education. The game playbook was developed based on “Cancer, Clear & Simple,” a curriculum intended to educate individuals about cancer, prevention, self-care, screening, and detection. In the game, the player learns that they have cancer and is given the opportunity to go back in time to reduce their cancer risk. A focus group discussion guide was developed and consisted of questions about aspects of the playbook and the participants’ gaming experience. The participants were eligible if they were 12 to 14 years old, could speak and understand English, and had parents who could read English or Spanish. Each focus group consisted of 5 to 10 persons. The focus groups were audio recorded and professionally transcribed; they were then analyzed content-wise and thematically by 2 study team members. Intercoder reliability (kappa coefficient) among the coders was reported as 0.97. The prevalent codes were identified and categorized into themes and subthemes. Results: A total of 18 focus groups were held with 139 participants from a Wisconsin middle school. Most participants had at least “some” gaming experience. Three major themes were identified, which were educational video games, game content, and purpose of game. The participants preferred customizable characters and realistic story lines that allowed players to make choices that affect the characters’ outcomes. Middle school students also preferred SGs over other educational methods such as lectures, books, videos, and websites. The participants desired SGs to be available across multiple platforms and suggested the use of SGs for cancer education in their school. Conclusions: Older children and adolescents consider SGs to be an entertaining tool to learn about cancer prevention and risk factors. Their design preferences should be considered to create a cancer education SG that is acceptable and engaging for youth. %M 34643533 %R 10.2196/31172 %U https://games.jmir.org/2022/1/e31172 %U https://doi.org/10.2196/31172 %U http://www.ncbi.nlm.nih.gov/pubmed/34643533 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e27058 %T The Effect of Video Game–Based Interventions on Performance and Cognitive Function in Older Adults: Bayesian Network Meta-analysis %A Yang,Chao %A Han,Xiaolei %A Jin,Mingxue %A Xu,Jianhui %A Wang,Yiren %A Zhang,Yajun %A Xu,Chonglong %A Zhang,Yingshi %A Jin,Enshi %A Piao,Chengzhe %+ Department of Ethnic Culture and Vocational Education, Liaoning National Normal College, No. 45 Chongshan Dong Road, Shenyang, 110032, China, 86 18642065021, jes61@163.com %K video game %K performance %K cognitive function %K older %K Bayesian network meta-analysis %D 2021 %7 30.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The decline in performance of older people includes balance function, physical function, and fear of falling and depression. General cognitive function decline is described in terms of processing speed, working memory, attention, and executive functioning, and video game interventions may be effective. Objective: This study evaluates the effect of video game interventions on performance and cognitive function in older participants in terms of 6 indicators: balance function, executive function, general cognitive function, physical function, processing speed, and fear of falling and depression. Methods: Electronic databases were searched for studies from inception to June 30, 2020. Randomized controlled trials and case-controlled trials comparing video game interventions versus nonvideo game control in terms of performance and cognitive function outcomes were incorporated into a Bayesian network meta-analysis. All data were continuous variables. Results: In total, 47 studies (3244 participants) were included. In pairwise meta-analysis, compared with nonvideo game control, video game interventions improved processing speed, general cognitive function, and depression scores. In the Bayesian network meta-analysis, interventions with video games improved balance function time (standardized mean difference [SMD] –3.34, 95% credible interval [CrI] –5.54 to –2.56), the cognitive function score (SMD 1.23, 95% CrI 0.82-1.86), processing speed time (SMD –0.29, 95% CrI –0.49 to –0.08), and processing speed number (SMD 0.72, 95% CrI 0.36-1.09), similar to the pairwise meta-analysis. Interventions with video games with strong visual senses and good interactivity ranked first, and these might be more beneficial for the elderly. Conclusions: Our comprehensive Bayesian network meta-analysis provides evidence that video game interventions could be considered for the elderly for improving performance and cognitive function, especially general cognitive scores and processing speed. Games with better interactivity and visual stimulation have better curative effects. Based on the available evidence, we recommend video game interventions for the elderly. Trial Registration: PROSPERO CRD42020197158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197158 %M 34967759 %R 10.2196/27058 %U https://games.jmir.org/2021/4/e27058 %U https://doi.org/10.2196/27058 %U http://www.ncbi.nlm.nih.gov/pubmed/34967759 %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 e29964 %T Using the Behaviour Change Wheel Program Planning Model to Design Games for Health: Development Study %A Robertson,Michael C %A Baranowski,Tom %A Thompson,Debbe %A Basen-Engquist,Karen M %A Swartz,Maria Chang %A Lyons,Elizabeth J %+ Department of Nutrition, Metabolism & Rehabilitation Sciences, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX, 77555, United States, 1 409 772 2578, ellyons@utmb.edu %K physical activity %K video games %K eHealth %K intervention %K behavior and behavior mechanisms %K psychological theory %K serious games %K gamification %K older women %K older adults %K behavior change %K behavioral interventions %K mobile phone %D 2021 %7 3.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Games for health are a promising approach to health promotion. Their success depends on achieving both experiential (game) and instrumental (health) objectives. There is little to guide game for health (G4H) designers in integrating the science of behavior change with the art of game design. Objective: The aim of this study is to extend the Behaviour Change Wheel program planning model to develop Challenges for Healthy Aging: Leveraging Limits for Engaging Networked Game-Based Exercise (CHALLENGE), a G4H centered on increasing physical activity in insufficiently active older women. Methods: We present and apply the G4H Mechanics, Experiences, and Change (MECHA) process, which supplements the Behaviour Change Wheel program planning model. The additional steps are centered on identifying target G4H player experiences and corresponding game mechanics to help game designers integrate design elements and G4H objectives into behavioral interventions. Results: We identified a target behavior of increasing moderate-intensity walking among insufficiently active older women and key psychosocial determinants of this behavior from self-determination theory (eg, autonomy). We used MECHA to map these constructs to intervention functions (eg, persuasion) and G4H target player experiences (eg, captivation). Next, we identified behavior change techniques (eg, framing or reframing) and specific game mechanics (eg, transforming) to help realize intervention functions and elicit targeted player experiences. Conclusions: MECHA can help researchers map specific linkages between distal intervention objectives and more proximal game design mechanics in games for health. This can facilitate G4H program planning, evaluation, and clearer scientific communication. %M 34870604 %R 10.2196/29964 %U https://games.jmir.org/2021/4/e29964 %U https://doi.org/10.2196/29964 %U http://www.ncbi.nlm.nih.gov/pubmed/34870604 %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 %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e33144 %T Contribution of the co.LAB Framework to the Collaborative Design of Serious Games: Mixed Methods Validation Study %A Jaccard,Dominique %A Suppan,Laurent %A Bielser,Félicia %+ Media Engineering Institute, HES-SO University of Applied Sciences and Arts Western Switzerland, Av. Sports 20, Yverdon, 1400, Switzerland, 41 245577556, dominique.jaccard@heig-vd.ch %K serious game %K educational game %K education %K simulation game %K gaming %K design %K framework %K methodology %K mixed method %K validation %D 2021 %7 24.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Multidisciplinary collaboration is essential to the successful development of serious games, albeit difficult to achieve. In a previous study, the co.LAB serious game design framework was created to support collaboration within serious game multidisciplinary design teams. Its use has not yet been validated in a real usage context. Objective: The objective of this study was to perform a first assessment of the impact of the co.LAB framework on collaboration within multidisciplinary teams during serious game design and development. Methods: A mixed methods study was conducted, based on 2 serious game design projects in which the co.LAB framework was used. The first phase was qualitative and carried out using a general inductive approach. To this end, all members of the first serious game project team who used the co.LAB framework were invited to take part in a focus group session (n=6). In a second phase, results inferred from qualitative data were used to define a quantitative instrument (questionnaire) that was designed according to the Checklist for Reporting Results of Internet E-Surveys. Members of both project teams (n=11) were then asked to answer the questionnaire. Quantitative results were reported as median (Q1, Q3), and appropriate nonparametric tests were used to assess between-group differences. Finally, results gathered through the qualitative and quantitative phases were integrated. Results: In both phases, the participation rate was 100% (6/6 and 11/11). Verbatim transcripts were classified into 4 high level themes: (1) influence on collaborative dimensions; (2) impact on project course, monitoring, and efficiency; (3) qualitative perceptions of the framework; and (4) influence of team composition on the use of the framework. The web-based questionnaire was then developed according to the 7 dimensions of collaboration by Burkhardt et al. In both projects, the co.LAB framework had a positive impact on most dimensions of collaboration during the multidisciplinary design and development of serious games. When all collaborative dimensions were aggregated, the overall impact of the framework was rated on a scale from –42 to 42 (very negative to very positive). The overall median score was 23 (Q1, Q3: 20, 27), with no significant difference between groups (P=.58). Most respondents also believed that all serious game design teams should include a member possessing significant expertise in serious game design to guide the development process. Conclusions: The co.LAB framework had a positive impact on collaboration within serious game design and development teams. However, expert guidance seems necessary to maximize development efficiency. Whether such guidance can be provided by means of a collaborative web platform remains to be determined. %M 34822336 %R 10.2196/33144 %U https://games.jmir.org/2021/4/e33144 %U https://doi.org/10.2196/33144 %U http://www.ncbi.nlm.nih.gov/pubmed/34822336 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e28079 %T Serious Games Are Not Serious Enough for Myoelectric Prosthetics %A Garske,Christian Alexander %A Dyson,Matthew %A Dupan,Sigrid %A Morgan,Graham %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 rehabilitation %K serious games %K engagement %K transfer %K upper limb %K arm prosthesis %K virtual training %K virtual games %D 2021 %7 8.11.2021 %9 Viewpoint %J JMIR Serious Games %G English %X Serious games show a lot of potential for use in movement rehabilitation (eg, after a stroke, injury to the spinal cord, or limb loss). However, the nature of this research leads to diversity both in the background of the researchers and in the approaches of their investigation. Our close examination and categorization of virtual training software for upper limb prosthetic rehabilitation found that researchers typically followed one of two broad approaches: (1) focusing on the game design aspects to increase engagement and muscle training and (2) concentrating on an accurate representation of prosthetic training tasks, to induce task-specific skill transfer. Previous studies indicate muscle training alone does not lead to improved prosthetic control without a transfer-enabling task structure. However, the literature shows a recent surge in the number of game-based prosthetic training tools, which focus on engagement without heeding the importance of skill transfer. This influx appears to have been strongly influenced by the availability of both software and hardware, specifically the launch of a commercially available acquisition device and freely available high-profile game development engines. In this Viewpoint, we share our perspective on the current trends and progress of serious games for prosthetic training. %M 34747715 %R 10.2196/28079 %U https://games.jmir.org/2021/4/e28079 %U https://doi.org/10.2196/28079 %U http://www.ncbi.nlm.nih.gov/pubmed/34747715 %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 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 e30672 %T Active Video Gaming Using an Adapted Gaming Mat in Youth and Adults With Physical Disabilities: Observational Study %A Malone,Laurie A %A Davlyatov,Ganisher K %A Padalabalanarayanan,Sangeetha %A Thirumalai,Mohanraj %+ University of Alabama at Birmingham/Lakeshore Research Collaborative, School of Health Professions, University of Alabama at Birmingham, 3810 Ridgeway Dr., Birmingham, AL, 35209, United States, 1 205 975 6432, lamalone@uab.edu %K exergaming %K video games %K disability %K exercise %K physical activity %K enjoyment %K dance mat %K serious games %K gaming mat %K mobility impairment %K physical impairment %D 2021 %7 26.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: A common leisure-time activity amongst youth and adults in the United States is video gameplay. Playing video games is typically a sedentary endeavor; however, to encourage an increased level of physical activity in an engaging and enjoyable way, active video gaming has become popular. Unfortunately, the accessibility of gaming controllers is often an issue for persons with disabilities. A commercial off-the-shelf (OTS) gaming mat was adapted to facilitate use by individuals with mobility impairments to address this issue. Objective: Our study aimed to examine energy expenditure, enjoyment, and gameplay experience in youth and adults with mobility impairment during active video gaming using an OTS and adapted versions of a gaming mat. Methods: The study used an observational design. During visit 1, physical function was assessed, and participants were given a familiarization period with the gaming system. For visit 2, based on observation during the physical function tests and discussion with the participant, it was decided whether the participant would play in a standing or seated position. For standing gameplay, the mat was placed on the floor, and for seated play, the mat was placed on a height-adjustable and tilt-adjustable tabletop. Metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus gameplay, with 2 bouts on each of the mats (adapted and OTS). During gameplay, the research staff observed and rated participants’ ability to use the game controller (mat) and the quality of gameplay. At the end of each game set, participants reported their rating of perceived exertion on a scale from 0 to 10. During rest, participants completed the physical activity enjoyment scale. Participants also answered additional questions regarding the system's usability with each controller (adapted mat and OTS mat). Statistical analyses were computed using Stata 16 (version 16.1; StataCorp). Linear mixed-effects maximum likelihood regression was performed separately for individuals who could play standing and for those who played seated. Results: A convenience sample of 78 individuals with mobility impairments between the ages of 12 and 60 years (mean 39.6, SD 15.8) participated in the study. Of the sample, 48 participants played the video games in a seated position, while 30 played the games standing. Energy expenditure and heart rate tended to be higher in the OTS mat condition for seated players, while values were similar for both conditions among standing players. However, seated participants reported greater gameplay experience, and both groups exhibited a higher quality of gameplay during the adapted mat condition. Conclusions: Active video gaming using an adapted gaming mat provided an enjoyable exercise activity for individuals with mobility impairments. The use of the adapted controller provides a means by which this population can engage in light to moderate intensity active video gaming, thereby reducing sedentary leisure time. Trial Registration: ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 %M 34435962 %R 10.2196/30672 %U https://games.jmir.org/2021/3/e30672 %U https://doi.org/10.2196/30672 %U http://www.ncbi.nlm.nih.gov/pubmed/34435962 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28650 %T Involvement of End Users in the Development of Serious Games for Health Care Professions Education: Systematic Descriptive Review %A Maheu-Cadotte,Marc-André %A Dubé,Véronique %A Cossette,Sylvie %A Lapierre,Alexandra %A Fontaine,Guillaume %A Deschênes,Marie-France %A Lavoie,Patrick %+ Faculty of Nursing, Université de Montréal, Pavillon Marguerite-d'Youville, 2375 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1A8, Canada, 1 514 376 3330 ext 2041, marc-andre.maheu-cadotte@umontreal.ca %K game-based learning %K health professions education %K participatory design %K systematic review %K user-centered design %K serious games %K game development %K end users %K education %D 2021 %7 19.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: On the basis of ethical and methodological arguments, numerous calls have been made to increase the involvement of end users in the development of serious games (SGs). Involving end users in the development process is considered a way to give them power and control over educational software that is designed for them. It can also help identify areas for improvement in the design of SGs and improve their efficacy in targeted learning outcomes. However, no recognized guidelines or frameworks exist to guide end users’ involvement in SG development. Objective: The aim of this study is to describe how end users are involved in the development of SGs for health care professions education. Methods: We examined the literature presenting the development of 45 SGs that had reached the stage of efficacy evaluation in randomized trials. One author performed data extraction using an ad hoc form based on a design and development framework for SGs. Data were then coded and synthesized on the basis of similarities. The coding scheme was refined iteratively with the involvement of a second author. Results are presented using frequencies and percentages. Results: End users’ involvement was mentioned in the development of 21 of 45 SGs. The number of end users involved ranged from 12 to 36. End users were often involved in answering specific concerns that arose during the SG design (n=6) or in testing a prototype (n=12). In many cases, researchers solicited input from end users regarding the goals to reach (n=10) or the functional esthetics of the SGs (n=7). Most researchers used self-reported questionnaires (n=7). Conclusions: Researchers mentioned end users’ involvement in the development of less than half of the identified SGs, and this involvement was also poorly described. These findings represent significant limitations to evaluating the impact of the involvement of end users on the efficacy of SGs and in making recommendations regarding their involvement. %M 34129514 %R 10.2196/28650 %U https://games.jmir.org/2021/3/e28650 %U https://doi.org/10.2196/28650 %U http://www.ncbi.nlm.nih.gov/pubmed/34129514 %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 e26062 %T A Therapeutic Game for Sexually Abused Children and Adolescents (Vil Du?!): Exploratory Mixed Methods Evaluation %A Endendijk,Joyce Johanna %A Tichelaar,Henny %A Deen,Menno %A Deković,Maja %+ Child and Adolescent Studies, Utrecht University, Heidelberglaan 1, Utrecht, 3548 CS, Netherlands, 31 30 253 4896, j.j.endendijk@uu.nl %K child sexual abuse %K psychotherapy %K serious games %K evaluation %K working elements %K acceptability %D 2021 %7 3.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Talking about experiences of sexual abuse in therapy is difficult for children and adolescents. Possible reasons for this difficulty are a lack of vocabulary to describe the situation or feelings of shame, fear, and self-blame associated with sexual abuse. The serious game Vil Du?! was developed to help children open up about their sexual abuse experiences. Vil Du?! is a nonverbal communication game that resembles a dress-up game in which children can show the therapist what happened to them. Objective: This exploratory evaluation study examines which working elements of the game could be identified in therapy with victims of sexual abuse (aim 1). In addition, this study examines how therapists evaluate the acceptability of the game (aim 2). Methods: The therapists completed 23 web-based surveys on the use of Vil Du?! In addition, semistructured interviews were conducted with 10 therapists. The data were analyzed in NVivo following previously reported stepwise guidelines. Results: Regarding aim 1, therapists mentioned various working elements of Vil Du?!; for instance, Vil Du?! puts the child in control of the situation. In addition, Vil Du?! reduces barriers to disclosure because there is no need to talk or have eye contact with the therapist. Regarding aim 2, Vil Du?! was generally evaluated more positively than negatively by the therapists. For instance, therapists indicated that using Vil Du?! is time efficient and might make the treatment process less confronting and difficult for the client. According to therapists, most clients indeed experienced less tension and more positive (or neutral) emotions than negative emotions when using Vil Du?! Conclusions: The most important working elements of Vil Du?!, according to therapists, are that it enables children to regain control over their sexual abuse experiences and reduces barriers to disclosing sexual abuse experiences. The more positive evaluation of Vil Du?! indicates the acceptability of the game for therapists as well as their clients. %M 34342592 %R 10.2196/26062 %U https://games.jmir.org/2021/3/e26062 %U https://doi.org/10.2196/26062 %U http://www.ncbi.nlm.nih.gov/pubmed/34342592 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26028 %T An Interactive Computer Game for Improving Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Development and Preliminary Feasibility Study %A Fahr,Annina %A Kläy,Andrina %A Keller,Jeffrey W %A van Hedel,Hubertus J A %+ Swiss Children's Rehab, University Children’s Hospital Zurich, Mühlebergstrasse 104, Affoltern a.A., 8910, Switzerland, 41 44 762 52 97, annina.fahr@kispi.uzh.ch %K virtual reality %K game therapy %K rehabilitation %K augmented feedback %K motivation %K mobile phone %D 2021 %7 28.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Computer game–based interventions are emerging in pediatric neurorehabilitation, as they can provide two key elements for motor learning—motivating environments that enable long-term compliance, which is particularly relevant for children, and augmented feedback for improving movement performance. Objective: The overall aim of this study is to develop an interactive computer play for children with upper motor neuron lesions to train selective voluntary motor control and give particular attention to motivation and feedback. We also aim to determine features that make games engaging, investigate which sensory feedback modality is noticed the fastest during play, develop an interactive game, and evaluate its feasibility. Methods: We identified engaging game features by interviewing 19 children and adolescents undergoing rehabilitation. By using a test version of the game, we determined the response times of 10 patients who had to react to visual, auditory, or combined feedback signals. On the basis of the results of these two subprojects, we developed and designed a game environment. Feasibility was studied in terms of the practicability and acceptability of the intervention among 5 children with upper motor neuron lesions. Results: The game features deemed the most important by pediatric patients were strategic gameplay (13/29, 45% of answers) and choice (6/29, 21%). While playing the game, an acoustic alarm signal (reaction time: median 2.8 seconds) was detected significantly faster (P=.01) than conditions with other feedback modalities (avatar velocity reduction: median 7.8 seconds; color desaturation: median 5.7 seconds). Most children enjoyed playing the game, despite some technical issues. Conclusions: The careful identification of game features that increase motivation and feedback modalities that inform children quickly led to the development of an interactive computer play for training selective voluntary motor control in children and adolescents with upper motor neuron lesions. %M 34319236 %R 10.2196/26028 %U https://games.jmir.org/2021/3/e26028 %U https://doi.org/10.2196/26028 %U http://www.ncbi.nlm.nih.gov/pubmed/34319236 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e18020 %T Using Visual Guides to Reduce Virtual Reality Sickness in First-Person Shooter Games: Correlation Analysis %A Seok,Kwang-Ho %A Kim,YeolHo %A Son,Wookho %A Kim,Yoon Sang %+ BioComputing Lab, Institute for Bio-engineering Application Technology, School of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 0415601496, yoonsang@koreatech.ac.kr %K virtual reality %K motion sickness %K VR sickness %K visual guide %K VR fidelity %D 2021 %7 15.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The virtual reality (VR) content market is rapidly growing due to an increased supply of VR devices such as head-mounted displays (HMDs), whereas VR sickness (reported to occur while experiencing VR) remains an unsolved problem. The most widely used method of reducing VR sickness is the use of a rest frame that stabilizes the user's viewpoint by providing fixed visual stimuli in VR content (including video). However, the earth-fixed grid and natural independent visual background that are widely used as rest frames cannot maintain VR fidelity, as they reduce the immersion and the presence of the user. A visual guide is a visual element (eg, a crosshair of first-person shooter [FPS]) that induces a user's gaze movement within the VR content while maintaining VR fidelity, whereas there are no studies on the correlation of visual guide with VR sickness. Objective: This study aimed to analyze the correlation between VR sickness and crosshair, which is widely used as a visual guide in FPS games. Methods: Eight experimental scenarios were designed and evaluated, including having the visual guide on/off, the game controller on/off, and varying the size and position of the visual guide to determine the effect of visual guide on VR sickness. Results: The results showed that VR sickness significantly decreased when visual guide was applied in an FPS game. In addition, VR sickness was lower when the visual guide was adjusted to 30% of the aspect ratio and positioned in the head-tracking direction. Conclusions: The experimental results of this study indicate that the visual guide can achieve VR sickness reduction while maintaining user presence and immersion in the virtual environment. In other words, the use of a visual guide is expected to solve the existing limitation of distributing various types of content due to VR sickness. %M 34264196 %R 10.2196/18020 %U https://games.jmir.org/2021/3/e18020 %U https://doi.org/10.2196/18020 %U http://www.ncbi.nlm.nih.gov/pubmed/34264196 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28674 %T The co.LAB Generic Framework for Collaborative Design of Serious Games: Development Study %A Jaccard,Dominique %A Suppan,Laurent %A Sanchez,Eric %A Huguenin,Audrey %A Laurent,Maxence %+ Media Engineering Institute, University of Applied Sciences Western Switzerland, Av. Sports 20, Yverdon, 1400, Switzerland, 41 244592638, dominique.jaccard@heig-vd.ch %K serious game %K educational game %K simulation game %K design %K design framework %K methodology %K collaborative design %K collaborative web platform %D 2021 %7 2.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games are increasingly used at all levels of education. However, research shows that serious games do not always fulfill all the targeted pedagogical objectives. Designing efficient and engaging serious games is a difficult and multidisciplinary process that requires a collaborative approach. Many design frameworks have been described, most of which are dedicated to the development of specific types of serious games and take the collaborative dimension into account only to a limited extent. Objective: Our aim was to create a generic serious game design framework that could be adapted to all kinds of serious games and implemented in a collaborative web platform. Methods: We combined the results of a literature review with our experience in serious game design and development to determine the basic building blocks of a collaborative design framework. We then organized these building blocks into categories and determined the features that a generic design framework should include. Finally, based on the paradigm of complex systems and systemic modelling, we created the co.LAB generic design framework and specifications to allow its implementation in a collaborative web platform. Results: Based on a total of 10 existing design methodologies or frameworks, 23 building blocks were identified and represent the foundation of the co.LAB framework. These blocks were organized into 5 categories: “context and objectives,” “game design,” “mechanics,” “learning design,” and “assessment.” The arrangement by categories provides a structure that can be visualized in multiple and complementary ways. The classical view links game and learning design while other views offer project, systemic, and process visualizations. For the implementation of the co.LAB framework in a web platform, we propose to convert the building blocks into “cards.” Each card would constitute a collaborative working space for the design of the corresponding block. To make the framework adaptive, cards could be added, adapted, or removed according to the kind of serious game intended. Enhancing the visualization of relationships between cards should support a systemic implementation of the framework. Conclusions: By offering a structured view of the fundamental design elements required to create serious games, the co.LAB framework can facilitate the design and development of such games by virtue of a collaborative, adaptive, and systemic approach. The different visualizations of the building blocks should allow for a shared understanding and a consistent approach throughout the design and development process. The implementation of the co.LAB framework in a collaborative web platform should now be performed and its actual usability and effectiveness tested. %M 34255655 %R 10.2196/28674 %U https://games.jmir.org/2021/3/e28674 %U https://doi.org/10.2196/28674 %U http://www.ncbi.nlm.nih.gov/pubmed/34255655 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e25854 %T Standardizing the Development of Serious Games for Physical Rehabilitation: Conceptual Framework Proposal %A Beristain-Colorado,María Del Pilar %A Ambros-Antemate,Jorge Fernando %A Vargas-Treviño,Marciano %A Gutiérrez-Gutiérrez,Jaime %A Moreno-Rodriguez,Adriana %A Hernández-Cruz,Pedro Antonio %A Gallegos-Velasco,Itandehui Belem %A Torres-Rosas,Rafael %+ Doctorado en Biociencias, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Ex Hacienda de Aguilera S/N, Calz. San Felipe del Agua., Oaxaca de Juárez, 68120, Mexico, 52 9511332346, pberistain.cat@uabjo.mx %K serious game %K physical rehabilitation %K framework %K software engineering %K gamification %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have been used as supportive therapy for traditional rehabilitation. However, most are designed without a systematic process to guide their development from the phases of requirement identification, planning, design, construction, and evaluation, which reflect the lack of adaptation of rehabilitation requirements and thus the patient’s needs. Objective: The aim of this study was to propose a conceptual framework with standardized elements for the development of information systems by using a flexible and an adaptable process centered on the patient’s needs and focused on the creation of serious games for physical rehabilitation. Methods: The conceptual framework is based on 3 fundamental concepts: (1) user-centered design, which is an iterative design process focused on users and their needs at each phase of the process, (2) generic structural activities of software engineering, which guides the independent development process regardless of the complexity or size of the problem, and (3) gamification elements, which allow the transformation of obstacles into positive and fun reinforcements, thereby encouraging patients in their rehabilitation process. Results: We propose a conceptual framework to guide the development of serious games through a systematic process by using an iterative and incremental process applying the phases of context identification, user requirements, planning, design, construction of the interaction devices and video game, and evaluation. Conclusions: This proposed framework will provide developers of serious games a systematic process with standardized elements for the development of flexible and adaptable software with a high level of patient commitment, which will effectively contribute to their rehabilitation process. %M 34185003 %R 10.2196/25854 %U https://games.jmir.org/2021/2/e25854/ %U https://doi.org/10.2196/25854 %U http://www.ncbi.nlm.nih.gov/pubmed/34185003 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e23130 %T A Prediction Model for Detecting Developmental Disabilities in Preschool-Age Children Through Digital Biomarker-Driven Deep Learning in Serious Games: Development Study %A Kim,Ho Heon %A An,Jae Il %A Park,Yu Rang %+ Department of Biomedical Systems Informatics, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2228 2493, yurangpark@yuhs.ac %K developmental delay %K diagnosis prediction %K deep learning %K serious games %K digital health %K digital phenotyping %K digital biomarkers %D 2021 %7 4.6.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Early detection of developmental disabilities in children is essential because early intervention can improve the prognosis of children. Meanwhile, a growing body of evidence has indicated a relationship between developmental disability and motor skill, and thus, motor skill is considered in the early diagnosis of developmental disability. However, there are challenges to assessing motor skill in the diagnosis of developmental disorder, such as a lack of specialists and time constraints, and thus it is commonly conducted through informal questions or surveys to parents. Objective: This study sought to evaluate the possibility of using drag-and-drop data as a digital biomarker and to develop a classification model based on drag-and-drop data with which to classify children with developmental disabilities. Methods: We collected drag-and-drop data from children with typical development and developmental disabilities from May 1, 2018, to May 1, 2020, via a mobile application (DoBrain). We used touch coordinates and extracted kinetic variables from these coordinates. A deep learning algorithm was developed to predict potential development disabilities in children. For interpretability of the model results, we identified which coordinates contributed to the classification results by applying gradient-weighted class activation mapping. Results: Of the 370 children in the study, 223 had typical development, and 147 had developmental disabilities. In all games, the number of changes in the acceleration sign based on the direction of progress both in the x- and y-axes showed significant differences between the 2 groups (P<.001; effect size >0.5). The deep learning convolutional neural network model showed that drag-and-drop data can help diagnose developmental disabilities, with an area under the receiving operating characteristics curve of 0.817. A gradient class activation map, which can interpret the results of a deep learning model, was visualized with the game results for specific children. Conclusions: Through the results of the deep learning model, we confirmed that drag-and-drop data can be a new digital biomarker for the diagnosis of developmental disabilities. %M 34085944 %R 10.2196/23130 %U https://games.jmir.org/2021/2/e23130 %U https://doi.org/10.2196/23130 %U http://www.ncbi.nlm.nih.gov/pubmed/34085944 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e25771 %T User Experience With Dynamic Difficulty Adjustment Methods for an Affective Exergame: Comparative Laboratory-Based Study %A Darzi,Ali %A McCrea,Sean M %A Novak,Domen %+ Department of Electrical and Computer Engineering, University of Wyoming, 1000 E University Avenue, Dept 3295, Laramie, WY, 82071, United States, 1 307 766 2279, dnovak1@uwyo.edu %K affective computing %K dynamic difficulty adaptation %K exergames %K physiological measurements %K task performance %K personality characteristics %K psychophysiology %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In affective exergames, game difficulty is dynamically adjusted to match the user’s physical and psychological state. Such an adjustment is commonly made based on a combination of performance measures (eg, in-game scores) and physiological measurements, which provide insight into the player’s psychological state. However, although many prototypes of affective games have been presented and many studies have shown that physiological measurements allow more accurate classification of the player’s psychological state than performance measures, few studies have examined whether dynamic difficulty adjustment (DDA) based on physiological measurements (which requires additional sensors) results in a better user experience than performance-based DDA or manual difficulty adjustment. Objective: This study aims to compare five DDA methods in an affective exergame: manual (player-controlled), random, performance-based, personality-performance–based, and physiology-personality-performance–based (all-data). Methods: A total of 50 participants (N=50) were divided into five groups, corresponding to the five DDA methods. They played an exergame version of Pong for 18 minutes, starting at a medium difficulty; every 2 minutes, two game difficulty parameters (ball speed and paddle size) were adjusted using the participant’s assigned DDA method. The DDA rules for the performance-based, personality-performance–based, and all-data groups were developed based on data from a previous open-loop study. Seven physiological responses were recorded throughout the sessions, and participants self-reported their preferred changes to difficulty every 2 minutes. After playing the game, participants reported their in-game experience using two questionnaires: the Intrinsic Motivation Inventory and the Flow Experience Measure. Results: Although the all-data method resulted in the most accurate changes to ball speed and paddle size (defined as the percentage match between DDA choice and participants’ preference), no significant differences between DDA methods were found on the Intrinsic Motivation Inventory and Flow Experience Measure. When the data from all four automated DDA methods were pooled together, the accuracy of changes in ball speed was significantly correlated with players’ enjoyment (r=0.38) and pressure (r=0.43). Conclusions: Although our study is limited by the use of a between-subjects design and may not generalize to other exergame designs, the results do not currently support the inclusion of physiological measurements in affective exergames, as they did not result in an improved user experience. As the accuracy of difficulty changes is correlated with user experience, the results support the development of more effective DDA methods. However, they show that the inclusion of physiological measurements does not guarantee a better user experience even if it yields promising results in offline cross-validation. %M 34057423 %R 10.2196/25771 %U https://games.jmir.org/2021/2/e25771 %U https://doi.org/10.2196/25771 %U http://www.ncbi.nlm.nih.gov/pubmed/34057423 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e24449 %T Mobile Game Design Guide to Improve Gaming Experience for the Middle-Aged and Older Adult Population: User-Centered Design Approach %A Lee,Seyeon %A Oh,Hyunyoung %A Shi,Chung-Kon %A Doh,Young Yim %+ Graduate School of Culture Technology, Korea Advanced Institute of Science and Technology, 291 Daehak-ro, Yuseong-gu, Daejeon, 34141, Republic of Korea, 82 42 350 2994, yydoh@kaist.ac.kr %K mobile games %K older adults %K middle-aged adults %K design guideline %K gaming experience %D 2021 %7 20.5.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The number of older adult gamers who play mobile games is growing worldwide. Earlier studies have reported that digital games provide cognitive, physical, and socioemotional benefits for older adults. However, current mobile games that understand older adults’ gameplay experience and reflect their needs are very scarce. Furthermore, studies that have analyzed older adults’ game experience in a holistic manner are rare. Objective: The purpose of this study was to suggest mobile game design guidelines for adults older than 50 years from a holistic gaming experience perspective. Adopting a human-centric approach, this study analyzes middle-aged and older adults’ gameplay experience and suggests practical design guides to increase accessibility and satisfaction. Methods: We organized a living laboratory project called the “Intergenerational Play Workshop.” In this workshop, 40 middle-aged and older adults (mean age 66.75 years, age range 50-85 years) played commercial mobile games of various genres with young adult partners for 1 month (8 sessions). Using a convergent parallel mixed-method design, we conducted a qualitative analysis of dialogue, game diaries, and behavioral observations during the workshop and a quantitative analysis of the satisfaction level of the game elements for the mobile games that they played. Results: This project was active from April 2019 to December 2021, and the data were collected at the workshops from July 1 to August 28, 2019. Based on the identified themes of positive and negative experiences from the qualitative data, we proposed 45 design guides under 3 categories: (1) cognitive and physical elements, (2) psychological and socioemotional elements, and (3) consumption contextual elements. Our empirical research could reaffirm the proposals from previous studies and provide new guidelines for improving the game design. In addition, we demonstrate how existing commercial games can be evaluated quantitatively by using the satisfaction level of each game’s elements and overall satisfaction level. Conclusions: The final guidelines were presented to game designers to easily find related information and enhance the overall understanding of the game experience of middle-aged and older adults. %M 34014175 %R 10.2196/24449 %U https://games.jmir.org/2021/2/e24449 %U https://doi.org/10.2196/24449 %U http://www.ncbi.nlm.nih.gov/pubmed/34014175 %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 %@ 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 e19765 %T The Development of an Escape Room–Based Serious Game to Trigger Social Interaction and Communication Between High-Functioning Children With Autism and Their Peers: Iterative Design Approach %A Terlouw,Gijs %A Kuipers,Derek %A van 't Veer,Job %A Prins,Jelle T %A Pierie,Jean Pierre E N %+ NHL Stenden University of Applied Sciences, Rengerslaan 10, Leeuwarden, Netherlands, 31 0628317457, gijs.terlouw@nhlstenden.com %K serious game %K autism %K design research %K boundary object %D 2021 %7 23.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Children with autism spectrum disorder (ASD) have social deficits that affect social interactions, communication, and relationships with peers. Many existing interventions focus mainly on improving social skills in clinical settings. In addition to the direct instruction–based programs, activity-based programs could be of added value, especially to bridge the relational gap between children with ASD and their peers. Objective: The aim of this study is to describe an iterative design process for the development of an escape room–based serious game as a boundary object. The purpose of the serious game is to facilitate direct communication between high-functioning children with ASD and their peers, for the development of social skills on the one hand and strengthening relationships with peers through a fun and engaging activity on the other hand. Methods: This study is structured around the Design Research Framework to develop an escape room through an iterative-incremental process. With a pool of 37 children, including 23 children diagnosed with ASD (5 girls) and 14 children (7 girls) attending special primary education for other additional needs, 4 testing sessions around different prototypes were conducted. The beta prototype was subsequently reviewed by experts (n=12). During the design research process, we examined in small steps whether the developed prototypes are feasible and whether they have the potential to achieve the formulated goals of different stakeholders. Results: By testing various prototypes, several insights were found and used to improve the design. Insights were gained in finding a fitting and appealing theme for the children, composing the content, and addressing different constraints in applying the goals from the children’s and therapeutic perspectives. Eventually, a multiplayer virtual escape room, AScapeD, was developed. Three children can play the serious game in the same room on tablets. The first test shows that the game enacts equal cooperation and communication among the children. Conclusions: This paper presents an iterative design process for AScapeD. AScapeD enacts equal cooperation and communication in a playful way between children with ASD and their peers. The conceptual structure of an escape room contributes to the natural emergence of communication and cooperation. The iterative design process has been beneficial for finding a constructive game structure to address all formulated goals, and it contributed to the design of a serious game as a boundary object that mediates the various objectives of different stakeholders. We present 5 lessons learned from the design process. The developed prototype is feasible and has the potential to achieve the goals of the serious game. %M 33755023 %R 10.2196/19765 %U https://games.jmir.org/2021/1/e19765 %U https://doi.org/10.2196/19765 %U http://www.ncbi.nlm.nih.gov/pubmed/33755023 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e21988 %T Game Experience and Learning Effects of a Scoring-Based Mechanic for Logistical Aspects of Pediatric Emergency Medicine: Development and Feasibility Study %A Zhang,Cevin %A Baalsrud Hauge,Jannicke %A Härenstam,Karin Pukk %A Meijer,Sebastiaan %+ School of Media and Design, Beijing Technology and Business University, Higher Education Garden, Sunlight South Road 1, Beijing, 102488, China, 86 15210583599, chenzh@btbu.edu.cn %K serious game %K emergency department %K experience %K learning engagement %K learning behavior transition %K logistical performance %D 2021 %7 11.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals. Objective: This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure. Methods: First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment. Results: A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR2 of 0.796 (F14,31=2725.49, P<.001) for the board version and 0.702 (F24,31=2635.31, P<.001) for the multiplayer online version after the learning engagement attributes. Conclusions: The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used. %M 33704081 %R 10.2196/21988 %U https://games.jmir.org/2021/1/e21988 %U https://doi.org/10.2196/21988 %U http://www.ncbi.nlm.nih.gov/pubmed/33704081 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e20209 %T The Effect of a Health Game Prompt on Self-efficacy: Online Between-Subjects Experimental Survey %A Haring,Priscilla %+ Witte de withstraat 20hs, Amsterdam, 1057XW, Netherlands, 31 624813683, priscillaharing@hotmail.com %K self-efficacy %K games for health %K serious games %K arousal congruent %K cognitive reappraisal %K prompt %K flourishing %K eHealth %K diabetes %D 2021 %7 3.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Games for health are increasingly used as (part of) health interventions and more effect research into games for health is being done. This online experiment questions expectancies of games for health by investigating whether a game for health prompt might be considered arousal congruent cognitive reappraisal and as such positively effects self-efficacy before gameplay. Objective: The aim of this study experiment is to test whether a game for health prompt effects self-efficacy and other well-being measurements, as a first step into investigating if a game prompt is a form of arousal congruent cognitive reappraisal. Methods: This study used an online, 2D, between-subjects experimental survey design with self-efficacy as the main dependent variable. Stimulus is an assignment for health-related problem solving concerning living with diabetes type II, introduced as a game (n=125) versus the same assignment introduced as a task (n=107). Measurements after prompting the game/task assignment include self-efficacy, positive and negative affect, expected difficulty, flourishing, and self-esteem. Results: The results indicate a small negative effect from prompting the game assignment on self-efficacy, compared with prompting a task assignment. This effect is mediated by the expected difficulty of the health game/task. No differences between the game and task groups were found in affect, flourishing, or self-esteem. Conclusions: This experiment provides no support for the notion that a game for health prompt might be seen as arousal congruent cognitive reappraisal. %M 33656447 %R 10.2196/20209 %U https://games.jmir.org/2021/1/e20209 %U https://doi.org/10.2196/20209 %U http://www.ncbi.nlm.nih.gov/pubmed/33656447 %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 e22802 %T Physiological Responses and User Feedback on a Gameful Breathing Training App: Within-Subject Experiment %A Lukic,Yanick Xavier %A Shih,Chen-Hsuan (Iris) %A Hernandez Reguera,Alvaro %A Cotti,Amanda %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 biofeedback %K mobile health %K mHealth %K mobile phone %D 2021 %7 8.2.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Slow-paced breathing training (6 breaths per minute [BPM]) improves physiological and psychological well-being by inducing relaxation characterized by increased heart rate variability (HRV). However, classic breathing training has a limited target group, and retention rates are very low. Although a gameful approach may help overcome these challenges, it is crucial to enable breathing training in a scalable context (eg, smartphone only) and ensure that they remain effective. However, despite the health benefits, no validated mobile gameful breathing training featuring a biofeedback component based on breathing seems to exist. Objective: This study aims to describe the design choices and their implementation in a concrete mobile gameful breathing training app. Furthermore, it aims to deliver an initial validation of the efficacy of the resulting app. Methods: Previous work was used to derive informed design choices, which, in turn, were applied to build the gameful breathing training app Breeze. In a pretest (n=3), design weaknesses in Breeze were identified, and Breeze was adjusted accordingly. The app was then evaluated in a pilot study (n=16). To ascertain that the effectiveness was maintained, recordings of breathing rates and HRV-derived measures (eg, root mean square of the successive differences [RMSSDs]) were collected. We compared 3 stages: baseline, standard breathing training deployed on a smartphone, and Breeze. Results: Overall, 5 design choices were made: use of cool colors, natural settings, tightly incorporated game elements, game mechanics reflecting physiological measures, and a light narrative and progression model. Breeze was effective, as it resulted in a slow-paced breathing rate of 6 BPM, which, in turn, resulted in significantly increased HRV measures compared with baseline (P<.001 for RMSSD). In general, the app was perceived positively by the participants. However, some criticized the somewhat weaker clarity of the breathing instructions when compared with a standard breathing training app. Conclusions: The implemented breathing training app Breeze maintained its efficacy despite the use of game elements. Moreover, the app was positively perceived by participants although there was room for improvement. %M 33555264 %R 10.2196/22802 %U http://games.jmir.org/2021/1/e22802/ %U https://doi.org/10.2196/22802 %U http://www.ncbi.nlm.nih.gov/pubmed/33555264 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e23423 %T A Bowling Exergame to Improve Functional Capacity in Older Adults: Co-Design, Development, and Testing to Compare the Progress of Playing Alone Versus Playing With Peers %A Da Silva Júnior,Jorge Luiz Andrade %A Biduski,Daiana %A Bellei,Ericles Andrei %A Becker,Osvaldo Henrique Cemin %A Daroit,Luciane %A Pasqualotti,Adriano %A Tourinho Filho,Hugo %A De Marchi,Ana Carolina Bertoletti %+ Institute of Exact Sciences and Geosciences, University of Passo Fundo, B5 Building, São José, Highway BR285, Km 292, Passo Fundo, 99052900, Brazil, 55 5433168354, 168729@upf.br %K functional status %K elderly %K virtual reality therapy %K user-centered design %K software design %K video games %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Older people often do not meet the recommended levels of exercise required to reduce functional decline. Social interaction is mentioned by this cohort as a reason for joining group-based exercises, which does not occur when exercising alone. This perspective shows that exergames can be used as motivational resources. However, most available exergames are generic, obtained from commercial sources, and usually not specifically designed or adapted for older people. Objective: In this study, we aim to co-design and develop a new exergame alongside older participants to (1) tailor the game mechanics and optimize participants’ adherence to and enjoyment of exercise; (2) test the participants’ functional capacity, motivation, and adherence to the exergaming program; and (3) compare these scores between those who played alone and those who played with peers. Methods: We conducted a co-design process to develop a new exergame adapted to older people. For user testing, 23 participants were divided into 2 groups to play individually (alone group) or to compete in pairs (with peers group). They played the game twice a week, resulting in 21 exergaming sessions. We assessed the participants’ General Physical Fitness Index (GPFI) before and after the user testing. We also administered questionnaires about the gaming experience and exercise adherence with its motivators and barriers. Results: We introduced a new bowling exergame for Xbox with a Kinect motion sensor that can be played in single or multiplayer mode. For the GPFI measurements, the sample was homogeneous in the pretest (with peers group: mean 40.5 [SD 9.6], alone group: mean 33.9 [SD 7.8]; P=.11). After the exergame testing sessions, both groups had significant gains (with peers group: mean 57.5 [SD 8.7], P=.005; alone group: mean 44.7 [SD 10.6]; P=.02). Comparing the posttest between groups, it was found that the group in which participants played with peers had better outcomes than the group in which participants played alone (P=.02). Regarding the gaming experience and exercise adherence, both groups recognized the benefits and expressed enthusiasm toward the exergame. Conclusions: The findings suggest that the developed exergame helps in improving the functional capacity and adherence to physical exercise among older people, with even better results for those who played with peers. In addition to leading to more appropriate products, a co-design approach may positively influence the motivation and adherence of participants. %M 33512319 %R 10.2196/23423 %U http://games.jmir.org/2021/1/e23423/ %U https://doi.org/10.2196/23423 %U http://www.ncbi.nlm.nih.gov/pubmed/33512319 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e23069 %T A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial %A Simmich,Joshua %A Mandrusiak,Allison %A Smith,Stuart Trevor %A Hartley,Nicole %A Russell,Trevor Glen %+ Faculty of Health and Behavioural Sciences, The University of Queensland, St Lucia, Brisbane, 4072, Australia, 61 733655344, joshua.simmich@uqconnect.edu.au %K fitness trackers %K chronic obstructive pulmonary disease %K physical activity %K video games %K smartphone %K mobile phone %D 2021 %7 27.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention. Objective: The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA). Methods: Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game. Results: Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA. Conclusions: The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population. %M 33502321 %R 10.2196/23069 %U http://games.jmir.org/2021/1/e23069/ %U https://doi.org/10.2196/23069 %U http://www.ncbi.nlm.nih.gov/pubmed/33502321 %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 %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e16029 %T Electronic Games for Facilitating Social Interaction Between Parents With Cancer and Their Children During Hospitalization: Interdisciplinary Game Development %A Piil,Karin %A Gyldenvang,Helle Holm %A Møller,Jeppe Kilberg %A Kjoelsen,Tine %A Juul,Jesper %A Pappot,Helle %+ Department of Oncology, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, Copenhagen Ø, 2100, Denmark, 45 35450733, Karin.piil@regionh.dk %K cancer patients %K children %K adolescents %K social relation %K emotional well-being %K gamification %K relatives %K visual design %K serious games %D 2021 %7 21.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Most cancer treatments today take place in outpatient clinics; however, it might be necessary for some patients to be admitted to hospital departments due to severe side effects or complications. In such situations, support from family and social relations can be crucial for the patients’ emotional well-being. Many young adolescents and children whose parents have cancer describe how they are not seen, heard, or listened to as the worried relatives they are. Within the intensive care unit, it has been recommended that early supportive interventions are tailored to include children of the intensive care patient; a similar approach might be relevant in the oncological setting. To our knowledge, no studies have explored how to involve young relatives who are visiting their parent at an oncological department. Recently, a framework for developing theory-driven, evidence-based serious games for health has been suggested. Such a process would include stakeholders from various disciplines, who only work toward one specific solution. However, it is possible that bringing together different disciplines, such as design, art, and health care, would allow a broader perspective, resulting in improved solutions. Objective: This study aims to develop tools to enhance the social interaction between a parent with cancer and their child when the child visits the parent in the hospital. Methods: In total, 4 groups of design students within the Visual Design program were tasked with developing games addressing the objective of strengthening relations in situ during treatment. To support their work, the applied methods included professional lectures, user studies, and visual communication (phase I); interviews with the relevant clinicians at the hospital (phase II), co-creative workshops with feedback (phase III), and evaluation sessions with selected populations (phase IV). The activities in the 4 phases were predefined. This modified user design had the child (aged 4-18 years) of a parent with cancer as its primary user. Results: Overall, 4 different games were designed based on the same information. All games had the ability to make adults with cancer and their children interact on a common electronic platform with a joint goal. However, the interaction, theme, and graphical expression differed between the games, suggesting that this is a wide and fertile field to explore. Conclusions: Playing a game can be an efficient way to create social interaction between a parent with cancer and a child or an adolescent, potentially improving the difficult social and psychological relations between them. The study showed that the development of serious games can be highly dependent on the designers involved and the processes used. This must be considered when a hospital aims to develop multiple games for different purposes. %M 33475523 %R 10.2196/16029 %U http://games.jmir.org/2021/1/e16029/ %U https://doi.org/10.2196/16029 %U http://www.ncbi.nlm.nih.gov/pubmed/33475523 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19968 %T Effects of a Personalized Fitness Recommender System Using Gamification and Continuous Player Modeling: System Design and Long-Term Validation Study %A Zhao,Zhao %A Arya,Ali %A Orji,Rita %A Chan,Gerry %+ Institute of Communication, Culture, Information and Technology, University of Toronto Mississauga, 3359 Mississauga Road, Mississauga, ON, L5L 1C6, Canada, 1 6137966008, zhao.zhao@utoronto.ca %K persuasive communication %K video games %K mobile apps %K wearable electronic devices %K motivation %K mobile phone %D 2020 %7 17.11.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification and persuasive games are effective tools to motivate behavior change, particularly to promote daily physical activities. On the one hand, studies have suggested that a one-size-fits-all approach does not work well for persuasive game design. On the other hand, player modeling and recommender systems are increasingly used for personalizing content. However, there are few existing studies on how to build comprehensive player models for personalizing gamified systems, recommending daily physical activities, or the long-term effectiveness of such gamified exercise-promoting systems. Objective: This paper aims to introduce a gamified, 24/7 fitness assistant system that provides personalized recommendations and generates gamified content targeted at individual users to bridge the aforementioned gaps. This research aims to investigate how to design gamified physical activity interventions to achieve long-term engagement. Methods: We proposed a comprehensive model for gamified fitness recommender systems that uses detailed and dynamic player modeling and wearable-based tracking to provide personalized game features and activity recommendations. Data were collected from 40 participants (23 men and 17 women) who participated in a long-term investigation on the effectiveness of our recommender system that gradually establishes and updates an individual player model (for each unique user) over a period of 60 days. Results: Our results showed the feasibility and effectiveness of the proposed system, particularly for generating personalized exercise recommendations using player modeling. There was a statistically significant difference among the 3 groups (full, personalized, and gamified) for overall motivation (F3,36=22.49; P<.001), satisfaction (F3,36=22.12; P<.001), and preference (F3,36=15.0; P<.001), suggesting that both gamification and personalization have positive effects on the levels of motivation, satisfaction, and preference. Furthermore, qualitative results revealed that a customized storyline was the most requested feature, followed by a multiplayer mode, more quality recommendations, a feature for setting and tracking fitness goals, and more location-based features. Conclusions: On the basis of these results and drawing from the gamer modeling literature, we conclude that personalizing recommendations using player modeling and gamification can improve participants’ engagement and motivation toward fitness activities over time. %M 33200994 %R 10.2196/19968 %U http://games.jmir.org/2020/4/e19968/ %U https://doi.org/10.2196/19968 %U http://www.ncbi.nlm.nih.gov/pubmed/33200994 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e21813 %T Relationship Between Children’s Enjoyment, User Experience Satisfaction, and Learning in a Serious Video Game for Nutrition Education: Empirical Pilot Study %A Espinosa-Curiel,Ismael Edrein %A Pozas-Bogarin,Edgar Efrén %A Martínez-Miranda,Juan %A Pérez-Espinosa,Humberto %+ 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 1295930 ext 28607, ecuriel@cicese.edu.mx %K Serious video games %K children %K enjoyment %K user experience %K satisfaction %K game-based learning %K nutrition %K serious game %K pilot study %D 2020 %7 17.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The design and use of serious video games for children have increased in recent years. To maximize the effects of these games, it is essential to understand the children’s experiences through playing. Previous studies identified that enjoyment and user experience satisfaction of the players are principal factors that can influence the success of serious video games and the learning of their players. However, research about the relationship between enjoyment and user experience satisfaction with learning in children 8 to 10 years old is sparse. Objective: We examined the relationship of enjoyment and user experience satisfaction with the learning of children aged 8 to 10 years while playing a serious video game for health, FoodRateMaster. This serious video game teaches children about the characteristics of healthy and unhealthy foods and how to identify them in their environment. Methods: Children aged 8 to 10 years were recruited from a primary school in Mexico. Participants completed 12 individual gaming sessions with FoodRateMaster in 6 weeks. A food knowledge questionnaire was administered before and after game play to assess the players’ food knowledge. In addition, after the gaming sessions, the children’s enjoyment and user experience satisfaction were evaluated using the EGameFlow questionnaire and the Game User Experience Satisfaction Scale (GUESS) questionnaire. Results: We found significant positive associations for children’s (n=60) posttest knowledge with enjoyment (r58=0.36, P=.005) and user experience satisfaction (r58=0.27, P=.04). The children’s posttest knowledge scores were also positively correlated with challenge (r58=0.38, P=.003), knowledge improvement (r58=0.38, P=.003), and goal clarity (r58=0.29, P=.02) EGameFlow subscales and with narrative (r58=0.35, P=.006), creative freedom (r58=0.26, P=.04), and visual esthetics (r58=0.32, P=.01) GUESS subscales. Regression analysis indicated that the EGameFlow (F7,52=2.74, P=.02, R2=0.27) and the GUESS (F8,51=2.20, P=.04, R2=0.26) ratings significantly predicted the children’s posttest knowledge scores. EGameFlow challenge (β=0.40, t52=2.17, P=.04) and knowledge improvement (β=0.29, t52=2.06, P=.04) subscales significantly contributed to predicting children’s learning. None of the GUESS subscales significantly contributed to predicting children’s learning. Conclusions: The findings of this study suggest that both enjoyment and user experience satisfaction for children aged 8 to 10 years were positively correlated with their learning and that were significant predictors of it. Challenge, knowledge improvement, narrative, creative freedom, and visual esthetics subscales correlated positively with children’s learning. In addition, challenge and knowledge improvement contributed to predicting their learning. These results are relevant to consider during the design stages of serious games developed for young children’s learning purposes. %M 32940609 %R 10.2196/21813 %U http://games.jmir.org/2020/3/e21813/ %U https://doi.org/10.2196/21813 %U http://www.ncbi.nlm.nih.gov/pubmed/32940609 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15967 %T Exploring Features of the Pervasive Game Pokémon GO That Enable Behavior Change: Qualitative Study %A Arjoranta,Jonne %A Kari,Tuomas %A Salo,Markus %+ University of Jyväskylä, FI-40014 University of Jyväskylä, Jyväskylä, Finland, 358 4080551, jonne.arjoranta@jyu.fi %K Pokémon GO %K digital gaming %K behavior change %K pervasive games %K augmented reality games %K location-based games %K exergames %K behavior change support system %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital gaming is one of the most popular forms of entertainment in the world. While prior literature concluded that digital games can enable changes in players’ behaviors, there is limited knowledge about different types of behavior changes and the game features driving them. Understanding behavior changes and the game features behind them is important because digital games can motivate players to change their behavior for the better (or worse). Objective: This study investigates the types of behavior changes and their underlying game features within the context of the popular pervasive game Pokémon GO. Methods: We collected data from 262 respondents with a critical incident technique (CIT) questionnaire. We analyzed the responses with applied thematic analysis with ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software. Results: We discovered 8 types of behavior changes and 13 game features relevant to those behavior changes. The behavior changes included added activity in life, enhancing routines, exploration, increased physical activity, strengthening social bonds, lowering social barriers, increased positive emotional expression and self-treatment. The game features included reaching a higher level, catching new Pokémon, evolving new Pokémon, visiting PokéStops, exploring PokéStops, hatching eggs, fighting in gyms, collaborative fighting, exploiting special events, finding specific Pokémon, using items, Pokémon theme, and game location tied to physical location. The behavior changes were connected to specific game features, with game location tied to physical location and catching new Pokémon being the most common and connected to all behavior changes. Conclusions: Our findings indicate that the surveyed players changed their behaviors while or after playing Pokémon GO. The respondents reported being more social, expressed more positive emotions, found more meaningfulness in their routines, and had increased motivation to explore their surroundings. %M 32449689 %R 10.2196/15967 %U http://games.jmir.org/2020/2/e15967/ %U https://doi.org/10.2196/15967 %U http://www.ncbi.nlm.nih.gov/pubmed/32449689 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 1 %P e16003 %T Learner Analysis to Inform the Design and Development of a Serious Game for Nongaming Female Emerging Health Care Preprofessionals: Qualitative Sample Study %A Glover,Kevin %A Bodzin,Alec %+ Lehigh University College of Education, Iacocca Hall, 111 Research Drive, Bethlehem, PA, 18015, United States, 1 2158202695, krg205@lehigh.edu %K games %K health care %K education %K females %K motivation %K instructional design %D 2020 %7 6.2.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Overall, 75% of health care practitioners are women, but half of all females do not play digital games of any kind. There is no consensus in the literature regarding optimal design elements to maximize the efficacy of serious games. To capitalize on the promise of serious games in health care education, it is important for instructional designers to understand the underlying learners’ values, attitudes, and beliefs that might motivate nongaming female health care preprofessional students to independently choose to persistently play serious games to mastery. Objective: Specifically, the aim of this study was to seek answers to 2 questions. First, what values, attitudes, and beliefs contribute to the nongaming behaviors of 12th-grade female emerging health care preprofessionals? Second, how do the values, attitudes, and beliefs of 12th-grade female emerging health care preprofessionals align with important design features of serious games? Methods: In this study, a learner analysis was conducted using semistructured interviews with 8 12th-grade college-bound female health science students to better understand learners’ values, attitudes, and beliefs to inform the design and development of a serious game. These interviewees represented a diverse subset of the female emerging health care preprofessionals who self-identified themselves as not playing games at all, not very often, or infrequently. Results: The findings suggest that the study participants exhibited a complex fusion of desire for both accomplishment and affiliation. The participants were all independent, competitive, and prosocial leaders. They thought strategically and consciously self-limited their leisure time to achieve personally meaningful long-term goals. They embraced overcoming expected failures and aimed to achieve relevant high-stakes wins in all academic, athletic, extracurricular, and leisure activities they valued while consciously avoiding what they considered to be non–goal-oriented activities. Conclusions: The results of this study reinforce the need for a robust learner analysis to identify the multifaceted behavioral characteristics of targeted learners before the design and development of serious games. The common characteristics of the 12th-grade female health science students in this study suggest that they will choose to invest their limited leisure time playing a personally meaningful, preprofessionally authentic serious game if the collective design elements are aligned with the students’ self-conceptualization of their present or future selves. %M 32027312 %R 10.2196/16003 %U https://games.jmir.org/2020/1/e16003 %U https://doi.org/10.2196/16003 %U http://www.ncbi.nlm.nih.gov/pubmed/32027312 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 4 %P e16031 %T Using Narrative Game Design to Increase Children’s Physical Activity: Exploratory Thematic Analysis %A Lu,Amy Shirong %A Green,Melanie C %A Thompson,Debbe %+ Health Technology Lab, College of Arts, Media, and Design, Bouvé College of Health Sciences, Northeastern University, 360 Huntington Ave, 212A Lake Hall, Boston, MA, United States, 1 617 373 7839, a.lu@northeastern.edu %K narrative %K physical activity %K active game %K children %K thematic analysis %D 2019 %7 21.11.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Physical activity is crucial for child obesity prevention and intervention. Narratives embedded in active games can increase children’s physical activity. Objective: Little is known about the narrative characteristics that would motivate children to exercise. We attempted to fill the gaps in understanding regarding narrative design for active video games. Methods: In this exploratory study, four animated narratives of different genres were professionally generated. Children (N=41) between the ages of 8 and 12 years were interviewed to identify their preferences. Sessions were digitally recorded, transcribed, and analyzed using exploratory thematic analysis. Results: Findings revealed that the children rated the dystopian science fiction story as their favorite across all weight, race, and gender groups. The physical activity-friendly narrative strategies included virtuous characters, extraordinary character actions, interesting plots, super powers, and engaging cliffhangers. Alternatively, information not related to physical activity, difficult-to-follow plot lines, passive protagonists, and repetitive narrative tropes were less appealing for physical activity. Conclusions: This research provides preliminary evidence that narratives have characteristics that may increase child physical activity when playing active games. Future empirical studies should verify and test these design principles. %M 31750833 %R 10.2196/16031 %U http://games.jmir.org/2019/4/e16031/ %U https://doi.org/10.2196/16031 %U http://www.ncbi.nlm.nih.gov/pubmed/31750833