%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66793 %T Smartwatch-Based Tailored Gamification and User Modeling for Motivating Physical Exercise: Experimental Study With the Maximum Difference Scaling Segmentation Method %A Yao,Jie %A Song,Di %A Xiao,Tao %A Zhao,Jiali %+ School of Economics and Management, Harbin Institute of Technology (Shenzhen), Nanshan District Xili University Town, Shenzhen, 518055, China, 86 0755 26033876, yaojiejulie@hit.edu.cn %K tailored gamification %K user segmentation %K maximum difference scaling %K MaxDiff %K smartwatch %K physical exercise %D 2025 %7 18.4.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smartwatch-based gamification holds great promise for enhancing fitness apps and promoting physical exercise; however, empirical evidence on its effectiveness remains inconclusive, partly due to “one-size-fits-all” design approaches that overlook individual differences. While the emerging research area of tailored gamification calls for more accurate user modeling and better customization of game elements, existing studies have relied primarily on rating scale–based measures and correlational analyses with methodological limitations. Objective: This study aimed to improve smartwatch-based gamification through an innovative user modeling approach to better motivate physical exercise among different user groups with tailored solutions. It incorporated both individual preferences and needs for game elements into the user segmentation process and used the maximum difference scaling (MaxDiff) technique, which can overcome the limitations of traditional methods. Methods: With data collected from 2 MaxDiff experiments involving 378 smartwatch users and latent class statistical models, the relative power of each of the 16 popular game elements was examined in terms of what users liked and what motivated them to exercise based on which distinct user segments were identified. Prediction models were also proposed for quickly classifying future users into the right segments to provide them with tailored gamification solutions on smartwatch fitness apps. Results: We identified 3 segments of smartwatch users based on their preferences for gamification. More importantly, we uncovered 4 segments motivated by goals, immersive experiences, rewards, or social comparison. Such user heterogeneity confirmed the susceptibility of the effects of gamification and indicated the necessity of accurately matching gamified solutions with user characteristics to better change health behaviors through different mechanisms for different targets. Important differences were also observed between the 2 sets of user segments (ie, those based on preferences for game elements vs those based on the motivational effects of the elements), indicating the gap between what people enjoy using on smartwatches and what can motivate them for physical exercise engagement. Conclusions: To our knowledge, this study is the first to investigate MaxDiff-based user segmentation for tailored gamification on smartwatches promoting physical exercise and contributes to a detailed understanding of preferences for, and the effectiveness of, different game elements among different groups of smartwatch users. As existing tailored gamification studies continue to explore ways of user modeling with mostly surveys and questionnaires, this study supported the adoption of MaxDiff experiments as an alternative method to better capture user heterogeneity in the health domain and inform the design of tailored solutions for more application types beyond smartphones. %M 40067118 %R 10.2196/66793 %U https://games.jmir.org/2025/1/e66793 %U https://doi.org/10.2196/66793 %U http://www.ncbi.nlm.nih.gov/pubmed/40067118 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e62778 %T Playful Antisedentary Interactions for Online Meeting Scenarios: A Research Through Design Approach %A Jiang,Jiaqi %A Li,Shanghao %A Li,Xian %A Xu,Yingxin %A Zhao,Jian %A An,Pengcheng %+ School of Design, Southern University of Science and Technology, No. 1088 Xueyuan Avenue, Nanshan District, Shenzhen, Guangdong, 518055, China, 86 13166272076, anpengcheng88@gmail.com %K gamification %K sedentary behavior %K videoconferencing %K exertion games %K embodied interaction %K design research %D 2025 %7 18.4.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Online meetings have become an integral part of daily life for many people. However, prolonged periods of sitting still in front of screens can lead to significant, long-term health risks. While previous studies have explored various interventions to address sedentary lifestyles, few have specifically focused on mitigating sedentary behavior during online meetings. Furthermore, design opportunities to address this issue in the context of online meetings remain underexplored. Objective: This study aims to investigate the design of effective antisedentary interactions for online meeting scenarios and understand user experiences with gamified bodily interactions as an antisedentary measure during online meetings. Methods: This study adopts a “research through design” approach to develop and explore user experiences of gamified bodily interactions as interventions to mitigate sedentary behavior during online meetings. In collaboration with 11 users, we co-designed and iterated 3 prototypes, which led to the development of the Bodily Interaction Gamification towards Anti-sedentary Online Meeting Environments (BIG-AOME) framework. Using these prototypes, we conducted user studies with 3 groups totaling 15 participants. During co-design and evaluation, all group semistructured interviews were transcribed into written format and analyzed using a conventional qualitative content analysis method. Results: The findings demonstrate that gamified bodily interactions encourage users to engage in physical movement while reducing the awkwardness of doing so during online meetings. Seamless integration with meeting software and the inclusion of long-term reward mechanisms can further contribute to sustained use. In addition, such games can serve as online icebreakers or playful tools for decision-making. Drawing from 3 design prototypes, this study offers a comprehensive analysis of each design dimension within the BIG-AOME framework: bodily engagement, attention, bodily interplay, timeliness, and virtual and physical environments. Conclusions: Our research findings indicate that antisedentary bodily interactions designed for online meetings have the potential to mitigate sedentary behaviors while enhancing social connections. Furthermore, the BIG-AOME framework that we propose explores the design space for antisedentary physical interactions in the context of online meetings, detailing pertinent design choices and considerations. %M 40249120 %R 10.2196/62778 %U https://games.jmir.org/2025/1/e62778 %U https://doi.org/10.2196/62778 %U http://www.ncbi.nlm.nih.gov/pubmed/40249120 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e69242 %T Evaluation of a Curriculum-Based Nutrition Education Intervention Protocol in Elementary Schools: Nonrandomized Feasibility Study %A Brown,Jacqueline Marie %A Rita,Nicholas %A Franco-Arellano,Beatriz %A LeSage,Ann %A Arcand,Joanne %K nutrition education %K serious games %K children %K food literacy %K school nutrition intervention %K feasibility %D 2025 %7 16.4.2025 %9 %J JMIR Form Res %G English %X Background: Improving children’s food literacy through school-based interventions can support developing healthy eating habits. However, teachers lack appropriate resources, time, and training to provide nutrition education in schools. Serious games, which are games designed for a purpose other than entertainment, have been demonstrated to improve children’s food literacy and dietary intake and can address the barriers teachers face in providing nutrition education. Foodbot Factory (Arcand Lab) is a nutrition education intervention that is aligned with curricula and uses a serious game to provide nutrition education to students. Further evidence is needed to understand how serious games, including Foodbot Factory, can be researched in schools to support nutrition education. Objective: The objective of this study was to evaluate the feasibility of a research study protocol that implements the curriculum-based nutrition education intervention Foodbot Factory into a real-world classroom setting. The evaluation of the protocol included study processes, resources, and management feasibility outcomes, as well as a preliminary assessment of scientific outcomes relevant to the intervention. Methods: A nonrandomized study determined the feasibility of intervention implementation. Grade 4 and 4/5 classrooms were assigned to have nutrition education lessons for 5 days with either the Foodbot Factory or a control intervention. Outcomes were assessed in 4 feasibility domains of study processes (eg, recruitment and attrition rates), resources (eg, time taken to deliver the intervention), and management (eg, challenges with intervention delivery), and a preliminary assessment of scientific outcomes pertaining to the acceptability and impacts of the interventions. These outcomes were captured in semistructured field notes completed by study staff and a Nutrition Attitudes and Knowledge questionnaire and acceptability questionnaire completed by participants. Data were analyzed descriptively and using a paired t test to assess within-group changes in nutrition knowledge. Results: In total, 4 classrooms participated in the feasibility study, with varying recruitment rates for schools (3/20, 15%), classrooms (4/4, 100%), parents (54/102, 53%), and children (49/54, 91%). The time required to implement the research protocol, including data collection and lesson plans, was sufficient and management of the intervention implementation was overall successful. Some challenges were experienced with classroom management during data collection, specifically with electronic data collection. After the intervention, participants reported a positive affective experience (26/41, 63%) and learning something new about healthy eating (31/41, 76%). Participants in both study groups improved their nutrition knowledge, but the changes were not statistically significant. The Foodbot Factory group had a statistically significant improvement in their knowledge of vegetables and fruit (P=.04) and protein foods (P=.03). Conclusions: These findings indicate that the study protocol is feasible to implement and evaluate Foodbot Factory in a representative sample with select modifications to improve recruitment and data collection procedures. %R 10.2196/69242 %U https://formative.jmir.org/2025/1/e69242 %U https://doi.org/10.2196/69242 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50992 %T Electrophysiological Insights in Exergaming—Electroencephalography Data Recording and Movement Artifact Detection: Systematic Review %A Rico-Olarte,Carolina %A Lopez,Diego M %A Eskofier,Bjoern M %A Becker,Linda %+ Machine Learning and Data Analytics Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Carl-Thiersch-Straße 2b, Erlangen, 91052, Germany, 49 9131 85 28990, carolinarico@unicauca.edu.co %K exergaming %K EEG %K brain activity %K motion artifact %K artifact removal %D 2025 %7 7.4.2025 %9 Review %J JMIR Serious Games %G English %X Background: Exergames are interactive solutions that require physical activity and are commonly used in learning or rehabilitation settings. For cognitive rehabilitation with exergames, the assessment of the intervention progress can be conducted by verifying the changes in brain activity. Electroencephalography (EEG) is a well-known method for this evaluation. However, motion artifacts due to large body movements can impede signal quality. No comprehensive guide on the artifact removal methods in the context of exergaming has been found. Objective: This paper aimed to identify studies that have assessed EEG signals while a user interacts with an exergame and the applied methods for data handling and analysis with a focus on dealing with movement artifacts. Methods: This review included studies on human participants while engaging in exergames, where the primary outcome was brain activity measured by EEG. A total of 5 databases were searched at 3 time points: March 2021, October 2022, and February 2024. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies assessed methodological quality, rating studies as “good,” “fair,” or “poor.” Data were synthesized quantitatively to identify characteristics across studies, including sample demographics and intervention details, and basic statistics (mean [SD]) were calculated. Results: A total of 494 papers were screened, resulting in 17 studies having been included. All studies carried out EEG recordings during exergame interactions, primarily assessing attention and concentration, with the alpha wave being the most analyzed EEG band. Common motion artifact removal methods included visual inspection and independent component analysis. The review identified significant risks of bias, with 2 studies rated as “good,” 7 as “fair,” and 8 as “poor.” Due to the small number of studies and their heterogeneity, a meta-analysis was not feasible. Conclusions: The study successfully identifies the feasibility of recording electrophysiological brain activity during exergaming and provides insights into EEG devices, analysis methods, and exergaming systems used in previous studies. However, limitations, such as the lack of sufficient detail on motion artifact removal and a focus on short-term effects, underscore the need for improved methodologies and reporting standards, with recommendations for enhancing reliability in cognitive rehabilitation with exergames. %M 40194274 %R 10.2196/50992 %U https://games.jmir.org/2025/1/e50992 %U https://doi.org/10.2196/50992 %U http://www.ncbi.nlm.nih.gov/pubmed/40194274 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e71326 %T Assessing the Noninferiority of a Rhythm and Language Training Serious Game Combined With Speech Therapy Versus Speech Therapy Care for Children With Dyslexia: Protocol for an Investigator-Blinded Randomized Controlled Trial %A Grossard,Charline %A Descamps,Mélanie %A Cadoni,Sara %A Pellerin,Hugues %A Vonthron,François %A Xavier,Jean %A Falissard,Bruno %A Cohen,David %+ Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'hôpital, Paris, 75013, France, 33 142162383, charline.grossard@aphp.fr %K dyslexia %K serious game %K rhythm %K randomized controlled trial %K non-inferiority protocol %D 2025 %7 3.4.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Specific learning disorder (SLD) of reading skills impacts approximately 7% of children. Speech and reading therapy is currently the gold-standard intervention for improving children’s reading abilities. However, intensive interventions are difficult to implement. Recently, numerous studies have investigated the interest of game- and home-based training approaches to enhance children’s motivation and facilitate intensive learning activities in home settings. The serious game Poppins Clinical integrates rhythm and specific written language exercises to improve reading skills in children with SLD. Objective: This study aimed to assess the noninferiority of Poppins Clinical combined with a reading specialist session once every 2 weeks versus a reading specialist session every week, on the reading skills of children with SLD. Methods: A total of 306 children with dyslexia will be recruited for this study and randomly assigned to either the experimental or control group. Children in the experimental group will use the serious game Poppins Clinical at home for 20 minutes, 5 days a week, and attend 1 reading therapy session every 2 weeks. The control group will participate in one reading therapy session per week. Poppins Clinical combines rhythm and language exercises integrated into an engaging game designed to maintain user motivation. We will use a noninferiority paradigm to assess the clinical impact of both interventions in terms of reading accuracy, reading speed, and reading comprehension. We will also investigate the evolution of phonological and visual-attentional skills. However, we will explore the impact of the protocol on parental stress and children’s perception of their difficulties. Finally, we will also assess the cost of medical care and the impact of introducing the serious game Poppins Clinical on reading therapy. To facilitate recruitment and ensure the representativeness of our sample, the evaluation of the children will be conducted via videoconference using standardized tests that have been adapted for videoconference administration. Results: Patient recruitment is expected to start in December 2024, with study completion by the end of August 2025. Conclusions: This study should allow us to assess the interest in using the serious game Poppins Clinical in addition to reading therapy to improve reading abilities in children with SLD. Trial Registration: ClinicalTrials.gov NCT06592911; https://clinicaltrials.gov/study/NCT06592911 International Registered Report Identifier (IRRID): DERR1-10.2196/71326 %M 40179385 %R 10.2196/71326 %U https://www.researchprotocols.org/2025/1/e71326 %U https://doi.org/10.2196/71326 %U http://www.ncbi.nlm.nih.gov/pubmed/40179385 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e72354 %T Is the Pinball Machine a Blind Spot in Serious Games Research? %A Eckardt,Jens Peter %K serious games %K research %K interventions %K arcade technology %K digital game paradigm %K pinball gaming %K arcade gaming %K executive functions %K neurodiversity %K cognitive training %K therapeutic interventions %D 2025 %7 2.4.2025 %9 %J JMIR Serious Games %G English %X %R 10.2196/72354 %U https://games.jmir.org/2025/1/e72354 %U https://doi.org/10.2196/72354 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e73034 %T Authors’ Reply: Is the Pinball Machine a Blind Spot in Serious Games Research? %A Rodríguez Timaná,Luis Carlos %A Castillo García,Javier Ferney %A Bastos Filho,Teodiano %A Ocampo González,Alvaro Alexander %A Hincapié Monsalve,Nazly Rocio %A Valencia Jimenez,Nicolas Jacobo %K serious games %K research %K interventions %K arcade technology %K digital game paradigm %K pinball gaming %K arcade gaming %K executive functions %K neurodiversity %K cognitive training %K therapeutic interventions %D 2025 %7 2.4.2025 %9 %J JMIR Serious Games %G English %X %R 10.2196/73034 %U https://games.jmir.org/2025/1/e73034 %U https://doi.org/10.2196/73034 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66167 %T Digital Ergonomics of NavegApp, a Novel Serious Game for Spatial Cognition Assessment: Content Validity and Usability Study %A Sanchez-Escudero,Juan Pablo %A Aguillon,David %A Valencia,Stella %A Garcia-Barrera,Mauricio A %A Aguirre-Acevedo,Daniel Camilo %A Trujillo,Natalia %+ Group of Epidemiology, Universidad de Antioquia, Calle 70 No. 52-21, Medellín, Colombia, 57 6042198332, juanp.sanchez@udea.edu.co %K serious games %K spatial cognition %K digital neuropsychology %K Alzheimer disease %K content validity %K usability %D 2025 %7 2.4.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Alzheimer disease (AD) is the leading cause of dementia worldwide. With aging populations and limited access to effective treatments, there is an urgent need for innovative markers to support timely preventive interventions. Emerging evidence highlights spatial cognition (SC) as a valuable source of cognitive markers for AD. This study presents NavegApp, a serious game (SG) designed to assess 3 key components of SC, which show potential as cognitive markers for the early detection of AD. Objective: This study aimed to determine the content validity and usability perception of NavegApp across multiple groups of interest. Methods: A multistep process integrating methodologies from software engineering, psychometrics, and health measurement was implemented to validate the software. Our approach was structured into 3 stages, guided by the software life cycle for health and the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations for evaluating the psychometric quality of health instruments. To assess content validity, a panel of 8 experts evaluated the relevance and representativeness of tasks included in the app. In addition, 212 participants, categorized into 5 groups based on their clinical status and risk level for AD, were recruited to evaluate the app’s digital ergonomics and usability at various stages of development. Complementary analyses were performed to identify group differences and to explore the association between task difficulty and user agreeableness. Results: NavegApp was validated as a highly usable tool by both experts and users. The expert panel confirmed that the tasks included in the game were representative (Aiken V=0.96-1.00) and relevant (Aiken V=0.96-1.00) for measuring SC components. Both experts and nonexperts rated NavegApp’s digital ergonomics positively, with minimal differences between groups (rrb 0.08-0.29). Differences in usability perceptions were observed among participants with sporadic mild cognitive impairment compared to cognitively healthy individuals (rrb 0.26-0.29). A moderate association was also identified between task difficulty and user agreeableness (Cramér V=0.37, 95% CI 0.28-0.54). Conclusions: NavegApp is a valid and user-friendly SG designed for SC assessment, developed by integrating software engineering and psychometric evaluation methodologies. While the results are promising, further studies are warranted to evaluate its diagnostic accuracy and construct validity. This work outlines a comprehensive framework for SG development in cognitive assessment, emphasizing the importance of incorporating psychometric validity measures from the outset of the design process. %M 40173437 %R 10.2196/66167 %U https://games.jmir.org/2025/1/e66167 %U https://doi.org/10.2196/66167 %U http://www.ncbi.nlm.nih.gov/pubmed/40173437 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66593 %T Physical Activity and Enjoyment in Active Virtual Reality Games in Youth: Comparative Analysis of Gorilla Tag and Beat Saber %A Boots,Brenden %A Berg,Daniel %A Hewitt,Easton %A Naugle,Keith %A Naugle,Kelly %K active gaming %K movement %K Gorilla Tag %K Beat Saber %K virtual reality %K VR %K physical activity %K youth %K early adolescents %K young adults %K gaming %K heart rate %K exergame %K enjoyment %D 2025 %7 1.4.2025 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) active gaming is growing in popularity, but little is known about physical activity during gameplay. Two popular VR games are Gorilla Tag (Another Axiom Inc) and Beat Saber (Beat Games). Little is known about physical activity during these games in youth. Objective: The purpose of this study was to investigate the enjoyment, intensity, and amount of physical activity while playing Gorilla Tag and Beat Saber in early adolescent youth. Methods: Sixteen participants, 13 males and 3 females with an average age of 10.7 (SD 0.34) years, played 2 VR games (Gorilla Tag and Beat Saber) in a single session. Both games followed the same procedure: a maximum of 10-minute familiarization period, 5 minutes of rest, 15 minutes of gameplay, and 10 minutes of rest. Participants wore a heart rate monitor to track heart rate reserve (%HRR) and accelerometers on the wrist and waist to monitor time in sedentary activity, light physical activity, and moderate to vigorous physical activity of the arm and whole body. The Physical Activity Enjoyment Scale–Child Version (PACES) and ratings of perceived exertion (RPE) were completed after each game. Dependent t tests compared measures between games. Results: The results revealed that average and maximum %HRR were significantly higher during Gorilla Tag than during Beat Saber, with heart rate–based physical activity intensity reaching light for Beat Saber and moderate for Gorilla Tag. Arm moderate to vigorous physical activity and whole-body moderate to vigorous physical activity and light physical activity were greater during Gorilla Tag than during Beat Saber. Arm and whole-body sedentary time were significantly lower during Gorilla Tag than during Beat Saber. Gorilla Tag and Beat Saber were rated as highly enjoyable. There were no differences between games for maximum (P=.352) or average (P=.362) RPE. Both games were rated as light intensity for average RPE (Gorilla Tag: mean 4.3, SD 1.9; Beat Saber: mean 4.7, SD 2.3) and moderate intensity for maximum RPE (Gorilla Tag: mean 5.4, SD 1.9; Beat Saber: mean 5.8, SD 2.4). Conclusions: These results suggest that Beat Saber produced light-intensity physical activity and Gorilla Tag produced light- to moderate-intensity physical activity in early adolescent youth, with both games rated as highly enjoyable. %R 10.2196/66593 %U https://games.jmir.org/2025/1/e66593 %U https://doi.org/10.2196/66593 %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 %@ 2369-2529 %I JMIR Publications %V 12 %N %P e64729 %T Home-Based Nonimmersive Virtual Reality Training After Discharge From Inpatient or Outpatient Stroke Rehabilitation: Parallel Feasibility Randomized Controlled Trial %A Sheehy,Lisa %A Taillon-Hobson,Anne %A Sveistrup,Heidi %A Bilodeau,Martin %A Yang,Christine %A Welch,Vivian %A Finestone,Hillel %+ , Bruyère Health Research Institute, 43 Bruyère St, Ottawa, ON, K1N5C8, Canada, 1 613 562 6262 ext 1593, lsheehy@bruyere.org %K virtual reality %K telerehabilitation %K stroke %K home %K exercises %K physical activity %K physiotherapy %K exergames %K rehabilitation intensity %K randomized controlled feasibility trial %K motor %K movement %K patient care %K patient engagement %K health intervention %K stroke rehabilitation %K interactive games %K game therapy %K interactive therapy %K rehabilitation %D 2025 %7 28.3.2025 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Nonimmersive virtual reality training (NIVRT) can be used to continue rehabilitative exercise for stroke recovery at home after discharge from inpatient or outpatient therapy. Objective: The objectives of this randomized controlled feasibility trial were to assess home-based NIVRT as telerehabilitation with patients living with stroke, and its potential to improve standing function and gait. Methods: Patients approaching discharge from inpatient or outpatient stroke rehabilitation were randomly allocated to NIVRT or iPad interventions. NIVRT provided interactive games and exercises designed to improve balance, stepping, and aerobic capacity. iPad apps addressed cognition and fine motor skills. Participants were visited in their homes by a physiotherapist, taught to use the program, and asked to do 30 minutes of exercise 5 days a week for 6 weeks, asynchronously. Feasibility was assessed by measuring recruitment, adherence, ability to set up and learn NIVRT, enjoyment, intent to continue, perception of impact, and safety. Participants completed assessments of standing balance, gait, and general function, before and after the intervention, by a blinded assessor. Results: NIVRT participants (n=11; 10 male participants; mean age 64, SD 12 years) did an average of 26 sessions (total 700 minutes), while iPad participants (n=9; 6 male participants; mean age 61, SD 20 years) did an average of 33 sessions (total 1241 minutes). Space was tight in 5 homes. All but 1 participant learned NIVRT and progressed. Most enjoyed it and felt that it improved their recovery. There were no serious adverse events. Most assessments showed improvement over time for both groups. Conclusions: Home-based NIVRT is safe and feasible to continue rehabilitative exercise after discharge. More research on efficacy and effectiveness in this population is required. Trial Registration: ClinicalTrials.gov NCT03261713; https://clinicaltrials.gov/study/NCT03261713 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3438-9 %M 40153779 %R 10.2196/64729 %U https://rehab.jmir.org/2025/1/e64729 %U https://doi.org/10.2196/64729 %U http://www.ncbi.nlm.nih.gov/pubmed/40153779 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e72565 %T Authors’ Reply: Addressing the Digital Divide Among the Older Population Presents a Substantial Challenge %A Kannan,Lakshmi %A Bhatt,Tanvi %+ Department of Physical Therapy, University of Illinois Chicago, 1919 W Taylor Street, Room 415, Chicago, IL, 60612, United States, 1 3123554443, tbhatt6@uic.edu %K exergame training %K Matter of Balance %K MOB %K pre-frail %K tele-exergame %K tele-rehabilitation %K gaming-based %K tele-exercise %K physical function %K frailty %K older adults %K aging %K physical activity %K dementia %K CogXergaming %K telehealth %K dynamic balance %D 2025 %7 28.3.2025 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 40153783 %R 10.2196/72565 %U https://www.jmir.org/2025/1/e72565 %U https://doi.org/10.2196/72565 %U http://www.ncbi.nlm.nih.gov/pubmed/40153783 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69482 %T Addressing the Digital Divide Among the Older Population Presents a Substantial Challenge %A Xie,Su-hang %+ Department of Rehabilitation Medicine, The First Medical Center of PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, Beijing, 100853, China, 86 13041075258, hxkfxsh@163.com %K exergame training %K Matter of Balance %K MOB %K pre-frail %K tele-exergame %K tele-rehabilitation %K gaming-based %K tele-exercise %K physical function %K frailty %K older adults %K aging %K physical activity %K dementia %K CogXergaming %K telehealth %K dynamic balance %D 2025 %7 28.3.2025 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 40153778 %R 10.2196/69482 %U https://www.jmir.org/2025/1/e69482 %U https://doi.org/10.2196/69482 %U http://www.ncbi.nlm.nih.gov/pubmed/40153778 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65498 %T Feasibility and Usability of an Artificial Intelligence—Powered Gamification Intervention for Enhancing Physical Activity Among College Students: Quasi-Experimental Study %A Gao,Yanan %A Zhang,Jinxi %A He,Zhonghui %A Zhou,Zhixiong %K physical activity %K gamification %K artificial intelligence %K digital health %K digital intervention %K feasibility study %D 2025 %7 24.3.2025 %9 %J JMIR Serious Games %G English %X Background: Physical activity (PA) is vital for physical and mental health, but many college students fail to meet recommended levels. Artificial intelligence (AI)-powered gamification interventions through mobile app have the potential to improve PA levels among Chinese college students. Objective: This study aimed to assess the feasibility and usability of an AI-powered gamification intervention. Methods: A quasi-experimental study spanning 2 months was conducted on a sample of college students aged 18 to 25 years old from 18 universities in Beijing. PA data were recorded using the ShouTi Fitness app, and participant engagement was evaluated through surveys. User satisfaction was gauged through the System Usability Scale, while the intervention’s feasibility was assessed through Spearman rank correlation analysis, Mann-Whitney tests, and additional descriptive analyses. Results: As of July 2023, we enrolled 456 college students. In total, 18,073 PA sessions were recorded, with men completing 8068 sessions and women completing 10,055 sessions. The average PA intensity was 7 metabolic equivalent of energy (MET)s per session. Most participants preferred afternoon sessions and favored short-duration sessions, with men averaging 66 seconds per session and women 42 seconds. The System Usability Scale score for the intervention based on app is 65.2. Users responded positively to the integration of AI and gamification elements, including personalized recommendations, action recognition, smart grouping, dynamic management, collaborative, and competition. Specifically, 341 users (75%) found the AI features very interesting, 365 (80%) were motivated by the gamification elements, 364 (80%) reported that the intervention supported their fitness goals, and 365 (80%) considered the intervention reliable. A significant positive correlation was observed between the duration of individual PA and intervention duration for men (ρ=0.510, P<.001), although the correlation was weaker for women (ρ=0.258, P=.046). However, the frequency of PA declined after 35 days. Conclusions: This study provides pioneering evidence of the feasibility and usability of the AI-powered gamification intervention. While adherence was successfully demonstrated, further studies or interventions are needed to directly assess the impact on PA levels and focus on optimizing long-term adherence strategies and evaluating health outcomes. %R 10.2196/65498 %U https://games.jmir.org/2025/1/e65498 %U https://doi.org/10.2196/65498 %0 Journal Article %@ 2817-092X %I JMIR Publications %V 4 %N %P e67779 %T A Game-Based Mechatronic Device for Digital Rehabilitation of Hand Function After a Stroke: Design, Prototyping, and Feasibility Study %A Kanitkar,Anuprita %A Sepehri,Nariman %A Lezen,Ariel %A Parmar,Sanjay Tejraj %A Hin,Cherry Kit-Fong %A Szturm,Tony Joseph %K stroke %K manual dexterity %K hand function %K poststroke %K fine motor %K thumb %K finger %K wrist %K movement %K motor rehabilitation %K assistive technology %K smart monitoring %K pilot %K feasibility %K prototyping %K prototype %K nervous system %K nerve %K motor neuron %D 2025 %7 19.3.2025 %9 %J JMIR Neurotech %G English %X Background: This paper presents an easy-to-use, affordable robotic manipulandum device (RMD) equipped with smart monitoring and assistive technologies to engage in game-based exercise and repetitive task practice. The RMD has been designed to enhance a wide range of fine motor manual dexterity skills, including thumb, finger, and wrist movements. By focusing on finger and hand functions, it extends its utility beyond basic reaching or object transfer movements. Various interchangeable 3D-printed therapy handles of different shapes and sizes can be easily attached to the RMD drive shaft. These handle movements can be used to engage with numerous affordable, commercially available computer games, allowing patients to practice tasks that involve varying movement amplitudes, speeds, precision, and cognitive challenges. Additionally, the device is capable of automatically recording and storing the patient’s real-time performance data on any given computer, integrating assessment into treatment. Objective: A pilot study was conducted with 5 patients with stroke to examine the feasibility and benefits of a 6-week game-based exercise program using the proposed device. Methods: A feasibility study was conducted with 5 participants. Data were collected using the computer game–based upper extremity assessment of manual dexterity and Wolf Motor Function Test (WMFT) before and after the intervention lasting 6 weeks. Results: The pilot study demonstrated that clients’ expectations related to manual dexterity were met. The average improvement in the functional ability score of the WMFT was 14 (SD 3) points, with all participants exceeding the minimal clinically important difference. The average reduction in total time was 30 (SD 14) seconds, with 4 of 5 participants surpassing the minimal clinically important difference. For the computer game–based upper extremity assessment, the average improvement in success rate was 23% (SD 12%), and the average decrease in response time was 105 (SD 44) milliseconds. Conclusions: Findings revealed acceptable, engaging, game-based, and task-oriented training with a high level of compliance. Substantial improvements from pre- to postintervention were observed using the WMFT and assessments of manual dexterity. Trial Registration: ClinicalTrials.gov NCT05071885; https://clinicaltrials.gov/study/NCT05071885 %R 10.2196/67779 %U https://neuro.jmir.org/2025/1/e67779 %U https://doi.org/10.2196/67779 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67007 %T Comparative Efficacy of Video Games Versus Midazolam in Reducing Perioperative Anxiety in Pediatric Patients: Systematic Review and Meta-Analysis %A Luo,Ziyue %A Deng,Sisi %A Zhou,Ruihao %A Ye,Ling %A Zhu,Tao %A Chen,Guo %K video games %K midazolam %K perioperative period %K anxiety %K meta-analysis %K pediatric patients %D 2025 %7 10.3.2025 %9 %J JMIR Serious Games %G English %X Background: Pediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions such as oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant adverse effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain. Objective: This study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia. Methods: We conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium, postoperative behavior, and length of stay in the postanesthesia care unit (PACU). The risk of bias was assessed using the Risk of Bias 2 scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Results: Six randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference, SMD −0.31, 95% CI −0.50 to −0.12; P=.001), with high certainty, and during mask induction (SMD −0.29, 95% CI −0.52 to −0.05; P=.02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD −0.35, 95% CI −0.62 to −0.09; P=.008). Children in the video game intervention groups also had a shorter length of stay in the PACU (mean difference, MD −19.43 min, 95% CI −31.71 to −7.16; P=.002). However, no significant differences were found in emergence delirium (MD −2.01, 95% CI −4.62 to 0.59; P=.13). Conclusions: Video game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening the length of stay in the PACU. However, video games alone did not outperform midazolam in managing emergence delirium. Further high-quality research is needed for more conclusive results. Trial Registration: PROSPERO CRD42023486085; https://tinyurl.com/yc3suavb %R 10.2196/67007 %U https://games.jmir.org/2025/1/e67007 %U https://doi.org/10.2196/67007 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e56978 %T Gamified Adaptive Approach Bias Modification in Individuals With Methamphetamine Use History From Communities in Sichuan: Pilot Randomized Controlled Trial %A Shen,Danlin %A Jiao,Jianping %A Zhang,Liqun %A Liu,Yanru %A Liu,Xiang %A Li,Yuanhui %A Zhang,Tianjiao %A Li,Dai %A Hao,Wei %K digital therapeutics %K substance use disorder %K game %K pilot RCT %K randomized controlled trial %K methamphetamine %K psychiatric %K gamified design %K engagement %K effectiveness %K smartphone app %K cognitive bias modification %D 2025 %7 10.3.2025 %9 %J JMIR Serious Games %G English %X Background: Cognitive bias modification (CBM) programs have shown promise in treating psychiatric conditions, but they can be perceived as boring and repetitive. Incorporating gamified designs and adaptive algorithms in CBM training may address this issue and enhance engagement and effectiveness. Objectives: This study aims to gather preliminary data and assess the preliminary efficacy of an adaptive approach bias modification (A-ApBM) paradigm in reducing cue-induced craving in individuals with methamphetamine use history. Methods: A randomized controlled trial with 3 arms was conducted. Individuals aged 18‐60 years with methamphetamine dependence and at least 1 year of methamphetamine use were recruited from 12 community-based rehabilitation centers in Sichuan, China. Individuals with the inability to fluently operate a smartphone and the presence of mental health conditions other than methamphetamine use disorder were excluded. The A-ApBM group engaged in ApBM training using a smartphone app for 4 weeks. The A-ApBM used an adaptive algorithm to dynamically adjust the difficulty level based on individual performance. Cue-induced craving scores and relapses were assessed using a visual analogue scale at baseline, postintervention, and at week-16 follow-up. Results: A total of 136 participants were recruited and randomized: 48 were randomized to the A-ApBM group, 48 were randomized to the static approach bias modification (S-ApBM) group, and 40 were randomized to the no-intervention control group. The A-ApBM group showed a significant reduction in cue-induced craving scores at postintervention compared with baseline (Cohen d=0.34; P<.01; 95% CI 0.03-0.54). The reduction remained significant at the week-16 follow-up (Cohen d=0.40; P=.01; 95% CI 0.18-0.57). No significant changes were observed in the S-ApBM and control groups. Conclusions: The A-ApBM paradigm with gamified designs and dynamic difficulty adjustments may be an effective intervention for reducing cue-induced craving in individuals with methamphetamine use history. This approach improves engagement and personalization, potentially enhancing the effectiveness of CBM programs. Further research is needed to validate these findings and explore the application of A-ApBM in other psychiatric conditions. Trial Registration: ClinicalTrials.gov NCT05794438; https://clinicaltrials.gov/study/NCT05794438 %R 10.2196/56978 %U https://games.jmir.org/2025/1/e56978 %U https://doi.org/10.2196/56978 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65562 %T Effects of a Session of Exergames and Traditional Games on Inhibitory Control in Children With Autism Spectrum Disorder: Randomized Controlled Crossover Trial %A Miranda,Juliana Macedo %A Browne,Rodrigo Alberto Vieira %A da Silva,Weslley Quirino Alves %A Rodrigues dos Santos,João Paulo %A Campbell,Carmen Silvia Grubert %A Ramos,Isabela Almeida %K children %K pediatric %K autism %K ASD, autistic %K behavior %K exergame %K physical education %K exercise %K physical activity %K cognition %K anthropometric %K Flanker test %K inhibitory control %K randomized control trial %K crossover %D 2025 %7 5.3.2025 %9 %J JMIR Serious Games %G English %X Background: Autism spectrum disorder (ASD) is characterized by deficits in executive functions, such as inhibitory control, which affect behavior and social adaptation. Although physical activity–based interventions, such as exergames, have shown potential to improve these functions, their comparative effects with active traditional games remain underexplored, particularly regarding inhibitory control in children with ASD. Objective: We aim to analyze the effects of a session of exergames and active traditional games on inhibitory control in children with ASD. Methods: This randomized controlled crossover trial included 9 male children with ASD (mean age 8.6, SD 1.4 y). Participants completed three 20-minute experimental sessions in random order, with a minimum interval of 48 hours: (1) active traditional games, (2) exergames using Just Dance 2022, and (3) a control session with manual painting activities. Inhibitory control was assessed 5 minutes postsession using a modified flanker task in the E-Prime (version 3.0; Psychological Software Tools Inc) program, recording reaction time (RT) and accuracy in congruent and incongruent phases. Repeated measures ANOVA was used to compare RT and accuracy between experimental and control conditions. Data are presented as means and 95% CIs. Results: There was a statistically significant effect of condition on RT in the incongruent phase (P=.02). RT in the exergame session (849 ms, 95% CI 642 to 1057) was lower compared to the traditional games (938 ms, 95% CI 684 to 1191; P=.02) and control (969 ms, 95% CI 742, 1196 to P=.01) sessions. No significant differences were observed in RT during the congruent phase or in accuracy across either phase. Conclusions: A 20-minute session of exergame improved inhibitory control performance in children with ASD compared to active traditional games and painting activities. Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) RBR-5r9xzbq, Universal Trial Number U1111-1302-3490; https://ensaiosclinicos.gov.br/rg/RBR-5r9xzbq %R 10.2196/65562 %U https://games.jmir.org/2025/1/e65562 %U https://doi.org/10.2196/65562 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e60185 %T Effect of a Gamified Family-Based Exercise Intervention on Adherence to 24-Hour Movement Behavior Recommendations in Preschool Children: Single-Center Pragmatic Trial %A Legarra-Gorgoñon,Gaizka %A García-Alonso,Yesenia %A Ramírez-Vélez,Robinson %A Alonso-Martínez,Loreto %A Izquierdo,Mikel %A Alonso-Martínez,Alicia M %K children %K gamification %K exercise %K physical fitness %K domains of physical activity %K game %K fitness %K child %K family-based %K exercise program %K randomized controlled trial %K strength %D 2025 %7 4.3.2025 %9 %J JMIR Serious Games %G English %X Background: Adherence to 24-hour movement behavior recommendations, including physical activity (PA), sedentary time, and sleep, is essential for the healthy development of preschool children. Gamified family-based interventions have shown the potential to improve adherence to these guidelines, but evidence of their effectiveness among children is limited. Objective: This study aimed to evaluate the effectiveness of a gamified family-based exercise intervention in promoting adherence to 24-hour movement behavior recommendations among preschool-aged children. Methods: This 12-week study is a single-center, pragmatic randomized controlled trial that included 80 preschool children (56% boys) and their families, who were randomly assigned to either the gamification group (n=40) or the control group (n=40). The “3, 2, 1 Move on Study” incorporates family-oriented physical activities and gamification techniques to increase PA domains, reduce sedentary behavior, and improve sleep patterns. The primary outcome was to increase moderate to vigorous PA (MVPA) by 5 minutes/day, as measured by accelerometer at follow-up. Accelerometer-determined daily time spent (PA domains, sedentary behavior, and sleep), physical fitness (cardiorespiratory, speed-agility, muscular, physical fitness z-score), basic motor competencies (self-movement and object movement), and executive function (memory, cognitive flexibility, and inhibitory control) were also included as secondary outcomes. Results: The 71 participants included in the per-protocol analyses (32 girls, 45%; 39 boys, 55%) had a mean (SD) age of 5.0 (0.5) years. Change in MVPA per day after the intervention (12 weeks) increased in both groups by +25.3 (SD 24.6) minutes/day in the gamification group and +10.0 (SD 31.4) minutes/day in the routine care group, but no significant between-group differences were observed (8.62, 95% CI –5.72 to 22.95 minutes/day, ηp2=.025; P=.23). The analysis of secondary outcomes showed significant between-group mean differences in the change in physical behaviors derived from the accelerometers from baseline to follow-up of 26.44 (95% CI 8.93 to 43.94) minutes/day in favor of light PA (ηp2=.138; P=.01) and 30.88 (95% CI 4.36 to 57.41) minutes/day in favor of total PA, which corresponds to a large effect size (ηp2=.087; P=.02). Likewise, the gamification group substantially increased their score in standing long jump and physical fitness z-score from baseline (P<.05). Conclusions: In the “3, 2, 1 Move on Study,” a gamified intervention showed a modest but relevant increase in MVPA and other domains of 24-hour movement behavior among preschool-aged children. Therefore, gamified family-based interventions may provide a viable alternative to improve adherence to 24-hour movement behavior recommendations. Trial Registration: ClinicalTrials.gov NCT05741879; https://clinicaltrials.gov/study/NCT05741879?tab=history %R 10.2196/60185 %U https://games.jmir.org/2025/1/e60185 %U https://doi.org/10.2196/60185 %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 %@ 2369-2529 %I JMIR Publications %V 12 %N %P e63512 %T Development of a Mobile App Game for Practicing Lung Exercises: Feasibility Study %A Pearkao,Chatkhane %A Apiratwarakul,Korakot %A Wicharit,Lerkiat %A Potisopha,Wiphawadee %A Jaitieng,Arunnee %A Homvisetvongsa,Sukuman %A Namwaing,Puthachad %A Pudtuan,Peerapon %K mobile app game %K practice lung exercises %K feasibility study %K mobile phone %K pulmo device %K app %D 2025 %7 4.3.2025 %9 %J JMIR Rehabil Assist Technol %G English %X Background: Chest injuries are a leading cause of death and disability, accounting for 10% of hospital admissions and 25% of injury-related deaths. About two-thirds of patients with thoracic injuries experience complications such as blood or air in the pleural space, causing lung deflation and poor gas exchange. Proper breathing management, using tools like incentive spirometers, improves lung function and recovery. However, there is a gap in mobile-based gaming apps designed for lung exercise, which could benefit both the general population and patients recovering from lung injuries. Objective: This research aimed to develop and evaluate a mobile app game for practicing lung exercises, accompanied by a prototype device called the Pulmo device. Methods: The study involved a sample group of 110 participants from the general public. It followed a research and development methodology comprising 4 steps. The research instruments included a mobile app game, a prototype lung exercise device, and questionnaires to assess users’ satisfaction and the feasibility of both the app and the device. Results: The findings revealed that the participants demonstrated a high level of overall satisfaction with both the mobile app game and the prototype lung exercise device (mean 4.4, SD 0.4). The feasibility for the mobile app game and the prototype lung exercise device connected to the game was evaluated. The results indicated that the sample group perceived the overall feasibility to be at a high level (mean 4.4, SD 0.5). Conclusions: The research results reflected that the sample group believed the mobile app game for practicing lung exercises and the prototype device developed in this project have a high potential for practical application in promoting lung rehabilitation through gameplay. The mobile app game and the Pulmo device prototype received positive user feedback, indicating potential practical use; however, further validation is required among patients in need of pulmonary rehabilitation. %R 10.2196/63512 %U https://rehab.jmir.org/2025/1/e63512 %U https://doi.org/10.2196/63512 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e64004 %T A Self-Adaptive Serious Game to Improve Motor Learning Among Older Adults in Immersive Virtual Reality: Short-Term Longitudinal Pre-Post Study on Retention and Transfer %A Everard,Gauthier %A Declerck,Louise %A Lejeune,Thierry %A Edwards,Martin Gareth %A Bogacki,Justine %A Reiprich,Cléo %A Delvigne,Kelly %A Legrain,Nicolas %A Batcho,Charles Sebiyo %+ School of Rehabilitation Sciences, Faculty of Medicine, Laval University, 2325 Rue de l'Université, Québec, QC, G1V0A6, Canada, 1 4185299141 ext 46914, gauthier.everard@uclouvain.be %K virtual reality %K aged %K learning %K upper extremity %K video games %K kinematics %D 2025 %7 3.3.2025 %9 Original Paper %J JMIR Aging %G English %X Background: Despite their potential, the use of serious games within immersive virtual reality (iVR) for enhancing motor skills in older adults remains relatively unexplored. In this study, we developed a self-adaptive serious game in iVR called REAsmash-iVR. This game involves swiftly locating and striking a digital mole presented with various distractors. Objective: This short-term longitudinal pre-post study aims to evaluate REAsmash-iVR’s efficacy in promoting motor learning in older adults. Specifically, we seek to determine the transfer and retention of motor learning achieved through REAsmash-iVR to other iVR tasks. Methods: A total of 20 older adults participated in the study, engaging with REAsmash-iVR over 7 consecutive days. The evaluation included iVR tests such as KinematicsVR and a VR adaptation of the Box and Block Test (BBT-VR). KinematicsVR tasks included drawing straight lines and circles as fast and as accurately as possible, while BBT-VR required participants to move digital cubes as quickly as possible within 60 seconds. Assessments were conducted before and after the intervention, with a follow-up at 1 week post intervention. The primary outcome focused on evaluating the impact of REAsmash-iVR on speed-accuracy trade-off during KinematicsVR tasks. Secondary outcomes included analyzing movement smoothness, measured by spectral arc length, and BBT-VR scores. Results: Results revealed significant improvements in speed-accuracy trade-off post intervention compared to that before the intervention, with notable retention of skills for straight lines (t19=5.46; P<.001; Cohen d=1.13) and circle drawing (t19=3.84; P=.001; Cohen d=0.787). Likewise, there was a significant enhancement in spectral arc length, particularly for circle drawing (χ²2=11.2; P=.004; ε2=0.23), but not for straight-line drawing (χ²2=2.1; P=.35; ε2=0.003). Additionally, participants demonstrated transfer with significant improvement (q=5.26; P<.001; Cohen r=0.678) and retention (q=6.82; P<.001; Cohen r=0.880) in BBT-VR skills. Conclusions: These findings provide perspectives for the use of iVR to improve motor learning in older adults through delivering self-adaptive serious games targeting motor and cognitive functions. Trial Registration: ClinicalTrials.gov NCT04694833; https://clinicaltrials.gov/study/NCT04694833 %M 40053708 %R 10.2196/64004 %U https://aging.jmir.org/2025/1/e64004 %U https://doi.org/10.2196/64004 %U http://www.ncbi.nlm.nih.gov/pubmed/40053708 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57802 %T Gamified mHealth System for Evaluating Upper Limb Motor Performance in Children: Cross-Sectional Feasibility Study %A Mia,Md Raihan %A Ahamed,Sheikh Iqbal %A Nemanich,Samuel %+ Department of Occupational Therapy, Marquette University, 1700 West Wells St, Milwaukee, WI, 53233, United States, 1 4142883243, sam.nemanich@marquette.edu %K mobile health %K mHealth %K digital health %K mobile apps %K smartphones %K iPad %K gamification %K serious games %K digital interventions %K digital technology %K spatiotemporal %K upper limb movement %K motor performance %K motor skills %K pediatrics %K toddler %K children %K youth %D 2025 %7 28.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Approximately 17% of children in the United States have been diagnosed with a developmental or neurological disorder that affects upper limb (UL) movements needed for completing activities of daily living. Gold-standard laboratory assessments of the UL are objective and precise but may not be portable, while clinical assessments can be time-intensive. We developed MoEvGame, a mobile health (mHealth) gamification software system for the iPad, as a potential advanced technology to assess UL motor functions. Objective: This feasibility study examines whether MoEvGame can assess children’s whole-limb movement, fine motor skills, manual dexterity, and bimanual coordination. The specific aims were to (1) design and develop novel mHealth gamified software tools to examine theory-driven features of UL movement, (2) analyze spatiotemporal game data with new algorithms and statistical techniques to quantify movement performance as a parameter of speed, accuracy, and precision, and (3) validate assessment methods with healthy participants from schools. Methods: Elementary school children (N=31, median 9.0, IQR 4.0-14.0 years old) participated by playing 5 games. The game tasks were focused on key features of skilled motor control: (1) whole limb reaching, (2) fine motor control and manual dexterity, and (3) bilateral coordination. Spatiotemporal game data were transferred and stored in a cloud-based data management server for further processing and analysis. We applied change point detection (ie, the pruned exact linear time method), signal processing techniques, and other algorithms to calculate movement speed and accuracy from spatiotemporal parameters. Different statistical methods (ie, Pearson correlation, mean, standard deviation, P value, 95% confidence interval) were used to compare speed-accuracy tradeoffs and evaluate the relationship between age and motor performance. Results: A negative correlation was identified between speed and accuracy in the whole limb movement (r=–0.30 to –0.42). Significant relationships between age and upper limb performance were found: older participants exhibited lower errors with faster completion times compared to younger participants. Significant differences in bimanual coordination were found related to phase synchronization (in-phase congruent [mean 28.85, SD 18.97] vs antiphase congruent [mean 112.64, SD 25.82] and in-phase mirrored [mean 23.78, SD 16.07] vs antiphase mirrored [mean 121.39, SD 28.19]). Moreover, the average speed (revolutions per second) and travel distance (m) of the in-phase mode were significantly higher than those of the antiphase coordination. Conclusions: Results of this feasibility study show that spatiotemporal data captured from the mHealth app can quantify motor performance. Moving beyond traditional assessments, MoEvGame incorporates gamification into ubiquitous and accessible technology as a fast, flexible, and objective tool for UL motor assessment. %M 40053722 %R 10.2196/57802 %U https://games.jmir.org/2025/1/e57802 %U https://doi.org/10.2196/57802 %U http://www.ncbi.nlm.nih.gov/pubmed/40053722 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67338 %T Reward Feedback Mechanism in Virtual Reality Serious Games in Interventions for Children With Attention Deficits: Pre- and Posttest Experimental Control Group Study %A Fang,Hao %A Fang,Changqing %A Che,Yan %A Peng,Xinyuan %A Zhang,Xiaofan %A Lin,Di %+ , Engineering Research Center for Big Data Application in Private Health Medicine of Fujian Universities, Putian University, No. 1133, Xueyuan Middle Street, Chengxiang District, Putian, 351100, China, 86 15959234669, lindi1015@163.com %K serious games %K virtual reality %K attention deficit %K inhibitory control ability %K reward feedback %D 2025 %7 24.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) serious games, due to their high level of freedom and realism, influence the rehabilitation training of inhibitory control abilities in children with attention-deficit/hyperactivity disorder (ADHD). Although reward feedback has a motivating effect on improving inhibitory control, the effectiveness and differences between various forms of rewards lack empirical research. Objective: This study aimed to investigate the effectiveness of different forms of reward feedback on the inhibitory control abilities of children with attention deficits in a VR serious game environment. Methods: This study focuses on children who meet the diagnostic criteria for ADHD tendencies, using a 2 (material rewards: coin reward and token reward) × 2 (psychological rewards: verbal encouragement and badge reward) factorial between-subject design (N=84), with a control group (n=15) for pre- and posttest experiments. The experimental group received VR feedback reinforcement training, while the control group underwent conventional VR training without feedback. The training period lasted 0.5 months, with each intervention session lasting 25 minutes, occurring twice daily with an interval of at least 5 hours for 28 sessions. Before and after training, the Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) Scale, stop signal task, inhibition conflict task, and Simon task were administered to assess the hyperactivity index and the 3 components of inhibitory control ability. The pretest included the SNAP-IV Scale and 3 task tests to obtain baseline data; the posttest involved repeating the above tests after completing all training. Data were entered and analyzed using SPSS (IBM) software. Independent sample t tests were performed on the experimental and control groups’ pre- and posttest task results to determine whether significant differences existed between group means. Paired sample t tests were also conducted on the SNAP-IV Scale’s pre- and posttest results to assess the intervention effect’s significance. Results: Reward feedback was more effective than no reward feedback in improving behaviors related to attention deficits in children. Material rewards showed significant effects in the Stop-Signal Task (F1=13.04, P=.001), Inhibition Conflict Task (F1=7.34, P=.008), and SNAP-IV test (F1=69.23, P<.001); mental rewards showed significant effects in the Stop-Signal Task (F1=38.54, P<.001) and SNAP-IV test (F1=70.78, P<.001); the interaction between the 2 showed significant effects in the Stop-Signal Task (F1=4.47, P=.04) and SNAP-IV test (F1=23.85, P<.001). Conclusions: Combining material and psychological rewards within a VR platform can effectively improve attention-deficit behaviors in children with ADHD, enhancing their inhibitory control abilities. Among these, coin rewards are more effective than token rewards, and verbal encouragement outperforms badge rewards. The combined feedback of coin rewards and verbal encouragement yields the most significant improvement in inhibitory control abilities. %M 39993290 %R 10.2196/67338 %U https://games.jmir.org/2025/1/e67338 %U https://doi.org/10.2196/67338 %U http://www.ncbi.nlm.nih.gov/pubmed/39993290 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e65358 %T Evaluation of a Game-Based Mechatronic Device for Rehabilitation of Hand-Arm Function in Children With Cerebral Palsy: Feasibility Randomized Controlled Trial %A Peramalaiah,Mrudula Kanakapura %A Parmar,Sanjay Tejraj %A Sepehri,Nariman %A Muthukumarana,Saman %A Kanitkar,Anuprita %A Hin,Cherry Kit-Fong %A Szturm,Tony Joseph %+ , SDM College of Physiotherapy, Shri Dharmasthala Manjunatheshwara University, Manjushree Nagar, Sattur, Dharwad, 580 009, India, 91 9845340450, sanjaytparmar777@gmail.com %K cerebral palsy %K computer game–assisted rehabilitation %K manual dexterity %K repetitive task practice %K robotic manipulandum %D 2025 %7 18.2.2025 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Children with neurodevelopmental disorders, such as cerebral palsy (CP), often experience motor impairments in manual dexterity, which hinder daily tasks and social interactions. Traditional rehabilitation methods require repetitive task practice, which can be difficult for children to sustain due to low engagement. Game-based rehabilitation devices and robots offer a promising alternative by combining therapy with digital play, improving motivation and compliance. However, many systems fail to incorporate actual object manipulation, which is essential for motor learning through sensory feedback. To address this limitation, a low-cost, easy-to-use robotic manipulandum device (RMD) was developed. The RMD enables real-time object manipulation during gameplay while providing assistive force, allowing the practice of a wide range of manual dexterity skills beyond gross reaching. This system offers an engaging and effective rehabilitation approach to enhance hand function in children with CP. Objective: This study aimed to provide evidence for the feasibility and therapeutic value of the RMD game–based exercise program for children with CP. Methods: In total, 34 children with CP, aged 4 to 10 years, were randomly assigned to the experimental group (XG) or the control group (CG). The XG received a computer game–based exercise program using the RMD, focusing on object manipulation tasks, while the CG received task-specific training similar to constraint-induced movement therapy. Both groups received their respective therapy programs 3 times per week for 8 weeks. Semistructured interviews with parents and children, along with qualitative analysis, were conducted to evaluate their experiences with the exercise program. The following outcome measures were used: (1) the Peabody Developmental Motor Scale-2 (PDMS-2) grasping and visual-motor integration subtests and (2) the computer game–based upper extremity (CUE) assessment of manual dexterity. Results: No dropouts occurred during the 8-week program. Both groups showed significant improvements in the PDMS-2 subtests (P<.001) and the CUE assessment of manual dexterity, including success rates (tennis ball: P=.001; cone: P<.001; medicine ball: P=.001; and peanut ball: P<.001) and movement errors (tennis ball: P=.01; cone: P<.001; medicine ball: P=.04; and peanut ball: P<.001). The XG outperformed the CG, showing greater improvements in PDMS-2 grasping (P=.002) and visual-motor integration (P=.01). In the CUE assessment, the XG demonstrated higher success rates (medicine ball: P=.001 and peanut ball: P=.02) and fewer movement errors (cone: P<.001). Parents reported an increase in the children’s independence in daily tasks. Conclusions: This study demonstrates the feasibility, acceptability, and positive outcomes of the RMD game–based exercise program for improving hand function in children with CP. The findings support further research and development of computer game–assisted rehabilitation technologies. Trial Registration: Clinical Trials Registry - India CTRI/2021/07/034903; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NTc4ODU %M 39964707 %R 10.2196/65358 %U https://rehab.jmir.org/2025/1/e65358 %U https://doi.org/10.2196/65358 %U http://www.ncbi.nlm.nih.gov/pubmed/39964707 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e56269 %T A Serious Game to Study Reduced Field of View in Keyhole Surgery: Development and Experimental Study %A Whitley,Phoebe %A Creasey,Connor %A Clarkson,Matthew J %A Thompson,Stephen %+ Advanced Research Computing, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 2076792000, s.thompson@ucl.ac.uk %K keyhole surgery %K laparoscopic surgery %K serious games %K image mosaicking %K field of view %K javascript %K html %K opensource %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: During keyhole surgery, the surgeon is required to perform highly demanding tasks while only being able to see part of the patient’s anatomy. This limited field of view is widely cited as a key limitation of the procedure, and many computational methods have been proposed to overcome it. However, the precise effects of a limited field of view on task performance remain unknown due to the lack of tools to study these effects effectively. Objective: This paper describes our work on developing a serious game with 2 objectives: (1) to create an engaging game that communicates some of the challenges of keyhole surgery, and (2) to test the effect of a limited field of view on task performance. The development of a serious game that can be played by a wide range of participants will enable us to gather quantitative data on the effects of the reduced field of view on task performance. These data can inform the future development of technologies to help surgeons reduce the impact of a limited field of view on clinical outcomes for patients. The game is open source and may be adapted and used by other researchers to study related problems. Methods: We implemented an open-source serious game in JavaScript, inspired by the surgical task of selectively cauterizing blood vessels during twin-to-twin transfusion surgery. During the game, the player is required to identify and cut the correct blood vessel under different fields of view and varying levels of vascular complexity. We conducted a quantitative analysis of task performance time under different conditions and a formative analysis of the game using participant questionnaires. Results: We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking significantly longer (P<.001) to perform otherwise identical tasks (mean 6.4 seconds, 95% CI 5.0-7.8 seconds vs mean 13.6 seconds, 95% CI 10.3-16.9 seconds). Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery. Conclusions: We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking statistically significantly longer (16.4 vs 9.8 seconds; P=.05) to perform otherwise identical tasks. Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery. %M 39933172 %R 10.2196/56269 %U https://games.jmir.org/2025/1/e56269 %U https://doi.org/10.2196/56269 %U http://www.ncbi.nlm.nih.gov/pubmed/39933172 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e60755 %T Evaluating the Efficacy of a Serious Game to Deliver Health Education About Invasive Meningococcal Disease: Clustered Randomized Controlled Equivalence Trial %A Bloomfield,Lauren %A Boston,Julie %A Masek,Martin %A Andrew,Lesley %A Barwood,Donna %A Devine,Amanda %+ Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027, Australia, 61 0863045702, julie.boston@ecu.edu.au %K serious games %K meningococcal disease %K immersive digital applications %K health promotion %K gaming %K meningitis %K infection %K bacteria %K contagious %K infectious %K immersive %K education %K mHealth %K mobile health %K applications %K youth %K adolescents %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Invasive meningococcal disease (IMD) is a serious, vaccine-preventable infectious disease that can be life-threatening. Teaching adolescents about the early detection and prevention of IMD can be challenging in a school environment, with educators reporting they lack confidence or expertise to cover this in the classroom environment. Professional guest educators are an alternative to cover specialist topics such as IMD; however, time and resourcing constraints can mean that these educators are not always available. Serious games may be an alternative to face-to-face education, where complex health information may be delivered via self-directed gameplay. Objective: This study aims to develop a serious game that can replace a face-to-face educator in a classroom setting to educate adolescents aged 12 years to 15 years. This study evaluates the efficacy of the Meningococcal Immunisation Awareness, Prevention and Protection app (MIApp), a serious game designed to replicate the information provided in a 30-minute face-to-face presentation provided by a trained educator. Methods: This clustered, randomized controlled equivalence trial involved students (Years 7-10) from 6 secondary schools across metropolitan Western Australia who completed pre- and postintervention questionnaires with a follow-up at 3 months postintervention to measure the primary outcome of IMD knowledge acquisition following this self-guided intervention. The findings were compared with changes in an active control (comparison) group who received an in-class educational presentation about IMD transmission and protection. A questionnaire was developed to assess 9 key areas of knowledge. Median scores for knowledge pre- and postintervention were collected from a self-administered assessment of this questionnaire and, at 3 months postintervention, were compared between groups. A knowledge score of +/–2/16 was determined a priori to meet the criteria for equivalence. Participants who used MIApp were also asked a series of questions to assess the enjoyment of and engagement with the game. Results: Of the 788 participating students, the median postintervention correct score in both the MIApp and control cohorts was 14/16 (87.5% correct responses), compared with the median pre-intervention correct score of 6/16 (37.5% correct responses), representing a significant (P<.001) increase in IMD knowledge in both groups. Improvements were retained in both groups 3 months after the initial intervention (median correct score: 11/16 in the intervention group; 12/16 in the control group; P=.86), demonstrating the efficacy of MIApp to deliver health education about IMD transmission and protection, although response rates in the follow-up cohort were low (255/788, 32.4%). Conclusions: MIApp met the predetermined threshold for equivalence, demonstrating similar improvements in knowledge posttrial and at the 3-month follow-up. Participating adolescents considered the MIApp game more enjoyable than a presentation, with equivalent improvements in knowledge. Serious games could represent a constructive tool to help teachers impart specialized health education. %M 39932769 %R 10.2196/60755 %U https://games.jmir.org/2025/1/e60755 %U https://doi.org/10.2196/60755 %U http://www.ncbi.nlm.nih.gov/pubmed/39932769 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66979 %T Assessing the Impact of a Virtual Reality Cognitive Intervention on Tennis Performance in Junior Tennis Players: Pilot Study %A Anguera,Joaquin A %A Choudhry,Aleem %A Seaman,Michael %A Fedele,Dominick %+ Neuroscape, Department of Neurology and Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, United States, 1 415 702 4322, joaquin.anguera@ucsf.edu %K executive function %K serious games %K cognitive training %K performance enhancement %K athletes %K sport %K pilot study %K VR %K virtual reality %K serious game %K tennis %K adolescents %K teenagers %K youth %K randomized controlled trial %K players %D 2025 %7 7.2.2025 %9 Short Paper %J JMIR Form Res %G English %X Background: There is evidence that cognitive training interventions can positively impact executive functions, and that some studies have demonstrated that athletes typically exhibit greater accuracy and faster response times on select cognitive tasks. While the engagement of executive functions is suggested to be part of high-level sporting activities, it is unclear whether such training approaches could directly benefit athletic performance. Objective: The objective of this study was to evaluate the impact of a combined virtual reality (VR)– and tablet-based cognitive training intervention on adolescent tennis players’ performance. Here, we examined differences in Universal Tennis Rating (UTR) between players who supplemented their regular tennis training with a cognitive training intervention and a group that continued regular tennis training alone. This custom cognitive training program targeted specific cognitive control abilities including attention, working memory, and goal management. Methods: Data were collected from a cohort of tennis players in a randomized controlled trial design led by the dedicated research team. Participants (N=23, age: mean 14.8, SD 2.4 years) from the Czech Lawn Tenis Klub (Prague, Czech Republic) were invited to participate in this study. These individuals were randomized into an intervention + training-as-usual group (n=13) or training-as-usual group (control group; n=10), with the change in UTR score being the primary metric of interest. Results: There was no difference in UTR between the 2 groups at baseline (intervention: mean 8.32, SD 2.7; control: mean 7.60, SD 2.3). Following the treatment period, individuals in the intervention group showed a significant improvement in their UTR (an increase of 0.5; t12=4.88, P<.001) unlike the control group (an increase of 0.02; t9=1.77, P=.12). On comparing the change in UTR (posttraining UTR minus pretraining UTR) attained by each group, we found that the intervention group had a 38% greater improvement in UTR than the control group. An analysis of covariance revealed a significantly greater improvement in UTR for the intervention group than for the control group (F1,20=8.82, P=.008). Conclusions: The present findings suggest that training cognitive abilities through an immersive visual platform may benefit athletic performance, including tennis. Such a result warrants careful consideration, given the known difficulties in evidencing far transfer not only in cognitive studies but also in athletic activities. These preliminary pilot findings suggest that the Mastermind Cognitive Training program may be a viable tool for supplementing athletic training practices, although this result warrants further investigation and replication. However, many questions remain unanswered, and further work is needed to better understand the potential utility and mechanisms underlying potential effects of such a platform. %M 39918854 %R 10.2196/66979 %U https://formative.jmir.org/2025/1/e66979 %U https://doi.org/10.2196/66979 %U http://www.ncbi.nlm.nih.gov/pubmed/39918854 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57297 %T Exploring Virtual Reality and Exercise Simulator Interventions in Patients With Attention Deficit Hyperactivity Disorder: Comprehensive Literature Review %A Sarai,Gurdeep %A Jayaraman,Prem Prakash %A Tirosh,Oren %A Wickramasinghe,Nilmini %+ School of Health Sciences, Swinburne University of Technology, 1 Almeida Cresent, Melbourne, 3141, Australia, 61 411362177, gurdeep.sarai@gmail.com %K exercise-based simulator %K exergame %K virtual reality %K physical activity %K attention-deficit/hyperactivity disorder %D 2025 %7 29.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: This review explores virtual reality (VR) and exercise simulator–based interventions for individuals with attention-deficit/hyperactivity disorder (ADHD). Past research indicates that both VR and simulator-based interventions enhance cognitive functions, such as executive function and memory, though their impacts on attention vary. Objective: This study aimed to contribute to the ongoing scientific discourse on integrating technology-driven interventions into the management and evaluation of ADHD. It specifically seeks to consolidate findings on how VR and exercise simulators may support individuals with ADHD, acknowledging associated challenges and implications inherent in both technological approaches. Methods: This research looks at existing literature to examine the potential efficacy of VR and exercise simulator–based interventions for individuals with ADHD. It evaluates the capacity of these interventions to address specific challenges along with an emphasis on the adjustments for accommodating unique user behaviors. Additionally, it underscores the limited exploration of user perceptions of exercise simulator–based interventions and the undervalued role of motor function in both ADHD assessment and symptom management. Results: The findings of this scoping review reveal that, while these interventions enhance user motivation and enjoyment, certain challenges resist modification through technology. Furthermore, this study explores the intricate complexities involved in customizing these technologies to accommodate the diverse aspects of user behavior and highlights the potential limitations in the use of VR. Conclusions: This scoping review contributes to the ongoing research on enhancing interventions to support individuals with ADHD. It advocates for participant-centric approaches that aim to optimize both cognitive and motor outcomes while prioritizing the enhancement of user experiences. This study emphasizes the need for a comprehensive approach to interventions, recognizing the relationship between cognitive and motor abilities, and calls for improving technological interventions to address the varied needs of individuals with ADHD. %M 39879092 %R 10.2196/57297 %U https://games.jmir.org/2025/1/e57297 %U https://doi.org/10.2196/57297 %U http://www.ncbi.nlm.nih.gov/pubmed/39879092 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69080 %T Digital Gaming and Subsequent Health and Well-Being Among Older Adults: Longitudinal Outcome-Wide Analysis %A Nakagomi,Atsushi %A Ide,Kazushige %A Kondo,Katsunori %A Shiba,Koichiro %+ Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba, 2638522, Japan, 81 432903177 ext 3177, anakagomi0211@gmail.com %K digital gaming %K older adults %K flourishing %K well-being %K physical activity %K social engagement %K mobile phone %D 2025 %7 27.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital gaming has become increasingly popular among older adults, potentially offering cognitive, social, and physical benefits. However, its broader impact on health and well-being, particularly in real-world settings, remains unclear. Objective: This study aimed to evaluate the multidimensional effects of digital gaming on health and well-being among older adults, using data from the Japan Gerontological Evaluation Study conducted in Matsudo City, Chiba, Japan. Methods: Data were drawn from 3 survey waves (2020 prebaseline, 2021 baseline, and 2022 follow-up) of the Japan Gerontological Evaluation Study, which targets functionally independent older adults. The exposure variable, digital gaming, was defined as regular video game play and was assessed in 2021. In total, 18 outcomes across 6 domains were evaluated in 2022; domain 1—happiness and life satisfaction, domain 2—physical and mental health, domain 3—meaning and purpose, domain 4—character and virtue, domain 5—close social relationships, and domain 6—health behavior. Furthermore, 10 items from the Human Flourishing Index were included in domains 1-5, with 2 items for each domain. Overall flourishing was defined as the average of the means across these 5 domains. In addition, 7 items related to domains 2, 5, and 6 were assessed. The final sample consisted of 2504 participants aged 65 years or older, with questionnaires containing the Human Flourishing Index randomly distributed to approximately half of the respondents (submodule: n=1243). Consequently, we used 2 datasets for analysis. We applied targeted maximum likelihood estimation to estimate the population average treatment effects, with Bonferroni correction used to adjust for multiple testing. Results: Digital gaming was not significantly associated with overall flourishing or with any of the 5 domains from the Human Flourishing Index. Although initial analyses indicated associations between digital gaming and participation in hobby groups (mean difference=0.12, P=.005) as well as meeting with friends (mean difference=0.076, P=.02), these associations did not remain significant after applying the Bonferroni correction for multiple testing. In addition, digital gaming was not associated with increased sedentary behavior or reduced outdoor activities. Conclusions: This study provides valuable insights into the impact of digital gaming on the health and well-being of older adults in a real-world context. Although digital gaming did not show a significant association with improvements in flourishing or in the individual items across the 5 domains, it was also not associated with increased sedentary behavior or reduced outdoor activities. These findings suggest that digital gaming can be part of a balanced lifestyle for older adults, offering opportunities for social engagement, particularly through hobby groups. Considering the solitary nature of gaming, promoting social gaming opportunities may be a promising approach to enhance the positive effects of digital gaming on well-being. %M 39869904 %R 10.2196/69080 %U https://www.jmir.org/2025/1/e69080 %U https://doi.org/10.2196/69080 %U http://www.ncbi.nlm.nih.gov/pubmed/39869904 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e64410 %T Effectiveness of Mobile Health–Based Gamification Interventions for Improving Physical Activity in Individuals With Cardiovascular Diseases: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Yu,Tianzhuo %A Parry,Monica %A Yu,Tianyue %A Xu,Linqi %A Wu,Yuejin %A Zeng,Ting %A Leng,Xin %A Tong,Qian %A Li,Feng %+ School of Nursing, Jilin University, School of Nursing Office Building, 4th Fl., 965 Xinjiang St, Changchun, 130021, China, 86 0431 85619377, fli@jlu.edu.cn %K cardiovascular diseases %K digital health %K mobile health %K gamification %K exercise %K physical activity %K systematic review %K meta-analysis %D 2025 %7 24.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: Gamification refers to using game design elements in nongame contexts. Promoting physical activity (PA) through gamification is a novel and promising avenue for improving lifestyles and mitigating the advancement of cardiovascular diseases (CVDs). However, evidence of its effectiveness remains mixed. Objective: This systematic review and meta-analysis aimed to evaluate the efficacy of gamification interventions in promoting PA during short-term and follow-up periods in individuals with CVDs and to explore the most effective game design elements. Methods: A comprehensive search of 7 electronic databases was conducted for randomized controlled trials published in English from January 1, 2010, to February 3, 2024. Eligible studies used mobile health–based gamification interventions to promote PA or reduce sedentary behavior in individuals with CVDs. In total, 2 independent reviewers screened the retrieved records, extracted data, and evaluated the risk of bias using the RoB 2 tool. Discrepancies were resolved by a third reviewer. Meta-analyses were performed using a random-effects model with the Sidik-Jonkman method adjusted by the Knapp-Hartung method. Sensitivity analysis and influence analysis examined the robustness of results, while prediction intervals indicated heterogeneity. A meta-regression using a multimodel inference approach explored the most important game design elements. Statistical analyses were conducted using R (version 4.3.2; R Foundation for Statistical Computing). Results: In total, 6 randomized controlled trials were included. Meta-analysis of 5 studies revealed a small effect of gamification interventions on short-term PA (after sensitivity analysis: Hedges g=0.32, 95% CI 0.19-0.45, 95% prediction interval [PI] 0.02-0.62). Meta-analysis of 3 studies found the maintenance effect (measured with follow-up averaging 2.5 months after the end of the intervention) was small (Hedges g=0.20, 95% CI 0.12-0.29, 95% PI –0.01 to 0.41). A meta-analysis of 3 studies found participants taking 696.96 more steps per day than the control group (95% CI 327.80 to 1066.12, 95% PI –121.39 to 1515.31). “Feedback” was the most important game design element, followed by “Avatar.” Conclusions: This meta-analysis demonstrates that gamification interventions effectively promote PA in individuals with CVD, with effects persisting beyond the intervention period, indicating they are not merely novel effects caused by the game nature of gamification. The 95% PI suggests that implementing gamification interventions in similar populations in the future will lead to actual effects in promoting PA in the vast majority of cases. However, the limited number of included studies underscores the urgent need for more high-quality research in this emerging field. Trial Registration: PROSPERO CRD42024518795; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=518795 %M 39854099 %R 10.2196/64410 %U https://games.jmir.org/2025/1/e64410 %U https://doi.org/10.2196/64410 %U http://www.ncbi.nlm.nih.gov/pubmed/39854099 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50669 %T The Usability and Effect of a Novel Intelligent Rehabilitation Exergame System on Quality of Life in Frail Older Adults: Prospective Cohort Study %A Chang,Chien-Hsiang %A Wei,Chun-Chun %A Lien,Wei-Chih %A Yang,Tai-Hua %A Liu,Bo %A Lin,Yimo %A Tan,Poh Thong %A Lin,Yang-Cheng %K frailty %K exergame %K older adults %K intelligent rehabilitation %K reminiscence therapy %K eHealth care %D 2025 %7 21.1.2025 %9 %J JMIR Serious Games %G English %X Background: Aging in older adults results in a decline in physical function and quality of daily life. Due to the COVID-19 pandemic, the exercise frequency among older adults decreased, further contributing to frailty. Traditional rehabilitation using repetitive movements tends not to attract older adults to perform independently. Objective: Intelligent Rehabilitation Exergame System (IRES), a novel retro interactive exergame that incorporates real-time surface electromyography, was developed and evaluated. Methods: Frail older adults were invited to use the IRES for rehabilitation using lower limb training twice per week for 4 weeks. Participants were required to have no mobility or communication difficulties and be willing to complete the 4-week study. The enrolled cohort had baseline scores ranging from 1 to 5 on the Clinical Frailty Scale, as described by Rockwood et al. Three major lower limb movements (knee extension, plantar flexion, and dorsiflexion) were performed 20 times for each leg within 30 minutes. The surface electromyography collected and analyzed muscle potential signals for review by health care professionals to customize the protocol for the next training. The System Usability Scale (SUS) and Taiwanese version of the EuroQol-5 Dimensions (EQ-5D) were administered after completing the first (week 1, baseline) and last training (week 4, one-month follow-up) to evaluate the usability of the IRES and its effects on the quality of life of participants. Results: A total of 49 frail older adults (mean age 74.6 years) were included in the analysis. The usability of the IRES improved according to the mean SUS score, from 82.09 (good) at baseline to 87.14 (good+) at 1-month follow-up. The willingness to use (t96=−4.51; P<.001), learnability (t96=−4.83; P<.001), and confidence (t96=−2.27; P=.02) in working with the IRES increased. After using the IRES for 1 month, significant improvements were observed in the ease of use (t47=2.05; P=.04) and confidence (t47=2.68; P<.001) among participants without previous rehabilitation experience. No sex-based differences in the SUS scores were found at baseline or 1-month follow-up. The quality of life, as assessed by the EQ-5D, improved significantly after 1 month of IRES training compared to that at baseline (t96=6.03; P<.001). Conclusions: The novel IRES proposed in this study received positive feedback from frail older adults. Integrating retro-style exergame training into rehabilitation not only improved their rehabilitation motivation but also increased their learning, system operability, and willingness to continue rehabilitation. The IRES provides an essential tool for the new eHealth care service in the post–COVID-19 era. %R 10.2196/50669 %U https://games.jmir.org/2025/1/e50669 %U https://doi.org/10.2196/50669 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 2 %N %P e49923 %T Immersive Virtual Reality for Health Promotion and Primary Prevention in Psychology: Scoping Review %A Bonneterre,Solenne %A Zerhouni,Oulmann %A Boffo,Marilisa %K virtual reality %K health psychology %K prevention psychology %K health promotion %D 2025 %7 20.1.2025 %9 %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR) has emerged as a promising tool in health promotion and prevention psychology. Its ability to create immersive, engaging, and standardized environments offers unique opportunities for interventions and assessments. However, the scope of VR applications in this field remains unclear. Objective: This scoping review aims to identify and map the applications of VR in health promotion and prevention psychology, focusing on its uses, outcomes, and challenges. Methods: A systematic search was conducted across 3 electronic databases (PubMed, PsycINFO, and Scopus) for studies published between 2010 and 2024. Eligibility criteria included empirical studies using immersive VR for health promotion and prevention, while studies using nonimmersive VR, lacking health-related applications, or focusing on clinical interventions were excluded. The review followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guidelines, and 4295 records were initially identified, with 51 studies included after screening. Data were synthesized qualitatively to identify key applications, limitations, and emerging trends. Results: VR was primarily used in three areas: (1) delivering interventions (eg, pilot testing, skills training), (2) exploring fundamental research questions, and (3) assessing outcomes such as behavioral or psychological responses. Although VR demonstrated potential for enhancing user engagement and replicating ecological scenarios, its effectiveness compared to nonimmersive methods varied. Most studies were pilot or feasibility studies with small, nonrepresentative samples, short follow-up periods, and limited methodological standardization. Conclusions: VR offers a versatile and promising tool for health promotion and prevention but its applications are still in the early stages. The evidence is limited by methodological weaknesses and variability in outcomes. Future research should prioritize replication, longitudinal designs, and standardized methodologies to strengthen the evidence base and expand the applicability of VR interventions. %R 10.2196/49923 %U https://xr.jmir.org/2025/1/e49923 %U https://doi.org/10.2196/49923 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e63384 %T Transformative Gamified Binocular Therapy for Unilateral Amblyopia in Young Children: Pilot Prospective Efficacy and Safety Study %A Zhu,Wenqing %A Gu,Shuneng %A Li,Jian %A Lin,Jin %A Hu,Chanling %A Liu,Rui %K amblyopia %K binocular treatment %K digital therapy %K game %K stereoacuity %K visual acuity %D 2025 %7 16.1.2025 %9 %J JMIR Serious Games %G English %X Background: Amblyopia is a common cause of visual impairment in children. Compliance with traditional treatments for amblyopia is challenging due to negative psychosocial impacts. Recent shifts in amblyopia treatment have moved from suppressing the dominant eye to enhancing binocular visual function. Binocular digital therapy has become a promising approach. Objective: The aim of this study was to evaluate the effects of binocular gamified digital therapy on visual acuity and stereoacuity (SA) in children with unilateral amblyopia. Methods: This pilot prospective study enrolled 11 children aged 4-6 years with unilateral amblyopia. Following at least 8 weeks of refractive correction, participants underwent binocular gamified digital therapy for 60 minutes per day, 5 days a week. The therapy used a roguelike shooting game delivered under binocular conditions through two independent channels with a real-time artificial intelligence visual engine. Assessments of distance visual acuity (DVA), near visual acuity (NVA), and SA were conducted at baseline and again at 4, 8, and 12 weeks. Results: At 12 weeks, the following significant improvements were noted: amblyopic eye DVA improved by 1.0 line (P=.01; d=0.77), binocular DVA improved by 0.7 lines (P=.006; d=1.00), and SA improved by 0.3 logarithm (log) arcseconds (P=.01; d=0.97). At 8 weeks, improvements included amblyopic eye DVA by 0.9 lines (P=.046; d=1.00) and SA by 0.28 log arcseconds (P=.02; d=0.90). No significant adverse events were observed, although one participant developed progressive esotropia. Conclusions: Binocular gamified digital therapy is effective and safe for improving visual outcomes in children aged 4-6 years with unilateral amblyopia. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300072066; https://www.chictr.org.cn/showproj.html?proj=198625 %R 10.2196/63384 %U https://games.jmir.org/2025/1/e63384 %U https://doi.org/10.2196/63384 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50635 %T Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Randomized, Double-Blind, Placebo-Controlled Trial %A Vermeir,Julie F %A White,Melanie J %A Johnson,Daniel %A Crombez,Geert %A Van Ryckeghem,Dimitri M L %+ School of Psychology and Counselling, Faculty of Health, Queensland University of Technology (QUT), 170 Victoria Park Road., Brisbane, 4059, Australia, 61 731384714, julie.vermeir@hdr.qut.edu.au %K chronic pain %K cognition %K attentional bias %K gamification %K motivation %K randomized controlled trial %K web-based intervention %K pain management %K digital intervention %K digital health %D 2025 %7 16.1.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Attentional bias to pain-related information has been implicated in pain chronicity. To date, research investigating attentional bias modification training (ABMT) procedures in people with chronic pain has found variable success, perhaps because training paradigms are typically repetitive and monotonous, which could negatively affect engagement and adherence. Increasing engagement through the gamification (ie, the use of game elements) of ABMT may provide the opportunity to overcome some of these barriers. However, ABMT studies applied to the chronic pain field have not yet incorporated gamification elements. Objective: This study aimed to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial. Methods: A final sample of 129 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, were included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants were randomly assigned to complete 6 web-based sessions of nongamified standard ABMT (n=43), gamified ABMT (n=41), or a control condition (nongamified sham ABMT; n=45) over a period of 3 weeks. Active ABMT conditions trained attention away from pain-related words. The gamified task included a combination of 5 game elements. Participant outcomes were assessed before training, during training, immediately after training, and at 1-month follow-up. Primary outcomes included self-reported and behavioral engagement, pain intensity, and pain interference. Secondary outcomes included anxiety, depression, cognitive biases, and perceived improvement. Results: Results of the linear mixed model analyses suggest that across all conditions, there was an overall small to medium decline in self-reported task-related engagement between sessions 1 and 2 (P<.001; Cohen d=0.257; 95% CI 0.13-0.39), sessions 1 and 3 (P<.001; Cohen d=0.368; 95% CI 0.23-0.50), sessions 1 and 4 (P<.001; Cohen d=0.473; 95% CI 0.34-0.61), sessions 1 and 5 (P<.001; Cohen d=0.488; 95% CI 0.35-0.63), and sessions 1 and 6 (P<.001; Cohen d=0.596; 95% CI 0.46-0.73). There was also an overall small decrease in depressive symptoms from baseline to posttraining assessment (P=.007; Cohen d=0.180; 95% CI 0.05-0.31) and in pain intensity (P=.008; Cohen d=0.180; 95% CI 0.05-0.31) and pain interference (P<.001; Cohen d=0.237; 95% CI 0.10-0.37) from baseline to follow-up assessment. However, no differential effects were observed over time between the 3 conditions on measures of engagement, pain intensity, pain interference, attentional bias, anxiety, depression, interpretation bias, or perceived improvement (all P values>.05). Conclusions: These findings suggest that gamification, in this context, was not effective at enhancing engagement, and they do not support the widespread clinical use of web-delivered ABMT in treating individuals with chronic musculoskeletal pain. The implications of these findings are discussed, and future directions for research are suggested. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx International Registered Report Identifier (IRRID): RR2-10.2196/32359 %M 39819575 %R 10.2196/50635 %U https://games.jmir.org/2025/1/e50635 %U https://doi.org/10.2196/50635 %U http://www.ncbi.nlm.nih.gov/pubmed/39819575 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e58912 %T Pervasive Games for Sexual Health Promotion: Scoping Literature Review %A Rubio,Claudio %A Besoain,Felipe %+ Department of Interactive Visualization and Virtual Reality, Faculty of Engineering, University of Talca, 2 norte #685, Talca, 3460000, Chile, 56 2201687 ext 2687, fbesoain@utalca.cl %K serious games %K promotion %K ubiquitous technologies %K healthy behaviors %K HIV %K sexually transmitted infection %K STI %K scoping review %K mobile phone %D 2025 %7 15.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: Serious games play a fundamental role in promoting safe sexual behaviors. This medium has great potential for promoting healthy behaviors that prevent potential risk factors, such as sexually transmitted infections, and promote adherence to sexual health treatments, such as antiretroviral therapy. The ubiquity of mobile devices enhances access to such tools, increasing the effectiveness of video games as agents of change. Objective: In this scoping review, we aimed to (1) identify the extent to which pervasive games have been used in the field of sexual health, (2) determine the theories used in the design and evaluation of pervasive games for sexual health, (3) identify the methods used to evaluate pervasive games for sexual health, and (4) explore the reported benefits of using pervasive games for sexual health. Methods: Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology, we conducted a comprehensive literature search in the Web of Science, Scopus, IEEE Xplore, and ACM databases for articles published between January 1, 2000, and August 4, 2024. Included articles were published in English between 2000 and 2024 and involved the design, implementation, or evaluation of a ubiquitous video game focused on promoting safe sexual behaviors, with qualitative and/or quantitative results based on theory-based techniques and ubiquitous technologies. Review articles, conference papers, or books without available data or quantitative or qualitative results were excluded. Results: We screened 521 of 612 articles (85.1%) after removing duplicates. After the title and abstract review, 51 (9.8%) articles were assessed for eligibility, and 30 (5.8%) articles meeting the criteria were studied and evaluated in depth. The results suggested that the use of pervasive video games has a positive impact on promoting safe sexual behaviors. This is enhanced by the effectiveness of theory-based techniques and the use of mobile technologies as developmental factors that drive the gaming experience. The results indicated that this domain is a growing field that should not be ignored. Conclusions: The literature showed that pervasive video games have been effective in promoting safe sexual behaviors. Substantial growth has been seen in scientific community interest in researching this domain; nevertheless, there is still much to work on. In this context, we advocate for the standardization of design, implementation, and experimentation as essential phases in creating video game experiences. These 3 fundamental aspects are critical in the development of video game–based studies to ensure the reproducibility of experiments. %M 39813670 %R 10.2196/58912 %U https://games.jmir.org/2025/1/e58912 %U https://doi.org/10.2196/58912 %U http://www.ncbi.nlm.nih.gov/pubmed/39813670 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59154 %T Considering Comorbidities and Individual Differences in Testing a Gaming Behavioral Activation App for Perinatal Depression and Anxiety: Open Trial Pilot Intervention Study %A Hamlett,Gabriella E %A Schrader,Chloe %A Ferguson,Craig %A Kobylski,Lauren A %A Picard,Rosalind %A Locascio,Joseph J %A McNally,Richard J %A Cohen,Lee S %A Vanderkruik,Rachel %K perinatal anxiety %K perinatal depression %K behavioral activation %K digital mental health %K mobile phone %D 2025 %7 14.1.2025 %9 %J JMIR Form Res %G English %X Background: There is increasing interest in the development of scalable digital mental health interventions for perinatal populations to increase accessibility. Mobile behavioral activation (BA) is efficacious for the treatment of perinatal depression; however, the effect of comorbid anxiety and depression (CAD) on symptom trajectories remains underexplored. This is important given that at least 10% of women in the perinatal period experience CAD. Objective: We assessed whether there were differences in symptom trajectories in pregnant participants with CAD as compared to those with depression only (ie, major depressive disorder [MDD]) during intervention with a BA mobile gaming app. Methods: Pregnant adults with either CAD (n=10) or MDD (n=7) used a BA app for 10 weeks and completed biweekly symptom severity questionnaires for depression and anxiety. We assessed whether baseline diagnoses were associated with differential symptom trajectories across the study with mixed effects longitudinal models. Results: When controlling for baseline symptoms, results revealed a significant interaction between baseline diagnosis and the quadratic component of study week on anxiety (β=.18, SE 0.07; t62=2.61; P=.01), revealing a tendency for anxiety in the CAD group to increase initially and then decrease at an accelerated rate, whereas MDD symptoms were relatively stable across time. There was a significant effect of linear time on depression (β=−.39, SE 0.11; t68=−3.51; P=.001), showing that depression declined steadily across time for both groups. There was a significant effect of baseline diagnosis on depression (β=−8.53, SE 3.93; t13=−2.17; P=.05), suggesting that those with MDD had higher follow-up depression compared to those with CAD when holding other predictors constant. Conclusions: The app was beneficial in reducing depression symptoms in perinatal individuals with different comorbidity profiles. With respect to anxiety symptom trajectories, however, there was more variability. The app may be especially effective for the treatment of anxiety symptoms among individuals with CAD, as it encourages in-the-moment ecologically relevant exposure to anxiety-provoking stimuli. Despite no significant group difference in baseline anxiety symptoms, the MDD group did not have a significant reduction in their anxiety symptoms across the study period, and some individuals had an increase in anxiety. Findings may point to opportunities for the augmentation of BA gaming apps for those with MDD to more effectively target anxiety symptoms. Overall, findings suggest there may be value in considering comorbidities and individual variations in participants when developing scalable mobile interventions for perinatal populations. %R 10.2196/59154 %U https://formative.jmir.org/2025/1/e59154 %U https://doi.org/10.2196/59154 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e62930 %T Exploring Dance as a Therapeutic Approach for Parkinson Disease Through the Social Robotics for Active and Healthy Ageing (SI-Robotics): Results From a Technical Feasibility Study %A Bevilacqua,Roberta %A Maranesi,Elvira %A Benadduci,Marco %A Cortellessa,Gabriella %A Umbrico,Alessandro %A Fracasso,Francesca %A Melone,Giovanni %A Margaritini,Arianna %A La Forgia,Angela %A Di Bitonto,Pierpaolo %A Potenza,Ada %A Fiorini,Laura %A La Viola,Carlo %A Cavallo,Filippo %A Leone,Alessandro %A Caroppo,Andrea %A Rescio,Gabriele %A Marzorati,Mauro %A Cesta,Amedeo %A Pelliccioni,Giuseppe %A Riccardi,Giovanni Renato %A Rossi,Lorena %K Parkinson disease %K rehabilitation %K Irish dancing %K balance %K gait %K socially interacting robot %D 2025 %7 14.1.2025 %9 %J JMIR Aging %G English %X Background: Parkinson disease (PD) is a progressive neurodegenerative disorder characterized by motor symptoms. Recently, dance has started to be considered an effective intervention for people with PD. Several findings in the literature emphasize the necessity for deeper exploration into the synergistic impacts of dance therapy and exergaming for PD management. Moreover, socially engaging robotic platforms equipped with advanced interaction and perception features offer potential for monitoring patients’ posture and enhancing workout routines with tailored cues. Objective: This paper presents the results of the Social Robotics for Active and Healthy Ageing (SI-Robotics) project, aimed at designing an innovative rehabilitation program targeted at seniors affected by (early-stage) PD. This study therefore aims to assess the usefulness of a dance-based rehabilitation program enriched by artificial intelligence–based exergames and contextual robotic assistance in improving motor function, balance, gait, and quality of life in patients with PD. The acceptability of the system is also investigated. Methods: The study is designed as a technical feasibility pilot to test the SI-Robotics system. For this study, 20 patients with PD were recruited. A total of 16 Irish dance–based rehabilitation sessions of 50 minutes were conducted (2 sessions per week, for 8 wks), involving 2 patients at a time. The designed rehabilitation session involves three main actors: (1) a therapist, (2) a patient, and (3) a socially interacting robot. To stimulate engagement, sessions were organized in the shape of exergames where an avatar shows patients the movements they should perform to correctly carry out a dance-based rehabilitation exercise. Results: Statistical analysis reveals a significant difference on the Performance-Oriented Mobility Assessment scale, both on balance and gait aspects, together with improvements in Short Physical Performance Battery, Unified Parkinson Disease Rating Scale–III, and Timed Up and Go test, underlying the usefulness of the rehabilitation intervention on the motor symptoms of PD. The analysis of the Unified Theory of Acceptance and Use of Technology subscales provided valuable insights into users’ perceptions and interactions with the system. Conclusions: This research underscores the promise of merging dance therapy with interactive exergaming on a robotic platform as an innovative strategy to enhance motor function, balance, gait, and overall quality of life for patients grappling with PD. Trial Registration: ClinicalTrials.gov NCT05005208; https://clinicaltrials.gov/study/NCT05005208 %R 10.2196/62930 %U https://aging.jmir.org/2025/1/e62930 %U https://doi.org/10.2196/62930 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e58421 %T Predicting Age and Visual-Motor Integration Using Origami Photographs: Deep Learning Study %A Huang,Chien-Yu %A Yu,Yen-Ting %A Chen,Kuan-Lin %A Lien,Jenn-Jier %A Lin,Gong-Hong %A Hsieh,Ching-Lin %K artificial intelligence %K origami %K child development screening %K child development %K visual motor integration %K children %K developmental status %K activity performance %K deep learning %D 2025 %7 10.1.2025 %9 %J JMIR Form Res %G English %X Background: Origami is a popular activity among preschool children and can be used by therapists as an evaluation tool to assess children’s development in clinical settings. It is easy to implement, appealing to children, and time-efficient, requiring only simple materials—pieces of paper. Furthermore, the products of origami may reflect children’s ages and their visual-motor integration (VMI) development. However, therapists typically evaluate children’s origami creations based primarily on their personal background knowledge and clinical experience, leading to subjective and descriptive feedback. Consequently, the effectiveness of using origami products to determine children’s age and VMI development lacks empirical support. Objective: This study had two main aims. First, we sought to apply artificial intelligence (AI) techniques to origami products to predict children’s ages and VMI development, including VMI level (standardized scores) and VMI developmental status (typical, borderline, or delayed). Second, we explored the performance of the AI models using all combinations of photographs taken from different angles. Methods: A total of 515 children aged 2-6 years were recruited and divided into training and testing groups at a 4:1 ratio. Children created origami dogs, which were photographed from 8 different angles. The Beery–Buktenica Developmental Test of Visual-Motor Integration, 6th Edition, was used to assess the children’s VMI levels and developmental status. Three AI models—ResNet-50, XGBoost, and a multilayer perceptron—were combined sequentially to predict age z scores and VMI z scores using the training group. The trained models were then tested using the testing group, and the accuracy of the predicted VMI developmental status was also calculated. Results: The R2 of the age and the VMI trained models ranged from 0.50 to 0.73 and from 0.50 to 0.66, respectively. The AI models that obtained an R2>0.70 for the age model and an R2>0.60 for the VMI model were selected for model testing. Those models were further examined for the accuracy of the VMI developmental status, the correlations, and the mean absolute error (MAE) of both the age and the VMI models. The accuracy of the VMI developmental status was about 71%-76%. The correlations between the final predicted age z score and the real age z score ranged from 0.84 to 0.85, and the correlations of the final predicted VMI z scores to the real z scores ranged from 0.77 to 0.81. The MAE of the age models ranged from 0.42 to 0.46 and those of the VMI models ranged from 0.43 to 0.48. Conclusion: Our findings indicate that AI techniques have a significant potential for predicting children’s development. The insights provided by AI may assist therapists in better interpreting children’s performance in activities. %R 10.2196/58421 %U https://formative.jmir.org/2025/1/e58421 %U https://doi.org/10.2196/58421 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e53045 %T Tongue Muscle Training App for Middle-Aged and Older Adults Incorporating Flow-Based Gameplay: Design and Feasibility Pilot Study %A Su,Kuan-Chu %A Wu,Ko-Chiu %A Chou,Kuei-Ru %A Huang,Chia-Hsu %K exergame %K mobile app %K flow %K self-care %K feasibility %K older adults %K dysphagia %K tongue exercises %D 2025 %7 9.1.2025 %9 %J JMIR Serious Games %G English %X Background: Complications due to dysphagia are increasingly prevalent among older adults; however, the tediousness and complexity of conventional tongue rehabilitation treatments affect their willingness to rehabilitate. It is unclear whether integrating gameplay into a tongue training app is a feasible approach to rehabilitation. Objective: Tongue training has been proven helpful for dysphagia treatment. Following the development of a tongue training app, a feasibility trial aimed to identify physiological and psychological factors that affect user and flow experience and explored whether training specialized muscles could produce a flow experience for optimal immersion. We aimed to provide a useful tool for medical rehabilitation so that older adults could retain tongue muscle flexibility. Methods: After consulting professional nurses, we developed a mobile gaming app for middle-aged and older adults to train their tongue muscles. This pilot study used an image recognition system to detect the tongue movements of 32 healthy middle-aged and older adults (7 males, 21.9%; 25 females, 78.1%) during 3 game training tasks, each requiring different reaction speeds. Their physiological and psychological signals, as well as the results of the Flow State Scale 2 (FSS2) questionnaire, were used for correlation analysis regarding relevant flow experiences to establish and evaluate the feasibility of our method. Results: Through exploratory factor analyses, a 2-factor (operation and immersion) structure was confirmed to have an adequate model fit (χ²36=448.478; P<.001; Kaiser-Meyer-Olkin=0.757) and internal consistency reliability (Cronbach α=0.802). The slow, medium, and fast levels all significantly affected the FSS2 score for operation (P=.001), the National Aeronautics and Space Administration Task Load Index (P<.001), and flow distance (P<.001). K-means clustering revealed that participants could be further categorized into 3 groups. Through the analysis of changes in the participants’ physiological and psychological signals for each given task, Pearson correlation indicated that changes were primarily related to flow distance. For the 12 indicators measured in this study, the low, medium, and high operation groups showed significance in 58% (7/12), 50% (6/12), and 25% (3/12) of the indicators, respectively. Similarly, the low, medium, and high immersion groups had changes in 50% (6/12), 33% (4/12), and 17% (2/12) of indicators, respectively. Conclusions: Our research supports the further development of a gaming app to aid older adults with tongue muscle training and measure flow using physiological and psychological signals to enhance training accuracy and feasibility. Next, we aim to conduct a randomized pilot trial, improve app functions, offer alternative rehabilitation options, and encourage long-term participation. Future goals include enhancing long-term efficacy, diversifying training modes, and adding a multiuser interactive option for an added challenge. %R 10.2196/53045 %U https://games.jmir.org/2025/1/e53045 %U https://doi.org/10.2196/53045 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e63461 %T Virtual Reality High-Intensity Interval Training Exergaming Compared to Traditional High-Intensity Circuit Training Among Medical Students: Pilot Crossover Study %A Merola,Pietro %A Cardoso,Marcos Barros %A Barreto,Gabriel %A Chagas,Matheus Carvalho %A Farias Oliveira Saunders,Luana %A Saunders,Bryan %A Cortozi Berton,Danilo %K virtual reality %K VR %K high-intensity interval training %K exercise motivation %K exergame %K physical activity %K exercise %K heart rate %D 2025 %7 7.1.2025 %9 %J JMIR Serious Games %G English %X Background: This study evaluated the effectiveness of a virtual reality (VR) high-intensity interval training (HIIT) boxing protocol compared to traditional high-intensity circuit training (HICT) in improving exercise motivation, engagement, and physiological responses among 30 healthy medical students. Objective: The purpose was to compare the VR HIIT protocol, which involved using an Oculus Quest 2 for a futuristic exoskeleton game experience, with a traditional 12-exercise HICT. Methods: In total, 30 medical students engaged in both VR HIIT, using an Oculus Quest 2 for a futuristic exoskeleton game experience, and a traditional 12-exercise HICT. Metrics included heart rate (HR) and blood lactate levels before and after exercise alongside ratings of perceived exertion and the Situational Motivation Scale. Results: VR HIIT showed significantly higher mean HR (mean 161, SD 15 vs mean 144, SD 11 bpm; d=1.5; P<.001), peak HR (mean 182, SD 15 vs mean 176, SD 11 bpm; d=0.8; P=.001), and ratings of perceived exertion (mean 16, SD 2 vs mean 15, SD 2; d=0.4; P=.03). Postexercise lactate levels were higher in HICT (mean 8.8, SD 4.5 vs mean 10.6, SD 3.0 mmol/L; d=0.6; P=.006). Intrinsic motivation and other psychological measures showed no significant differences, except for lower fatigue in HICT (d=0.5; P=.02). Conclusions: VR HIIT significantly enhances physiological parameters while maintaining intrinsic motivation, making it a viable alternative to traditional HICT. However, the short-term nature of this study is a limitation, and future research should explore the long-term engagement and therapeutic impacts of VR exercise in diverse and clinical populations. %R 10.2196/63461 %U https://games.jmir.org/2025/1/e63461 %U https://doi.org/10.2196/63461 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e58422 %T Factors That Influence Young Adults’ Preferences for Virtual Reality Exergames in a Weight Control Setting: Qualitative Study %A Chen,Yanya %A Guan,Lina %A Wu,Weixin %A Ye,Liang %A He,Yan %A Zheng,Xiaofen %A Li,Sicun %A Guan,Bingsheng %A Ming,Wai-kit %+ Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, To Yuen Building, 31 To Yuen Street, Hong Kong, China (Hong Kong), 852 56117116, wkming2@cityu.edu.hk %K virtual reality %K games %K weight control %K preferences %K young adults %K qualitative research %D 2024 %7 30.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Obesity could compromise people’s health and elevate the risk of numerous severe chronic conditions and premature mortality. Young adults are at high risk of adopting unhealthy lifestyles related to overweight and obesity, as they are at a phase marked by several significant life milestones that have been linked to weight gain. They gain weight rapidly and excess adiposity mostly accrues, compared with middle-aged and older adults when weight stabilizes or even decreases. Virtual reality exergames have the potential to increase physical activity in people’s daily lives. However, the factors that influence young adults’ preference for using virtual reality exergames for weight control remain unclear. Objective: The objective of this study is to identify, characterize, and explain the factors influencing young adults' preference for weight control using virtual reality exergames. Methods: This qualitative study used semistructured interviews. In total, 4 focus group interviews were conducted with 23 young adults aged between 18 and 25 years. The qualitative data were analyzed using the Colaizzi phenomenological methodology. Results: In total, 3 major factors were found to influence young adults’ preference for virtual reality exergames in weight control settings: individual factors, social or environmental factors, and expectations of virtual reality exergames. Individual factors included experience with previous weight control methods, previous experience with virtual reality, psychological status, attitudes toward personal BMI, preference for exercise type, and acceptance of virtual reality exergames. Social or environmental factors included social definitions of beauty, weather or public health events, and knowledge of virtual reality provided. Expectations of virtual reality exergames included cost of the device, the fun of virtual reality exergames, supervision, modality of virtual reality exergames, feedback after exercise, convenience to use, and weight loss effect. Conclusions: Young adults take various factors into account when deciding whether to use virtual reality exergames for weight control. These factors can inform the development and further refinement of devices, guides, and policies related to virtual reality exergames for controlling weight. %M 39753223 %R 10.2196/58422 %U https://www.jmir.org/2024/1/e58422 %U https://doi.org/10.2196/58422 %U http://www.ncbi.nlm.nih.gov/pubmed/39753223 %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 e59053 %T Use of Serious Games in Interventions of Executive Functions in Neurodiverse Children: Systematic Review %A Rodríguez Timaná,Luis Carlos %A Castillo García,Javier Ferney %A Bastos Filho,Teodiano %A Ocampo González,Alvaro Alexander %A Hincapié Monsalve,Nazly Rocio %A Valencia Jimenez,Nicolas Jacobo %+ Faculty of Engineering, Universidad Santiago de Cali, Calle 5 # 62-00 - Pampalinda, Santiago de Cali, 763022, Colombia, 57 3234664283, luis.rodriguez11@usc.edu.co %K executive functions %K neurodiversity %K serious games %K cognitive training %K therapeutic interventions %D 2024 %7 18.12.2024 %9 Review %J JMIR Serious Games %G English %X Background: Serious games (SG) have emerged as promising tools for cognitive training and therapeutic interventions, especially for enhancing executive functions. These games have demonstrated the potential to support individuals with diverse health conditions, including neurodevelopmental and cognitive disorders, through engaging and interactive experiences. However, a comprehensive understanding of the effectiveness of SG in enhancing executive functions is needed. Objective: This systematic review aims to assess the impact of serious games on executive functions (EF), focusing on attention, working memory, cognitive flexibility, and inhibitory control. In addition, it explores the integration of SG into educational and therapeutic settings for individuals with cognitive and neurodevelopmental conditions. Only open access articles published from 2019 to the search date were included to capture the most recent advancements in the field. Methods: A comprehensive search was conducted on June 20, 2024, across Scopus, Web of Science, and PubMed databases. Due to limited direct results linking SG and neurodiversity, separate searches were performed to analyze the relationship between SG and EF, as well as SG and neurodiverse populations. Two independent reviewers assessed the quality and risk of bias of the included studies using the Risk of Bias 2 tool for randomized studies and the Risk of Bias in Non-Randomized Studies of Interventions tool for nonrandomized studies. Results: The review identified 16 studies that met the inclusion criteria. Of these, 15 addressed the use of SG for improving EF in neurodiverse populations, such as children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and down syndrome. These studies demonstrated significant improvements in various EF domains, including attention, working memory, and cognitive flexibility. However, there was notable heterogeneity in sample sizes, participant ages, and game types. Three studies specifically focused on individuals with down syndrome, showing promising results in improving cognitive functions. Conclusions: SG hold considerable potential as therapeutic tools for enhancing EF across neurodiverse populations. They have shown positive effects in improving cognitive skills and promoting inclusion in both educational and therapeutic settings. However, further research is required to optimize game design, assess long-term outcomes, and address the variability in study quality. The exclusive inclusion of open access studies may have limited the scope of the review, and future research should incorporate a broader range of studies to provide a more comprehensive understanding of SG’s impact on neurodiversity. Trial Registration: PROSPERO CRD42024563231; https://tinyurl.com/ycxdymyb %M 39693133 %R 10.2196/59053 %U https://games.jmir.org/2024/1/e59053 %U https://doi.org/10.2196/59053 %U http://www.ncbi.nlm.nih.gov/pubmed/39693133 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63760 %T Open-World Games’ Affordance of Cognitive Escapism, Relaxation, and Mental Well-Being Among Postgraduate Students: Mixed Methods Study %A Anto,Ailin %A Basu,Arunima %A Selim,Rania %A Foscht,Thomas %A Eisingerich,Andreas Benedikt %+ Faculty of Medicine, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2AZ, United Kingdom, 44 020 7589 5111, ailin.anto18@imperial.ac.uk %K open-world games %K cognitive escapism %K relaxation %K mental well-being %K students %K video games %K stress %K freedom to explore %D 2024 %7 17.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Open-world games, characterized by their expansive and interactive environments, may offer unique cognitive escapism opportunities, potentially leading to relaxation and enhanced well-being. These games, such as “The Legend of Zelda: Breath of the Wild” and “The Legend of Zelda: Tears of the Kingdom,” allow players to experience a sense of freedom and autonomy, which can reduce stress and improve mental health. While previous research has examined the general impact of video games on mental well-being, specific studies on the effects of open-world games among postgraduate students are limited. Objective: This study aims to investigate the relationships between cognitive escapism provided by open-world games and their effects on relaxation and well-being. The goal was to understand how the immersive nature of these games contributes to stress reduction and overall mental health improvement among postgraduate students. Methods: A mixed methods approach was used, which involved in-depth exploratory qualitative interviews and a survey of 609 players of popular open-world games. Quantitative data were collected using standardized questionnaires to measure open-world games’ affordance of cognitive escapism, relaxation, and well-being. Qualitative data were obtained through 32 in-depth interviews that explored players’ experiences and perceptions of cognitive escapism, relaxation, and mental well-being. Results: Qualitative data (n=32; n=15, 47% female; n=16, 50% male; n=1, 3% preferred not to disclose gender; mean age 23.19, SD 2.19 y) revealed that cognitive escapism through immersive game worlds allowed players to temporarily disconnect from real-world stressors, resulting in enhanced mood and psychological well-being. Players indicated that the nonlinear gameplay and freedom to explore interactive environments provided a sense of relaxation and mental rejuvenation. Quantitative analysis (N=609) showed a substantial mediating role of relaxation in the relationship between cognitive escapism offered by open-world games and well-being. Specifically, cognitive escapism had a significant positive effect on players’ relaxation (β=.15; SE 0.04; P<.001; 95% CI 0.0695-0.2331), which in turn had a significant and positive effect on players’ well-being scores (β=.12; SE 0.04; P=.002; 95% CI 0.0445-0.2032). Conclusions: The study demonstrates that open-world games offer substantial benefits for cognitive escapism, significantly improving relaxation and well-being among postgraduate students. The immersive and autonomous nature of these games is crucial in reducing stress and enhancing mental health. Future research may investigate the long-term effects of regular engagement with open-world games and explore their potential therapeutic applications for managing stress and anxiety. %M 39689301 %R 10.2196/63760 %U https://www.jmir.org/2024/1/e63760 %U https://doi.org/10.2196/63760 %U http://www.ncbi.nlm.nih.gov/pubmed/39689301 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52340 %T Evaluation of a New Mobile Virtual Reality Setup to Alter Pain Perception: Pilot Development and Usability Study in Healthy Participants %A Knobel,Samuel E J %A Oberson,Raphael %A Räber,Jonas %A Schütz,Narayan %A Egloff,Niklaus %A Botros,Angela %A Gerber,Stephan M %A Nef,Tobias %A Heydrich,Lukas %K immersive virtual reality %K embodiment %K pain management %K chronic pain %K full-body illusion %K cardiovisual illusion %K pain %K virtual reality %K pilot study %K development %K mobile virtual reality %K mobile %K virtual environment %K usability %K heart rate %K mobile phone %D 2024 %7 11.12.2024 %9 %J JMIR Serious Games %G English %X Background: Chronic pain presents a significant treatment challenge, often leading to frustration for both patients and therapists due to the limitations of traditional methods. Research has shown that synchronous visuo-tactile stimulation, as used in the rubber hand experiment, can induce a sense of ownership over a fake body part and reduces pain perception when ownership of the fake body part is reported. The effect of the rubber hand experiment can be extended to the full body, for example, during the full-body illusion, using both visuo-tactile and cardiovisual signals. Objective: This study first aimed to evaluate the usability and accuracy of a novel, mobile virtual reality (VR) setup that displays participants’ heartbeats as a flashing silhouette on a virtual avatar, a technique known as the cardiovisual full-body illusion. The second part of the study investigated the effects of synchronous cardiovisual stimulation on pain perception and ownership in 20 healthy participants as compared with asynchronous stimulation (control condition). Methods: The setup comprised a head-mounted display (HMD) and a heart rate measurement device. A smartphone-based HMD (Samsung Galaxy S8+) was selected for its mobility, and heart rates were measured using smartwatches with photoplethysmography (PPG). The accuracy of 2 smartwatch positions was compared with a 5-point electrocardiogram (ECG) standard in terms of their accuracy (number and percent of missed beats). Each participant underwent two 5-minute sessions of synchronous cardiovisual stimulation and two 5-minute sessions of asynchronous cardiovisual stimulation (total of 4 sessions), followed by pain assessments. Usability, symptoms of cybersickness, and ownership of the virtual body were measured using established questionnaires (System Usability Scale, Simulator Sickness Questionnaire, Ownership Questionnaire). Pain perception was assessed using advanced algometric methods (Algopeg and Somedic algometer). Results: Results demonstrated high usability scores (mean 4.42, SD 0.56; out of 5), indicating ease of use and acceptance, with minimal side effects (mean 1.18, SD 0.46; out of a possible 4 points on the Simulator Sickness Questionnaire). The PPG device showed high heart rate measurement precision, which improved with optimized filtering and peak detection algorithms. However, compared with previous work, no significant effects on body ownership and pain perception were observed between the synchronous and asynchronous conditions. These findings are discussed in the context of existing literature on VR interventions for chronic pain. Conclusions: In conclusion, while the new VR setup showed high usability and minimal side effects, it did not significantly affect ownership or pain perception. This highlights the need for further research to refine VR-based interventions for chronic pain management, considering factors like visual realism and perspective. %R 10.2196/52340 %U https://games.jmir.org/2024/1/e52340 %U https://doi.org/10.2196/52340 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e63143 %T Optimizing a Novel Smartphone App to Prevent Postpartum Depression Adapted From an Evidence-Based Cognitive Behavioral Therapy Program: Qualitative Study %A Lewkowitz,Adam K %A Guillen,Melissa %A Ursino,Katrina %A Baker,Rackeem %A Lum,Liana %A Battle,Cynthia L %A Ware,Crystal %A Ayala,Nina K %A Clark,Melissa %A Ranney,Megan L %A Miller,Emily S %A Guthrie,Kate M %K cognitive behavioral therapy %K mothers and babies program %K digital health %K postpartum depression %K smartphone application %K FRAME for intervention adaptation %K Framework for Modification and Adaptation %K behavioral therapy %K mental health apps %D 2024 %7 9.12.2024 %9 %J JMIR Hum Factors %G English %X Background: Low-income pregnant patients are at high risk of postpartum depression (PPD). Mothers and Babies (MB) is a cognitive behavioral therapy–based program that prevents up to 50% of de novo PPD when provided in person to low-income Spanish- and English-speaking people who are pregnant without depression. MB is limited by the need for trained personnel to support it. Transforming MB into a smartphone app may mitigate this key barrier. Objective: We aimed to use qualitative data from target end users to create and optimize MBapp, a novel app centered on the MB program. Methods: Draft wireframes of MBapp were created in English and Spanish with cognitive behavioral therapy–based modules adapted from MB. These wireframes included several features shown previously to sustain app engagement: (1) push notifications delivered at participant-preferred times; (2) text-, graphic-, and video-based content; and (3) gamification with digital rewards for app engagement. English- or Spanish-speaking individuals with public health insurance who were between 32 weeks gestation and 6 months post partum and owned smartphones were eligible to consent for individual in-depth interviews. Individuals with prior or current depression were excluded. Interviews were recorded, transcribed, and analyzed using deductive and inductive codes to characterize opinions about MBapp and perceptions of challenges and facilitators of use of MBapp or other perinatal or mental health apps. End user feedback led to major modifications to the wireframes. Each of these changes was categorized according to the FRAME (Framework for Modification and Adaptation), an established method of systematically reporting adaptations and modifications to evidence-based interventions via end user feedback. Recruitment ceased with content saturation, defined as 3 successive participants providing only positive feedback on MBapp’s wireframe, without further suggestions for improvement. Results: A total of 25 interviews were completed. Participants were racially and ethnically diverse, generally representing our target end user population, and 48% (n=12) of interviews were conducted in Spanish. Participants’ suggestions to improve MBapp were categorized within the FRAME as adaptations that improved either content or context to optimize reach, retention, engagement, and fit for end users. Specifically, the following features were added to MBapp secondary to end user feedback: (1) audio narration; (2) “ask a clinician” nonurgent questions; (3) on-demand module summaries accessible upon module completion; and (4) choice to defer assessments and start the next module. Participants also provided insights into features of perinatal or mental health apps they found appealing or unappealing to understand preferences, challenges, and negotiables or nonnegotiables for MBapp. Conclusions: Adapting MBapp to incorporate end users’ perspectives optimized our digital PPD prevention intervention, ideally increasing its appeal to future users. Our team’s next steps will confirm that MBapp is a feasible, acceptable intervention among English- and Spanish-speaking perinatal people at risk of PPD. %R 10.2196/63143 %U https://humanfactors.jmir.org/2024/1/e63143 %U https://doi.org/10.2196/63143 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56598 %T High-Frequency Cognitive Control Training for Depression: Case Report %A Vander Zwalmen,Yannick %A Hoorelbeke,Kristof %A Demeester,David %A Koster,Ernst H W %+ Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 92649107, y.vander.zwalmen@ugent.be %K cognitive control training %K CCT %K cognitive function %K depression %K recurrence %K relapse %K prevention %K case report %K working memory %K memory training %K task performance %K digital health %D 2024 %7 29.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Cognitive control training (CCT) has gained attention in recent years as a preventative intervention in the context of major depressive disorder. To date, uncertainty exists around the working mechanisms of CCT and how its effects unfold overtime. Objective: This study aimed to examine cognitive and affective transfer effects following an unusually high number of training sessions. Methods: This case report presents data of a participant completing a large amount of training sessions (n=55) over the course of 1 year in 2 training phases: 10 initial sessions, followed by 45 additional sessions. Reliable change indices were calculated for several self-report questionnaires, measuring cognitive and affective functioning. Results: Cognitive task performance suggests improved cognitive functioning after training (accuracy scores increased from 43/181, 24% at baseline to 110/181, 61% shortly after training), which was maintained at follow-up (accuracy scores around 50%). Reliable change indices suggest a decrease in depressive symptoms (Beck Depression Inventory-II score decreased from 23 at baseline to 3 following initial training). Similarly, burnout symptoms following CCT showed a similar decrease. Maladaptive emotion regulation strategies displayed high variability, decreasing after periods of training but increasing when no training was performed. However, no changes in repetitive negative thinking were observed. Thematic analysis from an in-depth interview focusing on CCT adherence and user experience pointed to the importance of independency and accessibility of CCT in perceived agency, as well as the need for clear feedback mechanisms following training. Conclusions: Training task performance indicates further increases in performance beyond typical amounts of training sessions (10-20 sessions), hinting that more sessions could be beneficial for continued improvement in cognitive functioning. In line with previous research, CCT decreased depressive symptomatology. However, its effects on emotion regulation remain unclear. Further mechanistic studies into the temporal unfolding of CCT effects are necessary to investigate potential working mechanisms. Trial Registration: ClinicalTrials.gov NCT05166798; https://clinicaltrials.gov/study/NCT05166798 %M 39612206 %R 10.2196/56598 %U https://formative.jmir.org/2024/1/e56598 %U https://doi.org/10.2196/56598 %U http://www.ncbi.nlm.nih.gov/pubmed/39612206 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58499 %T Avatar Intervention in Virtual Reality for Cannabis Use Disorder in Individuals With Severe Mental Disorders: Results From a 1-Year, Single-Arm Clinical Trial %A Giguere,Sabrina %A Beaudoin,Mélissa %A Dellazizzo,Laura %A Phraxayavong,Kingsada %A Potvin,Stéphane %A Dumais,Alexandre %K cannabis use disorder %K cannabis use %K virtual reality therapy %K virtual reality %K addiction intervention %K relational therapy %K avatar %K digital mental health %D 2024 %7 27.11.2024 %9 %J JMIR Ment Health %G English %X Background: The dual diagnosis of cannabis use disorder (CUD) and severe mental disorder (SMD) results in clinically complex individuals. Cannabis use is known to have negative consequences on psychiatric symptoms, medication compliance, and disease prognosis. Moreover, the effectiveness of currently available psychotherapeutic treatments is limited in this population. In this context, our research team developed avatar intervention, an approach using virtual reality as a therapeutic tool to treat CUD in individuals with SMD. Objective: This pilot clinical trial aimed to evaluate, until the 1-year follow-up, the efficacy of avatar intervention for CUD among 32 participants with a dual diagnosis of SMD and CUD. Methods: Over the course of the 8 intervention sessions, participants were given the opportunity to enter a dialogue in virtual reality with an avatar representing a person with a significant role in their consumption, who was animated in real time by a therapist. The primary outcomes were the quantity of cannabis consumed and the frequency of use. Secondary outcomes included severity of problematic cannabis use, motivation for change, protective strategies for cannabis use, consequences of cannabis use, psychiatric symptoms, and quality of life. Changes in reported outcomes during the assessment periods before the intervention; postintervention; and 3, 6, and 12 months after the end of the intervention were assessed using a linear mixed-effects model. Results: Significant reductions were observed in the quantity of cannabis consumed, and these were maintained until the 12-month follow-up visit (d=0.804; P<.001; confirmed by urine quantification). Frequency of cannabis use showed a small significant reduction at the 3-month follow-up (d=0.384; P=.03). Moreover, improvements were observed in the severity of CUD, cannabis-related negative consequences, the motivation to change cannabis use, and the strategies used to mitigate harms related to cannabis use. Finally, moderate benefits were observed for quality of life and psychiatric symptoms. Conclusions: Overall, this unique intervention shows promising results that seem to be maintained up to 12 months after the end of the intervention. With the aim of overcoming the methodological limitations of a pilot study, a single-blind randomized controlled trial is currently underway to compare the avatar intervention for CUD with a conventional addiction intervention. Trial Registration: ClinicalTrials.gov NCT05726617; https://clinicaltrials.gov/study/NCT05726617 %R 10.2196/58499 %U https://mental.jmir.org/2024/1/e58499 %U https://doi.org/10.2196/58499 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56810 %T Gaming-Based Tele-Exercise Program to Improve Physical Function in Frail Older Adults: Feasibility Randomized Controlled Trial %A Kannan,Lakshmi %A Sahu,Upasana %A Subramaniam,Savitha %A Mehta,Neha %A Kaur,Tanjeev %A Hughes,Susan %A Bhatt,Tanvi %+ College of Applied Health Sciences, University of Illinois at Chicago, 1919, W Taylor St (M/C 898), Chicago, IL, 60612, United States, 1 3123554443, tbhatt6@uic.edu %K exergame training %K Matter of Balance %K MOB %K pre-frail %K tele-exergame %K tele-rehabilitation %K gaming-based %K tele-exercise %K physical function %K frailty %K older adults %K aging %K physical activity %K dementia %K CogXergaming %K telehealth %K dynamic balance %D 2024 %7 27.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Frailty leads to reduced physical activity can cause increased fall risk. This contributes to accelerated aging processes, leading to adverse health outcomes and reduced quality of life. We have developed and piloted the design, usability, safety, and feasibility of a gaming-based cognitive-motor (CogXergaming) tele-exercise protocol in prefrail older adults. Objective: This pilot randomized control trial tested preliminary feasibility and effectiveness of the CogXergaming telehealth protocol for improving physical function. Methods: Community-dwelling, prefrail older adults were randomly assigned to CogXergaming (n=13) or a control group (n=14). The CogXergaming group received supervised tele-exercises in a gaming format for 6 weeks (3 sessions per week) comprising 18 sessions lasting 90 minutes each. Control group participants participated in a Matter of Balance (MOB), an 8-week, once-a-week structured 90-minute tele-session that has been shown to reduce the fear of falling and increase physical activity. Feasibility of training was obtained by computing the median duration of training sessions for the CogXergaming group. Effectiveness was assessed using dynamic balance control (Four Square Step Test), subjective self-efficacy (Activities-Specific Balance Confidence scale), gait function (Tinetti Performance Oriented Mobility Assessment), muscle strength (30-second chair stand test), and endurance (2-minute step in-place test). Results: Of the 45 participants enrolled in the study, 4 participants from CogXergaming group and 5 from MOB group lost contact after signing the consent form and did not receive their respective intervention. Eighteen participants were randomized to each group. In the CogXergaming group, 15 (83%) completed the intervention, with 3 (16%) dropping out in the first week. In the MOB group, 16 (88%) completed the program, with 2 (11%) withdrawing during the first week. In addition, there was a significant time group interaction for Four Square Step Test (F1,21=5.55, P=.03), Tinetti Performance Oriented Mobility Assessment (F1,25=4.16, P=.05), and 30-second chair stand test (F1,21=5.06, P=.03), with a significant improvement in these measures for the CogXergaming group post training, compared with no change observed in the MOB group. Conclusions: These pilot findings indicate that CogXergaming is feasible and applicable in prefrail older adults. Such game-based protocols can be beneficial in improving physical function among community-dwelling, prefrail older adults, however, the efficacy of such training requires further investigation. Trial Registration: ClinicalTrials.gov NCT04534686; https://clinicaltrials.gov/study/NCT04534686 %M 39602215 %R 10.2196/56810 %U https://www.jmir.org/2024/1/e56810 %U https://doi.org/10.2196/56810 %U http://www.ncbi.nlm.nih.gov/pubmed/39602215 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e57352 %T The Effect of Young People–Assisted, Individualized, Motion-Based Video Games on Physical, Cognitive, and Social Frailty Among Community-Dwelling Older Adults With Frailty: Randomized Controlled Trial %A Wong,Arkers Kwan Ching %A Zhang,Melissa Qian %A Bayuo,Jonathan %A Chow,Karen Kit Sum %A Wong,Siu Man %A Wong,Bonnie Po %A Liu,Bob Chung Man %A Lau,David Chi Ho %A Kowatsch,Tobias %K frailty %K gaming intervention %K motion-based %K video games %K older adults %K gerontology %K geriatrics %K randomized controlled trial %K RCT %K physical fitness %K adolescents %K young people–assisted %K eHealth literacy %K well-being %K therapists %K youth volunteers %K social support %K exergames %K gamification %K active games %K physical activity %D 2024 %7 20.11.2024 %9 %J JMIR Serious Games %G English %X Background: The aging population highlights the need to maintain both physical and psychological well-being. Frailty, a multidimensional syndrome, increases vulnerability to adverse outcomes. Although physical exercise is effective, adherence among older adults with frailty is often low due to barriers. Motion-based video games (MBVGs) may enhance motivation and engagement. Objective: This study aims to evaluate the effect of individualized exercise programs that combine MBVGs, intergenerational support, and therapeutic frameworks on physical, cognitive, and social frailty outcomes in community-dwelling older adults. Methods: This randomized controlled trial was conducted from March 2022 to October 2023 across 6 community centers in Hong Kong. Participants aged 60 years and above with mild neurocognitive disorder were recruited, screened, and randomly assigned to either an intervention (n=101) or control group (n=101). The intervention included an 18-week program with 12 supervised exercise sessions utilizing motion-based technology, led by occupational therapists and assisted by youth volunteers. Data were collected at baseline (T1) and postintervention (T2), focusing on physical, cognitive, and social frailty outcomes, as well as client-related metrics. Statistical analyses were performed using SPSS, with significance set at P<.05. Results: A total of 202 participants were recruited, with a mean age of 78.8 years (SD 7.8). Both groups showed improvements in balance from T1 to T2, with a significant time effect (β=−0.63, P=.03). The intervention group demonstrated enhancements in hand strength and BMI, but no statistically significant between-group differences were observed. The intervention group also exhibited significant improvements in cognitive function (β=2.43, P<.001), while the control group’s scores declined. Short-term memory improved for both groups, with no significant differences noted. Both groups experienced a reduction in depression levels, with a significant within-group effect at T2 (β=−1.16, P=.001). Improvements in social connectedness and eHealth literacy were observed in both groups, with the latter showing a significant within-group effect at T2 (β=3.56, P=.002). No significant effects were found for social isolation, physical activities, or quality of life. Conclusions: The growing aging population necessitates innovative strategies to support aging in place. Results indicated statistically significant improvements only in BMI and cognition, while other outcomes such as loneliness, balance, and eHealth literacy showed positive trends but lacked significance. Despite the limitations observed, particularly regarding the role of volunteer support and the diverse needs of community-dwelling older adults, the findings contribute to the foundation for future research aimed at enhancing biopsychosocial outcomes. Future studies should explore tailored interventions that consider individual preferences and abilities, as well as evaluate specific components of motion-based video games to optimize their effectiveness. Trial Registration: ClinicalTrials.gov NCT05267444; https://clinicaltrials.gov/study/NCT05267444 %R 10.2196/57352 %U https://games.jmir.org/2024/1/e57352 %U https://doi.org/10.2196/57352 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e47754 %T Effectiveness of Game-Based Training of Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Randomized Multiple Baseline Design Study %A Fahr,Annina %A Kläy,Andrina %A Coka,Larissa S %A van Hedel,Hubertus J A %+ Swiss Children's Rehab, University Children's Hospital Zurich, Mühlebergstrasse 104, Affoltern am Albis, 8910, Switzerland, 41 44 762 52 91, hubertus.vanhedel@kispi.uzh.ch %K neurorehabilitation %K single-case design %K interactive computer play %K cerebral palsy %K surface electromyography %K motor control %K mirror movements %K involuntary movements %D 2024 %7 18.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Selective voluntary motor control (SVMC) is the ability to control joint movements independently. Impairments in SVMC can affect functional activities, but only a few interventions directly target SVMC. Therefore, we developed a game-based intervention for children with upper motor neuron lesions to improve SVMC. The intervention trained selective activation of a muscle or joint movement while providing immediate feedback about involuntarily occurring muscle activations or movements in another joint. The intervention was provided in a playful manner with a custom-made game environment and a technology-based interface to capture muscle activation or joint movements. Objective: This study aimed to investigate the effectiveness of this game-based intervention and explore treatment response–related factors in children with impaired SVMC undergoing inpatient neurorehabilitation. Methods: We conducted a single-case research study with a randomized, nonconcurrent, multiple baseline design. The study consisted of a random-length baseline phase where no SVMC-specific intervention was provided and an intervention phase with additional SVMC training. Concurrently in both phases, children attended their individual multimodal rehabilitation program at our clinic, Swiss Children’s Rehab. During the intervention phase, participants completed ten 45-minute sessions with our game-based SVMC training. SVMC was measured repeatedly throughout both phases and at the 3-month follow-up with a short custom-made assessment. Results: Eighteen children with reduced SVMC from upper motor neuron lesions participated in the study. The mean age of the children was 12.7 (SD 2.9) years, and they mostly had spastic cerebral palsy. A linear mixed-effects model revealed a significant trend (P<.001) for improved SVMC already in the baseline phase. This trend did not change significantly (P=.15) when the game-based SVMC training was introduced in the intervention phase, suggesting no additional improvements due to the SVMC training. Although we could not find an overall treatment effect, we could explain 89.4% of the total random variation of the treatment effect by patient and therapy characteristics. Children with spasticity in the trained movement (20.1%), and those who trained the more affected side (23.5%) benefited most from the intervention. At the 3-month follow-up, SVMC had deteriorated compared to the end of the intervention but was still better than at the beginning of the study. Conclusions: The regular concomitant rehabilitation program already yielded improvements in SVMC, while the game-based SVMC training showed no additional effects. Although the intervention did not show a group effect, we could identify patient and therapy characteristics that determine who is likely to profit from the intervention. Trial Registration: German Clinical Trials Register DRKS00025184; https://tinyurl.com/msnkek9b %M 39556826 %R 10.2196/47754 %U https://formative.jmir.org/2024/1/e47754 %U https://doi.org/10.2196/47754 %U http://www.ncbi.nlm.nih.gov/pubmed/39556826 %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 %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56201 %T Facilitating Thought Progression to Reduce Depressive Symptoms: Randomized Controlled Trial %A Yatziv,Shai-Lee %A Pedrelli,Paola %A Baror,Shira %A DeCaro,Sydney Ann %A Shachar,Noam %A Sofer,Bar %A Hull,Sunday %A Curtiss,Joshua %A Bar,Moshe %+ The Leslie and Susan Gonda Brain Science Center, Bar- Ilan University Building number 901, Ramat-Gan, 5290002, Israel, 972 35317795, moshe.bar@biu.ac.il %K depression %K cognitive neuroscience %K facilitating thought progression %K FTP %K mobile phone %K digital health %K gamification %K depression symptoms %K randomized controlled trial %K RCT %K app %K depressive disorder %K web-based platforms %K effectiveness %D 2024 %7 7.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The constant rise in the prevalence of major depressive disorder calls for new, effective, and accessible interventions that can rapidly and effectively reach a wide range of audiences. Recent developments in the digital health domain suggest that dedicated online platforms may potentially address this gap. Focusing on targeting ruminative thought, a major symptomatic hallmark of depression, in this study we hypothesized that delivering a digital health–based intervention designed to systematically facilitate thought progression would substantially alleviate depression. Objective: The study aims to investigate the efficacy of a novel digital intervention on the reduction of depressive symptoms. This intervention was designed as an easy-to-use gamified app specifically aimed to facilitate thought progression through intense practicing of associative, semantically broad, fast, and creative thought patterns. Methods: A randomized clinical trial was conducted, comparing changes in depression symptoms between participants who used the app in the intervention group (n=74) and waitlist control group (n=27) over the course of 8 weeks. All participants filled out a battery of clinical questionnaires to assess the severity of depression at baseline and 4 and 8 weeks after starting the study. These primarily included the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 as well as the Positive Affect Negative Affect Scale-Negative Affect Score, Ruminative Response Scale, and Symptoms of Depression Questionnaire. Additional questionnaires were implemented to assess anxiety, positive affect, anhedonia, and quality of life. Results: The results indicate that across multiple clinical measurements, participants in the intervention group who played the gamified app showed greater and faster improvement in depressive symptoms compared with their waitlist control counterparts. The difference between the groups in MADRS improvement was –7.01 points (95% CI –10.72 to –3.29; P<.001; Cohen d=0.67). Furthermore, the difference in improvement between groups persisted up to 4 weeks posttrial (MADRS differences at week 12: F49,2=6.62; P=.003; ηp2=0.21). At the end of the trial, participants who played the app showed high interest in continuing using the app. Conclusions: The results demonstrate that a gamified app designed to facilitate thought progression is associated with improvement in depressive symptoms. Given its innovative and accessibility features, this gamified method aiming to facilitate thought progression may successfully complement traditional treatments for depression in the future, providing a safe and impactful way to enhance the lives of individuals experiencing depression and anxiety. Trial Registration: ClinicalTrials.gov NCT05685758; https://clinicaltrials.gov/study/NCT05685758 %M 39350528 %R 10.2196/56201 %U https://www.jmir.org/2024/1/e56201 %U https://doi.org/10.2196/56201 %U http://www.ncbi.nlm.nih.gov/pubmed/39350528 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e63296 %T Risk Perception and Knowledge Following a Social Game–Based Tobacco Prevention Program for Adolescents: Pilot Randomized Comparative Trial %A Khalil,Georges %A Ramirez,Erica %A Khan,Meerah %A Zhao,Bairu %A Ribeiro,Nuno %A Balian,Patrick %+ Department of Health Outcomes and Biomedical Informatics, University of Florida, Malachowsky Hall for Data Science and Information Technology, 1889 Museum Rd, Suite 7000, Gainesville, FL, 32603, United States, 1 3526279467, gkhalil@ufl.edu %K tobacco prevention %K vaping %K combustible tobacco %K risk perception %K adolescent %K games %K social interaction %D 2024 %7 5.11.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescence is a critical developmental stage that is particularly vulnerable to the initiation of tobacco use. Despite the well-documented health risks associated with tobacco use, it remains prevalent among adolescents. Games for health are a promising strategy for tobacco prevention, using experiential and social learning theories to enhance engagement and improve behavior change. Objective: This pilot study aims to (1) compare the social game–based program Storm-Heroes to a nonsocial program regarding adolescents’ personal and social experiences and (2) examine how these experiences predict higher tobacco knowledge and perceived risks of vaping and conventional tobacco use. Methods: In a cluster-randomized comparative design, 4 after-school sites (N=79 adolescents) were recruited in person and randomized in a single-blinded format to 1 of 2 interventions: the social game Storm-Heroes (44/79, 56%) or the nonsocial program A Smoking Prevention Interactive Experience (ASPIRE; 35/79, 44%). A study team member supervised both interventions. Data were collected at baseline, immediate follow-up, and a 1.5-month follow-up (45/74, 61% retained). Repeated measures mixed effects models were conducted. Results: A total of 45 participants continued until the 1.5-month follow-up. Participants in the Strom-Heroes group were more likely to increase their perceived risk of vaping (B=0.40; P<.001), perceived risk of conventional tobacco use (B=0.35; P=.046), and tobacco knowledge (B=1.63; P<.001) than those in the control condition. The usability level of the program was related to a higher perceived risk of vaping (B=0.16; P=.003) and conventional tobacco use (B=0.16; P=.02) by follow-up. Attention to the program was also related to higher perceived risk of vaping (B=0.12; P=.002) and conventional tobacco use (B=0.14; P<.001). Distraction was not related to either perceived risk of vaping (P=.15) or perceived risk of conventional tobacco use (P=.71). In contrast, both more attention (B=0.60; P<.001) and less distraction (B=–0.37; P<.001) were related to higher tobacco knowledge. Conclusions: The increased perceived risk of vaping and conventional tobacco among Storm-Heroes participants aligns with the program’s goals of improving participants’ awareness of the risks associated with tobacco use and their tobacco knowledge. However, distraction weakened the effect of the program on tobacco knowledge, indicating that emphasis needs to be placed on minimizing distraction for better outcomes. With the results of this study, researchers can work to advance the current version of Storm-Heroes and amplify engagement in the program to improve its potential for preventing adolescents’ initiation of tobacco use. Trial Registration: ClinicalTrials.gov NCT02703597; https://clinicaltrials.gov/study/NCT02703597 %M 39499912 %R 10.2196/63296 %U https://games.jmir.org/2024/1/e63296 %U https://doi.org/10.2196/63296 %U http://www.ncbi.nlm.nih.gov/pubmed/39499912 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52153 %T Sensing In Exergames for Efficacy and Motion Quality: Scoping Review of Recent Publications %A Dill,Sebastian %A Müller,Philipp Niklas %A Caserman,Polona %A Göbel,Stefan %A Hoog Antink,Christoph %A Tregel,Thomas %+ KIS*MED (AI Systems in Medicine), Technical University of Darmstadt, Merckstraße 25, Darmstadt, 64283, Germany, 49 61511623754, dill@kismed.tu-darmstadt.de %K exergame efficacy %K motion quality assessment %K vital signs %K body sensors %K camera %K virtual reality %D 2024 %7 5.11.2024 %9 Review %J JMIR Serious Games %G English %X Background: Many studies have shown a direct relationship between physical activity and health. It has also been shown that the average fitness level in Western societies is lower than recommended by the World Health Organization. One tool that can be used to increase physical activity for individual people is exergaming, that is, serious games that motivate players to do physical exercises. Objective: This scoping review of recent studies regarding exergame efficacy aims to evaluate which sensing modalities are used to assess exergame efficacy as well as motion quality. We also analyze how the collected motion sensing data is being leveraged with respect to exergame efficacy and motion quality assessment. Methods: We conducted 2 extensive and systematic searches of the ACM Digital Library and the PubMed database, as well as a single search of the IEEE Xplore database, all according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Overall, 343 studies were assessed for eligibility by the following criteria: The study should be peer-reviewed; the year of publication should be between 2015 and 2023; the study should be available in English or German; the study evaluates the efficacy of at least 1 exergame; sensor data is recorded during the study and is used for evaluation; and the study is sufficiently described to extract information on the exergames, sensors, metrics, and results. Results: We found 67 eligible studies, which we analyzed with regard to sensor usage for both efficacy evaluation and motion analysis. Overall, heart rate (HR) was the most commonly used vital sign to evaluate efficacy (n=52), while the Microsoft Kinect was the most commonly used exergame sensor (n=26). The results of the analysis show that the sensors used in the exergames and the sensors used in the evaluation are, in most cases, mutually exclusive, with motion quality rarely being considered as a metric. Conclusions: The lack of motion quality assessment is identified as a problem both for the studies and the exergames themselves since incorrectly executed motions can reduce an exergame’s effectiveness and increase the risk of injury. Here we propose how to use the same sensors both as input for the exergame and to assess motion quality by presenting recent developments in motion recognition and sensing. %M 39499916 %R 10.2196/52153 %U https://games.jmir.org/2024/1/e52153 %U https://doi.org/10.2196/52153 %U http://www.ncbi.nlm.nih.gov/pubmed/39499916 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59490 %T Interaction Effects Between Low Self-Control and Meaning in Life on Internet Gaming Disorder Symptoms and Functioning in Chinese Adolescents: Cross-Sectional Latent Moderated Structural Equation Modeling Study %A Fong,Ted CT %A Cui,Kunjie %A Yip,Paul SF %+ Research Institute of Social Development, Southwestern University of Finance and Economics, No. 555 Liutai Road, Wenjiang District, Chengdu, 611100, China, 86 17512828565, cuikunjie@swufe.edu.cn %K Chinese %K impulsivity %K interaction effects %K internet gaming disorder %K latent moderation %K meaning in life %K self-control %K temper %D 2024 %7 4.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet gaming disorder (IGD) is an emerging behavioral addiction with mental health implications among adolescents. Low self-control is an established risk factor of IGD. Few studies have, however, examined the moderating role of meaning in life (MIL) on the relationships between low self-control and IGD symptoms and functioning. Objective: This study aimed to examine the effects of low self-control and MIL and their interaction effects on IGD symptoms and family and school functioning in a structural equation model. Methods: A sample of 2064 adolescents (967, 46.9% male; mean age 14.6 years) was recruited by multistage cluster random sampling from 5 middle schools in Sichuan, China, in 2022. The participants completed a self-report questionnaire with validated measures on low self-control, presence of MIL, search for MIL, IGD symptoms, school commitment, and family functioning. Construct validity, measurement invariance, and structural invariance of the measures were evaluated by confirmatory factor analysis across sex. Structural equation modeling was conducted to examine the indirect effects of low self-control and MIL on family and school functioning through IGD symptoms. Latent moderated structural equation modeling was performed to examine the interaction effects between low self-control and MIL on IGD symptoms, school commitment, and family functioning. Results: All scales showed satisfactory model fit and scalar measurement invariance by sex. Males showed significantly greater IGD symptoms and lower levels of self-control (Cohen d=0.25-1.20, P<.001) than females. IGD symptoms were significantly and positively associated with impulsivity (β=.20, P=.01), temper (β=.25, P<.001), and search for meaning (β=.11, P=.048) and significantly and negatively associated with presence of meaning (β=–.21, P<.001). Presence of MIL and impulsivity showed a significant and negative interaction effect (β=–.11, SE .05; P=.03) on IGD symptoms. The positive effect of impulsivity on IGD symptoms was stronger among adolescents with low presence of MIL than those with high presence of MIL. Temper showed significant and positive interaction effects with presence of MIL (β=.08, SE .04; P=.03) and search for MIL (β=.08, SE .04; P=.04) on family functioning. The negative effects of temper on family functioning were stronger among adolescents with low levels of MIL than among those with high levels of MIL. Conclusions: This study provides the first findings on the interaction effects between low self-control and presence of MIL and search for MIL on IGD symptoms and functioning among a large sample of adolescents in rural China. The results have implications for targeted interventions to help male adolescents with lower self-control and presence of meaning. %M 39496163 %R 10.2196/59490 %U https://www.jmir.org/2024/1/e59490 %U https://doi.org/10.2196/59490 %U http://www.ncbi.nlm.nih.gov/pubmed/39496163 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57839 %T Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial %A White,Justin S %A Toussaert,Séverine %A Raiff,Bethany R %A Salem,Marie K %A Chiang,Amy Yunyu %A Crane,David %A Warrender,Edward %A Lyles,Courtney R %A Abroms,Lorien C %A Westmaas,J Lee %A Thrul,Johannes %+ Department of Health Law, Policy and Management, Boston University School of Public Health, Talbot Building - 249W, 715 Albany Street, Boston, MA, 02118, United States, 1 617 358 1916, juswhite@bu.edu %K smoking cessation %K mobile app %K games for health %K gamification %K engagement %K randomized controlled trial %K mobile phone %D 2024 %7 30.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphone apps are a convenient, low-cost approach to delivering smoking cessation support to large numbers of individuals. Yet, the apps are susceptible to low rates of user engagement and retention. Objective: This study aims to test the effects of a new game module (called Inner Dragon) integrated into Smoke Free (23 Limited), a leading smoking cessation app with established efficacy. The primary outcomes measured user engagement with the app. Methods: A 2-arm, parallel-group, randomized controlled trial was conducted in the United States with an 8-week follow-up. Adult individuals who smoked ≥1 cigarettes daily and planned to quit smoking within 7 days were recruited and randomized (N=500), with equal allocation. Both groups received free access to the original Smoke Free app with “core” features of its smoking cessation program (eg, a diary and craving log). The treated group received additional access to the integrated Inner Dragon game that incorporated several game mechanics designed to increase user engagement. User engagement outcomes were the number of unique app sessions, average minutes per session, days with a session, and program adherence. Self-reported and verified smoking abstinence and app satisfaction were also assessed. The main analysis estimated the intention-to-treat effect of access to Inner Dragon on each outcome. Further analyses assessed effect modification by participant characteristics and the association of intensity of game use with program adherence and abstinence. Results: Overall, user engagement was greater for treated versus control participants: they had 5.3 more sessions of Smoke Free (mean 29.6, SD 36.5 sessions vs mean 24.3, SD 37.9 sessions; P=.06), 0.8 more minutes per session (mean 6.9, SD 5.4 min vs mean 6.1, SD 5.2 min; P=.047), and 3.4 more days with a session (mean 14.3, SD 15.3 days vs mean 11.9, SD 14.3 days; P=.03). Program adherence, based on the number of times core features of the original Smoke Free app were used, was higher for treated versus control participants (mean 29.4, SD 41.3 times vs mean 22.6, SD 35.6 times; P=.03). Self-reported 7-day and 30-day point-prevalence abstinence and verified 7-day point-prevalence abstinence at 8 weeks did not significantly differ by study group. The mean repeated 1-day prevalence of quitting was higher among the treated group versus the control group (mean 17.3%, SD 25.6 vs mean 12.4%, SD 21.3; P=.01). App satisfaction and the motivation to (stay) quit did not differ by study group. Higher intensity of game use was associated with increased program adherence and self-reported abstinence. Conclusions: Findings suggest that the Inner Dragon game increased user engagement and program adherence. Additional refinements to the game design may clarify whether the game increases abstinence rates. Overall, it is feasible to deploy games and gamification to enhance user engagement in existing smoking cessation interventions. Trial Registration: ClinicalTrials.gov NCT05227027; https://clinicaltrials.gov/study/NCT05227027 %M 39475840 %R 10.2196/57839 %U https://www.jmir.org/2024/1/e57839 %U https://doi.org/10.2196/57839 %U http://www.ncbi.nlm.nih.gov/pubmed/39475840 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e59141 %T Home-Based, Low-Intensity, Gamification-Based, Interactive Physical-Cognitive Training for Older Adults Using the ADDIE Model: Design, Development, and Evaluation of User Experience %A Kamnardsiri,Teerawat %A Kumfu,Sirintip %A Munkhetvit,Peeraya %A Boripuntakul,Sirinun %A Sungkarat,Somporn %K exergame %K physical-cognitive training %K computer-based interventions %K gamification %K older adults %K instructional design model %K low-intensity %D 2024 %7 29.10.2024 %9 %J JMIR Serious Games %G English %X Background: Declines in physical and cognitive function are natural biological processes, leading to an increased risk of falls. Promising evidence suggests that combined physical-cognitive exercise has beneficial effects in improving both physical and cognitive health. Although moderate-to-high exercise intensity is commonly recommended, it might be impractical for older adults facing physical limitations or contraindications. Thus, low-intensity exercise is a viable option. The main barriers to engaging in exercise in older adults include transportation, time, motivation, and enjoyment. To overcome these challenges, a home-based, gamification-based training system may provide an effective approach to enhance exercise adherence. Objective: This study aimed to develop and evaluate the usability of a low-intensity, gamification-based, interactive physical-cognitive exercise for older adults in a home-based setting. Methods: The prototype of a game-based physical-cognitive exercise was created following the ADDIE model (analysis, design, development, implementation, and evaluation) and assessed for user experience in older adults. A total of 15 older adults engaged in the game-based physical-cognitive exercise at home for 60 minutes per day, 3 days per week, for 4 weeks. The usability of the game-based training system was evaluated using the system usability scale (SUS) after completion of a 4-week training program. As for satisfaction, the 8-item Physical Activity Enjoyment Scale (PACES) questionnaire was used to assess participants’ enjoyment level after 1 week and 4 weeks of training. Descriptive statistics were used to illustrate the SUS score. A Wilcoxon signed-rank test was used to compare the PACES scores between the first week and the end of the 4-week period, with significance set at P<.05. Results: As for experts’ consensus, the game-based training consisted of 3 games: Ocean Diver, Road Runner, and Moving and Memorizing. The games had 3 levels of difficulty: beginner, intermediate, and advanced. A computer vision–based system was selected as the delivery platform for a home setting. The total SUS score for all participants was mean 87.22 (SD 5.76), indicating the user’s perception of the usability of a system ranging from good to excellent. At the end of the 4-week training, the total PACES score was significantly greater than the first week, suggesting an improvement in enjoyment (first week: mean 44.93, SD 3.99 vs fourth week: mean 50.53, SD 4.70; P=.001). Conclusions: The prototype of low-intensity, gamification-based, interactive physical-cognitive training was designed and developed using the ADDIE model, which included both experts and end users in the process. The findings showed that the exergame prototype was a usable and practical approach for a home-based setting, enhancing older adults’ enjoyment and motivation. Further research is warranted to determine the effectiveness of such gamification-based training in promoting physical and cognitive functions. %R 10.2196/59141 %U https://games.jmir.org/2024/1/e59141 %U https://doi.org/10.2196/59141 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e58963 %T Empowering Social Growth Through Virtual Reality–Based Intervention for Children With Attention-Deficit/Hyperactivity Disorder: 3-Arm Randomized Controlled Trial %A Wong,Ka Po %A Zhang,Bohan %A Lai,Cynthia Yuen Yi %A Xie,Yao Jie %A Li,Yan %A Li,Chen %A Qin,Jing %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Room GH329, 3rd Floor, Block G, 11 Yuk Choi Rd, Hung Hom, Hong Kong, 000000, China (Hong Kong), 852 64860214, portia.wong@polyu.edu.hk %K attention deficit and hyperactivity disorder %K virtual reality %K social skills %K social skills training %K emotional control %K social growth %K digital world %K social learning theory %D 2024 %7 28.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) usually begins in childhood and is often accompanied by impairments in social functioning. Virtual reality (VR) has emerged as an adjunctive tool to embed in social skills training to enhance the social skills of children with ADHD, but its effectiveness requires further investigation. Objective: This study aims to enhance the social skills of children with ADHD by examining the feasibility and effectiveness of VR-based training in comparison to traditional social skills training. Methods: A 3-arm randomized controlled trial was conducted with 90 children with ADHD aged 6-12 years. Participants were randomly assigned to 3 weeks of 12-session VR-based social skills training, traditional social skills training, or a waitlist control group of equivalent duration. Outcome measures included assessments by a clinical psychologist who was blinded to group assignments, the Social Skills Improvement System Rating Scale, the Behavior Rating Inventory of Executive Function, and the Simulator Sickness Questionnaire, conducted at baseline and after the intervention. Results: The preliminary results support the feasibility and acceptability of VR training for children with ADHD aged 6-12 years. Analysis showed that the VR and traditional social skills training groups experienced a statistically significant improvement in the clinical psychologist assessment of social skills and parent-rated self-control, initiative, and emotional control after the intervention compared with baseline. The VR group performed significantly better than the traditional social skills group on social skills assessed by clinical psychologists (F2,85=76.77; P<.001) and on parent-rated self-control (F2,85=18.77; P<.001), initiative (F2,85=11.93; P<.001), and emotional control (F2,85=17.27; P<.001). No significant between-group differences were found for parent-rated cooperation and inhibition (all P>.05). Conclusions: The findings provide preliminary evidence supporting the feasibility and superior effectiveness of VR-based social skills training compared to traditional approaches for enhancing social skills and related executive functions in children with ADHD. These results suggest that VR may be a valuable tool to embed within social skills interventions for this population. Further research is warranted to explore the long-term impacts and generalizability of these benefits. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): RR2-10.2196/48208 %M 39467288 %R 10.2196/58963 %U https://games.jmir.org/2024/1/e58963 %U https://doi.org/10.2196/58963 %U http://www.ncbi.nlm.nih.gov/pubmed/39467288 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53683 %T Exploring Immersive Multimodal Virtual Reality Training, Affective States, and Ecological Validity in Healthy Firefighters: Quasi-Experimental Study %A Oliveira,Joana %A Aires Dias,Joana %A Correia,Rita %A Pinheiro,Raquel %A Reis,Vítor %A Sousa,Daniela %A Agostinho,Daniel %A Simões,Marco %A Castelo-Branco,Miguel %+ Coimbra Institute for Biomedical Imaging and Translational Research, Institute for Nuclear Sciences Applied to Health, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, Coimbra, 3000-548, Portugal, 351 239488514, mcbranco@fmed.uc.pt %K virtual reality %K firefighter %K training %K posttraumatic stress disorder %K PTSD %K emotion %K situational awareness %K engagement %K ecological validity %K multivariate approach %D 2024 %7 24.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Firefighters face stressful life-threatening events requiring fast decision-making. To better prepare for those situations, training is paramount, but errors in real-life training can be harmful. Virtual reality (VR) simulations provide the desired realism while enabling practice in a secure and controlled environment. Firefighters’ affective states are also crucial as they are a higher-risk group. Objective: To assess the impact on affective states of 2 simulated immersive experiences in a sample of healthy firefighters (before, during, and after the simulation), we pursued a multivariate approach comprising cognitive performance, situational awareness, depression, anxiety, stress, number of previous adverse events experienced, posttraumatic stress disorder (PTSD) severity, and emotions. The efficacy and ecological validity of an innovative VR haptic system were also tested, exploring its impact on performance. Methods: In collaboration with the Portuguese National Fire Service School, we exposed 22 healthy firefighters to 2 immersive scenarios using the FLAIM Trainer VR system (neutral and arousing scenarios) while recording physiological data in a quasi-experimental study. Baseline cognitive performance, depression, anxiety, stress, number of adverse events, and severity of PTSD symptoms were evaluated. Positive and negative affective states were measured before, between, and after each scenario. Situational awareness, sense of presence, ecological validity, engagement, and negative effects resulting from VR immersion were tested. Results: Baseline positive affect score was high (mean 32.4, SD 7.2) and increased after the VR tasks (partial η2=0.52; Greenhouse-Geisser F1.82,32.78=19.73; P<.001). Contrarily, mean negative affect score remained low (range 11.0-11.9) throughout the study (partial η2=0.02; Greenhouse-Geisser F2.13,38.4=0.39; P=.69). Participants’ feedback on the VR sense of presence was also positive, reporting a high sense of physical space (mean score 3.9, SD 0.8), ecological validity (mean score 3.8, SD 0.6), and engagement (mean score 3.8, SD 0.6). Engagement was related to the number of previously experienced adverse events (r=0.49; P=.02) and positive affect (after the last VR task; r=0.55; P=.02). Conversely, participants reported few negative effects (mean score 1.7, SD 0.6). The negative effects correlated positively with negative affect (after the last VR task; r=0.53; P=.03); and avoidance (r=0.73; P<.001), a PTSD symptom, controlling for relevant baseline variables. Performance related to situational awareness was positive (mean 46.4, SD 34.5), although no relation was found to metacognitively perceived situational awareness (r=–0.12; P=.59). Conclusions: We show that VR is an effective alternative to in-person training as it was considered ecologically valid and engaging while promoting positive emotions, with few negative repercussions. This corroborates the use of VR to test firefighters’ performance and situational awareness. Further research is needed to ascertain that firefighters with PTSD symptomatology are not negatively affected by VR. This study favors the use of VR training and provides new insights on its emotional and cognitive impact on the trainee. %M 39446479 %R 10.2196/53683 %U https://games.jmir.org/2024/1/e53683 %U https://doi.org/10.2196/53683 %U http://www.ncbi.nlm.nih.gov/pubmed/39446479 %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 e54968 %T Serious Game Development for Public Health: Participatory Design Approach to COVID-19 Quarantine Policy Education %A Kwak,Myunghwan %A Kim,Byeong-Je %A Chung,Ji-Bum %K online learning %K serious game %K simulation %K quarantine policy %K social distancing policy %K game %K public health education %K infectious diseases %K learner-centric %D 2024 %7 15.10.2024 %9 %J JMIR Serious Games %G English %X Background: Public health education plays a crucial role in effectively addressing infectious diseases such as COVID-19. However, existing educational materials often provide only foundational information, and traditional group education faces challenges due to social distancing policies. Objective: Addressing these gaps, our study introduces a serious game called “Flattening the Curve.” This interactive experience immerses learners in the role of quarantine policy managers, offering unique insights into the effects and challenges of social distancing policies. Methods: The development of the game adhered to the SERES framework, ensuring a scientifically designed foundation. To achieve its learning objectives, the game incorporated learning and game mechanics including an agent-based infection model, a social distancing policy model, and an economic model, which were developed based on previous literature. After defining a broad concept of scientific and design foundations, we used a participatory design process. This study included 16 undergraduates and took place over one semester. Participants played the game, gave feedback, and answered surveys. The game was improved based on participants’ feedback throughout the process. Participants’ feedback was analyzed based on the Design, Play, and Experience framework. Surveys were conducted before and after the activity and analyzed to assess participants’ evaluation of and satisfaction with the game. Results: The game successfully achieved its learning objectives, encompassing a comprehensive understanding of infectious disease characteristics; the disease transmission process; the necessity and efficacy of quarantine policies and their delicate balance with economic factors; and the concept of flattening the curve. To achieve this, the game includes the following: (1) an agent-based infection model based on the modified Susceptible-Exposed-Infectious-Hospitalized-Recovered (SEIHR) model with five infectious disease scenarios; (2) a quarantine policy model with social distancing, travel control, and intensive care unit management; and (3) an economic model that allows users to consider the impact of quarantine policies on a community’s economy. In response to participatory design feedback, the game underwent meticulous modifications, including refining game systems, parameters, design elements, the user interface, and interactions. Key feedback included requests for more scenarios and engaging yet simple game elements, as well as suggestions for improving the scoring system and design features. Notably, concerns about the fairness of the outcome evaluation system (star rating system), which could incentivize prioritizing economic activity over minimizing casualties, were raised and addressed by replacing the star rating system with a progress-based vaccine development system. Quantitative evaluation results reflect participants’ positive assessments of the game through the learner-centric approach. Conclusions: The serious game “Flattening the Curve,” developed through a participatory design approach, emerges as a valuable tool for public health education, particularly concerning social distancing policies. The game and its source code are openly accessible online, enabling widespread use for research and educational purposes. %R 10.2196/54968 %U https://games.jmir.org/2024/1/e54968 %U https://doi.org/10.2196/54968 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e55333 %T Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale %A Flato,Uri Adrian Prync %A Beffa dos Santos,Emilio José %A Bispo Diaz T Martins,Isabella %A Rossignoli,Vinicius Gazin %A Dias Midega,Thais %A Kallas-Silva,Lucas %A Ferreira Mendes de Oliveira,Ricardo %A do Socorro Lima Figueiredo Flato,Adriana %A Vicente Guimarães,Mario %A Penna Guimarães,Hélio %K cardiopulmonary resuscitation %K basic life support %K serious game %K CPR training %K usability %K cardiopulmonary %K emergency %K life support %K CPR %K training %K education %K game %K gaming %K educational %K resuscitation %K survey %K satisfaction %K SUS %K user experience %K System Usability Scale %D 2024 %7 9.10.2024 %9 %J JMIR Serious Games %G English %X %R 10.2196/55333 %U https://games.jmir.org/2024/1/e55333 %U https://doi.org/10.2196/55333 %0 Journal Article %@ 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 %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53577 %T Impact of Video-Based Error Correction Learning for Cardiopulmonary Resuscitation Training: Quasi-Experimental Study %A Wang,Yun %A Fu,Junzuo %A Wang,Shaoping %A Wang,Huijuan %A Gao,Wei %A Huang,Lina %K video-based error correction %K video-prompting %K cardiopulmonary resuscitation training %K anesthesiology resident %K quasi-experimental study %K anesthesiology %K cardiopulmonary %K cardiopulmonary resuscitation %K training %K video %K learning %K residents %K CPR training %K CPR %K video prompting %D 2024 %7 3.10.2024 %9 %J JMIR Serious Games %G English %X Background: Video-based error correction (VBEC) in medical education could offer immediate feedback, promote enhanced learning retention, and foster reflective practice. However, its application in cardiopulmonary resuscitation (CPR) training has not been investigated. Objective: The objective of this study is to assess whether the VBEC procedure could improve the training performance of CPR among anesthesiology residents. Methods: A quasi-experimental study was conducted among anesthesiology residents between December 2022 and April 2023. Primary outcomes included a posttraining knowledge test and practical assessment scores. Secondary outcomes included the number of residents who correctly conducted CPR at each step, the rate of common mistakes during the CPR process, and the self-assessment results. A total of 80 anesthesiology residents were divided into a VBEC group (n=40) and a control group (n=40). The VBEC group underwent a 15-minute VBEC CPR training, whereas the control group underwent a 15-minute video-prompting CPR training. Results: The posttraining knowledge test score of the VBEC group was significantly higher than that of the control group (73, SD 10.5 vs 65.1, SD 11.4; P=.002). The residents in the VBEC group had lower error rates in “failure to anticipate the next move” (n=3, 7.5% vs n=13, 32.5%; P=.01) and “failure to debrief or problem solve after the code” (n=2, 5% vs n=11, 27.5%; P=.01), as well as better performance in the “secure own safety” step (n=34, 85% vs n=18, 45%; P<.001) than those in the control group. The VBEC group showed significantly higher confidence in CPR than the control group (n=?, 62.5% vs n=?, 35%; P=.03). Conclusions: VBEC may be a promising strategy compared to video prompting for CPR training among anesthesiology residents. %R 10.2196/53577 %U https://games.jmir.org/2024/1/e53577 %U https://doi.org/10.2196/53577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52323 %T Game-Based Assessment of Peripheral Neuropathy Combining Sensor-Equipped Insoles, Video Games, and AI: Proof-of-Concept Study %A Ming,Antao %A Clemens,Vera %A Lorek,Elisabeth %A Wall,Janina %A Alhajjar,Ahmad %A Galazky,Imke %A Baum,Anne-Katrin %A Li,Yang %A Li,Meng %A Stober,Sebastian %A Mertens,Nils David %A Mertens,Peter Rene %+ University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Otto von Guericke University Magdeburg, Leipziger Straße 44, Magdeburg, 39120, Germany, 49 391 6713236, peter.mertens@med.ovgu.de %K diabetes mellitus %K metabolic syndrome %K peripheral neuropathy %K sensor-equipped insoles %K video games %K machine learning %K feature extraction %D 2024 %7 1.10.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Detecting peripheral neuropathy (PNP) is crucial in preventing complications such as foot ulceration. Clinical examinations for PNP are infrequently provided to patients at high risk due to restrictions on facilities, care providers, or time. A gamified health assessment approach combining wearable sensors holds the potential to address these challenges and provide individuals with instantaneous feedback on their health status. Objective: We aimed to develop and evaluate an application that assesses PNP through video games controlled by pressure sensor–equipped insoles. Methods: In the proof-of-concept exploratory cohort study, a complete game-based framework that allowed the study participant to play 4 video games solely by modulating plantar pressure values was established in an outpatient clinic setting. Foot plantar pressures were measured by the sensor-equipped insole and transferred via Bluetooth to an Android tablet for game control in real time. Game results and sensor data were delivered to the study server for visualization and analysis. Each session lasted about 15 minutes. In total, 299 patients with diabetes mellitus and 30 with metabolic syndrome were tested using the game application. Patients’ game performance was initially assessed by hypothesis-driven key capabilities that consisted of reaction time, sensation, skillfulness, balance, endurance, and muscle strength. Subsequently, specific game features were extracted from gaming data sets and compared with nerve conduction study findings, neuropathy symptoms, or disability scores. Multiple machine learning algorithms were applied to 70% (n=122) of acquired data to train predictive models for PNP, while the remaining data were held out for final model evaluation. Results: Overall, clinically evident PNP was present in 247 of 329 (75.1%) participants, with 88 (26.7%) individuals showing asymmetric nerve deficits. In a subcohort (n=37) undergoing nerve conduction study as the gold standard, sensory and motor nerve conduction velocities and nerve amplitudes in lower extremities significantly correlated with 79 game features (|R|>0.4, highest R value +0.65; P<.001; adjusted R2=0.36). Within another subcohort (n=173) with normal cognition and matched covariates (age, sex, BMI, etc), hypothesis-driven key capabilities and specific game features were significantly correlated with the presence of PNP. Predictive models using selected game features achieved 76.1% (left) and 81.7% (right foot) accuracy for PNP detection. Multiclass models yielded an area under the receiver operating characteristic curve of 0.76 (left foot) and 0.72 (right foot) for assessing nerve damage patterns (small, large, or mixed nerve fiber damage). Conclusions: The game-based application presents a promising avenue for PNP screening and classification. Evaluation in expanded cohorts may iteratively optimize artificial intelligence model efficacy. The integration of engaging motivational elements and automated data interpretation will support acceptance as a telemedical application. %M 39353184 %R 10.2196/52323 %U https://www.jmir.org/2024/1/e52323 %U https://doi.org/10.2196/52323 %U http://www.ncbi.nlm.nih.gov/pubmed/39353184 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47141 %T Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation %A Taj,Umar %A Grimani,Aikaterini %A Read,Daniel %A Vlaev,Ivo %K behavior change %K experimental modeling %K gamification %K medication adherence %K antibiotics %K games %K medication %K testing behavior %K clinical outcome %K simulate %K diagnosis %K devices %K symptoms %K tool %D 2024 %7 24.9.2024 %9 %J JMIR Serious Games %G English %X Background: Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach “gamified behavioral simulation.” In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions. Objective: This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence. Methods: A laboratory experiment was conducted using a modified popular and addictive open-source video game called “2048,” which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups (“incentive” group, “reminder” group, “commitment device” group, and “elongated duration for symptoms” group). Results: The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI −33.97% to −11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen. Conclusions: Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial. %R 10.2196/47141 %U https://games.jmir.org/2024/1/e47141 %U https://doi.org/10.2196/47141 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e54082 %T Acceptability of a Serious Game About Proton Radiotherapy Designed for Children Aged 5 to 14 Years and Its Potential Impact on Perceived Anxiety: Feasibility and Randomized Controlled Pilot Trial %A Cederved,Catarina %A Ljungman,Gustaf %A Back,Jon %A Ångström-Brännström,Charlotte %A Engvall,Gunn %K anxiety %K feasibility %K acceptability %K pediatric oncology %K psychological preparation %K proton radiotherapy %K serious game %K games %K cancer %D 2024 %7 23.9.2024 %9 %J JMIR Serious Games %G English %X Background: Children who are going to undergo radiotherapy have displayed fear and anxiety. Therefore, a web-based serious game was developed as a psychological preparation to investigate if it could affect anxiety levels. In an earlier stage, children with experience of radiotherapy had been part of the developmental process. Objective: The study aimed to investigate the feasibility in terms of reach, usability, and acceptability of a serious game about proton radiotherapy and to pilot that it did not increase anxiety levels in children aged 5 to 14 years undergoing radiotherapy. Methods: The design was a randomized controlled pilot trial with predefined feasibility criteria. In total, 28 children were assessed for eligibility, and 23 met the inclusion criteria. They were consecutively randomized into 1 of 2 study arms. One child was excluded after randomization. If randomized into arm 1, the children received the intervention before treatment started. Children in arm 2 were treated as controls. Questionnaires with fixed answers were used to assess anxiety levels (an adapted version of the State-Trait Anxiety Inventory for Children) and experiences of gameplay (an adapted version of Player Experience of Need Satisfaction [PENS]). The children were asked to answer questionnaires at 5 different measurement occasions during their radiotherapy treatment. Results: In arm 1, age ranged from 5 to 13 (mean 8.4, SD 2.4) years. In arm 2, age ranged from 5 to 11 (mean 7.6, SD 2.3) years. The sample consisted of 15 girls and 7 boys. The feasibility criterion that the children should play the game for 20 minutes or more was not met. Mean playtime for children in arm 1 was 32.1 (SD 23.8) minutes, where 18 children had played for at least 15 minutes. The criterion that 70% (n=16) or more of the participants should return all of the questionnaires was not met; however, more than 73% (n=16) returned the PENS questionnaires. The State-Trait Anxiety Inventory for Children was returned by 73% (n=16) on day 0, 77% (n=17) on day 1, 82% (n=18) on day 3, 82% (n=18) on day 6, and 86% (n=19) on day 15. Conclusions: All feasibility criteria set for the study were not met, suggesting that adaptions need to be made if a future study is to be undertaken. Further, the analysis revealed that there was no indication that playing increased the children’s self-reported anxiety. The PENS questionnaire adapted for children showed promising results regarding player satisfaction when using the serious game. When studying children with severe conditions and young age, 5 measurement occasions seemed to be too many. Measuring both player satisfaction or experience and knowledge transfer would be preferable in future studies. Trial Registration: ClinicalTrials.gov NCT04728555; https://clinicaltrials.gov/study/NCT04728555 %R 10.2196/54082 %U https://games.jmir.org/2024/1/e54082 %U https://doi.org/10.2196/54082 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e62654 %T Education Program for Enhancing Health Care Students’ Attitudes Toward People Living With Dementia: Protocol for a Single-Arm Pre-Post Study %A Sari,Dianis Wulan %A Kugai,Haruna %A Igarashi,Ayumi %A Takaoka,Manami %A Matsumoto,Hiroshige %A Suzuki,Haruno %A Wu,Jinyan %A Fitryasari,Rizki %A Nasifah,Ike Ayunda %A Has,Eka Mishbahatul M %A Yamamoto-Mitani,Noriko %+ Faculty of Nursing, Universitas Airlangga, jl mulyorejo, Surabaya, 60115, Indonesia, 62 5913257, dianis.wulan.sari@fkp.unair.ac.id %K ageism %K dementia %K health professional %K education program %K long-term care %D 2024 %7 18.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Health care students are instrumental in shaping the future of dementia care. Cultivating a positive attitude and understanding toward people living with dementia is crucial for diminishing the stigma associated with the condition, providing effective and person-centered care, and enhancing the quality of life for people living with dementia. Educational programs about dementia are increasingly recognizing the potential of gaming tools. Objective: This study aimed to evaluate the effectiveness of gaming-based dementia educational programs in improving attitudes toward people living with dementia among health care students. Methods: This single-arm pre-post study will be conducted among health care students in Indonesian universities. This educational program based on gaming tools will consist of a lecture on dementia, the use of N-impro (gaming tool), and the enactment of short dramas depicting desirable and undesirable communication with people living with dementia behaviors. We will assess attitudes toward people living with dementia, intention to help people living with dementia, knowledge of dementia, and the stigma associated with people living with dementia. The gaming-based dementia education program will be integrated into the curriculum of the health care students. The program will be implemented once with a duration of 90 minutes. Results: Data collection will occur from August 2023 to March 2024. Analysis of the data will be finalized by May 2024, and the outcome will be determined by July 2024. The impact of the gaming-based dementia educational program on improving attitudes toward people living with dementia will be reported. The study findings will be published in a peer-reviewed journal. Conclusions: The gaming education program demonstrates significant potential in enhancing attitudes toward people living with dementia across various countries, introducing an innovative method for the community-based support of people living with dementia. Trial Registration: ClinicalTrials.gov NCT06122623; https://clinicaltrials.gov/study/NCT06122623 International Registered Report Identifier (IRRID): DERR1-10.2196/62654 %M 39293050 %R 10.2196/62654 %U https://www.researchprotocols.org/2024/1/e62654 %U https://doi.org/10.2196/62654 %U http://www.ncbi.nlm.nih.gov/pubmed/39293050 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55738 %T Analyzing the Influence of Video Game and Music Engagement on Technical Skills Acquisition in Dental Students in Preclinical Phase: Protocol for a Prospective, Controlled, Longitudinal Study %A Clouet,Roselyne %A Gaudin,Alexis %A Tourtelier,Jeanne %A Gogendeau,Claire %A Serisier,Samuel %A Prud'homme,Tony %+ Nantes Université, CHU Nantes, INSERM, RMeS ( Regenerative Medicine and Skeleton), UMR 1229, UFR Odontologie, 1 place Alexis Ricordeau, Nantes, 44042, France, 33 677489648, tony.prudhomme@univ-nantes.fr %K video game %K music practice %K dental education %K technical skills %K simulation %K video games %K music %K preclinical skills %K dental students %K dental student %K pre-clinical phases %K longitudinal investigation %K dentistry %K gestures %K gesture %K preclinical training %K training %K protocol %K tool %K tools %K cognitive skills, mobile phones %D 2024 %7 13.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The practice of dental surgery requires a few different skills, including mental rotation of an object, precision of movement with good hand-eye coordination, and speed of technical movement. Learning these different skills begins during the preclinical phase of dental student training. Moreover, playing a musical instrument or video game seems to promote the early development of these skills. However, we found that studies specifically addressing this issue in the field of dental education are lacking. Objective: The main aims of this study are to evaluate whether the ability to mentally represent a volume in 3D, the precision of gestures with their right and left hand, or the speed of gesture execution is better at baseline or progresses faster for players (video games or music or both). Methods: A prospective monocentric controlled and longitudinal study will be conducted from September 2023 and will last until April 2025 in the Faculty of Dental Surgery of Nantes. Participants were students before starting their preclinical training. Different tests will be used such as Vandenberg and Kuse’s mental rotation test, the modified Precision Manual Dexterity (PMD), and performing a pulpotomy on a permanent tooth. This protocol was approved by the Ethics, Deontology, and Scientific Integrity Committee of Nantes University (institutional review board approval number IORG0011023). Results: A total of 86 second-year dental surgery students were enrolled to participate in the study in September 2023. They will take part in 4 iterations of the study, the last of which will take place in April 2025. Conclusions: Playing video games or a musical instrument or both could be a potential tool for initiating or facilitating the learning of certain technical skills in dental surgery. International Registered Report Identifier (IRRID): DERR1-10.2196/55738 %M 39269750 %R 10.2196/55738 %U https://www.researchprotocols.org/2024/1/e55738 %U https://doi.org/10.2196/55738 %U http://www.ncbi.nlm.nih.gov/pubmed/39269750 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57809 %T Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial %A Kwan,Rick Yiu Cho %A Liu,Justina %A Sin,Olive Suk Kan %A Fong,Kenneth N K %A Qin,Jing %A Wong,Joe Chi Yin %A Lai,Claudia %+ School of Nursing, Tung Wah College, 31 Wylie Road, Homantin, Hong Kong, NA, China (Hong Kong), 852 34686813, rickkwan@twc.edu.hk %K virtual reality %K motor-cognitive training %K cognitive frailty %K gamification %D 2024 %7 11.9.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear. Objective: This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty. Methods: This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ≥60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time × group) effects on the outcomes. Results: In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2%), had completed primary education (152/293, 52.1%), were married (167/293, 57.2%), lived with friends (127/293, 43.3%), and had no VR experience (232/293, 79.5%). In the intervention group, 81.6% (119/146) of participants attended >80% (13/16, 81%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7% to 5/146, 3%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes. Conclusions: VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living. Trial Registration: ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817 %M 39259959 %R 10.2196/57809 %U https://www.jmir.org/2024/1/e57809 %U https://doi.org/10.2196/57809 %U http://www.ncbi.nlm.nih.gov/pubmed/39259959 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e63505 %T Effectiveness of an mHealth App That Uses Financial Incentives and Gamification to Promote Health Behavior Change in Adolescents and Caregivers: Protocol for a Clinic-Based Randomized Controlled Trial %A Braddock,Amy %A Ghosh,Parijat %A Montgomery,Emma %A Lim,Crystal %A Ghosh,Jaya %A Henry,Nicole %A Popescu,Mihail %A Kimchi,Kimberly %A Guo,Congyu %A Bosworth,K Taylor %A Koopman,Richelle J %+ Family and Community Medicine, University of Missouri, Columbia, MA306, 1 Hospital Drive, Columbia, MO, 65212, United States, 1 5738847733, williamsamy@health.missouri.edu %K mHealth %K adolescents %K apps %K caregivers %K obesity %K healthy lifestyle %K CommitFit %K mobile health %D 2024 %7 10.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers. Objective: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel “CommitFit” mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers. Methods: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates “CommitFit,” which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit$, where adolescents were paid US $0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits. Results: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025. Conclusions: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit. International Registered Report Identifier (IRRID): DERR1-10.2196/63505 %M 39255473 %R 10.2196/63505 %U https://www.researchprotocols.org/2024/1/e63505 %U https://doi.org/10.2196/63505 %U http://www.ncbi.nlm.nih.gov/pubmed/39255473 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e52978 %T COVID-19–Related Social Isolation, Self-Control, and Internet Gaming Disorder Among Chinese University Students: Cross-Sectional Survey %A Guo,Yufang %A Yue,Fangyan %A Lu,Xiangyu %A Sun,Fengye %A Pan,Meixing %A Jia,Yannan %+ School of Nursing and Rehabilitation, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China, 86 15269163352, cdguoyufang@163.com %K COVID-19 pandemic %K internet gaming disorder %K self-control %K social isolation %K university students %K game %K gaming %K games %K addict %K addictive %K addiction %K addictions %K university %K universities %K college %K colleges %K postsecondary %K higher education %K student %K students %K China %K Chinese %K isolation %K isolated %K self-compassion %K mental health %K association %K associations %K correlation %K causal %K correlated %K correlations %D 2024 %7 10.9.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet gaming disorder among university students has become a great concern for university counsellors worldwide since the COVID-19 pandemic. The factors influencing the development of internet gaming disorder in students during the COVID-19 pandemic could be different from those before the pandemic. Objective: This study aims to explore the associations among social isolation, self-control, and internet gaming disorder in Chinese university students and to examine whether self-control mediates the positive effects of social isolation on internet gaming disorder. Methods: A cross-sectional survey was employed to collect data from university students in Shandong province of China from April to September 2022. The Isolation subscale of the Self-Compassion Scale, Self-Control Scale, and Internet Gaming Disorder Scale were used to assess the social isolation, self-control, and internet gaming disorder among university students, respectively. Models 4 and 5 of PROCESS software were used to analyze the mediating role of self-control and the moderating role of gender on the association between social isolation and internet gaming disorder. Results: A total of 479 students were recruited from 6 universities located in 3 different regions of Shandong, China. Students had low levels of internet gaming disorder and moderate levels of social isolation and self-control, with mean scores of 8.94 (SD 9.06), 12.04 (SD 3.53), and 57.15 (SD 8.44), respectively. Social isolation was positively correlated with internet gaming disorder (r=0.217; P<.001), and self-control was negatively correlated with social isolation (r=–0.355; P<.001) and internet gaming disorder (r=–0.260; P<.001). Self-control played a mediating role in the association between social isolation and internet gaming disorder (β=–.185, 95% CI –.295 to –.087). The effects of social isolation on internet gaming disorder among female students were lower than those among male students. Conclusions: Self-control was a mediator in the association between social isolation and internet gaming disorder. Moreover, gender played a moderating role in the association between social isolation and internet gaming disorder. This study highlights the need to alleviate the development of internet gaming disorder among students during a pandemic, especially that of male students. Effective interventions that lessen social isolation and promote self-control should be developed. %M 39255486 %R 10.2196/52978 %U https://www.jmir.org/2024/1/e52978 %U https://doi.org/10.2196/52978 %U http://www.ncbi.nlm.nih.gov/pubmed/39255486 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55613 %T Digital Gamification Tool (Let’s Control Flu) to Increase Vaccination Coverage Rates: Proposal for Algorithm Development %A Lopes,Henrique %A Baptista-Leite,Ricardo %A Hermenegildo,Catarina %A Atun,Rifat %+ NOVA Center for Global Health, NOVA Information Management School, Universidade Nova de Lisboa, Campus de Campolide, Lisbon, 1070-312, Portugal, 351 962499020, hlopes@novaims.unl.pt %K influenza %K gamification %K public health policies %K vaccination coverage rates %K health promotion %D 2024 %7 10.9.2024 %9 Proposal %J JMIR Res Protoc %G English %X Background: Influenza represents a critical public health challenge, disproportionately affecting at-risk populations, including older adults and those with chronic conditions, often compounded by socioeconomic factors. Innovative strategies, such as gamification, are essential for augmenting risk communication and community engagement efforts to address this threat. Objective: This study aims to introduce the “Let’s Control Flu” (LCF) tool, a gamified, interactive platform aimed at simulating the impact of various public health policies (PHPs) on influenza vaccination coverage rates and health outcomes. The tool aligns with the World Health Organization’s goal of achieving a 75% influenza vaccination rate by 2030, facilitating strategic decision-making to enhance vaccination uptake. Methods: The LCF tool integrates a selection of 13 PHPs from an initial set proposed in another study, targeting specific population groups to evaluate 7 key health outcomes. A prioritization mechanism accounts for societal resistance and the synergistic effects of PHPs, projecting the potential policy impacts from 2022 to 2031. This methodology enables users to assess how PHPs could influence public health strategies within distinct target groups. Results: The LCF project began in February 2021 and is scheduled to end in December 2024. The model creation phase and its application to the pilot country, Sweden, took place between May 2021 and May 2023, with subsequent application to other European countries. The pilot phase demonstrated the tool’s potential, indicating a promising increase in the national influenza vaccination coverage rate, with uniform improvements across all targeted demographic groups. These initial findings highlight the tool’s capacity to model the effects of PHPs on improving vaccination rates and mitigating the health impact of influenza. Conclusions: By incorporating gamification into the analysis of PHPs, the LCF tool offers an innovative and accessible approach to supporting health decision makers and patient advocacy groups. It enhances the comprehension of policy impacts, promoting more effective influenza prevention and control strategies. This paper underscores the critical need for adaptable and engaging tools in PHP planning and implementation. International Registered Report Identifier (IRRID): RR1-10.2196/55613 %M 39255031 %R 10.2196/55613 %U https://www.researchprotocols.org/2024/1/e55613 %U https://doi.org/10.2196/55613 %U http://www.ncbi.nlm.nih.gov/pubmed/39255031 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57588 %T Feasibility of At-Home Hand Arm Bimanual Intensive Training in Virtual Reality: Case Study %A Gehringer,James E %A Woodruff Jameson,Anne %A Boyer,Hailey %A Konieczny,Jennifer %A Thomas,Ryan %A Pierce III,James %A Cunha,Andrea B %A Willett,Sandra %+ Virtual Reality Laboratory, Munroe-Meyer Insitute, University of Nebraska Medical Center, 985450 Nebraska Medical Center, Omaha, NE, 68198, United States, 1 4025592562, james.gehringer@unmc.edu %K cerebral palsy %K HABIT %K home intervention %K virtual reality %K rehabilitation %K VR %K case study %K hand %K hands %K arm %K arms %K intensive training %K feasibility %K game %K games %K gaming %K hand arm bimanual intensive training %K motor %K movement %K home setting %K home-based %K child %K children %K male %K males %K men %K quasi-experimental %K parent %K parents %K intervention %K interventions %D 2024 %7 6.9.2024 %9 Case Report %J JMIR Form Res %G English %X This single-participant case study examines the feasibility of using custom virtual reality (VR) gaming software in the home environment for low-dose Hand Arm Bimanual Intensive Training (HABIT). A 10-year-old with right unilateral cerebral palsy participated in this trial. Fine and gross motor skills as well as personal goals for motor outcomes were assessed before and after the intervention using the Box and Blocks Test, Nine-Hole Peg Test, and Canadian Occupational Performance Measure. Movement intensities collected via the VR hardware accelerometers, VR game scores, and task accuracy were recorded via the HABIT-VR software as indices of motor performance. The child and family were instructed to use the HABIT-VR games twice daily for 30 minutes over a 14-day period and asked to record when they used the system. The child used the system and completed the 14-hour, low-dose HABIT-VR intervention across 22 days. There was no change in Box and Blocks Test and Nine-Hole Peg Test scores before and after the intervention. Canadian Occupational Performance Measure scores increased but did not reach the clinically relevant threshold, due to high scores at baseline. Changes in motor task intensities during the use of VR and mastery of the VR bimanual tasks suggested improved motor efficiency. This case study provides preliminary evidence that HABIT-VR is useful for promoting adherence to HABIT activities and for the maintenance of upper extremity motor skills in the home setting. %M 39241226 %R 10.2196/57588 %U https://formative.jmir.org/2024/1/e57588 %U https://doi.org/10.2196/57588 %U http://www.ncbi.nlm.nih.gov/pubmed/39241226 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49029 %T Gamification in Mobile Apps for Children With Disabilities: Scoping Review %A Mahmoudi,Ebrahim %A Yejong Yoo,Paul %A Chandra,Ananya %A Cardoso,Roberta %A Denner Dos Santos,Carlos %A Majnemer,Annette %A Shikako,Keiko %+ School of Physical and Occupational Therapy, McGill University, 3654 Prom Sir-William-Osler, Montreal, QC, H3G 1Y5, Canada, 1 514 488 5552 ext 1141, keiko.thomas@mcgill.ca %K mobile health %K mHealth %K gamification %K children with disabilities %K mobile phone %D 2024 %7 6.9.2024 %9 Review %J JMIR Serious Games %G English %X Background: Children with disabilities face numerous challenges in accessing health services. Mobile health is an emerging field that could significantly reduce health inequities by providing more accessible services. Many mobile apps incorporate gamification elements such as feedback, points, and stories to increase engagement and motivation; however, little is known about how gamification has been incorporated in mobile apps for children with disabilities. Objective: This scoping review aims to identify and synthesize the existing research evidence on the use of gamification in mobile apps for children with disabilities. Specifically, the objectives were to (1) identify the categories of these mobile apps (eg, treatment and educational) (2), describe the health-related outcomes they target, (3) assess the types and levels of gamification elements used within these apps, and (4) determine the reasons for incorporating gamification elements into mobile apps. Methods: We searched MEDLINE, PsycINFO, CINAHL, Embase, the ACM Digital Library, and IEEE Xplore databases to identify papers published between 2008 and 2023. Original empirical research studies reporting on gamified mobile apps for children with disabilities that implemented at least 1 gamification strategy or tactic were included. Studies investigating serious games or full-fledged games were excluded. Results: A total of 38 studies reporting on 32 unique gamified mobile apps were included. Findings showed that gamified apps focus on communication skills and oral health in children with autism spectrum disorder while also addressing self-management and academic skills for other disability groups. Gamified mobile apps have demonstrated potential benefits across different populations and conditions; however, there were mixed results regarding their impact. The gamification strategies included fun and playfulness (23/32, 72%), feedback on performance (17/32, 53%), and reinforcement (17/32, 53%) in more than half of apps, whereas social connectivity was used as a gamification strategy in only 4 (12%) mobile apps. There were 2 main reasons for integrating gamification elements into mobile apps described in 16 (42%) studies: increasing user engagement and motivation and enhancing intervention effects. Conclusions: This scoping review offers researchers a comprehensive review of the gamification elements currently used in mobile apps for the purposes of treatment, education, symptom management, and assessment for children with disabilities. In addition, it indicates that studies on certain disability groups and examinations of health-related outcomes have been neglected, highlighting the need for further investigations in these areas. Furthermore, research is needed to investigate the effectiveness of mobile-based gamification elements on health and health behavior outcomes, as well as the healthy development of children with disabilities. %M 39240675 %R 10.2196/49029 %U https://games.jmir.org/2024/1/e49029 %U https://doi.org/10.2196/49029 %U http://www.ncbi.nlm.nih.gov/pubmed/39240675 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e59848 %T An Evidence-Based Serious Game App for Public Education on Antibiotic Use and Resistance: Randomized Controlled Trial %A Huang,Zhilian %A Ow,Jing Teng %A Tang,Wern Ee %A Chow,Angela %+ Department of Preventive and Population Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308322, Singapore, 65 6256 6011, zhilian_huang@ttsh.com.sg %K serious game application %K randomized controlled trial %K antimicrobial resistance %K antibiotic use %K public education %K mobile phone %D 2024 %7 5.9.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The misuse and overuse of antibiotics accelerate the development of antimicrobial resistance (AMR). Serious games, any form of games that serve a greater purpose other than entertainment, could augment public education above ongoing health promotion efforts. Hence, we developed an evidence-based educational serious game app—SteWARdS Antibiotic Defence—to educate players on good antibiotic use practices and AMR through a game quest comprising 3 minigames and interaction with the nonplayer characters. Objective: We aimed to evaluate the effectiveness of the SteWARdS Antibiotic Defence app in improving the knowledge of, attitude toward, and perceptions (KAP) of appropriate antibiotic use and AMR among the public in Singapore. Methods: We conducted a 2-arm parallel randomized controlled trial, recruiting visitors aged 18-65 years from 2 polyclinics in Singapore. Intervention group participants had to download the SteWARdS Antibiotic Defence app (available only in English and on the Android platform) on their smartphones and complete the quest in the app. Participants took half a day to 2 weeks to complete the quest. The control group received no intervention. Knowledge questions on antibiotic use and AMR (11 binary questions) were self-administered at baseline, immediately after the intervention, and 6-10 weeks post intervention, while attitudes and perception questions (14 three-point Likert-scale questions) were self-administered at baseline and 6-10 weeks post intervention. We also collected participants’ feedback on app usage. Results: Participants (n=348; intervention: n=142, control: n=206) had a mean age of 36.9 years. Intervention group participants showed a statistically significant improvement in mean knowledge score (effect size: 0.58 [95% CI 0.28-0.87]) compared with controls after accounting for age, educational level, and exposure to advertisements on antibiotics and AMR. Intervention participants also showed a statistically significant improvement in mean attitude-perception scores (effect size: 0.98 (95% CI 0.44-1.52)) after adjusting for marital status and race. A majority of participants agreed that the “SteWARdS Antibiotic Defence” app improved their awareness on antibiotic use (135/142, 95.1%) and AMR (136/142, 95.8%). About 73.9% (105/142) of the participants agreed that the app is easy to use, 70.4% (100/142) agreed that the app was enjoyable, and 85.2% (121/142) would recommend the app to others. Conclusions: Our educational serious game app improves participants’ KAP on appropriate antibiotic use and AMR. Public education apps should be engaging, educational, easy to use, and have an attractive user interface. Future research should assess the effectiveness of interventions in facilitating long-term knowledge retention and long-lasting behavioral change. Trial Registration: ClinicalTrials.gov NCT05445414; https://clinicaltrials.gov/ct2/show/NCT05445414 International Registered Report Identifier (IRRID): RR2-10.2196/45833 %M 39235853 %R 10.2196/59848 %U https://games.jmir.org/2024/1/e59848 %U https://doi.org/10.2196/59848 %U http://www.ncbi.nlm.nih.gov/pubmed/39235853 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52991 %T Perceived Barriers and Facilitators Regarding the Implementation of Gamification to Promote Physical Activity in the Neighborhood: Interview Study Among Intermediaries %A Schwarz,Ayla %A Verkooijen,Kirsten %A de Vet,Emely %A Simons,Monique %+ Wageningen University & Research, Hollandseweg 1, Wageningen, 6706KN, Netherlands, 31 0639187108, ayla.schwarz@wur.nl %K gamification %K gamified apps %K physical activity %K implementation %K intermediaries %K interview %D 2024 %7 28.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the Netherlands, neighborhood sport coaches (NSCs) play an important role as intermediaries in promoting physical activity (PA) in the neighborhood. Gamification is the use of game elements in nongame contexts; it can be implemented with or without technology and holds promise for promoting PA. NSCs infrequently make use of this option. Objective: This study aims to understand barriers to, and facilitators of, using gamification to promote PA, as perceived by NSCs. Methods: A total of 25 semistructured interviews were conducted with NSCs in the Netherlands. The interviews were audiotaped, transcribed, and analyzed by means of thematic analysis using ATLAS.ti (version 22; ATLAS.ti Scientific Software Development GmbH) software. The deductive coding was informed by the capability, opportunity, motivation, behavior model and the theoretical domains framework, complemented by inductive coding. Results: Barriers and facilitators identified as factors influencing the implementation of gamification were related to 7 themes. NSCs required technical, creative, and promotion skills; knowledge about existing gamification tools; and social support from their employer and professional network. Financial costs were identified as a barrier to the successful implementation of gamification. Lack of clarity regarding stakeholders’ responsibility to implement gamification could further hamper implementation. In general, NSCs were positive about investing time in implementing gamification and expected positive effects from implementing it. Conclusions: To overcome identified barriers, a clear overview of tools, best practices, and available subsidies must be created, a gamification network must be established, the responsibility of NSCs must be clarified, and guidance must be offered on the promotion of gamification. %M 39196618 %R 10.2196/52991 %U https://games.jmir.org/2024/1/e52991 %U https://doi.org/10.2196/52991 %U http://www.ncbi.nlm.nih.gov/pubmed/39196618 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e55905 %T Exploring the Psychological Effects and Physical Exertion of Using Different Movement Interactions in Casual Exergames That Promote Active Microbreaks: Quasi-Experimental Study %A Berglund,Aseel %A Orädd,Helena %+ Department of Computer and Information Science, Linköping University, Campus Valla, B-house, Linköping, 58329, Sweden, 46 0732703862, aseel.berglund@liu.se %K physical activity %K exergames %K casual exergames %K enjoyment %K exertion %K motion-based games %D 2024 %7 26.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Prolonged sedentary behavior, such as sitting or reclining, has consistently been identified as a stand-alone risk factor for heightened cardiometabolic risk and overall mortality. Conversely, interrupting sedentary periods by incorporating short, active microbreaks has been shown to mitigate the negative effects of sedentary behavior. Casual exergames, which mix elements of casual gaming with physical activity, are one prospective intervention to reduce sedentary behavior because they require physical exertion. Casual exergames have shown promise in fostering emotional and physical advantages when played in specific circumstances. However, little research exists on how different types of movement interactions impact the psychological effects as well as the physical exertion of playing casual exergames. Objective: The primary aim of this work was to explore the psychological effects and physical exertion of playing casual exergames lasting 2 minutes. More precisely, the investigation focused on comparing upper body and full body movement interactions. In addition, the work examined variations in body positions, considering both standing and seated positions during upper body movement interactions. Methods: Two casual exergames were developed and investigated through 2 quasi-experimental studies. In study 1, we investigated how players’ perceptions of control, exertion, and immersion were affected by using upper body as opposed to full body exergame controllers when playing casual exergames. In study 2, we investigated differences in positive affect, performance, enjoyment, and exertion when playing casual exergames with upper body movement interactions in seated and standing positions. Results: Study 1 showed that perceived control was significantly higher for upper body movement interactions than for full body movement interactions (P=.04), but there were no significant differences regarding perceived exertion (P=.15) or immersion (P=.66). Study 2 showed that positive affect increased significantly for both standing (P=.003) and seated (P=.001) gameplay. The participants in the standing gameplay group showed slightly higher actual exertion; however, there were no differences between the groups in terms of positive affect, perceived exertion, enjoyment, or performance. Conclusions: Casual exergames controlled by upper body movement interactions in seated gameplay can produce similar psychological effects and physical exertion as upper body movement interactions in standing gameplay and full body movement interactions. Therefore, upper body and seated casual exergames should not be overlooked as a suitable microbreak activity. %M 39186776 %R 10.2196/55905 %U https://games.jmir.org/2024/1/e55905 %U https://doi.org/10.2196/55905 %U http://www.ncbi.nlm.nih.gov/pubmed/39186776 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52017 %T The Impact and Acceptance of Gamification by Learners in a Digital Literacy Course at the Undergraduate Level: Randomized Controlled Trial %A Alnuaim,Abeer %K gamification %K games %K technology integration %K information literacy %K technology acceptance %D 2024 %7 23.8.2024 %9 %J JMIR Serious Games %G English %X Background: In recent years, the integration of technology in education has revolutionized traditional learning paradigms. Digital literacy, a crucial skill in the 21st century, has become a vital aspect of modern education, enabling students to navigate, critically assess, and effectively use digital tools. As educators strive to boost engagement and learning outcomes, gamification has appeared as an auspicious pedagogical approach. By applying game mechanics to nongame contexts, gamification seeks to create a more immersive and digital learning experience. Objective: This research paper aims to investigate the impact and acceptance of gamification by learners in a digital literacy course at the undergraduate level. Methods: In a pre-post intervention study, 168 undergraduate students were randomly assigned either to the experimental group (gamification based) or control group (conventional) learning condition. Both groups of participants learned the same topics in digital literacy. Results: Empirical findings showed that participants from the experimental group had better academic performance in digital literacy than those who were not exposed to the game-based learning environment. The participants’ prior experience with gamification was not found to be a significant predictor of their acceptance of gamification in a digital literacy course. Conclusions: The study provides evidence supporting the potential benefits of gamification in enhancing digital literacy education and opens the door for further exploration and implementation of gamified learning approaches in higher education settings. %R 10.2196/52017 %U https://games.jmir.org/2024/1/e52017 %U https://doi.org/10.2196/52017 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57351 %T Perceptions of HIV-Related Comorbidities and Usability of a Virtual Environment for Cardiovascular Disease Prevention Education in Sexual Minority Men With HIV: Formative Phases of a Pilot Randomized Controlled Trial %A Ramos,S Raquel %A Reynolds,Harmony %A Johnson,Constance %A Melkus,Gail %A Kershaw,Trace %A Thayer,Julian F %A Vorderstrasse,Allison %+ School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, United States, 1 2037372339, raquel.ramos@yale.edu %K virtual environment %K digital health %K gamification %K eHealth %K sexual minorities %K cardiovascular disease %K HIV %K cardiometabolic risk %K mental health %K lesbian, gay, bisexual, transgender, and queer %K LGBTQ health %K HIV care %K prevention %K virtual %K minority %K men %K Latin %K Black %K men who have sex with men %K intervention %K high blood pressure %K myocardial infarction %K preventive health screenings %K gay %K bisexual %K patients %K cancer %D 2024 %7 22.8.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Sexual minority men with HIV are at an increased risk of cardiovascular disease (CVD) and have been underrepresented in behavioral research and clinical trials. Objective: This study aims to explore perceptions of HIV-related comorbidities and assess the interest in and usability of a virtual environment for CVD prevention education in Black and Latinx sexual minority men with HIV. Methods: This is a 3-phase pilot behavioral randomized controlled trial. We report on formative phases 1 and 2 that informed virtual environment content and features using qualitative interviews, usability testing, and beta testing with a total of 25 individuals. In phase 1, a total of 15 participants completed interviews exploring HIV-related illnesses of concern that would be used to tailor the virtual environment. In phase 2, usability testing and beta testing were conducted with 10 participants to assess interest, features, and content. Results: In phase 1, we found that CVD risk factors included high blood pressure, myocardial infarction, stroke, and diabetes. Cancer (prostate, colon, and others) was a common concern, as were mental health conditions. In phase 2, all participants completed the 12-item usability checklist with favorable feedback within 30 to 60 minutes. Beta-testing interviews suggested (1) mixed perceptions of health and HIV, (2) high risk for comorbid conditions, (3) virtual environment features were promising, and (4) the need for diverse avatar representations. Conclusions: We identified several comorbid conditions of concern, and findings carry significant implications for mitigating barriers to preventive health screenings, given the shared risk factors between HIV and related comorbidities. Highly rated aspects of the virtual environment were anonymity; meeting others with HIV who identify as gay or bisexual; validating lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) images and content; and accessibility to CVD prevention education. Critical end-user feedback from beta testing suggested more options for avatar customization in skin, hair, and body representation. Our next phase will test the virtual environment as a new approach to advancing cardiovascular health equity in ethnic and racial sexual minority men with HIV. Trial Registration: ClinicalTrials.gov NCT04061915; https://clinicaltrials.gov/study/NCT05242952 International Registered Report Identifier (IRRID): RR2-10.2196/38348 %M 38924481 %R 10.2196/57351 %U https://www.jmir.org/2024/1/e57351 %U https://doi.org/10.2196/57351 %U http://www.ncbi.nlm.nih.gov/pubmed/38924481 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e54684 %T Feasibility and Acceptability of a Mobile Game to Support Smoking Cessation: Repeated Measures Study %A Goodwin,Shelby %A Nastasi,Jessica A %A Newman,Schyler T %A Rapoza,Darion %A Raiff,Bethany R %+ Department of Psychology, College of Science and Mathematics, Rowan University, 201 Mullica Hill Road, Glassboro, NJ, 08028, United States, 1 856 256 4500 ext 53782, raiff@rowan.edu %K mHealth %K mobile health %K smoking cessation %K video game intervention %K mobile phone %D 2024 %7 21.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Approximately half of smokers attempt to quit, but 90% of these attempts fail. Video game–based interventions have the potential to address common barriers to evidence-based smoking cessation treatment, including high cost, lack of health care access, and low engagement. Objective: The purpose of this study was to evaluate the feasibility and acceptability of a video game–based smoking cessation intervention called Inspired and its impact on the 7-day smoking point prevalence at the 30-day follow-up. Methods: US adults (n=48) were recruited via the web to use Inspired on their smartphones for 7 weeks. The object of the game was to defend a healing tree against attackers. Levels of the game were unlocked twice daily when participants self-reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which could strengthen in-game abilities. Participants received additional in-game rewards to aid gameplay by submitting either smoking self-reports only or self-reports indicating abstinence, determined through random assignment. In addition, participants completed a web-based survey at intake, week 4, week 7, and the 30-day follow-up. Results: Of the 48 participants, who had an average age of 39.8 (SD 10.7) years, 27 (56%) were female, 4 (8%) Hispanic, 37 (77%) White, and 27 (56%) employed; 26 (54%) earned 60 years) participants were used. The interview data were obtained from the 2 pilot studies we conducted on VR games for cognitive assessment. Inductive thematic analysis was conducted on the interview data, and later, the findings were carefully interpreted to develop implications for the key stakeholders. Results: We identified 5 themes: ergonomic issues, learning and training, postgame effects, game feedback, and system purpose. Regarding hardware, headset weight, adjustment straps, and controllers need to be improved to promote easy use of the device. Regarding software, graphics quality, immersion experience, and game mechanics are the primary deciding factors for a positive user experience. The younger group prioritized purpose and utility for long-term use, whereas the older participants cherished the entertainment aspect. Researchers and game developers must conceptualize and develop games that can provide maximum insights into real-world abilities. Manufacturing businesses need to improve the headset and accessories to make them more user-friendly. Finally, neuropsychology and allied practitioners must identify strategies to engage and train the participants to try VR-based cognitive assessment games. Conclusions: VR-based games for cognitive assessment are promising tools to improve the current practices of neuropsychological evaluations; however, a few changes are required to make the overall user experience enjoyable, purposeful, and sustainable. In addition, all the key stakeholders need to focus on meaning and purpose over the hype of VR and are advised to work in synergy. %R 10.2196/59197 %U https://xr.jmir.org/2024/1/e59197 %U https://doi.org/10.2196/59197 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e54220 %T Attentional Bias, Pupillometry, and Spontaneous Blink Rate: Eye Characteristic Assessment Within a Translatable Nicotine Cue Virtual Reality Paradigm %A Courtney,Kelly Elizabeth %A Liu,Weichen %A Andrade,Gianna %A Schulze,Jurgen %A Doran,Neal %K nicotine %K craving %K cue exposure %K virtual reality %K attentional bias %K pupillometry %K spontaneous blink rate %K eye-tracking %K tobacco %K VR %K development %K addiction %K eye %K pupil %K craving %K biomarker %K biomarkers %K tobacco product %D 2024 %7 27.6.2024 %9 %J JMIR Serious Games %G English %X Background: Incentive salience processes are important for the development and maintenance of addiction. Eye characteristics such as gaze fixation time, pupil diameter, and spontaneous eyeblink rate (EBR) are theorized to reflect incentive salience and may serve as useful biomarkers. However, conventional cue exposure paradigms have limitations that may impede accurate assessment of these markers. Objective: This study sought to evaluate the validity of these eye-tracking metrics as indicators of incentive salience within a virtual reality (VR) environment replicating real-world situations of nicotine and tobacco product (NTP) use. Methods: NTP users from the community were recruited and grouped by NTP use patterns: nondaily (n=33) and daily (n=75) use. Participants underwent the NTP cue VR paradigm and completed measures of nicotine craving, NTP use history, and VR-related assessments. Eye-gaze fixation time (attentional bias) and pupillometry in response to NTP versus control cues and EBR during the active and neutral VR scenes were recorded and analyzed using ANOVA and analysis of covariance models. Results: Greater subjective craving, as measured by the Tobacco Craving Questionnaire–Short Form, following active versus neutral scenes was observed (F1,106=47.95; P<.001). Greater mean eye-gaze fixation time (F1,106=48.34; P<.001) and pupil diameter (F1,102=5.99; P=.02) in response to NTP versus control cues were also detected. Evidence of NTP use group effects was observed in fixation time and pupillometry analyses, as well as correlations between these metrics, NTP use history, and nicotine craving. No significant associations were observed with EBR. Conclusions: This study provides additional evidence for attentional bias, as measured via eye-gaze fixation time, and pupillometry as useful biomarkers of incentive salience, and partially supports theories suggesting that incentive salience diminishes as nicotine dependence severity increases. %R 10.2196/54220 %U https://games.jmir.org/2024/1/e54220 %U https://doi.org/10.2196/54220 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e52231 %T Impact of Fruit and Vegetable Enzyme Supplementation on Aerobic Performance and Lactate Response in Older Adults Following High-Intensity Interval Exercise Through Exergaming: Randomized Experimental Matched-Pair Study %A Lin,Shu-Cheng %A Wang,Chien-Yen %A Hou,Tien-Hung %A Chen,Hong-Ching %A Wang,Chia-Chi %K Ring Fit Adventure %K training load %K older adult training %K training impulse %K food supplement %K older adults %K exergames %K exergame %K Taiwan %K female %K fruits %K vegetables %K blood lactate %K exercise %K feasibility %K aerobic %K enzymes %K enzyme %K female older adults %K fitness %K food intake %K diet %K exergaming %K enzyme supplements %K older adults training %K female older adult %K older adult %D 2024 %7 25.6.2024 %9 %J JMIR Serious Games %G English %X Background: Exercise offers substantial health benefits but can induce oxidative stress and inflammation, especially in high-intensity formats such as high-intensity interval exercise (HIIE). Exergaming has become an effective, enjoyable fitness tool for all ages, particularly older adults. Enzyme supplements may enhance exercise performance by improving lactate metabolism and reducing oxidative stress. Objective: This study investigates the efficacy of fruit and vegetable enzyme supplementation in modulating fatigue and enhancing aerobic capacity in older adults following HIIE through exergaming. Methods: The study recruited 16 older adult female participants and allocated them into 2 distinct groups (enzyme and placebo) based on their pretest lactate levels. This division used pairwise grouping to guarantee comparability between the groups, ensuring the integrity of the results. They engaged in HIIE using Nintendo Switch Ring Fit Adventure, performing 8 sets of 20 seconds of maximum effort exercise interspersed with 30 seconds of rest, totaling 370 seconds of exercise. Key metrics assessed included blood lactate levels, heart rate, rating of perceived exertion, and training impulse. Participants in the enzyme group were administered a fruit and vegetable enzyme supplement at a dosage of 30 mL twice daily over a period of 14 days. Results: The enzyme group showed significantly lower blood lactate levels compared to the placebo group, notably after the fourth (mean 4.29, SD 0.67 vs mean 6.34, SD 1.17 mmol/L; P=.001) and eighth (mean 5.84, SD 0.63 vs mean 8.20, SD 1.15 mmol/L; P<.001) exercise sessions. This trend continued at 5 minutes (mean 6.85, SD 0.82 vs mean 8.60, SD 1.13 mmol/L; P=.003) and 10 minutes (mean 5.91, SD 1.16 vs mean 8.21, SD 1.27 mmol/L; P=.002) after exercise. Although both groups exceeded 85% of their estimated maximum heart rate during the exercise, enzyme supplementation did not markedly affect the perceived intensity or effort. Conclusions: The study indicates that fruit and vegetable enzyme supplementation can significantly reduce blood lactate levels in older adults following HIIE through exergaming. This suggests a potential role for these enzymes in modulating lactate production or clearance during and after high-intensity exercise. These findings have implications for developing targeted interventions to enhance exercise tolerance and recovery in older adults. Trial Registration: ClinicalTrials.gov NCT06466408; https://clinicaltrials.gov/study/NCT06466408 %R 10.2196/52231 %U https://games.jmir.org/2024/1/e52231 %U https://doi.org/10.2196/52231 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53165 %T Pressure Ulcer Management Virtual Reality Simulation (PU-VRSim) for Novice Nurses: Mixed Methods Study %A Jung,Soo Youn %A Moon,Kyoung Ja %+ College of Nursing, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea, 82 53 258 7663, kjmoon2150@gmail.com %K virtual reality %K nursing %K simulation %K virtual training %K pressure ulcer %K simulation training %K nurse %K clinician %K health care worker %K ulcer %K hospital %K health care center %K PU-VRSim %K mixed methods study %K health professional %K medical education %K training %K games %K gamification %K learning %K decubitus ulcer %D 2024 %7 24.6.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pressure ulcers (PUs) are a common and serious complication in patients who are immobile in health care settings. Nurses play a fundamental role in the prevention of PUs; however, novice nurses lack experience in clinical situations. Virtual reality (VR) is highly conducive to clinical- and procedure-focused training because it facilitates simulations. Objective: We aimed to explore the feasibility of a novel PU management VR simulation (PU-VRSim) program using a head-mounted display for novice nurses and to investigate how different types of learning materials (ie, VR or a video-based lecture) impact learning outcomes and experiences. Methods: PU-VRSim was created in the Unity 3D platform. This mixed methods pilot quasi-experimental study included 35 novice nurses categorized into the experimental (n=18) and control (n=17) groups. The PU-VRSim program was applied using VR in the experimental group, whereas the control group received a video-based lecture. The PU knowledge test, critical thinking disposition measurement tool, and Korean version of the General Self-Efficacy Scale were assessed before and after the intervention in both groups. After the intervention, the experimental group was further assessed using the Clinical Judgment Rubric and interviewed to evaluate their experience with PU-VRSim. Results: The results compared before and after the intervention showed significant improvements in PU knowledge in both the experimental group (P=.001) and control group (P=.005). There were no significant differences in self-efficacy and critical thinking in either group. The experimental group scored a mean of 3.23 (SD 0.44) points (accomplished) on clinical judgment, assessed using a 4-point scale. The experimental group interviews revealed that the VR simulation was realistic and helpful for learning about PU management. Conclusions: The results revealed that PU-VRSim could improve novice nurses’ learning of PU management in realistic environments. Further studies using VR for clinical training are recommended for novice nurses. %M 38913417 %R 10.2196/53165 %U https://games.jmir.org/2024/1/e53165 %U https://doi.org/10.2196/53165 %U http://www.ncbi.nlm.nih.gov/pubmed/38913417 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e50086 %T Gamification Approach to Provide Support About the Deferral Experience in Blood Donation: Design and Feasibility Study %A Espinoza Chamorro,Roberto %A Santos,Luciano H O %A Mori,Yukiko %A Liu,Chang %A Yamamoto,Goshiro %A Kuroda,Tomohiro %+ Graduate School of Informatics, Kyoto University, 36-1 Yoshida-Honmachi, Sakyo-ku, Kyoto, 606-8501, Japan, 81 075 753 7531, rech91@outlook.com %K blood donation %K deferral experience %K Theory of Planned Behavior %K Self-Determination Theory %K gamification %K ICT design %K motivation %K patient education %K prototype %K feasibility %D 2024 %7 14.6.2024 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Multiple studies have examined the impact of deferral on the motivation of prospective blood donors, proposing various policies and strategies to support individuals who undergo this experience. However, existing information and communications technology systems focused on blood donation have not yet integrated these ideas or provided options to assist with the deferral experience. Objective: This study aims to propose an initial gamified design aimed at mitigating the impact of the deferral experience by addressing the drivers of awareness and knowledge, interaction and validation, and motivation. Additionally, the study explores the feasibility of implementing such a system for potential users. Methods: We conducted a literature review focusing on the dynamics of motivation and intention related to blood donation, as well as the deferral situation and its impact on citizens. Through this review, we identified weak donor identity, lack of knowledge, and reduced motivation as key factors requiring support from appropriate interventions. These factors were then defined as our key drivers. Taking these into account, we proposed a gamification approach that incorporates concepts from the MDA framework. The aim is to stimulate the aforementioned drivers and expand the concept of contribution and identity in blood donation. For a preliminary evaluation, we designed a prototype to collect feedback on usability, usefulness, and interest regarding a potential implementation of our proposed gamification approach. Results: Among the participants, a total of 11 citizens interacted with the app and provided feedback through our survey. They indicated that interacting with the app was relatively easy, with an average score of 4.13 out of 5 when considering the 11 tasks of interaction. The SUS results yielded a final average score of 70.91 from the participants’ answers. Positive responses were received when participants were asked about liking the concept of the app (3.82), being likely to download it (3.55), and being likely to recommend it to others (3.64). Participants expressed positivity about the implementation of the design but also highlighted current shortcomings and suggested possible improvements in both functionality and usability. Conclusions: Although deferral is a common issue in blood donation, there is a missed opportunity in existing ICT services regarding how to effectively handle such experiences. Our proposed design and implementation seem to have captured the interest of prospective users due to its perceived positive usefulness and potential. However, further confirmation is needed. Improving the design of activities that currently rely heavily on extrinsic motivation elements and integrating more social components to create an enhanced activity loop for intrinsic motivation could further increase the value of the proposed project. Future research could involve conducting a more specialized and longitudinal design evaluation with a larger sample size. %M 38875005 %R 10.2196/50086 %U https://humanfactors.jmir.org/2024/1/e50086 %U https://doi.org/10.2196/50086 %U http://www.ncbi.nlm.nih.gov/pubmed/38875005 %0 Journal Article %@ 2561-6722 %I %V 7 %N %P e57198 %T Digital Gaming and Exercise Among Youth With Type 1 Diabetes: Cross-Sectional Analysis of Data From the Type 1 Diabetes Exercise Initiative Pediatric Study %A Patton,Susana R %A Gal,Robin L %A Bergford,Simon %A Calhoun,Peter %A Clements,Mark A %A Sherr,Jennifer L %A Riddell,Michael C %K exercise %K exercises %K exercising %K physical activity %K physical activities %K digital game %K digital games %K gaming %K electronic game %K electronic games %K computerized game %K computerized games %K pediatric %K pediatrics %K child %K children %K youth %K adolescent %K adolescents %K teen %K teens %K teenager %K teenagers %K diabetes %K diabetic %K DM %K diabetes mellitus %K type 2 diabetes %K type 1 diabetes %K TD1 %K TD2 %K mobile phone %D 2024 %7 13.6.2024 %9 %J JMIR Pediatr Parent %G English %X Background: Regular physical activity and exercise are fundamental components of a healthy lifestyle for youth living with type 1 diabetes (T1D). Yet, few youth living with T1D achieve the daily minimum recommended levels of physical activity. For all youth, regardless of their disease status, minutes of physical activity compete with other daily activities, including digital gaming. There is an emerging area of research exploring whether digital games could be displacing other physical activities and exercise among youth, though, to date, no studies have examined this question in the context of youth living with T1D. Objective: We examined characteristics of digital gaming versus nondigital gaming (other exercise) sessions and whether youth with T1D who play digital games (gamers) engaged in less other exercise than youth who do not (nongamers), using data from the Type 1 Diabetes Exercise Initiative Pediatric study. Methods: During a 10-day observation period, youth self-reported exercise sessions, digital gaming sessions, and insulin use. We also collected data from activity wearables, continuous glucose monitors, and insulin pumps (if available). Results: The sample included 251 youths with T1D (age: mean 14, SD 2 y; self-reported glycated hemoglobin A1c level: mean 7.1%, SD 1.3%), of whom 105 (41.8%) were female. Youth logged 123 digital gaming sessions and 3658 other exercise (nondigital gaming) sessions during the 10-day observation period. Digital gaming sessions lasted longer, and youth had less changes in glucose and lower mean heart rates during these sessions than during other exercise sessions. Youth described a greater percentage of digital gaming sessions as low intensity (82/123, 66.7%) when compared to other exercise sessions (1104/3658, 30.2%). We had 31 youths with T1D who reported at least 1 digital gaming session (gamers) and 220 youths who reported no digital gaming (nongamers). Notably, gamers engaged in a mean of 86 (SD 43) minutes of other exercise per day, which was similar to the minutes of other exercise per day reported by nongamers (mean 80, SD 47 min). Conclusions: Digital gaming sessions were longer in duration, and youth had less changes in glucose and lower mean heart rates during these sessions when compared to other exercise sessions. Nevertheless, gamers reported similar levels of other exercise per day as nongamers, suggesting that digital gaming may not fully displace other exercise among youth with T1D. %R 10.2196/57198 %U https://pediatrics.jmir.org/2024/1/e57198 %U https://doi.org/10.2196/57198 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53999 %T Examining and Comparing the Energy Expenditure of Two Modes of a Virtual Reality Fitness Game (Supernatural): Indirect Calorimetry Study %A Craig,Tabitha V %A Rhodes,Ryan E %A Sui,Wuyou %+ Behavioural Medicine Lab, Department of Exercise Science, Physical & Health Education, University of Victoria, 3800 Finnerty Rd, Victoria, BC, V8P 5C2, Canada, 1 250 472 5288, yoahsui@gmail.com %K energy expenditure %K exergaming %K indirect calorimetry %K virtual reality %K VR %K VR fitness %K VR gaming %D 2024 %7 4.6.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The effectiveness of virtual reality (VR) fitness games as a form of moderate to vigorous physical activity has yet to be thoroughly quantified through gold standard energy expenditure measures. Objective: The purpose of this study was to examine the energy expenditure of 2 medium-intensity modes (“Flow and “Boxing”) of a VR fitness game, Supernatural, using indirect calorimetry. Methods: Indirect calorimetry was used to examine relative and objective maximal oxygen consumption (VO2 max), metabolic equivalents of task (METs), and calories burned during medium-intensity bouts of both Flow and Boxing gameplay modes in young (mean age 25.42, SD 3.25 years), active individuals (n=12 female and n=11 male). METs and calories were also compared using a triaxial waist-worn accelerometer, an Apple smartwatch, and a VR headset. Mood states were assessed pre- and postbout using the shortened Profile of Mood States Questionnaire. Paired 2-tailed t tests were used to examine differences in game modes, between sexes, and pre-post exercise sessions. Results: Objective and relative VO2 max averaged 1.93 (SD 0.44) L/min and 27.61 (SD 5.60) mL/kg/min, respectively, between modes. Flow (mean 8.2, SD 1.54 METs) and Boxing (mean 7.6, SD 1.66 METs) are both classified as high energy expenditure, vigorous activities. Calorie expenditure data of the accelerometer and VR headset differed significantly from the metabolic cart. Mood changes pre- to post exercise were consistent with expected values for moderate- to vigorous-intensity physical activity, with participants reporting that they felt more “active,” “full of pep,” “vigorous,” and “lively” (P<.05) following bouts. Male individuals reported higher objective oxygen consumption (VO2) for both Flow and Boxing modes; no other sex-specific differences were observed. Conclusions: Both Flow and Boxing gameplay modes of Supernatural classify as vigorous physical activity and demonstrate the potential to promote mental and physical health benefits. Supernatural may be an effective exercise modality in a VO2 training program. %M 38833285 %R 10.2196/53999 %U https://games.jmir.org/2024/1/e53999 %U https://doi.org/10.2196/53999 %U http://www.ncbi.nlm.nih.gov/pubmed/38833285 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 10 %N %P e56168 %T An Introduction to the OutSMART Cancer Serious Game: Current and Future Directions %A Abraham,Olufunmilola %A McCarthy,Tyler J %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Rm 2515 Rennebohm Hall, 777 Highland Ave, Madison, WI, 53705, United States, 1 6082634498, olufunmilola.abraham@wisc.edu %K serious game %K cancer %K health education %K adolescents %K health behavior %K United States %K young people %K adolescent %K teenager %K teenagers %K cancer prevention %K education %K cancer risk %K tool %K OutSMART Cancer %K innovative %K game development %K cancer awareness %K prevention %K wellness %D 2024 %7 29.5.2024 %9 Viewpoint %J JMIR Cancer %G English %X Given that cancer is a challenging disease that plagues millions of individuals of all age groups and socioeconomic statuses globally, developmentally appropriate education is often lacking for young people, particularly adolescents. Increasing cancer awareness and prevention education among adolescents using innovative strategies, such as game-based learning, is critical in reducing the burden of this disease. Adolescents are understudied in the field of cancer prevention and control, yet vulnerable as they tackle creating life-long health behavior patterns. Targeting cancer prevention education for adolescents has the potential to support long-term healthy behavior and reduce their risk of cancer. This paper provides an overview of the Collaborative Research on MEdication use and family health (CRoME) Lab’s novel game-based cancer prevention education tool. OutSMART Cancer is an innovative, novel educational intervention in the form of a serious game. Serious games are educational tools that seek to impart knowledge and improve behaviors in their players. This game covers information related to breast cancer, colon cancer, and lung cancer. This viewpoint is a summary of the developmental process for the OutSMART Cancer game. We describe in detail the work preceding initial game development, the current version of the game, future directions for the game, and its educational potential. The long-term goal of OutSMART Cancer is to improve cancer awareness and knowledge regarding prevention behaviors in adolescents and support a lifetime of health and wellness. %M 38809587 %R 10.2196/56168 %U https://cancer.jmir.org/2024/1/e56168 %U https://doi.org/10.2196/56168 %U http://www.ncbi.nlm.nih.gov/pubmed/38809587 %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 %@ 2561-326X %I JMIR Publications %V 8 %N %P e54101 %T Insights Into the Use of a Digital Healthy Aging Coach (AGATHA) for Older Adults From Malaysia: App Engagement, Usability, and Impact Study %A Teh,Pei-Lee %A Kwok,Andrei O J %A Cheong,Wing Loong %A Lee,Shaun %+ School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Subang Jaya, Malaysia, 60 355145890, shaun.lee@monash.edu %K digital health %K older adults %K digital divide %K aging %K pilot %K Malaysia %K coach %K digital access %K social barrier %K virtual %K virtual coach %K digital tool %K tool %K engagement %K gamification %K user experience %K app %K technology tool %K digital literacy %K user experience design %K decision support %K support %D 2024 %7 21.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital inclusion is considered a pivotal social determinant of health, particularly for older adults who may face significant barriers to digital access due to physical, sensory, and social limitations. Avatar for Global Access to Technology for Healthy Aging (AGATHA) is a virtual healthy aging coach developed by the World Health Organization to address these challenges. Designed as a comprehensive virtual coach, AGATHA comprises a gamified platform that covers multiple health-related topics and modules aimed at fostering user engagement and promoting healthy aging. Objective: The aim of this study was to explore the perception and user experience of Malaysian older adults in their interactions with the AGATHA app and its avatar. The focus of this study was to examine the engagement, usability, and educational impact of the app on health literacy and digital skills. Methods: We performed a qualitative study among adults 60 years and older from suburban and rural communities across six states in Malaysia. Participants were purposefully recruited to ensure representation across various socioeconomic and cultural backgrounds. Each participant attended a 1-hour training session to familiarize themselves with the interface and functionalities of AGATHA. Subsequently, all participants were required to engage with the AGATHA app two to three times per week for up to 2 weeks. Upon completion of this trial phase, an in-depth interview session was conducted to gather detailed feedback on their experiences. Results: Overall, the participants found AGATHA to be highly accessible and engaging. The content was reported to have a comprehensive structure and was delivered in an easily understandable and informative manner. Moreover, the participants found the app to be beneficial in enhancing their understanding pertaining to health-related issues in aging. Some key feedback gathered highlighted the need for increased interactive features that would allow for interaction with peers, better personalization of content tailored to the individual’s health condition, and improvement in the user-experience design to accommodate older users’ specific needs. Furthermore, enhancements in decision-support features within the app were suggested to better assist users in making health decisions. Conclusions: The prototype digital health coaching program AGATHA was well received as a user-friendly tool suitable for beginners, and was also perceived to be useful to enhance older adults’ digital literacy and confidence. The findings of this study offer important insights for designing other digital health tools and interventions targeting older adults, highlighting the importance of a user-centered design and personalization to improve the adoption of digital health solutions among older adults. This study also serves as a useful starting point for further development and refinement of digital health programs aimed at fostering an inclusive, supportive digital environment for older adults. %M 38772022 %R 10.2196/54101 %U https://formative.jmir.org/2024/1/e54101 %U https://doi.org/10.2196/54101 %U http://www.ncbi.nlm.nih.gov/pubmed/38772022 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e55569 %T A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial %A Zhao,Licong %A Agazzi,Heather %A Du,Yasong %A Meng,Hongdao %A Maku,Renya %A Li,Ke %A Aspinall,Peter %A Garvan,Cynthia Wilson %A Fang,Shuanfeng %+ Department of Child Healthcare, Children’s Hospital Affiliated to Zhengzhou University, 33 Longhu Waihuan East Road, Zhengdong New District, Zhengzhou, 450018, China, 86 0371 85515939, fangshuanfeng@126.com %K school-age children %K cognitive training %K exercise therapy %K gamification %K ADHD %K attention deficit %K attention-deficit/hyperactivity disorder %K RCT %K randomized controlled trial %K executive function %K digital intervention %K AR %K augmented reality %D 2024 %7 10.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear. Objective: The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD. Methods: This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects. Results: Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants’ average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (β=–12.203, 95% CI –17.882 to –6.523; P<.001), owing to lower scores on the subscales Inattention (β=–3.966, 95% CI –6.285 to –1.647; P<.001), Hyperactivity/Impulsivity (β=–5.735, 95% CI –8.334 to –3.137; P<.001), and Oppositional Defiant Disorder (β=–2.995, 95% CI –4.857 to –1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (β=–6.312, 95% CI –10.973 to –1.650; P=.006) and Global Executive Composite (β=–5.952, 95% CI –10.214 to –1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported. Conclusions: This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects. Trial Registration: Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806 %M 38728075 %R 10.2196/55569 %U https://www.jmir.org/2024/1/e55569 %U https://doi.org/10.2196/55569 %U http://www.ncbi.nlm.nih.gov/pubmed/38728075 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e47513 %T Effects of a Serious Game for Adolescent Mental Health on Cognitive Vulnerability: Pilot Usability Study %A De Jaegere,Eva %A van Heeringen,Kees %A Emmery,Peter %A Mommerency,Gijs %A Portzky,Gwendolyn %K e-health %K cognitive psychology %K cognitive distortion %K cognitive vulnerability %K digital health %K serious games %K adolescent mental health %K prototype %K adolescent %K prevention %K eHealth %D 2024 %7 9.5.2024 %9 %J JMIR Serious Games %G English %X Background: Adolescent mental health is of utmost importance. E-mental health interventions, and serious games in particular, are appealing to adolescents and can have beneficial effects on their mental health. A serious game aimed at improving cognitive vulnerability (ie, beliefs or attitudes), which can predispose an individual to mental health problems, can contribute to the prevention of these problems in adolescents. Objective: This study aimed to assess the feasibility of the prototype of a serious game called “Silver.” Methods: The prototype of the serious game was developed using a user-centered participatory design. The prototype of Silver focused on 1 aspect of a serious game for improving cognitive vulnerability in adolescents, that is, the recognition and identification of cognitive distortions. Through the game, players were required to identify and classify the character’s thoughts as helpful or unhelpful. Upon successful advancement to the next level, the task becomes more challenging, as players must also identify specific types of cognitive distortions. A pre- and posttest uncontrolled design was used to evaluate the game, with a 1-week intervention phase in which participants were asked to play the game. Participants aged 12-16 years were recruited in schools. The outcomes of interest were the recognition of cognitive distortions and presence of participants’ cognitive distortions. The game was also evaluated on its effects, content, and usefulness. Results: A total of 630 adolescents played Silver and completed the assessments. Adolescents were significantly better at recognizing cognitive distortions at the pretest (mean 13.09, SD 4.08) compared to the posttest (mean 13.82, SD 5.09; t629=−4.00, P<.001). Furthermore, their cognitive distortions decreased significantly at the posttest (mean 38.73, SD 12.79) compared to the pretest (mean 41.43, SD 10.90; t629=7.98, P<.001). Participants also indicated that the game helped them recognize cognitive distortions. Many participants considered the game appealing (294/610, 48.2%) but boring (317/610, 52%) and preferred a more comprehensive game (299/610, 49%). Conclusions: Findings from this study suggest that a serious game may be an effective tool for improving cognitive vulnerability in adolescents. The development of such a serious game, based on the prototype, is recommended. It may be an important and innovative tool for the universal prevention of mental health problems in adolescents. Future research on the effects of the game is warranted. %R 10.2196/47513 %U https://games.jmir.org/2024/1/e47513 %U https://doi.org/10.2196/47513 %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 %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55156 %T KIJANI App to Promote Physical Activity in Children and Adolescents: Protocol for a Mixed Method Evaluation %A Willinger,Laura %A Böhm,Birgit %A Schweizer,Florian %A Reimer,Lara Marie %A Jonas,Stephan %A Scheller,Daniel A %A Oberhoffer-Fritz,Renate %A Müller,Jan %+ Chair of Preventive Pediatrics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992 München, Munich, Germany, 49 28924900, laura.willinger@tum.de %K physical activity %K health promotion %K digital health %K gamification %K childhood %K adolescence %K adolescents %K adolescent %K children %K augmented reality %K KIJANI intervention %K KIJANI %K intervention %K user experience %D 2024 %7 3.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: The prevalence of physical inactivity among children and adolescents is alarmingly high despite the well-documented and comprehensive benefits of regular physical activity (PA). Therefore, PA promotion should start early in childhood and adolescence. Although reducing recreational screen time in children and adolescents is an urgent concern, digital approaches have the potential to make activity promotion attractive and age appropriate for the target group. KIJANI is a mobile app approach to promote PA in children and adolescents via gamification and augmented reality. Objective: This study protocol aims to describe the KIJANI intervention in detail, as well as the evaluation approach. Methods: KIJANI is based on the concept that virtual coins can be earned through PA, for example, in the form of a collected step count. With these coins, in turn, blocks can be bought, which can be used to create virtual buildings and integrate them into the player’s real-world environment via augmented reality. PA of users is detected via accelerometers integrated into the smartphones. KIJANI can be played at predefined play locations that were comprehensively identified as safe, child-friendly, and attractive for PA by the target group in a partner project. The evaluation process will be divided into 2 different stages. The phase-I evaluation will be a mixed methods approach with one-on-one semistructured interviews and questionnaires to evaluate the user experience and receive feedback from the target group. After the implementation of results and feedback from the target group, the phase-II evaluation will proceed in the form of a 2-arm randomized controlled trial, in which the effectiveness of KIJANI will be assessed via objectively measured PA as well as questionnaires. Results: The study received ethical approval from the ethical board of the Technical University of Munich. Participants for the phase-I evaluation are currently being recruited. Conclusions: The study will help to determine the efficacy, applicability, and user experience of a gamified activity promotion application in children and adolescents. Overall, digital health approaches provide easy and wide reachability at low cost and are age appropriate and attractive for the target group of adolescents. Strategies have to be developed to apply digital health approaches in the best possible way for activity promotion. International Registered Report Identifier (IRRID): DERR1-10.2196/55156 %M 38700911 %R 10.2196/55156 %U https://www.researchprotocols.org/2024/1/e55156 %U https://doi.org/10.2196/55156 %U http://www.ncbi.nlm.nih.gov/pubmed/38700911 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e51508 %T Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study %A Webster,Amy %A Poyade,Matthieu %A Coulter,Elaine %A Forrest,Lisa %A Paul,Lorna %+ School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, United Kingdom, 44 141 273 1345, Amy.Webster@gcu.ac.uk %K virtual reality %K multiple sclerosis %K upper limb rehabilitation %K coproduction %K activities of daily living %K exercise games %K upper limb impairment %D 2024 %7 26.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation. Objective: This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games. Methods: Separate focus groups were conducted with people with MS, recruited through the MS Society UK’s research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis. Results: People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities. Conclusions: VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS. %M 38669680 %R 10.2196/51508 %U https://games.jmir.org/2024/1/e51508 %U https://doi.org/10.2196/51508 %U http://www.ncbi.nlm.nih.gov/pubmed/38669680 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e57714 %T Therapeutic Uses of Gaming in Mental Health: An Untapped Potential %A Eckardt,Jens Peter %+ Bedre Psykiatri Research Unit (Videnscenter), Gammeltorv 14. 2 sal, Copenhagen, 1457, Denmark, 45 28943288, jp-mail@hotmail.com %K digital mental health interventions %K mental health %K psychiatry %K gaming %K serious games %K casual video games %K commercial games %K exergames %K adolescent %K anxiety %K teenage %K video game %K youth %D 2024 %7 25.4.2024 %9 Letter to the Editor %J JMIR Serious Games %G English %X %M 38662422 %R 10.2196/57714 %U https://games.jmir.org/2024/1/e57714 %U https://doi.org/10.2196/57714 %U http://www.ncbi.nlm.nih.gov/pubmed/38662422 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47600 %T Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study %A Lee,Edmund W J %A Tan,Warrick W %A Pham,Ben Tan Phat %A Kawaja,Ariffin %A Theng,Yin-Leng %+ Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore, 31 Nanyang Link, WKWSCI Building, #02-06, Singapore 639798, Singapore, 639798, Singapore, 65 6908 3429, elwj88@gmail.com %K wearables %K exergames %K older adults %K active aging %K rehabilitation %K stroke %D 2024 %7 24.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults’ views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness. Objective: In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation. Methods: We conducted a moderated usability study with 19 older adults, of which 11 (58%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise. Results: Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements. Conclusions: Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation. %M 38656778 %R 10.2196/47600 %U https://games.jmir.org/2024/1/e47600 %U https://doi.org/10.2196/47600 %U http://www.ncbi.nlm.nih.gov/pubmed/38656778 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e42829 %T Effects of Virtual Reality Therapy Combined With Conventional Rehabilitation on Pain, Kinematic Function, and Disability in Patients With Chronic Neck Pain: Randomized Controlled Trial %A Guo,Qifan %A Zhang,Liming %A Han,Leo Lianyi %A Gui,Chenfan %A Chen,Guanghui %A Ling,Chunyan %A Wang,Wei %A Gao,Qiang %+ West China Hospital, Sichuan University, No 37 Guoxuexiang, Chengdu, 610041, China, 86 18980605992, gaoqiang_hxkf@163.com %K virtual reality %K neck pain %K disability %K kinematic function %K rehabilitation %K physiotherapy %K neck %K pain %K chronic %K therapy %K kinematic %K efficacy %K patient %K effect %D 2024 %7 24.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neck pain is a common condition that leads to neck motor dysfunction and subsequent disability, with a significant global health care burden. As a newly emerging tool, virtual reality (VR) technology has been employed to address pain and reduce disability among patients with neck pain. However, there is still a lack of high-quality studies evaluating the efficacy of VR therapy combined with conventional rehabilitation for patients with chronic neck pain, particularly in terms of kinematic function. Objective: This study aims to investigate the effect of VR therapy combined with conventional rehabilitation on pain, kinematic function, and disability in patients with chronic neck pain. Methods: We conducted an assessor-blinded, allocation-concealed randomized controlled trial. Sixty-four participants experiencing chronic neck pain were randomly allocated into the experimental group that underwent VR rehabilitation plus conventional rehabilitation or the control group receiving the same amount of conventional rehabilitation alone for 10 sessions over 4 weeks. Pain intensity, disability, kinematic function (cervical range of motion, proprioception, and mean and peak velocity), degree of satisfaction, and relief of symptoms were evaluated at 3 timepoints (baseline, postintervention, and at 3 months follow-up). A 2*3 mixed repeated measures analysis of variance was utilized for analyzing the difference across indicators, with a significant difference level of .05. Results: Both groups demonstrated significant improvements in pain, disability, and kinematic functions (P<.05) at postintervention and at 3-month follow-up. The experimental group showed superior therapeutic outcomes compared to the control group in pain reduction (mean difference from the baseline: 5.50 vs 1.81 at posttreatment; 5.21 vs 1.91 at the 3-month follow-up, respectively; P<.001), disability improvement (mean difference from baseline: 3.04 vs 0.50 at posttreatment; 3.20 vs 0.85 at the 3-month follow-up, respectively; P<.001), and enhanced kinematic functions (P<.05). Moreover, participants in the experimental group reported better satisfaction and relief of symptoms than the control group (P<.05), with better initiative for exercising during the follow-up period. However, there was no between-group difference of improvement in proprioception. No adverse events were reported or observed in our research. Conclusions: The findings of our study support the efficacy of combining VR therapy with conventional rehabilitation in alleviating pain, enhancing kinematic function, and reducing disability of patients with chronic neck pain. Future research should focus on refining the therapeutic protocols and dosages for VR therapy as well as on optimizing its application in clinical settings for improved convenience and effectiveness. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040132; http://www.chictr.org.cn/showproj.aspx?proj=64346 %M 38656775 %R 10.2196/42829 %U https://games.jmir.org/2024/1/e42829 %U https://doi.org/10.2196/42829 %U http://www.ncbi.nlm.nih.gov/pubmed/38656775 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e54538 %T Integrating Biomarkers From Virtual Reality and Magnetic Resonance Imaging for the Early Detection of Mild Cognitive Impairment Using a Multimodal Learning Approach: Validation Study %A Park,Bogyeom %A Kim,Yuwon %A Park,Jinseok %A Choi,Hojin %A Kim,Seong-Eun %A Ryu,Hokyoung %A Seo,Kyoungwon %+ Department of Applied Artificial Intelligence, Seoul National University of Science and Technology, Sangsang Hall, 4th Fl, Gongneung-ro, Gongneung-dong, Nowon-gu, Seoul, 01811, Republic of Korea, 82 010 5668 8660, kwseo@seoultech.ac.kr %K magnetic resonance imaging %K MRI %K virtual reality %K VR %K early detection %K mild cognitive impairment %K multimodal learning %K hand movement %K eye movement %D 2024 %7 17.4.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Early detection of mild cognitive impairment (MCI), a transitional stage between normal aging and Alzheimer disease, is crucial for preventing the progression of dementia. Virtual reality (VR) biomarkers have proven to be effective in capturing behaviors associated with subtle deficits in instrumental activities of daily living, such as challenges in using a food-ordering kiosk, for early detection of MCI. On the other hand, magnetic resonance imaging (MRI) biomarkers have demonstrated their efficacy in quantifying observable structural brain changes that can aid in early MCI detection. Nevertheless, the relationship between VR-derived and MRI biomarkers remains an open question. In this context, we explored the integration of VR-derived and MRI biomarkers to enhance early MCI detection through a multimodal learning approach. Objective: We aimed to evaluate and compare the efficacy of VR-derived and MRI biomarkers in the classification of MCI while also examining the strengths and weaknesses of each approach. Furthermore, we focused on improving early MCI detection by leveraging multimodal learning to integrate VR-derived and MRI biomarkers. Methods: The study encompassed a total of 54 participants, comprising 22 (41%) healthy controls and 32 (59%) patients with MCI. Participants completed a virtual kiosk test to collect 4 VR-derived biomarkers (hand movement speed, scanpath length, time to completion, and the number of errors), and T1-weighted MRI scans were performed to collect 22 MRI biomarkers from both hemispheres. Analyses of covariance were used to compare these biomarkers between healthy controls and patients with MCI, with age considered as a covariate. Subsequently, the biomarkers that exhibited significant differences between the 2 groups were used to train and validate a multimodal learning model aimed at early screening for patients with MCI among healthy controls. Results: The support vector machine (SVM) using only VR-derived biomarkers achieved a sensitivity of 87.5% and specificity of 90%, whereas the MRI biomarkers showed a sensitivity of 90.9% and specificity of 71.4%. Moreover, a correlation analysis revealed a significant association between MRI-observed brain atrophy and impaired performance in instrumental activities of daily living in the VR environment. Notably, the integration of both VR-derived and MRI biomarkers into a multimodal SVM model yielded superior results compared to unimodal SVM models, achieving higher accuracy (94.4%), sensitivity (100%), specificity (90.9%), precision (87.5%), and F1-score (93.3%). Conclusions: The results indicate that VR-derived biomarkers, characterized by their high specificity, can be valuable as a robust, early screening tool for MCI in a broader older adult population. On the other hand, MRI biomarkers, known for their high sensitivity, excel at confirming the presence of MCI. Moreover, the multimodal learning approach introduced in our study provides valuable insights into the improvement of early MCI detection by integrating a diverse set of biomarkers. %M 38631021 %R 10.2196/54538 %U https://www.jmir.org/2024/1/e54538 %U https://doi.org/10.2196/54538 %U http://www.ncbi.nlm.nih.gov/pubmed/38631021 %0 Journal Article %@ 2291-5222 %I %V 12 %N %P e49509 %T mHealth-Based Gamification Interventions Among Men Who Have Sex With Men in the HIV Prevention and Care Continuum: Systematic Review and Meta-Analysis %A Luo,Qianqian %A Zhang,Yue %A Wang,Wei %A Cui,Tianyu %A Li,Tianying %K mHealth %K gamification %K HIV %K men who have sex with men %K meta-analysis %K PRISMA %K mobile health %K Preferred Reporting Items for Systematic Reviews and Meta-Analyses %D 2024 %7 15.4.2024 %9 %J JMIR Mhealth Uhealth %G English %X Background: In the past few years, a burgeoning interest has emerged in applying gamification to promote desired health behaviors. However, little is known about the effectiveness of such applications in the HIV prevention and care continuum among men who have sex with men (MSM). Objective: This study aims to summarize and evaluate research on the effectiveness of gamification on the HIV prevention and care continuum, including HIV-testing promotion; condomless anal sex (CAS) reduction; and uptake of and adherence to pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and antiretroviral therapy (ART). Methods: We comprehensively searched PubMed, Embase, the Cochrane Library, Web of Science, Scopus, and the Journal of Medical Internet Research and its sister journals for studies published in English and Chinese from inception to January 2024. Eligible studies were included when they used gamified interventions with an active or inactive control group and assessed at least one of the following outcomes: HIV testing; CAS; and uptake of and adherence to PrEP, PEP, and ART. During the meta-analysis, a random-effects model was applied. Two reviewers independently assessed the quality and risk of bias of each included study. Results: The systematic review identified 26 studies, including 10 randomized controlled trials (RCTs). The results indicated that gamified digital interventions had been applied to various HIV outcomes, such as HIV testing, CAS, PrEP uptake and adherence, PEP uptake, and ART adherence. Most of the studies were conducted in the United States (n=19, 73%). The most frequently used game component was gaining points, followed by challenges. The meta-analysis showed gamification interventions could reduce the number of CAS acts at the 3-month follow-up (n=2 RCTs; incidence rate ratio 0.62, 95% CI 0.44-0.88). The meta-analysis also suggested an effective but nonstatistically significant effect of PrEP adherence at the 3-month follow-up (n=3 RCTs; risk ratio 1.16, 95% CI 0.96-1.38) and 6-month follow-up (n=4 RCTs; risk ratio 1.28, 95% CI 0.89-1.84). Only 1 pilot RCT was designed to evaluate the effectiveness of a gamified app in promoting HIV testing and PrEP uptake. No RCT was conducted to evaluate the effect of the gamified digital intervention on PEP uptake and adherence, and ART initiation among MSM. Conclusions: Our findings suggest the short-term effect of gamified digital interventions on lowering the number of CAS acts in MSM. Further well-powered studies are still needed to evaluate the effect of the gamified digital intervention on HIV testing, PrEP uptake, PEP initiation and adherence, and ART initiation in MSM. Trial Registration: PROSPERO CRD42023392193; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=392193 %R 10.2196/49509 %U https://mhealth.jmir.org/2024/1/e49509 %U https://doi.org/10.2196/49509 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e50315 %T Measuring the Reliability of a Gamified Stroop Task: Quantitative Experiment %A Wiley,Katelyn %A Berger,Phaedra %A Friehs,Maximilian Achim %A Mandryk,Regan Lee %+ Department of Computer Science, University of Saskatchewan, 110 Science Place, University of Saskatchewan, Saskatoon, SK, S7N 5C9, Canada, 1 5878884567, katelyn.wiley@usask.ca %K cognitive assessment %K gamification %K serious games %K Stroop task %K reliability %D 2024 %7 10.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Few gamified cognitive tasks are subjected to rigorous examination of psychometric properties, despite their use in experimental and clinical settings. Even small manipulations to cognitive tasks require extensive research to understand their effects. Objective: This study aims to investigate how game elements can affect the reliability of scores on a Stroop task. We specifically investigated performance consistency within and across sessions. Methods: We created 2 versions of the Stroop task, with and without game elements, and then tested each task with participants at 2 time points. The gamified task used points and feedback as game elements. In this paper, we report on the reliability of the gamified Stroop task in terms of internal consistency and test-retest reliability, compared with the control task. We used a permutation approach to evaluate internal consistency. For test-retest reliability, we calculated the Pearson correlation and intraclass correlation coefficients between each time point. We also descriptively compared the reliability of scores on a trial-by-trial basis, considering the different trial types. Results: At the first time point, the Stroop effect was reduced in the game condition, indicating an increase in performance. Participants in the game condition had faster reaction times (P=.005) and lower error rates (P=.04) than those in the basic task condition. Furthermore, the game condition led to higher measures of internal consistency at both time points for reaction times and error rates, which indicates a more consistent response pattern. For reaction time in the basic task condition, at time 1, rSpearman-Brown=0.78, 95% CI 0.64-0.89. At time 2, rSpearman-Brown=0.64, 95% CI 0.40-0.81. For reaction time, in the game condition, at time 1, rSpearman-Brown=0.83, 95% CI 0.71-0.91. At time 2, rSpearman-Brown=0.76, 95% CI 0.60-0.88. Similarly, for error rates in the basic task condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. For error rates in the game condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. Test-retest reliability analysis revealed a distinctive performance pattern depending on the trial type, which may be reflective of motivational differences between task versions. In short, especially in the incongruent trials where cognitive conflict occurs, performance in the game condition reaches peak consistency after 100 trials, whereas performance consistency drops after 50 trials for the basic version and only catches up to the game after 250 trials. Conclusions: Even subtle gamification can impact task performance albeit not only in terms of a direct difference in performance between conditions. People playing the game reach peak performance sooner, and their performance is more consistent within and across sessions. We advocate for a closer examination of the impact of game elements on performance. %M 38598265 %R 10.2196/50315 %U https://games.jmir.org/2024/1/e50315 %U https://doi.org/10.2196/50315 %U http://www.ncbi.nlm.nih.gov/pubmed/38598265 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e56037 %T Effects of a Serious Smartphone Game on Nursing Students' Theoretical Knowledge and Practical Skills in Adult Basic Life Support: Randomized Wait List–Controlled Trial %A Fijačko,Nino %A Masterson Creber,Ruth %A Metličar,Špela %A Strnad,Matej %A Greif,Robert %A Štiglic,Gregor %A Skok,Pavel %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, 2000, Slovenia, 386 23004764, nino.fijacko@um.si %K serious smartphone game %K adult basic life support %K teaching %K game %K games %K gaming %K education %K nurse %K nursing %K nurses %K educational %K mHealth %K mobile health %K app %K apps %K application %K applications %K smartphone %K smartphones %K RCT %K randomized controlled trial %K controlled trial %K technology-enhanced learning %K TEL %K life support %K knowledge retention %K theoretical knowledge %K practice %K practical %K resuscitation %D 2024 %7 5.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Retention of adult basic life support (BLS) knowledge and skills after professional training declines over time. To combat this, the European Resuscitation Council and the American Heart Association recommend shorter, more frequent BLS sessions. Emphasizing technology-enhanced learning, such as mobile learning, aims to increase out-of-hospital cardiac arrest (OHCA) survival and is becoming more integral in nursing education. Objective: The aim of this study was to investigate whether playing a serious smartphone game called MOBICPR at home can improve and retain nursing students’ theoretical knowledge of and practical skills in adult BLS. Methods: This study used a randomized wait list–controlled design. Nursing students were randomly assigned in a 1:1 ratio to either a MOBICPR intervention group (MOBICPR-IG) or a wait-list control group (WL-CG), where the latter received the MOBICPR game 2 weeks after the MOBICPR-IG. The aim of the MOBICPR game is to engage participants in using smartphone gestures (eg, tapping) and actions (eg, talking) to perform evidence-based adult BLS on a virtual patient with OHCA. The participants’ theoretical knowledge of adult BLS was assessed using a questionnaire, while their practical skills were evaluated on cardiopulmonary resuscitation quality parameters using a manikin and a checklist. Results: In total, 43 nursing students participated in the study, 22 (51%) in MOBICPR-IG and 21 (49%) in WL-CG. There were differences between the MOBICPR-IG and the WL-CG in theoretical knowledge (P=.04) but not in practical skills (P=.45) after MOBICPR game playing at home. No difference was noted in the retention of participants’ theoretical knowledge and practical skills of adult BLS after a 2-week break from playing the MOBICPR game (P=.13). Key observations included challenges in response checks with a face-down manikin and a general neglect of safety protocols when using an automated external defibrillator. Conclusions: Playing the MOBICPR game at home has the greatest impact on improving the theoretical knowledge of adult BLS in nursing students but not their practical skills. Our findings underscore the importance of integrating diverse scenarios into adult BLS training. Trial Registration: ClinicalTrials.gov (NCT05784675); https://clinicaltrials.gov/study/NCT05784675 %M 38578690 %R 10.2196/56037 %U https://games.jmir.org/2024/1/e56037 %U https://doi.org/10.2196/56037 %U http://www.ncbi.nlm.nih.gov/pubmed/38578690 %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 %@ 1929-073X %I JMIR Publications %V 13 %N %P e35132 %T Gamification and Oral Health in Children and Adolescents: Scoping Review %A Moreira,Rui %A Silveira,Augusta %A Sequeira,Teresa %A Durão,Nuno %A Lourenço,Jessica %A Cascais,Inês %A Cabral,Rita Maria %A Taveira Gomes,Tiago %+ School of Medicine and Biomedical Sciences, Instituto de Ciencias Biomédicas Abel Salazar, University of Porto, Rua de Jorge Viterbo Ferreira, 228, Porto, 4050-313, Portugal, 351 914180479, ruidcmoreira@gmail.com %K gamification %K mechanisms of gamification %K gamification components %K intrinsic and extrinsic motivators %K oral health care %K health behavior %K oral health care applications %D 2024 %7 4.4.2024 %9 Review %J Interact J Med Res %G English %X Background: Oral health is a determinant of overall well-being and quality of life. Individual behaviors, such as oral hygiene and dietary habits, play a central role in oral health. Motivation is a crucial factor in promoting behavior change, and gamification offers a means to boost health-related knowledge and encourage positive health behaviors. Objective: This study aims to evaluate the impact of gamification and its mechanisms on oral health care of children and adolescents. Methods: A systematic search covered multiple databases: PubMed/MEDLINE, PsycINFO, the Cochrane Library, ScienceDirect, and LILACS. Gray literature, conference proceedings, and WHOQOL internet resources were considered. Studies from January 2013 to December 2022 were included, except for PubMed/MEDLINE, which was searched until January 2023. A total of 15 studies were selected following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The eligibility criteria were peer-reviewed, full-text, and empirical research related to gamification in oral health care, reports of impact, and oral health care outcomes. The exclusion criteria encompassed duplicate articles; unavailable full texts; nonoriginal articles; and non–digital game–related, non–oral health–related, and protocol studies. Selected studies were scrutinized for gamification mechanisms and outcomes. Two main questions were raised: “Does gamification in oral health care impact oral health?” and “Does oral health care gamification enhance health promotion and literacy?” The PICO (Patient, Intervention, Comparison, Outcome) framework guided the scoping review. Results: Initially, 617 records were obtained from 5 databases and gray literature sources. After applying exclusion criteria, 15 records were selected. Sample size in the selected studies ranged from 34 to 190 children and adolescents. A substantial portion (11/15, 73%) of the studies discussed oral self-care apps supported by evidence-based oral health. The most clearly defined data in the apps were “brushing time” (11/11, 100%) and “daily amount brushing” (10/11, 91%). Most studies (11/15, 73%) mentioned oral health care behavior change techniques and included “prompt intention formation” (11/26, 42%), “providing instructions” (11/26, 42%), “providing information on the behavior-health link” (10/26, 38%), “providing information on consequences” (9/26, 35%), “modeling or demonstrating behavior” (9/26, 35%), “providing feedback on performance” (8/26, 31%), and “providing contingent rewards” (8/26, 31%). Furthermore, 80% (12/15) of the studies identified game design elements incorporating gamification features in oral hygiene applications. The most prevalent gamification features were “ideological incentives” (10/12, 83%) and “goals” (9/16, 56%), which were found in user-specific and challenge categories, respectively. Conclusions: Gamification in oral health care shows potential as an innovative approach to promote positive health behaviors. Most studies reported evidence-based oral health and incorporated oral health care behavior change techniques. %M 38573750 %R 10.2196/35132 %U https://www.i-jmr.org/2024/1/e35132 %U https://doi.org/10.2196/35132 %U http://www.ncbi.nlm.nih.gov/pubmed/38573750 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e43078 %T Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study %A Lieder,Falk %A Chen,Pin-Zhen %A Prentice,Mike %A Amo,Victoria %A Tošić,Mateo %+ Department of Psychology, University of California, Los Angeles, 502 Portola Plaza, Los Angeles, Los Angeles, CA, 90095, United States, 1 424 259 5300, falk.lieder@psych.ucla.edu %K gamification %K points %K feedback %K behavior change %K habit formation %K chatbot %K digital interventions %K mobile phone %K artificial intelligence %D 2024 %7 22.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission. Objective: In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change. Methods: As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot’s optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants’ water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day. Results: A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P≥.17 in all cases). Conclusions: Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective. Trial Registration: Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8 %M 38517466 %R 10.2196/43078 %U https://games.jmir.org/2024/1/e43078 %U https://doi.org/10.2196/43078 %U http://www.ncbi.nlm.nih.gov/pubmed/38517466 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48545 %T An Escape Game on University Students’ Mental Health During the COVID-19 Pandemic: Cocreation Study %A Labrosse,David %A Vié,Clara %A Hajjam,Hana %A Tisseron,Clément %A Thellier,Dimitri %A Montagni,Ilaria %+ University of Bordeaux, Inserm, Bordeaux Population Health Research Center U1219, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 06 42 19 33 63, ilaria.montagni@u-bordeaux.fr %K students %K game %K mental health %K COVID-19 %K cocreation %K university student %K promote %K psychological well-being %K effective tool %K tool %K acceptability %K testing %K questionnaire %K learning %K motivation %K user centered %D 2024 %7 18.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The COVID-19 pandemic has had a severe impact on students’ mental health. Interventions are needed to promote their psychological well-being and prevent mental illnesses in the aftermath of this unprecedented situation. Digital escape games can be an effective tool to support students’ mental health. A cocreation approach can improve the acceptability of these interventions by involving different stakeholders (eg, end users, game designers, and health professionals) to obtain audience-specific games. Objective: This study aims to describe the process of testing and optimizing the game “EscapeCovid” on students’ mental health, to serve as a model for the cocreation of future similar interventions. Methods: The PRODUCES (Problem, Objective, Design, End Users, Cocreators, Evaluation, Scalability) framework was used. Cocreation steps (test and optimization) were detailed for replicability. A total of 45 students tested a pilot version of the game, with 10 undergoing a semistructured interview. Meetings with a group of stakeholders and brainwriting were organized to optimize the game. Results: We produced a new version of the game incorporating the suggestions provided by student testers and following the stakeholders’ guidelines. Improvements were made to both the content and the form of the new version of the pilot game. The storyline, including the protagonist and the scenes, was adapted to the student population. Conclusions: Our results suggested that cocreation can contribute to the design of more widely accepted interventions aimed at promoting mental health and preventing psychological disorders. Results also suggest that an end user–centered approach can facilitate intervention tailoring. When conceiving a health-related escape game for students, we recommend using the cocreation approach to enhance players’ experience, thus positively influencing their learning process and overall well-being. %M 38498033 %R 10.2196/48545 %U https://games.jmir.org/2024/1/e48545 %U https://doi.org/10.2196/48545 %U http://www.ncbi.nlm.nih.gov/pubmed/38498033 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e48080 %T Improving Behavioral-Based Safety Training in Using Verbal Commands Through a Theory-Driven and Feedback-Based Nonimmersive Virtual Reality Game: Development and Usability Study %A Atagbuzia,Chukwudiebube %A Ng,Ean H %A Natarajan,Ganapathy %+ Oregon State University, 204 Rogers Hall, Oregon State University, Corvallis, OR, 97331, United States, 1 15417370570, ean.ng@oregonstate.edu %K behavioral safety training %K SERES framework %K Reflection, Engagement, Choice, Information, Play, Exposition framework %K gamification %K gestalt laws of perception %D 2024 %7 12.3.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The construction, chemical, aviation, medical, and health care industries have used serious games for safety training. To our knowledge, serious games have not been developed focusing on behavioral change to improve safety through the use of verbal commands and instilling players with heightened awareness of their spatial proximity to other people in their surroundings. Objective: We aimed to develop a theory-driven serious game for improving safety behavior using verbal commands and validate the implementation of the theoretical frameworks used for game development. The game developed, KitchenSpeak, was a first-person character (FPC) game where users respond to in-game prompts to use loud verbal commands when they are approaching another employee’s blind spot. Methods: In addition to using the SERES framework in guiding the general game design and development, and the Reflection, Engagement, Choice, Information, Play, Exposition (RECIPE) framework to inform the design of the game mechanics, we also applied gestalt laws of perception for graphic design to guide the design of the game’s user interface. We conducted 2 evaluative tests (alpha and beta) to collect end user and stakeholder feedback on the implementation of the theoretical frameworks, as well as to collect relevant information for full-scale implementation and a future validation study. Results: The alpha and beta tests had 8 and 40 participants, respectively. The alpha test results revealed that the theoretical frameworks were adequately applied; however, suggestions were also made to modify and improve the game. The beta test results suggested further improvements for the game design and found no differences in the perception of ease of play between participants with and without previous FPC gaming experience (P=.47; Kruskal-Wallis). Results suggested that the game met its design and theoretical requirements, and it would be easily playable by all players regardless of their previous experience in FPC games. Conclusions: A theory-driven and evidence-based FPC game titled KitchenSpeak was developed to teach the use of kitchen-speak terms in commercial kitchens. Evaluative tests were conducted to validate the implementation of the theoretical frameworks. Our main contributions are creating and validating game-based training to improve behavioral-based safety in the workplace and the incorporation of gestalt laws of perception for graphic design in the game’s user interface. %M 38470470 %R 10.2196/48080 %U https://formative.jmir.org/2024/1/e48080 %U https://doi.org/10.2196/48080 %U http://www.ncbi.nlm.nih.gov/pubmed/38470470 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e34535 %T A Smartphone-Gamified Virtual Reality Exposure Therapy Augmented With Biofeedback for Ailurophobia: Development and Evaluation Study %A Khaleghi,Ali %A Narimani,Abbas %A Aghaei,Zahra %A Khorrami Banaraki,Anahita %A Hassani-Abharian,Peyman %+ Iranian Light Source Facility, Institute for Research in Fundamental Sciences, Opposite the Araj, Artesh Highway, Aghdassieh, Tehran, 19395-5746, Iran, 98 9121003006, ali.khaleghi.ir@gmail.com %K animal phobia %K specific phobia %K ailurophobia %K cat phobia %K biofeedback %K smartphones %K virtual reality %K gamification %K mobile phone %D 2024 %7 6.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: To the best of our knowledge, no specialized research has been conducted to address ailurophobia (fear of cats) in Iran or globally. This has driven our project, along with the prevalence of ailurophobia and the absence of a gamified virtual reality exposure therapy (VRET) that incorporates affordable and easily accessible biofeedback (BF) tools. We hypothesize that a gamified VRET augmented with BF will yield more positive effects than a similar device lacking BF. Objective: This study primarily focuses on the development and preliminary evaluation of a smartphone-gamified VRET integrated with BF, targeting animal phobia, with a specific case study on ailurophobia. The secondary objectives are using affordable and readily available BF found in devices such as smart bands and smartwatches and creating a mobile virtual reality gamified app to improve patients’ adherence to treatments while simultaneously enhancing the app’s accessibility, scalability, and outreach. Methods: Evaluations encompassed 3 methods. First, we identified the tool’s potential positive effects on phobia interventions, exploring 4 effects: intrinsic motivation, simulation of fearful situations, management of stressful circumstances without therapists’ presence and mitigation of catastrophic thoughts, and preliminary effects on ailurophobia treatment. Participants were divided into BF and non-BF groups. Second, we gathered user preferences and opinions about the treatment. Third, we conducted heuristic evaluations using 44 heuristics from existing system usability scales assessing user interfaces, virtual reality platforms, and video games’ playability. To interpret the data, mean scores; ANOVA, single factor; and ANOVA, 2-factor with replication were used. A total of 29 individuals were identified, of which 10 met the eligibility criteria or were accessible. Results: The smartphone-gamified VRET augmented with BF exhibited better results on the identified effects compared with the non-BF version and contributed to normalizing encounters with cats. Moreover, 41 of the 44 heuristics achieved a percentage above 62%, indicating its potential as a therapeutic product and its ability to enhance patient adherence to treatments. Patient preferences on the treatment and its strengths and weaknesses were provided for further improvement. Conclusions: The tool has the potential to evolve into a comprehensive solution by incorporating various types of cats and their behaviors, simulating environments in which they are commonly found, and enhancing its appeal through an increased sense of adventure without inducing unrealistic fears. By adapting fear elements, the game can be tailored to treat various animal phobias. Phobia-focused games should avoid action and combat scenarios to prevent reinforcement of fear responses. After rigorous evaluation, further exploration is required to provide remote use beyond clinical settings. %M 38446522 %R 10.2196/34535 %U https://games.jmir.org/2024/1/e34535 %U https://doi.org/10.2196/34535 %U http://www.ncbi.nlm.nih.gov/pubmed/38446522 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47257 %T Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review %A Hakim,Hina %A Driedger,S Michelle %A Gagnon,Dominique %A Chevrier,Julien %A Roch,Geneviève %A Dubé,Eve %A Witteman,Holly O %+ Department of Family and Emergency Medicine, Université Laval, 1050 avenue de la Médecine, Pavillon Ferdinand-Vandry, Québec City, QC, G1V 0A6, Canada, 1 418 656 2131, hina.hakim.1@ulaval.ca %K digital gamified tools %K digital game %K vaccination %K gamification %K vaccine uptake %K scoping review %K review method %K vaccine %K gamified %K COVID-19 %K COVID %K SARS-CoV-2 %K health behaviour %K health behavior %K health promotion %K behavior change %K behaviour change %D 2024 %7 29.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health. Objective: In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools. Methods: We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively. Results: Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature. Conclusions: Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts. %M 38421688 %R 10.2196/47257 %U https://games.jmir.org/2024/1/e47257 %U https://doi.org/10.2196/47257 %U http://www.ncbi.nlm.nih.gov/pubmed/38421688 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e54401 %T Development of a Clinical Simulation Video to Evaluate Multiple Domains of Clinical Competence: Cross-Sectional Study %A Shikino,Kiyoshi %A Nishizaki,Yuji %A Fukui,Sho %A Yokokawa,Daiki %A Yamamoto,Yu %A Kobayashi,Hiroyuki %A Shimizu,Taro %A Tokuda,Yasuharu %+ Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chiba, 2608677, Japan, 81 43 222 7171, kshikino@gmail.com %K discrimination index %K General Medicine In-Training Examination %K clinical simulation video %K postgraduate medical education %K video %K videos %K training %K examination %K examinations %K medical education %K resident %K residents %K postgraduate %K postgraduates %K simulation %K simulations %K diagnosis %K diagnoses %K diagnose %K general medicine %K general practice %K general practitioner %K skill %K skills %D 2024 %7 29.2.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents’ clinical knowledge. A clinical simulation video (CSV) may assess learners’ interpersonal abilities. Objective: This study aimed to evaluate the relationship between GM-ITE scores and resident physicians’ diagnostic skills by having them watch a CSV and to explore resident physicians’ perceptions of the CSV’s realism, educational value, and impact on their motivation to learn. Methods: The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject’s qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants’ views on the realism and educational value of the CSV and its impact on their motivation to learn. Results: Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn. Conclusions: The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees’ clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners’ motivation, suggesting a multifaceted role for simulation in medical education. %M 38421691 %R 10.2196/54401 %U https://mededu.jmir.org/2024/1/e54401 %U https://doi.org/10.2196/54401 %U http://www.ncbi.nlm.nih.gov/pubmed/38421691 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e45546 %T A Serious Game (“Fight With Virus”) for Preventing COVID-19 Health Rumors: Development and Experimental Study %A Xiong,Shuo %A Zuo,Long %A Chen,Qiwei %A Zeliang,Zhang %A Nor Akmal Khalid,Mohd %+ Philosophy and Social Sciences Laboratory of Big Data and National Communication Strategy, Huazhong University of Science and Technology, Building 6, No 1037, Luoyu Road, Wuhan, 430074, China, 86 15927188806, xiongshuo@hust.edu.cn %K serious game %K COVID-19 %K health rumor %K game communication %K game TCP model %K Transmission Control Protocol %K gaming %K misinformation %K disinformation %K rumor %K health communication %K false information %K elder %K older adult %D 2024 %7 26.2.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Health rumors arbitrarily spread in mainstream social media on the internet. Health rumors emerged in China during the outbreak of COVID-19 in early 2020. Many midelders/elders (age over 40 years) who lived in Wuhan believed these rumors. Objective: This study focused on designing a serious game as an experimental program to prevent and control health rumors. The focus of the study was explicitly on the context of the social networking service for midelders/elders. Methods: This research involved 2 major parts: adopting the Transmission Control Protocol model for games and then, based on the model, designing a game named “Fight With Virus” as an experimental platform and developing a cognitive questionnaire with a 5-point Likert scale. The relevant variables for this experimental study were defined, and 10 hypotheses were proposed and tested with an empirical study. In total, 200 participants were selected for the experiments. By collecting relevant data in the experiments, we conducted statistical observations and comparative analysis to test whether the experimental hypotheses could be proved. Results: We noted that compared to traditional media, serious games are more capable of inspiring interest in research participants toward their understanding of the knowledge and learning of health commonsense. In judging and recognizing the COVID-19 health rumor, the test group that used game education had a stronger ability regarding identification of the rumor and a higher accuracy rate of identification. Results showed that the more educated midelders/elders are, the more effective they are at using serious games. Conclusions: Compared to traditional media, serious games can effectively improve midelders’/elders’ cognitive abilities while they face a health rumor. The gameplay effect is related to the individual’s age and educational background, while income and gender have no impact. %M 38407954 %R 10.2196/45546 %U https://games.jmir.org/2024/1/e45546 %U https://doi.org/10.2196/45546 %U http://www.ncbi.nlm.nih.gov/pubmed/38407954 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53072 %T Exploring the Use of a Learning-Based Exergame to Enhance Physical Literacy, Soft Skills, and Academic Learning in School-Age Children: Pilot Interventional Study %A Goncalves,Aurelie %A Lespiau,Florence %A Briet,Gaëtan %A Vaillant-Coindard,Eugénie %A Palermo,Angèle %A Decobert,Elsa %A Allegret-Bourdon,Nathan %A Charbonnier,Elodie %+ APSY-v, University of Nîmes, Rue du docteur Georges Salan, CS13019, Nîmes, F-30021, France, 33 466364518, aurelie.goncalves@unimes.fr %K learning support %K exergaming %K physics playground %K educational games %K primary school %K children %D 2024 %7 23.2.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is ample evidence that most children do not perform enough physical activity (PA). To address this major public health problem, the French government implemented 30 minutes of daily PA (DPA) at schools but did not provide any supplemental resources or concrete guidance. Considering both children’s interest in video games and the need for teachers to complete their curriculum, the use of a learning-based exergame that combines PA and learning appears particularly relevant. Objective: The first objective of this study was to evaluate the feasibility of implementing 30 minutes of DPA through exergaming among school-age children. The second objective was to examine the effects of an exergaming program on physical literacy, academic learning, and soft skills (motivation, self-efficacy, and concentration). Methods: This interventional study had a pre-post design and used the Play LÜ exergame platform. The study included 79 children with a mean age of 8.9 (SD 1.2) years from grade 2 (7 years old) to grade 5 (11 years old). Play LÜ requires players to throw balls against a wall to reach a target or to activate an object and provides an interactive game area for educational activities linked to specific learning themes. After a 4-session familiarization phase during which the teachers chose to prioritize mathematics learning in 30-minute DPA sessions, students took part in DPA sessions over a period of 3 weeks with Play LÜ and a motor skills circuit behind the LÜ setup to keep them continuously active. All sessions were carried out by PA specialists. Each session started with a warm-up using the Grööve application, continued with main activities promoting mathematics learning adapted to each grade level, and ended with a 3-minute meditation for returning to a calm and serene state using the Gaïa application. Before (T0) and after (T1) the program, students completed a self-evaluation booklet to assess their levels of physical literacy, academic performance, and soft skills. Results: The implementation of this exergaming program was welcomed by the school’s administration, teaching staff, and parents. After the program, we observed increased scores for physical literacy (difference +2.6, percentage change +3.6%; W=933.0; P=.002; rrb=−0.39, 95% CI −0.58 to −0.16) and motivation in mathematics (+0.7, +9.8%; W=381.5; P=.005; rrb=−0.44, 95% CI −0.66 to −0.16). In addition, it is important to note that some measures progressed differently across learning levels and age groups. Conclusions: The study results indicate positive impacts of learning-based exergaming on physical literacy and motivation in mathematics among school-age children. %M 38393767 %R 10.2196/53072 %U https://games.jmir.org/2024/1/e53072 %U https://doi.org/10.2196/53072 %U http://www.ncbi.nlm.nih.gov/pubmed/38393767 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51908 %T Effect of a Mobile Game–Based Intervention to Enhance Child Safety: Randomized Controlled Trial %A Wong,Rosa S %A Tung,Keith T S %A Ho,Frederick K W %A Wong,Wilfred H S %A Chow,Chun Bong %A Chan,Ko Ling %A Fu,King Wa %A Ip,Patrick %+ Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China (Hong Kong), 852 22554090, patricip@hku.hk %K mobile game %K injury prevention %K safety education %K unintentional injuries %K gamification %K game %K games %K gaming %K safety %K injury %K injuries %K gamify %K gamified %K child %K children %K youth %K pediatric %K pediatrics %K danger %K hazard %K hazards %K RCT %K randomized %K controlled trial %K controlled trials %K mobile phone %D 2024 %7 14.2.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence supports the effectiveness of serious games in health education, but little is known about their effects on the psychosocial well-being of children in the general population. Objective: This study aimed to investigate the potential of a mobile game–based safety education program in improving children’s safety and psychosocial outcomes. Methods: Safe City is a mobile roleplaying game specifically designed to educate children in Hong Kong about safety. This randomized controlled trial included 340 children in grades 4 through 6. Intervention arm participants (n=170) were instructed to play the Safe City mobile game for 4 weeks, whereas control arm participants (n=170) received a safety booklet. All participants completed a survey on safety knowledge and behaviors and psychosocial problems at baseline (T1), 1 month postintervention (T2), and 3 months postintervention (T3). Cumulative game scores and mini-game performance were analyzed as a proxy for the extent of exposure to the game. Outcome data were analyzed using 2-sample 2-tailed t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. The association of game use with outcome changes postintervention was analyzed using generalized additive models. Results: No significant differences were found in mean changes between the intervention and control arms. However, use analyses showed that higher game scores were associated with improvements in safe behavior (P=.03) and internalizing problems (P=.01) at T3. Matching and Spot the Danger mini-game performance significantly predicted improvements in safety knowledge at T2 and T3. Conclusions: Analysis of use has shown that playing the Safe City mobile game can result in significant improvements in safety knowledge and reductions in unsafe behavior and internalizing problems. These findings provide evidence for the positive impact of serious games on psychological and social well-being, highlighting the potential of technology-driven interventions to assist children in learning about safety and preventing injuries. Trial Registration: ClinicalTrials.org NCT04096196; https://clinicaltrials.gov/show/NCT04096196 International Registered Report Identifier (IRRID): RR2-10.2196/17756 %M 38354042 %R 10.2196/51908 %U https://www.jmir.org/2024/1/e51908 %U https://doi.org/10.2196/51908 %U http://www.ncbi.nlm.nih.gov/pubmed/38354042 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e46697 %T A Novel Casual Video Game With Simple Mental Health and Well-Being Concepts (Match Emoji): Mixed Methods Feasibility Study %A Pine,Russell %A Mbinta,James %A Te Morenga,Lisa %A Fleming,Theresa %+ School of Health, Victoria University of Wellington, Kelburn Parade, Kelburn, Wellington, 6012, New Zealand, 64 4 472 1000, russell.pine@vuw.ac.nz %K adolescent %K anxiety %K casual video games %K digital mental health interventions %K gaming %K mental health %K micro interventions %K serious game %K teenage %K video game %K youth %D 2024 %7 12.2.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescence is a crucial phase for early intervention and prevention of mental health problems. Casual video games are popular and have promise as a novel mechanism for reaching young people, but this potential has seldom been explored. Objective: This study aimed to explore the acceptability, feasibility, and possible indicators of therapeutic changes after playing a purpose-built novel casual video game (Match Emoji) with simple mental health and well-being content among young adolescents. Methods: We conducted a single-arm, nonrandomized trial of Match Emoji with 12- to 14-year-old school students (N=45; 26 [57%] New Zealand European, 12 [26%] Māori; 7 [15%] Asian or Pacific; 27 [60%] boys, 3 [6%] non-binary). Participants were invited to play Match Emoji for 15 minutes, 2-3 times a week over 2 weeks (a total of 60 minutes). Acceptability was assessed through the frequency and duration of use (analytics analyzed at the end of the 2-week intervention period and at weeks 4 and 6) and through participant reports. The Child and Adolescent Mindfulness Measure (CAMM), General Help-Seeking Questionnaire (GHSQ), Flourishing Scale (FS), and Revised Children’s Anxiety and Depression Scale (RCADS) were assessed at baseline and week 2 to indicate possible effects. Focus groups were held in week 4. Results: Most participants (n=39, 87%) used Match Emoji for at least 60 minutes over the 2-week intervention, with 80% (36/45) continuing to play the game after the intervention period. Mean change (from baseline to 2 weeks) on each measure was 1.38 (95% CI –0.03 to 2.79; P=.06) for CAMM; 0.8 (95% CI –2.71 to 4.31; P=.64) for GHSQ; –1.09 (95% CI –2.83 to 0.66; P=.21) for FS; and –3.42 (95% CI –6.84 to –0.001; P=0.49) for RCADS. Focus group feedback suggested that Match Emoji was enjoyable and helpful. Conclusions: The casual video game with mental health content appeared to be acceptable and provided a promising indication of possible therapeutic effects. This approach is worthy of further investigation. International Registered Report Identifier (IRRID): RR2-10.2196/31588 %M 38345848 %R 10.2196/46697 %U https://games.jmir.org/2024/1/e46697 %U https://doi.org/10.2196/46697 %U http://www.ncbi.nlm.nih.gov/pubmed/38345848 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52990 %T The Effects of Serious Games on Cardiopulmonary Resuscitation Training and Education: Systematic Review With Meta-Analysis of Randomized Controlled Trials %A Cheng,Pengfei %A Huang,Yangxi %A Yang,Pengyu %A Wang,Haizhen %A Xu,Baichao %A Qu,Chaoran %A Zhang,Hua %+ International Nursing School, Hainan Medical University, Number 3, Xueyuan Road., Haikou, 571199, China, 86 13698954876, zhanghuashelley@hotmail.com %K CPR %K education %K meta-analysis %K serious game %K training %D 2024 %7 6.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Serious games have emerged as an innovative educational strategy with the potential to significantly enhance the quality and effectiveness of cardiopulmonary resuscitation (CPR) training. Despite their promise, there remains a degree of controversy when comparing the advantages of serious games with traditional CPR training methods. This study seeks to provide a comprehensive assessment of the impact of serious games on CPR training and education by systematically analyzing the results of previous research. Objective: This study aimed to assess the effect of serious games on CPR training and education by summarizing and pooling the results of previous studies. Methods: We conducted a thorough and systematic search across 9 prominent web-based databases, encompassing the period from the inception of these databases until April 1, 2023. The databases included in our search were PubMed, Cochrane Library, Wiley Online Library, EBSCO (PsycInfo), SpringerLink, Chinese Biology Medicine Disc, Vip Journal Integration Platform, Wanfang Database, and Chinese National Knowledge Infrastructure. The studies selected adhered to the following criteria: (1) being a randomized controlled trial comparing serious games and traditional methods for CPR training; (2) having participants aged 12 years or older in CPR; (3) having an experimental group using serious games and a control group using nongame methods for CPR instruction; and (4) having outcomes including theoretical and skill assessments, compression depth, and rate. The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Data analysis was performed using RevMan (version 5.3; Cochrane Training), and mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables. Results: A total of 9 articles were included, involving 791 study participants, of whom 395 in the experimental group taught CPR training using serious games and 396 in the control group taught CPR training using traditional methods. The results of our meta-analysis indicate that the use of serious games in CPR training yields outcomes that are comparable in effectiveness to traditional training methods across several key areas. Specifically, serious games demonstrated equivalence to traditional formats in theory assessment (SMD –0.22, 95% CI – 0.96 to 0.51; P=.55), skill assessment (SMD –0.49, 95% CI –1.52 to 0.55; P=.36), compression depth (MD –3.17, 95% CI –0.18 to 6.53; P=.06), and compression rate (MD –0.20, 95% CI –7.29 to 6.89; P=.96). Conclusions: In summary, serious games offer a viable and effective CPR education approach, yielding results comparable to traditional formats. This modality is a valuable addition to CPR training methodologies. However, caution is warranted in interpreting these findings due to limited controlled trials, small sample sizes, and low-quality meta-analyzed evidence. %M 38319697 %R 10.2196/52990 %U https://games.jmir.org/2024/1/e52990 %U https://doi.org/10.2196/52990 %U http://www.ncbi.nlm.nih.gov/pubmed/38319697 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e48649 %T Personalized Virtual Reality Compared With Guided Imagery for Enhancing the Impact of Progressive Muscle Relaxation Training: Pilot Randomized Controlled Trial %A Pardini,Susanna %A Gabrielli,Silvia %A Olivetto,Silvia %A Fusina,Francesca %A Dianti,Marco %A Forti,Stefano %A Lancini,Cristina %A Novara,Caterina %+ Department of General Psychology, University of Padova, 8 Venezia St, Padova, Italy, 39 3335944315, susanna.pardini@phd.unipd.it %K digital health %K progressive muscular relaxation technique %K mental well-being %K virtual reality therapy %K anxiety %K relaxation %K e-therapy %K eHealth %K mobile phone %D 2024 %7 30.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Empirical evidence has shown that virtual reality (VR) scenarios can increase the effects of relaxation techniques, reducing anxiety by enabling people to experience emotional conditions in more vivid settings. Objective: This pilot randomized controlled study aims to investigate whether the progressive muscle relaxation technique (PMRT) associated with a personalized scenario in VR promotes psychological well-being and facilitates the recall of relaxing images more than the standard complementary intervention that involves the integration of PMRT and guided imagery (GI). Methods: On the basis of a longitudinal, between-subject design, 72 university students were randomly exposed to one of two experimental conditions: (1) standard complementary procedure (PMRT and GI exposure) and (2) experimental procedure (PMRT and personalized VR exposure). Individuals were assessed by a therapist before and after 7 training sessions based on measures investigating anxiety, depression, quality of life, coping strategies, sense of presence, engagement, and side effects related to VR exposure. Heart rate data were also collected. Results: Differences in changes between the 2 groups after the in vivo PMRT session conducted by the psychotherapist (T1) were statistically significant for state anxiety (F1,67=30.56; P<.001) and heart rate (F1,67=4.87; P=.01). Individuals in the VR group obtained lower scores both before (t67=−2.63; P=.01; Cohen d=0.91) and after (t67=−7.23; P<.001; Cohen d=2.45) the relaxation session when it was self-administered by participants (T2). A significant reduction in perceived state anxiety at T1 and T2 was observed for both groups (P<.001). After the VR experience, individuals reported feeling higher engagement in the experience than what was mentioned by participants in the GI group (F1,67=2.85; P=.03; ηp2=0.15), and they experienced the environment as more realistic (F1,67=4.38; P=.003; ηp2=0.21). No differences between groups regarding sense of presence were found (F1,67=1.99; P=.11; ηp2=0.11). Individuals exposed before to the VR scenario (T1) referred to perceiving the scenario recalled in-imagination at T2 as more realistic than what those in the GI group experienced (F1,67=3.21; P=.02; ηp2=0.12). The VR group had lower trait anxiety levels than the GI group after the relaxation session during session 7 (T2; t67=−2.43; P=.02). Conclusions: Personalized relaxing VR scenarios can contribute to improving relaxation and decreasing anxiety when integrated with PMRT as a complementary relaxation method. Trial Registration: ClinicalTrials.gov NCT05478941; https://classic.clinicaltrials.gov/ct2/show/NCT05478941 International Registered Report Identifier (IRRID): RR2-10.2196/44183 %M 38289673 %R 10.2196/48649 %U https://mental.jmir.org/2024/1/e48649 %U https://doi.org/10.2196/48649 %U http://www.ncbi.nlm.nih.gov/pubmed/38289673 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52661 %T Health Care Professional–Supported Co-Design of a Mime Therapy–Based Serious Game for Facial Rehabilitation %A Sousa,Daniel Lima %A Teixeira,Silmar %A Fontenele,José Everton %A Santos,Renato Mendes %A Pereira,Leynilson %A Baluz,Rodrigo %A Bastos,Victor Hugo %A Teles,Ariel Soares %+ Federal Institute of Maranhão, Campus Araioses, Rua José de Alencar, S/N, Bairro Cumprida, Araioses, 65570-000, Brazil, 55 86995501313, ariel.teles@ifma.edu.br %K serious game %K serious games %K facial recognition %K face estimation %K computer vision %K facial rehabilitation %K face %K rehabilitation %K physiotherapy %K mime therapy %K co-design %K human face estimation %K facial palsy %K facial paralysis %K motor rehabilitation %K exergame %K physiotherapists %K psychologists %K participation %D 2024 %7 24.1.2024 %9 Research Letter %J JMIR Serious Games %G English %X This research letter presents the co-design process for RG4Face, a mime therapy–based serious game that uses computer vision for human facial movement recognition and estimation to help health care professionals and patients in the facial rehabilitation process. %M 38265856 %R 10.2196/52661 %U https://games.jmir.org/2024/1/e52661 %U https://doi.org/10.2196/52661 %U http://www.ncbi.nlm.nih.gov/pubmed/38265856 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51596 %T Effects of a Rice-Farming Simulation Video Game on Nature Relatedness, Nutritional Status, and Psychological State in Urban-Dwelling Adults During the COVID-19 Pandemic: Randomized Waitlist Controlled Trial %A Lee,Seulki %A Yuh,Chisung %A Shin,Yu-Bin %A Lee,Heon-Jeong %A Lee,Young-Mee %A Lee,Jungsil %A Cho,Chul-Hyun %+ Department of Psychiatry, Korea University College of Medicine, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea, 82 0221993827, david0203@gmail.com %K video game %K digital intervention %K nature relatedness %K nutritional status %K psychological state %K COVID-19 %K urban-dwelling adults %D 2024 %7 22.1.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: During the COVID-19 pandemic, urban inhabitants faced significant challenges in maintaining connections with nature, adhering to nutritional guidelines, and managing mental well-being. Objective: Recognizing the urgent need for innovative approaches, this study was designed to explore the potential benefits of a specific digital intervention, the rice-farming simulation game Sakuna: Of Rice and Ruin, for nature relatedness, nutritional behaviors, and psychological well-being. Methods: A total of 66 adults without any prior major psychiatric disorders residing in an urban area were recruited for the study. They were randomly assigned to 2 groups through block randomization: the immediate intervention group (IIG; 34/66, 52%) and the waitlist group (32/66, 48%). Participants in the IIG were instructed to play the game for at least 4 days per week for 3 weeks, with each session lasting from 30 minutes to 3 hours. Assessments were performed at baseline, week 1, and week 3. The Nature Relatedness Scale (NR) and Nutrition Quotient Scale were used to evaluate nature relatedness and nutritional state, respectively. Furthermore, psychological state was assessed using the World Health Organization Quality of Life–Brief Version (WHOQOL-BREF), Brief Fear of Negative Evaluation Scale, Social Avoidance and Distress Scale, Toronto Alexithymia Scale, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale Revised, and Korean Resilience Quotient. Results: This study’s results revealed significant time interactions between the IIG and waitlist group for both the total NR score (P=.001) and the score of the self subdomain of NR (P<.001), indicating an impact of the game on nature relatedness. No group×time interactions were found for the total Nutrition Quotient Scale and subdomain scores, although both groups showed increases from baseline. For psychological state, a significant group×time interaction was observed in the total WHOQOL-BREF score (P=.049), suggesting an impact of the game on quality of life. The psychological (P=.01), social (P=.003), and environmental (P=.04) subdomains of the WHOQOL-BREF showed only a significant time effect. Other psychological scales did not display any significant changes (all P>.05). Conclusions: Our findings suggest that the rice-farming game intervention might have positive effects on nature relatedness, nature-friendly dietary behaviors, quality of life, anxiety, depression, interpersonal relationships, and resilience among urban adults during the COVID-19 pandemic. The impact of pronature games in confined urban environments provides valuable evidence of how digital technologies can be used to enhance urban residents’ affinity for nature and psychological well-being. This understanding can be extended in the future to other digital platforms, such as metaverses. Trial Registration: Clinical Research Information Service (CRIS) KCT0007657; http://tinyurl.com/yck7zxp7 %M 38252464 %R 10.2196/51596 %U https://www.jmir.org/2024/1/e51596 %U https://doi.org/10.2196/51596 %U http://www.ncbi.nlm.nih.gov/pubmed/38252464 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48900 %T Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study %A Villada Castillo,Julian Felipe %A Montoya Vega,Maria Fernanda %A Muñoz Cardona,John Edison %A Lopez,David %A Quiñones,Leonardo %A Henao Gallo,Oscar Alberto %A Lopez,Jose Fernando %+ Faculty of Basic Sciences, Department of Physics, Universidad Tecnologica de Pereira, Carrera 27 #10-02 Álamos, Pereira, 660003, Colombia, 57 606 3137300, jfvillada@utp.edu.co %K stroke %K user-centered design %K exergame %K design %K virtual reality %K playtest %K upper limb rehabilitation %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)–based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. Objective: This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. Methods: We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. Results: The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. Conclusions: The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system’s responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches. %M 38206670 %R 10.2196/48900 %U https://games.jmir.org/2024/1/e48900 %U https://doi.org/10.2196/48900 %U http://www.ncbi.nlm.nih.gov/pubmed/38206670 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e42733 %T A Serious Game to Train Rhythmic Abilities in Children With Dyslexia: Feasibility and Usability Study %A Vonthron,Francois %A Yuen,Antoine %A Pellerin,Hugues %A Cohen,David %A Grossard,Charline %+ Poppins, 73 rue Leon Bourgeois, Palaiseau, 91120, France, 33 669515961, francois.vonthron@gmail.com %K serious game %K rhythm %K dyslexia %K musical abilities %K design framework %K reading skills %K children %K digital health intervention %K attention-deficit/hyperactivity disorder %K ADHD %K child development %K mobile phone %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Rhythm perception and production are related to phonological awareness and reading performance, and rhythmic deficits have been reported in dyslexia. In addition, rhythm-based interventions can improve cognitive function, and there is consistent evidence suggesting that they are an efficient tool for training reading skills in dyslexia. Objective: This paper describes a rhythmic training protocol for children with dyslexia provided through a serious game (SG) called Mila-Learn and the methodology used to test its usability. Methods: We computed Mila-Learn, an SG that makes training remotely accessible and consistently reproducible and follows an educative agenda using Unity (Unity Technologies). The SG’s development was informed by 2 studies conducted during the French COVID-19 lockdowns. Study 1 was a feasibility study evaluating the autonomous use of Mila-Learn with 2500 children with reading deficits. Data were analyzed from a subsample of 525 children who spontaneously played at least 15 (median 42) games. Study 2, following the same real-life setting as study 1, evaluated the usability of an enhanced version of Mila-Learn over 6 months in a sample of 3337 children. The analysis was carried out in 98 children with available diagnoses. Results: Benefiting from study 1 feedback, we improved Mila-Learn to enhance motivation and learning by adding specific features, including customization, storylines, humor, and increasing difficulty. Linear mixed models showed that performance improved over time. The scores were better for older children (P<.001), children with attention-deficit/hyperactivity disorder (P<.001), and children with dyslexia (P<.001). Performance improved significantly faster in children with attention-deficit/hyperactivity disorder (β=.06; t3754=3.91; P<.001) and slower in children with dyslexia (β=−.06; t3816=–5.08; P<.001). Conclusions: Given these encouraging results, future work will focus on the clinical evaluation of Mila-Learn through a large double-blind randomized controlled trial comparing Mila-Learn and a placebo game. %M 37830510 %R 10.2196/42733 %U https://games.jmir.org/2024/1/e42733 %U https://doi.org/10.2196/42733 %U http://www.ncbi.nlm.nih.gov/pubmed/37830510 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39019 %T The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review %A Huang,Xiting %A Xiang,Xinyue %A Liu,Yang %A Wang,Zhiqian %A Jiang,Zhili %A Huang,Lihua %+ Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Building 17, 3rd Floor, 79 Qingchun Road, Hangzhou, 310003, China, 86 13867129329, lihuahuang818@zju.edu.cn %K gamification %K chronic diseases %K self-management %K scoping review %K mobile phone %D 2023 %7 22.12.2023 %9 Review %J JMIR Serious Games %G English %X Background: Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients’ participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases. Objective: This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population. Methods: We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis. Results: We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard. Conclusions: This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification. %M 38133907 %R 10.2196/39019 %U https://games.jmir.org/2023/1/e39019 %U https://doi.org/10.2196/39019 %U http://www.ncbi.nlm.nih.gov/pubmed/38133907 %0 Journal Article %@ 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 %@ 2292-9495 %I JMIR Publications %V 10 %N %P e48845 %T A Newly Developed Exergame-Based Telerehabilitation System for Older Adults: Usability and Technology Acceptance Study %A Seinsche,Julia %A de Bruin,Eling D %A Saibene,Enrico %A Rizzo,Francesco %A Carpinella,Ilaria %A Ferrarin,Maurizio %A Moza,Sotiria %A Ritter,Tanja %A Giannouli,Eleftheria %+ Movement Control and Learning Group, Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Leopold-Ruzicka-Weg 4, HCP H 24.3, Zurich, 8093, Switzerland, 41 44 633 08 52, julia.seinsche@hest.ethz.ch %K older adults %K motor-cognitive intervention %K exergame %K telerehabilitation %K information and communications technologies %K user-centered design %K usability %K technology acceptance %D 2023 %7 7.12.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Telerehabilitation has gained significance as a tool to deliver and supervise therapy and training as effective as traditional rehabilitation methods yet more accessible and affordable. An exergame-based telerehabilitation system has recently been developed within the scope of the international Continuum-of-Care (COCARE) project. The system comprises training devices for use in clinics (Dividat Senso) and at home (Dividat Senso Flex), an assessment system, and a rehabilitation cockpit, and its focus lies on home-based motor-cognitive training, which is remotely managed by health care professionals (HPs). Objective: This study aims to analyze the usability, acceptance, and enjoyment of the COCARE system from the perspective of primary (older adults [OAs]) and secondary (HPs) end users. Methods: At 3 trial sites (located in Switzerland, Italy, and Cyprus), participants engaged in a single-session trial of the COCARE system, including testing of exergames and assessments. Mixed methods encompassing qualitative approaches (eg, think aloud) and quantitative measures (eg, Exergame Enjoyment Questionnaire [EEQ], System Usability Scale [SUS], and Unified Theory of Acceptance and Use of Technology [UTAUT] questionnaire) were used to analyze participants’ perceptions of the system and identify potential barriers to its implementation in a home setting. In addition, the associations of performance during gameplay and assessments, demographics, and training motivation (Behavioral Regulation in Exercise Questionnaire–3 [BREQ-3]) with usability, acceptance, and enjoyment were explored. Results: A total of 45 OAs and 15 HPs participated in this study. The COCARE system achieved good acceptance ratings (OAs: 83%, range 36%-100% and HPs: 81%, range 63.8%-93.3% of the maximum score), and OAs indicated high enjoyment (mean 73.3, SD 12.7 out of 100 points in the EEQ) during the exergame session. The system’s usability, assessed with the SUS, received scores of 68.1 (SD 18.8; OAs) and 70.7 (SD 12.3; HPs) out of 100 points, with substantial differences observed between the trial sites. Several requirements for improvement were identified. Commonly mentioned barriers to adoption included the movement-recognition sensitivity of the Senso Flex, its limited markings, and difficulties in understanding certain instructions for assessments and games. Performance in games and assessments showed the highest significant correlations with the SUS (Spearman ρ=0.35, P=.02 to ρ=0.52, P<.001). The BREQ-3 had significant correlations with all usability measures, thereby even large significant correlations with enjoyment (Spearman ρ=0.58; P<.001). Age had moderately significant correlations with the SUS (Spearman ρ=−0.35; P=.02) and the UTAUT total score (ρ=−0.35; P=.02) but no significant correlation with the EEQ. Concerning sex and years of education, no significant correlations were found. Conclusions: The study’s findings will inform the further development of the COCARE system toward a user-friendly and widely accepted version, enhancing cognitive and physical functions in OAs. Future randomized controlled trials should evaluate the system’s feasibility and effectiveness. %M 38060283 %R 10.2196/48845 %U https://humanfactors.jmir.org/2023/1/e48845 %U https://doi.org/10.2196/48845 %U http://www.ncbi.nlm.nih.gov/pubmed/38060283 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e51812 %T Assessing the Impact of a Serious Game (MedSMARxT: Adventures in PharmaCity) in Improving Opioid Safety Awareness Among Adolescents and Parents: Quantitative Study %A Abraham,Olufunmilola %A McCarthy,Tyler James %A Zaborek,Jen %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Room 2515 Rennebohm Hall, 777 Highland Avenue, Madison, WI, 53705, United States, 1 608 263 4498, olufunmilola.abraham@wisc.edu %K adolescent %K opioid %K medication safety %K serious games %K gamification %K health behavior %D 2023 %7 7.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: The opioid crisis continues to worsen across the United States, affecting people of all demographics. Few evidence-based interventions exist for educating families, particularly those with adolescents, about opioid prescription safety. Serious games have demonstrated impacts in improving medication-related outcomes for various health conditions. The characterizing goal of this serious game is to improve opioid safety knowledge and awareness among adolescents and their families. Objective: This study evaluated the impact of a serious game, MedSMARxT: Adventures in PharmaCity, designed to foster opioid safety awareness among adolescents and their parents. Methods: A national sample of parents and their adolescent children was recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Eligible participants were adolescents aged between 12 and 18 years and their parents. Study participants were required to reside in the United States; speak, read, and understand English; and have access to a computer with a webcam. Parent-child dyads completed pregame and postgame surveys and participated in gameplay for up to 30 minutes. Primary outcome scales have been previously evaluated by the study team. Results: A total of 60 adolescent participants and 68 parent participants met full attention criteria for inclusion in this study. Statistical analysis confirmed that both adolescents’ and parents’ concept scores improved from baseline regarding opioid safety self-efficacy (adolescent: mean 0.35, SD 0.60; P<.001; parent: mean 0.28, SD 0.42; P<.001), perceived knowledge (adolescent: mean 1.08, SD 1.04; P<.001; parent: mean 0.56, SD 0.55; P<.001), behavioral intent (adolescent: mean 0.26, SD 0.39; P<.001; parent: mean 0.25, SD 0.32; P<.001), safe storage (adolescent: mean 0.12, SD 0.27; P<.001; parent: mean 0.03, SD 0.11; P=.03), disposal knowledge (adolescent: mean 0.10, SD 0.27; P=.006; parent: mean 0.07, SD 0.16; P<.001), and knowledge about misuse behavior (adolescent: mean 0.05, SD 0.14; P=.002; parent: mean 0.04, SD 0.10; P<.001). Participant groups, stratified by who completed and who did not complete gameplay, improved their knowledge and awareness, with no significant differences between subgroups. Conclusions: The use of this serious game to improve opioid prescription safety practices among parents and adolescents was supported by the study findings. MedSMARxT: Adventures in PharmaCity is an intervention with the capability of teaching parents and adolescents about safe opioid prescription practices. Further studies and game refinement are needed to demonstrate the effectiveness of a game-based intervention in clinical settings and community pharmacies. %M 38060287 %R 10.2196/51812 %U https://formative.jmir.org/2023/1/e51812 %U https://doi.org/10.2196/51812 %U http://www.ncbi.nlm.nih.gov/pubmed/38060287 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47630 %T Improving Social Isolation and Loneliness Among Adolescents With Physical Disabilities Through Group-Based Virtual Reality Gaming: Feasibility Pre-Post Trial Study %A Lai,Byron %A Young,Raven %A Craig,Mary %A Chaviano,Kelli %A Swanson-Kimani,Erin %A Wozow,Cynthia %A Davis,Drew %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South, 5 Dearth, McWane 5601, Birmingham, AL, 35233, United States, 1 2056389790 ext 8 9725, blai@uabmc.edu %K therapy %K mindfulness %K play %K friend %K friends %K friendship %K lonely %K loneliness %K psychotherapy %K peer %K peers %K recreation %K disability %K adolescent %K adolescents %K disability %K disabled %K physical disability %K digital mental health intervention %K youth %K young adult %K virtual reality %K VR %K gaming %K depression %K depressive %K mental health %K social %K isolated %K isolation %K socialize %K socializing %K socialization %K interaction %K interactions %K acceptability %K game %K games %K gaming %K exergame %K exergames %K exergaming %D 2023 %7 6.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Adolescents with disabilities experience alarmingly higher rates of depression and isolation than peers without disabilities. There is a need to identify interventions that can improve mental health and isolation among this underserved population. Innovations in virtual reality (VR) gaming “standalone” headsets allow greater access to immersive high-quality digital experiences, due to their relatively low cost. Objective: This study had three purposes, which were to (1) examine the preliminary effects of a low-cost, home-based VR multiplayer recreation and socialization on depression, socialization, and loneliness; (2) quantify the acceptability of the program as measured by participant adherence, total play time, and exercise time; and (3) identify and describe behavioral mechanisms that affected participant engagement. Methods: This was a single-group, pre- to postdesign trial. The intervention was conducted at home. Participants were recruited from a children’s hospital. The intervention lasted 4 weeks and included 2×1-hour sessions per week of supervised peer-to-peer gaming. Participants used the Meta Quest 2 headset to meet peers and 2 coaches in a private party held digitally. Aim 1 was evaluated with the Children’s Depression Inventory 2 Short Form and the University of California, Los Angeles Loneliness Scale 20 items, which are measures of social isolation and loneliness, respectively. Aim 2 was evaluated through the following metrics: participant adherence, the types of games played, friendship building and playtime, and program satisfaction and enjoyment. Results: In total, 12 people enrolled (mean age 16.6, SD 1.8 years; male: n=9 and female: n=3), and 8 people completed the program. Mean attendance for the 8 participants was 77% (49 sessions of 64 total possible sessions; mean 6, SD 2 sessions). A trend was observed for improved Children’s Depression Inventory 2 Short Form scores (mean preintervention score 7.25, SD 4.2; mean postintervention score 5.38, SD 4.1; P=.06; effect size=0.45, 95% CI –0.15 to 3.9), but this was not statistically significant; no difference was observed for University of California, Los Angeles Loneliness Scale 20 items scores. Most participants (7/8, 88%) stated that they became friends with a peer in class; 50% (4/8) reported that they played with other people. Participants reported high levels of enjoyment and satisfaction with how the program was implemented. Qualitative analysis resulted in 4 qualitative themes that explained behavioral mechanisms that determined engagement in the program. Conclusions: The study findings demonstrated that a brief VR group program could be valuable for potentially improving mental health among adolescents with physical disabilities. Participants built friendships with peers and other players on the web, using low-cost consumer equipment that provided easy access and strong scale-up potential. Study findings identified factors that can be addressed to enhance the program within a larger clinical trial. Trial Registration: ClinicalTrials.gov NCT05259462; https://clinicaltrials.gov/study/NCT05259462 International Registered Report Identifier (IRRID): RR2-10.2196/42651 %M 38055309 %R 10.2196/47630 %U https://formative.jmir.org/2023/1/e47630 %U https://doi.org/10.2196/47630 %U http://www.ncbi.nlm.nih.gov/pubmed/38055309 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e48063 %T Effects of a Gamified Agent-Based System for Personalized Elderly Care: Pilot Usability Study %A Martinho,Diogo %A Crista,Vítor %A Carneiro,João %A Matsui,Kenji %A Corchado,Juan Manuel %A Marreiros,Goreti %+ Research Group on Intelligent Engineering and Computing for Advanced Innovation and Development, Polytechnic of Porto - School of Engineering (ISEP), R. Dr. António Bernardino de Almeida 431, Porto, 4249-015, Portugal, 351 911007406, diepm@isep.ipp.pt %K gamification %K cognitive assistants %K elderly care %K coaching system %K older people %K technology %K virtual assistant %K cognitive %K usability %K intervention %K physical activity %K agent-based system %D 2023 %7 23.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The global percentage of older people has increased significantly over the last decades. Information and communication technologies have become essential to develop and motivate them to pursue healthier ways of living. This paper examines a personalized coaching health care service designed to maintain living conditions and active aging among older people. Among the technologies the service includes, we highlight the use of both gamification and cognitive assistant technologies designed to support older people and an application combining a cognitive virtual assistant to directly interact with the older person and provide feedback on their current health condition and several gamification techniques to motivate the older person to stay engaged with the application and pursuit of healthier daily habits. Objective: This pilot study aimed to investigate the feasibility and usability of a gamified agent-based system for older people and obtain preliminary results on the effectiveness of the intervention regarding physical activity health outcomes. Methods: The study was designed as an intervention study comparing pre- and posttest results. The proposed gamified agent-based system was used by 12 participants over 7 days (1 week), and step count data were collected with access to the Google Fit application programming interface. Step count data after the intervention were compared with average step count data before the intervention (average daily values over a period of 4 weeks before the intervention). A　1-tailed Student t test was used to determine the relationship between the dependent and independent variables. Usability was measured using the System Usability Scale questionnaire, which was answered by 8 of the 12 participants in the study. Results: The posttest results showed significant pre- to posttest changes (P=.30; 1-tailed Student t test) with a moderate effect size (Cohen d=0.65). The application obtained an average usability score of 78. Conclusions: The presented pilot was validated, showing the positive health effects of using gamification techniques and a virtual cognitive assistant. Additionally, usability metrics considered for this study confirmed high adherence and interest from most participants in the pilot. %M 37995116 %R 10.2196/48063 %U https://games.jmir.org/2023/1/e48063 %U https://doi.org/10.2196/48063 %U http://www.ncbi.nlm.nih.gov/pubmed/37995116 %0 Journal Article %@ 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 %@ 1438-8871 %I JMIR Publications %V 25 %N %P e40190 %T The Relationship Between Lockdowns and Video Game Playtime: Multilevel Time-Series Analysis Using Massive-Scale Data Telemetry %A Zendle,David %A Flick,Catherine %A Halgarth,Darel %A Ballou,Nick %A Cutting,Joe %A Drachen,Anders %+ Department of Computer Science, University of York, Heslington Way, York, YO10 5GH, United Kingdom, 44 1904320000, david.zendle@york.ac.uk %K COVID-19 %K lockdown policy %K disordered gaming %K big data %K playtime %K policy %K lockdown %K public health %K side effects %K pandemic %K video games %K playing %K gaming %K time %K disordered %D 2023 %7 8.11.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 led governments worldwide to enact a variety of containment and closure policies. Substantial attention has been directed toward the idea that these public health measures may have unanticipated negative side effects. One proposed effect relates to video games. There is a nascent evidence base suggesting that individuals played video games for longer and in a more disordered manner during lockdowns and school closures specifically. These increases are commonly framed as a potential health concern in relation to disordered gaming. However, the evidence base regarding changes in gaming during the COVID-19 pandemic is based on self-report and, thus, is susceptible to bias. Therefore, it is unclear what the true consequences of lockdowns were for gaming behavior worldwide. Objective: The primary objective of this study was to estimate whether any specific lockdown policy led to meaningful increases in the amount of time individuals spent playing video games. Methods: Rather than relying on self-report, we used >251 billion hours of raw gameplay telemetry data from 184 separate countries to assess the behavioral correlates of COVID-19–related policy decisions. A multilevel model estimated the impact of varying enforcement levels of 8 containment and closure policies on the amount of time that individual users spent in-game. Similar models estimated the impact of policy on overall playtime and the number of users within a country. Results: No lockdown policy can explain substantial variance in playtime per gamer. School closures were uniquely associated with meaningful increases in total playtime within a country (r2=0.048). However, this was associated with increases in the number of unique individuals playing games (r2=0.057) rather than increases in playtime per gamer (r2<0.001). Conclusions: Previous work using self-report data has suggested that important increases in heavy gaming may occur during pandemics because of containment and closure (“lockdown”) procedures. This study contrasts with the previous evidence base and finds no evidence of such a relationship. It suggests that significant further work is needed before increases in disordered or heavy gaming are considered when planning public health policies for pandemic preparedness. %M 37938889 %R 10.2196/40190 %U https://www.jmir.org/2023/1/e40190 %U https://doi.org/10.2196/40190 %U http://www.ncbi.nlm.nih.gov/pubmed/37938889 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41371 %T An Internet- and Kinect-Based Multiple Sclerosis Fitness Intervention Training With Pilates Exercises: Development and Usability Study %A Tacchino,Andrea %A Ponzio,Michela %A Confalonieri,Paolo %A Leocani,Letizia %A Inglese,Matilde %A Centonze,Diego %A Cocco,Eleonora %A Gallo,Paolo %A Paolicelli,Damiano %A Rovaris,Marco %A Sabattini,Loredana %A Tedeschi,Gioacchino %A Prosperini,Luca %A Patti,Francesco %A Bramanti,Placido %A Pedrazzoli,Elisabetta %A Battaglia,Mario Alberto %A Brichetto,Giampaolo %+ Scientific Research Area, Italian Multiple Sclerosis Foundation, Via Operai 40, Genoa, 16149, Italy, 39 0102713812, andrea.tacchino@aism.it %K exergame %K Multiple Sclerosis Fitness Intervention Training %K MS-FIT %K Pilates %K Kinect %K multiple sclerosis %K exercise %K serious games %K balance %K mobile phone %D 2023 %7 8.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Balance impairments are common in people with multiple sclerosis (MS), with reduced ability to maintain position and delayed responses to postural adjustments. Pilates is a popular alternative method for balance training that may reduce the rapid worsening of symptoms and the increased risk of secondary conditions (eg, depression) that are frequently associated with physical inactivity. Objective: In this paper, we aimed to describe the design, development, and usability testing of MS Fitness Intervention Training (MS-FIT), a Kinect-based tool implementing Pilates exercises customized for MS. Methods: MS-FIT has been developed using a user-centered design approach (design, prototype, user feedback, and analysis) to gain the target user’s perspective. A team composed of 1 physical therapist, 2 game programmers, and 1 game designer developed the first version of MS-FIT that integrated the knowledge and experience of the team with MS literature findings related to Pilates exercises and balance interventions based on exergames. MS-FIT, developed by using the Unity 3D (Unity Technologies) game engine software with Kinect Sensor V2 for Windows, implements exercises for breathing, posture, and balance. Feedback from an Italian panel of experts in MS rehabilitation (neurologists, physiatrists, physical therapists, 1 statistician, and 1 bioengineer) and people with MS was collected to customize the tool for use in MS. The context of MS-FIT is traveling around the world to visit some of the most important cities to learn the aspects of their culture through pictures and stories. At each stay of the travel, the avatar of a Pilates teacher shows the user the exercises to be performed. Overall, 9 people with MS (n=4, 44% women; mean age 42.89, SD 11.97 years; mean disease duration 10.19, SD 9.18 years; Expanded Disability Status Scale score 3.17, SD 0.75) were involved in 3 outpatient user test sessions of 30 minutes; MS-FIT’s usability was assessed through an ad hoc questionnaire (maximum value=5; higher the score, higher the usability) evaluating easiness to use, playability, enjoyment, satisfaction, and acceptance. Results: A user-centered design approach was used to develop an accessible and challenging tool for balance training. All people with MS (9/9, 100%) completed the user test sessions and answered the ad hoc questionnaire. The average score on each item ranged from 3.78 (SD 0.67) to 4.33 (SD 1.00), which indicated a high usability level. The feedback and suggestions provided by 64% (9/14) of people with MS and 36% (5/14) of therapists involved in the user test were implemented to refine the first prototype to release MS-FIT 2.0. Conclusions: The participants reported that MS-FIT was a usable tool. It is a promising system for enhancing the motivation and engagement of people with MS in performing exercise with the aim of improving their physical status. %M 37938895 %R 10.2196/41371 %U https://games.jmir.org/2023/1/e41371 %U https://doi.org/10.2196/41371 %U http://www.ncbi.nlm.nih.gov/pubmed/37938895 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46912 %T A Video Game Intervention to Prevent Opioid Misuse Among Older Adolescents: Development and Preimplementation Study %A Aneni,Kammarauche %A Fernandes,Claudia-Santi F %A Hoerner,Lily A %A Szapary,Claire %A Pendergrass Boomer,Tyra M %A Fiellin,Lynn E %+ Department of Internal Medicine, Yale University School of Medicine, 2 Church Street South, Suite 515, New Haven, CT, 06519, United States, 1 203 785 2885, lynn.sullivan@yale.edu %K videogames %K serious games %K opioid misuse %K mental health %K adolescents %D 2023 %7 3.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Opioid misuse and mental disorders are highly comorbid conditions. The ongoing substance misuse and mental health crises among adolescents in the United States underscores the importance of widely scalable substance misuse preventive interventions that also address mental health risks. Serious video games offer an engaging, widely scalable method for delivering and implementing preventive interventions. However, there are no video game interventions that focus on preventing opioid misuse among older adolescents, and there are limited existing video game interventions that address mental health. Objective: This study aims to develop and conduct a formative evaluation of a video game intervention to prevent opioid misuse and promote mental health among adolescents aged 16-19 years (PlaySmart). We conducted formative work in preparation for a subsequent randomized controlled trial. Methods: We conducted development and formative evaluation of PlaySmart in 3 phases (development, playtesting, and preimplementation) through individual interviews and focus groups with multiple stakeholders (adolescents: n=103; school-based health care providers: n=51; and addiction treatment providers: n=6). PlaySmart content development was informed by the health belief model, the theory of planned behavior, and social cognitive theory. User-centered design principles informed the approach to development and play testing. The Exploration, Preparation, Implementation, and Sustainability framework informed preimplementation activities. Thematic analysis was used to identify themes from interviews and focus groups that informed PlaySmart game content and approaches to future implementation of PlaySmart. Results: We developed a novel video game PlaySmart for older adolescents that addresses the risk and protective factors for opioid misuse and mental health. Nine themes emerged from the focus groups that provided information regarding game content. Playtesting revealed areas of the game that required improvement, which were modified for the final game. Preimplementation focus groups identified potential barriers and facilitators for implementing PlaySmart in school settings. Conclusions: PlaySmart offers a promising digital intervention to address the current opioid and mental health crises among adolescents in a scalable manner. %M 37921851 %R 10.2196/46912 %U https://games.jmir.org/2023/1/e46912 %U https://doi.org/10.2196/46912 %U http://www.ncbi.nlm.nih.gov/pubmed/37921851 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46243 %T Social Presence, Negative Emotions, and Self-Protective Behavioral Intentions of Nonsmokers in Response to Secondhand Smoking in Virtual Reality: Quasi-Experimental Design %A Liu,Miao %A Zhu,Yicheng %A Xu,Zihan %A Meng,Sitong %+ School of Journalism and Communication, Beijing Normal University, 19 Xinjiekou Outer St. Beijing Normal University, Haidian Dist., Beijing, 100875, China, 86 13436952270, yichengresearch@gmail.com %K virtual reality %K VR %K social presence %K emotions %K secondhand smoking %D 2023 %7 25.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The application of virtual reality (VR) in health care has grown rapidly in China, where approximately half of the population is directly exposed to secondhand smoke (SHS). As VR headsets have become increasingly popular and short video platforms have incorporated 360° videos in China, new formats and opportunities for health campaigns about SHS have emerged. Objective: In a simulated environment of exposure to SHS, this study aims to explore the emotional and behavioral responses to enhanced social presence brought about by VR in contrast to flat-screen videos. It also aims to examine whether and to what extent video modality (360° video vs flat-screen video) and contextual cues (high threat vs low threat) influence psychometric and intentional variables among viewers. Methods: A total of 245 undergraduate and graduate students who were nonsmokers and from a large university in China participated in this study between October 2020 and January 2021. This study created 4 different versions of a SHS experience in a café with a 2 (360° video on a head-mounted display vs flat-screen display) × 2 (high threat vs low threat) experimental design. It developed and tested a path model examining the effects of experience modality and threat levels on social presence, emotions (anger and disgust), and eventually behavioral intentions (staying away and asking for help). Results: We found that both video modality (P<.001) and threat level (P=.005) significantly influenced social presence, whereas the interaction of video modality and threat level did not have a statistically significant effect on social presence (P=.55). Negative emotions mediated the relationships between social presence and SHS-related self-protective behaviors. Specifically, anger positively predicted the intention to ask smokers to stop smoking through the waitress (P<.001). Disgust and fear both positively predicted the intention to stay away from the SHS environment (P<.001 for disgust; P=.002 for fear). Conclusions: This study explored the potential mediating mechanisms that influence individuals’ responses to the risks of SHS in public areas. The results demonstrated that social presence and negative emotions are 2 important mediators that underlie the relationship between video modality and behavioral intention regarding SHS in a VR setting. These findings suggest that an immersive environment could be a better stimulator of anti-SHS emotions and behaviors than flat-screen videos. %M 37878358 %R 10.2196/46243 %U https://games.jmir.org/2023/1/e46243 %U https://doi.org/10.2196/46243 %U http://www.ncbi.nlm.nih.gov/pubmed/37878358 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e49080 %T Effects of Virtual Reality Pilates Training on Duration of Posture Maintenance and Flow in Young, Healthy Individuals: Randomized Crossover Trial %A Park,Sung Je %A Lee,Jea Woog %+ Intelligence Information Processing Lab, Chung-Ang University, 84, Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea, 82 010 5426 7318, yyizeuks@cau.ac.kr %K virtual reality %K Pilates %K exercise program %K flow %K duration of posture maintenance %K sport video data analytics %K video %K data analytics %K sport %K sports %K exercise %K physical activity %K posture %K VR %K balance %K movement %K self-reported %K patient reported %D 2023 %7 19.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: This study explored the use of virtual reality (VR) technology to enhance the effectiveness and duration of low-intensity movements and postures in Pilates-derived exercises. We postulate that by leveraging the flow state in VR, individuals can engage in these exercises for longer periods while maintaining a high level of flow. Objective: The purpose of this study was to compare differences in posture maintenance and flow between VR Pilates training and conventional Pilates training, and the correlation between the 2 factors. Methods: The 18 participants in each group received either VR training or conventional training and were switched to the other training type after a 2-day wash-out period. Each group performed Pilates movements in a VR environment and a conventional environment, divided into 4 types. After training sessions, participants were evaluated for flow using a self-report questionnaire. In addition, a sports video analysis program was used to measure the duration of posture maintenance in 2 video-recorded sessions. Repeated-measures ANOVA and correlation analysis were performed on the measured duration of posture maintenance and flow scores. In all cases, the statistical significance level was set at P<.05. Results: Results for the duration of posture maintenance verification by type showed that simple behavior (F1,16=17.631; P<.001), upper body–arm coordination behavior (F1,16=6.083; P=.04), upper body–leg coordination behavior (F1,16=8.359; P<.001), and whole-body coordination behavior (F1,16=8.426; P<.001) all showed an interaction effect at P<.05. Flow (F1,16=15.250; P<.001) also showed an interaction effect. In addition, significant correlations were determined between duration of all types of posture maintenance and flow in the VR training group at P<.05. Conclusions: Our results indicate that VR Pilates training may be more useful than conventional Pilates training in improving the duration of posture maintenance and that it promotes a significantly higher degree of flow when compared with conventional Pilates training. %M 37856178 %R 10.2196/49080 %U https://games.jmir.org/2023/1/e49080 %U https://doi.org/10.2196/49080 %U http://www.ncbi.nlm.nih.gov/pubmed/37856178 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42697 %T Effects of Commercial Exergames and Conventional Exercises on Improving Executive Functions in Children and Adolescents: Meta-Analysis of Randomized Controlled Trials %A Wu,Jinlong %A Xu,Zhuang %A Liu,Haowei %A Chen,Xiaoke %A Huang,Li %A Shi,Qiuqiong %A Weng,Linman %A Ji,Yemeng %A Zeng,Hao %A Peng,Li %+ College of Physical Education, Southwest University, 2 Tiansheng Road, Beibei District, Chongqing, China, 86 13699878189, 804455169@qq.com %K commercial exergames %K exergame %K randomized controlled trial %K RCT %K conventional exercises %K executive function %K children %K adolescent %K pediatric %K youth %K exergaming %K randomized %K meta-analysis %K meta analyses %K review method %K systematic review %D 2023 %7 19.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergames are promising exercise tools for improving health. To the best of our knowledge, no systematic review has compared the effects of commercial exergames and conventional exercises on improving executive functions (EFs) in children and adolescents. Objective: This study aimed to investigate the effects of commercial exergames and conventional exercises on improving EFs in children and adolescents. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 5 randomized controlled trial (RCT) databases (PubMed, Web of Science, Scopus, PsycINFO, and SPORTDiscus) were searched from their inception to July 7, 2022, to identify relevant RCTs. The Cochrane Collaboration tool was used to evaluate the risk of bias for each study. GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) was used to evaluate the overall quality of evidence. Results: In total, 8 RCTs including 435 children and adolescents were included in the analysis. Commercial exergames had no significant benefit on overall EFs compared to conventional exercises (Hedges g=1.464, 95% CI –0.352 to 3.280; P=.06). For core EFs, there was no evidence to suggest that commercial exergames are more beneficial for improving cognitive flexibility (g=0.906, 95% CI –0.274 to 2.086; P=.13), inhibitory control (g=1.323, 95% CI –0.398 to 3.044; P=.13), or working memory (g=2.420, 95% CI –1.199 to 6.038; P=.19) than conventional exercises. We rated the evidence for overall EFs, cognitive flexibility, inhibitory control, and working memory as being of very low quality due to inconsistency (large heterogeneity) and imprecision (low number of people). Additionally, no effects of the intervention were observed in the acute and chronic groups. Conclusions: We do not have strong evidence to support the benefit of commercial exergaming on EFs because we did not observe a Hedges g close to 0 with tight CIs. Further research is needed to confirm this hypothesis. Trial Registration: PROSPERO CRD42022324111; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=324111 %M 37856191 %R 10.2196/42697 %U https://games.jmir.org/2023/1/e42697 %U https://doi.org/10.2196/42697 %U http://www.ncbi.nlm.nih.gov/pubmed/37856191 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44904 %T Playfulness and New Technologies in Hand Therapy for Children With Cerebral Palsy: Scoping Review %A Pinos Cisneros,Tamara Veronica %A Brons,Annette %A Kröse,Ben %A Schouten,Ben %A Ludden,Geke %+ Digital Life Centre, Amsterdam University of Applied Sciences, Wibauthuis (WBH) | 06A02, Wibautstraat 3-b, Amsterdam, 1091 GH, Netherlands, 31 621157005, t.v.pinoscisneros@utwente.nl %K technology %K cerebral palsy %K play %K children %K hand therapy %D 2023 %7 16.10.2023 %9 Review %J JMIR Serious Games %G English %X Background: Innovative technologies such as game consoles and smart toys used with games or playful approaches have proven to be successful and attractive in providing effective and motivating hand therapy for children with cerebral palsy (CP). Thus, there is an increased interest in designing and implementing interventions that can improve the well-being of these children. However, to understand how and why these interventions are motivating children, we need a better understanding of the playful elements of technology-supported hand therapy. Objective: This scoping review aims to identify the playful elements and the innovative technologies currently used in hand therapy for children with CP. Methods: We included studies that design or evaluate interventions for children with CP that use innovative technologies with game or play strategies. Data were extracted and analyzed based on the type of technology, description of the system, and playful elements according to the Lenses of Play, a play design toolkit. A total of 31 studies were included in the analysis. Results: Overall, 54 papers were included in the analysis. The results showed high use of consumer technologies in hand therapy for children with CP. Although several studies have used a combination of consumer technologies with therapeutic-specific technologies, only a few studies focused on the exclusive use of therapeutic-specific technologies. To analyze the playfulness of these interventions that make use of innovative technologies, we focused our review on 3 lenses of play: Open-ended Play, where it was found that the characteristics of ludus, such as a structured form of play and defined goals and rules, were the most common, whereas strategies that relate to paidia were less common. The most commonly used Forms of Play were physical or active form and games with rules. Finally, the most popular Playful experiences were control, challenge, and competition. Conclusions: The inventory and analysis of innovative technology and playful elements provided in this study can be a starting point for new developments of fun and engaging tools to assist hand therapy for children with CP. %M 37843886 %R 10.2196/44904 %U https://games.jmir.org/2023/1/e44904 %U https://doi.org/10.2196/44904 %U http://www.ncbi.nlm.nih.gov/pubmed/37843886 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42025 %T An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study %A Healy,Pat %A Lu,Celine %A Silk,Jennifer S %A Lindhiem,Oliver %A Harper,Reagan %A Viswanathan,Abhishek %A Babichenko,Dmitriy %+ University of Pittsburgh, School of Computing and Information, 135 N. Bellefield Avenue, Pittsburgh, PA, 15213, United States, 1 (412) 624 5015, pat.healy@pitt.edu %K needle phobia %K serious games %K children %K exposure therapy %K cognitive behavioral therapy %K anxiety %K mobile phone %D 2023 %7 16.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure. Objective: We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals. Methods: We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus. Results: Parents rated their child’s difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo’s strong ease of use and high acceptability. In the exit survey, parents rated their child’s fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=−4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child’s fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game’s interactive design, as observed in 69% (24/35) of our participants. Conclusions: The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children’s fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern. %M 37843885 %R 10.2196/42025 %U https://games.jmir.org/2023/1/e42025 %U https://doi.org/10.2196/42025 %U http://www.ncbi.nlm.nih.gov/pubmed/37843885 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e49263 %T A Video Game for Entrepreneurship Learning in Ecuador: Development Study %A Crespo-Martinez,Esteban %A Bueno,Salvador %A Gallego,M Dolores %+ Department of Business Organization and Marketing, Universidad Pablo de Olavide, Carretera Utreras 41089, Seville, 41013, Spain, 34 67 3404321, ecrespo@uazuay.edu.ec %K video game %K computer game %K serious game %K Unity 3D platform %K entrepreneurship %K business simulator %D 2023 %7 11.10.2023 %9 Viewpoint %J JMIR Form Res %G English %X Background: Games have been a part of human life since ancient times and are taught to children and adults who want to simultaneously have fun and learn. Nevertheless, in the third decade of this century, technology invites us to consider using video games to learn topics such as entrepreneurship. However, developing a serious game (SG) is difficult because everyone who forms part of the game development team requires adequate learning resources to acquire the necessary information and improve their game development skills. Objective: This work aimed to detail the experience gained in developing ATIC (Aprende, Trabaja, Innova, Conquista [learn, work, innovate, conquer]), an SG proposed for teaching and learning entrepreneurship. Methods: To develop a videogame, first, we established a game development team formed by professors, professionals, and students who have different roles in this project. Scrum was adopted as a project management method. To create concept art for the video game, designers collected ideas from various games, known as “getting references.” In contrast, narratology considers the life of a recent university graduate immersed in real life, considering locations, characteristics, and representative characters from an essential city of Ecuador Results: In a Unity 3D video game in ATIC, the life of a university student who graduates and ventures into a world full of opportunities, barriers, and risks, where the player needs to make decisions, is simulated. The art of this video game, including sounds and music, is based on the landscape and characteristics of and characters from Cuenca, Ecuador. The game aims to teach entrepreneurs the mechanisms and processes to form their businesses. Thus, we developed the following elements of an SG: (1) world, (2) objects, (3) agents, and (4) events. Conclusions: The narrative, mechanics, and art of video games are relevant. However, project management tools such as leaderboards and appointments are crucial to influencing individuals’ decision to continue to play, or not play, an SG. Developing a serious video game is not an easy task. It was essential to consider many factors, such as the video game audience, needs of learning, context, similarities with the real world, narrative, game mechanics, game art, and game sounds. However, overall, the primary purpose of a serious video game is to transmit knowledge in a fun way and to give adequate and timely feedback to the gamer. Finally, nothing is possible if the members of game development team are not satisfied with the project and not clear about their roles. %M 37819700 %R 10.2196/49263 %U https://formative.jmir.org/2023/1/e49263 %U https://doi.org/10.2196/49263 %U http://www.ncbi.nlm.nih.gov/pubmed/37819700 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43843 %T Translating and Testing a Digital Game Promoting Vegetable Consumption in Young Children: Usability Study %A Bucher Della Torre,Sophie %A Lages,Marlene %A Dias,Sara S %A Guarino,Maria P %A Braga-Pontes,Cátia %+ Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Rue des Caroubiers 25, Carouge, 1227, Switzerland, 41 225586604, sophie.bucher@hesge.ch %K vegetable %K food preference %K serious games %K video game %K children %K child %K pediatric %K obesity prevention %K pilot study %K gaming %K educational game %K nutrition %K diet %K healthy eating %K food consumption %K food intake %D 2023 %7 3.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Promoting healthy eating in children is key to preventing chronic diseases, and vegetable consumption is notably lower than recommended in this population. Among the interventions tested, gamification has shown promise in promoting familiarization, increasing knowledge, and potentially increasing vegetable intake. Objective: This pilot study aimed first to translate the digital game “Veggies4myHeart” into French and to assess its influence on young children’s preferences and willingness to taste vegetables when combined with repeated tasting and education. We also aimed to investigate the acceptability and applicability of the game in 2 classrooms. Methods: During 5 consecutive weekly sessions, children from 2 elementary classes played the digital game consisting of 5 mini games on different vegetables (lettuce, carrot, red cabbage, cucumber, and tomato) in pairs for 10-15 minutes. In addition, they discussed one of the vegetables and tasted the 5 vegetables in each session. Pretest and posttest food preferences and willingness to taste the vegetables were compared. Teachers participated in a semistructured interview. Results: A total of 45 children aged 5 to 6 years tested the French version of the digital game. The children’s declared food preferences were already high for carrot, cucumber, and tomato, with scores higher than 4 out of a maximum of 5. The scores did not change significantly after the intervention, except for red cabbage (pretest: mean 2.52, SD 1.49; posttest: mean 3.29, SD 1.67; P=.006) and a composite score (pretest: mean 3.76, SD 1.06; posttest: mean 4.05, SD 1.03; P=.001). Before the intervention, 18 (44%), 30 (73%), 16 (39%), 29 (71%), and 26 (63%) children out of 41 were willing to taste lettuce, carrot, red cabbage, cucumber, and tomato, respectively. After the intervention, no significant statistical differences were observed, with 23 (51%), 36 (80%), 24 (53%), 33 (73%), and 29 (64%) children out of 45 willing to taste lettuce, carrot, red cabbage, cucumber, and tomato, respectively. Teachers supported this tool combined with repeated tasting and education and highlighted facilitators and barriers that should be anticipated to improve implementation in schools. Conclusions: In this study, we translated an existing digital game applicable and acceptable to both children and teachers. A larger study is warranted to confirm the effectiveness of interventions using the digital game to promote vegetable preference, willingness to taste, and intake. %M 37788064 %R 10.2196/43843 %U https://games.jmir.org/2023/1/e43843 %U https://doi.org/10.2196/43843 %U http://www.ncbi.nlm.nih.gov/pubmed/37788064 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e50492 %T Serious Game for Fine Motor Control Rehabilitation for Children With Epileptic Encephalopathy: Development and Usability Study %A Vidal,Elizabeth %A Castro-Gutierrez,Eveling %A Arisaca,Robert %A Paz-Valderrama,Alfredo %A Albiol-Pérez,Sergio %+ Universidad Nacional de San Agustín de Arequipa, Av. Venezuela s/n, Arequipa, 54, Peru, 51 986451412, evidald@unsa.edu.pe %K serious game %K virtual motor rehabilitation %K ecologic virtual system %K fine motor rehabilitation %K virtual reality %K rare diseases %K children with epileptic encephalopathy %D 2023 %7 3.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Epileptic encephalopathy (EE) is defined as the presence of frequent epileptiform activity that adversely impacts development, typically causing the slowing or regression of developmental skills, and is usually associated with frequent seizures. One of the main disturbances in EE is in the coordination of the upper extremities and hands. Traditional rehabilitation for this type of pathology focuses on the alleviation of gross or fine motor disability. In the last few years, the use of low-cost devices together with customized serious games has shown improvements in motor disorders and enrichments in activities of daily living. Objective: This study aims to explore the feasibility of a new serious game for improving fine motor control in children with EE. Methods: The participants were 4 children with EE (male: n=2, 50%; female: n=2, 50%) who were classified as belonging to level 1 in the Gross Motor Classification System. The children were tested over 10 sessions during the intervention period (before and after treatment). The clinical tests performed were the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition and Pittsburgh Rehabilitation Participation Scale. The subscales of the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition were fine motor precision, fine motor integration, manual dexterity, and upper-limb coordination. At the end of the first session, we used the User Satisfaction Evaluation Questionnaire to analyze user satisfaction. Results: The significance outcomes for a Student t test (1-tailed) were as follows: P=.009 for fine motor precision, P=.002 for fine motor integration, P=.56 for manual dexterity, and P=.99 for upper-limb coordination. The participation rate as measured using the Pittsburgh Rehabilitation Participation Scale was between good and very good, which means that, based on the therapist’s evaluation, interest, independence, and motivation were achieved by each participant. The mean User Satisfaction Evaluation Questionnaire score was close to 30, which is the maximum value. Conclusions: The results support the use of the proposed serious game as a complement in therapeutic sessions during the rehabilitation processes for children with EE. Significant improvements in fine motor control and activities of daily living revealed that the proposed serious game is beneficial for fine motor disorders of this pathology. %M 37788071 %R 10.2196/50492 %U https://formative.jmir.org/2023/1/e50492 %U https://doi.org/10.2196/50492 %U http://www.ncbi.nlm.nih.gov/pubmed/37788071 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46989 %T Effectiveness of a Mobile App Intervention for Preparing Preschool Children and Parents for Day Surgery: Randomized Controlled Trial %A Kerimaa,Heli %A Hakala,Mervi %A Haapea,Marianne %A Vähänikkilä,Hannu %A Serlo,Willy %A He,Hong-Gu %A Pölkki,Tarja %+ Research Unit of Health Sciences and Technology, University of Oulu, Aapistie 5A, Oulu, 90220, Finland, 358 294485602, heli.kerimaa@oulu.fi %K anxiety %K day surgery %K fear %K mobile app %K pain %K parents %K preparation %K preschool child %K randomized controlled trial %K stress %K mobile phone %D 2023 %7 29.9.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Day surgery allows families to return home quickly. Only a few approaches to preparing for day surgery have demonstrated how digital solutions can support families and children. Objective: This study aims to evaluate the effectiveness of a mobile app intervention on preschool children’s fear and pain and parents’ anxiety and stress in preparing children for day surgery. Methods: This study was conducted at the Pediatric Day Surgical Department of a university hospital in Finland between 2018 and 2020. Parents of children (aged 2-6 y) who were in a queue for elective day surgery were randomized into the intervention group (IG; n=36) and control group (CG; n=34). The CG received routine preparations, whereas the IG was prepared using a mobile app. Parents’ and children’s outcomes were measured using validated scales at 4 different points: at home (T1 and T4) and at the hospital (T2 and T3) before and after surgery. Group differences were analyzed using statistical methods suitable for the material. Results: Before surgery, parents in both groups experienced mild anxiety, which decreased after surgery. Parental anxiety did not differ between groups preoperatively (P=.78) or postoperatively (P=.63). Both groups had less anxiety at home after surgery compared with before. The IG showed a significant decrease (P=.003); the CG also improved (P=.002). Preoperatively at home, most parents in both groups experienced no stress or mild stress (P=.61). Preoperatively at the hospital, parents in both groups experienced mild stress; however, parents in the IG experienced more stress during this phase (P=.02). Parents in the IG experienced significantly less stress postoperatively than those in the CG (P=.05). Both groups showed decreased stress levels from before to after surgery (IG: P=.003; CG: P=.004) within each group. There were no significant differences in children’s pain levels between the groups and measurement points. This was observed before surgery at home (P=.25), before surgery at the hospital (P=.98), and after surgery at the hospital (P=.72). Children’s fear decreased more in the IG (P=.006) than in the CG (P=.44) comparing the phases before and after surgery at home. Fear did not differ between the IG and CG preoperatively at home (P=.20) or at the hospital (P=.59) or postoperatively at the hospital (P=.62) or at home (P=.81). Conclusions: The mobile app intervention did not reduce anxiety or pain. However, it was observed that parents in the IG experienced substantially heightened stress levels before surgery at the hospital, which decreased significantly after surgery at home. In addition, fear levels in children in the IG decreased over time, whereas no significant change was observed in the CG. These results are important for developing health care service chains and providing families with innovative and customer-oriented preparation methods. Trial Registration: ClinicalTrials.gov NCT03774303; https://classic.clinicaltrials.gov/ct2/show/NCT03774303 %M 37773624 %R 10.2196/46989 %U https://www.jmir.org/2023/1/e46989 %U https://doi.org/10.2196/46989 %U http://www.ncbi.nlm.nih.gov/pubmed/37773624 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e49898 %T Parkinson Disease Recognition Using a Gamified Website: Machine Learning Development and Usability Study %A Parab,Shubham %A Boster,Jerry %A Washington,Peter %+ Department of Information & Computer Sciences, University of Hawaii at Manoa, 2500 Campus Rd, Honolulu, HI, 96822, United States, 1 1 512 680 0926, pyw@hawaii.edu %K Parkinson disease %K digital health %K machine learning %K remote screening %K accessible screening %D 2023 %7 29.9.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Parkinson disease (PD) affects millions globally, causing motor function impairments. Early detection is vital, and diverse data sources aid diagnosis. We focus on lower arm movements during keyboard and trackpad or touchscreen interactions, which serve as reliable indicators of PD. Previous works explore keyboard tapping and unstructured device monitoring; we attempt to further these works with structured tests taking into account 2D hand movement in addition to finger tapping. Our feasibility study uses keystroke and mouse movement data from a remotely conducted, structured, web-based test combined with self-reported PD status to create a predictive model for detecting the presence of PD. Objective: Analysis of finger tapping speed and accuracy through keyboard input and analysis of 2D hand movement through mouse input allowed differentiation between participants with and without PD. This comparative analysis enables us to establish clear distinctions between the two groups and explore the feasibility of using motor behavior to predict the presence of the disease. Methods: Participants were recruited via email by the Hawaii Parkinson Association (HPA) and directed to a web application for the tests. The 2023 HPA symposium was also used as a forum to recruit participants and spread information about our study. The application recorded participant demographics, including age, gender, and race, as well as PD status. We conducted a series of tests to assess finger tapping, using on-screen prompts to request key presses of constant and random keys. Response times, accuracy, and unintended movements resulting in accidental presses were recorded. Participants performed a hand movement test consisting of tracing straight and curved on-screen ribbons using a trackpad or mouse, allowing us to evaluate stability and precision of 2D hand movement. From this tracing, the test collected and stored insights concerning lower arm motor movement. Results: Our formative study included 31 participants, 18 without PD and 13 with PD, and analyzed their lower limb movement data collected from keyboards and computer mice. From the data set, we extracted 28 features and evaluated their significances using an extra tree classifier predictor. A random forest model was trained using the 6 most important features identified by the predictor. These selected features provided insights into precision and movement speed derived from keyboard tapping and mouse tracing tests. This final model achieved an average F1-score of 0.7311 (SD 0.1663) and an average accuracy of 0.7429 (SD 0.1400) over 20 runs for predicting the presence of PD. Conclusions: This preliminary feasibility study suggests the possibility of using technology-based limb movement data to predict the presence of PD, demonstrating the practicality of implementing this approach in a cost-effective and accessible manner. In addition, this study demonstrates that structured mouse movement tests can be used in combination with finger tapping to detect PD. %M 37773607 %R 10.2196/49898 %U https://formative.jmir.org/2023/1/e49898 %U https://doi.org/10.2196/49898 %U http://www.ncbi.nlm.nih.gov/pubmed/37773607 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e38521 %T Epidemiological Modeling of the Impact of Public Health Policies on Hepatitis C: Protocol for a Gamification Tool Targeting Microelimination %A Baptista-Leite,Ricardo %A Lopes,Henrique %A Vandewalle,Björn %A Félix,Jorge %A Franco,Diogo %A Clemens,Timo %A Brand,Helmut %+ NOVA Center for Global Health - Information Management School, Universidade Nova de Lisboa, Campus de Campolide, Lisbon, 1070-312 Lisboa, Portugal, 351 919276865, r.guerreirobaptistaleite@maastrichtuniversity.nl %K hepatitis C %K modeling %K public health policies %K patient advocacy %K mobile phone %D 2023 %7 25.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Hepatitis C is a disease with a strong social component, as its main transmission route is via blood, making it associated with lifestyle. Therefore, it is suitable to be worked on from the perspective of public health policy, which still has a lot of room to explore and improve, contrary to diagnoses and treatments, which are already very refined and effective. Objective: An interactive gamified policy tool, designated as Let’s End HepC (LEHC), was created to understand the impact of policies related to hepatitis C on the disease’s epidemiology on a yearly basis until 2030. Methods: To this end, an innovative epidemiological model was developed, integrating Markov chains to model the natural history of the disease and adaptive conjoint analysis to reflect the degree of application of each of the 24 public health policies included in the model. This double imputation model makes it possible to assess a set of indicators such as liver transplant, incidence, and deaths year by year until 2030 in different risk groups. Populations at a higher risk were integrated into the model to understand the specific epidemiological dynamics within the total population of each country and within segments that comprise people who have received blood products, prisoners, people who inject drugs, people infected through vertical transmission, and the remaining population. Results: The model has already been applied to a group of countries, and studies in 5 of these countries have already been concluded, showing results very close to those obtained through other forms of evaluation. Conclusions: The LEHC model allows the simulation of different degrees of implementation of each policy and thus the verification of its epidemiological impact on each studied population. The gamification feature allows assessing the adequate fulfillment of the World Health Organization goals for the elimination of hepatitis C by 2030. LEHC supports health decision makers and people who practice patient advocacy in making decisions based on science, and because LEHC is democratically shared, it ends up contributing to the increase of citizenship in health. International Registered Report Identifier (IRRID): RR1-10.2196/38521 %M 37747764 %R 10.2196/38521 %U https://www.researchprotocols.org/2023/1/e38521 %U https://doi.org/10.2196/38521 %U http://www.ncbi.nlm.nih.gov/pubmed/37747764 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e49372 %T Health Care and Social Work Students’ Experiences With a Virtual Reality Simulation Learning Activity: Qualitative Study %A Helle,Nikolina %A Vikman,Miriam Dubland %A Dahl-Michelsen,Tone %A Lie,Silje Stangeland %+ Institute of Health, Faculty of Health Sciences, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 990 90 005, miriam.vikman@vid.no %K virtual reality %K virtual reality simulation %K learning %K experiences %K health care and social work %K higher education %K health care %K social work %D 2023 %7 20.9.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality is used to an increasing extent in various fields and is now making inroads into health and social education. Virtual reality simulation can provide a safe and controlled environment for students to practice and master skills that are transferable to real-world situations without putting patients, clients, or themselves at risk of any harm. Virtual reality simulation using 360° videos represents a novel approach to simulation in health care and social work education, and this inspired our interest in exploring students’ experiences with such a learning activity. Objective: The aim of this study was to explore occupational therapy, social education, nursing, and social work students’ experiences with virtual reality simulation as a learning activity in an interdisciplinary subject. Methods: The data were collected through 6 semistructured focus groups with 28 students. We conducted the focus groups after the students from the 4 education programs had participated in the virtual reality simulation at 3 campuses at a specialized university in Norway. Each focus group interview was facilitated by 1 moderator and 1 facilitator, a combination of experienced researchers and novices. We followed a qualitative design using the 6-step thematic analysis described by Braun and Clarke. Results: The analysis revealed 3 overall themes for students’ experiences with the virtual reality simulation. The first theme, 360° videos provide observations for individual learning, illustrates how learning can take place through the students’ experiences with sensory inputs and observations from the 360° videos. Students experienced that the video enabled them to individually reflect and achieve learning from what was considered a clinically relevant video. The second theme, 360° videos activate emotional learning, demonstrates how the students experienced emotional engagement when watching the 360° videos. The degree of realism provided in the video was considered as important for the students’ learning. The last theme, Debrief sessions enhance comprehensive learning, pinpoints how the students experienced learning through reflective discussions with other students after watching the 360° videos. Students claimed this process to be a vital part of the learning activity. Conclusions: Virtual reality simulation represents a promising learning activity to enhance the professional learning of health care and social work students. It offers opportunities for individualized learning through observations, and it also engages students emotionally in the learning process. The combination of 360° videos and group discussions in virtual reality appears promising to enhance professional learning outcomes and competence, which may contribute to improved health care and social work services. %M 37728988 %R 10.2196/49372 %U https://mededu.jmir.org/2023/1/e49372 %U https://doi.org/10.2196/49372 %U http://www.ncbi.nlm.nih.gov/pubmed/37728988 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e47496 %T Working Memory Training for Children Using the Adaptive, Self-Select, and Stepwise Approaches to Setting the Difficulty Level of Training Activities: Protocol for a Randomized Controlled Trial %A Lau,Regine Cassandra %A Anderson,Peter John %A Wiley,Joshua F %A Huang,Derek %A Surjatin,Faisha %A McIntosh,Paul %A Gathercole,Susan %A Spencer-Smith,Megan %+ School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, 18 Innovation Walk, Clayton, 3166, Australia, 61 399059148, megan.spencer-smith@monash.edu %K children %K working memory %K memory training %K adaptive training %K cognitive training %K transfer effects %K training effects %K cognitive outcomes %K randomized controlled trial %D 2023 %7 19.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: A common yet untested assumption of cognitive training in children is that activities should be adaptive, with difficulty adjusted to the individual’s performance in order to maximize improvements on untrained tasks (known as transfer). Working memory training provides the ideal testbed to systematically examine this assumption as it is one of the most widely studied domains in the cognitive training literature, and is critical for children’s learning, including following instructions and reasoning. Objective: This trial aimed to examine children’s outcomes of working memory training using adaptive, self-select (child selects difficulty level), and stepwise (difficulty level increases incrementally) approaches to setting the difficulty of training activities compared to an active control condition immediately and 6-month postintervention. While the aim is exploratory, we hypothesized that children allocated to a working memory training condition would show greater improvements: (1) on near transfer measures compared to intermediate and far transfer measures and (2) immediately postintervention compared to 6-month postintervention. Methods: This double-blinded, active-controlled, parallel-group randomized trial aimed to recruit 128 children aged 7 to 11 years from 1 metropolitan primary school in Melbourne, Australia. Following baseline testing, children were randomized into 1 of 4 conditions: adaptive, self-select, or stepwise working memory training, or active control. An experimental intervention embedded in Minecraft was developed for teachers to deliver in class over 2 consecutive weeks (10 × 20-minute sessions). The working memory training comprised 2 training activities with processing demands similar to daily activities: backward span and following instructions. The control comprised creative activities. Pre- and postintervention, children completed a set of working memory tests (near and intermediate transfer) and the Raven’s Standard Progressive Matrices (far transfer) to determine training outcomes, as well as motivation questionnaires to determine if motivations toward learning and the intervention were similar across conditions. Caregivers completed the ADHD-Rating Scale-5 to measure their child’s attention (far transfer). Statistical analysis will include traditional null hypothesis significance testing and Bayesian methods to quantify evidence for both the null and alternative hypotheses. Results: Data collection concluded in December 2022. Data are currently being processed and analyzed. Conclusions: This trial will determine whether the adaptive approach to setting the difficulty of training activities maximizes cognitive training outcomes for children. This trial has several strengths: it adopts best practices for cognitive training studies (design, methods, and analysis plan); uses a range of measures to detect discrete levels of transfer; has a 6-month postintervention assessment; is appropriately powered; and uses an experimental working memory training intervention based on our current understanding of the cognitive mechanisms of training. Findings will inform future research and design of cognitive training interventions and highlight the value of the evidence-based principles of cognitive training. Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12621000990820; https://www.anzctr.org.au/ACTRN12621000990820.aspx International Registered Report Identifier (IRRID): DERR1-10.2196/47496 %M 37725418 %R 10.2196/47496 %U https://www.researchprotocols.org/2023/1/e47496 %U https://doi.org/10.2196/47496 %U http://www.ncbi.nlm.nih.gov/pubmed/37725418 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48208 %T Effectiveness of Social Virtual Reality Training in Enhancing Social Interaction Skills in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Three-Arm Pilot Randomized Controlled Trial %A Wong,Ka Po %A Qin,Jing %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China (Hong Kong), 852 64860214, wongkapoportia@gmail.com %K attention-deficit/hyperactivity disorder %K social interaction skills %K executive functioning %K emotional control %K 3-arm randomized controlled trial %K ADHD %K attention deficit %K hyperactive %K hyperactivity %K randomized %K RCT %K social interaction %K social interactions %K social skills %K child %K children %K youth %K pediatric %K pediatrics %K VR %K virtual reality %K childhood %K neurodevelopmental %D 2023 %7 18.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Children with ADHD have challenges in understanding social cues and behavioral problems when entering a social setting. Virtual reality (VR) has been applied to improve cognitive behaviors in children with ADHD. Previous studies have not adopted VR to improve social interaction competence and appropriateness in children with ADHD. VR offers a more effective alternative to therapeutic strategies for children with ADHD. Objective: This study aims to examine the feasibility and effectiveness of social VR training in enhancing social interaction skills compared to traditional social skills training in children with ADHD. We hypothesize that participants in the social VR training group are likely to perform better on social interaction skills than those in the traditional social skills training group. Methods: In this nonblinded, 3-arm randomized controlled trial (RCT), 90 participants with ADHD recruited from the community will be randomized 1:1:1 to the social VR intervention group, traditional social skills training group, or waitlist control group. The child psychiatrist will conduct assessments for each participant at baseline and after the intervention. The Social Skills Rating Scale–Parent will be used to assess the social interaction skills of the participants before and after the intervention. Participants in the social VR intervention group and traditional social skills training group will receive twelve 20-minute training sessions for 3 weeks. The participants in the waitlist control group will receive no training. The primary outcome measure is training acceptability and compliance. The secondary outcome measures are the child psychiatrist's assessment and the Social Skills Rating Scale–Parent before and after the intervention. Another outcome measure is the Behavior Rating Inventory of Executive Function and Attention. Differences in the scale scores will be examined using a t test and an F test. Results: This study is set to commence in the fourth quarter of 2023. It is anticipated that participants in the social VR intervention group will exhibit superior social interaction skills than those in the traditional social skills training group. Conclusions: To our knowledge, this RCT is the first study examining the feasibility and effectiveness of a social VR-based intervention for enhancing the social interaction skills of children with ADHD in Hong Kong. The VR-based social skills training is expected to provide a safer and more effective environment for children with ADHD to learn than the traditional approach. This study can lead to a full-scale RCT. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): PRR1-10.2196/48208 %M 37721790 %R 10.2196/48208 %U https://www.researchprotocols.org/2023/1/e48208 %U https://doi.org/10.2196/48208 %U http://www.ncbi.nlm.nih.gov/pubmed/37721790 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e49382 %T Parents’ Perceptions of a Serious Game for Educating Families on Prescription Opioid Safety: Qualitative Pilot Study of MedSMARxT: Adventures in PharmaCity %A Abraham,Olufunmilola %A Nixon,Grace Ann %A Seitz,Laura Louise %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Room 2515 Rennebohm Hall, 777 Highland Avenue, Madison, WI, 53705, United States, 1 6082634498, olufunmilola.abraham@wisc.edu %K opioids %K opioid %K parents %K adolescents %K medication safety %K family health %K serious games %K parent %K adolescent %K youths %K gaming %K game %K games %K teenager %K teenagers %K acceptance %K perception %K perceptions %K patient education %K pharmacy %K pharmaceutic %K pharmaceutics %K pharmaceutical %K drug %K safety %D 2023 %7 12.9.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Opioid misuse is a pervasive, worsening problem that affects the health of people throughout the United States, including adolescents. There are few adolescent-focused interventions designed to educate them about opioid medication safety. The MedSMARxT: Adventures in PharmaCity, is a serious educational video game that teaches parents and their youths about safe opioid practices. Objective: This study aimed to elucidate parent’s perceptions of MedSMARxT: Adventures in PharmaCity and its potential use by parents and their adolescents. Methods: Parents of adolescents aged 12 to 18 years who live in the United States were recruited from April to October 2021 via Qualtrics research panels, social media, email listserves, and snowball sampling. The study participants played MedSMARxT: Adventures in PharmaCity for 30 minutes and then participated in a 30-minute postgame interview via WebEx (Cisco). Questions were developed and piloted to examine adults’ perceptions of the game. Participants were asked three sets of open-ended questions: (1) questions about the game and elements of the game, (2) what they learned from the game, and (3) questions about their experience with games. Audio recordings were transcribed verbatim. Interview transcripts were coded using content and thematic analysis by study team members to identify major themes and subthemes from the data. Results: Parent participants (N=67) played MedSMARxT: Adventures in PharmaCity and completed a postgame interview. Analysis extrapolated four primary themes from the data: (1) participant gaming experience, (2) perception of game features, (3) educational purpose of the game, and (4) future use of the game. Most participants (n=56, 84%), had at least some experience with video games. More than half of the participants (n=35, 52%) participants, had positive reactions to the game characters and scenes depicted in MedSMARxT: Adventures in PharmaCity and stated they were realistic for adolescents. Most participants (n=39, 58%), would recommend the game to others. Significant difficulties with gameplay navigation were reported by 38 (57%) participants, as well as a slow game pace. All participants were able to accurately identify the overarching goal of the game: opioid or medication safety. The game reinforced existing knowledge for participants, though many (n=15, 22%), reported a new awareness of the need to store opioid medications in a locked area and the availability of medication disposal drop boxes at pharmacies. Participants stated that they would recommend the game for future use by families and youths in various health care and non–health care settings. Conclusions: The use of a tailored serious game is a novel, engaging tool to educate adolescents on opioid safety. MedSMARxT: Adventures in PharmaCity can be used as a tool for parents and adolescents to facilitate meaningful dialogue about safe and appropriate opioid use. %M 37698899 %R 10.2196/49382 %U https://games.jmir.org/2023/1/e49382 %U https://doi.org/10.2196/49382 %U http://www.ncbi.nlm.nih.gov/pubmed/37698899 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e51772 %T The Effectiveness of Video-Based Game Exercise Therapy Applications in Pes Planus Rehabilitation: Protocol for a Randomized Controlled Trial %A Erten,Ayşe Büşra %A Tarakçı,Devrim %A Çaçan,Mehmet Akif %+ Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Istanbul Medipol University, Kavacık South Campus, Göztepe Mahallesi Atatürk Caddesi No: 40/16, Beykoz, Istanbul, 34815, Turkey, 90 0216 681 51 00, abertenn@gmail.com %K exergame %K pes planus %K rehabilitation %K serious game %K video-based game therapy %D 2023 %7 11.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Pes planus is one of the most common foot deformities. Although there are many studies on the effectiveness of various exercise methods in pes planus rehabilitation, the number of studies on video-based game exercise therapy applications is very limited. Objective: This study aims to evaluate the effectiveness of 2 video-based game exercise therapies and structured exercise practices in pes planus rehabilitation. Methods: This study is a 3-arm, parallel-group, single-blinded randomized controlled trial. The study will include 69 patients with flexible pes planus aged between 18 and 25 years who attend the orthopedics and traumatology clinic and meet the inclusion criteria. The primary outcomes are measures of navicular drop and pedobarographic analysis before and after the intervention, and the secondary outcomes include balance, femoral anteversion, and lower extremity muscle strength. Participants will be evaluated with a navicular drop test for medial longitudinal arch height, a pedobarographic analysis system for plantar pressure analysis, a Craig test for femoral anteversion, the Becure Balance System for balance measurement, and a myometer device for lower extremity muscle strength measurement. Participants will be randomly assigned to a structured exercise group, an exergame group, or a serious game group according to their order of arrival. The structured exercise group will use a short foot exercise, a towel-picking exercise, and various walking and balance exercises. Patients in the serious play group will play the lower extremity games in the Becure Balance System. Patients in the exergame group will play balance games on the Nintendo Wii game console. All participants will participate in 18 exercise sessions (3 days a week for 6 weeks). After the treatment, the initial measurements will be repeated. Results: The study started in January 2023. It is expected to be completed in June 2024. Conclusions: This study will be the first randomized controlled study to evaluate the effectiveness of 2 different video-based game exercise therapy applications in pes planus rehabilitation. Through this study, the use of video-based game exercise therapy in pes planus rehabilitation, together with the developing technology, will be a guide. In addition, a new exercise protocol, including serious game exercises, will be added to the literature. In the future, it is expected that our study on the development of different game systems, especially for the ankle, will provide pioneering feedback. Trial Registration: ClinicalTrials.gov NCT05679219; https://clinicaltrials.gov/study/NCT05679219 International Registered Report Identifier (IRRID): DERR1-10.2196/51772 %M 37695657 %R 10.2196/51772 %U https://www.researchprotocols.org/2023/1/e51772 %U https://doi.org/10.2196/51772 %U http://www.ncbi.nlm.nih.gov/pubmed/37695657 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45969 %T Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review %A Stathakarou,Natalia %A Kononowicz,Andrzej A %A Swain,Cara %A Karlgren,Klas %+ Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, Solna, Stockholm, 171 77, Sweden, 46 8 524 852 98, natalia.stathakarou@ki.se %K gamification %K game elements %K military medicine %K trauma %K medical education %K military training %K systematic review %K game %K gaming %K simulation %D 2023 %7 8.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. Objective: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. Methods: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. Results: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20% (126/630) of the identified abstracts in groups of 2 reviewers. Conclusions: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. International Registered Report Identifier (IRRID): DERR1-10.2196/45969 %M 37682596 %R 10.2196/45969 %U https://www.researchprotocols.org/2023/1/e45969 %U https://doi.org/10.2196/45969 %U http://www.ncbi.nlm.nih.gov/pubmed/37682596 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39915 %T The Success of Serious Games and Gamified Systems in HIV Prevention and Care: Scoping Review %A Jitmun,Waritsara %A Palee,Patison %A Choosri,Noppon %A Surapunt,Tisinee %+ Data Analytics and Knowledge Synthesis for Healthcare (DAKSH) Research Group, College of Arts, Media, and Technology, Chiang Mai University, 239 Huay Kaew Rd, Su Thep Road, Mueang, Chiang Mai, 50200, Thailand, 66 918592114, noppon.c@cmu.ac.th %K HIV %K serious game %K gamification %K public health %K primary health care %K patient care %K behavioral health %D 2023 %7 5.9.2023 %9 Review %J JMIR Serious Games %G English %X Background: AIDS, which is caused by HIV, has long been one of the most significant global public health issues. Since the beginning of the HIV epidemic, various types of nonelectronic communication tools have been commonly used in HIV/AIDS prevention and care, but studies that apply the potential of electronic games are still limited. Objective: We aimed to identify, compare, and describe serious games and gamified systems currently used in HIV/AIDS prevention and care that were studied over a specific period of time. Methods: A scoping review was conducted into serious games and gamified systems used in HIV prevention and care in various well-known digital libraries from January 2010 to July 2021. Results: After identifying research papers and completing the article selection process, 49 of the 496 publications met the inclusion criteria and were examined. A total of 32 articles described 22 different serious games, while 17 articles described 13 gamified systems for HIV prevention and care. Conclusions: Most of the studies described in the publications were conducted in the United States, while only a few studies were performed in sub-Saharan African countries, which have the highest global HIV/AIDS infection rates. Regarding the development platform, the vast majority of HIV/AIDS gaming systems were typically deployed on mobile devices. This study demonstrates the effectiveness of using serious games and gamified systems. Both can improve the efficacy of HIV/AIDS prevention strategies, particularly those that encourage behavior change. %M 37669098 %R 10.2196/39915 %U https://games.jmir.org/2023/1/e39915 %U https://doi.org/10.2196/39915 %U http://www.ncbi.nlm.nih.gov/pubmed/37669098 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44414 %T A Novel, Expert-Endorsed, Neurocognitive Digital Assessment Tool for Addictive Disorders: Development and Validation Study %A Lee,Rico S C %A Albertella,Lucy %A Christensen,Erynn %A Suo,Chao %A Segrave,Rebecca A %A Brydevall,Maja %A Kirkham,Rebecca %A Liu,Chang %A Fontenelle,Leonardo F %A Chamberlain,Samuel R %A Rotaru,Kristian %A Yücel,Murat %+ QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, 4006, Australia, 61 412494834, muratyucel40@gmail.com %K cognitive neuroscience %K addictive behaviors %K mental health %K gaming %K gamified %K gamification %K development %K assessment %K software %K addiction %K mental disorder %K neurocognition %K neurocognitive %K brain health %K gamified task %K psychometric %K game developer %K game development %K validation %K validate %K validity %D 2023 %7 25.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Many people with harmful addictive behaviors may not meet formal diagnostic thresholds for a disorder. A dimensional approach, by contrast, including clinical and community samples, is potentially key to early detection, prevention, and intervention. Importantly, while neurocognitive dysfunction underpins addictive behaviors, established assessment tools for neurocognitive assessment are lengthy and unengaging, difficult to administer at scale, and not suited to clinical or community needs. The BrainPark Assessment of Cognition (BrainPAC) Project sought to develop and validate an engaging and user-friendly digital assessment tool purpose-built to comprehensively assess the main consensus-driven constructs underpinning addictive behaviors. Objective: The purpose of this study was to psychometrically validate a gamified battery of consensus-based neurocognitive tasks against standard laboratory paradigms, ascertain test-retest reliability, and determine their sensitivity to addictive behaviors (eg, alcohol use) and other risk factors (eg, trait impulsivity). Methods: Gold standard laboratory paradigms were selected to measure key neurocognitive constructs (Balloon Analogue Risk Task [BART], Stop Signal Task [SST], Delay Discounting Task [DDT], Value-Modulated Attentional Capture [VMAC] Task, and Sequential Decision-Making Task [SDT]), as endorsed by an international panel of addiction experts; namely, response selection and inhibition, reward valuation, action selection, reward learning, expectancy and reward prediction error, habit, and compulsivity. Working with game developers, BrainPAC tasks were developed and validated in 3 successive cohorts (total N=600) and a separate test-retest cohort (N=50) via Mechanical Turk using a cross-sectional design. Results: BrainPAC tasks were significantly correlated with the original laboratory paradigms on most metrics (r=0.18-0.63, P<.05). With the exception of the DDT k function and VMAC total points, all other task metrics across the 5 tasks did not differ between the gamified and nongamified versions (P>.05). Out of 5 tasks, 4 demonstrated adequate to excellent test-retest reliability (intraclass correlation coefficient 0.72-0.91, P<.001; except SDT). Gamified metrics were significantly associated with addictive behaviors on behavioral inventories, though largely independent of trait-based scales known to predict addiction risk. Conclusions: A purpose-built battery of digitally gamified tasks is sufficiently valid for the scalable assessment of key neurocognitive processes underpinning addictive behaviors. This validation provides evidence that a novel approach, purported to enhance task engagement, in the assessment of addiction-related neurocognition is feasible and empirically defensible. These findings have significant implications for risk detection and the successful deployment of next-generation assessment tools for substance use or misuse and other mental disorders characterized by neurocognitive anomalies related to motivation and self-regulation. Future development and validation of the BrainPAC tool should consider further enhancing convergence with established measures as well as collecting population-representative data to use clinically as normative comparisons. %M 37624635 %R 10.2196/44414 %U https://www.jmir.org/2023/1/e44414 %U https://doi.org/10.2196/44414 %U http://www.ncbi.nlm.nih.gov/pubmed/37624635 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46351 %T A Serious Game to Self-Regulate Heart Rate Variability as a Technique to Manage Arousal Level Through Cardiorespiratory Biofeedback: Development and Pilot Evaluation Study %A Estrella,Tony %A Alfonso,Carla %A Ramos-Castro,Juan %A Alsina,Aitor %A Capdevila,Lluis %+ Sport Research Institute, Universitat Autònoma de Barcelona, Edifici N, Planta 1, Barcelona, 08193, Spain, 34 93 581 3329, lluis.capdevila@uab.cat %K serious game %K heart rate variability %K biofeedback %K mobile health %K mHealth %K app %K mobile phone %D 2023 %7 24.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Heart rate variability biofeedback (HRVB) is an established intervention for increasing heart rate variability (HRV) in the clinical context. Using this technique, participants become aware of their HRV through real-time feedback and can self-regulate it. Objective: The aim of this study was 2-fold: first, to develop a serious game that applies the HRVB technique to teach participants to self-regulate HRV and, second, to test the app with participants in a pilot study. Methods: An HRVB app called the FitLab Game was developed for this study. To play the game, users must move the main character up and down the screen, avoiding collisions with obstacles. The wavelength that users must follow to avoid these obstacles is based on the user’s basal heart rate and changes in instantaneous heart rate. To test the FitLab Game, a total of 16 participants (mean age 23, SD 0.69 years) were divided into a control group (n=8) and an experimental group (n=8). A 2 × 2 factorial design was used in each session. Participants in the experimental condition were trained in breathing techniques. Results: Changes in the frequency and time domain parameters of HRV and the game’s performance features were evaluated. Significant changes in the average RR intervals and root mean square of differences between adjacent RR intervals (RMSSD) were found between the groups (P=.02 and P=.04, respectively). Regarding performance, both groups showed a tendency to increase the evaluated outcomes from baseline to the test condition. Conclusions: The results may indicate that playing different levels leads to an improvement in the game’s final score by repeated training. The tendency of changes in HRV may reflect a higher activation of the mental system of attention and control in the experimental group versus the control group. In this context, learning simple, voluntary strategies through a serious game can aid the improvement of self-control and arousal management. The FitLab Game appears to be a promising serious game owing to its ease of use, high engagement, and enjoyability provided by the instantaneous feedback. %M 37616033 %R 10.2196/46351 %U https://games.jmir.org/2023/1/e46351 %U https://doi.org/10.2196/46351 %U http://www.ncbi.nlm.nih.gov/pubmed/37616033 %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 %@ 2369-3762 %I JMIR Publications %V 9 %N %P e43710 %T Teaching Palliative Care to Emergency Medicine Residents Using Gamified Deliberate Practice-Based Simulation: Palliative Gaming Simulation Study %A Stanich,Jessica %A Sunga,Kharmene %A Loprinzi-Brauer,Caitlin %A Ginsburg,Alexander %A Ingram,Cory %A Bellolio,Fernanda %A Cabrera,Daniel %+ Department of Emergency Medicine, Mayo Clinic, 200 First Steet SW, Rochester, MN, 55905, United States, 1 5072554137, jstans44@gmail.com %K palliative care %K emergency medicine %K gaming simulation %K resident education %K medical education %K residency %K end of life %K palliative %K dying %K death %K interpersonal skill %D 2023 %7 16.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care. Objective: We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills. Methods: This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool–Modified survey to evaluate perceived effectiveness in teaching end-of-life management. Results: Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool–Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient’s condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context. Conclusions: This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management. %M 37585258 %R 10.2196/43710 %U https://mededu.jmir.org/2023/1/e43710 %U https://doi.org/10.2196/43710 %U http://www.ncbi.nlm.nih.gov/pubmed/37585258 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46602 %T Developing a Game (Inner Dragon) Within a Leading Smartphone App for Smoking Cessation: Design and Feasibility Evaluation Study %A White,Justin S %A Salem,Marie K %A Toussaert,Séverine %A Westmaas,J Lee %A Raiff,Bethany R %A Crane,David %A Warrender,Edward %A Lyles,Courtney %A Abroms,Lorien %A Thrul,Johannes %+ Philip R Lee Institute for Health Policy Studies, University of California, 490 Illinois Street, Box 0936, San Francisco, CA, 94158, United States, 1 415 476 8045, Justin.White@ucsf.edu %K smoking cessation %K mobile app %K games for health %K gamification %K software design %K feasibility %K mobile phone %D 2023 %7 11.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. Objective: The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation. Methods: In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. Results: Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users’ progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants. Conclusions: Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app. %M 37566442 %R 10.2196/46602 %U https://games.jmir.org/2023/1/e46602 %U https://doi.org/10.2196/46602 %U http://www.ncbi.nlm.nih.gov/pubmed/37566442 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44348 %T Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study %A Glympi,Alkyoni %A Odegi,Dorothy %A Zandian,Modjtaba %A Södersten,Per %A Bergh,Cecilia %A Langlet,Billy %+ Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, Huddinge, Stockholm, 141 52, Sweden, 46 086905826, billy.langlet@ki.se %K exposure therapy %K eating behavior %K anorexia nervosa %K bulimia nervosa %K binge eating disorder %K overweight %K obesity %K immersive virtual reality %K VR %K virtual reality %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. Objective: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. Methods: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. Results: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=–5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. Conclusions: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. Trial Registration: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209 %M 37561558 %R 10.2196/44348 %U https://games.jmir.org/2023/1/e44348 %U https://doi.org/10.2196/44348 %U http://www.ncbi.nlm.nih.gov/pubmed/37561558 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45541 %T Usability and Satisfaction Testing of Game-Based Learning Avatar-Navigated Mobile (GLAm), an App for Cervical Cancer Screening: Mixed Methods Study %A Wanberg,Lindsey J %A Kim,Angela %A Vogel,Rachel I %A Sadak,Karim Thomas %A Teoh,Deanna %+ Division of Gynecologic Oncology, Masonic Cancer Center, University of Minnesota, 420 Delaware Street SE, MMC 395, Minneapolis, MN, 55455, United States, 1 612 625 6503, dkteoh@umn.edu %K cancer screening %K cervical cancer screening %K cervical cancer %K Game-based Learning Avatar-navigated mobile %K health care app %K mixed methods study %K mobile health %K mobile technology %K Pap test %K usability testing %K young adult health care %D 2023 %7 8.8.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Barriers to cervical cancer screening in young adults include a lack of knowledge and negative perceptions of testing. Evidence shows that mobile technology reduces these barriers; thus, we developed a web app, Game-based Learning Avatar-navigated mobile (GLAm), to educate and motivate cervical cancer screening using the Fogg Behavioral Model as a theoretic guide. Users create avatars to navigate the app, answer short quizzes with education about cervical cancer and screening, watch videos of the screening process, and earn digital trophies. Objective: We tested ease of use, usefulness, and satisfaction with the GLAm app among young adults. Methods: This mixed methods study comprised a qualitative think-aloud play interview session and a quantitative survey study. Participants were cervical cancer screening–eligible US residents aged 21 to 29 years recruited through social media. Qualitative study participants explored the app in a think-aloud play session conducted through videoconference. Data were analyzed using directed content analysis to identify themes of ease of use, usefulness, and content satisfaction. Qualitative study participants and additional participants then used the app independently for 1 week and completed a web-based survey (the quantitative study). Ease of use, usefulness, and satisfaction were assessed using the validated Technology Acceptance Model and Computer System Usability Questionnaire adapted to use of an app. Mean (SD) scores (range 1-7) are presented. Results: A total of 23 individuals participated in one or both study components. The mean age was 25.6 years. A majority were cisgender women (21/23, 91%) and White (18/23, 78%), and 83% (19/23) had at least some secondary education. Nine participants completed the think-aloud play session. Direct content analysis showed desire for content that is concise, eases anxiety around screenings, and uses game features (avatars and rewards). Twenty-three individuals completed the quantitative survey study. Mean scores showed the app was perceived to be easy to use (mean score 6.17, SD 0.27) and moderately useful to increase cervical cancer screening knowledge and uptake (mean score 4.94, SD 0.27). Participants were highly satisfied with the app (mean score 6.21, SD 1.20). Conclusions: Survey results showed participants were satisfied with the app format and found it easy to use. The app was perceived to be moderately useful to inform and motivate cervical cancer screening; notably, the screening reminder function was not tested in this study. Qualitative study results demonstrated the app’s ability to ease anxiety about screening through demonstration of the screening process, and brevity of app components was favored. Interpretation of results is limited by the predominantly cisgender, White, and educated study population; additional testing in populations which historically have lower cervical cancer screening uptake is needed. A modified version of the app is undergoing efficacy testing in a randomized clinical trial. %M 37552527 %R 10.2196/45541 %U https://formative.jmir.org/2023/1/e45541 %U https://doi.org/10.2196/45541 %U http://www.ncbi.nlm.nih.gov/pubmed/37552527 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e41993 %T The Usability of a Touchpad Active Video Game Controller for Individuals With Impaired Mobility: Observational Study %A Mendonca,Christen J %A Malone,Laurie A %A Mohanraj,Sangeetha %A Thirumalai,Mohanraj %+ School of Health Professions, The University of Alabama at Birmingham, SHPB 331, 1720 2nd Ave S, Birmingham, AL, 35294-3361, United States, 1 205 975 6415, christenjm@uab.edu %K active video games %K exergames %K usability %K enjoyment %K disability %K mobility limitation %K mobility impairment %D 2023 %7 3.8.2023 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Video games are a popular sedentary activity among people with impaired mobility; however, active video game hardware typically lacks accessibility and customization options for individuals with mobility impairments. A touchpad video game system can elicit moderate physical activity in healthy adults; however, it is unclear if this system is usable by adults with impaired mobility. Objective: The purpose of this study was to assess the usability of a touchpad video game controller system adapted for adults with impaired mobility. Additional outcomes explored were enjoyment, perceived exertion, self-efficacy, participant feedback, and researcher observations of gameplay. Methods: Participants played several video game titles for 20 minutes with a touchpad video game controller as they stood or sat in a chair or their wheelchair. Usability was assessed with the System Usability Scale (SUS) and the Health Information Technology Usability Evaluation Scale (Health-ITUES) surveys after gameplay. After each video game, participants reported enjoyment using a visual analog scale (0 to 100 mm) and a rating of perceived exertion using the OMNI 0 to 10 scale. Self-efficacy was measured before and after gameplay. Participants provided feedback at the end of their session. Results: In total, 21 adults (6 females and 15 males) with a mean age of 48.8 (SD 13.8) years with various mobility impairments participated in this study. The touchpads received mean usability scores on the SUS 80.1 (SD 18.5) and Health-ITUES 4.23 (SD 0.67). Conclusions: The SUS scores reported suggest the touchpad system is “usable”; however, the Health-ITUES scores were slightly below a suggested benchmark. Participants reported moderate to high enjoyment but perceived the exertion as “somewhat easy.” Self-efficacy was moderate to high and did not differ pre- to postgame play. The participants regarded the touchpads as novel, fun, and entertaining. The generalizability of our results is limited due to the heterogenous sample; however, our participants identified several areas of improvement for future iteration. %M 37535411 %R 10.2196/41993 %U https://rehab.jmir.org/2023/1/e41993 %U https://doi.org/10.2196/41993 %U http://www.ncbi.nlm.nih.gov/pubmed/37535411 %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 e45816 %T Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial %A Specht,Julian %A Stegmann,Barbara %A Gross,Hanna %A Krakow,Karsten %+ SRH University of Applied Sciences Heidelberg, Department of Applied Psychology, Ludwig-Guttmann-Straße 6, Heidelberg, 69123, Germany, 49 01737808422, julian.specht@livingbrain.de %K cognitive rehabilitation %K virtual reality %K neurorehabilitation %K psychology %K stroke %D 2023 %7 21.7.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap. Objective: This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life. Methods: We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale—Revised, Trail Making Test A and B, Tower of London—German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR). Results: Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London—German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale—Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t0 and t1 was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02). Conclusions: The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction. Trial Registration: Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605 %M 37477957 %R 10.2196/45816 %U https://games.jmir.org/2023/1/e45816 %U https://doi.org/10.2196/45816 %U http://www.ncbi.nlm.nih.gov/pubmed/37477957 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45600 %T Impact of a Serious Game (#RedPingüiNO) to Reduce Facial Self-Touches and Prevent Exposure to Pathogens Transmitted via Hands: Quasi-Experimental Intervention %A Arévalo-Baeza,Marta %A Viuda-Serrano,Alejandro %A Juan-Llamas,Carmen %A Sotoca-Orgaz,Pablo %A Asín-Izquierdo,Iván %+ Department of Education Sciences, Faculty of Medicine and Health Science, Universidad de Alcalá, Campus Universitario C/ 19, Av. de Madrid, Km 33,600, Alcalá de Henares, Madrid, 28871, Spain, 34 651569136, marta.arevalo@uah.es %K self-touching %K face %K serious game %K health %K pathogen transmission %K hazard scenarios %K body language %D 2023 %7 30.6.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: After the COVID-19 pandemic, society has become more aware of the importance of some basic hygienic habits to avoid exposure to pathogens transmitted via hands. Given that a high frequency of touching mucous membranes can lead to a high risk of infection, it is essential to establish strategies to reduce this behavior as a preventive measure against contagion. This risk can be extrapolated to a multitude of health scenarios and transmission of many infectious diseases. #RedPingüiNO was designed as an intervention to prevent the transmission of SARS-CoV-2 and other pathogens through the reduction of facial self-touches by thoughtfully engaging participants in a serious game. Objective: Facial self-touches should be understood as behaviors of limited control and awareness, used to regulate situations of cognitive and emotional demands, or as part of nonverbal communication. The objective of this study was to ensure that participants become aware of and reduce these behaviors through a game of self-perception. Methods: The quasi-experimental intervention was applied to 103 healthy university students selected by convenience sampling and put into practice for 2 weeks, with 1 control group (n=24, 23.3%) and 2 experimental groups (experimental group with no additional social reinforcement interventions: n=36, 35%; experimental group with additional social reinforcement interventions: n=43, 41.7%). The objective was to improve knowledge and perception and reduce facial self-touches to prevent exposure to pathogens transmitted via hands not only in health multihazard scenarios but also in ordinary circumstances. The ad hoc instrument used to analyze the experience consisted of 43 items and was valid and reliable for the purpose of this study. The items were divided into 5 blocks extracted from the theoretical framework: sociological issues (1-5); hygiene habits (6-13); risk awareness (14-19); strategies for not touching the face (20-26); and questions after the intervention (27-42), designed as a postintervention tool assessing the game experience. Validation of the content was achieved through assessment by 12 expert referees. External validation was performed using a test-retest procedure, and reliability was verified using the Spearman correlation. Results: The results of the ad hoc questionnaire, which were analyzed using the Wilcoxon signed-rank test and McNemar index to identify significant differences between test and retest for a 95% CI, showed that facial self-touches were reduced (item 20, P<.001; item 26, P=.04), and awareness of this spontaneous behavior and its triggers increased (item 15; P=.007). The results were reinforced by qualitative findings from the daily logs. Conclusions: The intervention exhibited a greater effect from sharing the game, with interactions between people; however, in both cases, it was helpful in reducing facial self-touches. In summary, this game is suitable for reducing facial self-touches, and owing to its free availability and design, it can be adapted to various contexts. %M 37389910 %R 10.2196/45600 %U https://games.jmir.org/2023/1/e45600 %U https://doi.org/10.2196/45600 %U http://www.ncbi.nlm.nih.gov/pubmed/37389910 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43987 %T Evaluating the Feasibility of a Multiplayer Role-Playing Game as a Behavioral Health Intervention in Adolescent Patients With Chronic Physical or Mental Conditions: Protocol for a Cohort Study %A Babichenko,Dmitriy %A Radovic,Ana %A Patel,Ravi %A Hester,Alexis %A Powell,Koehler %A Eggers,Nicholas %A Happe,David %+ School of Computing and Information, University of Pittsburgh, 135 N. Bellefield Avenue, Room 721, Pittsburgh, PA, 15213, United States, 1 4122609194, dmb72@pitt.edu %K role-playing games %K social isolation %K depression %K game-based interventions %K development %K intervention %K game %K teen %K patient %K chronic %K mental condition %K quality of life %K engagement %K symptoms %K data %K clinical %D 2023 %7 27.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Numerous studies have revealed that adolescents with chronic physical or mental conditions (CPMCs) are at an increased risk for depression and anxiety, with serious direct and indirect negative effects on treatment adherence, family functioning, and health-related quality of life. As game-based approaches are effective interventions in treating anxiety and depression, we propose to explore the use of a multiplayer role-playing game (RPG) as a potential intervention for social isolation, anxiety, and depression. Objective: The objectives of this study were to (1) determine the feasibility of using Masks, a multiplayer RPG, as an intervention for social isolation, anxiety, and depression in adolescents with CPMCs; (2) evaluate the viability of the research process; and (3) gauge participation in and engagement with RPG-based interventions. Methods: This study is a remote synchronous game-based intervention for adolescents with CPMCs aged 14-19 years. Eligible participants completed a web-based baseline survey to assess anxiety, depression, and social isolation and to identify their gaming habits. After completing the baseline survey, they participated in 5 moderated Masks game sessions. In Masks, players assume the roles of young superheroes; select their character types, superpowers; and perform actions determined by the game’s rule system and dice rolls. All game sessions were played using Discord, a communication platform commonly used by gaming communities. Games were led and moderated by game masters (GMs). After each game session, participants completed surveys to assess changes in anxiety, depression, and social isolation, and their attitude toward the game and the user experience. The participants also completed an exit survey after all 5 game sessions (modified version of the Patient Health Questionnaire and the Generalized Anxiety Disorder Questionnaire, and 17 open-ended questions). The GMs rated each game session and reported on gameplay, player behavior, comfort, and engagement levels of the players. Results: As of March 2020, six participants were recruited for the pilot study to participate in moderated web-based game sessions of Masks; 3 completed all game sessions and all required assessments. Although the number of participants was too low to draw generalizable conclusions, self-reported clinical outcomes did seem to indicate a positive change in depression, anxiety, and social isolation symptoms. Qualitative analysis of postgame survey data from participants and GMs indicated high levels of engagement and enjoyment. Furthermore, the participants provided feedback about improved mood and engagement related to weekly participation in Masks. Lastly, responses to the exit survey showed interest in future RPG-related studies. Conclusions: We established a workflow for gameplay and evaluated a research protocol for evaluating the impact of RPG participation on isolation, anxiety, and depression symptoms in adolescents with CPMCs. Preliminary data collected from the pilot study support the validity of the research protocol and the use of RPG-based interventions in larger clinical studies. International Registered Report Identifier (IRRID): RR1-10.2196/43987 %M 37368477 %R 10.2196/43987 %U https://www.researchprotocols.org/2023/1/e43987 %U https://doi.org/10.2196/43987 %U http://www.ncbi.nlm.nih.gov/pubmed/37368477 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42374 %T Comparison of Exergames Versus Conventional Exercises on the Health Benefits of Older Adults: Systematic Review With Meta-Analysis of Randomized Controlled Trials %A Chen,Xi %A Wu,Lina %A Feng,Hui %A Ning,Hongting %A Wu,Shuang %A Hu,Mingyue %A Jiang,Dian %A Chen,Yifei %A Jiang,Yu %A Liu,Xin %+ Department of General Practice, 921 Hospital of Joint Logistics Support Force, The Chinese People's Liberation Army, No.1 Hongshan Bridge, Changsha, 410008, China, 86 13308490423, 281039313@qq.com %K exergame %K exergaming %K older adult %K elder %K geriatric %K gerontology %K physical function %K mental health %K systematic review %K meta-analysis %K meta-analyses %K review methodology %K RCT %K randomized %K cognitive function %K depression %K QOL %K quality of life %D 2023 %7 22.6.2023 %9 Review %J JMIR Serious Games %G English %X Background: Conventional exercises (CEs) can provide health benefits for older adults, but the long-term exercise adherence rate is low. As an emerging, stimulating, and self-motivating strategy, exergames (EGs) are defined as combinations of exercises and games that users carry out through physical actions. They can promote exercise, but the health effects of EGs versus CEs on the physical function and mental health (cognitive function, depression, and quality of life) of older adults remain controversial. Objective: The aim of the study is to compare the health benefits of EGs versus those of CEs for the physical function and mental health of older adults. Methods: A comprehensive search was conducted from the earliest available date to February 2023 in the following 6 databases: PubMed, Web of Science, Embase, Cochrane, CINAHL, and PsycINFO. All English-language randomized controlled trials comparing the effects of EGs versus those of CEs on the physical function and mental health of older adults, with nearly same physical activity between the 2 interventions, were included. Risk of bias was independently evaluated by 2 authors using the Cochrane risk of bias in randomized trials tool. Two authors independently extracted data. We followed the Cochrane Handbook of Systematic Reviews of Interventions to process and analyze the data for meta-analysis. Standardized mean differences (SMDs) and 95% CIs were used for continuous data, and random models were used for analyses. Results: We included 12 studies consisting of 919 participants in total. Of these, 10 studies were eventually included in the meta-analysis. The results showed that EGs versus CEs exhibited no significant differences in physical (P=.13; τ2=0.31; χ26=26.6; I2=77%; SMD=0.37; 95% CI –0.11 to 0.86) or cognitive function (P=.63; τ2=0.01; χ23=3.1; I2=4%; SMD=0.09; 95% CI –0.27 to 0.44) effects. Conclusions: Our findings indicate no significant difference between EGs and CEs in improving the physical function and cognitive function of older adults. Future studies are required to compare the effects of EGs versus those of CEs on cognitive function according to cognitive status, quantify the “dose-effect” relationship between EGs and health benefits, and evaluate the effects of different types and devices of EGs with regard to the health benefits of older adults. Trial Registration: PROSPERO CRD42022322734; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=322734 %M 37347534 %R 10.2196/42374 %U https://games.jmir.org/2023/1/e42374 %U https://doi.org/10.2196/42374 %U http://www.ncbi.nlm.nih.gov/pubmed/37347534 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44538 %T Novel Software for High-level Virological Testing: Self-Designed Immersive Virtual Reality Training Approach %A Tsai,Huey-Pin %A Lin,Che-Wei %A Lin,Ying-Jun %A Yeh,Chun-Sheng %A Shan,Yan-Shen %+ Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan, 886 62353535 ext 2616, tsaihp@mail.ncku.edu.tw %K design %K immersive %K virtual reality %K VR %K high-level clinical virology %K skill training %K testing %K virology %K virological %K medical education %K clinical practice %K simulation %K biotechnology %K molecular %K detection %K pathogen %K development %K software %K teaching %D 2023 %7 21.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: To ensure the timely diagnosis of emerging infectious diseases, high-tech molecular biotechnology is often used to detect pathogens and has gradually become the gold standard for virological testing. However, beginners and students are often unable to practice their skills due to the higher costs associated with high-level virological testing, the increasing complexity of the equipment, and the limited number of specimens from patients. Therefore, a new training program is necessary to increase training and reduce the risk of test failure. Objective: The aim of the study is to (1) develop and implement a virtual reality (VR) software for simulated and interactive high-level virological testing that can be applied in clinical practice and skills building or training settings and (2) evaluate the VR simulation’s effectiveness on reaction, learning, and behavior of the students (trainees). Methods: Viral nucleic acid tests on a BD MAX instrument were selected for our VR project because it is a high-tech automatic detection system. There was cooperation between teachers of medical technology and biomedical engineering. Medical technology teachers were responsible for designing the lesson plan, and the biomedical engineering personnel developed the VR software. We designed a novel VR teaching software to simulate cognitive learning via various procedure scenarios and interactive models. The VR software contains 2D VR “cognitive test and learning” lessons and 3D VR “practical skills training” lessons. We evaluated students’ learning effectiveness pre- and posttraining and then recorded their behavior patterns when answering questions, performing repeated exercises, and engaging in clinical practice. Results: The results showed that the use of the VR software met participants’ needs and enhanced their interest in learning. The average posttraining scores of participants exposed to 2D and 3D VR training were significantly higher than participants who were exposed solely to traditional demonstration teaching (P<.001). Behavioral assessments of students pre- and posttraining showed that students exposed to VR-based training to acquire relevant knowledge of advanced virological testing exhibited significantly improved knowledge of specific items posttraining (P<.01). A higher participant score led to fewer attempts when responding to each item in a matching task. Thus, VR can enhance students’ understanding of difficult topics. Conclusions: The VR program designed for this study can reduce the costs associated with virological testing training, thus, increasing their accessibility for students and beginners. It can also reduce the risk of viral infections particularly during disease outbreaks (eg, the COVID-19 pandemic) and also enhance students’ learning motivation to strengthen their practical skills. %M 37342081 %R 10.2196/44538 %U https://www.jmir.org/2023/1/e44538 %U https://doi.org/10.2196/44538 %U http://www.ncbi.nlm.nih.gov/pubmed/37342081 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44429 %T A Gamified Mobile App That Helps People Develop the Metacognitive Skills to Cope With Stressful Situations and Difficult Emotions: Formative Assessment of the InsightApp %A Amo,Victoria %A Prentice,Mike %A Lieder,Falk %+ Max Planck Institute for Intelligent Systems, Max Planck Ring 4, Tübingen, 72076, Germany, 49 15730645508, victoria.amo@tuebingen.mpg.de %K ecological momentary interventions %K serious games %K mindfulness-based interventions %K acceptance and commitment therapy %K cognitive behavioral therapy %K mobile phone %D 2023 %7 16.6.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Ecological momentary interventions open up new and exciting possibilities for delivering mental health interventions and conducting research in real-life environments via smartphones. This makes designing psychotherapeutic ecological momentary interventions a promising step toward cost-effective and scalable digital solutions for improving mental health and understanding the effects and mechanisms of psychotherapy. Objective: The first objective of this study was to formatively assess and improve the usability and efficacy of a gamified mobile app, the InsightApp, for helping people learn some of the metacognitive skills taught in cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based interventions. The app aims to help people constructively cope with stressful situations and difficult emotions in everyday life. The second objective of this study was to test the feasibility of using the InsightApp as a research tool for investigating the efficacy of psychological interventions and their underlying mechanisms. Methods: We conducted 2 experiments. In experiment 1 (n=65; completion rate: 63/65, 97%), participants (mean age 27, SD 14.9; range 19-55 years; 41/60, 68% female) completed a single session with the InsightApp. The intervention effects on affect, belief endorsement, and propensity for action were measured immediately before and after the intervention. Experiment 2 (n=200; completion rate: 142/200, 71%) assessed the feasibility of conducting a randomized controlled trial using the InsightApp. We randomly assigned participants to an experimental or a control condition, and they interacted with the InsightApp for 2 weeks (mean age 37, SD 12.16; range 20-78 years; 78/142, 55% female). Experiment 2 included all the outcome measures of experiment 1 except for the self-reported propensity to engage in predefined adaptive and maladaptive behaviors. Both experiments included user experience surveys. Results: In experiment 1, a single session with the app seemed to decrease participants’ emotional struggle, the intensity of their negative emotions, their endorsement of negative beliefs, and their self-reported propensity to engage in maladaptive coping behaviors (P<.001 in all cases; average effect size=−0.82). Conversely, participants’ endorsement of adaptive beliefs and their self-reported propensity to act in accordance with their values significantly increased (P<.001 in all cases; average effect size=0.48). Experiment 2 replicated the findings of experiment 1 (P<.001 in all cases; average effect size=0.55). Moreover, experiment 2 identified a critical obstacle to conducting a randomized controlled trial (ie, asymmetric attrition) and how it might be overcome. User experience surveys suggested that the app’s design is suitable for helping people apply psychotherapeutic techniques to cope with everyday stress and anxiety. User feedback provided valuable information on how to further improve app usability. Conclusions: In this study, we tested the first prototype of the InsightApp. Our encouraging preliminary results show that it is worthwhile to continue developing the InsightApp and further evaluate it in a randomized controlled trial. %M 37327040 %R 10.2196/44429 %U https://formative.jmir.org/2023/1/e44429 %U https://doi.org/10.2196/44429 %U http://www.ncbi.nlm.nih.gov/pubmed/37327040 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39465 %T Health Promotion in Popular Web-Based Community Games Among Young People: Proposals, Recommendations, and Applications %A Martin,Philippe %A Chapoton,Boris %A Bourmaud,Aurélie %A Dumas,Agnès %A Kivits,Joëlle %A Eyraud,Clara %A Dubois,Capucine %A Alberti,Corinne %A Le Roux,Enora %+ Université Paris Cité, Epidémiologie Clinique Evaluation Economique Appliquées aux Populations Vulnérables, Inserm, 10 Avenue de Verdun, Paris, 75010, France, 33 0676606491, philippe.martin@inserm.fr %K health promotion %K web-based community games %K young people %K interventional research %K recommendations %D 2023 %7 9.6.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Young people use digital technology on a daily basis and enjoy web-based games that promote social interactions among peers. These interactions in web-based communities can develop social knowledge and life skills. Intervening via existing web-based community games represents an innovative opportunity for health promotion interventions. Objective: The aim of this study was to collect and describe players’ proposals for delivering health promotion through existing web-based community games among young people, elaborate on related recommendations adapted from a concrete experience of intervention research, and describe the application of these recommendations in new interventions. Methods: We implemented a health promotion and prevention intervention via a web-based community game (Habbo; Sulake Oy). During the implementation of the intervention, we conducted an observational qualitative study on young people’s proposals via an intercept web-based focus group. We asked 22 young participants (3 groups in total) for their proposals about the best ways to carry out a health intervention in this context. First, using verbatim transcriptions of the players’ proposals, we conducted a qualitative thematic analysis. Second, we elaborated on recommendations for action development and implementation based on our experiences and work with a multidisciplinary consortium of experts. Third, we applied these recommendations in new interventions and described their application. Results: A thematic analysis of the participants’ proposals revealed 3 main themes and 14 subthemes related to their proposals and process elements: the conditions for developing an attractive intervention within a game, the value of involving peers in developing the intervention, and the ways to mobilize and monitor gamers’ participation. These proposals emphasized the importance of interventions involving and moderating a small group of players in a playful manner but with professional aspects. We established 16 domains with 27 recommendations for preparing an intervention and implementing it in web-based games by adopting the codes of game culture. The application of the recommendations showed their usefulness and that it was possible to make adapted and diverse interventions in the game. Conclusions: Integrated health promotion interventions in existing web-based community games have the potential for promoting the health and well-being of young people. There is a need to incorporate specific key aspects of the games and gaming community recommendations, from conception to implementation, to maximize the relevance, acceptability, and feasibility of the interventions integrated in current digital practices. Trial Registration: ClinicalTrials.gov NCT04888208; https://clinicaltrials.gov/ct2/show/NCT04888208 %M 37294609 %R 10.2196/39465 %U https://games.jmir.org/2023/1/e39465 %U https://doi.org/10.2196/39465 %U http://www.ncbi.nlm.nih.gov/pubmed/37294609 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45857 %T Virtual Risk Management—Exploring Effects of Childhood Risk Experiences through Innovative Methods (ViRMa) for Primary School Children in Norway: Study Protocol for the ViRMa Project %A Sandseter,Ellen Beate Hansen %A Sando,Ole Johan %A Lorås,Håvard %A Kleppe,Rasmus %A Storli,Lise %A Brussoni,Mariana %A Bundy,Anita %A Schwebel,David C %A Ball,David J %A Haga,Monika %A Little,Helen %+ Department of Physical Education and Health, Queen Maud University College of Early Childhood Education, Thrond Nergaaeds veg 7, Trondheim, 7044, Norway, 47 93658663, ebs@dmmh.no %K anxiety %K childhood education %K childhood risk experiences %K children %K development %K eye tracking %K injury prevention %K injury %K motion capturing %K physical activity %K prevention %K questionnaire %K resilience %K risk management %K risky play %K social skills %K validation %K virtual reality %K VR %K well-being %K willingness %K Xsens %D 2023 %7 7.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Research indicates that risky play benefits children’s risk assessment and risk management skills and offers several positive health effects such as resilience, social skills, physical activity, well-being, and involvement. There are also indications that the lack of risky play and autonomy increases the likelihood of anxiety. Despite its well-documented importance, and the willingness of children to engage in risky play, this type of play is increasingly restricted. Assessing long-term effects of risky play has been problematic because of ethical issues with conducting studies designed to allow or encourage children to take physical risks with the potential of injury. Objective: The Virtual Risk Management project aims to examine children’s development of risk management skills through risky play. To accomplish this, the project aims to use and validate newly developed and ethically appropriate data collection tools such as virtual reality, eye tracking, and motion capturing, and to provide insight into how children assess and handle risk situations and how children’s past risky play experiences are associated with their risk management. Methods: We will recruit 500 children aged 7-10 years and their parents from primary schools in Norway. Children’s risk management will be measured through data concerning their risk assessment, risk willingness, and risk handling when completing a number of tasks in 3 categories of virtual reality scenarios: street crossing, river crossing, and playing on playground equipment. The children will move around physically in a large space while conducting the tasks and wear 17 motion-capturing sensors that will measure their movements to analyze motor skills. We will also collect data on children’s perceived motor competence and their sensation-seeking personality. To obtain data on children’s risk experiences, parents will complete questionnaires on their parental style and risk tolerance, as well as information about the child’s practical risk experience. Results: Four schools have been recruited to participate in data collection. The recruitment of children and parents for this study started in December 2022, and as of April 2023, a total of 433 parents have consented for their children to participate. Conclusions: The Virtual Risk Management project will increase our understanding of how children’s characteristics, upbringing, and previous experiences influence their learning and ability to handle challenges. Through development and use of cutting-edge technology and previously developed measures to describe aspects of the children’s past experiences, this project addresses crucial topics related to children’s health and development. Such knowledge may guide pedagogical questions and the development of educational, injury prevention, and other health-related interventions, and reveal essential areas for focus in future studies. It may also impact how risk is addressed in crucial societal institutions such as the family, early childhood education, and schools. International Registered Report Identifier (IRRID): DERR1-10.2196/45857 %M 37285210 %R 10.2196/45857 %U https://www.researchprotocols.org/2023/1/e45857 %U https://doi.org/10.2196/45857 %U http://www.ncbi.nlm.nih.gov/pubmed/37285210 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44132 %T Effectiveness of Digital Health Interventions Containing Game Components for the Self-management of Type 2 Diabetes: Systematic Review %A Ossenbrink,Linda %A Haase,Tina %A Timpel,Patrick %A Schoffer,Olaf %A Scheibe,Madlen %A Schmitt,Jochen %A Deckert,Stefanie %A Harst,Lorenz %+ Center for Evidence-based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, Dresden, 01307, Germany, 49 37133335325, lorenz.harst@tu-dresden.de %K diabetes %K gamification %K digital health %K diabetes self-management %K mobile phone %D 2023 %7 1.6.2023 %9 Review %J JMIR Serious Games %G English %X Background: Games and game components have become a major trend in the realm of digital health research and practice as they are assumed to foster behavior change and thereby improve patient-reported and clinical outcomes for patients with type 2 diabetes. Objective: The aim of this systematic review was to summarize and evaluate the current evidence on the effectiveness of digital health interventions containing game components on behavioral, patient-reported, and clinical outcomes for patients with type 2 diabetes. Methods: An electronic search was conducted in MEDLINE and PsycINFO in April 2020; updated in April 2022; and supplemented by additional searches via Google Scholar, Web of Science (which was used for forward citation tracking), and within the references of the included records. Articles were identified using predefined inclusion and exclusion criteria. In total, 2 reviewers independently conducted title, abstract, and full-text screening and then individually performed a critical appraisal of all the included studies using the Cochrane risk-of-bias tool version 2. A consensus was reached through discussion. Results: Of 2325 potentially relevant titles (duplicates excluded), 10 (0.43%) randomized controlled trials were included in this review. Quality assessment revealed a high risk of bias for all randomized controlled trials except for 10% (1/10), with performance bias due to the lack of blinding being the major source of bias. There is evidence suggesting that digital health interventions containing game components can substantially improve motivation for physical activity (1/1, 100% of the studies dealing with PA motivation), exercise intensity (3/5, 60%), dietary behavior (4/4, 100%), health literacy (1/3, 33%), mental quality of life (2/2, 100%), glycated hemoglobin level (2/6, 33%), BMI (1/3, 33%), fasting plasma glucose level (1/2, 50%), waist circumference (1/1, 100%), and aerobic capacity (1/1, 100%). Conclusions: Published studies indicated that digital health interventions containing game components might improve health behavior patterns, quality of life, and clinical outcomes in patients with type 2 diabetes. However, the intervention types and outcomes studied were heterogeneous, and study quality was mostly low, which translates to ambiguous results. Future research should focus on sound methodology and reporting as well as on identifying game components that contribute to significant positive effects. Trial Registration: PROSPERO CRD42020209706; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209706 %M 37261900 %R 10.2196/44132 %U https://games.jmir.org/2023/1/e44132 %U https://doi.org/10.2196/44132 %U http://www.ncbi.nlm.nih.gov/pubmed/37261900 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 9 %N %P e45037 %T Effects of Active Video Games in Patients With Cancer: Systematic Review %A Peyrachon,Romane %A Rébillard,Amélie %+ Movement, Sport and Heath Sciences laboratory M2S-EA7470, University of Rennes 2, 14 Av. Robert Schuman, Campus de Ker Lann, Rennes, 35170, France, 33 609379245, romane.peyrachon@ens-rennes.fr %K exergaming %K cancer %K physical activity %K fatigue %K endurance %K strength %K adjuvant therapy %K cancer therapy %K cancer treatment %K video games %K digital health intervention %K cancer patient %D 2023 %7 26.5.2023 %9 Review %J JMIR Cancer %G English %X Background: Physical activity (PA) is now considered an adjuvant therapy in cancer treatment; nevertheless, multiple barriers could reduce PA engagement during treatment. Active video games (AVGs) lead to the achievement of mild- to moderate-intensity PA and represent a promising tool for regular movement and exercise. Objective: This paper aims to review the current literature and provide updated content on the physiological and psychological effects of AVG-based interventions in patients with cancer undergoing treatment. Methods: Four electronic databases were investigated. Studies reporting on AVG interventions delivered to patients undergoing treatment were included. A total of 21 articles (17 interventions) were identified for data extraction and quality assessment. Results: A total of 362 patients with cancer participated in the studies (number of participants 3-70). The majority underwent treatment for breast, lung, prostate, hematologic, or oral or laryngeal cancer. The types and stages of cancer varied in all studies. Participants ranged in age from 3 to 93 years. Four studies included patients with pediatric cancer. The duration of interventions ranged from 2 to 16 weeks, with a minimum of 2 sessions per week and a maximum of 1 daily session. Sessions were supervised in 10 studies, and 7 included home-based interventions. AVG interventions improved endurance, quality of life, cancer-related fatigue, and self-efficacy. Effects were mixed on strength, physical function, and depression. AVGs did not affect activity level, body composition, or anxiety. Compared with standard physiotherapy, physiological effects were lower or similar, and psychological effects were higher or similar. Conclusions: Overall, our results suggest that AVGs can be recommended to patients undergoing cancer treatment, given the physiological and psychological benefits. When AVGs are proposed, supervision of the sessions should be considered as it can limit dropouts. In the future, it is important to develop AVGs that combine endurance and muscle strengthening, with the possibility of achieving moderate to high exercise intensity, depending on the physical abilities of the patients, as indicated in the World Health Organization’s recommendations. %M 37234028 %R 10.2196/45037 %U https://cancer.jmir.org/2023/1/e45037 %U https://doi.org/10.2196/45037 %U http://www.ncbi.nlm.nih.gov/pubmed/37234028 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41553 %T The Change in Exergaming From Before to During the COVID-19 Pandemic Among Young Adults: Longitudinal Study %A O'Loughlin,Erin K %A Sabiston,Catherine M %A O'Rourke,Roxy H %A Bélanger,Mathieu %A Sylvestre,Marie-Pierre %A O'Loughlin,Jennifer L %+ Department of Social and Preventive Medicine, Centre de recherche du centre hospitalier de l’Université de Montréal, 900 Saint Denis St, Montreal, QC, H2X 0A9, Canada, 1 514 890 8000 ext 31473, erin_oloughlin@hotmail.com %K exergaming %K active video games %K longitudinal study %K COVID-19 pandemic %K physical activity %K serious game %K youth %K young adult %K health promotion %K digital health intervention %K exergame %D 2023 %7 22.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergaming may be an important option to support an active lifestyle, especially during pandemics. Objective: Our objectives were (1) to explore whether change in exergaming status (stopped, started or sustained exergaming, or never exergamed) from before to during the COVID-19 pandemic was related to changes in walking, moderate-to-vigorous physical activity (MVPA) or meeting MVPA guidelines and (2) to describe changes among past-year exergamers in minutes per week exergaming from before to during the pandemic. Methods: A total of 681 participants (mean age 33.6; SD 0.5 years; n=280, 41% male) from the 22-year Nicotine Dependence in Teens (NDIT) study provided data on walking, MVPA, and exergaming before (2017 to 2020) and during (2021) the COVID-19 pandemic. Physical activity (PA) change scores were described by change in exergaming status. Results: We found that 62.4% (n=425) of the 681 participants never exergamed, 8.2% (n=56) started exergaming during the pandemic, 19.7% (n=134) stopped exergaming, and 9.7% (n=66) sustained exergaming. Declines were observed in all 3 PA indicators in all 4 exergaming groups. The more salient findings were that (1) participants who started exergaming during COVID-19 reported the highest MVPA levels before and during the pandemic and declined the least (mean –35 minutes/week), (2) sustained exergamers reported the lowest MVPA levels during the pandemic (median 66 minutes/week) and declined the most in MVPA (mean change of –92 minutes/week) and in meeting MVPA guidelines (–23.6%). During the pandemic, starting exergamers reported 85 minutes of exergaming per week and sustained exergamers increased exergaming by a median 60 minutes per week. Conclusions: Although starting and sustaining exergaming did not appear to help exergamers maintain prepandemic PA levels, exergaming can contribute a substantial proportion of total PA in young adults and may still represent a useful option to promote PA during pandemics. %M 36952329 %R 10.2196/41553 %U https://games.jmir.org/2023/1/e41553 %U https://doi.org/10.2196/41553 %U http://www.ncbi.nlm.nih.gov/pubmed/36952329 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45243 %T Active Video Game Interventions Targeting Physical Activity Behaviors: Systematic Review and Meta-analysis %A Moller,Arlen C %A Sousa,Caio Victor %A Lee,Kelly Jihyeon %A Alon,Dar %A Lu,Amy Shirong %+ Department of Psychology, Lewis College of Science and Letters, Illinois Institute of Technology, 3424 S State St, Tech Central Suite 201, Chicago, IL, 60616, United States, 1 585 615 4490, amoller@iit.edu %K active video game %K exergame %K games for health %K digital health %K physical activity %K systematic review %K meta-analysis %K digital game %K digital health intervention %K health promotion %D 2023 %7 16.5.2023 %9 Review %J J Med Internet Res %G English %X Background: Research on digital games designed to increase physical activity (PA), also known as exergames or active video games (AVGs), has proliferated over the past 2 decades. As a result, reviews of literature in this field can become outdated, revealing the need for updated high-quality reviews that identify overarching insights. Furthermore, given the significant heterogeneity in AVG research, study inclusion criteria may significantly influence conclusions. To the best of our knowledge, no prior systematic review or meta-analysis has specifically focused on studies of longitudinal AVG interventions targeting increases in PA behaviors. Objective: The aim of this study was to obtain insights into when and why longitudinal AVG interventions are more or less successful for sustained increases in PA, especially for public health. Methods: Six databases (PubMed, PsycINFO, SPORTDiscus, MEDLINE, Web of Science, and Google Scholar) were reviewed until December 31, 2020. This protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020204191). For inclusion, randomized controlled trials had to prominently (>50% of intervention) feature AVG technology, involve repeated AVG exposure, and target changes in PA behavior. Experimental designs had to include ≥2 within- or between-participant conditions with ≥10 participants per condition. Results: A total of 25 studies published in English between 1996 and 2020 were identified, with 19 studies providing sufficient data for inclusion in the meta-analysis. Our findings indicated that AVG interventions had a moderately positive effect, thereby increasing overall PA (Hedges g=0.525, 95% CI 0.322-0.728). Our analysis showed substantial heterogeneity (I2=87.7%; Q=154.1). The main findings were consistent across all subgroup analyses. The comparison between PA assessment type groups showed a moderate effect for objective measures (Hedges g=0.586, 95% CI 0.321-0.852) and a small effect for subjective measures (Hedges g=0.301, 95% CI 0.049-0.554) but no significant difference between the groups (P=.13). The platform subgroup analysis indicated a moderate effect for stepping devices (Hedges g=0.303, 95% CI 0.110-0.496), combination of handheld and body-sensing devices (Hedges g=0.512, 95% CI 0.288-0.736), and other devices (Hedges g=0.694, 95% CI 0.350-1.039). The type of control group showed a wide range of effects sizes, ranging from a small effect size (Hedges g=0.370, 95% CI 0.212-0.527) for the passive control group (nothing) to a moderate effect size for the conventional PA intervention group (Hedges g=0.693, 95% CI 0.107-1.279) and ultimately to a large effect size for sedentary game as control groups (Hedges g=0.932, 95% CI 0.043-1.821). There was no significant difference among the groups (P=.29). Conclusions: AVGs represent a promising tool for PA promotion among the general population and clinical subpopulations. However, significant variabilities in AVG quality, study design, and impact were also detected. Suggestions for improving AVG interventions and related research will be discussed. Trial Registration: PROSPERO CRD42020204191; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=204191 %M 37191992 %R 10.2196/45243 %U https://www.jmir.org/2023/1/e45243 %U https://doi.org/10.2196/45243 %U http://www.ncbi.nlm.nih.gov/pubmed/37191992 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40931 %T Computerized Block Games for Automated Cognitive Assessment: Development and Evaluation Study %A Cheng,Xiangyi %A Gilmore,Grover C %A Lerner,Alan J %A Lee,Kiju %+ Department of Engineering Technology and Industrial Distribution, Texas A&M University, Fermier Hall, 3367 TAMU, 466 Ross St, College Station, TX, 77843, United States, 1 979 458 6479, kiju.lee@tamu.edu %K cognitive assessment %K computerized block games %K adaptive serious games %K computerized cognitive assessment %D 2023 %7 16.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive assessment using tangible objects can measure fine motor and hand-eye coordination skills along with other cognitive domains. Administering such tests is often expensive, labor-intensive, and error prone owing to manual recording and potential subjectivity. Automating the administration and scoring processes can address these difficulties while reducing time and cost. e-Cube is a new vision-based, computerized cognitive assessment tool that integrates computational measures of play complexity and item generators to enable automated and adaptive testing. The e-Cube games use a set of cubes, and the system tracks the movements and locations of these cubes as manipulated by the player. Objective: The primary objectives of the study were to validate the play complexity measures that form the basis of developing the adaptive assessment system and evaluate the preliminary utility and usability of the e-Cube system as an automated cognitive assessment tool. Methods: This study used 6 e-Cube games, namely, Assembly, Shape-Matching, Sequence-Memory, Spatial-Memory, Path-Tracking, and Maze, each targeting different cognitive domains. In total, 2 versions of the games, the fixed version with predetermined sets of items and the adaptive version using the autonomous item generators, were prepared for comparative evaluation. Enrolled participants (N=80; aged 18-60 years) were divided into 2 groups: 48% (38/80) of the participants in the fixed group and 52% (42/80) in the adaptive group. Each was administered the 6 e-Cube games; 3 subtests of the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV; Block Design, Digit Span, and Matrix Reasoning); and the System Usability Scale (SUS). Statistical analyses at the 95% significance level were applied. Results: The play complexity values were correlated with the performance indicators (ie, correctness and completion time). The adaptive e-Cube games were correlated with the WAIS-IV subtests (r=0.49, 95% CI 0.21-0.70; P<.001 for Assembly and Block Design; r=0.34, 95% CI 0.03-0.59; P=.03 for Shape-Matching and Matrix Reasoning; r=0.51, 95% CI 0.24-0.72; P<.001 for Spatial-Memory and Digit Span; r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Block Design; and r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Matrix Reasoning). The fixed version showed weaker correlations with the WAIS-IV subtests. The e-Cube system showed a low false detection rate (6/5990, 0.1%) and was determined to be usable, with an average SUS score of 86.01 (SD 8.75). Conclusions: The correlations between the play complexity values and performance indicators supported the validity of the play complexity measures. Correlations between the adaptive e-Cube games and the WAIS-IV subtests demonstrated the potential utility of the e-Cube games for cognitive assessment, but a further validation study is needed to confirm this. The low false detection rate and high SUS scores indicated that e-Cube is technically reliable and usable. %M 37191993 %R 10.2196/40931 %U https://games.jmir.org/2023/1/e40931 %U https://doi.org/10.2196/40931 %U http://www.ncbi.nlm.nih.gov/pubmed/37191993 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e37742 %T Effects of Music on Attention-Deficit/Hyperactivity Disorder (ADHD) and Potential Application in Serious Video Games: Systematic Review %A Martin-Moratinos,Marina %A Bella-Fernández,Marcos %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Puerta de Hierro University Hospital - Majadahonda, C/ Joaquín Rodrigo, Majadahonda, 28222, Spain, 34 911911690, hmblasco@yahoo.es %K attention-deficit/hyperactivity disorder %K music therapy %K music %K video games %K rhythm %K timing deficits %D 2023 %7 12.5.2023 %9 Review %J J Med Internet Res %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) has a considerable impact on an individual’s daily life. Some difficulties with timing deficits may be associated with deficiencies in attention, reading, language skills, or executive function. Music therapy, either active (playing an instrument) or passive (listening to music) has demonstrated its efficacy in reducing symptomatology in many disorders. Video games may prove to be a useful assessment and treatment tool in compensating for the difficulties with multimodal treatment in ADHD. Objective: The aim of the study is to (1) analyze the evidence that music is beneficial in reducing the symptomatology of ADHD using systematic review and (2) propose the application of music in video games following music therapy strategies. Methods: Searches were conducted in PubMed, Embase, PsycINFO, Cochrane, and gray literature (Google Scholar and WorldCat). We used the following search syntax: ((music[Title/Abstract]) or (music therapy[Title/Abstract])) and (attention deficit disorder[MeSH or thesaurus term]). Results: Of the 70 records identified, 17 provided findings that music can be beneficial in various domains of ADHD. Active music therapy improves hemispheric synchrony, social skills, aggressivity, and impulsivity. Passive music therapy improves academic skills like arithmetic, drawing, and reading comprehension, as well as attention and disruptive behaviors. The effects depend on the music genre, tempo, or task difficulty. Music in video games was generally found to be beneficial for people with ADHD. Music improves immersion and flow while playing video games. Using rhythm may also improve timing skills and immersion in patients with ADHD. Regarding the proposed application of aspects of music to therapeutic video games for ADHD, some paradigms in timing and music therapy were considered in the proposed design of video games. Conclusions: Improving ADHD treatment through the application of music in video games is proposed. Trial Registration: PROSPERO CRD42021288226; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=288226 %M 37171837 %R 10.2196/37742 %U https://www.jmir.org/2023/1/e37742 %U https://doi.org/10.2196/37742 %U http://www.ncbi.nlm.nih.gov/pubmed/37171837 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41638 %T Gamifying Cognitive Behavioral Therapy Techniques on Smartphones for Bangkok’s Millennials With Depressive Symptoms: Interdisciplinary Game Development %A Sriwatanathamma,Poe %A Sirivesmas,Veerawat %A Simatrang,Sone %A Bhowmik,Nobonita Himani %+ Doctor of Philosophy Program in Design Arts (International Program), Faculty of Decorative Arts, Silpakorn University, 22 Borommaratchachonnani Rd, Khwaeng Taling Chan, Khet Taling Chan, Bangkok, 10170, Thailand, 66 917655317, poesriwatana@gmail.com %K cognitive behavioral therapy %K gamification %K Bangkok’s millennials %K depressive symptoms %K mobile phone %D 2023 %7 12.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand. Objective: This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok’s millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones. Methods: First, this paper follows each development step of solidifying BlueLine’s game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player’s interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions. Results: With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions. Conclusions: This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine’s game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism. %M 37171845 %R 10.2196/41638 %U https://games.jmir.org/2023/1/e41638 %U https://doi.org/10.2196/41638 %U http://www.ncbi.nlm.nih.gov/pubmed/37171845 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44831 %T Development and Evaluation of a Serious Game Application to Engage University Students in Critical Thinking About Health Claims: Mixed Methods Study %A Elvsaas,Ida-Kristin Orjasaeter %A Garnweidner-Holme,Lisa %A Habib,Laurence %A Molin,Marianne %+ Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, P.O. Box 4 St. Olavs plass, Oslo, NO-0130, Norway, 47 93429562, idakrist@oslomet.no %K game application %K critical thinking %K critical health literacy %K Informed Health Choices %K evaluation %K mixed methods study %K serious games %K behind the headlines %K mobile phone %D 2023 %7 11.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Misleading health claims are widespread in the media, and making choices based on such claims can negatively affect health. Thus, developing effective learning resources to enable people to think critically about health claims is of great value. Serious games can become an effective learning resource in this respect, as they can affect motivation and learning. Objective: This study aims to document how user insights and input can inform the concept and development of a serious game application in critical thinking about health claims in addition to gathering user experiences with the game application. Methods: This was a mixed methods study in 4 successive phases with both qualitative and quantitative data collected in the period from 2020-2022. Qualitative data on design and development were obtained from 4 unrecorded discussions, and qualitative evaluation data were obtained from 1 recorded focus group interview and 3 open-ended questions in the game application. The quantitative data originate from user statistics. The qualitative data were analyzed thematically, and user data were analyzed using nonparametric tests. Results: The first unrecorded discussion revealed that the students’ (3 participants’) assessment of whether a claim was reliable or not was limited to performing Google searches when faced with an ad for a health intervention. On the basis of the acquired knowledge of the target group, the game’s prerequisites, and the technical possibilities, a pilot of the game was created and reviewed question by question in 3 unrecorded discussions (6 participants). After adjustments, the game was advertised at the Oslo Metropolitan University, and 193 students tested the game. A correlation (r=0.77; P<.001) was found between the number of replays and total points achieved in the game. There was no demonstrable difference (P=.07) between the total scores of students from different faculties. Overall, 36.3% (70/193) of the students answered the evaluation questions in the game. They used words such as “fun” and “educational” about the experiences with the game, and words such as “motivating” and “engaging” related to the learning experience. The design was described as “varied” and “user-friendly.” Suggested improvements include adding references, more games and modules, more difficult questions, and an introductory text explaining the game. The results from the focus group interview (4 participants) corresponded to a large extent with the results of the open-ended questions in the game. Conclusions: We found that user insights and inputs can be successfully used in the concept and development of a serious game that aims to engage students to think critically about health claims. The mixed methods evaluation revealed that the users experienced the game as educational and fun. Future research may focus on assessing the effect of the serious game on learning outcomes and health choices in randomized trials. %M 37166972 %R 10.2196/44831 %U https://formative.jmir.org/2023/1/e44831 %U https://doi.org/10.2196/44831 %U http://www.ncbi.nlm.nih.gov/pubmed/37166972 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45801 %T Sensor-Controlled Digital Game for Heart Failure Self-management: Protocol for a Randomized Controlled Trial %A Radhakrishnan,Kavita %A Julien,Christine %A O'Hair,Matthew %A Tunis,Rachel %A Lee,Grace %A Rangel,Angelica %A Custer,James %A Baranowski,Tom %A Rathouz,Paul J %A Kim,Miyong T %+ School of Information, University of Texas at Austin, 1616 Guadalupe St, Suite 5.202, Austin, TX, 78712, United States, 1 (512) 471 3821, rtunis@utexas.edu %K heart failure %K digital game %K self-management %K mobile phone %K older adults %D 2023 %7 10.5.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. There are substantial racial and geographic disparities in HF outcomes, with patients living in southern US states having a mortality rate 69% higher than the national average. Self-management behaviors, particularly daily weight monitoring and physical activity, are extremely important in improving HF outcomes; however, patients typically have particularly low adherence to these behaviors. With the rise of digital technologies to improve health outcomes and motivate health behaviors, sensor-controlled digital games (SCDGs) have become a promising approach. SCDGs, which leverage sensor-connected technologies, offer the benefits of being portable and scalable and allowing for continuous observation and motivation of health behaviors in their real-world contexts. They are also becoming increasingly popular among older adults and offer an immersive and accessible way to measure self-management behaviors and improve adherence. No SCDGs have been designed for older adults or evaluated to test their outcomes. Objective: This randomized clinical trial aims to assess the efficacy of a SCDG in integrating the behavioral data of participants with HF from weight scale and activity tracker sensors to activate game progress, rewards, and feedback and, ultimately, to improve adherence to important self-management behaviors. Methods: A total of 200 participants with HF, aged ≥45 years, will be recruited and randomized into 2 groups: the SCDG playing group (intervention group) and sensor-only group (control group). Both groups will receive a weight scale, physical activity tracker, and accompanying app, whereas only the intervention group will play the SCDG. This design, thereby, assesses the contributions of the game. All participants will complete a baseline survey as well as posttests at 6 and 12 weeks to assess the immediate effect of the intervention. They will also complete a third posttest at 24 weeks to assess the maintenance of behavioral changes. Efficacy and benefits will be assessed by measuring improvements in HF-related proximal outcomes (self-management behaviors of daily weight monitoring and physical activity) and distal outcomes (HF hospitalization, quality of life, and functional status) between baseline and weeks 6, 12, and 24. The primary outcome measured will be days with weight monitoring, for which this design provides at least 80% power to detect differences between the 2 groups. Results: Recruitment began in the fall of 2022, and the first patient was enrolled in the study on November 7, 2022. Recruitment of the last participant is expected in quarter 1 of 2025. Publication of complete results and data from this study is expected in 2026. Conclusions: This project will generate insight and guidance for scalable and easy-to-use digital gaming solutions to motivate persistent adherence to HF self-management behaviors and improve health outcomes among individuals with HF. Trial Registration: ClinicalTrials.gov NCT05056129; https://clinicaltrials.gov/ct2/show/NCT05056129 International Registered Report Identifier (IRRID): DERR1-10.2196/45801 %M 37163342 %R 10.2196/45801 %U https://www.researchprotocols.org/2023/1/e45801 %U https://doi.org/10.2196/45801 %U http://www.ncbi.nlm.nih.gov/pubmed/37163342 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40438 %T The Effects of Exergaming on Attention in Children With Attention Deficit/Hyperactivity Disorder: Randomized Controlled Trial %A Ji,HongQing %A Wu,Shanshan %A Won,Junyeon %A Weng,Shiyang %A Lee,Sujin %A Seo,Sangmin %A Park,Jung-Jun %+ Division of Sport Science, Pusan National University, 63 beon-gil 2 Busandaehak-ro, Geumjeong-gu, Busan, 46241, Republic of Korea, 82 051 510 2713, jjparkpnu@pusan.ac.kr %K exergame %K N2 amplitude %K attention function %K response time %K attention deficit/hyperactivity disorder %K ADHD %D 2023 %7 9.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Despite growing evidence showing the effects of exercise and cognitive trainings on enhancing attention, little is known about the combined effects of exergame on attention in children with attention deficit/hyperactivity disorder (ADHD). Exergame, a form of exercise using a video game, has both cognitive stimulation and physical activity components and has been shown to improve cognitive function in children. Objective: The purpose of this study was to investigate the effect of exergaming on attention and to compare the effect induced by exergaming with the effect of aerobic exercise on attention in children with ADHD. Methods: In all, 30 children with ADHD, aged 8-12 years, were randomly divided into an exergaming group (EXG; n=16) or a bicycle exercise group (BEG; n=14). Before and after the 4-week intervention, the Frankfurter Aufmerksamkeits-Inventar (FAIR; Frankfurt Attention Inventory) test was administrated, and event-related potentials during the Go/No-go task was measured to assess attention. Results: After intervention, both the EXG and BEG had significantly increased selective attention and continuous attention (all P<.001), as well as self-control on the FAIR test (EXG: P=.02 and BEG: P=.005). Similarly, both the EXG and BEG had significantly reduced response time on the Go/No-go test (all P<.001). For the Go response, the N2 amplitude (frontocentral maximal negativity) was significantly increased in Fz (midfrontal line) in the EXG (P=.003) but was not changed in the BEG (P=.97). Importantly, the N2 amplitude in Fz was significantly greater in the EXG compared to the BEG (Go: P=.001 and No-go: P=.008). Conclusions: Exergaming has the comparable effects to bicycle exercise to enhance attention in children with ADHD, suggesting that exergaming can be used as an alternative treatment for children with ADHD. Trial Registration: Clinical Research Information Service KCT0008239; https://tinyurl.com/57e4jtnb %M 37159253 %R 10.2196/40438 %U https://games.jmir.org/2023/1/e40438 %U https://doi.org/10.2196/40438 %U http://www.ncbi.nlm.nih.gov/pubmed/37159253 %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 %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43221 %T Combining Intensive Rehabilitation With a Nonfunctional Isokinetic Strengthening Program in Adolescents With Cerebral Palsy: Protocol for a Randomized Controlled Trial %A Guérin,Mathias %A Sijobert,Benoit %A Zaragoza,Benjamin %A Cambon,Flore %A Boyer,Laurence %A Patte,Karine %+ Unité de rééducation, Institut Saint-Pierre, 371, avenue de l'Évêché-de-Maguelone, Palavas-les-Flots, 34250, France, 33 467077500, mathias.guerin74370@gmail.com %K isokinetic %K cerebral palsy %K gait analysis %K spasticity %K muscle strength %D 2023 %7 3.5.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cerebral palsy is the most common brain injury in the pediatric population. Patients with cerebral palsy present different affectations such as decreased muscle strength, gait deviations, impaired proprioception, and spasticity. Isokinetic strengthening programs combined with intensive rehabilitation may improve muscle strength and therefore gait efficiency. Objective: The primary aim of this randomized controlled trial is to compare the effect of an intensive rehabilitation combined with a nonfunctional isokinetic progressive strengthening program to an intensive rehabilitation alone on gait parameters and muscle strength in patients with cerebral palsy. Another goal of this study is to determine whether adding an isokinetic program to intensive rehabilitation is more effective than intensive rehabilitation alone at decreasing spasticity and improving joint position sense in patients with cerebral palsy. Methods: A total of 30 adolescents with spastic diplegia cerebral palsy (Gross Motor Function Classification System levels I to III) will be randomized, by an independent researcher, into a 3-week intensive rehabilitation and isokinetic progressive strengthening group or an intensive rehabilitation control group. Gait parameters, muscle strength, spasticity, and knee joint position sense will be assessed. These variables will be evaluated at baseline (T0) and at the end of the intervention (T1). The intensive rehabilitation will consist of physiotherapy sessions twice a day and hydrotherapy and virtual reality gait training once a day. The isokinetic training group will have a total of 9 supervised isokinetic strength training sessions focusing on knee flexors and extensors with different execution speeds. Results: The protocol has been accepted by the French National Ethics Committee in October 2022. The inclusion of patients will start in November 2022. Conclusions: The combination of intensive rehabilitation with an isokinetic program on knee flexors and extensors has not been studied yet. The findings of this study may determine if an isokinetic strength training program of knee flexors and extensors is beneficial for the improvement of gait parameters, muscle strength, spasticity, and joint position sense in adolescents with spastic diplegia. International Registered Report Identifier (IRRID): PRR1-10.2196/43221 %M 36790338 %R 10.2196/43221 %U https://www.researchprotocols.org/2023/1/e43221 %U https://doi.org/10.2196/43221 %U http://www.ncbi.nlm.nih.gov/pubmed/36790338 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40284 %T Serious Game for the Screening of Central Auditory Processing Disorder in School-Age Children: Development and Validation Study %A Gabaldón-Pérez,Ana-Marta %A Dolón-Poza,María %A Eckert,Martina %A Máximo-Bocanegra,Nuria %A Martín-Ruiz,María-Luisa %A Pau De La Cruz,Iván %+ Grupo de Investigación Innovación Tecnológica para las Personas (InnoTep), Departamento de Ingeniería Telemática y Electrónica, ETSIS de Telecomunicación, Campus Sur, Universidad Politécnica de Madrid, Calle Nikola Tesla, Madrid, 28031, Spain, 34 910673316, marialuisa.martinr@upm.es %K serious games %K central auditory processing disorder %K process mining %K screening %K school environment %K children %D 2023 %7 26.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Currently, many central auditory processing disorder screening tests are available for children, and serious games (SGs) are frequently used as a tool for the diagnosis of different neural deficits and disorders in health care. However, it has not been possible to find a proposal that unifies both ideas. In addition, the validation and improvement of SGs, in general, does not take into account the player-game interaction, thus omitting valuable information about the playability and usability of the game. Objective: This study presented Amalia’s Planet, a game conceived for use in school environments, which allows a first assessment of a child through their performance of the proposed tasks related to different aspects of auditory performance. In addition, the game defines a series of events in relation to the execution of the tasks, which were evaluated for the subsequent optimization of its performance and the improvement of its usability. Methods: Using screening tools based on the use of SG technologies, a total of 87 school-age children were evaluated to test the various hypotheses proposed in this study. By grouping users according to whether they had personal history of hearing pathologies, the discriminant power, playability, and usability of the final solution were examined using traditional statistical techniques and process mining (PM) algorithms. Results: With a confidence level of 80% for test 2 (P=.19), there was no statistical evidence to reject the null hypothesis that a player’s performance is affected by whether the player had a previous auditory pathology. Furthermore, the tool allowed the screening of 2 players initially categorized as healthy because of their low level of performance in the tests and the similarity of their behavior with that of the group of children with a previous pathology. With regard to the validation of the proposed solution, the use of PM techniques made it possible to detect the existence of events that lasted too long, which can lead to player frustration, and to discover small structural flaws in the game. Conclusions: SGs seem to be an appropriate tool for the screening of children at risk of central auditory processing disorder. Moreover, the set of PM techniques provides a reliable source of information regarding the playability and usability of the solution to the development team, allowing its continuous optimization. %M 37099359 %R 10.2196/40284 %U https://games.jmir.org/2023/1/e40284 %U https://doi.org/10.2196/40284 %U http://www.ncbi.nlm.nih.gov/pubmed/37099359 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42944 %T Effects of Exergaming on Musculoskeletal Pain in Older Adults: Systematic Review and Meta-analysis %A Mo,Nan %A Feng,Jin yu %A Liu,Hai xia %A Chen,Xiao yu %A Zhang,Hui %A Zeng,Hui %+ Xiangya Nursing School, Central South University, Xiangya School of Medicine, Number 172, Tong zipo Road, Changsha, 410013, China, 86 1 378 615 5688, zenghui@csu.edu.cn %K aged %K exergaming %K pain %K review %K video game %K virtual reality %D 2023 %7 25.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exercise is effective for musculoskeletal pain. However, physical, social, and environmental factors make it difficult for older adults to persist in exercising. Exergaming is a new pathway that combines exercise with gameplay and may be helpful for older adults to overcome these difficulties and engage in regular exercise. Objective: This systematic review aimed to determine the efficacy of exergaming to improve musculoskeletal pain in older adults. Methods: The search was performed in 5 databases (PubMed, Embase, CINAHL, Web of Science, and Cochrane Library). The risk of bias for randomized controlled studies was assessed using the revised Cochrane Risk of Bias tool in randomized trials (RoB 2), and the methodological quality was assessed using the Physiotherapy Evidence-Based Database scale. Standardized mean difference and 95% CI were calculated using fixed-effects model meta-analyses in the Review Manager version 5.3 (RevMan 5.3). Results: Seven randomized controlled studies were included, which contained 264 older adults. Three of the 7 studies reported significant improvements in pain after the exergaming intervention, but only 1 reported a significant difference between groups after adjustment for baseline (P<.05), and another reported a significant improvement in thermal pain between the 2 groups (P<.001). The results of the meta-analysis of the 7 studies showed no statistically significant improvement in pain compared to the control group (standardized mean difference –0.22; 95% CI –0.47 to 0.02; P=.07). Conclusions: Although the effects of exergames on musculoskeletal pain in older adults are unknown, exergame training is generally safe, fun, and appealing to older adults. Unsupervised exercise at home is feasible and cost-effective. However, most of the current studies have used commercial exergames, and it is recommended that there should be more cooperation between industries in the future to develop professional rehabilitation exergames that are more suitable for older adults. The sample sizes of the studies included are small, the risk of bias is high, and the results should be interpreted with caution. Further randomized controlled studies with large sample sizes, high quality, and rigor are needed in the future. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42022342325; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342325 %M 37097717 %R 10.2196/42944 %U https://games.jmir.org/2023/1/e42944 %U https://doi.org/10.2196/42944 %U http://www.ncbi.nlm.nih.gov/pubmed/37097717 %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 e39874 %T Effectiveness of a Personalized, Chess-Based Training Serious Video Game in the Treatment of Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial %A Rodrigo-Yanguas,María %A Martín-Moratinos,Marina %A González-Tardón,Carlos %A Sanchez-Sanchez,Fernando %A Royuela,Ana %A Bella-Fernández,Marcos %A Blasco-Fontecilla,Hilario %+ Servicio de Psiquiatría, Hospital Universitario Puerta de Hierro Majadahonda, C/ Manuel de Falla s/n, Majadahonda, 28222, Spain, 34 911911690, hmblasco@yahoo.es %K attention-deficit hyperactivity disorder %K ADHD %K serious video games %K cognitive training %K chess %K video game %K teen %K young adult %K game %K intervention %K treatment %K emotional %K control %K regulation %K attention %K school %K function %K symptom %D 2023 %7 24.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Compared with traditional approaches, gaming strategies are promising interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). We developed a serious game, The Secret Trail of Moon (TSTM), for ADHD treatment. Objective: The main objective of this clinical trial was to demonstrate the effectiveness of an add-on, either TSTM or Therapeutic Chess (TC), in previously optimally drug-titrated, clinically stable patients with ADHD. Methods: This study is a prospective, unicentric, randomized clinical trial in clinically stable patients with ADHD, aged 12 to 22 years. The TSTM (n=35) and TC groups (n=34) performed 12 weekly sessions of their respective treatments. The control group (CG) patients (n=35) were called by phone every week, but they received no cognitive intervention. The primary end point was the change from baseline to end point in the parent “Behavior Rating Inventory of Executive Function-2” (BRIEF-2; patients’ parents) in the per-protocol population (31 serious videogame: 24 TC and 34 CG). Results: Our study failed to probe clear-cut improvements in the global score of the BRIEF-2. However, the TC group showed improvements in measures of emotional control, emotional regulation, and inattention. The TSTM group showed improvements in measures of emotional regulation, inattention, and school context. Conclusions: TSTM and TC did not improve executive function symptoms, but they improved ADHD symptomatology related to emotional regulation. Further studies with bigger samples are required to confirm these preliminary findings. Trial Registration: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065 %M 37093628 %R 10.2196/39874 %U https://games.jmir.org/2023/1/e39874 %U https://doi.org/10.2196/39874 %U http://www.ncbi.nlm.nih.gov/pubmed/37093628 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 12 %N %P e44135 %T Creation of a Holistic Platform for Health Boosting Using a Blockchain-Based Approach: Development Study %A Lopez-Barreiro,Juan %A Alvarez-Sabucedo,Luis %A Garcia-Soidan,Jose-Luis %A Santos-Gago,Juan M %+ Faculty of Education and Sport Sciences, University of Vigo, Campus A Xunqueira, s/n, Pontevedra, 36005, Spain, 34 610669712, juan.lopez.barreiro@uvigo.es %K blockchain %K exercise %K gamification %K habits %K healthy lifestyle %K physical fitness %D 2023 %7 19.4.2023 %9 Original Paper %J Interact J Med Res %G English %X Background: Low adherence to healthy habits, which is associated with a higher risk of disease and death, among citizens of Organization for Economic Co-operation and Development countries is a serious concern. The World Health Organization (WHO) and the physical activity (PA) guidelines for Americans provide recommendations on PA and healthy diets. To promote these habits, we suggest using a blockchain-based platform, using the PA Messaging Framework to deliver messages and rewards to users. Blockchain is a decentralized secure platform for data management, which can be used for value-added controls and services such as smart contracts (SCs), oracles, and decentralized applications (dApps). Of note, there is a substantial penetration of blockchain technologies in the field of PA, but there is a need for more implementations of dApps to take advantage of features such as nonfungible tokens. Objective: This study aimed to create a comprehensive platform for promoting healthy habits, using scientific evidence and blockchain technology. The platform will use gamification to encourage healthy PA and eating habits; in addition, it will monitor the activities through noninvasive means, evaluate them using open-source software, and follow up through blockchain messages. Methods: A literature search was conducted on the use of blockchain technology in the field of PA and healthy eating. On the basis of the results of this search, it is possible to define an innovative platform for promoting and monitoring healthy habits through health-related challenges on a dApp. Contact with the user will be maintained through messages following a proposed model in the literature to improve adherence to the challenges. Results: The proposed strategy is based on a dApp that relies on blockchain technology. The challenges include PA and healthy eating habits based on the recommendations of the WHO and the Food and Agriculture Organization. The system is constituted of a blockchain network where challenge-related achievements are stored and verified using SCs. The user interacts with the system through a dApp that runs on their local device, monitors the challenge, and self-authenticates by providing their public and private keys. The SC verifies challenge fulfillment and generates messages, and the information stored in the network can be used to encourage competition among participants. The ultimate goal is to create a habit of healthy activities through rewards and peer competition. Conclusions: The use of blockchain technology has the potential to improve people’s quality of life through the development of relevant services. In this work, strategies using gamification and blockchain are proposed for monitoring healthy activities, with a focus on transparency and reward allocation. The results are promising, but compliance with the General Data Protection Regulation is still a concern. Personal data are stored on personal devices, whereas challenge data are recorded on the blockchain. %M 37074766 %R 10.2196/44135 %U https://www.i-jmr.org/2023/1/e44135 %U https://doi.org/10.2196/44135 %U http://www.ncbi.nlm.nih.gov/pubmed/37074766 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43085 %T A Design-Led Theory of Change for a Mobile Game App (Go Nisha Go) for Adolescent Girls in India: Multimix Methodology Study %A Shankar,Lalita %A Dixit,Anvita %A Howard,Susan %+ Howard Delafield International LLP, 1101 30th St NW, Suite 500, Washington, DC, 20007, United States, 1 202 625 4364, lalita@howard-delafield.com %K Theory of Change %K social behavior change %K mobile game app %K digital innovation %K adolescent girls %K sexual and reproductive health %K India %D 2023 %7 18.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: India has one of the largest adolescent populations in the world. Yet adolescents, particularly adolescent girls, have limited access to correct sexual and reproductive health information and services. The context in which adolescent girls live is one of gender inequity where they contend with early marriage and early pregnancy and have few opportunities for quality education and labor force participation. The digital revolution has expanded the penetration of mobile phones across India, increasingly being used by adolescent girls. Health interventions are also moving onto digital platforms. Evidence has shown that applications of game elements and game-based learning can be powerful tools in behavior change and health interventions. This provides a unique opportunity, particularly for the private sector, to reach and empower adolescent girls directly with information, products, and services in a private and fun manner. Objective: The objective of this paper is to describe how a design-led Theory of Change (ToC) was formulated for a mobile game app that is not only underpinned by theories of various behavior change models but also identifies variables and triggers for in-game behavioral intentions that can be tracked and measured within the game and validated through a rigorous post-gameplay outcome evaluation. Methods: We describe the use of a multimix methodology to formulate a ToC informing behavioral frameworks and co-design approaches in our proof-of-concept product development journey. This process created a statement of hypothesis and “pathways to impact” with a continuous, cumulative, and iterative design process that included key stakeholders in the production of a smartphone app. With theoretical underpinnings of social behavior and modeling frameworks, systematic research, and other creative methods, we developed a design-led ToC pathway that can delineate complex and multidisciplinary outputs for measuring impact. Results: The statement of hypothesis that emerged posits that “If girls virtually experience the outcomes of choices that they make for their avatar in the mobile game, then they can make informed decisions that direct the course of their own life.” Four learning pathways (DISCOVER, PLAY, DECIDE, and ACT) are scaffolded on 3 pillars of evidence, engagement, and evaluation to support the ToC-led framework. It informs decision-making and life outcomes through game-based objectives and in-game triggers that offer direct access to information, products, and services. Conclusions: This approach of using a multimix methodology for identifying varied and multidisciplinary pathways to change is of particular interest to measuring the impact of innovations, especially digital products, that do not necessarily conform with traditional behavioral change models or standard co-design approaches. We also explain the benefits of using iterative and cumulative inputs to integrate ongoing user feedback, while identifying pathways to various impacts, and not limiting it to only the design and development phase. %M 37071463 %R 10.2196/43085 %U https://formative.jmir.org/2023/1/e43085 %U https://doi.org/10.2196/43085 %U http://www.ncbi.nlm.nih.gov/pubmed/37071463 %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 e40806 %T Appropriate Image Selection With Virtual Reality in Vestibular Rehabilitation: Cross-sectional Study %A Ersin,Kerem %A Gürlek,Emre %A Güler,Hakan %A Kalaycık Ertugay,Çiğdem %A Şerbetçioğlu,Mustafa Bülent %+ Graduate School of Health Sciences, Istanbul Medipol University, Göztepe Mahallesi Atatürk Caddesi No. 40 Beykoz, Istanbul, 34820, Turkey, 90 507 934 71 16, emregurlek1622@gmail.com %K balance %K computerized dynamic posturography %K stress %K vestibular rehabilitation %K vestibular system %K virtual reality %D 2023 %7 13.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: While vestibular rehabilitation with virtual reality (VR) is becoming more popular every day, the disadvantages of this method are not yet clear. Objective: The aim of this study is to examine the effect of the image to be used in vestibular rehabilitation with VR on the systems that provide body posture. Methods: The study was carried out with 36 participants (18 women and 18 men) aged 18 to 30 years. To assess balance control components separately, a sensory organization test was administered to the participants in the presence of stressful and relaxing environment images with VR technology. The State-Trait Anxiety Inventory survey was also used to measure the stress values in the created environments. Results: The State-Trait Anxiety Inventory survey revealed that while stressful videos significantly increased stress, relaxing videos reduced stress. Among measurements obtained in the presence of VR, significant decreases were observed mostly in the visual system data. A significant increase in vestibular system data (P=.01) was observed with a decrease in visual system data (P<.001) when the relaxing image was presented. Additionally, there was a significant difference in the somatosensory (P=.001), composite (P=.002), and visual system (P<.001) data in the presence of stressful videos. Conclusions: Although the use of a VR system for vestibular rehabilitation is relatively new, no extant studies have examined how the image type used in VR can affect the integration of visual system data. Therefore, this study is unique in terms of showing the effects of the stress created by the change in the type of the image used in VR. When VR technology is used for therapeutic vestibular rehabilitation for patients whose balance disorder is due to the vestibular system, stress-free videos should be used. However, the use of stressful videos in VR technology will be beneficial in the rehabilitation of those with balance disorders due to the somatosensory system. %M 37052976 %R 10.2196/40806 %U https://games.jmir.org/2023/1/e40806 %U https://doi.org/10.2196/40806 %U http://www.ncbi.nlm.nih.gov/pubmed/37052976 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43607 %T Serious Games for Learning Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Abuelezz,Israa %A AlSaad,Rawan %A Al-Jafar,Eiman %A Ahmed,Arfan %A Aziz,Sarah %A Nashwan,Abdulqadir %A Sheikh,Javaid %+ AI Center for Precision Health, Weill Cornell Medicine-Qatar, 202 A15, Ezdan Oasis, Doha, Qatar, 974 55708549, alaa_alzoubi88@yahooo.com %K serious games %K cognitive training %K learning %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K learning %K systematic reviews %K meta-analysis %K mobile phone %D 2023 %7 12.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Learning disabilities are among the major cognitive impairments caused by aging. Among the interventions used to improve learning among older adults are serious games, which are participative electronic games designed for purposes other than entertainment. Although some systematic reviews have examined the effectiveness of serious games on learning, they are undermined by some limitations, such as focusing on older adults without cognitive impairments, focusing on particular types of serious games, and not considering the comparator type in the analysis. Objective: This review aimed to evaluate the effectiveness of serious games on verbal and nonverbal learning among older adults with cognitive impairment. Methods: Eight electronic databases were searched to retrieve studies relevant to this systematic review and meta-analysis. Furthermore, we went through the studies that cited the included studies and screened the reference lists of the included studies and relevant reviews. Two reviewers independently checked the eligibility of the identified studies, extracted data from the included studies, and appraised their risk of bias and the quality of the evidence. The results of the included studies were summarized using a narrative synthesis or meta-analysis, as appropriate. Results: Of the 559 citations retrieved, 11 (2%) randomized controlled trials (RCTs) ultimately met all eligibility criteria for this review. A meta-analysis of 45% (5/11) of the RCTs revealed that serious games are effective in improving verbal learning among older adults with cognitive impairment in comparison with no or sham interventions (P=.04), and serious games do not have a different effect on verbal learning between patients with mild cognitive impairment and those with Alzheimer disease (P=.89). A meta-analysis of 18% (2/11) of the RCTs revealed that serious games are as effective as conventional exercises in promoting verbal learning (P=.98). We also found that serious games outperformed no or sham interventions (4/11, 36%; P=.03) and conventional cognitive training (2/11, 18%; P<.001) in enhancing nonverbal learning. Conclusions: Serious games have the potential to enhance verbal and nonverbal learning among older adults with cognitive impairment. However, our findings remain inconclusive because of the low quality of evidence, the small sample size in most of the meta-analyzed studies (6/8, 75%), and the paucity of studies included in the meta-analyses. Thus, until further convincing proof of their effectiveness is offered, serious games should be used to supplement current interventions for verbal and nonverbal learning rather than replace them entirely. Further studies are needed to compare serious games with conventional cognitive training and conventional exercises, as well as different types of serious games, different platforms, different intervention periods, and different follow-up periods. Trial Registration: PROSPERO CRD42022348849; https://tinyurl.com/y6yewwfa %M 37043277 %R 10.2196/43607 %U https://www.jmir.org/2023/1/e43607 %U https://doi.org/10.2196/43607 %U http://www.ncbi.nlm.nih.gov/pubmed/37043277 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43904 %T Co-design of a Virtual Reality Cognitive Remediation Program for Depression (bWell-D) With Patient End Users and Clinicians: Qualitative Interview Study Among Patients and Clinicians %A Hernandez Hernandez,Maria Elena %A Michalak,Erin %A Choudhury,Nusrat %A Hewko,Mark %A Torres,Ivan %A Menon,Mahesh %A Lam,Raymond W %A Chakrabarty,Trisha %+ University of British Columbia, Faculty of Medicine, Department of Psychiatry, 2255 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 822 7314, elena.hernandez@ntnu.no %K depression %K cognitive remediation %K cognitive dysfunction %K thematic analysis %K virtual reality %K VR %K qualitative study %K user-centered design %K immersive %K co-design %K depressive %K mental health %K mental illness %D 2023 %7 7.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction—a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation. Objective: This study aimed to develop the first prototype VR cognitive remediation program for MDD (“bWell-D”). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings. Methods: Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants’ perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis. Results: End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid (ie, home and clinic) treatment modality was preferred. Conclusions: Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes. %M 37027183 %R 10.2196/43904 %U https://games.jmir.org/2023/1/e43904 %U https://doi.org/10.2196/43904 %U http://www.ncbi.nlm.nih.gov/pubmed/37027183 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45833 %T An Evidence-Based Serious Game App for Public Education on Antibiotic Use and Antimicrobial Resistance: Protocol of a Randomized Controlled Trial %A Huang,Zhilian %A Tang,Wern Ee %A Guo,Huiling %A Natarajan,Karthiga %A Lee,Tau Hong %A Yeo,Tsin Wen %A Chow,Angela %+ Infectious Diseases Research and Training Office, National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, Singapore, 308433, Singapore, 65 65115076, zhilian_huang@ttsh.com.sg %K antibiotic resistance %K antibiotic use %K app development %K development %K educational intervention %K health education %K public education %K randomized controlled trial %K serious games %K user engagement %K user satisfaction %D 2023 %7 28.3.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: The misuse and overuse of antibiotics contribute to the acceleration of antimicrobial resistance (AMR), but public knowledge on appropriate antibiotic use and AMR remained low despite ongoing health promotion efforts. App gamification has gained traction in recent years for health promotion and to affect change in health behaviors. Hence, we developed an evidence-based serious game app “SteWARdS Antibiotic Defence” to educate the public on appropriate antibiotic use and AMR and address knowledge gaps. Objective: We aim to evaluate the effectiveness of the “SteWARdS Antibiotic Defence” app in improving the knowledge of, attitude toward, and perception (KAP) of appropriate antibiotic use and AMR among the public. The primary objective is to assess the changes in KAP of antibiotic use and AMR in our participants, while the secondary objectives are to assess the extent of user engagement with the app and the level of user satisfaction in using the app. Methods: Our study is a parallel 2-armed randomized controlled trial with a 1:1 allocation. We plan to recruit 400 participants (patients or their caregivers) aged 18-65 years from government-funded primary care clinics in Singapore. Participants are randomized in blocks of 4 and into the intervention or control group. Participants in the intervention group are required to download the “SteWARdS Antibiotic Defence” app on their smartphones and complete a game quest within 2 weeks. Users will learn about appropriate antibiotic use and effective methods to recover from uncomplicated upper respiratory tract infections by interacting with the nonplayer characters and playing 3 minigames in the app. The control group will not receive any intervention. Results: The primary study outcome is the change in participants’ KAP toward antibiotic use and AMR 6-10 weeks post intervention or 6-10 weeks from baseline for the control group (web-based survey). We will also assess the knowledge level of participants immediately after the participant completes the game quest (in the app). The secondary study outcomes are the user engagement level (tracked by the app) and satisfaction level of playing the game (via the immediate postgame survey). The satisfaction survey will also collect participants’ feedback on the game app. Conclusions: Our proposed study provides a unique opportunity to assess the effectiveness of a serious game app in public health education. We anticipate possible ceiling effects and selection bias in our study and have planned to perform subgroup analyses to adjust for confounding factors. The app intervention will benefit a larger population if it is proven to be effective and acceptable to users. Trial Registration: ClinicalTrials.gov NCT05445414; https://clinicaltrials.gov/ct2/show/NCT05445414 International Registered Report Identifier (IRRID): DERR1-10.2196/45833 %M 36976619 %R 10.2196/45833 %U https://www.researchprotocols.org/2023/1/e45833 %U https://doi.org/10.2196/45833 %U http://www.ncbi.nlm.nih.gov/pubmed/36976619 %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 e38493 %T Evaluating the Utility of a Psychoeducational Serious Game (SPARX) in Protecting Inuit Youth From Depression: Pilot Randomized Controlled Trial %A Bohr,Yvonne %A Litwin,Leah %A Hankey,Jeffrey Ryan %A McCague,Hugh %A Singoorie,Chelsea %A Lucassen,Mathijs F G %A Shepherd,Matthew %A Barnhardt,Jenna %+ LaMarsh Centre for Child and Youth Research, York University, 4700 Keele Street, Toronto, ON, M3J1P3, Canada, 1 6475616464, jrhankey@yorku.ca %K psychoeducation %K cognitive behavioral therapy %K Inuit youth %K Nunavut %K depression %K suicide %K resilience %K serious game %K youth %K mental health %K teen %K adolescent %K pilot study %K community %D 2023 %7 9.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Inuit youth in Northern Canada show considerable resilience in the face of extreme adversities. However, they also experience significant mental health needs and some of the highest adolescent suicide rates in the world. Disproportionate rates of truancy, depression, and suicide among Inuit adolescents have captured the attention of all levels of government and the country. Inuit communities have expressed an urgent imperative to create, or adapt, and then evaluate prevention and intervention tools for mental health. These tools should build upon existing strengths, be culturally appropriate for Inuit communities, and be accessible and sustainable in Northern contexts, where mental health resources are often scarce. Objective: This pilot study assesses the utility, for Inuit youth in Canada, of a psychoeducational e-intervention designed to teach cognitive behavioral therapy strategies and techniques. This serious game, SPARX, had previously demonstrated effectiveness in addressing depression with Māori youth in New Zealand. Methods: The Nunavut Territorial Department of Health sponsored this study, and a team of Nunavut-based community mental health staff facilitated youth’s participation in an entirely remotely administered pilot trial using a modified randomized control approach with 24 youths aged 13-18 across 11 communities in Nunavut. These youth had been identified by the community facilitators as exhibiting low mood, negative affect, depressive presentations, or significant levels of stress. Entire communities, instead of individual youth, were randomly assigned to an intervention group or a waitlist control group. Results: Mixed models (multilevel regression) revealed that participating youth felt less hopeless (P=.02) and engaged in less self-blame (P=.03), rumination (P=.04), and catastrophizing (P=.03) following the SPARX intervention. However, participants did not show a decrease in depressive symptoms or an increase in formal resilience indicators. Conclusions: Preliminary results suggest that SPARX may be a good first step for supporting Inuit youth with skill development to regulate their emotions, challenge maladaptive thoughts, and provide behavioral management techniques such as deep breathing. However, it will be imperative to work with youth and communities to design, develop, and test an Inuit version of the SPARX program, tailored to fit the interests of Inuit youth and Elders in Canada and to increase engagement and effectiveness of the program. Trial Registration: ClinicalTrials.gov NCT05702086; https://www.clinicaltrials.gov/ct2/show/NCT05702086 %M 36892940 %R 10.2196/38493 %U https://games.jmir.org/2023/1/e38493 %U https://doi.org/10.2196/38493 %U http://www.ncbi.nlm.nih.gov/pubmed/36892940 %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 11 %N %P e40054 %T A Software Engineering Framework for Reusable Design of Personalized Serious Games for Health: Development Study %A Carlier,Stéphanie %A Naessens,Vince %A De Backere,Femke %A De Turck,Filip %+ Internet Technology and Data Science Lab, Faculty of Engineering and Architecture, Ghent University, Technologiepark-Zwijnaarde 126, Ghent, 9052, Belgium, 32 9 331 49 38, stephanie.carlier@ugent.be %K serious game %K health care %K personalization %K domain knowledge %K framework %K eHealth %K cocreation %D 2023 %7 6.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of serious games in health care is on the rise, as these games motivate treatment adherence, reduce treatment costs, and educate patients and families. However, current serious games fail to offer personalized interventions, ignoring the need to abandon the one-size-fits-all approach. Moreover, these games, with a primary objective other than pure entertainment, are costly and complex to develop and require the constant involvement of a multidisciplinary team. No standardized approach exists on how serious games can be personalized, as existing literature focuses on specific use cases and scenarios. The serious game development domain fails to consider any transfer of domain knowledge, which means this labor-intensive process must be repeated for each serious game. Objective: We proposed a software engineering framework that aims to streamline the multidisciplinary design process of personalized serious games in health care and facilitates the reuse of domain knowledge and personalization algorithms. By focusing on the transfer of knowledge to new serious games by reusing components and personalization algorithms, the comparison and evaluation of different personalization strategies can be simplified and expedited. In doing so, the first steps are taken in advancing the state of the art of knowledge regarding personalized serious games in health care. Methods: The proposed framework aimed to answer 3 questions that need to be asked when designing personalized serious games: Why is the game personalized? What parameters can be used for personalization? and How is the personalization achieved? The 3 involved stakeholders, namely, the domain expert, the (game) developer, and the software engineer, were each assigned a question and then assigned responsibilities regarding the design of the personalized serious game. The (game) developer was responsible for all the game-related components; the domain expert was in charge of the modeling of the domain knowledge using simple or complex concepts (eg, ontologies); and the software engineer managed the personalization algorithms or models integrated into the system. The framework acted as an intermediate step between game conceptualization and implementation; it was illustrated by developing and evaluating a proof of concept. Results: The proof of concept, a serious game for shoulder rehabilitation, was evaluated using simulations of heart rate and game scores to assess how personalization was achieved and whether the framework responded as expected. The simulations indicated the value of both real-time and offline personalization. The proof of concept illustrated how the interaction between different components worked and how the framework was used to simplify the design process. Conclusions: The proposed framework for personalized serious games in health care identifies the responsibilities of the involved stakeholders in the design process, using 3 key questions for personalization. The framework focuses on the transferability of knowledge and reusability of personalization algorithms to simplify the design process of personalized serious games. %M 36877554 %R 10.2196/40054 %U https://games.jmir.org/2023/1/e40054 %U https://doi.org/10.2196/40054 %U http://www.ncbi.nlm.nih.gov/pubmed/36877554 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e39543 %T Gamified Physical Rehabilitation for Older Adults With Musculoskeletal Issues: Pilot Noninferiority Randomized Clinical Trial %A Randriambelonoro,Mirana %A Perrin Franck,Caroline %A Herrmann,François %A Carmona,Gorki Antonio %A Geissbuhler,Antoine %A Graf,Christophe %A Frangos,Emilia %+ HI5Lab, Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Chemin des Mines 9, Geneva, 1202, Switzerland, 41 22 379 08 29, mirana.randriambelonoro@unige.ch %K rehabilitation %K gamification %K emerging technologies %K experimental %K randomized controlled trial %K mobility %K device %K musculoskeletal %K older patients %K elderly %K aging %K functionality %K physical therapy %K computer-aided %K intervention %K serious games %D 2023 %7 6.3.2023 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Resource-rich countries are facing the challenge of aging societies, a high risk of dependence, and a high cost of care. Researchers attempted to address these issues by using cost-efficient, innovative technology to promote healthy aging and regain functionality. After an injury, efficient rehabilitation is crucial to promote returning home and prevent institutionalization. However, there is often a lack of motivation to carry out physical therapies. Consequently, there is a growing interest in testing new approaches like gamified physical rehabilitation to achieve functional targets and prevent rehospitalization. Objective: The purpose of this study is to assess the effectiveness of a personal mobility device compared with standard care in the rehabilitation treatment of patients with musculoskeletal issues. Methods: A total of 57 patients aged 67-95 years were randomly assigned to the intervention group (n=35) using the gamified rehabilitation equipment 3 times a week or to the control group (n=22) receiving usual standard care. Due to dropout, only 41 patients were included in the postintervention analysis. Outcome measures included the short physical performance battery (SPPB), isometric hand grip strength (IHGS), functional independence measure (FIM), and the number of steps. Results: A noninferiority related to the primary outcome (SPPB) was identified during the hospital stay, and no significant differences were found between the control and intervention groups for any of the secondary outcomes (IHGS, FIM, or steps), which demonstrates the potential of the serious game-based intervention to be as effective as the standard physical rehabilitation at the hospital. The analysis by mixed-effects regression on SPPB showed a group×time interaction (SPPB_I_t1=–0.77, 95% CI –2.03 to 0.50, P=.23; SPPB_I_t2=0.21, 95% CI –1.07 to 0.48, P=.75). Although not significant, a positive IHGS improvement of more than 2 kg (Right: 2.52 kg, 95% CI –0.72 to 5.37, P=.13; Left: 2.43 kg, 95% CI –0.18 to 4.23, P=.07) for the patient from the intervention group was observed. Conclusions: Serious game-based rehabilitation could potentially be an effective alternative for older patients to regain their functional capacities. Trial Registration: ClinicalTrials.gov NCT03847454; https://clinicaltrials.gov/ct2/show/NCT03847454 %M 36877563 %R 10.2196/39543 %U https://rehab.jmir.org/2023/1/e39543 %U https://doi.org/10.2196/39543 %U http://www.ncbi.nlm.nih.gov/pubmed/36877563 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40651 %T Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke %A Stammler,Britta %A Flammer,Kathrin %A Schuster,Thomas %A Lambert,Marian %A Karnath,Hans-Otto %+ Center of Neurology, Division of Neuropsychology, University of Tübingen, Hoppe-Seyler-Strasse 3, Tübingen, 72076, Germany, 49 7071 29 80467, Karnath@uni-tuebingen.de %K spatial neglect %K gamification %K augmented reality %K visual exploration training %K stroke rehabilitation %K serious games %K rehabilitation %K stroke %D 2023 %7 27.2.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is “visual exploration training.” Patients improve their ipsilesional bias of attention and orientation by training exploration movements and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality. Objective: This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk. Methods: The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed by various questionnaires. Results: Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions of motivation, satisfaction, and fun. Conclusions: The Negami app represents a promising extension by adding AR to traditional exploration training for spatial neglect. Through participants’ natural interaction with the physical surrounding environment during playful tasks, side effects as symptoms of cybersickness are minimized and patients’ motivation appeared to markedly increase. The use of AR in cognitive rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation. %M 36848215 %R 10.2196/40651 %U https://games.jmir.org/2023/1/e40651 %U https://doi.org/10.2196/40651 %U http://www.ncbi.nlm.nih.gov/pubmed/36848215 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e38350 %T Diversity in Stakeholder Groups in Generative Co-design for Digital Health: Assembly Procedure and Preliminary Assessment %A Vandekerckhove,Pieter %A Timmermans,Job %A de Bont,Antoinette %A de Mul,Marleen %+ Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, Rotterdam, 3062PA, Netherlands, 31 10 408 8555, vandekerckhove@eshpm.eur.nl %K collaborative design %K design methodology %K stakeholder involvement %K participatory design %K digital health %D 2023 %7 14.2.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Diverse knowledge and ways of thinking are claimed to be important when involving stakeholders such as patients, care professionals, and care managers in a generative co-design (GCD) process. However, this claim is rather general and has not been operationalized; therefore, the influence of various stakeholders on the GCD process has not been empirically tested. Objective: In this study, we aimed to take the first step in assessing stakeholder diversity by formulating a procedure to assemble a group of diverse stakeholders and test its influence in a GCD process. Methods: To test the procedure and assess its influence on the GCD process, a case was selected involving a foundation that planned to develop a serious game to help people with cancer return to work. The procedure for assembling a stakeholder group involves snowball sampling and individual interviews, leading to the formation of 2 groups of stakeholders. Thirteen people were identified through snowball sampling, and they were briefly interviewed to assess their knowledge, inference experience, and communication skills. Two diverse stakeholder groups were formed, with one more potent than the other. The influence of both stakeholder groups on the GCD process was qualitatively assessed by comparing the knowledge output and related knowledge processing in 2 identical GCD workshops. Results: Our hypothesis on diverse stakeholders was confirmed, although it also appeared that merely assessing the professional background of stakeholders was not sufficient to reach the full potential of the GCD process. The more potently diverse group had a stronger influence on knowledge output and knowledge processing, resulting in a more comprehensive problem definition and more precisely described solutions. In the less potently diverse group, none of the stakeholders had experience with abduction-2 inferencing, and this did not emerge in the GCD process, suggesting that at least one stakeholder should have previous abduction-2 experience. Conclusions: A procedure to assemble a stakeholder group with specific criteria to assess the diversity of knowledge, ways of thinking, and communication can improve the potential of the GCD process and the resulting digital health. %M 36787170 %R 10.2196/38350 %U https://humanfactors.jmir.org/2023/1/e38350 %U https://doi.org/10.2196/38350 %U http://www.ncbi.nlm.nih.gov/pubmed/36787170 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40350 %T A Serious Game About Hematology for Health Care Workers (SUPER HEMO): Development and Validation Study %A Perrin,Julien %A Meeus,Amélie %A Broseus,Julien %A Morieux,Pierre-Jean %A Di Ceglie,Valentine %A Gravoulet,Julien %A D'Aveni,Maud %+ Faculté de Médecine, Maïeutique et Métiers de la Santé, Université de Lorraine, 9 avenue de la Forêt de Haye, Vandoeuvre-Lès-Nancy, 54505, France, 33 383153289, m.daveni-piney@chru-nancy.fr %K educational technology %K hematology %K health care students %K education %K teaching %K validation %K methodological study %K video support tool %K continuing education %K serious games %K educational games %D 2023 %7 13.2.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Complete blood count (CBC) and hemostatic screening tests are among the most commonly prescribed blood tests worldwide. All health care workers (nurse practitioners, pharmacists, dentists, midwives, and physicians) are expected to correctly interpret the results in their daily practice. Currently, the undergraduate hematology curriculum consists predominantly of lecture-based teaching. Because hematology combines basic science (blood cells and hemostasis physiology) and clinical skills, students report that they do not easily master hematology with only lecture-based teaching. Having interviewed students at the University of Lorraine, we considered it necessary to develop new teaching approaches and methods. Objective: We aimed to develop and validate a serious game about CBC analysis for health care students. Our primary objective was to help students perceive hematology as being a playful and easy topic and for them to feel truly involved in taking care of their patients by analyzing blood tests. We considered that this game-based approach would be attractive to students as an addition to the classic lecture-based approach and improve their knowledge and skills in hematology. Methods: We developed an adventure game called SUPER HEMO, a video game in which the player assumes the role of a protagonist in an interactive story driven by exploration and problem-solving tests. Following validation with beta testing by a panel of volunteer students, we used a novel, integrated teaching approach. We added 1.5 hours of gaming to the standard curriculum for a small group of volunteer students. Physician and pharmacy students in their third year at a single French university were invited to attend this extracurricular course. Pregame and postgame tests and satisfaction surveys were immediately recorded. Final hematology exam results were analyzed. Results: A total of 86 of 324 physician students (26.5%) and 67 of 115 pharmacy students (58%) opted to participate. Median scores on the pre- and posttests were 6 out of 10 versus 7 out of 10, respectively, for the physician students, (P<.001) and 7.5 out of 10 versus 8 out of 10, respectively, for the pharmacy students (P<.001). At the final hematology evaluation, physician students who played SUPER HEMO had a slightly better median score than those who did not: 13 out of 20 versus 12 out of 20, respectively (P=.002). Pharmacy students who played SUPER HEMO had a median score of 21.75 out of 30; this was not significantly different from pharmacy students who did not play SUPER HEMO (20/30; P=.12). Among the participants who answered the survey (n=143), more than 86% (123/143) believed they had strengthened their knowledge and nearly 80% (114/143) of them had fun. Conclusions: Feedback from this game session provided evidence to support the integration of interactive teaching methods in undergraduate hematology teaching. The development of SUPER HEMO is intended to be completed so that it can become a support tool for continuing education. %M 36780215 %R 10.2196/40350 %U https://games.jmir.org/2023/1/e40350 %U https://doi.org/10.2196/40350 %U http://www.ncbi.nlm.nih.gov/pubmed/36780215 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e36126 %T Measured and Perceived Exercise Intensity During the Performance of Single-Task, Cognitive-Motor Dual-Task, and Exergame Training: Transversal Study %A Gallou-Guyot,Matthieu %A Perrochon,Anaick %A Marie,Romain %A Bourgeois,Maxence %A Mandigout,Stephane %+ HAVAE, UR 20217, Université de Limoges, 123, avenue Albert Thomas, Limoges, F–87000, France, 33 607087516, matthieu.gallou.guyot@gmail.com %K exergame %K dual-task %K exercise intensity %K heart rate %K cognitive load %K active video game %K physical activity %D 2023 %7 2.2.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The physical and cognitive loads borne during exergaming may differ from more conventional cognitive-motor dual-task trainings. Objective: The aim of this pilot transversal study was to compare objectively measured and perceived exercise intensity during exergame, cognitive-motor dual-task, and single-task training sessions. Methods: We recruited apparently healthy young adults who carried out one session of each type of training: exergaming, cognitive-motor dual-tasking, and single-tasking. We used a custom-made exergame as support. The sessions lasted 30 minutes, were spaced at least 24 hours apart, and took place in random order for each group of 4 participants. We used heart rates to assess exercise intensity and the modified Borg scale to assess perception of intensity. In all, 16 apparently healthy young participants carried out all sessions. Results: There was no difference between the different types of training in mean heart rates (P=.27), peak heart rates (P=.50), or Borg scale scores (P=.40). Our custom-made exergame’s objectively measured and perceived physical load did not differ between cognitive-motor dual-task and single-task training. Conclusions: As a result, our exergame can be considered to be as challenging as more traditional physical training. Future studies should be conducted in older adults with or without cognitive impairments and incorporate an assessment of cognitive performance. %M 36729572 %R 10.2196/36126 %U https://games.jmir.org/2023/1/e36126 %U https://doi.org/10.2196/36126 %U http://www.ncbi.nlm.nih.gov/pubmed/36729572 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e39975 %T Engagement With Gamification Elements in a Smoking Cessation App and Short-term Smoking Abstinence: Quantitative Assessment %A Rajani,Nikita B %A Bustamante,Luz %A Weth,Dominik %A Romo,Lucia %A Mastellos,Nikolaos %A Filippidis,Filippos T %+ Department of Primary Care and Public Health, Imperial College London, St Dunstan's Road, London, W6 8RP, United Kingdom, 44 7427615928, nikita.rajani14@imperial.ac.uk %K gamification %K smoking cessation %K smoking abstinence %K mHealth %K mobile apps %K mobile phone %K smartphone %K digital health %K user engagement %K cognitive outcome %K self-support %K in-app metrics %D 2023 %7 1.2.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification in smoking cessation apps has been found to improve cognitive outcomes associated with higher odds of quitting. Although some research has shown that gamification can also positively impact behavioral outcomes such as smoking cessation, studies have largely focused on physical activity and mental health. Only a few studies have explored the effects of gamification on smoking cessation outcomes, of which the majority have adopted qualitative methodologies and/or assessed engagement with apps using self-report. Objective: This study aimed to explore levels of user engagement with gamification features in a smoking cessation app via in-app metrics. Specifically, the objective of this paper was to investigate whether higher engagement with gamification features is associated with the likelihood of quitting in the short term. Methods: Data from a larger online study that recruited smokers seeking to quit were analyzed to address the objectives presented in this paper. The study took place between June 2019 and July 2020, and participants were primarily recruited via social media posts. Participants who met the eligibility criteria used 1 of 2 mobile apps for smoking cessation. In-app metrics shared by the developer of one of the smoking cessation apps, called Kwit, were used to assess engagement with gamification features. Out of 58 participants who used the Kwit app, 14 were excluded due to missing data or low engagement with the app (ie, not opening the app once a week). For the remaining 44 participants, mean (SD) values were calculated for engagement with the app using in-app metrics. A logistic regression model was used to investigate the association between engagement with gamification and 7-day smoking abstinence. Results: In total, data from 44 participants who used the Kwit app were analyzed. The majority of participants were male, married, and employed. Almost 30% (n=13) of participants self-reported successful 7-day abstinence at the end of the study. On average, the Kwit app was opened almost 31 (SD 39) times during the 4-week study period, with the diary feature used the most often (mean 22.8, SD 49.3). Moreover, it was found that each additional level unlocked was associated with approximately 22% higher odds of achieving 7-day abstinence after controlling for other factors such as age and gender (odds ratio 1.22, 95% CI 1.01-1.47). Conclusions: This study highlights the likely positive effects of certain gamification elements such as levels and achievements on short-term smoking abstinence. Although more robust research with a larger sample size is needed, this research highlights the important role that gamification features integrated into mobile apps can play in facilitating and supporting health behavior change. %M 36724003 %R 10.2196/39975 %U https://games.jmir.org/2023/1/e39975 %U https://doi.org/10.2196/39975 %U http://www.ncbi.nlm.nih.gov/pubmed/36724003 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 6 %N %P e32282 %T Gamification to Support Adherence to a Therapeutic Ambylopia Treatment for Children: Retrospective Study Using a Focal Ambient Visual Acuity Stimulation Game %A Bocqué,Catheline %A Wang,Jingyun %A Rickmann,Annekatrin %A Julich-Haertel,Henrike %A Kaempf,Uwe %A Januschowski,Kai %+ Klaus Heimann Eye Research Institute, An der Klinik 10, Sulzbach, 66280, Germany, 49 6897 574 1119, cathelinebocque@gmail.com %K amblyopia %K children %K compliance %K adherence %K occlusion %K patching %K therapeutic game %K FAVAS %D 2023 %7 1.2.2023 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: The gold standard treatment for amblyopia is patching the better eye. Improvement of visual acuity in the amblyopic eye is significantly impacted by the adherence to the patching therapy. It is known that the overall adherence is rather low. Objective: This retrospective study evaluated whether an updated version of attention-binding digital therapeutic games based on the principle of focal ambient visual acuity stimulation (FAVAS) would result in improved patient adherence in 4- to 16-year-old patients with amblyopia associated with anisometropia or strabismus. Methods: We analyzed electronically pseudonymized recorded data from patients treated with occlusion therapy and FAVAS therapeutic games. One group used an older version (2015) and the other group used a newer version (2020) that provided more attractive therapeutic games with tablet computer functionality. Objective adherence was calculated by comparing the number of minutes using the therapeutic games as monitored in the automatized logbook versus the prescribed number of minutes for using the games. Results: Children in group 2015 (n=138) spent on average 2009.3 (SD 1372.1; range 36-5556) minutes using FAVAS; children in group 2020 (n=129) spent on average 2651.2 (SD 1557.1; range 38-5672) minutes using the newer version. Group 2020 spent on average 641.9 more minutes on FAVAS than group 2015 (t255.49=3.56, P<.001, d=0.45; 95% CI 0.69-0.20). Although patient adherence was very variable, compared to the 55.0% (SD 29.4%) in group 2015, it significantly improved up to 68.5% (SD 33.7%) in group 2020 (t254.38=3.48, P=.001, d=0.44; 95% CI 0.68-0.19). Conclusions: FAVAS 2020, with improved gamification aspect as well as tablet computer functionality, increased adherence significantly compared to the earlier version of FAVAS 2015, indicating that FAVAS 2020 could be an effective approach to support adherence to amblyopia treatment. Trial Registration: German Clinical Trials Register (DRKS) DRKS00017633; https://drks.de/search/de/trial/DRKS00017633 %M 36724007 %R 10.2196/32282 %U https://pediatrics.jmir.org/2023/1/e32282 %U https://doi.org/10.2196/32282 %U http://www.ncbi.nlm.nih.gov/pubmed/36724007 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40130 %T Role of Gaming Devices Associated With Internet Gaming Disorder in China: Cross-sectional Study %A Li,Yifan %A Tang,Ying %A Huang,Shucai %A Tan,Linxiang %A Huang,Qiuping %A Chen,Xinxin %A Lin,Shuhong %A Hao,Jingyue %A Liao,Zhenjiang %A Shen,Hongxian %+ Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011, China, 86 13875970393, shenhx2018@csu.edu.cn %K internet gaming disorder %K gaming device %K gaming motivation %K personality traits %K gaming use characteristics %D 2023 %7 16.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Chinese gamers use computer and mobile phone games widely. Consequently, concerns regarding the development of internet gaming disorder (IGD) in adolescents have been raised. However, only a few studies have focused on the influence of gaming devices on IGD. Objective: This study aims to compare sociodemographic information, gaming use characteristics, personality traits, and gaming motivations between computer game users (CGUs) and mobile phone game users (MGUs), as well as identifying IGD predictors. Methods: This was a cross-sectional study. A total of 3593 internet game players took part in an online survey, which included sociodemographic information, gaming patterns, gaming motivations, the Chinese version of the Video Game Dependency Scale, and the Chinese Big Five Personality Inventory brief version. The population was divided into 2 groups for comparison by mobile phone or computer use, and the IGD population was also compared within the 2 groups. Results: There were significant differences between the 2 gaming device groups in the time (t2994=7.75, P<.001) and money (t2994=5.11, P<.001) spent on gaming and in internet game addiction scores (t2994=3.68, P<.001). Individuals using different gaming devices had different game motivations and personality traits and preferred different genres of games. Results showed that IGD predictors were different for the 2 groups, for example, strategy (odds ratio [OR] 4.452, 95% CI 1.938-10.227; P<.001) and action shooter (OR 3.725, 95% CI 1.465-9.474; P=.01) games increased the risk for MGUs. Conclusions: Gaming devices should be considered during early identification, such as long daily gaming time, much money spent on gaming, neuroticism, and conscientiousness. In addition, more research should be conducted on new gaming devices and IGD treatment. %M 36645700 %R 10.2196/40130 %U https://games.jmir.org/2023/1/e40130 %U https://doi.org/10.2196/40130 %U http://www.ncbi.nlm.nih.gov/pubmed/36645700 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e34586 %T Preference of Virtual Reality Games in Psychological Pressure and Depression Treatment: Discrete Choice Experiment %A Jin,Shan %A Tan,Zijian %A Liu,Taoran %A Chan,Sze Ngai %A Sheng,Jie %A Wong,Tak-hap %A Huang,Jian %A Zhang,Casper J P %A Ming,Wai-Kit %+ Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Room 1A-503, 5/F, Block 1, To Yuen Building, 31 To Yuen Street, Hong Kong, China (Hong Kong), 852 34426956, wkming2@cityu.edu.hk %K virtual reality %K discrete choice experiment %K college student %K depression therapy %D 2023 %7 16.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) can be used to build many different scenes aimed at reducing study-related stress. However, only few academic experiments on university students for preference testing have been performed. Objective: This study aims to assess the preference of VR games for stress and depression treatment using a discrete choice experiment (DCE). Methods: A total of 5 different attributes were selected based on the depression therapy parameters and attributes related to VR: (1) treatment modality; (2) therapy duration; (3) perceived remission rate; (4) probability of adverse events; and the (5) monthly cost of adding treatment to a discrete choice experiment. By comparing different attributes and levels, we could draw some conclusions about the depression therapy testing preference for university students; 1 university student was responsible for VR scene development and 1 for participant recruitment. Results: The utility value of different attributes for “0% Probability of adverse events” was higher than others (99.22), and the utility value of VR treatment as the most popular treatment method compared with counseling and medicine treatment was 80.95. Three parameter aspects (different treatments for depression) were statistically significant (P<.001), including “0%” and “50%” of “Probability of adverse events” and “¥500” (a currency exchange rate of ¥1 [Chinese yuan]=US $0.15 is applicable) of “The monthly cost of treatment.” Most individuals preferred 12 months as the therapy duration, and the odds ratio of “12 months” was 1.095 (95% CI 0.945-1.270) when compared with the reference level (6 months). Meanwhile, the cheapest price (¥500) of depression therapy was the optimum choice for most students. Conclusions: People placed great preference on VR technology psychological intervention methods, which indicates that VR may have a potential market in the treatment of psychological problems. However, adverse events and treatment costs need to be considered. This study can be used to guide policies that are relevant to the development of the application of VR technology in the field of psychological pressure and depression treatment. %M 36645698 %R 10.2196/34586 %U https://games.jmir.org/2023/1/e34586 %U https://doi.org/10.2196/34586 %U http://www.ncbi.nlm.nih.gov/pubmed/36645698 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e36110 %T Finding Effective Adjustment Levels for Upper Limb Exergames: Focus Group Study With Children With Physical Disabilities %A Eckert,Martina %A Domingo Soria,Beatriz %A Terroso Gil,Noelia %+ Group of Acoustics and Multimedia Applications, Department ot Audiovisual Engineering, Universidad Politécnica de Madrid, Calle Alan Turing 3, Madrid, 28031, Spain, 34 91 067 87 62, martina.eckert@upm.es %K rehabilitation %K physical therapy %K cerebral palsy %K obstetric brachial plexus palsy %K serious games %K exergames %K Kinect %D 2023 %7 13.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: We developed the Blexer system consisting of a database and a web interface for therapists that can host different types of adaptive and personally configurable virtual reality exergames based on Kinect (Microsoft Corp) motion capture to provide entertaining exercises for children with motor disabilities. It allows for parameter adjustment and the monitoring of results remotely, thereby providing a useful tool to complement traditional physical therapy sessions with home exercises. Objective: The aim of this study was to observe the motor benefits achieved through the use of a video exergame and the importance and implications of correctly setting the game’s difficulty parameters. Methods: This was an observational case study of 6 children with different physical disabilities receiving physical therapy at school combined with the use of a fully configurable exergame under research that forms a part of the Blexer environment. The game integrates 4 repeatedly appearing upper limb exercises with individually adjustable difficulties (intermittent arm rising, arm forward and backward movement, rising and holding of one arm, and trunk control in all directions). The outcomes were 3 assessments of 2 efficacy measures: Box and Block Test and Jebsen Taylor Hand Function Test. Results: A total of 5 children with cerebral palsy (mean 8.4, SD 2.7 years; Gross Motor Function Classification II—2/5, 40%; III—2/5, 40%; and IV—1/5, 20%) and 1 child with obstetric brachial plexus palsy (aged 8 years; Mallet Classification III) received between 8 and 11 sessions of training (10-20 minutes per session), depending on age, motivation, and fatigue. Significant associations were observed between game parameter settings and improvements in motor function, on the one hand, and between the type of improvement and disability severity, on the other: with adjusted game parameters goal and time in the range of 70% to 100%, only less affected children improved in the Box and Block Test (+11 blocks vs −1 block), and more affected children improved more in the Jebsen Taylor Hand Function Test (+90 seconds vs +27 seconds). Conclusions: When defining the difficulty parameters for an exergame, we suggest a classification in levels ranging from very easy to very hard. For practical use, we suggest setting the difficulty for the player to an easy or medium level rather than high-commitment goals, as this leads to a longer playtime with more fun and, therefore, seems to improve the results of the game and, consequently, mobility. %M 36637882 %R 10.2196/36110 %U https://games.jmir.org/2023/1/e36110 %U https://doi.org/10.2196/36110 %U http://www.ncbi.nlm.nih.gov/pubmed/36637882 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e38484 %T Usability of the GAIMplank Video Game Controller for People With Mobility Impairments: Observational Study %A Malone,Laurie A %A Mendonca,Christen J %A Mohanraj,Sangeetha %A Misko,Samuel R %A Moore,Joseph %A Brascome,James Michael %A Thirumalai,Mohanraj %+ School of Health Professions, The University of Alabama at Birmingham, 3810 Ridgeway Dr., Birmingham, AL, 35209, United States, 1 205 934 0142, lamalone@uab.edu %K exergaming %K physical disability %K equipment design %K video gaming %K physical activity %K exercise %K wheelchair %D 2023 %7 10.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Replacing sedentary behaviors during leisure time with active video gaming has been shown to be an enjoyable option for increasing physical activity. However, most off-the-shelf active video gaming controllers are not accessible or usable for individuals with mobility impairments. To address this requirement, a universal video game controller (called the GAIMplank) was designed and developed. Objective: This study aimed to assess the usability of the GAIMplank video game controller for playing PC video games among individuals with mobility impairments. Measures of enjoyment, perceived exertion, and qualitative data on the user experience were also examined. Methods: Adults (aged 18-75 years) with a mobility impairment were recruited to participate in a single testing session in the laboratory. Before testing began, basic demographic information, along with minutes of weekday and weekend physical activity, minutes of weekday and weekend video game play, and video game play experience were collected. The GAIMplank was mapped to operate as a typical joystick controller. Depending on their comfort and functional ability, participants chose to play seated in a chair, standing, or in their own manual wheelchair. Leaning movements of the trunk created corresponding action in the game (ie, lean right to move right). The participants played a total of 5 preselected video games for approximately 5 minutes each. Data were collected to assess the usability of the GAIMplank, along with self-efficacy regarding execution of game play actions, rating of perceived exertion and enjoyment for each game, and overall qualitative feedback. Results: A total of 21 adults (n=15, 71% men; n=6, 29% women) completed the usability testing, with a mean age of 48.8 (SD 13.8; range 21-73) years. Overall, 38% (8/21) of adults played while standing, 33% (7/21) of adults played while seated in a chair, and 29% (6/21) played in their own manual wheelchair. Scores from the System Usability Scale indicated above average (74.8, SD 14.5) usability, with scores best for those who played seated in a chair, followed by those standing, and then individuals who played seated in their own wheelchairs. Inconsistencies in the responsiveness of the controller and general feedback for minor improvements were documented. Rating of perceived exertion scores ranged from light to moderate intensity, with the highest scores for those who played seated in a chair. Participants rated their experience with playing each game from above average to very enjoyable. Conclusions: The GAIMplank video game controller was found to be usable and accessible, providing an enjoyable option for light-to-moderate intensity exercise among adults with mobility impairments. Minor issues with inconsistencies in controller responsiveness were also recorded. Following further development and refinement, the next phase will include a pilot exercise intervention using the GAIMplank system. %M 36626195 %R 10.2196/38484 %U https://games.jmir.org/2023/1/e38484 %U https://doi.org/10.2196/38484 %U http://www.ncbi.nlm.nih.gov/pubmed/36626195 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e35756 %T Impact of Gamification on Consumers’ Favorability in Cause-Related Marketing Programs: Between-Subjects Experiments %A Li,Yanhe %A Li,Yanchen %A Zhou,Xiu %A Ma,Kunshu %+ School of Business, Macau University of Science and Technology, Avenida Wai Long, Taipa, Macau S.A.R, 999078, China, 86 88972037, ycli@must.edu.mo %K cause-related marketing %K gamification %K enjoyment %K favorability %K business %K marketing %K gamified %D 2023 %7 10.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Successful cause-related marketing (CRM) campaigns can help companies stand out from their competitors; however, CRM may not have pleasant outcomes, even if it receives substantial investment. Objective: This research aimed to investigate how gamified CRM projects influence consumers’ favorability. Methods: We introduced 3 different CRM projects in 3 different studies. Every project had 2 versions according to the level of gamification, and participants were randomly assigned into these 2 groups. Additionally, we used a 2 (gamification: lower, higher) 2 (rules presentation: without visual cues, with visual cues) between-subjects design to test the moderation role of rules presentation in gamified CRM projects. Results: In Study 1, we identified that the highly gamified CRM program induces more enjoyment (F1,139=21.11, P<.001) and higher favorability (F1,139=14.57, P<.001). Moreover, we found that enjoyment played a mediation role between gamification and favorability (P<.001) in Study 2. In addition, the results of Study 3 indicated rules presentation in a gamified CRM program can moderate the indirect effect of gamification on favorability via enjoyment (index of the moderated mediation: 95% CI –1.12 to –0.10; for rules presentation with visual cues: 95% CI 0.69 to 1.40; for rules presentation without visual cues: 95% CI 0.08 to 0.83). Conclusions: Overall, this research contributes to the CRM literature and suggests gamification is an effective way of managing CRM campaigns. %M 36626196 %R 10.2196/35756 %U https://games.jmir.org/2023/1/e35756 %U https://doi.org/10.2196/35756 %U http://www.ncbi.nlm.nih.gov/pubmed/36626196 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40421 %T Differences in Brain Activity and Body Movements Between Virtual Reality and Offline Exercise: Randomized Crossover Trial %A Kim,Hee Jin %A Lee,Jea Woog %A Choi,Gangta %A Huh,Junghoon %A Han,Doug Hyun %+ Department of Psychiatry, College of Medicine, Chung-Ang University, Heuk Seok Ro 84, Seoul, 06974, Republic of Korea, 82 2 6299 3132, hduk70@gmail.com %K virtual reality exercise %K near-infrared spectroscopy %K spectroscopy %K hemodynamic %K blood flow %K hemoglobin %K brain %K prefrontal cortex %K orbitofrontal cortex %K immersion %K virtual reality %K VR %K exercise %K range of motion %K physical activity %K fitness %K motion %K movement %K randomized %K calorie %D 2023 %7 5.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has been suggested to be effective at enhancing physical exercises because of its immersive characteristics. However, few studies have quantitatively assessed the range of motion and brain activity during VR exercises. Objective: We hypothesized that 3D immersive VR could stimulate body movement and brain activity more effectively than standard exercises and that the increased range of motions during 3D immersive VR exercises would be associated with orbitofrontal activation. Methods: A randomized crossover trial was conducted to compare exercises with and without VR. A total of 24 healthy males performed the same motions when exercising with and without 3D immersive VR, and the recorded videos were used for motion analysis. Hemodynamic changes in the prefrontal cortex were assessed using functional near-infrared spectroscopy. Results: There were significant differences in the total angle (z=−2.31; P=.02), length (z=−2.78; P=.005), calorie consumption (z=−3.04; P=.002), and change in accumulated oxygenated hemoglobin within the right orbitofrontal cortex (F1,94=9.36; P=.003) between the VR and offline trials. Hemodynamic changes in the right orbitofrontal cortex were positively correlated with the total angle (r=0.45; P=.001) and length (r=0.38; P=.007) in the VR exercise; however, there was no significant correlation in the offline trial. Conclusions: The results of this study suggest that 3D immersive VR exercise effectively increases the range of motion in healthy individuals in relation to orbitofrontal activation. Trial Registration: Clinical Research Information Service KCT0008021; https://cris.nih.go.kr/cris/search/detailSearch.do/23671 %M 36602842 %R 10.2196/40421 %U https://games.jmir.org/2023/1/e40421 %U https://doi.org/10.2196/40421 %U http://www.ncbi.nlm.nih.gov/pubmed/36602842 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e37616 %T Design Considerations for an Exergame-Based Training Intervention for Older Adults With Mild Neurocognitive Disorder: Qualitative Study Including Focus Groups With Experts and Health Care Professionals and Individual Semistructured In-depth Patient Interviews %A Manser,Patrick %A Adcock-Omlin,Manuela %A de Bruin,Eling D %+ Motor Control and Learning Group – Institute of Human Movement Sciences and Sport, Department of Health Sciences and Technology, ETH Zurich, Leopold-Ruzicka-Weg 4, CH-8093 Zurich, Switzerland, Zurich, CH-8093, Switzerland, 41 79 519 96 46, patrick.manser@hest.ethz.ch %K cognition %K exercise %K exergame %K design %K development %K neurosciences %K technology %K training %D 2023 %7 5.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergames have attracted growing interest in the prevention and treatment of neurocognitive disorders. The most effective exergame and training components (ie, exercise and training variables such as frequency, intensity, duration, or volume of training and type and content of specific exergame scenarios) however remain to be established for older adults with mild neurocognitive disorders (mNCDs). Regarding the design and development of novel exergame-based training concepts, it seems of crucial importance to explicitly include the intended users’ perspective by adopting an interactive and participatory design that includes end users throughout different iterative cycles of development. Objective: This study aimed to determine the capabilities, treatment preferences, and motivators for the training of older adults with mNCD and the perspectives of individuals on training goals and settings and requirements for exergame and training components. Methods: A qualitative study including expert focus groups and individual semistructured in-depth patient interviews was conducted. Data were transcribed to a written format to perform qualitative content analysis using QCAmap software. Results: In total, 10 experts and health care professionals (80% females) and 8 older adults with mNCD (38% females; mean age 82.4, SD 6.2 years) were recruited until data saturation was observed. Conclusions: The psychosocial consequences of patients’ self-perceived cognitive deterioration might be more burdensome than the cognitive changes themselves. Older adults with mNCD prefer integrative forms of training (such as exergaming) and are primarily motivated by enjoyment or fun in exercising and the effectiveness of the training. Putting the synthesized perspectives of training goals, settings, and requirements for exergames and training components into context, our considerations point to opportunities for improvement in research and rehabilitation, either by adapting existing exergames to patients with mNCDs or by developing novel exergames and exergame-based training concepts specifically tailored to meet patient requirements and needs. %M 36602851 %R 10.2196/37616 %U https://games.jmir.org/2023/1/e37616 %U https://doi.org/10.2196/37616 %U http://www.ncbi.nlm.nih.gov/pubmed/36602851 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44318 %T Relapse Prevention Therapy for Problem Gaming or Internet Gaming Disorder in Swedish Child and Youth Psychiatric Clinics: Protocol for a Randomized Controlled Trial %A Kapetanovic,Sabina %A Gurdal,Sevtap %A Einarsson,Isak %A Werner,Marie %A André,Frida %A Håkansson,Anders %A Claesdotter-Knutsson,Emma %+ Department of Social and Behavioral Sciences, University West, Gustava Melinsgata 2, Trollhättan, 46132, Sweden, 46 704851666, sabina.kapetanovic@hv.se %K problem gaming %K internet gaming disorder %K parent-child relationship %K randomized controlled trial %K relapse prevention %K psychiatry %K psychology %K treatment %D 2023 %7 5.1.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Although gaming is a common arena where children socialize, an increasing number of children are exhibiting signs of problem gaming or internet gaming disorder. An important factor to the development of problem gaming is parent-child relationships. A cognitive behavioral therapy–based form of treatment, labeled relapse prevention, has been developed as a treatment for child and adolescent problem gaming or internet gaming disorder. However, no study has evaluated the effect of this treatment among Swedish children and youth nor the role of the parent-child relationships in this treatment. Objective: This study aims (1) to evaluate a relapse prevention treatment for patients showing signs of problem gaming or internet gaming disorder recruited from child and youth psychiatric clinics and (2) to test whether the quality of parent-child relationships plays a role in the effect of relapse prevention treatment and vice versa—whether the relapse prevention treatment has a spillover effect on the quality of parent-child relationships. Moreover, we explore the carer’s attitudes about parent-child relationships and child gaming, as well as experiences of the treatment among the children, their carers, and the clinicians who carried out the treatment. Methods: This study is a 2-arm, parallel-group, early-stage randomized controlled trial with embedded qualitative components. Children aged 12-18 years who meet the criteria for problem gaming or internet gaming disorder will be randomized in a 1:1 ratio to either intervention (relapse prevention treatment) or control (treatment as usual), with a total of 160 (80 + 80) participants. The primary outcomes are measures of gaming and gambling behavior before and after intervention, and the secondary outcomes include child ratings of parent-child communication and family functioning. The study is supplemented with a qualitative component with semistructured interviews to capture participants’ and clinicians’ experiences of the relapse prevention, as well as attitudes about parent-child relationships and parenting needs in carers whose children completed the treatment. Results: The trial started in January 2022 and is expected to end in December 2023. The first results are expected in March 2023. Conclusions: This study will be the first randomized controlled trial evaluating relapse prevention as a treatment for child and adolescent problem gaming and internet gaming disorder in Sweden. Since problem behaviors in children interact with the family context, investigating parent-child relationships adjacent to the treatment of child problem gaming and internet gaming disorder is an important strength of the study. Further, different parties, ie, children, carers, and clinicians, will be directly or indirectly involved in the evaluation of the treatment, providing more knowledge of the treatment and its effect. Limitations include comorbidity in children with problem gaming and internet gaming disorder and challenges with the recruitment of participants. Trial Registration: ClinicalTrials.gov NCT05506384 (retrospectively registered); https://clinicaltrials.gov/ct2/show/NCT05506384 International Registered Report Identifier (IRRID): DERR1-10.2196/44318 %M 36602846 %R 10.2196/44318 %U https://www.researchprotocols.org/2023/1/e44318 %U https://doi.org/10.2196/44318 %U http://www.ncbi.nlm.nih.gov/pubmed/36602846 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e37228 %T Key Stakeholders’ Experiences and Perceptions of Virtual Reality for Older Adults Living With Dementia: Systematic Review and Thematic Synthesis %A Flynn,Aisling %A Healy,David %A Barry,Marguerite %A Brennan,Attracta %A Redfern,Sam %A Houghton,Catherine %A Casey,Dympna %+ School of Nursing and Midwifery, Aras Moyola, University of Galway, Galway, H91 TK33, Ireland, 353 91493973, a.flynn15@universityofgalway.ie %K virtual reality %K VR %K dementia %K experience %K perception %K qualitative evidence synthesis (QES) %K thematic synthesis %D 2022 %7 23.12.2022 %9 Review %J JMIR Serious Games %G English %X Background: Technology is increasingly being used and evolving in the dementia care landscape. One such technology that has gained traction over the last decade is virtual reality (VR). VR is being applied in many areas of dementia care, including cognitive assessment and training, reminiscence therapy, music therapy, and other recreational VR applications. Despite the plethora of applications, they are often not shaped by the experiences and perceptions of older adults living with dementia. Currently, there is no qualitative evidence synthesis (QES) to explore this area. This review aimed to provide qualitative evidence supporting existing systematic reviews in this area. Objective: The aim of this QES was to explore key stakeholders’ experiences and perceptions of VR for older adults living with dementia. It aimed to explore the barriers and facilitators to VR use and provide recommendations for future design and implementation. Methods: QES was used, which involved a systematic search of 6 databases to identify studies that qualitatively explored key stakeholders’ experiences and perceptions of VR for older adults living with dementia. Thematic synthesis was used to integrate the findings of 14 studies (from 15 reports). The Critical Appraisal Skills Programme tool was used to assess the methodological quality of the included studies. The confidence placed in the review findings was assessed using the GRADE-CERQUAL (Confidence in the Evidence from Reviews of Qualitative research). Results: A total of 15 reports from 14 studies were included in the review, consisting of a range of levels of VR immersion, stages of dementia, and care contexts. Three analytical themes were generated: stepping into virtuality, a virtual world, and returning to reality. The results indicate the importance of sensitively designing and introducing VR to this population, as older adults living with dementia often have no prior experience of using this technology. VR can be a positive experience for older adults living with dementia and can provide meaningful interactions, positive expressions, and long-term impacts on everyday functioning. However, it should be acknowledged that some negative associations must be accounted for before, during, and after use. Conclusions: This review highlights the positive implications as well as negative associations of VR use. It emphasizes the need for VR design and implementation driven by the needs and views of older adults living with dementia as well as with other key stakeholders. Future research needs to explore the vital role that older adults living with dementia can play in the design process and how they can be empowered to meaningfully design and use this technology. %M 36563042 %R 10.2196/37228 %U https://games.jmir.org/2022/4/e37228 %U https://doi.org/10.2196/37228 %U http://www.ncbi.nlm.nih.gov/pubmed/36563042 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38133 %T Applying Gamification Principles and Therapeutic Movement Sequences to Design an Interactive Physical Activity Game: Development Study %A Kim,Hyungsook %A O'Sullivan,David Michael %A Chung,Seong Hee %+ Division of Sport Science, Pusan National University, 2, Busandaehak-ro 63beon-gil, Geumjeong-gu, Pusan, 46241, Republic of Korea, 82 1076845811, davidosullivan@pusan.ac.kr %K home workout %K mobile assistant %K movement %K physical activity %K depression %D 2022 %7 16.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a severe illness that has accelerated with the spread of COVID-19 and associated lockdowns. As a result, reported physical activity has substantially decreased, further increasing depressive symptoms. Objective: This study aims to explain the use of gamification principles to develop content for an interactive physical activity game for depression based on clinically proven depression diagnostic criteria. Methods: We discuss related work in this field, the game design framework, the users’ depression severity, how we customize the contents accordingly, the gradual progression of the game to match exercise principles, and user flow optimization. Results: We provide a brief description of each of the games developed, including instructions on how to play and design aspects for flow, audio, and visual feedback methods. Exergames (interactive physical activity–based games) stimulate certain physical fitness factors such as improving reaction time, endurance, cardiovascular fitness, and flexibility. In addition, the game difficulty progresses based on various factors, such as the user’s performance for successful completion, reaction time, movement speed, and stimulated larger joint range of motions. Cognitive aspects are included, as the user has to memorize particular movement sequences. Conclusions: Mental health issues are linked to behavior and movement; therefore, future physical activity–based interactive games may provide excellent stimulation for inducing user flow, while physical activity can help train various physical fitness factors linked to depression. %M 36525298 %R 10.2196/38133 %U https://games.jmir.org/2022/4/e38133 %U https://doi.org/10.2196/38133 %U http://www.ncbi.nlm.nih.gov/pubmed/36525298 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e37219 %T A Web-Based Gaming Approach to Decrease HIV-Related Stigma: Game Development and Mixed Methods Evaluation %A Zhang,Xiaoxiao %A Lai,Erman %+ School of Journalism and Communication, Jinan University, 601 West Huangpu Ave, Tianhe District, Guangzhou, 510632, China, 86 13798184756, xiaoxiaozhang@jnu.edu.cn %K serious games %K interactive narrative games %K games for health %K entertainment education %K digital health intervention %K game development and evaluation %K mixed methods evaluation %K participatory culture %K people living with HIV %K HIV-related stigma %K intimacy stigma %D 2022 %7 15.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The stigma faced by people living with HIV causes difficulties in the treatment of HIV/AIDS. Decreasing this stigma is thus no less urgent than implementing behavioral interventions. Serious games are being increasingly adopted as an intervention mechanism to control HIV/AIDS around the world. However, the development and evaluation of these games in China are far from adequate. Objective: This research aimed to help decrease HIV-related stigma in China via the development and evaluation of a serious game, as well as promote a participatory gamification culture for health interventions. Methods: Initially, a serious game was developed using free resources from a user-generated content website. Then, quantitative and qualitative methods were employed for game evaluation. A randomized controlled trial was conducted to explore the game’s effect on HIV-related stigma. The trial included 167 university students, who were randomly allocated to game and control groups. After the experimental evaluation, focus group discussions were held with 64 participants, who were invited to form 16 groups. Results: The game was called The Second Kind of Life with HIV (SKLWH), which is a free online game that can be played on computers and smartphones. This game hopes to publicize that people living with HIV can live a normal life, that is, a second life different from that imagined by the public. Based on the gamification practice of SKLWH, the participatory serious game development model (PSGDM) was proposed, which guided the development of 3 other HIV-themed games. The trial showed that intimacy stigma was much more severe than morality stigma and personal interaction stigma. Females were more tolerant of morality stigma than males (mean score: 1.29 vs 1.50; P=.01). The game intervention showed an advantage in decreasing intimacy stigma (mean score [game vs control]: 2.43 vs 2.73; P=.04). The group discussions validated the quantitative results and provided further in-depth information. The game intervention was largely preferred by participants, and the belief in intimacy impossibility was commonly expressed by participants when considering their relationship with people living with HIV. Conclusions: HIV/AIDS education should adopt appropriate media interventions to mitigate different dimensions of HIV-related stigma. Serious games should be used to decrease intimacy stigma, which is the hardest form to diminish. It is expected that the PSGDM can promote the development of more health games. Furthermore, HIV/AIDS intervention requires interdisciplinary efforts and cooperation that will allow more people to participate and share the responsibility of promoting health. %M 36520508 %R 10.2196/37219 %U https://games.jmir.org/2022/4/e37219 %U https://doi.org/10.2196/37219 %U http://www.ncbi.nlm.nih.gov/pubmed/36520508 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38009 %T Teamwork Training With a Multiplayer Game in Health Care: Content Analysis of the Teamwork Principles Applied %A van Peppen,Lara %A Faber,Tjitske J E %A Erasmus,Vicki %A Dankbaar,Mary E W %+ Anesthesiologie, Pijn en Palliatieve Geneeskunde, Radboud Universitair Medisch Centrum, Huispost 717, Route 714, PO Box 9101, Nijmegen, 6500 HB, Netherlands, 31 243614406, Tjitske.Faber@radboudumc.nl %K teamwork %K skills training %K serious games %K multiplayer game %K medical students %K content-analysis %K health care %K interprofessional teamwork %D 2022 %7 9.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In health care, teamwork skills are critical for patient safety; therefore, great emphasis is placed on training these skills. Given that training is increasingly designed in a blended way, serious games may offer an efficient method of preparing face-to-face simulation training of these procedural skills. Objective: This study aimed to investigate the teamwork principles that were used during gameplay by medical students and teamwork experts. Findings can improve our understanding of the potential of serious games for training these complex skills. Methods: We investigated a web-based multiplayer game designed for training students’ interprofessional teamwork skills. During gameplay, 4 players in different roles (physician, nurse, medical student, and student nurse) had to share information, prioritize tasks, and decide on next steps to take in web-based patient scenarios, using one-to-one and team chats. We performed a qualitative study (content analysis) on these chats with 144 fifth-year medical students and 24 health care teamwork experts (as a benchmark study) playing the game in groups of 4. Game chat data from 2 scenarios were analyzed. For the analysis, a deductive approach was used, starting with a conceptual framework based on Crew Resource Management principles, including shared situational awareness, decision-making, communication, team management, and debriefing. Results: Results showed that most teamwork principles were used during gameplay: shared situational awareness, decision-making (eg, re-evaluation), communication (eg, closed loop), and team management (eg, distributing the workload). Among students, these principles were often used on a basic level. Among experts, teamwork principles were used with more open forms of speak up and more justification of decisions. Some specific Crew Resource Management principles were less observed among both groups, for example, prevention of fixation errors and use of cognitive aids. Both groups showed relatively superficial debriefing reflections. Conclusions: Playing a multiplayer game for interprofessional teamwork appears to facilitate the application of teamwork principles by students in all important teamwork domains on a basic level. Expert players applied similar teamwork principles on a moderately high complexity level. Some teamwork principles were less observed among both students and expert groups, probably owing to the artifacts of the game environment (eg, chatting instead of talking). A multiplayer game for teamwork training can elicit the application of important, basic teamwork principles, both among novices and experts, and provides them with a flexible, accessible, and engaging learning environment. This may create time for exercising more complex skills during face-to-face training. %M 36485016 %R 10.2196/38009 %U https://games.jmir.org/2022/4/e38009 %U https://doi.org/10.2196/38009 %U http://www.ncbi.nlm.nih.gov/pubmed/36485016 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e36390 %T An Emotional Bias Modification for Children With Attention-Deficit/Hyperactivity Disorder: Co-design Study %A Zhang,Melvyn %A Ranganath,Vallabhajosyula %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 11, Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 98556631, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K attention-deficit/hyperactivity disorder %K ADHD %K child psychiatry %D 2022 %7 9.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the common neurodevelopment disorders. Children with ADHD typically have difficulties with emotional regulation. Previous studies have investigated the assessment for underlying emotional biases using the visual probe task. However, one of the significant limitations of the visual probe task is that it is demanding and repetitive over time. Previous studies have examined the use of gamification methods in addressing the limitations of the emotional bias visual probe task. There has also been increased recognition of the potential of participatory action research methods and how it could help to make the conceptualized interventions more relevant. Objective: The primary aim of this study was to collate health care professionals’ perspectives on the limitations of the existing visual probe task and to determine if gamification elements were viable to be incorporated into an emotional bias modification task. Methods: A co-design workshop was conducted. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore, were invited to participate. Considering the COVID-19 pandemic and the restrictions, a web-based workshop was conducted. There were 3 main phases in the workshops. First, participants were asked to identify limitations and suggest potential methods to overcome some of the identified limitations. Second, participants were shown examples of existing gaming interventions in published literature and commercial stores. They were also asked to comment on the advantages and limitations of these interventions. Finally, participants were asked if gamification techniques would be appropriate. Results: Overall, 4 health care professionals consented and participated. Several limitations were identified regarding the conventional emotional bias intervention. These included the nature of the task parameters, included stimulus set, and factors that could have an impact on the accuracy of responding to the task. After examining the existing ADHD games, participants raised concerns about the evidence base of some of the apps. They articulated that any developed ADHD game ought to identify the specific skill set that was targeted clearly. Regarding gamification strategies, participants preferred economic and performance-based gamification approaches. Conclusions: This study has managed to elucidate health care professionals’ perspectives toward refining a conventional emotional bias intervention for children with ADHD. In view of the repetitiveness of the conventional task, the suggested gamification techniques might help in influencing task adherence and reduce the attrition rates. %M 36485019 %R 10.2196/36390 %U https://formative.jmir.org/2022/12/e36390 %U https://doi.org/10.2196/36390 %U http://www.ncbi.nlm.nih.gov/pubmed/36485019 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e39966 %T Immersive Virtual Reality Avatars for Embodiment Illusions in People With Mild to Borderline Intellectual Disability: User-Centered Development and Feasibility Study %A Langener,Simon %A Klaassen,Randy %A VanDerNagel,Joanne %A Heylen,Dirk %+ Department of Human Media Interaction, University of Twente, PO Box 217, Enschede, 7500 AE, Netherlands, 31 534898771, s.langener@utwente.nl %K virtual reality %K VR %K embodiment %K avatar %K embodied learning %K body-centered %K intellectual disability %K addiction %K user-centered design %D 2022 %7 7.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (IVR) has been investigated as a tool for treating psychiatric conditions. In particular, the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID; IQ=50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (ie, avatar) appears promising for enhancing learning (eg, by changing perspectives) and usability (eg, natural interactions). However, design requirements, immersion procedures, and proof of concept of such embodiment illusion (ie, substituting the real body with a virtual one) have not been explored in this group. Objective: Our study aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored 3 factors to induce the illusion, by testing the avatar’s appearance, locomotion using IVR controllers, and virtual object manipulation. Furthermore, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. Methods: We conducted a user-centered study with 29 end users in care facilities, to investigate the avatar’s appearance, controller-based locomotion (ie, teleport, joystick, or hybrid), and object manipulation. Overall, 3 iterations were conducted using semistructured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the sense of embodiment (SoE) during 5 interaction tasks. Results: IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants’ desire to replicate their own body image. Similarly, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notably, interactions that are implausible (eg, teleport and occlusions when grabbing) showed a negative influence on SoE. In contrast, implementing artificial interaction aids into the IVR avatar’s hands (ie, for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (eg, motion sickness), possibly hindering uptake in practice. Conclusions: Balancing the embodiment immersion by focusing on interaction habituation (eg, controller-based locomotion) and lowering customization effort seems crucial to achieve both high SoE and usability for people with MBID. Hence, future studies should investigate the requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (eg, animations, physics-based collision, and touch) and other interaction techniques (eg, hand tracking and redirected walking). In addition, procedures and use for learning should be explored for tailored mental health therapies in people with MBID. %M 36476721 %R 10.2196/39966 %U https://games.jmir.org/2022/4/e39966 %U https://doi.org/10.2196/39966 %U http://www.ncbi.nlm.nih.gov/pubmed/36476721 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e40727 %T A Novel Scenario-Based, Mixed-Reality Platform for Training Nontechnical Skills of Battlefield First Aid: Prospective Interventional Study %A Du,Wenqiong %A Zhong,Xin %A Jia,Yijun %A Jiang,Renqing %A Yang,Haoyang %A Ye,Zhao %A Zong,Zhaowen %+ State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, 30 Gaotanyan St, Shapingba District, Chongqing, 400038, China, 86 138 8350 6677, zongzhaowen@163.com %K mixed reality %K decision-making %K team work %K battlefield first aid %K nontechnical skills %K training %K next-generation modeling %K virtual reality %K medical education %D 2022 %7 6.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although battlefield first aid (BFA) training shares many common features with civilian training, such as the need to address technical skills and nontechnical skills (NTSs), it is more highly scenario-dependent. Studies into extended reality show clear benefits in medical training; however, the training effects of extended reality on NTSs, including teamwork and decision-making in BFA, have not been fully proven. Objective: The current study aimed to create and test a scenario-based, mixed-reality platform suitable for training NTSs in BFA. Methods: First, using next-generation modeling technology and an animation synchronization system, a 10-person offensive battle drill was established. Decision-making training software addressing basic principles of tactical combat casualty care was constructed and integrated into the scenarios with Unreal Engine 4 (Epic Games). Large-space teamwork and virtual interaction systems that made sense in the proposed platform were developed. Unreal Engine 4 and software engineering technology were used to combine modules to establish a mixed-reality BFA training platform. A total of 20 Grade 4 medical students were recruited to accept BFA training with the platform. Pretraining and posttraining tests were carried out in 2 forms to evaluate the training effectiveness: one was knowledge acquisition regarding the NTS and the other was a real-world, scenario-based test. In addition, the students were asked to rate their agreement with a series of survey items on a 5-point Likert scale. Results: A battlefield geographic environment, tactical scenarios, scenario-based decision software, large-space teamwork, and virtual interaction system modules were successfully developed and combined to establish the mixed-reality training platform for BFA. The posttraining score of the students’ knowledge acquisition was significantly higher than that of pretraining (t=−12.114; P≤.001). Furthermore, the NTS score and the total score that the students obtained in the real-world test were significantly higher than those before training (t=−17.756 and t=−21.354, respectively; P≤.001). However, there was no significant difference between the scores of technical skills that the students obtained before and after training. A posttraining survey revealed that the students found the platform helpful in improving NTSs for BFA, and they were confident in applying BFA skills after training. However, most trainees thought that the platform was not helpful for improving the technical skills of BFA, and 45% (9/20) of the trainees were not satisfied with the simulation effect. Conclusions: A scenario-based, mixed-reality platform was constructed in this study. In this platform, interaction of the movement of multiple players in a large space and the interaction of decision-making by the trainees between the real world and the virtual world were accomplished. The platform could improve the NTSs of BFA. Future works, including improvement of the simulation effects and development of a training platform that could effectively improve both the technical skills and NTSs of BFA, will be carried out. %M 36472903 %R 10.2196/40727 %U https://games.jmir.org/2022/4/e40727 %U https://doi.org/10.2196/40727 %U http://www.ncbi.nlm.nih.gov/pubmed/36472903 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38703 %T Development of a Novel Home-Based Exergame With On-Body Feedback: Usability Study %A Schättin,Alexandra %A Pickles,Jordan %A Flagmeier,David %A Schärer,Benjamin %A Riederer,Yanick %A Niedecken,Stephan %A Villiger,Stefan %A Jurt,Roman %A Kind,Nicole %A Scott,Sam N %A Stettler,Christoph %A Martin-Niedecken,Anna Lisa %+ Department of Design, Institute of Design Research, Zurich University of the Arts, Pfingstweidstrasse 96, Zurich, 8031, Switzerland, 41 79 775 06 73, anna.martin@zhdk.ch %K exergame %K iterative design %K home-based exergame %K on-body feedback %K usability %K training experience %K gameplay experience %K home-based exercise %K serious games %K physical activity %D 2022 %7 6.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: With more than 1.4 billion adults worldwide classified as physically inactive, physical inactivity is a public health crisis leading to an increased risk of cardiometabolic diseases. Motivating and engaging training strategies are needed to tackle this public health crisis. Studies have shown that exergames, games controlled by active body movements, are potentially usable, attractive, and effective tools for home-based training. The ExerCube (by Sphery Ltd) has been developed as a physically immersive and adaptive functional fitness game. The development of a home-based version of the ExerCube could increase accessibility, reduce barriers to exercise, and provide an attractive solution to improve physical and cognitive health. Objective: The aim was threefold: (1) to develop a usable home-based exergame system, (2) to evaluate the usability and training experience of the home-based exergame and its early-stage on-body feedback system, and (3) to identify avenues for further user-centered design iterations of the system. Methods: A total of 15 healthy participants (mean age 25, SD 3 years) completed 2 laboratory visits consisting of four 5-minute exergame sessions. In each session, the on-body feedback system provided a different feedback modality (auditory, haptic, and visual feedback) to the participant. Following the second visit, participants completed a range of assessments, including the System Usability Scale (SUS), the Physical Activity Enjoyment Scale (PACES), the Flow Short Scale (FSS), the Immersive Experience Questionnaire (IEQ), and a rating of perceived exertions (RPEs) both physically and cognitively. Participants answered questions regarding the on-body feedback system and completed a semistructured interview. Results: Usability was rated as acceptable, with a SUS score of 70.5 (SD 12). The questionnaires revealed medium-to-high values for the training experience (FSS: 5.3, SD 1; PACES: 5.3, SD 1.1; IEQ: 4.7, SD 0.9. Physical (mean 4.8, SD 1.6) and cognitive (mean 3.9, SD 1.4) RPEs were moderate. Interviews about the on-body feedback system revealed that the majority of participants liked the haptic feedback and the combination of haptic and auditory feedback the best. Participants enjoyed the distinct perceptibility, processing, and integration of the exergame and its supportive and motivating effect. The visual feedback was perceived less positively by participants but was still classified as “potentially” helpful. The auditory feedback was rated well but highlighted an area for further improvement. Participants enjoyed the training experience and described it as motivating, interactive, immersive, something new, interesting, self-explanatory, as well as physically and cognitively challenging. Moreover, 67% (n=10) of the participants could imagine exercising at home and continuing to play the exergame in the future. Conclusions: The home-based exergame and its early-stage on-body feedback system were rated as usable and an enjoyable training experience by a young healthy population. Promising avenues emerged for future design iterations. %M 36472900 %R 10.2196/38703 %U https://games.jmir.org/2022/4/e38703 %U https://doi.org/10.2196/38703 %U http://www.ncbi.nlm.nih.gov/pubmed/36472900 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e41234 %T Effects of a Modern Virtual Reality 3D Head-Mounted Display Exergame on Simulator Sickness and Immersion Under Specific Conditions in Young Women and Men: Experimental Study %A Ciążyńska,Julia %A Janowski,Michał %A Maciaszek,Janusz %+ Department of Physical Activity and Health Promotion Science, Poznan University of Physical Education, 61-871 Poznan, Królowej Jadwigi 27/39, Poznan, 61-871, Poland, 48 (61) 835 52 14, ciazynska@awf.poznan.pl %K virtual reality %K HMD %K simulator sickness %K immersion %K physical activity %K exergame %K Zephyr %K gender differences %K WHO recommendation %K young adult %K digital health %K energy expenditure %K exercise game %D 2022 %7 29.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many young adults do not reach the World Health Organization’s minimum recommendations for the amount of weekly physical activity. The virtual reality 3D head-mounted display (VR 3D HMD) exergame is a technology that is more immersive than a typical exercise session. Our study considers gender differences in the experience of using VR games for increasing physical activity. Objective: The aim of this study was to examine the differences in the effects of VR 3D HMD gaming in terms of immersion, simulator sickness, heart rate, breathing rate, and energy expenditure during two 30-minute sessions of playing an exergame of increasing intensity on males and females. Methods: To examine the effects of the VR 3D HMD exergame, we experimented with 45 participants (23 males and 22 females) exercising with VR 3D HMD Oculus Quest 1, hand controllers, and Zephyr BioHarness 3.0. Players exercised according to the Audio Trip exergame. We evaluated the immersion levels and monitored the average heart rate, maximum heart rate, average breathing rate, maximum breathing rate, and energy expenditure in addition to simulator sickness during two 30-minute exergame sessions of increasing intensity. Results: Audio Trip was well-tolerated, as there were no dropouts due to simulator sickness. Significant differences between genders were observed in the simulator sickness questionnaire for nausea (F2,86=0.80; P=.046), oculomotor disorders (F2,86=2.37; P=.010), disorientation (F2,86=0.92; P=.040), and total of all these symptoms (F2,86=3.33; P=.04). The measurements after the first 30-minute VR 3D HMD exergame session for all the participants showed no significant change compared to the measurements before the first 30-minute exergame session according to the total score. There were no gender differences in the immersion (F1,43=0.02; P=.90), but the measurements after the second 30-minute exergame session showed an increase in the average points for immersion in women and men. The increase in the level of immersion in the female group was higher than that in the male group. A significant difference between genders was observed in the average breathing rate (F2,86=1.44; P=.04), maximum breathing rate (F2,86=1.15; P=.047), and energy expenditure (F2,86=10.51; P=.001) measurements. No gender differences were observed in the average heart rate and maximum heart rate measurements in the two 30-minute sessions. Conclusions: Our 30-minute VR 3D HMD exergame session does not cause simulator sickness and is a very immersive type of exercise for men and women users. This exergame allows reaching the minimum recommendations for the amount of weekly physical activity for adults. The second exergame session resulted in simulator sickness in both groups, more noticeably in women, as reflected in the responses in the simulator sickness questionnaire. The gender differences observed in the breathing rates and energy expenditure measurements can be helpful when programming VR exergame intensity in future research. %M 36445744 %R 10.2196/41234 %U https://games.jmir.org/2022/4/e41234 %U https://doi.org/10.2196/41234 %U http://www.ncbi.nlm.nih.gov/pubmed/36445744 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e39840 %T Artificial Intelligence–Driven Serious Games in Health Care: Scoping Review %A Abd-alrazaq,Alaa %A Abuelezz,Israa %A Hassan,Asma %A AlSammarraie,AlHasan %A Alhuwail,Dari %A Irshaidat,Sara %A Abu Serhan,Hashem %A Ahmed,Arfan %A Alabed Alrazak,Sadam %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, 0000, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K artificial intelligence %K deep learning %K machine learning %K health care %K digital health %K eHealth %K mobile phone %D 2022 %7 29.11.2022 %9 Review %J JMIR Serious Games %G English %X Background: Artificial intelligence (AI)–driven serious games have been used in health care to offer a customizable and immersive experience. Summarizing the features of the current AI-driven serious games is very important to explore how they have been developed and used and their current state to plan on how to leverage them in the current and future health care needs. Objective: This study aimed to explore the features of AI-driven serious games in health care as reported by previous research. Methods: We conducted a scoping review to achieve the abovementioned objective. The most popular databases in the information technology and health fields (ie, MEDLINE, PsycInfo, Embase, CINAHL, IEEE Xplore, ACM Digital Library, and Google Scholar) were searched using keywords related to serious games and AI. Two reviewers independently performed the study selection process. Three reviewers independently extracted data from the included studies. A narrative approach was used for data synthesis. Results: The search process returned 1470 records. Of these 1470 records, 46 (31.29%) met all eligibility criteria. A total of 64 different serious games were found in the included studies. Motor impairment was the most common health condition targeted by these serious games. Serious games were used for rehabilitation in most of the studies. The most common genres of serious games were role-playing games, puzzle games, and platform games. Unity was the most prominent game engine used to develop serious games. PCs were the most common platform used to play serious games. The most common algorithm used in the included studies was support vector machine. The most common purposes of AI were the detection of disease and the evaluation of user performance. The size of the data set ranged from 36 to 795,600. The most common validation techniques used in the included studies were k-fold cross-validation and training-test split validation. Accuracy was the most commonly used metric for evaluating the performance of AI models. Conclusions: The last decade witnessed an increase in the development of AI-driven serious games for health care purposes, targeting various health conditions, and leveraging multiple AI algorithms; this rising trend is expected to continue for years to come. Although the evidence uncovered in this study shows promising applications of AI-driven serious games, larger and more rigorous, diverse, and robust studies may be needed to examine the efficacy and effectiveness of AI-driven serious games in different populations with different health conditions. %M 36445731 %R 10.2196/39840 %U https://games.jmir.org/2022/4/e39840 %U https://doi.org/10.2196/39840 %U http://www.ncbi.nlm.nih.gov/pubmed/36445731 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e38434 %T Effectiveness of Gamification in Knee Replacement Rehabilitation: Protocol for a Randomized Controlled Trial With a Qualitative Approach %A Aartolahti,Eeva %A Janhunen,Maarit %A Katajapuu,Niina %A Paloneva,Juha %A Pamilo,Konsta %A Oksanen,Airi %A Keemu,Hannes %A Karvonen,Mikko %A Luimula,Mika %A Korpelainen,Raija %A Jämsä,Timo %A Mäkelä,Keijo %A Heinonen,Ari %+ Institute of Rehabilitation, JAMK University of Applied Sciences, Piippukatu 2, Jyväskylä, FI-40100, Finland, 358 503237511, eeva.aartolahti@jamk.fi %K knee arthroplasty %K serious game %K gamification %K therapeutic exercise %K rehabilitation %K physical therapy %K Kinect %K mixed methods %K randomized controlled trial %D 2022 %7 28.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Exergames can provide encouraging exercise options. Currently, there is limited evidence regarding home-based exergaming in the postoperative phase of total knee replacement (TKR). Objective: This study aimed to investigate the effects of a 4-month postoperative home-based exergame intervention with an 8-month follow-up on physical function and symptoms among older persons undergoing TKR compared with home exercise using a standard protocol. In addition, a concurrent embedded design of a mixed methods study was used by including a qualitative component within a quantitative study of exergame effects. Methods: This was a dual-center, nonblinded, two-arm, parallel group randomized controlled trial with an embedded qualitative approach. This study aimed to recruit 100 patients who underwent their first unilateral TKR (aged 60-75 years). Participants were randomized to the exergame or standard home exercise arms. Participants followed a custom-made exergame program independently at their homes daily for 4 months. The primary outcomes at 4 months were function and pain related to the knee using the Oxford Knee Score questionnaire and mobility using the Timed Up and Go test. Other outcomes, in addition to physical function, symptoms, and disability, were game user experience, exercise adherence, physical activity, and satisfaction with the operated knee. Assessments were performed at the preoperative baseline and at 2, 4, and 12 months postoperatively. Exergame adherence was followed from game computers and using a structured diary. Self-reported standard exercise was followed for 4 months of intervention and physical activity was followed for 12 months using a structured diary. Qualitative data on patients’ perspectives on rehabilitation and exergames were collected through laddering interviews at 4 and 12 months. Results: This study was funded in 2018. Data collection began in 2019 and was completed in January 2022. The COVID-19 pandemic caused an unavoidable situation in the study for recruitment, data collection, and statistical analysis. As of November 2020, a total of 52 participants had been enrolled in the study. Primary results are expected to be published by the end of 2022. Conclusions: Our study provides new knowledge on the effects of postoperative exergame intervention among older patients with TKR. In addition, this study provides a new understanding of gamified postoperative rehabilitation, home exercise adherence, physical function, and physical activity among older adults undergoing TKR. Trial Registration: ClinicalTrials.gov NCT03717727; https://clinicaltrials.gov/ct2/show/NCT03717727 International Registered Report Identifier (IRRID): RR1-10.2196/38434 %M 36441574 %R 10.2196/38434 %U https://www.researchprotocols.org/2022/11/e38434 %U https://doi.org/10.2196/38434 %U http://www.ncbi.nlm.nih.gov/pubmed/36441574 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e39932 %T Handheld Weights as an Effective and Comfortable Way To Increase Exercise Intensity of Physical Activity in Virtual Reality: Empirical Study %A Polechoński,Jacek %A Zwierzchowska,Anna %A Makioła,Łukasz %A Groffik,Dorota %A Kostorz,Karolina %+ Institute of Sport Sciences, The Jerzy Kukuczka Academy of Physical Education in Katowice, 72A, Mikołowska St, Katowice, 40-065, Poland, 48 32 207 51 93, j.polechonski@awf.katowice.pl %K immersive virtual reality %K virtual reality %K health-related physical activity %K intensity of physical activity %K active video games %K serious games %D 2022 %7 23.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, there has been a growing interest in active virtual reality games (AVRGs) that provide entertainment and encourage more physical activity (PA). Since playing AVRGs involves primarily arm movements, the intensity of this form of PA may not be sufficient for health benefits. Therefore, it is worth looking for virtual entertainment solutions that are comfortable for users and at the same time increase physical exercise. Objective: The main objective of this study was to evaluate the effect of external loading of the arms in the form of handheld weights (HHWs) on exercise intensity in users playing a popular AVRG. The results obtained in the study were compared with the PA recommendations for health. The study also assessed the perceptions of the users about the attractiveness and usefulness of this type of exercise and discomfort caused by additional load on the arms. Methods: The study covered 17 young adults aged 18 to 25 years playing an AVRG (Beat Saber) with no arm load and with HHWs (0.5 kg). A PlayStation 4 PRO console (Sony) with accessories including a head-mounted display and controllers was used in the study. PA intensity was evaluated using a heart rate monitor based on the percentage of maximal heart rate (% HRmax). The usability, attractiveness, and comfort perceived during exercise by users were evaluated using a survey questionnaire. Results: The measurements showed that the mean % HRmax in participants playing Beat Saber without HHWs was significantly lower (P<.001; Cohen d=1.07) than that observed when playing with HHWs. It should be emphasized that with no additional load, the intensity of PA was low (mean 63.7% HRmax, SD 9.3% HRmax), while with the upper limb load, it increased to a moderate level (mean 67.1% HRmax, SD 10.3% HRmax), which is recommended for health benefits. The survey conducted in the study showed that HHWs (0.5 kg) attached to the wrists did not disturb Beat Saber players. Conclusions: Since PA in most of the modern AVRGs primarily involves upper limb movements, the use of HHW seems to be a simple and effective way to increase exercise intensity, especially because, as reported by the study participants, such a procedure does not cause discomfort while using the application. %M 36416873 %R 10.2196/39932 %U https://games.jmir.org/2022/4/e39932 %U https://doi.org/10.2196/39932 %U http://www.ncbi.nlm.nih.gov/pubmed/36416873 %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 4 %P e33806 %T Parental Factors Associated With Internet Gaming Disorder Among First-Year High School Students: Longitudinal Study %A She,Rui %A Zhang,Youmin %A Yang,Xue %+ The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, 5/F, Ngan Shing Street, Shatin, Hong Kong, HKG, China, 852 2647 5108, sherryxueyang@cuhk.edu.hk %K internet gaming disorder %K adolescents %K parental factors %K longitudinal study %K parenting %K gaming %K gaming disorder %K health intervention %K treatment %K mental health %D 2022 %7 8.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Parents play central roles in adolescents’ socialization, behavioral development, and health, including the development of internet gaming disorder (IGD). However, longitudinal research on the parental predictors of adolescent IGD is limited. Objective: This study aimed to investigate the reciprocal associations between various parental factors and adolescent IGD using 2-wave cross-lagged models. Methods: A sample of 1200 year-one high school students in central China completed a baseline assessment in 2018 (mean age 15.6 years; 633/1200, 52.8% male) and a follow-up survey in 2019. IGD was measured using the 9-item DSM-5 IGD Symptoms checklist. Perceptions related to parental variables, including psychological control, parental abuse, parental support, and the parent-child relationship, were also collected from the adolescents. Results: Of all the participants, 12.4% (148/1200) and 11.7% (140/1200) were classified as having IGD at baseline (T1) and follow-up (T2), respectively. All 4 cross-lagged models fit the data well (range for the comparative fit index .91-.95; range for the standardized root mean square residual .05-.06). Parental support (β=–.06, P=.02) and parental abuse (β=.08, P=.002) at T1 predicted IGD symptoms at T2, while parental psychological control (β=.03, P=.25) and a positive relationship with parents (β=–.05, P=.07) at T1 had nonsignificant effects on IGD symptoms at T2, when controlling for background variables. In addition, IGD symptoms at T1 did not predict parental factors at T2. Conclusions: The findings suggest that parental factors may be significant predictors of adolescent IGD. Health interventions should consider involving parents to increase the effectiveness of treatment to prevent and reduce adolescent IGD. %M 36346660 %R 10.2196/33806 %U https://games.jmir.org/2022/4/e33806 %U https://doi.org/10.2196/33806 %U http://www.ncbi.nlm.nih.gov/pubmed/36346660 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38315 %T Virtual Reality Technology in Cognitive Rehabilitation Application: Bibliometric Analysis %A He,Danni %A Cao,Shihua %A Le,Yuchao %A Wang,Mengxin %A Chen,Yanfei %A Qian,Beiying %+ Nursing Department, Hangzhou Normal University Qianjiang College, No.16 Xuelin St, Jianggan District, Hangzhou City, Zhejiang Province, Hangzhou, 310036, China, 86 13777861361, csh@hznu.edu.cn %K virtual reality %K cognitive rehabilitation %K bibliometric analysis %K CiteSpace %K gCLUTO %K rehabilitation %K cognitive disorder %K visual content analysis %D 2022 %7 19.10.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention. Objective: This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years. Methods: Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software. Results: A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was “Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer’s Disease: Influence of Active and Passive Encoding.” The most common keywords used by researchers include “virtual reality,” “cognition,” “rehabilitation,” “performance,” and “older adult.” The largest source of research funding is from the public sector in the United States. Conclusions: The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards. %M 36260388 %R 10.2196/38315 %U https://games.jmir.org/2022/4/e38315 %U https://doi.org/10.2196/38315 %U http://www.ncbi.nlm.nih.gov/pubmed/36260388 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 10 %P e42651 %T Group Telegaming Through Immersive Virtual Reality to Improve Mental Health Among Adolescents With Physical Disabilities: Pre- and Posttrial Protocol %A Lai,Byron %A Davis,Drew %A Young,Raven %A Swanson-Kimani,Erin %A Wozow,Cynthia %A Chaviano,Kelli %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35233, United States, 1 205 638 9790 ext 8 9725, blai@uabmc.edu %K disability %K physical activity %K active video gaming %K mindfulness %D 2022 %7 13.10.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents with physical disabilities have higher rates of mental health conditions and issues than adolescents without disabilities, and this disparity was exacerbated by the onset of the COVID-19 pandemic. They also have limited access to on-site programs and nearby peers. Objective: This pilot aims to investigate the potential effects of a low-dose multiplayer virtual reality telegaming program on depression, socialization, and loneliness among a cohort of children with physical disabilities. A secondary aim is to describe feasibility metrics, namely, recruitment and adherence rates and perceived program enjoyment and satisfaction. The tertiary aim is to describe behavioral mechanisms that affect participant adherence and social participation in the classes. Methods: This study is a single-group pre- and posttest–designed trial. A single cohort of 12 children with physical disabilities will pilot a 1-month program that includes 2 supervised 1-hour sessions per week of group-based exergaming. Participants will complete questionnaires before and after the program. The primary aim measures will include the Children’s Depression Inventory 2 Short Form, a measure of feelings of depression, and the UCLA Loneliness Scale, a measure of both loneliness and social isolation. Secondary aim measures will include three posttest Likert scale questionnaires: perceived program enjoyment, program satisfaction, and satisfaction with multiplayer experiences. At postintervention or dropout, participants will undergo semistructured interviews to identify behavioral mechanisms that underlie participation. Data will be reported descriptively and be supported by t tests as appropriate. Results: Recruitment procedures started in July 2022. All data are expected to be collected by January 2023. Full trial results are expected to be published by March 2023. Secondary analyses of data will be subsequently published. Conclusions: This trial tests a peer-to-peer virtual reality telegaming program that includes a completely remote enrollment, assessment, and intervention protocol. This program is accessible and short in duration and frequency, allowing it to be integrated into other interventions. Knowledge obtained from this study will inform the development of a larger trial for improving the mental health and well-being of adolescents with physical disabilities. Trial Registration: ClinicalTrials.gov NCT05259462; https://clinicaltrials.gov/ct2/show/NCT05259462 International Registered Report Identifier (IRRID): PRR1-10.2196/42651 %M 36194864 %R 10.2196/42651 %U https://www.researchprotocols.org/2022/10/e42651 %U https://doi.org/10.2196/42651 %U http://www.ncbi.nlm.nih.gov/pubmed/36194864 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38192 %T Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to Improve Brain and Cognition in Healthy Older Adults? Data-Based Viewpoint %A Temprado,Jean-Jacques %A Torre,Marta Maria %+ Aix Marseille Université, Institut des Sciences du Mouvement, 163 Avenue de Luminy, BP 910, Marseille, 13288, France, 33 611837288, jean-jacques.temprado@univ-amu.fr %K aging %K older %K gerontology %K exergame %K physical activity %K cognition %K training %K intervention %K cognitive %K brain %K older adult %K motor skills %K exercise %K physical %K motor %K combined training %D 2022 %7 3.10.2022 %9 Viewpoint %J JMIR Serious Games %G English %X Combining physical, motor, and cognitive exercises is expected to be effective to attenuate age-related declines of brain and cognition in older adults. This can be achieved either by conventional interventions or by exergames. This paper aimed to determine whether conventional combined training and exergame interventions are two comparable ways for delivering combined training. In total, 24 studies on conventional training and 23 studies on exergames were selected and compared. A common framework was used to analyze both types of combined training interventions. Our analysis showed that conventional combined training interventions were more effective than separated physical and motor training to improve brain and cognition, while their superiority over cognitive training alone remains to be confirmed. Exergames scarcely led to cognitive benefits superior to those observed after physical, motor, or cognitive training alone. Thus, although both conventional training interventions and exergames allowed delivering combined training programs, they are not two facets of the same coin. Further studies that are more theoretically grounded are necessary to determine whether interventions delivered via exergames may lead to superior benefits compared to conventional separated and combined training interventions. %M 36190757 %R 10.2196/38192 %U https://games.jmir.org/2022/4/e38192 %U https://doi.org/10.2196/38192 %U http://www.ncbi.nlm.nih.gov/pubmed/36190757 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e35907 %T Points and the Delivery of Gameful Experiences in a Gamified Environment: Framework Development and Case Analysis %A Park,Sungjin %A Kim,Sangkyun %+ Graduate School of Business, Kyung Hee University, 506, Orbis Hall, 24, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea, 82 02 961 0448, saviour@khu.ac.kr %K point %K design framework %K gamification %K gameful experience %K pointsification %K overjustification effect %D 2022 %7 29.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Points represent one of the most widely used game mechanics in gamification. They have been used as a means to provide feedback to users. They visually show user performance and are used along with other game mechanics to produce synergy effects. However, using points without analyzing the application environment and targets adversely affects users. Objective: This study aims to identify the problems that users encounter when points are applied improperly, to solve problems based on an analysis of previous studies and actual point use cases, and to develop a point design framework to deliver gameful experiences. Methods: Three problems were identified by analyzing previous studies. The first problem is points that only accumulate. The second is points that emphasize a user’s difference from other people. The third pertains to the reward distribution problem that occurs when points are used as rewards. Results: We developed a framework by deriving 3 criteria for applying points. The first criterion is based on the passive acquisition approach and the active use approach. The second criterion is used to classify points as “high/low” and “many/few” types. The third criterion is the classification of personal reward points and group reward points based on segmentation of the reward criteria. We developed 8 types of points based on the derived point design framework. Conclusions: We expect that some of the problems that users experience when using points can be solved. Furthermore, we expect that some of the problems that arise when points are used as rewards, such as pointsification and the overjustification effect, can be solved. By solving such problems, we suggest a direction that enables a gameful experience for point users and improves the core value delivery through gameful experiences. We also suggest a gameful experience delivery method in the context of the ongoing COVID-19 pandemic. %M 36173674 %R 10.2196/35907 %U https://games.jmir.org/2022/3/e35907 %U https://doi.org/10.2196/35907 %U http://www.ncbi.nlm.nih.gov/pubmed/36173674 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 11 %N 2 %P e25886 %T The Use of Compression Stockings to Reduce Water Retention in the Legs During Gaming and Esports: Randomized Controlled Field Study %A Schmidt,Steffen Christian Ekkehard %A Sell,Stefan %A Woll,Alexander %+ Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Engler-Bunte-Ring 15, Karlsruhe, 76131, Germany, 49 176 24569222, steffen.schmidt@kit.edu %K esport %K streaming %K gaming %K water retention %K fluid balance %K compression stockings %K bioelectrical impedance %K mobile phone %D 2022 %7 29.9.2022 %9 Original Paper %J Interact J Med Res %G English %X Background: With the increasing digitalization of daily life, internet-based entertainment such as gaming and streaming has advanced to one of the megatrends of the 21st century. Besides offering a multitude of controversially discussed opportunities for entertainment and social interaction, there is reasonable concern about health issues caused by the absence of physical activity among activities linked to gaming and streaming. Objective: The aim of this study is to compare the water balance of recreational gamers with and those without compression stockings during a gaming event. Methods: We measured body composition and water balance with 8-electrode bioelectrical impedance analysis among 46 recreational gamers with an average age of 27.1 (SD 6.5) years (5/46, 11% women and 41/46, 89% men) before and after 24 hours at a gaming event. Of the 46 gamers, 23 (50%) gamers wore compression stockings for the duration of the study. Results: Our study shows that prolonged gaming and associated behaviors during a 24-hour time frame lead to an increase in total body water (+0.76 L; P<.001) and a decrease of phase angle in the lower extremities (−0.47°; P<.001) but not in the upper extremities (+0.09°; P=.80), when no compression is used. Gamers using compression socks did not show any significant negative effects on their body composition. Conclusions: Prolonged gaming and streaming are serious risk factors for diseases associated with water retention in the legs, and these risks can be measured by bioelectrical impedance and reduced by wearing compression stockings. We conclude that these findings should be discussed and replicated in larger studies and that there is a considerably large market for compression stockings among gamers and live streamers. %M 36173666 %R 10.2196/25886 %U https://www.i-jmr.org/2022/2/e25886 %U https://doi.org/10.2196/25886 %U http://www.ncbi.nlm.nih.gov/pubmed/36173666 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38200 %T The Effects of Acute Virtual Reality Exergaming on Mood and Executive Function: Exploratory Crossover Trial %A Ochi,Genta %A Kuwamizu,Ryuta %A Fujimoto,Tomomi %A Ikarashi,Koyuki %A Yamashiro,Koya %A Sato,Daisuke %+ Department of Health and Sports, Niigata University of Health and Welfare, Kita-ku, Shimami-cho, 1398, Niigata, 950-3198, Japan, 81 025 257 4595, ochi@nuhw.ac.jp %K virtual reality %K exergaming %K exercise %K executive function %K physical activity %K mental health %D 2022 %7 28.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) exergaming is a new intervention strategy to help humans engage in physical activity to enhance mood. VR exergaming may improve both mood and executive function by acting on the prefrontal cortex, expanding the potential benefits. However, the impact of VR exergaming on executive function has not been fully investigated, and associated intervention strategies have not yet been established. Objective: This study aims to investigate the effects of 10 minutes of VR exergaming on mood and executive function. Methods: A total of 12 participants played the exergame “FitXR” under 3 conditions: (1) a VR exergame condition (ie, exercise with a head-mounted display condition [VR-EX]) in which they played using a head-mounted display, (2) playing the exergame in front of a flat display (2D-EX), and (3) a resting condition in which they sat in a chair. The color-word Stroop task (CWST), which assesses executive function; the short form of the Profile of Mood States second edition (POMS2); and the short form of the Two-Dimensional Mood Scale (TDMS), which assess mood, were administered before and after the exercise or rest conditions. Results: The VR-EX condition increased the POMS2 vigor activity score (rest and VR-EX: t11=3.69, P=.003) as well as the TDMS arousal (rest vs 2D-EX: t11=5.34, P<.001; rest vs VR-EX: t11=5.99, P<.001; 2D-EX vs VR-EX: t11=3.02, P=.01) and vitality scores (rest vs 2D-EX: t11=3.74, P=.007; rest vs VR-EX: t11=4.84, P=.002; 2D-EX vs VR-EX: t11=3.53, P=.006), suggesting that VR exergaming enhanced mood. Conversely, there was no effect on CWST performance in either the 2D-EX or VR-EX conditions. Interestingly, the VR-EX condition showed a significant positive correlation between changes in CWST arousal and reaction time (r=0.58, P=.046). This suggests that the effect of exergaming on improving executive function may disappear under an excessively increased arousal level in VR exergaming. Conclusions: Our findings showed that 10 minutes of VR exergaming enhanced mood but did not affect executive function. This suggests that some VR content may increase cognitive demands, leading to psychological fatigue and cognitive decline as an individual approaches the limits of available attentional capacity. Future research must examine the combination of exercise and VR that enhances both brain function and mood. %M 36169992 %R 10.2196/38200 %U https://games.jmir.org/2022/3/e38200 %U https://doi.org/10.2196/38200 %U http://www.ncbi.nlm.nih.gov/pubmed/36169992 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 9 %P e40189 %T Information System for Symptom Diagnosis and Improvement of Attention Deficit Hyperactivity Disorder: Protocol for a Nonrandomized Controlled Pilot Study %A Pandria,Niki %A Petronikolou,Vasileia %A Lazaridis,Aristotelis %A Karapiperis,Christos %A Kouloumpris,Eleftherios %A Spachos,Dimitris %A Fachantidis,Anestis %A Vasiliou,Dimitris %A Vlahavas,Ioannis %A Bamidis,Panagiotis %+ Medical Physics and Digital Innovation Lab, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Building D, Entrance 8, 3rd floor, Campus of Aristotle University of Thessaloniki, Thessaloniki, 54124, Greece, 30 2310999310, bamidis@auth.gr %K attention deficit hyperactivity disorder (ADHD) %K machine learning %K web health %K serious games %K ADHD monitoring %D 2022 %7 28.9.2022 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders during childhood; however, the diagnosis procedure remains challenging, as it is nonstandardized, multiparametric, and highly dependent on subjective evaluation of the perceived behavior. Objective: To address the challenges of existing procedures for ADHD diagnosis, the ADHD360 project aims to develop a platform for (1) early detection of ADHD by assessing the user’s likelihood of having ADHD characteristics and (2) providing complementary training for ADHD management. Methods: A 2-phase nonrandomized controlled pilot study was designed to evaluate the ADHD360 platform, including ADHD and non-ADHD participants aged 7 to 16 years. At the first stage, an initial neuropsychological evaluation along with an interaction with the serious game developed (“Pizza on Time”) for approximately 30-45 minutes is performed. Subsequently, a 2-week behavior monitoring of the participants through the mADHD360 app is planned after a telephone conversation between the participants’ parents and the psychologist, where the existence of any behaviors characteristic of ADHD that affect daily functioning is assessed. Once behavior monitoring is complete, the research team invites the participants to the second stage, where they play the game for a mean duration of 10 weeks (2 times per week). Once the serious game is finished, a second round of behavior monitoring is performed following the same procedures as the initial one. During the study, gameplay data were collected and preprocessed. The protocol of the pilot trials was initially designed for in-person participation, but after the COVID-19 outbreak, it was adjusted for remote participation. State-of-the-art machine learning (ML) algorithms were used to analyze labeled gameplay data aiming to detect discriminative gameplay patterns among the 2 groups (ADHD and non-ADHD) and estimate a player’s likelihood of having ADHD characteristics. A schema including a train-test splitting with a 75:25 split ratio, k-fold cross-validation with k=3, an ML pipeline, and data evaluation were designed. Results: A total of 43 participants were recruited for this study, where 18 were diagnosed with ADHD and the remaining 25 were controls. Initial neuropsychological assessment confirmed that the participants in the ADHD group showed a deviation from the participants without ADHD characteristics. A preliminary analysis of collected data consisting of 30 gameplay sessions showed that the trained ML models achieve high performance (ie, accuracy up to 0.85) in correctly predicting the users’ labels (ADHD or non-ADHD) from their gameplay session on the ADHD360 platform. Conclusions: ADHD360 is characterized by its notable capacity to discriminate player gameplay behavior as either ADHD or non-ADHD. Therefore, the ADHD360 platform could be a valuable complementary tool for early ADHD detection. Trial Registration: ClinicalTrials.gov NCT04362982; https://clinicaltrials.gov/ct2/show/NCT04362982 International Registered Report Identifier (IRRID): RR1-10.2196/40189 %M 36169998 %R 10.2196/40189 %U https://www.researchprotocols.org/2022/9/e40189 %U https://doi.org/10.2196/40189 %U http://www.ncbi.nlm.nih.gov/pubmed/36169998 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e37506 %T Virtual Reality–Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial %A Hernandez,Alejandro %A Bubyr,Liudmila %A Archambault,Philippe S %A Higgins,Johanne %A Levin,Mindy F %A Kairy,Dahlia %+ Centre for Interdisciplinary Research in Rehabilitation, 6363 Hudson Road, Office 061, Lindsay Pavilion of the Institut universitaire sur la réadaptation en déficience physique de Montréal, Montreal, QC, H3S 1M9, Canada, 1 514 737 0592 ext 4778, alejandro.hernandez@mail.mcgill.ca %K rehabilitation %K serious game %K stroke %K telerehabilitation %K upper extremity %K virtual reality–based rehabilitation %K virtual reality %K virtual care %D 2022 %7 27.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)–based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function. Objective: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants’ homes. Methods: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group. Results: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants. Conclusions: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services. Trial Registration: ClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203 International Registered Report Identifier (IRRID): RR2-10.1016/j.cct.2015.12.006 %M 36166289 %R 10.2196/37506 %U https://games.jmir.org/2022/3/e37506 %U https://doi.org/10.2196/37506 %U http://www.ncbi.nlm.nih.gov/pubmed/36166289 %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 e34501 %T Augmented Reality in Vascular and Endovascular Surgery: Scoping Review %A Eves,Joshua %A Sudarsanam,Abhilash %A Shalhoub,Joseph %A Amiras,Dimitri %+ Imperial Vascular Unit, Imperial College Healthcare NHS Trust, St Marys Hospital, Praed Street, London, W2 1NY, United Kingdom, 44 7881389569, joshua.eves@nhs.net %K augmented reality %K surgery %K vascular %K endovascular %K head-mounted display %K mobile phone %D 2022 %7 23.9.2022 %9 Review %J JMIR Serious Games %G English %X Background: Technological advances have transformed vascular intervention in recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest in surgery, with the potential to improve clinicians’ understanding of 3D anatomy and aid in the processing of real-time information. This study hopes to elucidate the potential impact of AR technology in the rapidly evolving fields of vascular and endovascular surgery. Objective: The aim of this review is to summarize the fundamental concepts of AR technologies and conduct a scoping review of the impact of AR and mixed reality in vascular and endovascular surgery. Methods: A systematic search of MEDLINE, Scopus, and Embase was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies written in English from inception until January 8, 2021, were included in the search. Combinations of the following keywords were used in the systematic search string: (“augmented reality” OR “hololens” OR “image overlay” OR “daqri” OR “magic leap” OR “immersive reality” OR “extended reality” OR “mixed reality” OR “head mounted display”) AND (“vascular surgery” OR “endovascular”). Studies were selected through a blinded process between 2 investigators (JE and AS) and assessed using data quality tools. Results: AR technologies have had a number of applications in vascular and endovascular surgery. Most studies (22/32, 69%) used 3D imaging of computed tomography angiogram–derived images of vascular anatomy to augment clinicians’ anatomical understanding during procedures. A wide range of AR technologies were used, with heads up fusion imaging and AR head-mounted displays being the most commonly applied clinically. AR applications included guiding open, robotic, and endovascular surgery while minimizing dissection, improving procedural times, and reducing radiation and contrast exposure. Conclusions: AR has shown promising developments in the field of vascular and endovascular surgery, with potential benefits to surgeons and patients alike. These include reductions in patient risk and operating times as well as in contrast and radiation exposure for radiological interventions. Further technological advances are required to overcome current limitations, including processing capacity and vascular deformation by instrumentation. %M 36149736 %R 10.2196/34501 %U https://games.jmir.org/2022/3/e34501 %U https://doi.org/10.2196/34501 %U http://www.ncbi.nlm.nih.gov/pubmed/36149736 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e34768 %T Digital Biomarkers for Well-being Through Exergame Interactions: Exploratory Study %A Petsani,Despoina %A Konstantinidis,Evdokimos %A Katsouli,Aikaterini-Marina %A Zilidou,Vasiliki %A Dias,Sofia B %A Hadjileontiadis,Leontios %A Bamidis,Panagiotis %+ Medical Physics and Digital Innovation Laboratory, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Medical Physics and Digital Innovation Laboratory, Thessaloniki, 54124, Greece, 30 2310999310, bamidis@med.auth.gr %K serious games %K machine learning %K physical well-being %K cognitive well-being %D 2022 %7 13.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Ecologically valid evaluations of patient states or well-being by means of new technologies is a key issue in contemporary research in health and well-being of the aging population. The in-game metrics generated from the interaction of users with serious games (SG) can potentially be used to predict or characterize a user’s state of health and well-being. There is currently an increasing body of research that investigates the use of measures of interaction with games as digital biomarkers for health and well-being. Objective: The aim of this paper is to predict well-being digital biomarkers from data collected during interactions with SG, using the values of standard clinical assessment tests as ground truth. Methods: The data set was gathered during the interaction with patients with Parkinson disease with the webFitForAll exergame platform, an SG engine designed to promote physical activity among older adults, patients, and vulnerable populations. The collected data, referred to as in-game metrics, represent the body movements captured by a 3D sensor camera and translated into game analytics. Standard clinical tests gathered before and after the long-term interaction with exergames (preintervention test vs postintervention test) were used to provide user baselines. Results: Our results showed that in-game metrics can effectively categorize participants into groups of different cognitive and physical states. Different in-game metrics have higher descriptive values for specific tests and can be used to predict the value range for these tests. Conclusions: Our results provide encouraging evidence for the value of in-game metrics as digital biomarkers and can boost the analysis of improving in-game metrics to obtain more detailed results. %M 36099000 %R 10.2196/34768 %U https://games.jmir.org/2022/3/e34768 %U https://doi.org/10.2196/34768 %U http://www.ncbi.nlm.nih.gov/pubmed/36099000 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36288 %T The Design, Development, and Testing of a Virtual Reality Device for Upper Limb Training in People With Multiple Sclerosis: Single-Center Feasibility Study %A Kalron,Alon %A Frid,Lior %A Fonkatz,Iliya %A Menascu,Shay %A Dolev,Mark %A Magalashvili,David %A Achiron,Anat %+ Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, 39040, Israel, 972 036405430, alonkalr@post.tau.ac.il %K virtual reality %K rehabilitation %K feasibility %K upper limb %K multiple sclerosis %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction. Objective: The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction. Methods: A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training. Results: Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported. Conclusions: These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment. %M 36094809 %R 10.2196/36288 %U https://games.jmir.org/2022/3/e36288 %U https://doi.org/10.2196/36288 %U http://www.ncbi.nlm.nih.gov/pubmed/36094809 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36754 %T The Effectiveness of Serious Games on Cognitive Processing Speed Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Ahmed,Arfan %A Alali,Haitham %A Aldardour,Ahmad Mohammad %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, 0000, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K processing speed %K mild cognitive impairment %K Alzheimer disease %K dementia %K systematic reviews %K meta-analysis %K mobile phone %D 2022 %7 9.9.2022 %9 Review %J JMIR Serious Games %G English %X Background: Human cognitive processing speed is known to decline with age. Human cognitive processing speed refers to the time that an individual takes from receiving a stimulus to reacting to it. Serious games, which are video games used for training and educational purposes, have the potential to improve processing speed. Numerous systematic reviews have summarized the evidence regarding the effectiveness of serious games in improving processing speed, but they are undermined by some limitations. Objective: This study aimed to examine the effectiveness of serious games on the cognitive processing speed of an older adult population living with cognitive impairment. Methods: A systematic review of randomized controlled trials (RCTs) was conducted. Two search sources were used in this review: 8 electronic databases and backward and forward reference list checking. A total of 2 reviewers independently checked the eligibility of the studies, extracted data from the included studies, and appraised the risk of bias and quality of the evidence. Evidence from the included studies was synthesized using a narrative and statistical approach (ie, meta-analysis), as appropriate. Results: Of the 548 publications identified, 16 (2.9%) RCTs eventually met all eligibility criteria. Very-low-quality evidence from 50% (8/16) and 38% (6/16) of the RCTs showed no statistically significant effect of serious games on processing speed compared with no or passive intervention groups (P=.77) and conventional exercises (P=.58), respectively. A subgroup analysis showed that both types of serious games (cognitive training games: P=.26; exergames: P=.88) were as effective as conventional exercises in improving processing speed. Conclusions: There is no superiority of serious games over no or passive interventions and conventional exercises in improving processing speed among older adults with cognitive impairment. However, our findings remain inconclusive because of the low quality of the evidence, the small sample size in most of the included studies, and the paucity of studies included in the meta-analyses. Therefore, until more robust evidence is published, serious games should be offered or used as an adjunct to existing interventions. Further trials should be undertaken to investigate the effect of serious games that specifically target processing speed rather than cognitive abilities in general. Trial Registration: PROSPERO CRD42022301667; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=301667 %M 36083623 %R 10.2196/36754 %U https://games.jmir.org/2022/3/e36754 %U https://doi.org/10.2196/36754 %U http://www.ncbi.nlm.nih.gov/pubmed/36083623 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e33858 %T Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report %A Mena-Moreno,Teresa %A Munguía,Lucero %A Granero,Rosario %A Lucas,Ignacio %A Sánchez-Gómez,Almudena %A Cámara,Ana %A Compta,Yaroslau %A Valldeoriola,Francesc %A Fernandez-Aranda,Fernando %A Sauvaget,Anne %A Menchón,José M %A Jiménez-Murcia,Susana %+ Department of Psychiatry, Bellvitge University Hospital, c/ Feixa Llarga, s/n, Hospitalet de Llobregat, 08907, Spain, 34 93 2607988, sjimenez@bellvitgehospital.cat %K Parkinson disease %K impulse control disorder %K hypersexuality %K multidisciplinary approach %K serious game %D 2022 %7 9.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD. Objective: The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game—e-Estesia—whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease. Methods: After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity. Results: After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased. Conclusions: The combined intervention—CBT and a serious game—showed positive results in terms of treatment outcomes. %M 36083621 %R 10.2196/33858 %U https://games.jmir.org/2022/3/e33858 %U https://doi.org/10.2196/33858 %U http://www.ncbi.nlm.nih.gov/pubmed/36083621 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 8 %P e39527 %T The Role of Serious Video Games in the Treatment of Disordered Eating Behaviors: Systematic Review %A Tang,Wymann S W %A Ng,Tricia J Y %A Wong,Joseph Z A %A Ho,Cyrus S H %+ Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore, 65 67727831, pcmhsh@nus.edu.sg %K serious video games %K serious games %K video games %K gamification %K digital health %K eHealth %K mobile health %K mHealth %K disordered eating %K eating disorders %D 2022 %7 29.8.2022 %9 Review %J J Med Internet Res %G English %X Background: Eating disorders and other forms of disordered eating cause significant complications and comorbidities in patients. However, full remission with current standard treatment remains low. Challenges to treatment include underdiagnosis and high dropout rates, as well as difficulties in addressing underlying emotion dysregulation, poor impulse control, and personality traits. Serious video games (SVGs), which have the advantages of being highly engaging and accessible, may be potential tools for delivering various forms of treatment in addressing the underlying psychopathology of disordered eating. Objective: This review aims to provide an overview of the possible mechanisms by which SVGs may affect the clinical course of disordered eating, while evaluating the outcomes of studies that have assessed the role of SVGs in the treatment of disordered eating. Methods: A systematic search was performed on PubMed, PsycINFO, and Embase, using keywords related to SVGs, disordered eating, and eating disorders. A narrative synthesis was subsequently carried out. Results: In total, 2151 papers were identified, of which 11 (0.51%) were included. Of these 11 studies, 10 (91%) were randomized controlled trials, and 1 (9%) was a quasi-experimental study. The types of SVG interventions varied across the studies and targeted different mechanisms of disordered eating, ranging from addressing problem-solving and emotion regulation skills to neurocognitive training for inhibitory control. Most (10/11, 91%) of the studies showed some benefit of the SVGs in improving certain physical, behavioral, or psychological outcomes related to disordered eating. Some (4/11, 36%) of the studies also showed encouraging evidence of the retention of these benefits at follow-up. Conclusions: The studies included in this review provide collective evidence to suggest the various roles SVGs can play in plugging potential gaps in conventional therapy. Nonetheless, challenges exist in designing these games to prevent potential pitfalls, such as excessive stress arising from the SVGs themselves or potential gaming addiction. Further studies will also be required to assess the long-term benefits of SVGs as well as explore their potential preventive, and not just curative, effects on disordered eating. %M 36036967 %R 10.2196/39527 %U https://www.jmir.org/2022/8/e39527 %U https://doi.org/10.2196/39527 %U http://www.ncbi.nlm.nih.gov/pubmed/36036967 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e39086 %T Serious Games Supporting the Prevention and Treatment of Alcohol and Drug Consumption in Youth: Scoping Review %A Martínez-Miranda,Juan %A Espinosa-Curiel,Ismael Edrein %+ Centro de Investigación Científica y de Educación Superior de Ensenada, Unidad de Transferencia Tecnológica Tepic, Andador 10, Ciudad del Conocimiento, Tepic, 63173, Mexico, 52 3111295930 ext 28602, jmiranda@cicese.mx %K serious games %K substance use %K alcohol and drugs %K young population %K mobile phone %D 2022 %7 25.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: The consumption of alcohol and drugs, particularly in adolescents and young adults, has increased worldwide in the last several years, representing a significant public health challenge. Serious games have the potential to support preventive and treatment interventions for substance use, facilitating the acquisition of relevant knowledge and the motivation for changes in attitudes and behaviors regarding substance consumption. Objective: This scoping review aims to analyze a set of 7 relevant characteristics of current serious games designed to support the prevention and treatment of alcohol and drug consumption in adolescents and young adults—the substance addressed, the type of intervention, the theoretical basis, the computational techniques used, the mechanism for data security and privacy, the evaluation procedure followed, and the main results obtained. Methods: The review was performed by following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Data were retrieved from January 2010 to May 2022, using PubMed, Scopus (Elsevier), IEEE Xplore, and ACM Digital as data sources. The eligibility criteria included studies that described serious games designed to support the prevention or treatment of alcohol and drug consumption, targeted a population aged between 12 and 30 years, and included an evaluation procedure. Authors (JMM and IEEC) individually screened the titles and abstracts, and then full articles were reviewed for a final inclusion decision. Results: A total of 629 records were obtained, and 29 (4.6%) fulfilled the inclusion criteria. Most of the serious games (14/29, 48%) were focused on the prevention or treatment of alcohol use. The type of intervention that was the most supported was prevention (18/29, 62%), and most studies mentioned the theory, theoretical construct, or therapeutic technique used as a foundation (22/29, 76%). Most of the studies only provided information about the platform for execution (23/29, 79%), and few described the use of computational techniques, such as virtual reality or motion-based interaction (5/29, 17%). A small set of studies (10/29, 34%) explicitly mentioned how data security and privacy were addressed. Most of the reported evaluation protocols were pilot studies (11/29, 38%), followed by randomized controlled trials (10/29, 34%), and the reported results were positive in terms of acceptability, usability, and efficacy. However, more research is needed to assess long-term effects. Conclusions: Given the increasing interest in the use of serious games as digital interventions to support the prevention or treatment of substance use, knowing their main features is highly important. This review highlights whether and how current serious games incorporate 7 key features that are useful to consider for the further development of the area. %M 36006694 %R 10.2196/39086 %U https://games.jmir.org/2022/3/e39086 %U https://doi.org/10.2196/39086 %U http://www.ncbi.nlm.nih.gov/pubmed/36006694 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e37079 %T Development of a Therapeutic Video Game With the MDA Framework to Decrease Anxiety in Preschool-Aged Children With Acute Lymphoblastic Leukemia: Mixed Methods Approach %A Yang,Dai-Jie %A Lu,Meng-Yao %A Chen,Chi-Wen %A Liu,Pei-Ching %A Hou,I-Ching %+ College of Nursing, National Yang Ming Chiao Tung University, Number 155, Section 2, Linong Street, Beitou District, Taipei City, 11221, Taiwan, 886 28267000 ext 67315, evidta@gmail.com %K acute lymphoblastic leukemia %K therapeutic video games %K childhood cancer %K preschoolers %K anxiety %D 2022 %7 22.8.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Preschool-aged children with acute lymphoblastic leukemia (ALL) receive long-term treatment according to the Taiwan Pediatric Oncology Group (TPOG)–ALL 2013 protocol. Severe anxiety and noncompliance ahead of frequent invasive therapies leads to an increase in health care costs. Previous studies have shown that therapeutic video games (TVGs) can decrease the anxiety experienced by children who are ill. To our knowledge, no existing TVG has been designed specifically for preschool-aged children with ALL in Taiwan. Objective: The purpose of this study was to develop a TVG using the popular Mechanics, Dynamics, and Aesthetics (MDA) framework for game design and to investigate the effect of this TVG on the reduction of therapy-related anxiety among preschool-aged children with ALL. Methods: This study used a mixed methods approach over three phases: (1) develop a TVG using the MDA framework, (2) test the reliability of the TVG among three certified children’s art therapists, and (3) evaluate the reduction of therapy-related anxiety among participants after using the TVG for 6 weeks, using a two-group, stratified randomized controlled trial at a medical center in northern Taiwan. Eligible preschool-aged children with ALL were randomly assigned 1:1 into an experimental group or a control group. The two groups of subjects received the same usual care, and only the experimental group had access to and used the TVG. The children’s anxiety responses were reported by their family caregivers using the face rating scale (FRS). Descriptive analyses, the Fisher exact test, the Pearson chi-square test, and the Mann-Whitney U test were used to statistically analyze the variables. Results: Six mechanics rules supported the dynamics of the TVG using four main features—character, nursery, tasks, and market—in order to complete all of the therapy-related anxiety reduction scenarios and to achieve eight aesthetics goals. The results of reliability test showed that participants found the TVG to be useful and trustworthy for preschool-aged children with ALL (Cronbach α=.98). A total of 15 participants were enrolled and randomly allocated to the experimental group (n=7) or the control group (n=8). The average number of TVG log-ins was 37.9 (SD 15.30, range 14-62) in the experimental group. The demographic data showed homogeneity across the two groups regarding age (3 to 5 years), sex (male), risk classification (standard risk), and treatment status (continuation therapy). The mean FRS score was 6.16 (SD 3.31) for the experimental group as compared to 7.45 (SD 2.71) for the control group (P=.04), which represented a significant difference between the groups at the 6-week follow-up. Conclusions: This research provides evidence that using a TVG can decrease anxiety in preschool-aged children with ALL in Taiwan. The TVG could be used to support clinical professionals before they perform invasive therapies. However, it is recommended to increase the statistical power for inference. Trial Registration: ClinicalTrials.gov NCT04199637; https://www.clinicaltrials.gov/ct2/show/NCT04199637 %M 35994340 %R 10.2196/37079 %U https://games.jmir.org/2022/3/e37079 %U https://doi.org/10.2196/37079 %U http://www.ncbi.nlm.nih.gov/pubmed/35994340 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e31456 %T Digital Interventions for Emotion Regulation in Children and Early Adolescents: Systematic Review and Meta-analysis %A Reynard,Sally %A Dias,Joao %A Mitic,Marija %A Schrank,Beate %A Woodcock,Kate Anne %+ Centre for Applied Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2SA, United Kingdom, 44 0121 414 6036, sallyreynard1@gmail.com %K emotion regulation %K digital interventions %K youth %K systematic review %K meta-analysis %K children %K early adolescents %K serious games %K training %K biofeedback %K mobile phone %D 2022 %7 19.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Difficulties in emotion regulation are common in adolescence and are associated with poor social and mental health outcomes. However, psychological therapies that promote adaptive emotion regulation may be inaccessible and unattractive to youth. Digital interventions may help address this need. Objective: The aim of this systematic review and meta-analysis was to synthesize evidence on the efficacy, feasibility, and acceptability of emotion regulation digital interventions in children and early adolescents aged 8 to 14 years. Methods: Systematic searches of Web of Science, MEDLINE, PsycINFO, EMBASE, Education Resources Information Centre, ACM Digital Library, and IEEE Xplore up to July 2020 identified 39 studies, of which 11 (28%) were included in the meta-analyses (n=2476 participants). A bespoke tool was used to assess risk of bias. Results: The studies evaluated digital games (27/39, 69%), biofeedback (4/39, 10%), virtual or augmented reality (4/39, 10%), and program or multimedia (4/39, 10%) digital interventions in samples classified as diagnosed, at risk, healthy, and universal. The most consistent evidence came from digital games, which reduced negative emotional experience with a small significant effect, largely in youth at risk of anxiety (Hedges g=–0.19, 95% CI –0.34 to –0.04). In general, digital interventions tended to improve emotion regulation, but this effect was not significant (Hedges g=0.19, 95% CI –0.16 to 0.54). Conclusions: Most feasibility issues were identified in diagnosed youth, and acceptability was generally high across intervention types and samples. Although there is cause to be optimistic about digital interventions supporting the difficulties that youth experience in emotion regulation, the predominance of early-stage development studies highlights the need for more work in this area. %M 35984681 %R 10.2196/31456 %U https://games.jmir.org/2022/3/e31456 %U https://doi.org/10.2196/31456 %U http://www.ncbi.nlm.nih.gov/pubmed/35984681 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e26615 %T A Game-Based School Program for Mental Health Literacy and Stigma on Depression (Moving Stories): Cluster Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Olthof,Merlijn %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University Nijmegen, Postbus 9104, Nijmegen, 6500 HE, Netherlands, 31 243610082, anouk.tuijnman@ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %K mental health %K digital health %D 2022 %7 17.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depressive symptoms are highly prevalent among adolescents in Western countries. However, although treatment for depressive symptoms is available, many adolescents do not seek help when they need it. Important barriers to help-seeking among adolescents include low mental health literacy and high stigma. Therefore, we have developed a game-based school program, Moving Stories, which combines mental health literacy training for depression with contact with someone with lived experience both in the digital and nondigital world. Objective: The aim of this study is to conduct a first test of the effectiveness of the newly developed game-based program, Moving Stories, using a cluster randomized controlled trial. Methods: A total of 185 adolescents participated, divided over 10 classes from 4 schools. Half of the classes were randomly selected to follow the Moving Stories program, whereas the other half were in the control group, where no intervention was provided. The adolescents filled out digital questionnaires at 4 time points, with questions on mental health literacy, stigma, depressive symptoms, and the program itself (before the program, after the program, 3-month follow-up, and 6-month follow-up). Using R (R Foundation for Statistical Computing), we ran linear mixed-effects models for all continuous outcome variables and generalized linear mixed-effects models for all binary outcome variables. Results: Compared with the control group, participants in the Moving Stories group improved after the program in personal stigma (b=−0.53, 95% CI −1.02 to −0.03; t179.16=−2.08; P=.04). Effects on personal stigma lasted over time (3-month follow-up: b=−0.57, 95% CI −1.11 to −0.03; t174.39=−2.07; P=.04). Most adolescents in the Moving Stories group participated in the introduction (97/99, 98%) and contact session (93/99, 94%), played the game for 4 or 5 days (83/99, 83%), and indicated that they would recommend the game to their peers (90/98, 92%). Conclusions: The results of this study show the potential of Moving Stories as a stigma reduction program. With changes in the program to improve its effects on mental health literacy, Moving Stories could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms. Trial Registration: Dutch Trial Register NTR7033; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7033 International Registered Report Identifier (IRRID): RR2-10.2196/11255 %M 35976200 %R 10.2196/26615 %U https://mental.jmir.org/2022/8/e26615 %U https://doi.org/10.2196/26615 %U http://www.ncbi.nlm.nih.gov/pubmed/35976200 %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 e35202 %T The Effectiveness of Serious Games in Improving Memory Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Alhuwail,Dari %A Al-Jafar,Eiman %A Ahmed,Arfan %A Shuweihdi,Farag %A Reagu,Shuja Mohd %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K memory %K systematic reviews %K meta-analysis %K mobile phone %D 2022 %7 9.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Memory, one of the main cognitive functions, is known to decline with age. Serious games have been used for improving memory in older adults. The effectiveness of serious games in improving memory has been assessed by many studies. To draw definitive conclusions about the effectiveness of serious games, the findings of these studies need to be pooled and aggregated. Objective: This study aimed to assess the effectiveness of serious games in improving memory in older adults with cognitive impairment. Methods: A systematic review of randomized controlled trials was carried out. The search sources included 8 databases, the reference lists of the included studies and relevant reviews, and the studies that cited the included studies. In total, 2 reviewers (AA and MH) independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Extracted data were synthesized using a narrative approach and a statistical approach (ie, multilevel meta-analysis), as appropriate. Results: Of the 618 citations retrieved, 18 (2.9%) met the eligibility criteria for this review. Of these 18 studies, 15 (83%) randomized controlled trials were included in 10 multilevel meta-analyses. We found that serious games were more effective than no or passive interventions in improving nonverbal memory (P=.02; standardized mean difference [SMD]=0.46, 95% CI 0.09-0.83) and working memory (P=.04; SMD=0.31, 95% CI 0.01-0.60) but not verbal memory (P=.13; SMD=0.39, 95% CI −0.11 to 0.89). The review also showed that serious games were more effective than conventional exercises in improving verbal memory (P=.003; SMD=0.46, 95% CI 0.16-0.77) but not nonverbal memory (P=.30; SMD=−0.19, 95% CI −0.54 to 0.17) or working memory (P=.99; SMD=0.00, 95% CI −0.45 to 0.45). Serious games were as effective as conventional cognitive activities in improving verbal memory (P=.14; SMD=0.66, 95% CI −0.21 to 1.54), nonverbal memory (P=.94; SMD=−0.01, 95% CI −0.32 to 0.30), and working memory (P=.08; SMD=0.37, 95% CI −0.05 to 0.78) among older adults with cognitive impairment. Finally, the effect of adaptive serious games on working memory was comparable with that of nonadaptive serious games (P=.08; SMD=0.18, 95% CI −0.02 to 0.37). Conclusions: Serious games have the potential to improve verbal, nonverbal, and working memory in older adults with cognitive impairment. However, our findings should be interpreted cautiously given that most meta-analyses were based on a few studies (≤3) and judged to have a low quality of evidence. Therefore, serious games should be offered as a supplement to existing proven and safe interventions rather than as a complete substitute until further, more robust evidence is available. Future studies should investigate the short- and long-term effects of serious games on memory and other cognitive abilities among people of different age groups with or without cognitive impairment. %M 35943792 %R 10.2196/35202 %U https://games.jmir.org/2022/3/e35202 %U https://doi.org/10.2196/35202 %U http://www.ncbi.nlm.nih.gov/pubmed/35943792 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 5 %N 3 %P e34588 %T Intervention Mapping of a Gamified Therapy Prescription App for Children With Disabilities: User-Centered Design Approach %A Johnson,Rowan W %A White,Becky K %A Gucciardi,Daniel F %A Gibson,Noula %A Williams,Sian A %+ Therapy Services, Ability WA, 106 Bradford Street, Coolbinia, Perth, 6069, Australia, 61 1300106106, rowan.johnson@abilitywa.com.au %K neurodevelopmental disability %K mobile health %K self-determination theory %K gamification %K physiotherapy %K occupational therapy %K speech pathology %K behavior change %K mobile phone %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Mobile health (mHealth) apps for children are increasing in availability and scope. Therapy (physiotherapy, speech pathology, and occupational therapy) prescription apps to improve home or school program adherence work best when developed to be highly engaging for children and when they incorporate behavior change techniques (BCTs) within their design. Objective: The aim of this study was to describe the development of a user-centered therapy prescription app for children (aged 6-12 years) with neurodevelopmental disabilities (eg, cerebral palsy, autism spectrum disorder, and intellectual disability) incorporating intervention mapping (IM) and gamified design. Methods: We used an iterative, user-centered app development model incorporating the first 3 steps of IM. We conducted a needs analysis with user feedback from our previous mHealth app study, a literature review, and a market audit. Change objectives were then specified in alignment with the psychological needs of autonomy, competence, and relatedness identified in self-determination theory. From these objectives, we then selected BCTs, stipulating parameters for effectiveness and how each BCT would be operationalized. A gamification design was planned and implemented focusing on maximizing engagement in children. In total, 2 rounds of consultations with parents, teachers, and therapists and 1 round of prototype app testing with children were conducted to inform app development, with a final iteration developed for further testing. Results: The IM process resulted in the specification of app elements, self-determination theory–informed BCTs, that were embedded into the app design. The gamification design yielded the selection of a digital pet avatar with a fantasy anime visual theme and multiple layers of incentives earned by completing prescribed therapy activities. Consultation groups with professionals working with children with disabilities (4 therapists and 3 teachers) and parents of children with disabilities (n=3) provided insights into the motivation of children and the pragmatics of implementing app-delivered therapy programs that informed the app development. User testing with children with disabilities (n=4) highlighted their enthusiasm for the app and the need for support in the initial phase of learning the app. App quality testing (Mobile Application Rating Scale-user version) with the children yielded means (out of 5) of 4.5 (SD 0.8) for engagement, 3.3 (SD 1.6) for function, 3.3 (SD 1.7) for aesthetics, and 4.3 (SD 1.1) for subjective quality. Conclusions: mHealth apps designed for children can be greatly enhanced with a systematic yet flexible development process considering the specific contextual needs of the children with user-centered design, addressing the need for behavior change using the IM process, and maximizing engagement with gamification and strong visual design. %M 35943782 %R 10.2196/34588 %U https://pediatrics.jmir.org/2022/3/e34588 %U https://doi.org/10.2196/34588 %U http://www.ncbi.nlm.nih.gov/pubmed/35943782 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 8 %P e28851 %T A Psychological Support Intervention to Help Injured Athletes “Get Back in the Game”: Design and Development Study %A Ardern,Clare L %A Hooper,Nicholas %A O'Halloran,Paul %A Webster,Kate E %A Kvist,Joanna %+ Department of Family Practice, University of British Columbia, Robert H.N. Ho Research Centre (level 6), 2635 Laurel Street, Vancouver, BC, V5Z 1M9, Canada, 1 6046752575, clare.ardern@liu.se %K sports %K medicine %K rehabilitation %K sports injury %K psychological support %K mental health %K postoperative medicine %K feasibility %K eHealth %K mobile phone %D 2022 %7 9.8.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support. Objective: We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery. Methods: Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population–based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes’ experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases—(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31). Results: The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features. Conclusions: The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies. %M 35943769 %R 10.2196/28851 %U https://formative.jmir.org/2022/8/e28851 %U https://doi.org/10.2196/28851 %U http://www.ncbi.nlm.nih.gov/pubmed/35943769 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36850 %T Social Media Users’ Perceptions of a Wearable Mixed Reality Headset During the COVID-19 Pandemic: Aspect-Based Sentiment Analysis %A Jeong,Heejin %A Bayro,Allison %A Umesh,Sai Patipati %A Mamgain,Kaushal %A Lee,Moontae %+ Department of Mechanical and Industrial Engineering, University of Illinois Chicago, 842 W Taylor St, Chicago, IL, 60607, United States, 1 312 355 5558, heejinj@uic.edu %K HoloLens 2 %K sentiment analysis %K natural language processing, Twitter %K COVID-19 %K usability evaluation %D 2022 %7 4.8.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Mixed reality (MR) devices provide real-time environments for physical-digital interactions across many domains. Owing to the unprecedented COVID-19 pandemic, MR technologies have supported many new use cases in the health care industry, enabling social distancing practices to minimize the risk of contact and transmission. Despite their novelty and increasing popularity, public evaluations are sparse and often rely on social interactions among users, developers, researchers, and potential buyers. Objective: The purpose of this study is to use aspect-based sentiment analysis to explore changes in sentiment during the onset of the COVID-19 pandemic as new use cases emerged in the health care industry; to characterize net insights for MR developers, researchers, and users; and to analyze the features of HoloLens 2 (Microsoft Corporation) that are helpful for certain fields and purposes. Methods: To investigate the user sentiment, we collected 8492 tweets on a wearable MR headset, HoloLens 2, during the initial 10 months since its release in late 2019, coinciding with the onset of the pandemic. Human annotators rated the individual tweets as positive, negative, neutral, or inconclusive. Furthermore, by hiring an interannotator to ensure agreements between the annotators, we used various word vector representations to measure the impact of specific words on sentiment ratings. Following the sentiment classification for each tweet, we trained a model for sentiment analysis via supervised learning. Results: The results of our sentiment analysis showed that the bag-of-words tokenizing method using a random forest supervised learning approach produced the highest accuracy of the test set at 81.29%. Furthermore, the results showed an apparent change in sentiment during the COVID-19 pandemic period. During the onset of the pandemic, consumer goods were severely affected, which aligns with a drop in both positive and negative sentiment. Following this, there is a sudden spike in positive sentiment, hypothesized to be caused by the new use cases of the device in health care education and training. This pandemic also aligns with drastic changes in the increased number of practical insights for MR developers, researchers, and users and positive net sentiments toward the HoloLens 2 characteristics. Conclusions: Our approach suggests a simple yet effective way to survey public opinion about new hardware devices quickly. The findings of this study contribute to a holistic understanding of public perception and acceptance of MR technologies during the COVID-19 pandemic and highlight several new implementations of HoloLens 2 in health care. We hope that these findings will inspire new use cases and technological features. %M 35708916 %R 10.2196/36850 %U https://games.jmir.org/2022/3/e36850 %U https://doi.org/10.2196/36850 %U http://www.ncbi.nlm.nih.gov/pubmed/35708916 %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 e33884 %T Developing Serious Video Games to Treat Attention Deficit Hyperactivity Disorder: Tutorial Guide %A Sújar,Aarón %A Martín-Moratinos,Marina %A Rodrigo-Yanguas,María %A Bella-Fernández,Marcos %A González-Tardón,Carlos %A Delgado-Gómez,David %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Hospital Universitario Puerta de Hierro Majadahonda, 1 C Joaquín Rodrigo, Majadahonda, 28222, Spain, 34 911916019, hmblasco@yahoo.es %K serious video games %K ADHD %K treatment %K video games %K cognitive %K cognitive disorder %K games %D 2022 %7 1.8.2022 %9 Tutorial %J JMIR Serious Games %G English %X Video game–based therapeutic interventions have demonstrated some effectiveness in decreasing the symptoms of attention deficit hyperactivity disorder (ADHD). Compared with more traditional strategies within the multimodal treatment of ADHD, video games have certain advantages such as being comfortable, flexible, and cost-efficient. However, establishing the most appropriate type(s) of video games that should be used for this treatment remains a matter of debate, including the commercial existing video games or serious video games that are specifically constructed to target specific disorders. This guide represents a starting point for developing serious video games aimed at treating ADHD. We summarize the key points that need to be addressed to generate an effective and motivating game-based treatment. Following recommendations from the literature to create game-based treatments, we describe the development stages of a serious video game for treating ADHD. Game design should consider the interests of future users; game mechanics should be based on cognitive exercises; and therapeutic mechanisms must include the control of difficulty, engagement, motivation, time constraints, and reinforcement. To elaborate upon this guide, we performed a narrative review focused on the use of video games for the treatment of ADHD, and were inspired by our own experience during the development of the game “The Secret Trail of Moon.” %M 35916694 %R 10.2196/33884 %U https://games.jmir.org/2022/3/e33884 %U https://doi.org/10.2196/33884 %U http://www.ncbi.nlm.nih.gov/pubmed/35916694 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e32297 %T Speech Processing as a Far-Transfer Gauge of Serious Games for Cognitive Training in Aging: Randomized Controlled Trial of Web-Based Effectivate Training %A Nitsan,Gal %A Baharav,Shai %A Tal-Shir,Dalith %A Shakuf,Vered %A Ben-David,Boaz M %+ Baruch Ivcher School of Psychology, Reichman University (IDC), P.O. Box 167, Herzliya, 4610101, Israel, 972 584004055, boaz.ben.david@idc.ac.il %K aging %K cognitive aging %K cognitive games %K serious games %K speech processing %K spoken language processing %K eye tracking %K visual world paradigm %D 2022 %7 28.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The number of serious games for cognitive training in aging (SGCTAs) is proliferating in the market and attempting to combat one of the most feared aspects of aging—cognitive decline. However, the efficacy of many SGCTAs is still questionable. Even the measures used to validate SGCTAs are up for debate, with most studies using cognitive measures that gauge improvement in trained tasks, also known as near transfer. This study takes a different approach, testing the efficacy of the SGCTA—Effectivate—in generating tangible far-transfer improvements in a nontrained task—the Eye tracking of Word Identification in Noise Under Memory Increased Load (E-WINDMIL)—which tests speech processing in adverse conditions. Objective: This study aimed to validate the use of a real-time measure of speech processing as a gauge of the far-transfer efficacy of an SGCTA designed to train executive functions. Methods: In a randomized controlled trial that included 40 participants, we tested 20 (50%) older adults before and after self-administering the SGCTA Effectivate training and compared their performance with that of the control group of 20 (50%) older adults. The E-WINDMIL eye-tracking task was administered to all participants by blinded experimenters in 2 sessions separated by 2 to 8 weeks. Results: Specifically, we tested the change between sessions in the efficiency of segregating the spoken target word from its sound-sharing alternative, as the word unfolds in time. We found that training with the SGCTA Effectivate improved both early and late speech processing in adverse conditions, with higher discrimination scores in the training group than in the control group (early processing: F1,38=7.371; P=.01; ηp2=0.162 and late processing: F1,38=9.003; P=.005; ηp2=0.192). Conclusions: This study found the E-WINDMIL measure of speech processing to be a valid gauge for the far-transfer effects of executive function training. As the SGCTA Effectivate does not train any auditory task or language processing, our results provide preliminary support for the ability of Effectivate to create a generalized cognitive improvement. Given the crucial role of speech processing in healthy and successful aging, we encourage researchers and developers to use speech processing measures, the E-WINDMIL in particular, to gauge the efficacy of SGCTAs. We advocate for increased industry-wide adoption of far-transfer metrics to gauge SGCTAs. %M 35900825 %R 10.2196/32297 %U https://games.jmir.org/2022/3/e32297 %U https://doi.org/10.2196/32297 %U http://www.ncbi.nlm.nih.gov/pubmed/35900825 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36123 %T Effectiveness of Serious Games for Improving Executive Functions Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis %A Abd-alrazaq,Alaa %A Alhuwail,Dari %A Ahmed,Arfan %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708546, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K executive functions %K mild cognitive impairment %K Alzheimer disease %K dementia %K systematic reviews %K meta-analysis %D 2022 %7 25.7.2022 %9 Review %J JMIR Serious Games %G English %X Background: Executive functions are one of the known cognitive abilities that decline with age. They are the high-order cognitive processes that enable an individual to concentrate, plan, and take action. Serious games, which are games developed for specific purposes other than entertainment, could play a positive role in improving executive functions. Several systematic reviews have pooled the evidence about the effectiveness of serious games in improving executive functions; however, they are limited by some weaknesses. Objective: This study aims to investigate the effectiveness of serious games for improving executive functions among older adults with cognitive impairment. Methods: A systematic review of randomized controlled trials (RCTs) was conducted. To retrieve relevant studies, 8 electronic databases were searched. Further, reference lists of the included studies and relevant reviews were screened, and we checked studies that cited our included studies. Two reviewers independently checked the eligibility of the studies, extracted data from the included studies, assessed the risk of bias, and appraised the quality of the evidence. We used a narrative and statistical approach, as appropriate, to synthesize results of the included studies. Results: Of 548 publications identified, 16 RCTs were eventually included in this review. Of the 16 studies, 14 studies were included in 6 meta-analyses. Our meta-analyses showed that serious games are as effective as no or passive interventions at improving executive functions (P=.29). Surprisingly, conventional exercises were more effective than serious games at improving executive functions (P=.03). Our subgroup analysis showed that both types of serious games (cognitive training games, P=.08; exergames, P=.16) are as effective as conventional exercises at improving executive functions. No difference was found between adaptive serious games and nonadaptive serious games for improving executive functions (P=.59). Conclusions: Serious games are not superior to no or passive interventions and conventional exercises at improving executive functions among older adults with cognitive impairment. However, our findings remain inconclusive due to the low quality of the evidence, the small sample size in most included studies, and the paucity of studies included in the meta-analyses. Accordingly, until more robust evidence is available, serious games should not be offered by health care providers nor used by patients for improving executive functions among older adults with cognitive impairment. Further reviews are needed to assess the long-term effect of serious games on specific executive functions or other cognitive abilities among people from different age groups with or without cognitive impairment. Trial Registration: PROSPERO CRD42021272757; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272757 %M 35877166 %R 10.2196/36123 %U https://games.jmir.org/2022/3/e36123 %U https://doi.org/10.2196/36123 %U http://www.ncbi.nlm.nih.gov/pubmed/35877166 %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 3 %P e37026 %T Effect of the “Art Coloring” Online Coloring Game on Subjective Well-Being Increase and Anxiety Reduction During the COVID-19 Pandemic: Development and Evaluation %A Xi,JuZhe %A Gao,YuHan %A Lyu,Na %A She,Zhuang %A Wang,XinYue %A Zhang,Xin-An %A Yu,XiaoYu %A Ji,WeiDong %A Wei,MengSheng %A Dai,WeiHui %A Qian,Xuesheng %+ School of Management, Fudan University, Room 722, Siyuan Building, 670 Guoshun Road, Shanghai, 200433, China, 86 13916208229, qianxuesheng@fudan.edu.cn %K coloring game %K online intervention %K mental health %K COVID-19 pandemic %K gamification %K game-based intervention %K commercially released game %D 2022 %7 8.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: COVID-19 has spread worldwide and generated tremendous stress on human beings. Unfortunately, it is often hard for distressed individuals to access mental health services under conditions of restricted movement or even lockdown. Objective: The study first aims to develop an online digital intervention package based on a commercially released coloring game. The second aim is to test the effectiveness of difference intervention packages for players to increase subjective well-being (SWB) and reduce anxiety during the pandemic. Methods: An evidence-based coloring intervention package was developed and uploaded to an online coloring game covering almost 1.5 million players worldwide in January 2021. Players worldwide participated to color either 4 rounds of images characterized by awe, pink, nature, and blue or 4 rounds of irrelevant images. Participants' SWB and anxiety and the perceived effectiveness of the game in reducing anxiety (subjective effectiveness [SE]) were assessed 1 week before the intervention (T1), after the participants completed pictures in each round (T2-T5), and after the intervention (T6). Independent 2-tailed t tests were conducted to examine the general intervention (GI) effect and the intervention effect of each round. Univariate analysis was used to examine whether these outcome variables were influenced by the number of rounds completed. Results: In total, 1390 players worldwide responded and completed at least 1 assessment. Overall, the GI group showed a statistical significantly greater increase in SWB than the general control (GC) group (N=164, t162=3.59, Cohen d=0.59, 95% CI 0.36-1.24, P<.001). Compared to the control group, the best effectiveness of the intervention group was seen in the awe round, in which the increase in SWB was significant (N=171, t169=2.51, Cohen d=0.39, 95% CI 0.10-0.82, P=.01), and players who colored all 4 pictures had nearly significant improvements in SWB (N=171, F4,170=2.34, partial ŋ2=0.053, P=.06) and a significant decrease in anxiety (N=171, F4,170=3.39, partial ŋ2=0.075, P=.01). Conclusions: These data indicate the effectiveness of online psychological interventions, such as coloring games, for mental health in the specific period. They also show the feasibility of applying existing commercial games embedded with scientific psychological interventions that can fill the gap in mental crises and services for a wider group of people during the pandemic. The results would inspire innovations to prevent the psychological problems caused by public emergencies and encourage more games, especially the most popular ones, to take more positive action for the common crises of humankind. %M 35575761 %R 10.2196/37026 %U https://games.jmir.org/2022/3/e37026 %U https://doi.org/10.2196/37026 %U http://www.ncbi.nlm.nih.gov/pubmed/35575761 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e33755 %T The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up %A Leng,Yan %A Lo,Wai Leung Ambrose %A Mao,Yu Rong %A Bian,Ruihao %A Zhao,Jiang Li %A Xu,Zhiqin %A Li,Le %A Huang,Dong Feng %+ Guangdong Engineering and Technology Research Center for Rehabilitation Medicine and Translation, Sun Yat-sen University, 58 Zhongshan Er Lu Road, Guangzhou, 510080, China, 86 13922318919, huangdf@mail.sysu.edu.cn %K stroke %K motor function of upper extremity %K virtual reality %K cognitive function %D 2022 %7 8.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes. Objective: This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention. Methods: Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA). Results: The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04). Conclusions: VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn %M 35802415 %R 10.2196/33755 %U https://games.jmir.org/2022/3/e33755 %U https://doi.org/10.2196/33755 %U http://www.ncbi.nlm.nih.gov/pubmed/35802415 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e32715 %T Effectiveness of Using Augmented Reality for Training in the Medical Professions: Meta-analysis %A Baashar,Yahia %A Alkawsi,Gamal %A Ahmad,Wan Nooraishya Wan %A Alhussian,Hitham %A Alwadain,Ayed %A Capretz,Luiz Fernando %A Babiker,Areej %A Alghail,Adnan %+ Faculty of Computing and Informatics, Universiti Malaysia Sabah, 751 Bandar, Labuan, 88400, Malaysia, 60 0102207514, yahia.baashar@gmail.com %K augmented reality %K medical %K training %K virtual %K meta-analysis %D 2022 %7 5.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Augmented reality (AR) is an interactive technology that uses persuasive digital data and real-world surroundings to expand the user's reality, wherein objects are produced by various computer applications. It constitutes a novel advancement in medical care, education, and training. Objective: The aim of this work was to assess how effective AR is in training medical students when compared to other educational methods in terms of skills, knowledge, confidence, performance time, and satisfaction. Methods: We performed a meta-analysis on the effectiveness of AR in medical training that was constructed by using the Cochrane methodology. A web-based literature search was performed by using the Cochrane Library, Web of Science, PubMed, and Embase databases to find studies that recorded the effect of AR in medical training up to April 2021. The quality of the selected studies was assessed by following the Cochrane criteria for risk of bias evaluations. Results: In total, 13 studies with a total of 654 participants were included in the meta-analysis. The findings showed that using AR in training can improve participants' performance time (I2=99.9%; P<.001), confidence (I2=97.7%; P=.02), and satisfaction (I2=99.8%; P=.006) more than what occurs under control conditions. Further, AR did not have any effect on the participants’ knowledge (I2=99.4%; P=.90) and skills (I2=97.5%; P=.10). The meta-regression plot shows that there has been an increase in the number of articles discussing AR over the years and that there is no publication bias in the studies used for the meta-analysis. Conclusions: The findings of this work suggest that AR can effectively improve performance time, satisfaction, and confidence in medical training but is not very effective in areas such as knowledge and skill. Therefore, more AR technologies should be implemented in the field of medical training and education. However, to confirm these findings, more meticulous research with more participants is needed. %M 35787488 %R 10.2196/32715 %U https://games.jmir.org/2022/3/e32715 %U https://doi.org/10.2196/32715 %U http://www.ncbi.nlm.nih.gov/pubmed/35787488 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e33137 %T The Effects of a Computer Game (Healthy Rat King) on Preschool Children’s Nutritional Knowledge and Junk Food Intake Behavior: Nonrandomized Controlled Trial %A Chang,Ing-Chau %A Yang,Cheng-Ying %A Yen,Chin-En %+ Department of Early Childhood Development and Education, Chaoyang University of Technology, 168, Jifeng East Road, Wufeng District, Taichung, 41349, Taiwan, 886 4 23323000 ext 4706, ceyen@cyut.edu.tw %K computer games %K nutrition knowledge %K junk food %D 2022 %7 1.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Playing computer-aided games could enhance children’s interest in learning about nutritional knowledge and eventually promote healthy dietary intake behavior. Objective: This study aims to evaluate the effectiveness of a computer game (Healthy Rat King) in improving the knowledge on nutrition and junk food intake among preschool children in Taiwan. Methods: This was a quasi-experimental study that utilized the computer game Healthy Rat King as the nutrition education tool. We recruited 104 preschool children (aged 5-6 years) from preschools in central Taiwan, who were assigned to either the experimental group (n=56) or the control group (n=48). In the experimental group, a 1-hour computer-based educational game intervention was included in the course for 4 consecutive weeks. The control group did not receive this intervention. Results: The level of nutritional knowledge for children in the experimental group was significantly higher than those in the control group after 4 weeks (P=.002). Furthermore, the frequency of consumption of chocolate, candies, and ice cream (high-calorie junk food) was reduced in the experimental group. There was also no significant difference in the consumption of candy and chocolate (P=.54), ice cream and ice pops (P=.21), cake (P=.92), biscuit (P=.98), soft drinks (P=.52), and fruit juice and sugary drinks (P=.31) between the 2 groups in the posttest. Conclusions: Teaching using a computer game could improve children’s nutritional knowledge. However, the intake frequency of junk food among children in the experimental group showed no significant difference from those in the control group. %M 35776502 %R 10.2196/33137 %U https://games.jmir.org/2022/3/e33137 %U https://doi.org/10.2196/33137 %U http://www.ncbi.nlm.nih.gov/pubmed/35776502 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35869 %T User Experience and Usability of Neumorphism and Gamification User Interface Designs in an HIV Self-Test Referral Program for Men Who Have Sex With Men: Prospective Open-Label Parallel-Group Randomized Controlled Trial %A Kwan,Tsz Ho %A Chan,Denise Pui Chung %A Lee,Shui Shan %+ Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Room 207, Postgraduate Education Centre, Prince of Wales Hospital, Hong Kong, China (Hong Kong), 852 22528812, sslee@cuhk.edu.hk %K HIV %K self-test %K men who have sex with men %K gamification %K neumorphism %K digital intervention %K HIV prevention %K user interface %K games %K digital health %D 2022 %7 22.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital interventions have been applied for promoting HIV prevention and care among men who have sex with men (MSM). As user interface (UI) design plays a role in determining usability and user experience (UX), the intervention outcome could be affected. Objective: In this study, we hypothesized that 2 UI design styles, namely gamification and neumorphism, could impact usability and be differentially preferred by distinct groups of MSM. Methods: A prospective parallel-group open-label randomized controlled trial was conducted in Hong Kong. Eligible participants were adult MSM recruited by the research team or referred by enrolled participants, who followed instructions for performing an HIV self-test and promoted its use within their social network. Participants were randomized in a 1:1 ratio into either a gamification or neumorphism arm, with primarily visual differences in the UI only. The primary outcome was usability measured by the System Usability Scale (SUS) between the 2 arms. Distinct characteristics of promoters in the 2 arms who gave an SUS score of 80 or above were identified. Results: Of 463 MSM registered in the study, 232 and 231 were randomized to the gamification and neumorphism arms, respectively. Excluding those who did not request a self-test kit, data from 218 and 216 participants in the gamification and neumorphism arms, respectively, were analyzed (totally 434 participants). With a median SUS score of 80 overall, participants in the neumorphism arm gave a higher score (P<.001), with a higher proportion giving a promoter-level SUS score (P=.002). Promoters used social media for sex networking (P=.02), used pre-exposure prophylaxis in the preceding year (P=.006), had higher satisfaction in UI design (P<.001), and had made a self-test referral (P=.04). In general, higher usability was recorded among participants who were confident in performing the HIV self-test (P<.001), and this was associated with a promoter-level SUS score in both arms. While no other personal characteristics were associated with promoters in the neumorphism arm, those in the gamification arm had higher HIV-related knowledge (P=.01), preferred a specific partner body image type (P=.03), and progressed toward peer referral by completing online training (P=.04). Conclusions: Both gamified and neumorphic UI designs were well-accepted by MSM. UX and satisfaction of UI were both crucial in influencing the willingness of MSM to promote the application by referring their peers in the community to participate. The simplistic visual design of neumorphism conferred a more general acceptance in the community, whereas gamification was preferred in certain MSM subcommunities. Appropriate UI/UX design should be considered when developing digital interventions targeting the MSM community. Trial Registration: ClinicalTrials.gov NCT04379206; https://clinicaltrials.gov/ct2/show/NCT04379206 %M 35731564 %R 10.2196/35869 %U https://games.jmir.org/2022/2/e35869 %U https://doi.org/10.2196/35869 %U http://www.ncbi.nlm.nih.gov/pubmed/35731564 %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 %@ 2561-326X %I JMIR Publications %V 6 %N 6 %P e33693 %T Online Knowledge Translation Program Involving Video Games and University Student–Led Tutorials About Cannabis and Psychosis for Black Youth: Mixed Method Feasibility Study %A Jani,Payal %A Song,Nuri %A Artna,Erin %A Lyeo,Joonsoo %A Assam,Ashley %A Maelzer,Faith %A Murphy,Andriene %A Grant,Angelo %A Archie,Suzanne %+ Faculty of Health Sciences, McMaster University, East Region Mental Health Services, King Campus - St Joseph's Healthcare Hamilton, 2757 King St East, Hamilton, ON, L8N 3K7, Canada, 1 905 573 4801, archies@mcmaster.ca %K knowledge translation %K Black youth %K video game %K psychosis %K cannabis use %K knowledge %K young adult %K race %K demographic %K minority %K gaming %K mental health %K drug %K cannabis %K acceptability %K feasibility %K risk %D 2022 %7 20.6.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: We have piloted a new online knowledge translation (KT) program created to educate youth about cannabis effects, which uniquely focuses on mental health risks for Black youth. Youth are generally unaware of the research linking underage usage and the risk of psychosis. Youth from some Black racialized communities in Ontario may be disproportionately affected and in need of this knowledge. Objective: Because very little is known about the acceptability and feasibility of programs educating Black youth about cannabis and psychosis risk, we evaluated this KT program, which consists of tutorials facilitated by university students and video games. Methods: This mixed methods pilot study evaluates the transfer of knowledge about cannabis and psychosis risk before and after the online KT program and, at the same time, explores participant satisfaction with the program and views about underage use. Eligible participants were youth 16-19 years of age of Black African or Caribbean descent. Trained undergraduate students from McMaster University administered a quiz (psychosis and cannabis test; PCT) to evaluate knowledge before and after the KT program. After playing the psychoeducational video games, participants attended two tutorial group sessions led by undergraduate students. The undergraduate students facilitated the online tutorials about cannabis and psychosis. The tutorials augmented the educational content embedded within the gameplay: participants discussed what they learned from the video games and their understanding of psychosis and the effects of cannabis. In addition, undergraduate students qualitatively analyzed the tutorial discussions for themes, and the prequiz and postquiz scores were analyzed for significant differences in scores. Results: A total of 9 Black youth were recruited and completed this pilot study. The mean PCT scores were 5.67 (SD 1.7) and 7.78 (SD 1.8) before and after the KT program, respectively. There was a significant improvement in scores (P<.05) post-KT program. Thematic analysis of the facilitated tutorials revealed three major themes: video game satisfaction, marijuana and psychosis literacy, and help-seeking awareness. Overall, participants showed an increased awareness and understanding of the subject matter after the gameplay and tutorial intervention. Conclusions: When supplemented with tutorial sessions, the Back to Reality Series shows promise for addressing the gap in knowledge about cannabis and psychosis, and the results provide preliminary evidence that the games appeal to Black youth. %M 35315782 %R 10.2196/33693 %U https://formative.jmir.org/2022/6/e33693 %U https://doi.org/10.2196/33693 %U http://www.ncbi.nlm.nih.gov/pubmed/35315782 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e29830 %T Virtual Reality Training Using Nintendo Wii Games for Patients With Stroke: Randomized Controlled Trial %A Anwar,Naveed %A Karimi,Hossein %A Ahmad,Ashfaq %A Gilani,Syed Amir %A Khalid,Kehkshan %A Aslam,Ahmed Sohaib %A Hanif,Asif %+ University Institute of Physical Therapy, University of Lahore, 1-Km, Defence Road, Bhupatian Chowk, Off Raiwind Road, Lahore, Pakistan, 92 3336140916, dr.hossein.karimi@gmail.com %K stroke %K virtual reality %K Fugl-Meyer score %K rehabilitation %K training %K physical therapy %K therapy %K balance %K function %K randomized controlled trial %D 2022 %7 13.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial. Objective: The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke. Methods: It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22. Results: The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted. Conclusions: VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability. Trial Registration: Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view %M 35699989 %R 10.2196/29830 %U https://games.jmir.org/2022/2/e29830 %U https://doi.org/10.2196/29830 %U http://www.ncbi.nlm.nih.gov/pubmed/35699989 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 6 %P e30616 %T The Efficacy of Virtual Reality Game Preparation for Children Scheduled for Magnetic Resonance Imaging Procedures (IMAGINE): Protocol for a Randomized Controlled Trial %A Le May,Sylvie %A Genest,Christine %A Hung,Nicole %A Francoeur,Maxime %A Guingo,Estelle %A Paquette,Julie %A Fortin,Olivier %A Guay,Stéphane %+ Research Center, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada, 1 514 345 4931, sylvie.lemay@umontreal.ca %K virtual reality %K children %K video games %K magnetic resonance imaging %K anxiety %K pediatrics %K patient collaboration %K patient preparation %K biofeedback %D 2022 %7 13.6.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: It is known that magnetic resonance imaging (MRI) procedures generate fear and anxiety. Children may become restless during scanning, which results in movement artifacts requiring the MRI procedure to be repeated with sedation. Few studies seem to have looked at the effect of immersive virtual reality (IVR) on anxiety in children scheduled for MRI scans and how to identify which children are more responsive. Objective: The aims of this study are 3-fold: develop an algorithm of predictability based on biofeedback, address feasibility and acceptability of preprocedural IVR game preparation for anxiety management during MRI procedures, and examine the efficacy of IVR game preparation compared with usual care for the management of procedural anxiety during MRI scans. Methods: This study will have 2 phases. We will first conduct a field test with 10 participants aged 7 to 17 years to develop a predictive algorithm for biofeedback solution and to address the feasibility and acceptability of the research. After the field test, a randomized controlled trial will be completed using a parallel design with 2 groups: an experimental group (preprocedural IVR game preparation) and a usual care group (standard care as per the radiology department’s protocol) in an equal ratio of 49 participants per group for 98 participants. Recruitment will be carried out at a hospital in Quebec, Canada. The experimental group will receive a preprocedural IVR game preparation (IMAGINE) that offers an immersive simulation of the MRI scan. Participants will complete a questionnaire to assess the acceptability, feasibility, and incidence of side effects related to the intervention and the biofeedback device. Data collected will include sociodemographic and clinical characteristics as well as measures of procedure-related anxiety with the French-Canadian version of the State-Trait Anxiety Inventory for Children (score 1-3) and the Children’s Fear Scale (score 0-4). Physiological signs will be noted and include heart rate, skin conductance, hand temperature, and muscle tension. Measures of the level of satisfaction of health care professionals, parents, and participants will also be collected. Analyses will be carried out according to the intention-to-treat principle, with a Cronbach α significance level of .05. Results: As of May 10, 2022, no participant was enrolled in the clinical trial. The data collection time frame is projected to be between April 1, 2022, and March 31, 2023. Findings will be disseminated through peer-reviewed publications. Conclusions: Our study provides an alternative method for anxiety management to better prepare patients for an awake MRI procedure. The biofeedback will help predict which children are more responsive to this type of intervention. This study will guide future medical practice by providing evidence-based knowledge on a nonpharmacological therapeutic modality for anxiety management in children scheduled for an MRI scan. Trial Registration: ClinicalTrials.gov NCT04988516; https://clinicaltrials.gov/ct2/show/NCT04988516 International Registered Report Identifier (IRRID): PRR1-10.2196/30616 %M 35700000 %R 10.2196/30616 %U https://www.researchprotocols.org/2022/6/e30616 %U https://doi.org/10.2196/30616 %U http://www.ncbi.nlm.nih.gov/pubmed/35700000 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e31685 %T Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial %A Meinke,Anita %A Peters,Rick %A Knols,Ruud H %A Swanenburg,Jaap %A Karlen,Walter %+ Mobile Health Systems Lab, Department of Health Sciences and Technology, ETH Zurich, Balgrist Campus, BAA, Lengghalde 5, Zurich, 8008, Switzerland, 41 446337754, meinke_a@outlook.de %K low back pain %K postural balance %K exergame %K postural feedback %K motor control %K kinesiophobia %K inertial measurement unit %K randomized controlled trial %D 2022 %7 10.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain. Objective: We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined. Methods: A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires. Results: A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule. Conclusions: The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions. Trial Registration: ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243 International Registered Report Identifier (IRRID): RR2-10.2196/26982 %M 35687390 %R 10.2196/31685 %U https://games.jmir.org/2022/2/e31685 %U https://doi.org/10.2196/31685 %U http://www.ncbi.nlm.nih.gov/pubmed/35687390 %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 e35099 %T Innovative Technology–Based Interventions to Reduce Stigma Toward People With Mental Illness: Systematic Review and Meta-analysis %A Rodríguez-Rivas,Matías E %A Cangas,Adolfo J %A Cariola,Laura A %A Varela,Jorge J %A Valdebenito,Sara %+ Facultad de Psicología, Universidad del Desarrollo, Avenida Plaza 680, Santiago, Chile, 56 223279110, matrodriguezr@udd.cl %K stigma %K mental illness %K technology-based %K serious games %K virtual reality %K e-contact %K simulation intervention %K internet intervention %K meta-analysis %D 2022 %7 30.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Stigma toward people with mental illness presents serious consequences for the impacted individuals, such as social exclusion and increased difficulties in the recovery process. Recently, several interventions have been developed to mitigate public stigma, based on the use of innovative technologies, such as virtual reality and video games. Objective: This review aims to systematically review, synthesize, measure, and critically discuss experimental studies that measure the effect of technological interventions on stigmatization levels. Methods: This systematic review and meta-analysis was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and included studies in English and Spanish published between 2016 and 2021. Searches were run in 5 different databases (ie, PubMed, PsycInfo, Scopus, Cochrane Library, and ScienceDirect). Only randomized controlled trials were included. Two independent reviewers determined the eligibility, extracted data, and rated methodological quality of the studies. Meta-analyses were performed using the Comprehensive Meta-Analysis software. Results: Based on the 1158 articles screened, 72 articles were evaluated as full text, of which 9 were included in the qualitative and quantitative syntheses. A diversity of interventions was observed, including video games, audiovisual simulation of hallucinations, virtual reality, and electronic contact with mental health services users. The meta-analysis (n=1832 participants) demonstrated that these interventions had a consistent medium effect on reducing the level of public stigma (d=–0.64; 95% CI 0.31-0.96; P<.001). Conclusions: Innovative interventions involving the use of technologies are an effective tool in stigma reduction, therefore new challenges are proposed and discussed for the demonstration of their adaptability to different contexts and countries, thus leading to their massification. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021261935; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021261935 %M 35635744 %R 10.2196/35099 %U https://games.jmir.org/2022/2/e35099 %U https://doi.org/10.2196/35099 %U http://www.ncbi.nlm.nih.gov/pubmed/35635744 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e36707 %T Effectiveness and Utility of Virtual Reality Infection Control Simulation for Children With COVID-19: Quasi-Experimental Study %A Yu,Mi %A Yang,Mi Ran %+ College of Nursing, Institute of Health Sciences, Gyeongsang National University, 816 beongil-15, Jinju-daero, Jinju, 52727, Republic of Korea, 82 10 5258 7075, yumi825@gnu.ac.kr %K children %K infection control %K nursing student %K simulation training %K virtual reality %K digital health %K medical education %K COVID-19 %K patient management %K pediatrics %K nursing education %K respiratory care skills %K program usability %K digital learning %D 2022 %7 27.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: It is essential that nurses quickly learn the proper methods for preventing and controlling nosocomial infection and managing intensive care patients during the COVID-19 pandemic, including the donning and doffing of personal protective equipment (PPE). Virtual reality (VR) simulation offers the advantage of learning in a safe environment with a sense of realism similar to that of an actual clinical setting and has been reported to enhance self-efficacy in infection control, safety performance, and learning satisfaction among students. Objective: This study aims to develop a virtual reality infection control simulation (VRICS) program regarding donning and doffing of PPE and respiratory care for pediatric patients admitted to an isolation unit for COVID-19 and to identify the effects of the program on PPE knowledge, infection control performance, and self-efficacy for nursing students. Additionally, the realism of the VRICS program and the students’ level of satisfaction with the program were assessed. Methods: This was a quasi-experimental study based on a controlled pretest-posttest design. Third- and fourth-year nursing students were divided into an experimental group (n=25) who participated in a VRICS program and a control group (n=25) with no participation. Data were collected from November 13 to December 10, 2021, and analyzed using descriptive statistics and the t test, paired t test, Mann-Whitney U test, and Wilcoxon matched-pair signed-rank test. The VRICS program consisted of a prebriefing, including direct practice of donning and doffing PPE, VR simulation, and debriefing. The VR simulation comprised 3 sessions: donning and inspection of PPE in the dressing room before entering the negative-pressure isolation unit; assessing for suction care, nasopharyngeal suctioning, and checking of COVID-19 patients in the negative-pressure isolation unit; and doffing PPE in the dressing room. The total execution time for the program was 180 min. Results: Compared with the control group, the experimental group showed significantly greater improvements in PPE knowledge (z=–3.28, P<.001), infection control performance (t48=4.89, P<.001), and self-efficacy (t36.2=4.93, P<.001). The experimental group’s mean scores for realistic immersion and learner satisfaction were 4.49 (SD 0.50) points and 4.75 (SD 0.38) points (on a 5-point Likert scale), respectively. Conclusions: The VR simulation training program involving pediatric COVID-19 patients combined skills training effectively and enhanced theoretical knowledge, respiratory care skills, and infectious disease preparedness. Thus, it could be applied to training nurses to respond more effectively to public health situations involving infectious diseases, including the COVID-19 pandemic. %M 35575818 %R 10.2196/36707 %U https://games.jmir.org/2022/2/e36707 %U https://doi.org/10.2196/36707 %U http://www.ncbi.nlm.nih.gov/pubmed/35575818 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e33782 %T Effect of an Active Video Game Intervention Combined With Multicomponent Exercise for Cardiorespiratory Fitness in Children With Overweight and Obesity: Randomized Controlled Trial %A Comeras-Chueca,Cristina %A Villalba-Heredia,Lorena %A Perez-Lasierra,Jose Luis %A Lozano-Berges,Gabriel %A Matute-Llorente,Angel %A Vicente-Rodriguez,German %A Casajus,Jose Antonio %A Gonzalez-Aguero,Alex %+ Department of Physiatry and Nursing, Faculty of Health and Sport Science, Universidad de Zaragoza, San Juan Bosco St., nº 13; 2th Ft., Zaragoza, 50009, Spain, 34 876 55 37 56, alexgonz@unizar.es %K active videogames %K VO2peak %K obesity %K prepuberty %K cardiorespiratory %K fitness %K gaming %K childhood %K intervention %D 2022 %7 24.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Childhood overweight and obesity have become major global health problems and are negatively related with the cardiorespiratory fitness (CRF) level in school children and adolescents. Exercise, specifically multicomponent training, is effective for CRF improvement, but the main challenge is to ensure adherence to exercise in children with overweight and obesity. Therefore, new ways of exercising that are more attractive and motivational for this population are needed and playing or training with active video games (AVGs) has been proposed as an effective alternative because they require full-body movement and therefore increase energy expenditure. Objective: The main aim of this study was to investigate the effects of an AVG intervention combined with multicomponent training on CRF at maximal and submaximal intensities in children with overweight or obesity. Methods: We recruited 28 children (13 girls and 15 boys) aged 9 to 11 years with overweight or obesity from medical centers and divided them into 2 groups, an intervention group (n=20) that participated in a 5-month supervised AVG exercise program combined with multicomponent exercise, and a control group (n=8) that continued daily activities without modification. A maximal stress test to measure CRF using a walking-graded protocol with respiratory gas exchange was performed by the participants. Results: The AVG group showed a significant decrease in heart rate and oxygen uptake for the same intensities in the submaximal stages of the maximal treadmill test, as well as a lower oxygen uptake percentage according to the individual maximal oxygen uptake, whereas the control group did not show overall changes. No change in the peak oxygen uptake (VO2peak) was found. Conclusions: A 5-month AVG intervention combined with multicomponent exercise had positive effects on CRF at submaximal intensity, showing a lower heart rate and oxygen uptake at the same intensities and displaying a lower oxygen uptake percentage according to the individual (VO2peak). Greater benefits were found in children with the highest fat percentage. Trial Registration: ClinicalTrials.gov NCT04418713; https://clinicaltrials.gov/show/NCT04418713 %M 35471240 %R 10.2196/33782 %U https://games.jmir.org/2022/2/e33782 %U https://doi.org/10.2196/33782 %U http://www.ncbi.nlm.nih.gov/pubmed/35471240 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e33207 %T Using Video Games to Improve the Sexual Health of Young People Aged 15 to 25 Years: Rapid Review %A Franco Vega,Ignacio %A Eleftheriou,Anastasia %A Graham,Cynthia %+ Department of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, University Road, Room 44/3073, Southampton, SO17 1BJ, United Kingdom, 44 023 8059 3091, c.a.graham@soton.ac.uk %K sex education %K serious games %K sexually transmitted infections %K rapid review %K mobile phone %D 2022 %7 19.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Sexually transmitted infections and unintended pregnancies among young people remain public health concerns in many countries. To date, interventions that address these concerns have had limited success. Serious games are increasingly being used as educational tools in health and professional public education. Although acknowledged as having great potential, few studies have evaluated the use of serious games in sexual health education among young people, and to date, there have been no published reviews of these studies. Objective: This study aims to assess the effects of video game–based sexual health interventions for risky sexual behavior in young people aged between 15 and 25 years. Methods: A rapid review of randomized controlled trials and quasi–randomized controlled trials was performed. The search included the following bibliographic databases: Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and Scopus. A total of 2 reviewers independently screened 50% (35/70) of the retrieved articles during the full-text screening phase. Results: From a total of 459 identified citations, after removing duplicates, 327 (71.2%) articles were deemed eligible for title and abstract screening. Of the 327 articles, 70 (21.4%) full texts were screened, from which 10 (3.1%) articles (evaluating 11 different games) were included in the review. The findings highlighted the considerable diversity in video game–based interventions and assessed sexual health outcomes. Although there were some promising findings in outcome studies using game-based interventions, the results across studies were mixed. Conclusions: Although game interventions for sexual health have been in existence for almost three decades, relatively few studies have evaluated them, and the results of previous outcome studies have been mixed. Moreover, there is little clarity regarding which specific elements of a game facilitate positive outcomes. We provide recommendations for future researchers developing video game–based interventions to improve sexual health in young people. %M 35587873 %R 10.2196/33207 %U https://games.jmir.org/2022/2/e33207 %U https://doi.org/10.2196/33207 %U http://www.ncbi.nlm.nih.gov/pubmed/35587873 %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 %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e36820 %T Video Game to Attenuate Pandemic-Related Stress From an Equity Lens: Development and Usability Study %A Minian,Nadia %A Saiva,Anika %A Gayapersad,Allison %A Dragonetti,Rosa %A Proulx,Catherine %A Debergue,Patricia %A Lecce,Julia %A Hussain,Sarwar %A Desjardins,Eric %A Selby,Peter %+ Nicotine Dependence Service, Centre for Addiction and Mental Health, 1025 Queen St W, Toronto, ON, M6H 1H4, Canada, 1 416 535 8501, peter_selby@camh.net %K video games %K cognitive behavioral therapy %K usability study %K self-care %K digital health %K technological infrastructure %K video game development %K user engagement %K user perception %K COVID-19 %K Mental health %K mental health care system %K depression %K anxiety %K digital therapy %D 2022 %7 12.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The emergence of the novel coronavirus (COVID-19) has introduced additional pressures on an already fragile mental health care system due to a significant rise in depression, anxiety, and stress among Canadians. Although cognitive behavioral therapy (CBT) is known to be an efficacious treatment to reduce such mental health issues, few people have access to CBT in an engaging and sustainable manner. To address this gap, a collaboration between the Centre for Addiction and Mental Health (CAMH) and the National Research Council of Canada (NRC) developed CBT-based self-led, online, clinician-tested modules in the form of a video game, named Legend of Evelys, and evaluated its usability in the attenuation of a COVID-19–related increase in stress. Objective: We here present the conceptualization and design of new self-care modules in the form of a video game, its implementation in a technological infrastructure, and inclusivity and privacy considerations that informed the development. A usability study of the modules was performed to assess the video game’s usability, user engagement, and user perceptions. Methods: The development of the video game involved establishment of a technology infrastructure for secure implementation of the software for the modules and a clinician-led assessment of the clinical utility of these modules through two “whiteboard” sessions. The usability study was informed by a mixed methods sequential explanatory design to evaluate the intervention of the mobile app through two distinct phases: quantitative data collection using in-app analytics data and two surveys, followed by qualitative data collection by semistructured interviews. Results: A total of 32 participants trialed the app for 2 weeks. They used the video game an average of six times and rated the game as “good” based on the Systems Usability Scale score. In terms of stress reduction, the study demonstrated a significant difference in the participants’ Perceived Stress Scale score at baseline (mean 22.14, SD 6.187) compared with that at the 2-week follow-up (mean 18.04, SD 6.083; t27=3.628, P=.001). Qualitative interviews helped participants identify numerous functionality issues and provided specific recommendations, most of which were successfully integrated into the video game for future release. Conclusions: Through this collaboration, we have established that it is possible to incorporate CBT exercises into a video game and have these exercises adopted to address stress. While video games are a promising strategy to help people with their stress and anxiety, there is a further need to examine the real-world effectiveness of the Legend of Evelys in reducing anxiety. %M 35413001 %R 10.2196/36820 %U https://formative.jmir.org/2022/5/e36820 %U https://doi.org/10.2196/36820 %U http://www.ncbi.nlm.nih.gov/pubmed/35413001 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34402 %T Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis %A Goudman,Lisa %A Jansen,Julie %A Billot,Maxime %A Vets,Nieke %A De Smedt,Ann %A Roulaud,Manuel %A Rigoard,Philippe %A Moens,Maarten %+ STIMULUS, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090, Belgium, 32 2477 5514, lisa.goudman@gmail.com %K virtual reality %K chronic pain %K systematic review %K multilevel meta-analysis %K immersive technologies %K clinical outcomes %K mobile phone %D 2022 %7 10.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is a computer technology that immerses a user in a completely different reality. The application of VR in acute pain settings is well established. However, in chronic pain, the applications and outcome parameters influenced by VR are less clear. Objective: This review aimed to systematically identify all outcome parameters that are reported in relation to VR in patients with chronic pain. Methods: A total of 4 electronic databases (PubMed, Scopus, Web of Science, and Embase) were searched for relevant studies. Multilevel random-effect meta-analyses were performed, whereby the standardized mean difference was chosen as the effect size to denote the difference between measurements before and after a VR intervention. Results: The initial database search identified 1430 studies, of which 41 (2.87%) were eventually included in the systematic review. Evidence has been found for the effects of VR on pain, functioning, mobility, functional capacity, psychological outcomes, quality of life, neuropsychological outcomes, and physical sensations. The overall effect size (a total of 194 effect sizes from 25 studies) based on a three level meta-analysis was estimated at 1.22 (95% CI 0.55-1.89; z=3.56; P<.001), in favor of improvements after a VR intervention. When categorizing effect sizes, the overall effect sizes were reported as follows: 1.60 (95% CI 0.83-2.36; z=4.09; P<.001) for the effect of VR on pain (n=31), 1.40 (95% CI 0.13-2.67; z=2.17; P=.03) for functioning (n=60), 0.49 (95% CI −0.71 to 1.68; z=0.80; P=.42) for mobility (n=24), and 0.34 (95% CI −1.52 to 2.20; z=0.36; P=.72) for functional capacity (n=21). Conclusions: This systematic review revealed a broad range of outcome variables influenced by an intervention of VR technology, with statistically significant pain relief and improvements in functioning. These findings indicate that VR not only has applications in acute pain management but also in chronic pain settings, whereby VR might be able to become a promising first-line intervention as complementary therapy for patients with chronic pain. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227016; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227016 %M 35536641 %R 10.2196/34402 %U https://games.jmir.org/2022/2/e34402 %U https://doi.org/10.2196/34402 %U http://www.ncbi.nlm.nih.gov/pubmed/35536641 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e36768 %T Modification in the Motor Skills of Seniors in Care Homes Using Serious Games and the Impact of COVID-19: Field Study %A Kleschnitzki,Jana Marina %A Grossmann,Inga %A Beyer,Reinhard %A Beyer,Luzi %+ Institute of Psychology, Faculty of Human Sciences, Humboldt-University of Berlin, Rudower Chaussee 18, Berlin, 12489, Germany, 49 15231964606, janakleschnitzki@posteo.de %K serious games %K motor skills %K motor %K long-term care %K exercise %K movement %K coronavirus effects %K eHealth %K seniors %K older adult %K elder %K senior population %K aged %K care home %K intervention effects analysis %K COVID-19 %K pandemic %K digital game %K digital health %K physical activity %D 2022 %7 10.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. At the beginning of 2020, the COVID-19 pandemic led to many restrictions, which affected seniors in care facilities in the form of severe isolation. The isolation led, among other things, to a lack of exercise, which has led to a multitude of negative effects for this target group. Serious games can potentially help by being used anywhere at any time to strengthen skills with few resources. Objective: The aim of this study is to evaluate the effectiveness of a serious game to strengthen motor skills (study 1) and the influence of pandemic restrictions (study 2) on seniors in care facilities. Methods: The data on motor skills (measured by the Tinetti test) originated from an intervention study with repeated measurements that was interrupted by the pandemic conditions. Data were collected 4 times every 3 months with an intervention group (IG, training 3 times for 1 hour per week) and a control group (CG, no intervention). There were 2 substudies. The first considered the first 6 months until the pandemic restrictions, while the second considered the influence of the restrictions on motor skills. Results: The sample size was 70. The IG comprised 31 (44%) participants, with 22 (71%) female and 9 (29%) male seniors with an average age of 85 years. The CG comprised 39 (56%) participants, with 31 (79%) female and 8 (21%) male seniors with an average age of 87 years. In study 1, mixed-design ANOVA showed no significant interaction between measurement times and group membership for the first measurements (F2.136=1.414, P<.25, partial η2=.044), but there was a significant difference between the CG (mean 16.23, SD 1.1) and the IG (mean 19.81, SD 1.2) at the third time of measurement (P=.02). In study 2 the mixed-design ANOVA (used to investigate motor skills before and after the pandemic conditions between the 2 groups) couldn’t reveal any significant interaction between measurement times and group membership: F1.67=2.997, P<.09, partial η2=.043. However, there was a significant main effect of the time of measurement: F1.67=5.44, P<.02, partial η²=.075. Conclusions: During the first 6 months, the IG showed increased motor skills, whereas the motor skills of the CG slightly deteriorated and showed a statistically significant difference after 6 months. The pandemic restrictions leveled the difference and showed a significant negative effect on motor skills over 3 months. As our results show, digital games have the potential to break down access barriers and promote necessary maintenance for important skills. The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. This potentially great benefit for the challenges of tomorrow shows the relevance of the topic and demonstrates the urgent need for action and research. Trial Registration: Deutsches Register klinischer Studien DRKS00016633; https://tinyurl.com/yckmj4px %M 35536610 %R 10.2196/36768 %U https://games.jmir.org/2022/2/e36768 %U https://doi.org/10.2196/36768 %U http://www.ncbi.nlm.nih.gov/pubmed/35536610 %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 e34222 %T A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial %A Rodriguez-Ferrer,Jose M %A Manzano-León,Ana %A Cangas,Adolfo J %A Aguilar-Parra,Jose M %+ Faculty of Psychology, University of Almeria, Carretera Sacramento s/n, La Cañada de San Urbano, Almería, 04120, Spain, 34 950 01 55 50, aml570@ual.es %K escape room %K severe mental disorder %K higher education %K nursing education %K mental health %K mental disorder %K serious games %D 2022 %7 5.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: People with severe mental illness (SMI) face discriminatory situations because of prejudice toward them, even among health care personnel. Escape rooms can be a novel educational strategy for learning about and empathizing with SMI, thus reducing stigma among health care students. Objective: This study aimed to examine the effect of the Without Memories escape room on nursing students’ stigma against SMI. Methods: A pre- and postintervention study was conducted with a control group and an experimental group. A total of 306 students from 2 Andalusian universities participated in the study. Data were collected through a pre-post study questionnaire, consisting of an adapted version of the Attributional Style Questionnaire and a questionnaire on motivation for cooperative playful learning strategies. The control group carried out an escape room scenario without sensitizing content, whereas the experimental group carried out an escape room scenario on SMI, with both escape rooms being carried out in a 1-hour session of subjects related to mental health. To answer the research questions, a 2-way analysis of variance with repeated measures, a linear regression, and a 2-way analysis of variance were performed. Results: After the intervention, a significant reduction (P<.001) was observed in the experimental group in stigmatizing attitudes compared with the control group, in which no statistically significant changes (P>.05) were observed. In contrast, the linear regression (t195=−22.15; P<.001) showed that there was an inverse relationship between flow and the level of reduced stigma. When controlling for having or not having a close relative, the intervention was also shown to be effective (P<.001) in reducing the stigma displayed, both for people with affected and unaffected relatives. Conclusions: Our findings suggest that the Without Memories escape room can be used as an effective tool to educate and raise awareness about stigmatizing attitudes toward SMI in university students studying health care. Future testing of the effectiveness of educational escape rooms should be designed with new programs through playful strategies of longer duration to evaluate whether they can achieve a greater impact on motivation, acquisition of knowledge, and awareness. In addition, the feasibility of implementing the Without Memories escape room in other careers related to health and community should be investigated. %M 35511232 %R 10.2196/34222 %U https://games.jmir.org/2022/2/e34222 %U https://doi.org/10.2196/34222 %U http://www.ncbi.nlm.nih.gov/pubmed/35511232 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e38212 %T Authors’ Reply to: Learning More About the Effects of Gamification on Physical Activity. Comment on “Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials” %A Mazeas,Alexandre %A Duclos,Martine %A Pereira,Bruno %A Chalabaev,Aïna %+ Univ Grenoble Alpes, SENS, 1741 rue de la Piscine, 38000 Grenoble, France, 33 476635081, alexandre.mazeas@univ-grenoble-alpes.fr %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %K elderly %K old adults %D 2022 %7 3.5.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 35503414 %R 10.2196/38212 %U https://www.jmir.org/2022/5/e38212 %U https://doi.org/10.2196/38212 %U http://www.ncbi.nlm.nih.gov/pubmed/35503414 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e36396 %T Learning More About the Effects of Gamification on Physical Activity. Comment on “Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials” %A Hung,Cheng-Hsien %A Kao,Yung-Shuo %+ Department of Pharmacy, Chang Bing Show Chwan Memorial Hospital, No 6, Lugong Rd, Lukang Township, Changhua County, 50544, Taiwan, 886 4 7813888 ext 71255, chenghsien823@gmail.com %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %K elderly %K old adults %D 2022 %7 3.5.2022 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 35503654 %R 10.2196/36396 %U https://www.jmir.org/2022/5/e36396 %U https://doi.org/10.2196/36396 %U http://www.ncbi.nlm.nih.gov/pubmed/35503654 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e28072 %T Effect of a Virtual Reality Contact-Based Educational Intervention on the Public Stigma of Depression: Randomized Controlled Pilot Study %A Lem,Wey Guan %A Kohyama-Koganeya,Ayako %A Saito,Toki %A Oyama,Hiroshi %+ Department of Clinical Information Engineering, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan, 81 3 5841 1893, vyrolwg@m.u-tokyo.ac.jp %K major depressive disorder %K depression stigma %K virtual reality %K contact-based educational intervention %K virtual patient %D 2022 %7 2.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Public stigma against depression contributes to low employment rates among individuals with depression. Contact-based educational (CBE) interventions have been shown to reduce this public stigma. Objective: We investigated the ability of our Virtual Reality Antistigma (VRAS) app developed for CBE interventions to reduce the stigma of depression. Methods: Sixteen medical students were recruited and randomized 1:1 to the intervention group, who used the VRAS app (VRAS group), and the control group, who watched a video on depression. The depression stigma score was assessed using the Depression Stigma Scale (DSS) and Attitudinal Social Distance (ASD) questionnaire at pre- and postintervention. Feasibility was assessed in both groups and usability was assessed only in the VRAS group after the intervention. A qualitative study was performed on the acquisition of knowledge about stigma in both groups based on participants’ answers to open-ended questions and interviews after the intervention. Results: The feasibility score was significantly higher in the VRAS group (mean 5.63, SD 0.74) than in the control group (mean 3.88, SD 1.73; P=.03). However, no significant differences were apparent between the VRAS and control groups for the DSS (VRAS: mean 35.13, SD 5.30; control: mean 35.38, SD 4.50; P=.92) or ASD (VRAS: mean 12.25, SD 3.33; control: mean 11.25, SD 1.91; P=.92). Stigma scores tended to decrease; however, the stigma-reducing effects of the VRAS app were not significant for the DSS (pre: mean 33.00, SD 4.44; post: mean 35.13, SD 5.30; P=.12) or ASD (pre: mean 13.25, SD 3.92; post: mean 12.25, SD 3.33; P=.12). Qualitative analysis suggested that the VRAS app facilitated perspective-taking and promoted empathy toward the patient. Conclusions: The CBE intervention using virtual reality technology (VRAS app) was as effective as the video intervention. The results of the qualitative study suggested that the virtual reality intervention was able to promote perspective-taking and empathy toward patients. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000043020; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000049109 %M 35499865 %R 10.2196/28072 %U https://formative.jmir.org/2022/5/e28072 %U https://doi.org/10.2196/28072 %U http://www.ncbi.nlm.nih.gov/pubmed/35499865 %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 e28276 %T Adapting the Use of Digital Content to Improve the Learning of Numeracy Among Children With Autism Spectrum Disorder in Rwanda: Thematic Content Analysis Study %A Ntalindwa,Theoneste %A Nduwingoma,Mathias %A Uworwabayeho,Alphonse %A Nyirahabimana,Pascasie %A Karangwa,Evariste %A Rashid Soron,Tanjir %A Westin,Thomas %A Karunaratne,Thashmee %A Hansson,Henrik %+ Telepsychiatry Research and Innovation Network Ltd, 114, Kazi Nazrul Islam Avenue, Dhaka, 1205, Bangladesh, 880 1718827138, tanjirsoron@gmail.com %K autism %K learning %K ICT %K e-learning %K education %K children %K ASD %K teaching %K teachers %K communication %K communication technology %K online content %K Rwanda %K gamification %K school %K school-age children %K behavior %D 2022 %7 19.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many teachers consider it challenging to teach children with autism spectrum disorder (ASD) in an inclusive classroom due to their unique needs and challenges. The integration of information communication technology (ICT) in the education system allows children with ASD to improve their learning. However, these ICT tools should meet their needs to lead a productive life. Objective: This study aimed to examine the possibilities of re-creating and adapting digital content to improve the learning of numeracy among children with ASD in inclusive school settings. Methods: We conducted 7 focus group discussions (FGDs) with 56 teachers from 7 schools and 14 parents from April to November 2019. Each of the FGDs took around 1 hour. Two clustered sets of questions were used: (1) general knowledge about teaching children with ASD and (2) analysis of selected online educational video content of early math (specifically, counting numbers). The researchers used video to understand current methodologies used in teaching children with ASD, possibilities of adaptation of the content in the current teaching environment, future challenges when the content is adapted, and possible solutions to overcome those challenges. All data, including audio recordings, field notes, and participants’ comments, were transcribed, recorded, and analyzed following the steps recommended in qualitative data analysis. Results: The researchers identified ten themes from the analysis of the data: (1) awareness of the existence of ASD among children in schools and the community, (2) acceptance of children with ASD in an inclusive classroom and the community, (3) methods and models used when teaching children with ASD, (4)realia used to improve the learning of children with ASD, (5) the design of educational digital content, (6) the accessibility of online educational content, (7) quality of the content of the educational multimedia, (8) the opportunity of using the translated and re-created content inside and outside the classroom, (9) the relevance of the digital content in the Rwandan educational system, and (10) enhancement of the accessibility and quality of the digital content. We found that participants assumed that the content translation, gamification, and re-creation would help teach children with ASD. Moreover, they recommended contextualizing the content, increasing access to digital devices, and further research in the education of different subjects. Conclusions: Although many studies have identified the possibilities of using ICT to support children with ASD, few studies have documented the possibilities of integrating the existing technologies tested in the international community. This study is charting new territory to investigate online content to suit the context of schools. This study recommends further exploration of possible methodologies, such as applied behavior analysis or verbal behavior therapy, and the development of contextualized technologies that respond to the educational needs of children with ASD. %M 35438638 %R 10.2196/28276 %U https://games.jmir.org/2022/2/e28276 %U https://doi.org/10.2196/28276 %U http://www.ncbi.nlm.nih.gov/pubmed/35438638 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e30260 %T Distracting Through Procedural Pain and Distress Using Virtual Reality and Guided Imagery in Pediatric, Adolescent, and Young Adult Patients: Randomized Controlled Trial %A Hoag,Jennifer A %A Karst,Jeffrey %A Bingen,Kristin %A Palou-Torres,Akasha %A Yan,Ke %+ Division of Pediatric Psychology and Developmental Medicine, Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Road, MFRC 3018, Milwaukee, WI, 53226, United States, 1 414 955 5738, jhoag@mcw.edu %K virtual reality %K procedural %K pain %K anxiety %K pediatric %K guided imagery %D 2022 %7 18.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Children with acute and chronic illness undergo frequent, painful, and distressing procedures. Objective: This randomized controlled trial was used to evaluate the effectiveness of guided imagery (GI) versus virtual reality (VR) on the procedural pain and state anxiety of children and young adults undergoing unsedated procedures. We explored the role of trait anxiety and pain catastrophizing in intervention response. Methods: Children and young adults were recruited from the hematology, oncology, and blood and marrow transplant clinics at a children’s hospital. Each study participant completed the GI and VR intervention during separate but consecutive unsedated procedures. Self-report measures of pain and anxiety were completed before and after the procedures. Results: A total of 50 participants (median age 13 years) completed both interventions. GI and VR performed similarly in the management of procedural pain. Those with high pain catastrophizing reported experiencing less nervousness about pain during procedures that used VR than those using GI. State anxiety declined pre- to postprocedure in both interventions; however, the decrease reached the level of significance during the VR intervention only. Those with high trait anxiety had less pain during GI. Conclusions: In our sample, VR worked as well as GI to manage the pain and distress associated with common procedures experienced by children with acute or chronic illnesses. Children who are primed for pain based on beliefs about pain or because of their history of chronic pain had a better response to VR. GI was a better intervention for those with high trait anxiety. Trial Registration: ClinicalTrials.gov NCT04892160; https://clinicaltrials.gov/ct2/show/NCT04892160 %M 35436209 %R 10.2196/30260 %U https://www.jmir.org/2022/4/e30260 %U https://doi.org/10.2196/30260 %U http://www.ncbi.nlm.nih.gov/pubmed/35436209 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e35058 %T The Effect of a Sepsis Interprofessional Education Using Virtual Patient Telesimulation on Sepsis Team Care in Clinical Practice: Mixed Methods Study %A Chua,Wei Ling %A Ooi,Sim Leng %A Chan,Gene Wai Han %A Lau,Tang Ching %A Liaw,Sok Ying %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Level 3, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597, Singapore, 65 6516 7449, chuaweiling@nus.edu.sg %K sepsis %K interprofessional education %K team training %K nurse-physician communication %K simulation %K telesimulation %D 2022 %7 18.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Improving interprofessional communication and collaboration is necessary to facilitate the early identification and treatment of patients with sepsis. Preparing undergraduate medical and nursing students for the knowledge and skills required to assess, escalate, and manage patients with sepsis is crucial for their entry into clinical practice. However, the COVID-19 pandemic and social distancing measures have created the need for interactive distance learning to support collaborative learning. Objective: This study aimed to evaluate the effect of sepsis interprofessional education on medical and nursing students’ sepsis knowledge, team communication skills, and skill use in clinical practice. Methods: A mixed methods design using a 1-group pretest-posttest design and focus group discussions was used. This study involved 415 undergraduate medical and nursing students from a university in Singapore. After a baseline evaluation of the participants’ sepsis knowledge and team communication skills, they underwent didactic e-learning followed by virtual telesimulation on early recognition and management of sepsis and team communication strategies. The participants’ sepsis knowledge and team communication skills were evaluated immediately and 2 months after the telesimulation. In total, 4 focus group discussions were conducted using a purposive sample of 18 medical and nursing students to explore their transfer of learning to clinical practice. Results: Compared with the baseline scores, both the medical and nursing students demonstrated a significant improvement in sepsis knowledge (P<.001) and team communication skills (P<.001) in immediate posttest scores. At the 2-month follow-up, the nursing students continued to have statistically significantly higher sepsis knowledge (P<.001) and communication scores (P<.001) than the pretest scores, whereas the medical students had no significant changes in test scores between the 2-month follow-up and pretest time points (P=.99). A total of three themes emerged from the qualitative findings: greater understanding of each other’s roles, application of mental models in clinical practice, and theory-practice gaps. The sepsis interprofessional education—particularly the use of virtual telesimulation—fostered participants’ understanding and appreciation of each other’s interprofessional roles when caring for patients with sepsis. Despite noting some incongruities with the real-world clinical practice and not encountering many sepsis scenarios in clinical settings, participants shared the application of mental models using interprofessional communication strategies and the patient assessment framework in their daily clinical practice. Conclusions: Although the study did not show long-term knowledge retention, the use of virtual telesimulation played a critical role in facilitating the application of mental models for learning transfer and therefore could serve as a promising education modality for sepsis training. For a greater clinical effect, future studies could complement virtual telesimulation with a mannequin-based simulation and provide more evidence on the long-term retention of sepsis knowledge and clinical skills performance. %M 35436237 %R 10.2196/35058 %U https://www.jmir.org/2022/4/e35058 %U https://doi.org/10.2196/35058 %U http://www.ncbi.nlm.nih.gov/pubmed/35436237 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 5 %N 1 %P e35415 %T Assessing the Different Levels of Virtual Reality That Influence Anxiety, Behavior, and Oral Health Status in Preschool Children: Randomized Controlled Clinical Trial %A Aminabadi,Naser Asl %A Golsanamlou,Ozra %A Halimi,Zohreh %A Jamali,Zahra %+ Faculty of Dentistry, Tabriz University of Medical Sciences, Golgasht St, Tabriz, 5166746911, Iran, 98 9144157200, aslaminabadi@gmail.com %K virtual reality %K anxiety %K behavior %K oral health training %D 2022 %7 18.4.2022 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Compared with a traditional behavior management strategy and oral health training, virtual reality (VR) integrated with multisensory feedback possesses potential advantages in dentistry. Objective: This study aimed to assess the impact of different levels of VR on anxiety, behavior, and oral health status. Methods: This study was carried out in the Department of Pediatric Dentistry at the Tabriz University of Medical Sciences from December 2020 to June 2021. We randomly assigned 60 healthy children aged 4 years to 6 years to 4 groups, each consisting of 15 children. The study consisted of 2 consecutive sessions. During the first visit, the plaque index was calculated, and oral health education was carried out in all groups using Immersive VR (group I), Semi-immersive VR (group II), Nonimmersive VR (group III), and tell-show-do (TSD; group IV). In the second session, an amalgam restoration was performed in all groups. Participants’ anxiety and behavior were recorded using the face version of the Modified Child Dental Anxiety Scale (MCDAS[f]) and Frankl scale. The plaque index was recorded in 2 follow-up sessions. Results: The greatest prevalence of positive behavior (P=.004) and the lowest anxiety (P<.001) were recorded in group I, followed by group II, group III, and group IV. The plaque index scores showed a reduced trend between the first session and follow-up sessions (P<.001), but the values did not differ significantly between the 4 groups during the 3 sessions (P=.28, P=.54, P=.18). Conclusions: The most positive behavior was observed in the Immersive VR group, followed by the Semi-immersive VR, Nonimmersive VR, and TSD groups. Moreover, oral health education using VR resources can improve oral health status in children. Trial Registration: Iranian Registry of Clinical Trials 20210103049926N1; https://www.irct.ir/trial/53475 %M 35436233 %R 10.2196/35415 %U https://periop.jmir.org/2022/1/e35415 %U https://doi.org/10.2196/35415 %U http://www.ncbi.nlm.nih.gov/pubmed/35436233 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34756 %T Interactive Digital Game for Improving Visual–Perceptual Defects in Children With a Developmental Disability: Randomized Controlled Trial %A Wu,Wen-Lan %A Huang,Yu-Ling %A Liang,Jing-Min %A Chen,Chia-Hsin %A Wang,Chih-Chung %A Ho,Wen-Hsien %+ Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, No.100, Shih-Chuan 1st Road, Kaohsiung, 807, Taiwan, 886 7 3121101 ext 2648, whho@kmu.edu.tw %K interactive digital game %K visual–perceptual defect %K developmental disability %K Children %K Test of Visual Perceptual Skills %K rehabilitation %D 2022 %7 15.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Visual–perceptual defects in children can negatively affect their ability to perform activities of daily living. Conventional rehabilitation training for correcting visual–perceptual defects has limited training patterns and limited interactivity, which makes motivation difficult to sustain. Objective: We aimed to develop and evaluate an interactive digital game system for correcting visual–perceptual defects and evaluate its effectiveness. Methods: Participants were children aged 5 to 10 years with a diagnosis of visual–perceptual defect associated with a developmental disability. The children were randomized into a digital game group who received the traditional course of rehabilitation combined with an interactive digital game intervention (n=12) and a standard rehabilitation group (n=11) who only received the traditional course of rehabilitation. Each group underwent rehabilitation once a week for 4 weeks. Overall improvement in Test of Visual Perceptual Skills 3rd edition (TVPS-3) score and overall improvement in performance in the interactive digital game were evaluated. Parents and therapists were asked to complete a satisfaction questionnaire. Results: After 4 weeks, the TVPS-3 score had significantly increased (P=.002) in the digital game group (pre: mean 41.67, SD 13.88; post: 61.50, SD 21.64). In the standard rehabilitation group, the TVPS-3 score also increased, but the increase was not statistically significant (P=.58). Additionally, TVPS-3 score increases were significantly larger for the digital game group compared with those for the standard rehabilitation group (P=.005). Moreover, both parents and therapists were highly satisfied with the system. All 5 themes of satisfaction had mean scores higher than 4 in a 5-point scale questionnaire (mean 4.30, SD 0.56). Conclusions: The system has potential applications for improving visual–perceptual function in children undergoing medical rehabilitation for developmental disability. Trial Registration: ClinicalTrials.gov NCT05016492; http://clinicaltrials.gov/ct2/show/NCT05016492 %M 35436215 %R 10.2196/34756 %U https://games.jmir.org/2022/2/e34756 %U https://doi.org/10.2196/34756 %U http://www.ncbi.nlm.nih.gov/pubmed/35436215 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35511 %T A Photography-based, Social Media Walking Intervention Targeting Autonomous Motivations for Physical Activity: Semistructured Interviews With Older Women %A Robertson,Michael C %A Swartz,Maria Chang %A Christopherson,Ursela %A Bentley,Jason R %A Basen-Engquist,Karen M %A Thompson,Debbe %A Volpi,Elena %A Lyons,Elizabeth J %+ Department of Nutrition, Metabolism & Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX, 77555, United States, 1 409 772 2575, ellyons@utmb.edu %K physical activity %K walking %K exercise %K fitness %K social media %K health %K intervention %K behavior %K behavior mechanism %K psychological theory %K serious games %K gamification %K older women %K older adults %K behavior change %K behavioral interventions %K mobile phone %K photography %K patient perspective %K patient attitude %D 2022 %7 14.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Older adult women are at risk for negative health outcomes that engaging in sustained physical activity can help prevent. However, promoting long-term maintenance of physical activity in this population has proven to be a challenge. Increasing autonomous motivations (ie, intrinsic, integrated, and identified regulations) for physical activity may facilitate enduring behavior change. Digitally delivered games for health that take a celebratory technology approach, that is, using technology to create new ways to experience valued behaviors and express valued beliefs, may be a useful way to target autonomous motivations for physical activity. Formative research with the target population is needed to design compelling intervention content. Objective: The objective of this study is to investigate older adult women’s reactions to and thoughts about a photography-based, social media walking game targeting autonomous motivations for physical activity. Methods: During an individual semistructured interview, a moderator solicited feedback from 20 older adult women (age range 65-74 years) as part of formative research to develop a social media game featuring weekly walking challenges. The challenges were designed to target autonomous motivations for physical activity. Interviews were audio-recorded and transcribed verbatim. Two reviewers conducted thematic content analysis on interview transcripts. Results: We identified 3 overarching themes in qualitative data analysis. These reflected the playful experiences, value, and acceptability associated with the intervention challenges. Generally, participants understood what the challenges were asking them to do, proffered appropriate example responses, and indicated that the challenges would be enjoyable. Participants reported that the intervention content afforded many and varied playful experiences (eg, competition, discovery, exploration, expression, fellowship, humor, nurture, sensation). Further, participants indicated that the intervention increased their motivation for physical activity, occasioned meaningful shifts in perspective, increased their knowledge of various topics of interest, provided an opportunity to create valued connection with others, and provided health-related benefits. Participants suggested the intervention emphasize local history, nature, and cultural events. Conclusions: The photography-based, social media walking game with relatively simple game mechanics was well received and judged to be apt to bring about a wide variety of emotive experiences. A clear, geographically specific identity emerged as a key driver of interest for intervention content. Taking a celebratory technology approach holds promise for targeting autonomous motivations for physical activity in older adult women. %M 35436205 %R 10.2196/35511 %U https://games.jmir.org/2022/2/e35511 %U https://doi.org/10.2196/35511 %U http://www.ncbi.nlm.nih.gov/pubmed/35436205 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e29846 %T Online Support and Intervention for Child Anxiety (OSI): Development and Usability Testing %A Hill,Claire %A Reardon,Tessa %A Taylor,Lucy %A Creswell,Cathy %+ School of Psychology & Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights Campus, Reading, RG6 6AL, United Kingdom, 44 0118 378 8579, claire.hill@reading.ac.uk %K user-centered design %K co-design %K usability testing %K internet-based treatment %K app %K CBT %K anxiety %K children %K mobile phone %D 2022 %7 13.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Internet-based treatments for child anxiety may help to increase access to evidence-based therapies; however, user engagement, uptake, and adherence within routine clinical practice remain as challenges. Involving the intended end users in the development process through user-centered design and usability testing is crucial for maximizing user engagement and adoption of internet-based treatments, but so far this has been lacking for internet-based treatments for child anxiety. Objective: The aim of this study is to develop an internet-based treatment for child anxiety through a process of user-centered design (phase 1) and usability testing (phase 2), based on an existing evidence-based, face-to-face, therapist-supported, parent-led cognitive behavioral therapy intervention. It is intended that the internet-based version of this treatment would consist of a parent website, case management system for clinicians, and mobile game app for children. Methods: Parents, children, and clinicians who were familiar with the face-to-face version of the treatment were recruited from 2 National Health Service clinics. In phase 1, participants participated in 3 workshops to gain feedback on the overall concept, explore their wants and needs for the websites and game, generate ideas on how the treatment may look, and gain feedback on initial mock-ups of the websites and game. In phase 2, participants attended 3 individual usability testing sessions where they were presented with working prototypes of the website or game and asked to perform a series of tasks on the website (parents and clinicians) or play the game (children). The frequency and details on usability errors were recorded. Participants were asked for their feedback on the website and game using a standardized usability questionnaire and semistructured interviews. The websites and game were iterated after each round of usability testing in response to this feedback. Results: In phase 1, participants approved the general concept and rated the initial mock-ups of the website and game positively. In phase 2, working prototypes were rated positively and usability errors declined across the iterations and were mainly cosmetic or minor issues relating to esthetic preference, with few issues regarding ability to navigate the website or technical issues affecting functionality. Feedback from the semistructured interviews further supported the positive response of participants to the website and game, and helped identify areas for improvement during the iteration process. The final iteration of the website and game are presented. Conclusions: Taking an iterative approach to development through user-centered design and usability testing has resulted in an internet-based treatment for child anxiety (Online Support and Intervention for child anxiety) that appears to meet the needs and expectations of the intended users (parents, children, and clinicians) and is easy and enjoyable to use. %M 35416781 %R 10.2196/29846 %U https://formative.jmir.org/2022/4/e29846 %U https://doi.org/10.2196/29846 %U http://www.ncbi.nlm.nih.gov/pubmed/35416781 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 5 %N 2 %P e26760 %T Improved Digital Therapy for Developmental Pediatrics Using Domain-Specific Artificial Intelligence: Machine Learning Study %A Washington,Peter %A Kalantarian,Haik %A Kent,John %A Husic,Arman %A Kline,Aaron %A Leblanc,Emilie %A Hou,Cathy %A Mutlu,Onur Cezmi %A Dunlap,Kaitlyn %A Penev,Yordan %A Varma,Maya %A Stockham,Nate Tyler %A Chrisman,Brianna %A Paskov,Kelley %A Sun,Min Woo %A Jung,Jae-Yoon %A Voss,Catalin %A Haber,Nick %A Wall,Dennis Paul %+ Departments of Pediatrics (Systems Medicine) and Biomedical Data Science, Stanford University, Stanford, CA, United States, 1 5126800926, peterwashington@stanford.edu %K computer vision %K emotion recognition %K affective computing %K autism spectrum disorder %K pediatrics %K mobile health %K digital therapy %K convolutional neural network %K machine learning %K artificial intelligence %D 2022 %7 8.4.2022 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Automated emotion classification could aid those who struggle to recognize emotions, including children with developmental behavioral conditions such as autism. However, most computer vision emotion recognition models are trained on adult emotion and therefore underperform when applied to child faces. Objective: We designed a strategy to gamify the collection and labeling of child emotion–enriched images to boost the performance of automatic child emotion recognition models to a level closer to what will be needed for digital health care approaches. Methods: We leveraged our prototype therapeutic smartphone game, GuessWhat, which was designed in large part for children with developmental and behavioral conditions, to gamify the secure collection of video data of children expressing a variety of emotions prompted by the game. Independently, we created a secure web interface to gamify the human labeling effort, called HollywoodSquares, tailored for use by any qualified labeler. We gathered and labeled 2155 videos, 39,968 emotion frames, and 106,001 labels on all images. With this drastically expanded pediatric emotion–centric database (>30 times larger than existing public pediatric emotion data sets), we trained a convolutional neural network (CNN) computer vision classifier of happy, sad, surprised, fearful, angry, disgust, and neutral expressions evoked by children. Results: The classifier achieved a 66.9% balanced accuracy and 67.4% F1-score on the entirety of the Child Affective Facial Expression (CAFE) as well as a 79.1% balanced accuracy and 78% F1-score on CAFE Subset A, a subset containing at least 60% human agreement on emotions labels. This performance is at least 10% higher than all previously developed classifiers evaluated against CAFE, the best of which reached a 56% balanced accuracy even when combining “anger” and “disgust” into a single class. Conclusions: This work validates that mobile games designed for pediatric therapies can generate high volumes of domain-relevant data sets to train state-of-the-art classifiers to perform tasks helpful to precision health efforts. %M 35394438 %R 10.2196/26760 %U https://pediatrics.jmir.org/2022/2/e26760 %U https://doi.org/10.2196/26760 %U http://www.ncbi.nlm.nih.gov/pubmed/35394438 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e30196 %T A Mobile-based Virtual Reality Speech Rehabilitation App for Patients With Aphasia After Stroke: Development and Pilot Usability Study %A Bu,Xiaofan %A Ng,Peter HF %A Tong,Ying %A Chen,Peter Q %A Fan,Rongrong %A Tang,Qingping %A Cheng,Qinqin %A Li,Shuangshuang %A Cheng,Andy SK %A Liu,Xiangyu %+ Department of Health Service Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283, Tongzipo Road, Yuelu District, Changsha, 410013, China, 86 18674869736, 979596459@qq.com %K virtual reality %K speech rehabilitation %K stroke %K app %K Delphi %D 2022 %7 7.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke has the highest disability-adjusted life-years lost in any disease, and approximately one-third of the patients get aphasia. Computers and tablets are innovative and aid in intensive treatments in speech rehabilitation for patients with aphasia. However, mechanical training limits the help to patients. Objective: This study aims to provide a framework for an integrated virtual reality (VR) app to provide speech rehabilitation for patients with aphasia. Methods: The content was generated through an in-depth literature review and discussion with experienced rehabilitation physicians and occupational therapists. We then conducted a 2-round Delphi study with 15 experts from hospitals and universities to rate the content using a 5-point Likert scale. The app was developed by an interdisciplinary team involving VR, medical science of rehabilitation, and therapeutic rehabilitation. Pilot usability testing of this novel app was conducted among 5 patients with aphasia, 5 healthy volunteers, 5 medical staff, and 2 VR experts. Results: We designed 4 modules of speech rehabilitation: oral expression, auditory comprehension, cognition, and comprehensive application. Our VR-based interactive and intelligent app was developed to provide an alternative option for patients with aphasia. Pilot usability testing revealed user satisfaction with the app. Conclusions: This study designed and tested a novel VR-based app for speech rehabilitation specifically adapted to patients with aphasia. This will guide other studies to develop a similar program or intelligent system in a clinical setting. %M 35389349 %R 10.2196/30196 %U https://games.jmir.org/2022/2/e30196 %U https://doi.org/10.2196/30196 %U http://www.ncbi.nlm.nih.gov/pubmed/35389349 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e33526 %T A Serious Game for Young People With First Episode Psychosis (OnTrack>The Game): Qualitative Findings of a Randomized Controlled Trial %A Jankowski,Samantha %A Ferreira,Kathleen %A Mascayano,Franco %A Donovan,Effy %A Rahim,Reanne %A Birnbaum,Michael L %A Yum-Chan,Sabrina %A Medoff,Deborah %A Marcogliese,Bethany %A Fang,Lijuan %A Nicholson,Terriann %A Dixon,Lisa %+ Department of Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, United States, 1 212 326 8441, Lisa.Dixon@nyspi.columbia.edu %K video gaming %K internet %K recovery %K schizophrenia %K psychosis %K clinicians %K mobile phone %D 2022 %7 6.4.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Several studies have shown the benefits of coordinated specialty care (CSC) for individuals with first episode psychosis; however, pathways to care are marred by lack of knowledge, stigma, and difficulties with treatment engagement. Serious games or video interventions may provide a way to address these factors. Objective: This study focuses on qualitative results of a randomized controlled trial comparing OnTrack>The Game (OTG) with recovery videos (RVs) on engagement, stigma, empowerment, hope, recovery, and understanding of psychosis in clients receiving CSC. Clinicians are also interviewed regarding their perceptions of the interventions and suggestions for improvement. Methods: A total of 16 clients aged 16-30 years, with first episode psychosis attending a CSC program in New York State, and 9 clinicians participated in the qualitative interviews. Interviews were analyzed using the rapid identification of themes from audio recordings method. Results: For clients, themes included relatability of game content, an increased sense of hope and the possibility of recovery, decreased self-stigma and public stigma, increased understanding of the importance of social support, and increased empowerment in the OTG group. Clinicians had a preference for RV and provided suggestions for dissemination and implementation. Conclusions: Themes that may help inform future research in this area, particularly regarding dissemination and implementation of OTG and RV, emerged. Trial Registration: ClinicalTrials.gov NCT03390491; https://clinicaltrials.gov/ct2/show/NCT03390491 %M 35384847 %R 10.2196/33526 %U https://mental.jmir.org/2022/4/e33526 %U https://doi.org/10.2196/33526 %U http://www.ncbi.nlm.nih.gov/pubmed/35384847 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e33169 %T The Effectiveness of a Serious Game (MemoreBox) for Cognitive Functioning Among Seniors in Care Facilities: Field Study %A Kleschnitzki,Jana Marina %A Beyer,Luzi %A Beyer,Reinhard %A Großmann,Inga %+ Department of Psychology, Humboldt-University of Berlin, Rudower Chaussee 18, Berlin, 12489, Germany, 49 15231964606, janakleschnitzki@posteo.de %K serious game %K cognitive function %K mental health %K seniors %K care facilities %K aging %K cognitive impairments %K health technology %D 2022 %7 1.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have been found to have enhancing and preventative effects on cognitive abilities in healthy older adults. Yet, there are few results on the effects in older seniors with age-related low cognitive impairments. Their special needs were considered when designing and using innovate technology in the area of prevention, which is especially relevant owing to the continuously aging population. Objective: The objective of this study was to evaluate the impact of a serious game on the cognitive abilities of seniors in order to potentially implement innovative resource-oriented technological interventions that can help to meet future challenges. Methods: In this controlled trial, we tested the serious game MemoreBox, which features modules specifically designed for seniors in nursing homes. Over a period of 1 year, we tested the cognitive abilities of 1000 seniors at 4 time points using the Mini-Mental Status Test. Only half of the participating seniors engaged with the serious game. Results: The study included an intervention group (n=56) and a control group (did not play; n=55). Based on the in-game data collection, a second intervention group (n=38) was identified within the original intervention group, which exactly followed the planned protocol. There were no noteworthy differences between the demographic and main variables of the overall sample. The large reduction in the sample size was due to the effects of the COVID-19 pandemic (drop-out rate: 88.9%). The CI was set at 5%. Mixed analysis of variance (ANOVA) between the cognitive abilities of the intervention and control groups did not show a statistically significant difference between time and group (F2.710,295.379=1.942; P=.13; partial η²=0.018). We noted approximately the same findings for mixed ANOVA between the cognitive abilities of the second intervention and control groups (F3,273=2.574; P=.054; partial η²=0.028). However, we did observe clear tendencies and a statistically significant difference between the 2 groups after 9 months of the intervention (t88.1=−2.394; P=.02). Conclusions: The results of this study show similarities with the current research situation. Moreover, the data indicate that the intervention can have an effect on the cognitive abilities of seniors, provided that they regularly play the serious game of MemoreBox. The small sample size means that the tendency toward improvement cannot be proven as statistically significant. However, the tendency shown warrants further research. Establishing an effective prevention tool as part of standard care in nursing homes by means of an easy-to-use serious game would be a considerable contribution to the weakened health care system in Germany as it would offer a means of activating senior citizens in partially and fully inpatient care facilities. Trial Registration: German Clinical Trials Register DRKS00016633; https://tinyurl.com/2e4765nj %M 35172959 %R 10.2196/33169 %U https://games.jmir.org/2022/2/e33169 %U https://doi.org/10.2196/33169 %U http://www.ncbi.nlm.nih.gov/pubmed/35172959 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 3 %P e28801 %T Evaluating the Impact of Adaptive Personalized Goal Setting on Engagement Levels of Government Staff With a Gamified mHealth Tool: Results From a 2-Month Randomized Controlled Trial %A Nuijten,Raoul %A Van Gorp,Pieter %A Khanshan,Alireza %A Le Blanc,Pascale %A van den Berg,Pauline %A Kemperman,Astrid %A Simons,Monique %+ Department of Industrial Engineering, Eindhoven University of Technology, Groene Loper 3, Eindhoven, 5612 AE, Netherlands, 31 040 247 2290, r.c.y.nuijten@tue.nl %K mHealth %K health promotion %K physical activity %K personalization %K adaptive goal setting %K gamification %K office workers %D 2022 %7 31.3.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although the health benefits of physical activity are well established, it remains challenging for people to adopt a more active lifestyle. Mobile health (mHealth) interventions can be effective tools to promote physical activity and reduce sedentary behavior. Promising results have been obtained by using gamification techniques as behavior change strategies, especially when they were tailored toward an individual’s preferences and goals; yet, it remains unclear how goals could be personalized to effectively promote health behaviors. Objective: In this study, we aim to evaluate the impact of personalized goal setting in the context of gamified mHealth interventions. We hypothesize that interventions suggesting health goals that are tailored based on end users’ (self-reported) current and desired capabilities will be more engaging than interventions with generic goals. Methods: The study was designed as a 2-arm randomized intervention trial. Participants were recruited among staff members of 7 governmental organizations. They participated in an 8-week digital health promotion campaign that was especially designed to promote walks, bike rides, and sports sessions. Using an mHealth app, participants could track their performance on two social leaderboards: a leaderboard displaying the individual scores of participants and a leaderboard displaying the average scores per organizational department. The mHealth app also provided a news feed that showed when other participants had scored points. Points could be collected by performing any of the 6 assigned tasks (eg, walk for at least 2000 m). The level of complexity of 3 of these 6 tasks was updated every 2 weeks by changing either the suggested task intensity or the suggested frequency of the task. The 2 intervention arms—with participants randomly assigned—consisted of a personalized treatment that tailored the complexity parameters based on participants’ self-reported capabilities and goals and a control treatment where the complexity parameters were set generically based on national guidelines. Measures were collected from the mHealth app as well as from intake and posttest surveys and analyzed using hierarchical linear models. Results: The results indicated that engagement with the program inevitably dropped over time. However, engagement was higher for participants who had set themselves a goal in the intake survey. The impact of personalization was especially observed for frequency parameters because the personalization of sports session frequency did foster higher engagement levels, especially when participants set a goal to improve their capabilities. In addition, the personalization of suggested ride duration had a positive effect on self-perceived biking performance. Conclusions: Personalization seems particularly promising for promoting the frequency of physical activity (eg, promoting the number of suggested sports sessions per week), as opposed to the intensity of the physical activity (eg, distance or duration). Replications and variations of our study setup are critical for consolidating and explaining (or refuting) these effects. Trial Registration: ClinicalTrials.gov NCT05264155; https://clinicaltrials.gov/ct2/show/NCT05264155 %M 35357323 %R 10.2196/28801 %U https://mhealth.jmir.org/2022/3/e28801 %U https://doi.org/10.2196/28801 %U http://www.ncbi.nlm.nih.gov/pubmed/35357323 %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 %@ 2561-6722 %I JMIR Publications %V 5 %N 1 %P e29164 %T Immersive Reality Experience Technology for Reducing Social Isolation and Improving Social Connectedness and Well-being of Children and Young People Who Are Hospitalized: Open Trial %A Thabrew,Hiran %A Chubb,Laura A %A Kumar,Harshali %A Fouché,Christa %+ The Werry Centre, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, 20-22 Park Road, Grafton, Auckland, 1142, New Zealand, 64 21 402 055, h.thabrew@auckland.ac.nz %K immersive reality experiences %K social isolation %K hospitalized children %K well-being %K social connectedness %K immersive reality %K virtual reality %K serious games %K pediatrics %K mental health %K isolation %K hospitalized patients %K adolescents %D 2022 %7 25.3.2022 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Children and young people who are hospitalized can feel disconnected from their peers and families, which can, in turn, predispose them to psychological problems, including anxiety and depression. Immersive reality experience technology, recently developed by the New Zealand Patience Project Charitable Trust, may help to overcome these issues. Immersive reality experience technology uses immersive 360° live streaming and a virtual reality headset to enable children and young people who are hospitalized to connect through cameras located in either their school or home environment and via SMS text messaging with a designated buddy. Objective: This trial aims to expand qualitative findings from a previous smaller proof of concept trial to ascertain the views of New Zealand children and young people who are hospitalized, their caregivers, and teachers regarding immersive reality experience technology and quantitatively evaluate the effectiveness of immersive reality experience technology in reducing social isolation and improving social connectedness and well-being using validated outcome measures. Methods: An open trial of immersive reality experience technology was conducted between December 2019 and December 2020 for which 19 New Zealand children and young people aged 13 to 18 years who had been hospitalized at Starship Hospital—a specialist pediatric hospital in Auckland—for at least 2 weeks were recruited. All young people completed the Short Warwick–Edinburgh Mental Well-Being Scale, an abbreviated version of the Social Connectedness Scale, and the Social Inclusion Scale at baseline. Of the 19 participants, 10 (53%) used immersive reality experience technology as often as they wished over a 6-week period and completed postintervention measures. Semistructured interviews with a subset of the 10 young people, 4 caregivers, and 6 teachers were conducted immediately after the intervention. Results: Participants reported improvements in social inclusion (mean change 3.9, SD 2.8; P=.06), social connectedness (mean change 14.2, SD 10.0; P=.002), and well-being (mean change 5.7, SD 4.0; P=.001). Key themes from interviews with participants, caregivers, and teachers were the importance of support for using immersive reality experience technology, connecting versus connectedness, choice and connection, and the value of setting it up and getting it right. Recommendations for improving connectedness via immersive reality experience and related technologies were also provided. Conclusions: Immersive reality experience technology can improve the social inclusion, social connectedness, and well-being of New Zealand children and young people who are hospitalized. With some technological modifications and simplified implementation, immersive reality experience and related technology could become part of standard care and support children and young people who are hospitalized in New Zealand and elsewhere to sustain family and peer cohesion, experience fewer psychological problems, and more easily return to normal life following the completion of treatment. Trial Registration: Australian New Zealand Clinical Trials Network Registry ACTRN12619000252112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376837&isReview=true %M 35333184 %R 10.2196/29164 %U https://pediatrics.jmir.org/2022/1/e29164 %U https://doi.org/10.2196/29164 %U http://www.ncbi.nlm.nih.gov/pubmed/35333184 %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 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 e30366 %T Determining the Optimal Virtual Reality Exergame Approach for Balance Therapy in Persons With Neurological Disorders Using a Rasch Analysis: Longitudinal Observational Study %A Wiskerke,Evelyne %A Kool,Jan %A Hilfiker,Roger %A Sattelmayer,Karl Martin %A Verheyden,Geert %+ Rehazentrum Valens, Kliniken Valens, Taminaplatz 1, Valens, 7317, Switzerland, 41 813031403, evelien.wiskerke@kuleuven.be %K digital therapeutics %K virtual reality %K exergaming %K balance %K stroke %K multiple sclerosis %K neurorehabilitation %K Rasch analysis %D 2022 %7 22.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient’s ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy. Objective: The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation. Methods: A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition–based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability. Results: Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability. Conclusions: The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises. Trial Registration: ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275 %M 35315785 %R 10.2196/30366 %U https://games.jmir.org/2022/1/e30366 %U https://doi.org/10.2196/30366 %U http://www.ncbi.nlm.nih.gov/pubmed/35315785 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e35040 %T Effect of the Nintendo Ring Fit Adventure Exergame on Running Completion Time and Psychological Factors Among University Students Engaging in Distance Learning During the COVID-19 Pandemic: Randomized Controlled Trial %A Wu,Yi-Syuan %A Wang,Wei-Yun %A Chan,Ta-Chien %A Chiu,Yu-Lung %A Lin,Hung-Che %A Chang,Yu-Tien %A Wu,Hao-Yi %A Liu,Tzu-Chi %A Chuang,Yu-Cheng %A Wu,Jonan %A Chang,Wen-Yen %A Sun,Chien-An %A Lin,Meng-Chiung %A Tseng,Vincent S %A Hu,Je-Ming %A Li,Yuan-Kuei %A Hsiao,Po-Jen %A Chen,Chao-Wen %A Kao,Hao-Yun %A Lee,Chia-Cheng %A Hsieh,Chung-Bao %A Wang,Chih-Hung %A Chu,Chi-Ming %+ School of Public Health, National Defense Medical Center, Rm. 4317, 4F., No. 161, Sec. 6, Minquan E. Rd., Neihu Dist., Taipei, 114201, Taiwan, 886 2 8792 3100 ext 18438, chuchiming@web.de %K exergaming %K cardiac force index %K running %K physical activity %K sleep quality %K mood disorders %K digital health %K physical fitness %K Nintendo Ring Fit Adventure %K COVID-19 pandemic %D 2022 %7 22.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The COVID-19 outbreak has not only changed the lifestyles of people globally but has also resulted in other challenges, such as the requirement of self-isolation and distance learning. Moreover, people are unable to venture out to exercise, leading to reduced movement, and therefore, the demand for exercise at home has increased. Objective: We intended to investigate the relationships between a Nintendo Ring Fit Adventure (RFA) intervention and improvements in running time, cardiac force index (CFI), sleep quality (Chinese version of the Pittsburgh Sleep Quality Index score), and mood disorders (5-item Brief Symptom Rating Scale score). Methods: This was a randomized prospective study and included 80 students who were required to complete a 1600-meter outdoor run before and after the intervention, the completion times of which were recorded in seconds. They were also required to fill out a lifestyle questionnaire. During the study, 40 participants (16 males and 24 females, with an average age of 23.75 years) were assigned to the RFA group and were required to exercise for 30 minutes 3 times per week (in the adventure mode) over 4 weeks. The exercise intensity was set according to the instructions given by the virtual coach during the first game. The remaining 40 participants (30 males and 10 females, with an average age of 22.65 years) were assigned to the control group and maintained their regular habits during the study period. Results: The study was completed by 80 participants aged 20 to 36 years (mean 23.20, SD 2.96 years). The results showed that the running time in the RFA group was significantly reduced. After 4 weeks of physical training, it took females in the RFA group 19.79 seconds (P=.03) and males 22.56 seconds (P=.03) less than the baseline to complete the 1600-meter run. In contrast, there were no significant differences in the performance of the control group in the run before and after the fourth week of intervention. In terms of mood disorders, the average score of the RFA group increased from 1.81 to 3.31 for males (difference=1.50, P=.04) and from 3.17 to 4.54 for females (difference=1.38, P=.06). In addition, no significant differences between the RFA and control groups were observed for the CFI peak acceleration (CFIPA)_walk, CFIPA_run, or sleep quality. Conclusions: RFA could either maintain or improve an individual’s physical fitness, thereby providing a good solution for people involved in distance learning or those who have not exercised for an extended period. Trial Registration: ClinicalTrials.gov NCT05227040; https://clinicaltrials.gov/ct2/show/NCT05227040 %M 35315780 %R 10.2196/35040 %U https://games.jmir.org/2022/1/e35040 %U https://doi.org/10.2196/35040 %U http://www.ncbi.nlm.nih.gov/pubmed/35315780 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31974 %T The Potential Application of Commercially Available Active Video Games to Cardiac Rehabilitation: Scoping Review %A Sawa,Ryuichi %A Saitoh,Masakazu %A Morisawa,Tomoyuki %A Takahashi,Tetsuya %A Morimoto,Yuh %A Kagiyama,Nobuyuki %A Kasai,Takatoshi %A Dinesen,Birthe %A Daida,Hiroyuki %+ Department of Physical Therapy, Faculty of Health Science, Juntendo University, 3-2-12 Hongo, Bunkyoku, Tokyo, 113-0033, Japan, 81 3 3813 3111, daida@juntendo.ac.jp %K active video game %K cardiac rehabilitation %K physical exercise %K rehabilitation %K serious games %K CVD %K AVG %K cardiovascular disease %K exercise %K safety %K adherence %D 2022 %7 18.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Commercially available active video games (AVGs) have recently been used for rehabilitation in some specific patient populations but rarely in those with cardiovascular disease (CVD). Commercially available AVGs are designed to increase motivation for continuous play, which could be applicable to the long-term cardiac rehabilitation process. Objective: The objective of this scoping review was to assess the effectiveness of AVG-induced physical exercise, safety management, and patient adherence by applying commercially available AVGs to cardiac rehabilitation. Methods: Four databases (CINAHL, MEDLINE, PubMed, and SPORTDiscus) were searched for all years up to August 12, 2020. Articles were retained if they were written in English, included patients with CVD who were aged 18 years or older, and used AVGs as part of a physical exercise program. The included studies were then evaluated from the viewpoints of effectiveness as physical exercise, safety, and adherence management. Results: Among 120 nonduplicate articles reviewed, 5 (4.2%) were eligible for inclusion, of which 3 (2.5%) were reported by the same research group. The AVG consoles used were Xbox Kinect and Nintendo Wii, and sports-related programs were adopted for the intervention. No adverse cardiac events occurred in the identified studies, and dropout rates tended to be low. Conclusions: AVGs appear to be safe and feasible for promoting an active lifestyle in patients with CVD. However, the effectiveness of AVGs alone as a therapeutic exercise to improve physical function may be limited. %M 35302503 %R 10.2196/31974 %U https://games.jmir.org/2022/1/e31974 %U https://doi.org/10.2196/31974 %U http://www.ncbi.nlm.nih.gov/pubmed/35302503 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31638 %T A Reusable Multiplayer Game for Promoting Active School Transport: Development Study %A Laine,Teemu H %A Duong,Nhi %A Lindvall,Helena %A Oyelere,Solomon Sunday %A Rutberg,Stina %A Lindqvist,Anna-Karin %+ Department of Digital Media, Ajou University, Sanhak Hall 618, 206 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea, 82 312191851, teemu@ubilife.net %K gamification %K active school transport %K physical activity %K formative evaluation %K architecture %K mobile phone %K web browser %D 2022 %7 14.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Most children and adolescents in Sweden do not meet the recommended daily physical activity levels of the World Health Organization. Active school transport (AST) and gamification are potential methods for increasing children’s daily physical activity. We previously developed a game named Tic-Tac-Training for promoting active transport at workplaces; however, the game has not been applied to AST. Objective: The objectives of this study are to investigate how Tic-Tac-Training functions to promote AST among schoolchildren in northern Sweden, improve the game to be more suitable for schoolchildren, and construct a road map for future development based on children’s ideas. Methods: First, we developed Tic-Tac-Training using the Scrum agile software development method. Second, we conducted a questionnaire-based formative evaluation of the game with schoolchildren (n=16; 9/16, 56% male; 6/16, 38% female; and 1/16, 6% other aged 11-12 years) in Luleå, Sweden. Third, we conducted focus group interviews with 33 children (13/33, 39% male and 20/33, 61% female aged 12-13 years) to gather ideas for gamifying AST. We mapped the interview results to the Octalysis gamification framework and established a road map for future development. Results: The formative evaluation revealed several issues, including a lack of interesting game features, lack of support for continuous engagement, disliked competitive features, and lack of incentives for discourse and participation. New features such as rewards, collectibles, and levels were implemented based on the results. The focus group interviews revealed additional ideas for gamifying AST, such as using avatars, in-game currency and trading, and context-sensitive tasks. Conclusions: The results have several potential impacts on how reusable, gamified AST interventions can be developed and what kind of gamification elements schoolchildren in northern Sweden wish to see. These results can interest game researchers and teachers who wish to apply gamification in school contexts. Finally, we aim to continue developing the game based on the road map. %M 35285815 %R 10.2196/31638 %U https://games.jmir.org/2022/1/e31638 %U https://doi.org/10.2196/31638 %U http://www.ncbi.nlm.nih.gov/pubmed/35285815 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e34592 %T The Effectiveness and Safety of Serious Games for Improving Cognitive Abilities Among Elderly People With Cognitive Impairment: Systematic Review and Meta-Analysis %A Abd-alrazaq,Alaa %A Alajlani,Mohannad %A Alhuwail,Dari %A Toro,Carla T %A Giannicchi,Anna %A Ahmed,Arfan %A Makhlouf,Ahmed %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 5825, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K global cognition %K systematic review %K meta-analysis %D 2022 %7 10.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Cognitive impairment is a mental disorder that commonly affects elderly people. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological intervention for improving cognitive abilities. The effectiveness and safety of serious games for improving cognitive abilities have been investigated by several systematic reviews; however, they are limited by design and methodological weaknesses. Objective: This study aims to assess the effectiveness and safety of serious games for improving cognitive abilities among elderly people with cognitive impairment. Methods: A systematic review of randomized controlled trials (RCTs) was conducted. The following 8 electronic databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also screened reference lists of the included studies and relevant reviews, as well as checked studies citing our included studies. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies. Results: Fifteen studies met the eligibility criteria among 466 citations retrieved. Of those, 14 RCTs were eventually included in the meta-analysis. We found that, regardless of their type, serious games were more effective than no intervention (P=.04) and conventional exercises (P=.002) for improving global cognition among elderly people with cognitive impairment. Further, a subgroup analysis showed that cognitive training games were more effective than no intervention (P=.05) and conventional exercises (P<.001) for improving global cognition among elderly people with cognitive impairment. Another subgroup analysis demonstrated that exergames (a category of serious games that includes physical exercises) are as effective as no intervention and conventional exercises (P=.38) for improving global cognition among elderly people with cognitive impairment. Although some studies found adverse events from using serious games, the number of adverse events (ie, falls and exacerbations of pre-existing arthritis symptoms) was comparable between the serious game and control groups. Conclusions: Serious games and specifically cognitive training games have the potential to improve global cognition among elderly people with cognitive impairment. However, our findings remain inconclusive because the quality of evidence in all meta-analyses was very low, mainly due to the risk of bias raised in the majority of the included studies, high heterogeneity of the evidence, and imprecision of total effect sizes. Therefore, psychologists, psychiatrists, and patients should consider offering serious games as a complement and not a substitute to existing interventions until further more robust evidence is available. Further studies are needed to assess the effect of exergames, the safety of serious games, and their long-term effects. %M 35266877 %R 10.2196/34592 %U https://games.jmir.org/2022/1/e34592 %U https://doi.org/10.2196/34592 %U http://www.ncbi.nlm.nih.gov/pubmed/35266877 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 3 %P e35117 %T The Efficacy of a Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Controlled Trial in the Context of COVID-19 %A Mudhune,Victor %A Sabben,Gaëlle %A Ondenge,Ken %A Mbeda,Calvin %A Morales,Marissa %A Lyles,Robert H %A Arego,Judith %A Ndivo,Richard %A Bednarczyk,Robert A %A Komro,Kelli %A Winskell,Kate %+ Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 404 7275286, swinske@emory.edu %K HIV %K young Africans %K adolescent %K Kenya %K serious game %K game for health %K randomized controlled trial %K mHealth %K prevention %K smartphone %K teenager %K young adult %K Africa %K gaming %K COVID-19 %K efficacy %D 2022 %7 3.3.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents contribute slightly less than one-third of all new HIV infections in sub-Saharan Africa. There is a need for more effective intervention approaches to help young adolescents safely navigate through adolescence and into adulthood. We are assessing the efficacy of Tumaini, a smartphone game designed to prevent HIV among young Africans. Against the background of COVID-19, meaningful alteration of the research protocol was necessary to ensure successful implementation and retention of the study participants in ongoing research. Objective: The objective of our protocol is to determine (1) if Tumaini delays sexual debut and increases condom use at first sex and (2) whether it influences behavioral mediators of early and unprotected sex. Methods: Participants were recruited from Kisumu County in Western Kenya. This study is a 2-arm, individual-randomized controlled trial that enrolled 1004 adolescents aged between 12 years and 15 years. The intervention arm participants are playing Tumaini, while the control arm is provided with Brainilis, a commercially available control game. The study period will last 45 months. At baseline, participants in both arms completed a baseline survey and biological testing for HIV and herpes simplex virus, type 2 (HSV-2); participants will have annual game play periods in years 1-3. They will also complete a total of 12 follow-up surveys. At endline, repeat biological testing will be conducted. Protocol adaptations were necessitated by the COVID-19 pandemic and implemented in accordance with local public health guidelines. Results: Participants were enrolled between October 2020 and November 2020. We plan to complete study procedures in September 2024. The enrolled participant sample was 50.1% (499/996) female and had a mean age of 14.0 (SD 0.6) years. Conclusions: This ongoing research demonstrates that, with appropriate revisions to planned protocol activities guided by the need to maintain study integrity, protect both study participants and staff, and adhere to institutional review board and local health authority guidelines, human subject research is possible in the context of a global pandemic. If the trial demonstrates efficacy, Tumaini would provide an alternative, remote means of delivering age-appropriate education to adolescents on safer sex, HIV prevention, and effective life skills on a highly scalable, low-cost, and culturally adaptable platform. Trial Registration: ClinicalTrials.gov NCT04437667; https://clinicaltrials.gov/ct2/show/NCT04437667 International Registered Report Identifier (IRRID): DERR1-10.2196/35117 %M 35030090 %R 10.2196/35117 %U https://www.researchprotocols.org/2022/3/e35117 %U https://doi.org/10.2196/35117 %U http://www.ncbi.nlm.nih.gov/pubmed/35030090 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30882 %T Benefits of Virtual Reality Balance Training for Patients With Parkinson Disease: Systematic Review, Meta-analysis, and Meta-Regression of a Randomized Controlled Trial %A Wu,Jinlong %A Zhang,Hui %A Chen,Ziyan %A Fu,Ruijia %A Yang,Hao %A Zeng,Hongfa %A Ren,Zhanbing %+ Department of Physical Education, Shenzhen University, No 3588 Nanhai Road, Shenzhen, 518060, China, 86 13318881919, rzb@szu.edu.cn %K virtual reality %K Parkinson disease %K balance %K systematic review %K meta-analysis %K meta-regression %K serious games %K VR %K rehabilitation %K VR training %D 2022 %7 1.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) balance training is increasingly being pursued in biomedical research, specifically with respect to investigating balance ability with VR. However, existing systematic reviews have found inconsistent conclusions about the efficacy of VR in improving balance in Parkinson disease (PD) patients. Objective: The goal of the research was to evaluate the impact of VR balance training on the balance ability of patients with PD. Methods: All major databases, including Web of Science, PubMed, Scopus, China National Knowledge Infrastructure, and Wanfang, were searched to identify all relevant studies published in English or Chinese since September 15, 2010. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation. Results: A total of 16 randomized controlled trials were analyzed (n=583 patients with PD), with the methodological quality evaluation score ranging from 5 to 8 points. A random effects model was selected to combine effect sizes. Meta-analysis showed that the balance ability of PD was significantly improved after VR training compared with the control group (standardized mean difference [SMD] 2.127, 95% CI 1.202 to 3.052, P<.001, I2=95.1, df=15). It is worth noting that the intervention platform may be the main reason for heterogeneity. Meta regression analysis showed that no training program could predict the impact of VR training (P=.57 to .94) on PD balance ability. Subgroup result showed that a single training time of 0 to 20 minutes (SMD 6.446), 4 to 6 times per week (SMD 4.067), training for 3 to 5 weeks (SMD 62.478), training course reached more than 30 times (SMD 4.405), and 201 to 300 minutes per week (SMD 4.059) maybe have more benefit. Conclusions: A systematic review and meta-analysis confirmed that VR balance training is a highly effective means to improve balance performance with large effects in PD. In addition, we preliminarily extracted dose-effect relationships for training volume, informing clinicians and practitioners to design effective VR balance training for balance ability. Further research is needed to reveal optimal dose-response relationships following VR balance training. %M 35230242 %R 10.2196/30882 %U https://games.jmir.org/2022/1/e30882 %U https://doi.org/10.2196/30882 %U http://www.ncbi.nlm.nih.gov/pubmed/35230242 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31395 %T The Effectiveness of Virtual Reality–Based Interventions in Rehabilitation Management of Breast Cancer Survivors: Systematic Review and Meta-analysis %A Bu,Xiaofan %A Ng,Peter H F %A Xu,Wenjing %A Cheng,Qinqin %A Chen,Peter Q %A Cheng,Andy S K %A Liu,Xiangyu %+ Department of Health Service Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Number 283, Tongzi Road, Changsha, 410013, China, 86 18674869736, 979596459@qq.com %K virtual reality %K rehabilitation management %K symptom %K motor function %K systematic review %K meta-analysis %D 2022 %7 28.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Breast cancer survivors (BCSs) can present with various physical and psychological symptoms and functional deficits that impact their quality of life. Virtual reality (VR) technology is being used in breast cancer rehabilitation management to improve the emotional, cognitive, and physical well-being of BCSs. Objective: This systematic review aimed to examine the effectiveness of VR-based interventions on health-related outcomes in BCSs. A meta-analysis was conducted to evaluate the effectiveness of VR-based interventions in the rehabilitation management of BCSs. Methods: A systematic search was conducted on PubMed, Web of Science, EMBASE, CINAHL with Full Text, the Cochrane Central Register of Controlled Trials, CNKI, WanFang, VIP, and CBM, from inception to May 25, 2021. The inclusion criteria of the selected studies were as follows: (1) adults diagnosed with breast cancer; (2) any type of VR-based interventions (immersive and nonimmersive virtual environment); (3) comparison of traditional rehabilitation methods; (4) outcomes including pain, depression, anxiety, fatigue, cognitive function, shoulder range of motion (ROM), hand grip strength, lymphedema, cybersickness symptoms, fear of movement, bleeding, effusion, and flap necrosis, both during and after treatment; and (5) randomized controlled trials (RCTs), case-controlled trials, and quasi-experimental studies. The Cochrane Collaboration Tool was used to evaluate the risk of bias. Review Manager version 5.3 (Cochrane Collaboration) was used to conduct the meta-analysis. The mean difference (MD) and SDs with 95% CIs were used to calculate continuous variables. Results: Twelve articles were included in this systematic review, of which 10 contributed information to the meta-analysis. A total of 604 participants were analyzed. The statistical analysis showed significant results for flexion (standard mean difference [SMD] 1.79; 95% CI 0.55 to 3.03; P=.005), extension (SMD 1.54; 95% CI 0.83 to 2.25; P<.001), abduction (MD 17.53; 95% CI 14.33 to 20.72; P<.001), adduction (MD 15.98; 95% CI 14.02 to 17.94; P<.001), internal rotation (MD 7.12; 95% CI 5.54 to 8.70; P<.001), external rotation (SMD 0.96; 95% CI 0.62 to 1.29; P<.001), anxiety (MD −6.47; 95% CI −7.21 to −5.73; P<.001), depression (MD −4.27; 95% CI −4.64 to −3.91; P<.001), pain (MD −1.32; 95% CI −2.56 to −0.09; P=.04), and cognitive function (MD 8.80; 95% CI 8.24 to 9.36; P<.001). The meta-analysis indicated little to no difference in hand grip strength (MD 1.96; 95% CI –0.93 to 4.85; P=.18). Conclusions: Findings of this review noted a weak but consistent positive association between VR-based interventions and outcomes. However, these results must be interpreted with caution due to the limited number of controlled trials analyzed, small sample sizes, and poor methodological quality. Well‐designed, large, high‐quality trials may have a significant impact on our confidence in the results. Future studies should identify specific aspects that improve the clinical impact of VR-based interventions on major outcomes in BCSs in the clinical setting. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021250727; https://tinyurl.com/2p89rmnk %M 35225817 %R 10.2196/31395 %U https://games.jmir.org/2022/1/e31395 %U https://doi.org/10.2196/31395 %U http://www.ncbi.nlm.nih.gov/pubmed/35225817 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 2 %P e30671 %T The Use of Gamification and Incentives in Mobile Health Apps to Improve Medication Adherence: Scoping Review %A Tran,Steven %A Smith,Lorraine %A El-Den,Sarira %A Carter,Stephen %+ School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, Sydney, 2006, Australia, 61 93512222, steventran@hotmail.com.au %K gamification %K incentives %K mobile application %K mHealth %K medication adherence %K mobile phone %D 2022 %7 21.2.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Emerging health care strategies addressing medication adherence include the use of direct-to-patient incentives or elements adapted from computer games. However, there is currently no published evidence synthesis on the use of gamification or financial incentives in mobile apps to improve medication adherence. Objective: The aim of this scoping review is to synthesize and appraise the literature pertaining to the use of mobile apps containing gamification or financial incentives for medication adherence. There were two objectives: to explore the reported effectiveness of these features and to describe and appraise the design and development process, including patient involvement. Methods: The following databases were searched for relevant articles published in English from database inception to September 24, 2020: Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science. The framework by Arksey and O’Malley and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist guided this scoping review. Using a systematic screening process, studies were included if incentives or game features were used within mobile apps to specifically address medication adherence. An appraisal using risk of bias tools was also applied to their respective study design. Results: A total of 11 studies from the initial 691 retrieved articles were included in this review. Across the studies, gamification alone (9/11, 82%) was used more than financial incentives (1/11, 9%) alone or a combination of the two (1/11, 9%). The studies generally reported improved or sustained optimal medication adherence outcomes; however, there was significant heterogeneity in the patient population, methodology such as outcome measures, and reporting of these studies. There was considerable variability in the development process and evaluation of the apps, with authors opting for either the waterfall or agile methodology. App development was often guided by a theory, but across the reviewed studies, there were no common theories used. Patient involvement was not commonly evident in predevelopment phases but were generally reserved for evaluations of feasibility, acceptance, and effectiveness. Patient perspectives on gamified app features indicated a potential to motivate positive health behaviors such as medication adherence along with critical themes of repetitiveness and irrelevance of certain features. The appraisal indicated a low risk of bias in most studies, although concerns were identified in potential confounding. Conclusions: To effectively address medication adherence via gamified and incentivized mobile apps, an evidence-based co-design approach and agile methodology should be used. This review indicates some adoption of an agile approach in app development; however, patient involvement is lacking in earlier stages. Further research in a generalized cohort of patients living with chronic conditions would facilitate the identification of barriers, potential opportunities, and the justification for the use of gamification and financial incentives in mobile apps for medication adherence. %M 35188475 %R 10.2196/30671 %U https://mhealth.jmir.org/2022/2/e30671 %U https://doi.org/10.2196/30671 %U http://www.ncbi.nlm.nih.gov/pubmed/35188475 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32117 %T Immersive Virtual Reality–Based Cognitive Intervention for the Improvement of Cognitive Function, Depression, and Perceived Stress in Older Adults With Mild Cognitive Impairment and Mild Dementia: Pilot Pre-Post Study %A Zhu,KaiYan %A Zhang,QiongYao %A He,BingWei %A Huang,MeiZhen %A Lin,Rong %A Li,Hong %+ Research Center for Nursing Theory and Practice, Department of Nursing, Fujian Provincial Hospital, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, China, 86 13705070219, leehong99@126.com %K cognitive intervention %K dementia %K immersive virtual reality %K mild cognitive impairment %K cognitive impairment %K virtual reality %K VR %K older patients %K usability %K memory %K stress %D 2022 %7 21.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The incidence of dementia is increasing annually, resulting in varying degrees of adverse effects for individuals, families, and society. With the continuous development of computer information technology, cognitive interventions are constantly evolving. The use of immersive virtual reality (IVR) as a cognitive intervention for older adults with mild cognitive impairment (MCI) and mild dementia (MD) is promising, although only few studies have focused on its use. Objective: The Chinese virtual supermarket (CVSM) IVR system was developed to provide a comprehensive and individual cognitive intervention program for older patients with MCI and MD. The aim of this study was to explore the feasibility and clinical effectiveness of this 5-week IVR-based cognitive intervention. Methods: A pretest-posttest study design was conducted with 31 older adults with MCI and MD from August 2020 to January 2021. All participants participated in a 5-week immersive virtual cognitive training program using the CVSM system. Feasibility was assessed as the incidence and severity of cybersickness symptoms and participant satisfaction based on questionnaires conducted after the intervention. Clinical effectiveness was evaluated using neuropsychological assessments, including several commonly used measures of cognitive function, depression, perceived stress, and activities of daily living. Measurements were obtained at baseline and after the intervention period. Results: A total of 18 patients with MCI (mean age 82.94 [SD 5.44] years; 12 females) and 13 patients with MD (mean age 85.7 [SD 4.67] years, 10 females) participated in this pilot study. Both groups showed significant improvements in all cognitive function measurements (P<.001). The MD group had a significantly greater improvement in general cognitive function compared to the MCI group in Montreal Cognitive Assessment Scale, Symbol Digit Modalities Test, Shape Trail Test, and Auditory Verbal Learning Test. Furthermore, an intervention effect was observed in the improvement of perceived stress (P=.048 for MD group, P=.03 for MCI group ). Conclusions: The use of the CVSM system may be effective in enhancing the cognitive function of patients with MCI and MD, including general cognitive function, memory, executive function, and attention. IVR technology enriches cognitive intervention approaches and provides acceptable, professional, personalized, and interesting cognitive training for older adults with cognitive impairment. Trial Registration: ClinicalTrials ChiCTR2100043753; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2100043753 %M 35188466 %R 10.2196/32117 %U https://games.jmir.org/2022/1/e32117 %U https://doi.org/10.2196/32117 %U http://www.ncbi.nlm.nih.gov/pubmed/35188466 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e29579 %T Experiences of Patients Undergoing Chemotherapy With Virtual Reality: Mixed Methods Feasibility Study %A Janssen,Anna %A Fletcher,Jennifer %A Keep,Melanie %A Ahmadpour,Naseem %A Rouf,Anika %A Marthick,Michael %A Booth,Rebecca %+ Research in Implementation Science and eHealth Group, Faculty of Medicine and Health, The University of Sydney, Level 2, Charles Perkins Centre D17, Sydney, 2006, Australia, 61 9036 9406, anna.janssen@sydney.edu.au %K eHealth %K digital health %K virtual reality %K cancer %K chemotherapy %K mixed methods research %K virtual health %K serious games %K treatment %D 2022 %7 21.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Current research into virtual reality (VR) use during chemotherapy shows that it can be an effective distraction intervention. However, there is limited research in adult patients and to investigate how VR can be sustainably implemented in health care organizations. Objective: The aim of this study was to explore the feasibility and acceptability of using VR for adult patients undergoing chemotherapy, and to identify the factors that would enable the sustained use of VR during chemotherapy in health care organizations. Methods: Patients undergoing chemotherapy were recruited to participate in a VR intervention during chemotherapy infusion. Participants were observed during the session and completed a postintervention survey. Each participant was invited to participate in a semistructured interview about their experience. Results: A total of 18 patients participated in the study, 5 of whom participated in semistructured interviews. Findings indicated that the use of VR was acceptable for patients undergoing chemotherapy and the intervention was also feasible. Some participants felt that the VR was an effective distraction during chemotherapy infusion, although most still seemed to be aware of how long their treatment was taking. Although VR was acceptable and feasible to patients, interviews identified several barriers to sustained implementation, including access to a reliable app library and impact on staff workloads. Conclusions: VR was acceptable to patients with a diagnosis of cancer undergoing chemotherapy treatment. Patients found VR beneficial for breaking up the monotony of treatment, to provide an additional choice of activity in addition to other recreation, and in some instances as a distraction from the treatment itself. However, there are challenges to address if VR is to be implemented in practice for this patient group. %M 35188474 %R 10.2196/29579 %U https://games.jmir.org/2022/1/e29579 %U https://doi.org/10.2196/29579 %U http://www.ncbi.nlm.nih.gov/pubmed/35188474 %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 e30738 %T A Serious Game (Immunitates) About Immunization: Development and Validation Study %A Lima,Isabela Dantas de Araujo %A Ponce de Leon,Casandra Genoveva Rosales Martins %A Ribeiro,Laiane Medeiros %A Silva,Izabel Cristina Rodrigues da %A Vilela,Danielle Monteiro %A Fonseca,Luciana Mara Monti %A Góes,Fernanda dos Santos Nogueira de %A Funghetto,Silvana Schwerz %+ Graduate Program in Health Sciences and Technologies, Ceilândia College, University of Brasília, Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília, 72220-275, Brazil, 55 61 3107 8418, isabeladantas.al@gmail.com %K educational technology %K immunization %K nursing education %K validation %K methodological study %K vaccination %K public health %K nursing students %K teaching %K education %K support tool %K continuing education %D 2022 %7 18.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Vaccination is a fundamental part of all levels—local to worldwide—of public health, and it can be considered one of humanity's greatest achievements in the control and elimination of infectious diseases. Teaching immunization and vaccination can be monotonous and tiring. It is necessary to develop new approaches for teaching these themes in nursing school. Objective: We aimed to develop and validate a serious game about immunization and vaccination for Brazilian nursing students. Methods: We developed a quiz-type game, Immunitates, using design and educational theoretical models and Brazilian National Health Guidelines. The game’s heuristics and content were evaluated with 2 different instruments by a team of experts. A sample of nursing students evaluated the validity of the game’s heuristics only. We calculated the content validity index (CVI) for each evaluation. Results: The study included 49 experts and 15 nursing students. All evaluations demonstrated high internal consistency (Cronbach α≥.86). The game’s heuristics (experts: CVI 0.75-1.0; students: CVI 0.67-1.0) and the game’s contents demonstrated validity (experts: CVI 0.73-1.0). Participants identified some specific areas for improvement in the next version. Conclusions: The serious game appears to be valid. It is intended as a support tool for nursing students in the teaching–learning process and as a tool for continuing education for nurses. %M 35179496 %R 10.2196/30738 %U https://games.jmir.org/2022/1/e30738 %U https://doi.org/10.2196/30738 %U http://www.ncbi.nlm.nih.gov/pubmed/35179496 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 2 %P e29179 %T Effects of Game Mode in Multiplayer Video Games on Intergenerational Social Interaction: Randomized Field Study %A Zahn,Carmen %A Leisner,David %A Niederhauser,Mario %A Roos,Anna-Lena %A Iseli,Tabea %A Soldati,Marco %+ School of Applied Psychology, University of Applied Sciences and Arts Northwestern Switzerland, Riggenbachstrasse 16, Olten, CH-4600, Switzerland, 41 (0)629572473, carmen.zahn@fhnw.ch %K video games %K computer games %K older adults %K game mode %K serious game %K social interaction %K video analysis methods %D 2022 %7 16.2.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Maintaining social relationships is a basic human need and particularly essential in old age, including when living in a retirement home. Multiplayer video games can promote positive social interactions among players from different generations while playing. Yet, such facilitation of positive social interactions depends on specific game design. To systematically investigate the effects of game design on social interaction between seniors and their coplayers, the game Myosotis FoodPlanet was developed in this study, and the impacts of 3 different game modes on social interaction were compared in a controlled field trial. Objective: This study aims to compare the effects of 3 different game modes (competitive, cooperative, and creative) on social interactions (verbal and nonverbal communication) between seniors and their younger coplayers. Methods: This study was conducted in a Swiss retirement home as a controlled field trial. Participants were residents of the retirement home (N=10; mean age 84.8 years, SD 5.9 years) and played in pairs with their caregivers. Each pair played 3 game modes in random order. This resulted in 30 game sequences of 20 minutes each. A within-subject design was applied with game mode as the within-factor and social interaction as the outcome variable. To assess the quality of social interaction, 30 video-recorded game sequences were analyzed based on an event sampling method. Results: Analysis of variance for repeated measurements revealed significant effects: there was significantly more verbal communication in the creative mode than in the cooperative mode (P=.04) with a strong effect size (Cohen f=0.611). An examination of verbal communication revealed more game-related communication in the creative mode than in the cooperative mode (P=.01) and the competitive mode (P=.09) with marginally significant effects and strong effect sizes (Cohen f=0.841). In addition, significantly more biography-related communication occurred in the creative mode than in the cooperative mode (P=.03), with a strong effect size (r=0.707). Regarding nonverbal communication (eg, laughing together), analysis of variance for repeated measurements showed significant differences among the game modes (P=.02) with a strong effect size (Cohen f=0.758). Results showed that there was significantly more laughing together in the competitive mode (competitive>cooperative>creative). Conclusions: The results show that game mode can be an important factor for shaping the social interactions of players playing together. Compared with other modes, creative game modes can increase verbal communication. In contrast, competitive modes may stimulate more laughing together. This has important implications for game design and the use of computer games to promote social interaction between seniors and their coplayers in practice. %M 35171097 %R 10.2196/29179 %U https://formative.jmir.org/2022/2/e29179 %U https://doi.org/10.2196/29179 %U http://www.ncbi.nlm.nih.gov/pubmed/35171097 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32243 %T Using Virtual Reality to Induce and Assess Objective Correlates of Nicotine Craving: Paradigm Development Study %A Liu,Weichen %A Andrade,Gianna %A Schulze,Jurgen %A Doran,Neal %A Courtney,Kelly E %+ Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, United States, 1 858 534 5157, kecourtney@health.ucsd.edu %K nicotine %K craving %K cue-exposure %K virtual reality %K attentional bias %K pupillometry %K development %K smoking %K addiction %K eye-tracking %D 2022 %7 15.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Craving is a clinically important phenotype for the development and maintenance of nicotine addiction. Virtual reality (VR) paradigms are successful in eliciting cue-induced subjective craving and may even elicit stronger craving than traditional picture-cue methods. However, few studies have leveraged the advances of this technology to improve the assessment of craving. Objective: This report details the development of a novel, translatable VR paradigm designed to both elicit nicotine craving and assess multiple eye-related characteristics as potential objective correlates of craving. Methods: A VR paradigm was developed, which includes three Active scenes with nicotine and tobacco product (NTP) cues present, and three Neutral scenes devoid of NTP cues. A pilot sample (N=31) of NTP users underwent the paradigm and completed subjective measures of nicotine craving, sense of presence in the VR paradigm, and VR-related sickness. Eye-gaze fixation time (“attentional bias”) and pupil diameter toward Active versus Neutral cues, as well as spontaneous blink rate during the Active and Neutral scenes, were recorded. Results: The NTP Cue VR paradigm was found to elicit a moderate sense of presence (mean Igroup Presence Questionnaire score 60.05, SD 9.66) and low VR-related sickness (mean Virtual Reality Sickness Questionnaire score 16.25, SD 13.94). Scene-specific effects on attentional bias and pupil diameter were observed, with two of the three Active scenes eliciting greater NTP versus control cue attentional bias and pupil diameter (Cohen d=0.30-0.92). The spontaneous blink rate metrics did not differ across Active and Neutral scenes. Conclusions: This report outlines the development of the NTP Cue VR paradigm. Our results support the potential of this paradigm as an effective laboratory-based cue-exposure task and provide early evidence of the utility of attentional bias and pupillometry, as measured during VR, as useful markers for nicotine addiction. %M 35166685 %R 10.2196/32243 %U https://games.jmir.org/2022/1/e32243 %U https://doi.org/10.2196/32243 %U http://www.ncbi.nlm.nih.gov/pubmed/35166685 %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 e31644 %T How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis %A Gasteiger,Norina %A van der Veer,Sabine N %A Wilson,Paul %A Dowding,Dawn %+ Division of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom, 44 01613067798, norina.gasteiger@postgrad.manchester.ac.uk %K realist synthesis %K realist review %K review %K virtual reality %K augmented reality %K simulation %K training %K health %K health personnel %K education %K mobile phone %D 2022 %7 14.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Using traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation. Objective: The aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance. Methods: We conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration. Results: Of the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration. Conclusions: Technical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations. %M 35156931 %R 10.2196/31644 %U https://games.jmir.org/2022/1/e31644 %U https://doi.org/10.2196/31644 %U http://www.ncbi.nlm.nih.gov/pubmed/35156931 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e27597 %T Data-Driven Classification of Human Movements in Virtual Reality–Based Serious Games: Preclinical Rehabilitation Study in Citizen Science %A Barak Ventura,Roni %A Stewart Hughes,Kora %A Nov,Oded %A Raghavan,Preeti %A Ruiz Marín,Manuel %A Porfiri,Maurizio %+ Center for Urban Science and Progress, New York University, 370 Jay Street, Brooklyn, NY, 11201, United States, 1 646 997 3681, mporfiri@nyu.edu %K motion analysis %K principal component analysis %K telerehabilitation %K virtual reality %D 2022 %7 10.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients’ lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science–based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users’ range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software’s response to their movements. During calibration, the time series of the users’ movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation. %M 35142629 %R 10.2196/27597 %U https://games.jmir.org/2022/1/e27597 %U https://doi.org/10.2196/27597 %U http://www.ncbi.nlm.nih.gov/pubmed/35142629 %0 Journal Article %@ 2291-9279 %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 e24946 %T Evaluation of a Digitally Guided Self-Rehabilitation Device Coupled With Telerehabilitation Monitoring in Patients With Parkinson Disease (TELEP@RK): Open, Prospective Observational Study %A Blanc,Margaux %A Roy,Anne-Laure %A Fraudet,Bastien %A Piette,Patrice %A Le Toullec,Elodie %A Nicolas,Benoit %A Gallien,Philippe %A Leblong,Emilie %+ Hospital Center (CH) Saint Malo, 1 rue de la Marne, Saint Malo, 35403, France, 33 299212121, M.BLANC@ch-stmalo.fr %K Parkinson's disease %K telerehabilitation %K serious games %K UTAUT %K physiotherapist %K acceptability %K acceptance %D 2022 %7 7.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Parkinson disease is a neurodegenerative disease causing a progressive loss of autonomy. This requires long-term rehabilitation care. Currently, new technologies are being developed for use in daily life, and there is a progressive implementation of telerehabilitation. Objective: The aim of this study (the TELEP@RK study) is to evaluate the uses of a digital self-rehabilitation device in patients with Parkinson disease and their independent physiotherapists on the scale of a health territory. Methods: A total of 10 independent physiotherapists and 31 patients with Parkinson disease were followed for 1 year to evaluate the use of a telerehabilitation tool (digital tablet and inertial sensor) via questionnaires of the Unified Theory of Acceptance and Use of Technology (UTAUT). The questionnaires were submitted to participants at 0, 2, and 12 months from the start of follow-up. The averages of the scores of the different determinants and constructs of the UTAUT questionnaires were compared at the different follow-up times. Results: Among professionals, the averages of the various determinants were generally high at the beginning of the study with an average (out of 5) performance expectancy of 4.19, effort expectancy of 3.88, social influence of 3.95, facilitating conditions of 4, and intention to use of 3.97. These averages decreased over time. Conclusions: Acceptability, acceptance, and appropriation of the tool were very high among the physiotherapists as well as the patients, despite the tool’s lack of evolution during the study. In the current health care context, these results allow us to envision a new organization of the care pathway for patients with chronic diseases, with the increased use of new technologies associated with telecare. %M 35129449 %R 10.2196/24946 %U https://games.jmir.org/2022/1/e24946 %U https://doi.org/10.2196/24946 %U http://www.ncbi.nlm.nih.gov/pubmed/35129449 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 2 %P e27794 %T The Effects of mHealth-Based Gamification Interventions on Participation in Physical Activity: Systematic Review %A Xu,Linqi %A Shi,Hongyu %A Shen,Meidi %A Ni,Yuanyuan %A Zhang,Xin %A Pang,Yue %A Yu,Tianzhuo %A Lian,Xiaoqian %A Yu,Tianyue %A Yang,Xige %A Li,Feng %+ School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, 130012, China, 86 1 779 008 9009, fli@jlu.edu.cn %K mobile health %K gamification %K physical activity %K systematic review %K mobile phone %D 2022 %7 3.2.2022 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: It is well known that regular physical exercise has associated benefits; yet, participation remains suboptimal. Mobile health (mHealth) has become an indispensable medium to deliver behavior change interventions, and there is a growing interest in the gamification apps in mHealth to promote physical activity (PA) participation. Gamification could use game design elements (such as points, leaderboards, and progress bars), and it has the potential to increase motivation for PA and engagement. However, mHealth-based gamification interventions are still emerging, and little is known about the application status and efficacy of such interventions. Objective: This systematic review aims to investigate gamification apps in mHealth for improving PA levels and simultaneously summarize the impact of gamification interventions on PA participation. Methods: We searched PubMed, Scopus, Web of Science, Embase, CINAHL (EBSCO host), and IEEE Xplore from inception to December 20, 2020. Original empirical research exploring the effects of gamification interventions on PA participation was included. The papers described at least one outcome regarding exercise or PA participation, which could be subjective self-report or objective indicator measurement. Of note, we excluded studies about serious games or full-fledged games. Results: Of 2944 studies identified from the database search, 50 (1.69%) were included, and the information was synthesized. The review revealed that gamification of PA had been applied to various population groups and broadly distributed among young people but less distributed among older adults and patients with a disease. Most of the studies (30/50, 60%) combined gamification with wearable devices to improve PA behavior change, and 50% (25/50) of the studies used theories or principles for designing gamified PA interventions. The most frequently used game elements were goal-setting, followed by progress bars, rewards, points, and feedback. This review demonstrated that gamification interventions could increase PA participation; however, the results were mixed, and modest changes were attained, which could be attributed to the heterogeneity across studies. Conclusions: Overall, this study provides an overview of the existing empirical research in PA gamification interventions and provides evidence for the efficacy of gamification in enhancing PA participation. High-quality empirical studies are needed in the future to assess the efficacy of a combination of gamification and wearable activity devices to promote PA, and further exploration is needed to investigate the optimal implementation of these features of game elements and theories to enhance PA participation. %M 35113034 %R 10.2196/27794 %U https://mhealth.jmir.org/2022/2/e27794 %U https://doi.org/10.2196/27794 %U http://www.ncbi.nlm.nih.gov/pubmed/35113034 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31747 %T Development and Evaluation of a Virtual Reality Puzzle Game to Decrease Food Intake: Randomized Controlled Trial %A Liu,Yunxin %A Stamos,Angelos %A Dewitte,Siegfried %A van Berlo,Zeph M C %A van der Laan,Laura N %+ Department of Communication and Cognition, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 (0)134664811, L.N.vdLaan@tilburguniversity.edu %K virtual reality %K pre-exposure %K self-control %K hedonic consumption %K food cravings %D 2022 %7 3.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has gained popularity in daily life, and VR food cues seem to elicit food cravings, similar to real food cues. However, little is known about the impact of VR food cues on actual food intake. Objective: In real life (RL), exposure to food cues in a situation in which the desire to eat food interferes with the completion of a food-related task reduces the subsequent food intake (ie, the pre-exposure effect). In this study, we examine, on the one hand, whether the pre-exposure effect could be replicated in RL and, on the other hand, whether this effect could be extended to VR contexts. Methods: The study used a 2 (stimulus type: food vs nonfood) × 2 (mode: VR vs RL) between-subject design (n=175). Participants were randomly assigned to 1 of the 4 conditions. Results: We found the main effect of mode on food intake, with a higher food intake after both VR conditions than after RL conditions (P=.02). In addition, among female participants, we found that exposure to both food cues (ie, VR and RL) resulted in lower food intake than exposure to both nonfood cues (P=.05). In contrast, this effect was not observed among male participants (P=.34). Additionally, VR and RL cues generated similar emotional and behavioral responses (eg, arousal and game difficulty). Conclusions: We were unable to replicate the exposure effect in our complete sample. Subgroup analyses, however, showed that for women, exposure to food cues (either in VR or in RL) reduces food intake, indicating that a VR pre-exposure procedure may effectively be applied exclusively for women. Trial Registration: ClinicalTrials.gov NCT05169996; https://clinicaltrials.gov/ct2/show/NCT05169996 %M 35113028 %R 10.2196/31747 %U https://games.jmir.org/2022/1/e31747 %U https://doi.org/10.2196/31747 %U http://www.ncbi.nlm.nih.gov/pubmed/35113028 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30526 %T An Evidence Map on Serious Games in Preventing Sexually Transmitted Infections Among Adolescents: Systematic Review About Outcome Categories Investigated in Primary Studies %A Ilskens,Karina %A Wrona,Kamil J %A Dockweiler,Christoph %A Fischer,Florian %+ School of Public Health, Bielefeld University, Universitätsstr. 25, Bielefeld, 33615, Germany, 49 5211065160, kamil.wrona@uni-bielefeld.de %K serious games %K entertainment education %K STI %K STD %K sexual health %K effect %K impact %K sexually transmitted infections %K adolescents %K adolescent sexual health %D 2022 %7 2.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Sexually transmitted infections (STIs) represent a global health risk. Adolescents are at increased risk of infection for several reasons such as lack of knowledge, risky sexual behaviors, and lack of behavioral sills (eg, to negotiate safer sex). Given the fact that adolescents often use digital media and that serious games are considered to have the potential to change knowledge, attitudes and behavior, serious games represent an opportunity for the prevention of STIs. Objective: The aim of this systematic review was to identify and systematically summarize the dimensions that have been investigated in primary studies on serious games targeting STI prevention among adolescents. Methods: A systematic review was conducted in PubMed and Web of Science. Studies published from 2009 to 2021 were included that assessed the effectiveness of serious games on adolescent sexual health. A total of 18 studies met the inclusion criteria and were categorized according to dimensions of effectiveness and user experience. Results: Various dimensions of effectiveness and aspects of user experience were investigated in the primary studies. In total, 9 dimensions of effectiveness were observed: sexual behavior, behavioral intentions, knowledge, attitudes and beliefs, self-efficacy and personal limitations, character traits and future orientation, environmental and individual risk factors, risk perception and risk assessment, as well as normative beliefs and (social) norms. Furthermore, several dimensions related to user experience were investigated in primary studies, that is, motivation, acceptability, trustworthiness, comprehensibility, handling and control, perceived effectiveness, as well as satisfaction. Conclusions: This review provides an overview of serious games interventions that are vastly different in approach, content, and even platform. In previous studies, knowledge has already been comprehensively assessed, and a positive influence of serious games on knowledge about sexual topics is evident. The results clearly show that adolescents’ sexual knowledge has been increased by the serious games interventions. However, methodological and content differences in the surveys make it difficult to draw conclusions about the effectiveness related to changes in attitudes and behavior. %M 35107438 %R 10.2196/30526 %U https://games.jmir.org/2022/1/e30526 %U https://doi.org/10.2196/30526 %U http://www.ncbi.nlm.nih.gov/pubmed/35107438 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31404 %T A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study %A Beltran-Alacreu,Hector %A Navarro-Fernández,Gonzalo %A Godia-Lledó,Daniela %A Graell-Pasarón,Lucas %A Ramos-González,Álvaro %A Raya,Rafael %A Martin-Pintado Zugasti,Aitor %A Fernandez-Carnero,Josue %+ Departamento de Fisioterapia, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities, Avenida de Monteprincipe s/n Boadilla del Monte, Madrid, 28668, Spain, 34 91 3724700 ext 14635, martinpintado.a@gmail.com %K video games %K neck pain %K aged %K virtual reality %K exercise therapy %K physical therapy modalities %K technology %D 2022 %7 1.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population. Objective: The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain. Methods: A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game. Results: A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session. Conclusions: The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology. %M 35103608 %R 10.2196/31404 %U https://games.jmir.org/2022/1/e31404 %U https://doi.org/10.2196/31404 %U http://www.ncbi.nlm.nih.gov/pubmed/35103608 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 2 %P e31036 %T Promoting Resilience and Well-being Through Co-design (The PRIDE Project): Protocol for the Development and Preliminary Evaluation of a Prototype Resilience-Based Intervention for Sexual and Gender Minority Youth %A Lucassen,Mathijs F G %A Samra,Rajvinder %A Rimes,Katharine A %A Brown,Katherine E %A Wallace,Louise M %+ Department of Health and Social Care, The Open University, Walton Hall, School of Health, Wellbeing and Social Care, Milton Keynes, MK7 6AA, United Kingdom, 44 01908652987, mathijs.lucassen@open.ac.uk %K LGBT %K e-therapy %K depression %K adolescent %K youth %K online %K sexuality %K gender %K resilience %K public health %D 2022 %7 1.2.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sexual and gender minority youth (SGMY) are at an increased risk of a range of mental health problems. However, few evidence-informed interventions have been developed specifically to support their mental well-being. Interventions that are evidence-informed for the general population and are fine-tuned specifically with SGMY in mind proffer considerable potential. A particular opportunity lies in the delivery of engaging interventions on the web, where the focus is on enhancing the coping skills and building the resilience of SGMY, in a way that is directly relevant to their experiences. On the basis of earlier work related to an intervention called Rainbow SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), we seek to create a new resource, especially for SGMY in the United Kingdom. Objective: This project has 3 main objectives. First, together with SGMY as well as key adult experts, we aim to co-design a media-rich evidence-informed web-based SGMY well-being prototype toolkit aimed at those aged between 13 and 19 years. Second, we will explore how the web-based toolkit can be used within public health systems in the United Kingdom by SGMY and potentially other relevant stakeholders. Third, we aim to conduct a preliminary evaluation of the toolkit, which will inform the design of a future effectiveness study. Methods: The first objective will be met by conducting the following: approximately 10 interviews with SGMY and 15 interviews with adult experts, a scoping review of studies focused on psychosocial coping strategies for SGMY, and co-design workshops with approximately 20 SGMY, which will inform the creation of the prototype toolkit. The second objective will be met by carrying out interviews with approximately 5 selected adult experts and 10 SGMY to explore how the toolkit can be best used and to determine the parameters and user-generated standards for a future effectiveness trial. The final objective will be met with a small-scale process evaluation, using the think out loud methodology, conducted with approximately 10 SGMY. Results: The study commenced on September 1, 2021, and data gathering for phase 1 began in October 2021. Conclusions: A considerable body of work has described the issues faced by the SGMY. However, there is a dearth of research seeking to develop interventions for SGMY so that they can thrive. This project aims to co-design such an intervention. Trial Registration: Research Registry Reference researchregistry6815; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/609e81bda4a706001c94b63a/ International Registered Report Identifier (IRRID): PRR1-10.2196/31036 %M 35103613 %R 10.2196/31036 %U https://www.researchprotocols.org/2022/2/e31036 %U https://doi.org/10.2196/31036 %U http://www.ncbi.nlm.nih.gov/pubmed/35103613 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e32359 %T Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial %A Vermeir,Julie F %A White,Melanie J %A Johnson,Daniel %A Crombez,Geert %A Van Ryckeghem,Dimitri M L %+ School of Psychology and Counselling, Faculty of Health, Queensland University of Technology, 170 Victoria Park Road, Brisbane, 4059, Australia, 61 731384714, julie.vermeir@hdr.qut.edu.au %K chronic pain %K cognition %K attentional bias %K gamification %K motivation %K randomized controlled trial %K web-based intervention %K pain management %K digital intervention %K digital health %D 2022 %7 27.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits. Objective: The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial. Methods: A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement. Results: The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively. Conclusions: This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx International Registered Report Identifier (IRRID): PRR1-10.2196/32359 %M 35084344 %R 10.2196/32359 %U https://www.researchprotocols.org/2022/1/e32359 %U https://doi.org/10.2196/32359 %U http://www.ncbi.nlm.nih.gov/pubmed/35084344 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e32759 %T Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial %A Luderer,Hilary %A Chiodo,Lisa %A Wilson,Amanda %A Brezing,Christina %A Martinez,Suky %A Xiong,Xiaorui %A Gerwien,Robert %A Imbert,Bruce %A Deeg,Mark %A Maricich,Yuri %A Campbell,Aimee %+ Pear Therapeutics, Inc, 200 State St., Boston, MA, 02109, United States, 1 (617) 932 7504, hilary.luderer@peartherapeutics.com %K decentralized trial %K game-based %K gamification %K prescription digital therapeutic %K digital therapeutics %K opioid use disorder %K reSET-O %K virtual trial %K trial %K game %K therapy %K opioid %K drug %K engagement %K treatment %K disorder %K addiction %K randomized controlled trial %K mental health %K symptom %D 2022 %7 26.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes. Objective: We aim to investigate how participants interact with the prescription digital therapeutic’s new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development. Methods: Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O. Results: As of February 2021, participant enrollment is ongoing. Conclusions: This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population. Trial Registration: ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642 International Registered Report Identifier (IRRID): DERR1-10.2196/32759 %M 35080499 %R 10.2196/32759 %U https://www.researchprotocols.org/2022/1/e32759 %U https://doi.org/10.2196/32759 %U http://www.ncbi.nlm.nih.gov/pubmed/35080499 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e29008 %T Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study %A Lockwood,Joanna %A Williams,Laura %A Martin,Jennifer L %A Rathee,Manjul %A Hill,Claire %+ National Institute of Health Research MindTech MedTech Co-operative, School of Medicine, University of Nottingham, Institute of Mental Health, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231294, joanna.lockwood@nottingham.ac.uk %K anxiety %K children %K exposure therapy %K cognitive behavioral therapy %K immersive gaming %K digital intervention %K app %K smartphone %K mobile phone %D 2022 %7 24.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition. Objective: In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova. Methods: Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app’s effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined. Results: Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t29=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data. Conclusions: This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch. %M 35072644 %R 10.2196/29008 %U https://mental.jmir.org/2022/1/e29008 %U https://doi.org/10.2196/29008 %U http://www.ncbi.nlm.nih.gov/pubmed/35072644 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32400 %T Evaluation of an AIDS Educational Mobile Game (AIDS Fighter · Health Defense) for Young Students to Improve AIDS-Related Knowledge, Stigma, and Attitude Linked to High-Risk Behaviors in China: Randomized Controlled Trial %A Tang,Jian %A Zheng,Yu %A Zhang,Daiying %A Yu,Xingli %A Ren,Jianlan %A Li,Mei %A Luo,Yue %A Tian,Min %A Chen,Yanhua %+ Department of Nursing, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Jiangyang District, Luzhou, 646000, China, 86 18982765016, chen_yanhua25@163.com %K young students %K AIDS education %K educational game %K game-based intervention %K serious games %K public health %K HIV %K AIDS epidemic %K stigma %K health defense %K health knowledge %K digital health %K digital health intervention %D 2022 %7 24.1.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: The AIDS epidemic among young students is serious, and effective preventive interventions are urgently needed. Game-based intervention has become an innovative way to change healthy behaviors, and we have developed an AIDS educational game called AIDS Fighter · Health Defense. Objective: In this study, we tested the effect of AIDS Fighter · Health Defense on young students in improving AIDS-related knowledge, stigma, and attitude related to high-risk behaviors in Southwest China. Methods: A randomized controlled trial was conducted from September 14 to 27, 2020. In total, 96 students from 2 classes in a middle school were selected by stratified cluster sampling in Luzhou City, Southwest China. The students were randomly divided into the intervention group (n=50, 52%) and the control group (n=46, 48%). The intervention group played the AIDS educational game AIDS Fighter · Health Defense; the control group learned AIDS-related knowledge through independent learning on the QQ chat group. An AIDS-related knowledge questionnaire, a stigma scale, and an attitude questionnaire on AIDS-related high-risk behaviors were used to measure the effect of the AIDS educational game via face-to-face interviews. The user experience of the game was assessed using the Educational Game User Experience Evaluation Scale. The difference was statistically significant at P≤.05. Results: After the intervention, the AIDS knowledge awareness rate (X̅ [SD], %) of the intervention and control groups were 70.09 (SD 11.58) and 57.49 (SD 16.58), with t=4.282 and P<.001. The stigma scores of the 2 groups were 2.44 (SD 0.57) and 2.48 (SD 0.47), with t=0.373 and P=0.71. The positive rate (X̅ [SD], %) of attitudes of high-risk AIDS behaviors of the 2 groups were 82.00 (SD 23.44) and 79.62 (SD 17.94), with t=0.555 and P=0.58. The mean percentage of the game evaluation was 54.73% as excellent, 31.45% as good, 13.09% as medium, and 0.73% as poor. Conclusions: AIDS Fighter · Health Defense could increase AIDS-related knowledge among young students, but the effect of the game in reducing AIDS-related stigma and improving the attitudes of high-risk AIDS behaviors was not seen. Long-term effects and large-scale studies are needed to assess the efficacy of game-based intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000038230; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2000038230 %M 34870603 %R 10.2196/32400 %U https://games.jmir.org/2022/1/e32400 %U https://doi.org/10.2196/32400 %U http://www.ncbi.nlm.nih.gov/pubmed/34870603 %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 10 %N 1 %P e31471 %T Developing a Health Game to Prepare Preschool Children for Anesthesia: Formative Study Using a Child-Centered Approach %A Ingadottir,Brynja %A Laitonen,Elina %A Stefansdottir,Adalheidur %A Sigurdardottir,Anna Olafia %A Brynjolfsdottir,Berglind %A Parisod,Heidi %A Nyman,Johanna %A Gunnarsdottir,Karitas %A Jónsdóttir,Katrín %A Salanterä,Sanna %A Pakarinen,Anni %+ Faculty of Nursing, School of Health Sciences, University of Iceland, Eiriksgata 34, Reykjavik, 101, Iceland, 354 8651817, brynjain@hi.is %K anesthesia %K child-centred design %K children %K digital health %K educational games %K health games %K hospital %K patient education %K serious games %K surgery %K user-centred design %K video games %D 2022 %7 20.1.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Every year, millions of children undergo medical procedures that require anesthesia. Fear and anxiety are common among young children undergoing such procedures and can interfere with the child’s recovery and well-being. Relaxation, distraction, and education are methods that can be used to prepare children and help them cope with fear and anxiety, and serious games may be a suitable medium for these purposes. User-centered design emphasizes the involvement of end users during the development and testing of products, but involving young, preschool children may be challenging. Objective: One objective of this study was to describe the development and usability of a computer-based educational health game intended for preschool children to prepare them for upcoming anesthesia. A further objective was to describe the lessons learned from using a child-centered approach with the young target group. Methods: A formative mixed methods child (user)-centered study design was used to develop and test the usability of the game. Preschool children (4-6 years old) informed the game design through playful workshops (n=26), and usability testing was conducted through game-playing and interviews (n=16). Data were collected in Iceland and Finland with video-recorded direct observation and interviews, as well as children’s drawings, and analyzed with content analysis and descriptive statistics. Results: The children shared their knowledge and ideas about hospitals, different emotions, and their preferences concerning game elements. Testing revealed the high usability of the game and provided important information that was used to modify the game before publishing and that will be used in its further development. Conclusions: Preschool children can inform game design through playful workshops about health-related subjects that they are not necessarily familiar with but that are relevant for them. The game’s usability was improved with the participation of the target group, and the game is now ready for clinical testing. %M 35049507 %R 10.2196/31471 %U https://games.jmir.org/2022/1/e31471 %U https://doi.org/10.2196/31471 %U http://www.ncbi.nlm.nih.gov/pubmed/35049507 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e29987 %T Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic %A Muñoz,John %A Mehrabi,Samira %A Li,Yirou %A Basharat,Aysha %A Middleton,Laura E %A Cao,Shi %A Barnett-Cowan,Michael %A Boger,Jennifer %+ Department of Systems Design Engineering, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada, 1 (519) 888 4567, john.munoz.hci@uwaterloo.ca %K virtual reality %K exergames %K persons living with dementia %K physical activity %K head mounted displays %K participatory design %K co-development %K gaming %K older adults %K elderly %K design %K dementia %K VR %K user-centered %K physical activity %K exercise %K COVID-19 %D 2022 %7 19.1.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible. Objective: This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI. Methods: Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts. Results: An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users. Conclusions: This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic. %M 35044320 %R 10.2196/29987 %U https://games.jmir.org/2022/1/e29987 %U https://doi.org/10.2196/29987 %U http://www.ncbi.nlm.nih.gov/pubmed/35044320 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32331 %T The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis %A Abd-Alrazaq,Alaa %A Al-Jafar,Eiman %A Alajlani,Mohannad %A Toro,Carla %A Alhuwail,Dari %A Ahmed,Arfan %A Reagu,Shuja Mohd %A Al-Shorbaji,Najeeb %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K exergames %K depression %K cognitive behavioral therapy %K systematic reviews %K meta-analysis %D 2022 %7 14.1.2022 %9 Review %J JMIR Serious Games %G English %X Background: Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings. Objective: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. Methods: A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of 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. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games). Results: From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). Conclusions: Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969 %M 35029530 %R 10.2196/32331 %U https://games.jmir.org/2022/1/e32331 %U https://doi.org/10.2196/32331 %U http://www.ncbi.nlm.nih.gov/pubmed/35029530 %0 Journal Article %@ 2152-7202 %I JMIR Publications %V 14 %N 1 %P e29743 %T A Norm-Creative Method for Co-constructing Personas With Children With Disabilities: Multiphase Design Study %A Teleman,Britta %A Svedberg,Petra %A Larsson,Ingrid %A Karlsson,Caroline %A Nygren,Jens M %+ School of Health and Welfare, Halmstad University, Box 823, Halmstad, 30118, Sweden, 46 705652316, britta.teleman@hh.se %K disability %K children %K norm-critical %K participatory design %K personas %K co-produced care %K health care %D 2022 %7 6.1.2022 %9 Original Paper %J J Particip Med %G English %X Background: An increase in the demand for child participation in health care requires tools that enable and empower children to be involved in the co-production of their own care. The development of such tools should involve children, but participatory design and research with children have challenges, in particular, when involving children with disabilities where a low level of participation is the norm. Norm-creative and participatory approaches may bring more effective design solutions for this group. “Personas” is a methodology for increasing user perspectives in design and offers representation when users are absent. However, research on participatory persona generation in this context is limited. Objective: The objective of this study was to investigate how norm-creative and participatory design approaches can be integrated in a persona generation method to suit children with disabilities in the design of games for health that target this group. Methods: The method development involved interview transcripts and image-based workshops. Sixteen children with various disabilities participated in persona generation through co-creation of characters and scenarios. The results from the workshops were validated together with 8 children without disabilities, 1 young adult with a disability, and 1 rehabilitation professional. A qualitative thematic design analysis was iterated throughout the process. Results: The results consisted of an image-based and iterative co-construction method. It was accompanied by examples of personas that were generated and validated within a games for health case. The method showed effectiveness in enabling flexible co-construction and communication. The data resonated with social model perspectives, and the development is discussed in terms of participation levels, salutogenic descriptions of barriers, and norm-creative tradeoffs. Conclusions: The resulting method may influence future design projects toward more inclusiveness and enable increased representation for children with disabilities in research and design. Using this method to its full potential requires a norm-critical awareness as well as extensive facilitation. Suggestions for further research include the application of the method to design processes in similar contexts or user groups. %M 34989695 %R 10.2196/29743 %U https://jopm.jmir.org/2022/1/e29743 %U https://doi.org/10.2196/29743 %U http://www.ncbi.nlm.nih.gov/pubmed/34989695 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e26779 %T Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials %A Mazeas,Alexandre %A Duclos,Martine %A Pereira,Bruno %A Chalabaev,Aïna %+ Univ. Grenoble Alpes, SENS, 1741 rue de la Piscine, 38000 Grenoble, France, 33 4 76 63 50 81, alexandre.mazeas@univ-grenoble-alpes.fr %K behavior change %K eHealth %K gamification %K health behavior %K intervention %K meta-analysis %K mobile phone %K physical activity %K systematic review %D 2022 %7 4.1.2022 %9 Review %J J Med Internet Res %G English %X Background: Gamification refers to the use of game elements in nongame contexts. The use of gamification to change behaviors and promote physical activity (PA) is a promising avenue for tackling the global physical inactivity pandemic and the current prevalence of chronic diseases. However, there is no evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature. Objective: The aim of this systematic review and meta-analysis is to evaluate the effectiveness of gamified interventions and their health care potential by testing the generalizability and sustainability of their influence on PA and sedentary behavior. Methods: A total of 5 electronic databases (PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials published in English from 2010 to 2020. Eligibility criteria were based on the components of the participants, interventions, comparators, and outcomes framework. Studies were included when they used gamified interventions in daily life with an active or inactive control group and when they assessed a PA or sedentary behavior outcome. We conducted meta-analyses using a random-effects model approach. Sensitivity analyses, influence analyses, and publication bias analyses were performed to examine the robustness of our results. Results: The main meta-analysis performed on 16 studies and 2407 participants revealed a small to medium summary effect of gamified interventions on PA behavior (Hedges g=0.42, 95% CI 0.14-0.69). No statistical difference among different subgroups (adults vs adolescents and healthy participants vs adults with chronic diseases) and no interaction effects with moderators such as age, gender, or BMI were found, suggesting good generalizability of gamified interventions to different user populations. The effect was statistically significant when gamified interventions were compared with inactive control groups, such as waiting lists (Hedges g=0.58, 95% CI 0.08-1.07), and active control groups that included a nongamified PA intervention (Hedges g=0.23, 95% CI 0.05-0.41). This suggests that gamified interventions are not only efficient in changing behavior but also more effective compared with other behavioral interventions. The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) was weaker, with a very small to small effect (Hedges g=0.15, 95% CI 0.07-0.23). Conclusions: This meta-analysis confirms that gamified interventions are promising for promoting PA in various populations. Additional analyses revealed that this effect persists after the follow-up period, suggesting that it is not just a novelty effect caused by the playful nature of gamification, and that gamified products appear effective compared with equivalent nongamified PA interventions. Future rigorous trials are required to confirm these findings. %M 34982715 %R 10.2196/26779 %U https://www.jmir.org/2022/1/e26779 %U https://doi.org/10.2196/26779 %U http://www.ncbi.nlm.nih.gov/pubmed/34982715 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 10 %N 1 %P e30352 %T A Mobile App to Increase Fruit and Vegetable Acceptance Among Finnish and Polish Preschoolers: Randomized Trial %A Vepsäläinen,Henna %A Skaffari,Essi %A Wojtkowska,Katarzyna %A Barlińska,Julia %A Kinnunen,Satu %A Makkonen,Riikka %A Heikkilä,Maria %A Lehtovirta,Mikko %A Ray,Carola %A Suhonen,Eira %A Nevalainen,Jaakko %A Sajaniemi,Nina %A Erkkola,Maijaliisa %+ Department of Food and Nutrition, University of Helsinki, PO Box 66, Helsinki, 00014, Finland, 358 443581467, henna.vepsalainen@helsinki.fi %K gamification %K intervention %K behavior change %K health game %K games for health %K smartphone app %K mobile phone %D 2022 %7 4.1.2022 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Early childhood education and care (ECEC) centers are ideal venues for food education. As smartphones and tablets are becoming increasingly popular in ECEC centers, technology can be used to deliver such pedagogical content. Evidence suggests that video games can affect fruit and vegetable (FV) consumption among 9- to 12-year-old children, but studies among preschoolers are scarce. Objective: This paper describes the development of the Mole’s Veggie Adventures app and its effectiveness in increasing FV acceptance among Finnish and Polish preschoolers aged 3 to 6 years. Methods: A multiprofessional team created an app to be used in ECEC centers in groups of 3 to 10 children. The app aimed to increase vegetable acceptance, and it was built using elements that support the development of self-regulation and social skills. Altogether, 7 Finnish and 4 Polish ECEC centers participated in the study. Before randomization, parents reported background factors and their children’s willingness to taste different FVs. The ECEC professionals in the intervention arm were instructed to use the app at least once a week during the 3- to 4-week intervention period. The main outcomes in this unblinded, cluster-randomized study were FV acceptance and relative FV acceptance. The first was calculated as a sum variable describing the children’s willingness to taste 25 different FVs, the second as FV acceptance divided by the number of FVs served. We used analysis of covariance to compare the FV acceptance and relative FV acceptance scores between the intervention and control groups at follow-up. Results: A total of 221 children were included in the analysis. At follow-up, the intervention group (115/221, 52%) had higher FV acceptance scores (baseline adjusted difference of mean 7.22; 95% CI 1.41-13.03) than the control group (106/221, 48%). The intervention effect was parallel for relative FV acceptance scores (baseline adjusted difference of mean 0.28; 95% CI 0.05-0.52). Conclusions: The Mole’s Veggie Adventures app has the potential to increase FV acceptance among preschoolers and can be a valuable tool in supporting food education in ECEC centers. Furthermore, the app can be feasibly incorporated into preschool routines in countries with different educational environments. Trial Registration: ClinicalTrials.gov NCT05173311; https://tinyurl.com/4vfbh283 %M 34982718 %R 10.2196/30352 %U https://mhealth.jmir.org/2022/1/e30352 %U https://doi.org/10.2196/30352 %U http://www.ncbi.nlm.nih.gov/pubmed/34982718 %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 e30482 %T Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review %A Martinez,Kim %A Menéndez-Menéndez,Maria Isabel %A Bustillo,Andres %+ Department of History, Geography and Communication, University of Burgos, Don Juan de Austria, Burgos, 09001, Spain, 34 947 49 91 12, kmartinez@ubu.es %K serious games %K depression %K anxiety %K children %K adolescents %K virtual reality %K mental health %K detection %K awareness %K prevention %K therapy %D 2021 %7 16.12.2021 %9 Review %J JMIR Serious Games %G English %X Background: Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities. Objective: This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines. Methods: The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents. Results: A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play. Conclusions: The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology. %M 34927589 %R 10.2196/30482 %U https://games.jmir.org/2021/4/e30482 %U https://doi.org/10.2196/30482 %U http://www.ncbi.nlm.nih.gov/pubmed/34927589 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30985 %T Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis %A Vinolo Gil,Maria Jesus %A Gonzalez-Medina,Gloria %A Lucena-Anton,David %A Perez-Cabezas,Veronica %A Ruiz-Molinero,María Del Carmen %A Martín-Valero,Rocío %+ Department of Nursing and Physical Therapy, University of Cadiz, Avda Ana de Viya 52, Cadiz, 11009, Spain, 34 670609656, gloriagonzalez.medina@uca.es %K augmented reality %K physical therapy %K rehabilitation %K functionality %D 2021 %7 15.12.2021 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole. Objective: This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective. Methods: A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias. Results: In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23). Conclusions: AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766 %M 34914611 %R 10.2196/30985 %U https://games.jmir.org/2021/4/e30985 %U https://doi.org/10.2196/30985 %U http://www.ncbi.nlm.nih.gov/pubmed/34914611 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29956 %T Design of a Virtual Reality Interactive Training System for Public Health Emergency Preparedness for Major Emerging Infectious Diseases: Theory and Framework %A Luo,Yue %A Li,Mei %A Tang,Jian %A Ren,JianLan %A Zheng,Yu %A Yu,XingLi %A Jiang,LinRui %A Fan,DingLin %A Chen,YanHua %+ Department of Nursing, The Affiliated Hospital of Southwest Medical University, 25, Taiping Road, Luzhou City, 646000, China, 86 18982765016, Chen_yanhua25@163.com %K virtual reality %K major emerging infectious diseases %K emergency preparedness %K interactive narrative theory %K situated learning theory %K human-computer interaction theory %K emergency simulation %K public health %K training %K VR %K epidemic %K medical education %K education %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sufficient public health emergency preparedness (PHEP) is the key factor in effectively responding to and recovering from major emerging infectious diseases (MEIDs). However, in the face of MEIDs, PHEP is insufficient, so it is necessary to improve PHEP. The rapid development of virtual reality and human-computer interaction provides unprecedented opportunities for innovative educational methods. Objective: This study designed a virtual reality interactive training system (VRITS) to provide an effective path for improving PHEP in the context of MEIDs so that the public can effectively respond to and recover from MEIDs. Methods: This study used interactive narrative, situated learning and human-computer interaction theories as a theoretical framework to guide the design of the system. We used the literature research method and the Delphi method; consulted multidisciplinary experts, such as infectious diseases, disease control, psychology, and public health personnel, to determine the educational content framework; and set up an interdisciplinary team to construct an operating system framework for the VRITS. Results: We named the VRITS “People’s War Against Pandemic.” The educational content framework includes 20 knowledge, emotion, and behavior skills in 5 aspects (cooperating with prevention and control work, improving emergency response ability, guaranteeing supplies and equipment, preparing economic resources, and maintaining physical and mental health). The operating system framework includes virtual interactive training, knowledge corner, intelligent evaluation, and community forum modules, and the core module is the virtual interactive training module. In this module, users control virtual characters to move in various scenes, and then identify and analyze the controllability and harmfulness of the evolving pandemic and select the correct prevention and control strategy to avoid infecting themselves and others. Conclusions: The development and sharing of the multidisciplinary theoretical framework adopted by People’s War Against Pandemic can help us clarify the design ideas and assumptions of the VRITS; predict training results; understand the ability of training to change emergency knowledge, emergency emotion, and behavioral responses to MEIDs; and promote the development of more effective training systems based on virtual reality. %M 34904951 %R 10.2196/29956 %U https://games.jmir.org/2021/4/e29956 %U https://doi.org/10.2196/29956 %U http://www.ncbi.nlm.nih.gov/pubmed/34904951 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 12 %P e31353 %T A Personalized Approach Bias Modification Smartphone App (“SWiPE”) to Reduce Alcohol Use: Open-Label Feasibility, Acceptability, and Preliminary Effectiveness Study %A Manning,Victoria %A Piercy,Hugh %A Garfield,Joshua Benjamin Bernard %A Clark,Stuart Gregory %A Andrabi,Mah Noor %A Lubman,Dan Ian %+ Turning Point, Eastern Health, 110 Church St, Richmond, Melbourne, 3121, Australia, 61 0428337961, victoria.manning@monash.edu %K alcohol %K hazardous alcohol use %K alcohol use disorder %K approach bias modification %K cognitive bias modification %K smartphone app %K ehealth %K mobile phone app %K mhealth %K digital health %D 2021 %7 10.12.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Approach bias modification (ApBM), a computerized cognitive intervention that trains people to “avoid” alcohol-related images and “approach” nonalcohol images, reduces the likelihood of relapse when administered during residential alcohol treatment. However, most individuals experiencing alcohol problems do not require, do not seek, or have difficulty accessing residential treatment. Smartphone-delivered ApBM could offer an easily accessible intervention to reduce alcohol consumption that can be personalized (eg, allowing selection of personally relevant alcohol and positive nonalcohol training images) and gamified to optimize engagement. Objective: We examined the feasibility, acceptability, and preliminary effectiveness of “SWiPE,” a gamified, personalized alcohol ApBM smartphone app, and explored alcohol consumption and craving outcomes in people drinking at hazardous levels or above (Alcohol Use Disorders Identification Test [AUDIT] score ≥8) who wanted to reduce their alcohol use. Methods: In this open-label trial, frequency and quantity of alcohol consumption, alcohol dependence severity, and craving were measured prior to participants downloading SWiPE. Participants (n=1309) were instructed to complete at least 2 sessions per week for 4 weeks. Recruitment and completion rates were indicators of feasibility. Functionality, aesthetics, and quality ratings were indicators of acceptability. Participants were prompted to report frequency and quantity of alcohol consumption weekly during training and 1 month after training. They completed measures of craving and dependence after 4 weeks of training. Results: We recruited 1309 participants (mean age 47.0, SD 10.0 years; 758/1309, 57.9% female; mean AUDIT score 21.8, SD 6.5) over 6 months. Participants completed a median of 5 sessions (IQR 2-9); 31.2% (409/1309) completed ≥8 sessions; and 34.8% (455/1309) completed the posttraining survey. Mean Mobile Application Rating Scale scores indicated good acceptability for functionality and aesthetics and fair acceptability for subjective quality. Among those who completed the posttraining assessment, mean past-week drinking days reduced from 5.1 (SD 2.0) pre-training to 4.2 (SD 2.3) in week 4 (t454=7.87; P<.001), and mean past-week standard drinks reduced from 32.8 (SD 22.1) to 24.7 (SD 20.1; t454=8.58; P<.001). Mean Craving Experience Questionnaire frequency scores reduced from 4.5 (SD 2.0) to 2.8 (SD 1.8; t435=19.39; P<.001). Severity of Dependence scores reduced from 7.7 (SD 3.0) to 6.0 (SD 3.2; t435=12.44; P<.001). For the 19.4% (254/1309) of participants who completed a 1-month follow-up, mean past-week drinking days and standard drinks were 3.9 (SD 2.5) and 23.9 (SD 20.7), respectively, both significantly lower than at baseline (P<.001). Conclusions: The findings suggest SWiPE is feasible and acceptable and may be effective at reducing alcohol consumption and craving in a predominantly nontreatment-seeking sample of adult Australians drinking at hazardous levels. SWiPE’s efficacy, relative to a control condition, now needs establishing in a randomized controlled trial. Smartphone-delivered personalized ApBM could be a highly scalable, widely accessible support tool for reducing alcohol use. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000638932; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000638932p International Registered Report Identifier (IRRID): RR2-10.2196/21278 %M 34890355 %R 10.2196/31353 %U https://mhealth.jmir.org/2021/12/e31353 %U https://doi.org/10.2196/31353 %U http://www.ncbi.nlm.nih.gov/pubmed/34890355 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e22557 %T Comparing the Effects of Gamification and Teach-Back Training Methods on Adherence to a Therapeutic Regimen in Patients After Coronary Artery Bypass Graft Surgery: Randomized Clinical Trial %A Ghorbani,Banafsheh %A Jackson,Alun C %A Noorchenarboo,Mohammad %A Mandegar,Mohammad H %A Sharifi,Farshad %A Mirmoghtadaie,Zohrehsadat %A Bahramnezhad,Fatemeh %+ School of Nursing & Midwifery, Nursing and Midwifery Care Research Center, Spiritual Health Group, Research Center of Quran, Hadith and Medicine, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Tehran, 141973317, Iran, 98 2166914368, bahramnezhad@sina.tums.ac.ir %K teach back %K gamification %K treatment regimen %K coronary artery bypass graft %K patient training %D 2021 %7 10.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients undergoing coronary artery bypass graft surgery (CABGS) may fail to adhere to their treatment regimen for many reasons. Among these, one of the most important reasons for nonadherence is the inadequate training of such patients or training using inappropriate methods. Objective: This study aimed to compare the effect of gamification and teach-back training methods on adherence to a therapeutic regimen in patients after CABGS. Methods: This randomized clinical trial was conducted on 123 patients undergoing CABGS in Tehran, Iran, in 2019. Training was provided to the teach-back group individually. In the gamification group, an app developed for the purpose was installed on each patient’s smartphone, with training given via this device. The control group received usual care, or routine training. Adherence to the therapeutic regimen was assessed using a questionnaire on adherence to a therapeutic regimen (physical activity and dietary regimen) and an adherence scale as a pretest and a 1-month posttest. Results: One-way analysis of variance (ANOVA) for comparing the mean scores of teach-back and gamification training methods showed that the mean normalized scores for the dietary regimen (P<.001, F=71.80), movement regimen (P<.001, F=124.53), and medication regimen (P<.001, F=9.66) before and after intervention were significantly different between the teach-back, gamification, and control groups. In addition, the results of the Dunnett test showed that the teach-back and gamification groups were significantly different from the control group in all three treatment regimen methods. There was no statistically significant difference in adherence to the therapeutic regimen between the teach-back and control groups. Conclusions: Based on the results of this study, the use of teach-back and gamification training approaches may be suggested for patients after CABGS to facilitate adherence to the therapeutic regimen. Trial Registration: Iranian Registry of Clinical Trials IRCT20111203008286N8; https://en.irct.ir/trial/41507 %M 34890346 %R 10.2196/22557 %U https://www.jmir.org/2021/12/e22557 %U https://doi.org/10.2196/22557 %U http://www.ncbi.nlm.nih.gov/pubmed/34890346 %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 e32721 %T Virtual Reality in Health Care: Bibliometric Analysis %A Pawassar,Christian Matthias %A Tiberius,Victor %+ Faculty of Economics and Social Sciences, University of Potsdam, August-Bebel-Str 89, Potsdam, 14482, Germany, 49 3319773593, tiberius@uni-potsdam.de %K virtual reality %K healthcare %K bibliometric analysis %K literature review %K citation analysis %K VR %K usability %K review %K health care %D 2021 %7 1.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Research into the application of virtual reality technology in the health care sector has rapidly increased, resulting in a large body of research that is difficult to keep up with. Objective: We will provide an overview of the annual publication numbers in this field and the most productive and influential countries, journals, and authors, as well as the most used, most co-occurring, and most recent keywords. Methods: Based on a data set of 356 publications and 20,363 citations derived from Web of Science, we conducted a bibliometric analysis using BibExcel, HistCite, and VOSviewer. Results: The strongest growth in publications occurred in 2020, accounting for 29.49% of all publications so far. The most productive countries are the United States, the United Kingdom, and Spain; the most influential countries are the United States, Canada, and the United Kingdom. The most productive journals are the Journal of Medical Internet Research (JMIR), JMIR Serious Games, and the Games for Health Journal; the most influential journals are Patient Education and Counselling, Medical Education, and Quality of Life Research. The most productive authors are Riva, del Piccolo, and Schwebel; the most influential authors are Finset, del Piccolo, and Eide. The most frequently occurring keywords other than “virtual” and “reality” are “training,” “trial,” and “patients.” The most relevant research themes are communication, education, and novel treatments; the most recent research trends are fitness and exergames. Conclusions: The analysis shows that the field has left its infant state and its specialization is advancing, with a clear focus on patient usability. %M 34855606 %R 10.2196/32721 %U https://games.jmir.org/2021/4/e32721 %U https://doi.org/10.2196/32721 %U http://www.ncbi.nlm.nih.gov/pubmed/34855606 %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 %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32199 %T Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis %A Six,Stephanie G %A Byrne,Kaileigh A %A Tibbett,Thomas P %A Pericot-Valverde,Irene %+ Department of Psychology, Clemson University, 418 Brackett Hall, Clemson, SC, 29634, United States, 1 864 656 3935, kaileib@clemson.edu %K depression %K reward %K gamification %K mental health apps %K apps %D 2021 %7 29.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification. Objective: The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements. Methods: A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis. Results: A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=–0.27, 95% CI –0.36 to –0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=–0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=–1.93, SE=2.28; P=.40). Conclusions: The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms. %M 34847058 %R 10.2196/32199 %U https://mental.jmir.org/2021/11/e32199 %U https://doi.org/10.2196/32199 %U http://www.ncbi.nlm.nih.gov/pubmed/34847058 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e33003 %T Nationwide Deployment of a Serious Game Designed to Improve COVID-19 Infection Prevention Practices in Switzerland: Prospective Web-Based Study %A Suppan,Melanie %A Stuby,Loric %A Harbarth,Stephan %A Fehlmann,Christophe A %A Achab,Sophia %A Abbas,Mohamed %A Suppan,Laurent %+ Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, Geneva, 1211, Switzerland, 41 223723311, laurent.suppan@hcuge.ch %K COVID-19 %K serious game %K infection prevention %K SARS-CoV-2 %K prospective %K web-based %K deployment %K prevention %K gaming %K public health %K dissemination %K health information %K behavior %K survey %D 2021 %7 25.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Lassitude and a rather high degree of mistrust toward the authorities can make regular or overly constraining COVID-19 infection prevention and control campaigns inefficient and even counterproductive. Serious games provide an original, engaging, and potentially effective way of disseminating COVID-19 infection prevention and control guidelines. Escape COVID-19 is a serious game for teaching COVID-19 infection prevention and control practices that has previously been validated in a population of nursing home personnel. Objective: We aimed to identify factors learned from playing the serious game Escape COVID-19 that facilitate or impede intentions of changing infection prevention and control behavior in a large and heterogeneous Swiss population. Methods: This fully automated, prospective web-based study, compliant with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was conducted in all 3 main language regions of Switzerland. After creating an account on the platform, participants were asked to complete a short demographic questionnaire before accessing the serious game. The only incentive given to the potential participants was a course completion certificate, which participants obtained after completing the postgame questionnaire. The primary outcome was the proportion of participants who reported that they were willing to change their infection prevention and control behavior. Secondary outcomes were the infection prevention and control areas affected by this willingness and the presumed evolution in the use of specific personal protective equipment items. The elements associated with intention to change infection prevention and control behavior, or lack thereof, were also assessed. Other secondary outcomes were the subjective perceptions regarding length, difficulty, meaningfulness, and usefulness of the serious game; impression of engagement and boredom while playing the serious game; and willingness to recommend its use to friends or colleagues. Results: From March 9 to June 9, 2021, a total of 3227 accounts were created on the platform, and 1104 participants (34.2%) completed the postgame questionnaire. Of the 1104 respondents, 509 respondents (46.1%) answered that they intended to change their infection prevention and control behavior after playing the game. Among the respondents who answered that they did not intend to change their behavior, 86.1% (512/595) answered that they already apply these guidelines. Participants who followed the German version were less likely to intend to change their infection prevention and control behavior (odds ratio [OR] 0.48, 95% CI 0.24-0.96; P=.04) and found the game less engaging (P<.001). Conversely, participants aged 53 years or older had stronger intentions of changing infection prevention and control behavior (OR 2.07, 95% CI 1.44-2.97; P<.001). Conclusions: Escape COVID-19 is a useful tool to enhance correct infection prevention and control measures on a national scale, even after 2 COVID-19 pandemic waves; however, the serious game's impact was affected by language, age category, and previous educational training, and the game should be adapted to enhance its impact on specific populations. %M 34635472 %R 10.2196/33003 %U https://games.jmir.org/2021/4/e33003 %U https://doi.org/10.2196/33003 %U http://www.ncbi.nlm.nih.gov/pubmed/34635472 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30249 %T Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review %A Kim,Euisung %A Han,Jieun %A Choi,Hojin %A Prié,Yannick %A Vigier,Toinon %A Bulteau,Samuel %A Kwon,Gyu Hyun %+ Graduate School of Technology and Innovation Management, Hanyang University, Wangsimni-ro 222, Multidisciplinary Lecture Hall 703, Seoul, 04763, Republic of Korea, 82 222202414, ghkwon@hanyang.ac.kr %K virtual reality %K neuropsychological test %K executive function %K cognitive ability %K brain disorder %K immersive %K digital health %K cognition %K academic trends %K neurology %D 2021 %7 24.11.2021 %9 Review %J JMIR Serious Games %G English %X Background: In neuropsychology, fully immersive virtual reality (VR) has been spotlighted as a promising tool. It is considered that VR not only overcomes the existing limitation of neuropsychological tests but is also appropriate for treating executive functions (EFs) within activities of daily living (ADL) due to its high ecological validity. While fully immersive VR offers new possibilities of neuropsychological tests, there are few studies that overview the intellectual landscape and academic trends in the research related to mainly targeted EFs with fully immersive VR. Objective: The objective of this study is to get an overview of the research trends that use VR in neuropsychological tests and to analyze the research trends using fully immersive VR neuropsychological tests with experimental articles. Methods: This review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were searched in three web databases using keywords related to VR, EFs, and cognitive abilities. The study was conducted in two steps, keyword analysis and in-depth systematic review. In the web database search from 2000 to 2019, 1167 articles were initially collected, of which 234 articles in the eligibility phase were used to conduct keyword analysis and a total of 47 articles were included for systematic review. Results: In keyword analysis, the number of articles focused on dementia including the keywords “MCI,” “SCD,” and “dementia” were highlighted over the period, rather than other symptoms. In addition, we identified that the use of behavioral and physiological data in virtual environments (VEs) has dramatically increased in recent studies. In the systematic review, we focused on the purpose of study, assessment, treatment, and validation of usability and structure. We found that treatment studies and uncategorized studies including presence and cybersickness issues have emerged in the recent period. In addition, the target symptoms and range of participants were diversified. Conclusions: There has been a continuously increasing interest in dealing with neuropsychology by using fully immersive VR. Target cognitive abilities have been diversified, as well as target symptoms. Moreover, the concept of embodied cognition was transplanted in this research area. %M 34822341 %R 10.2196/30249 %U https://games.jmir.org/2021/4/e30249 %U https://doi.org/10.2196/30249 %U http://www.ncbi.nlm.nih.gov/pubmed/34822341 %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 e29330 %T Effects of an Immersive Virtual Reality Exergame on University Students’ Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study %A Xu,Wenge %A Liang,Hai-Ning %A Baghaei,Nilufar %A Ma,Xiaoyue %A Yu,Kangyou %A Meng,Xuanru %A Wen,Shaoyue %+ Department of Computing, School of Advanced Technology, Xi'an Jiaotong-Liverpool University, 111 Renai Road, Suzhou Industrial Park, Suzhou, 215123, China, 86 51288161516, haining.liang@xjtlu.edu.cn %K university students %K depression %K anxiety %K stress %K immersive virtual reality %K exergame %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. Objective: This study aimed to explore the feasibility of a 6-week iVR exergame–based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. Methods: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. Results: A total of 15 participants completed the 6-week study. Our results suggested that participants’ mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73%) would recommend the iVR exergame to their friends. Conclusions: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students. %M 34813487 %R 10.2196/29330 %U https://games.jmir.org/2021/4/e29330 %U https://doi.org/10.2196/29330 %U http://www.ncbi.nlm.nih.gov/pubmed/34813487 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e30572 %T Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial %A Jessen,Stian %A Mirkovic,Jelena %A Halvorsen Brendmo,Elanor %A Solberg Nes,Lise %+ Department of Digital Health Research, Division of Medicine, Oslo University Hospital HF, Aker Sykehus, Trondheimsveien 23, Oslo, 0586, Norway, 47 9804 9759, stian.jessen@rr-research.no %K mHealth %K personal strengths %K gameful design %K gamification %K user engagement %K explorative %K feasibility %K usefulness %K usability %K design %K self-management %K chronic illness %D 2021 %7 17.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life. Objective: The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes. Methods: A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre– and post–psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data. Results: In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received. Conclusions: Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life. %M 34787580 %R 10.2196/30572 %U https://formative.jmir.org/2021/11/e30572 %U https://doi.org/10.2196/30572 %U http://www.ncbi.nlm.nih.gov/pubmed/34787580 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e25831 %T Software Engineering Frameworks Used for Serious Games Development in Physical Rehabilitation: Systematic Review %A Ambros-Antemate,Jorge Fernando %A Beristain-Colorado,María Del Pilar %A Vargas-Treviño,Marciano %A Gutiérrez-Gutiérrez,Jaime %A Hernández-Cruz,Pedro Antonio %A Gallegos-Velasco,Itandehui Belem %A Moreno-Rodríguez,Adriana %+ 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, jambros.cat@uabjo.mx %K serious game %K physical rehabilitation %K framework %K methodology %D 2021 %7 11.11.2021 %9 Review %J JMIR Serious Games %G English %X Background: Serious games are a support in the rehabilitation process for treating people with physical disabilities. However, many of these serious games are not adapted to the patient’s needs because they are not developed with a software engineering framework with a set of activities, actions, and tasks that must be executed when creating a software product. Better serious games for rehabilitation will be developed if the patient and therapist requirements are identified, the development is planned, and system improvements and feedback are involved. The goal is that the serious game must offer a more attractive environment, while maintaining patient interest in the rehabilitation process. Objective: This paper submits the results of a systematic review of serious games in physical rehabilitation identifying the benefits of using a software engineering framework. Methods: A systematic research was conducted using PubMed, PEDro (Physiotherapy Evidence Database), IEEE Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, Taylor & Francis Online, Wiley Online Library, and Springer databases. The initial search resulted in 701 papers. After assessing the results according to the inclusion criteria, 83 papers were selected for this study. Results: From the 83 papers reviewed, 8 used a software engineering framework for its development. Most of them focused their efforts on 1 or more aspects, such as data acquisition and processing, game levels, motivation, therapist supervision. Conclusions: This systematic review proves that most of the serious games do not use a software engineering framework for their development. As a result, development systems overlook several aspects and do not have a standardized process, eventually omitting important implementation aspects, which impact the patient’s recovery time. %M 34762052 %R 10.2196/25831 %U https://games.jmir.org/2021/4/e25831 %U https://doi.org/10.2196/25831 %U http://www.ncbi.nlm.nih.gov/pubmed/34762052 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30350 %T Development and Validation of a Mobile Game for Culturally Sensitive Child Sexual Abuse Prevention Education in Tanzania: Mixed Methods Study %A Malamsha,Maria Proches %A Sauli,Elingarami %A Luhanga,Edith Talina %+ School of Computation and Communication Science and Engineering, Nelson Mandela African Institution of Science and Technology, PO Box 447, Nelson Mandela Rd, Arusha, United Republic of Tanzania, 255 715261702, selestinapro@gmail.com %K child sexual abuse %K social cultural belief %K ecological setting %K prevention %K parents %K caretakers %K child experts %K mobile game %D 2021 %7 8.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Globally, 3 out of 20 children experience sexual abuse before the age of 18 years. Educating children about sexual abuse and prevention is an evidence-based strategy that is recommended for ending child sexual abuse. Digital games are increasingly being used to influence healthy behaviors in children and could be an efficient and friendly approach to educating children about sexual abuse prevention. However, little is known on the best way to develop a culturally sensitive game that targets children in Africa—where sexual education is still taboo—that would be engaging, effective, and acceptable to parents and caretakers. Objective: This study aimed to develop a socioculturally appropriate, mobile-based game for educating young children (<5 years) and parents and caretakers in Tanzania on sexual abuse prevention. Methods:  HappyToto children’s game was co-designed with 111 parents and caretakers (females: n=58, 52.3%; male: n=53, 47.7%) of children below 18 years of age and 24 child experts in Tanzania through surveys and focus group discussions conducted from March 2020 to April 2020. From these, we derived an overview of topics, sociocultural practices, social environment, and game interface designs that should be considered when designing child sexual abuse prevention (CSAP) education interventions. We also conducted paper prototyping and storyboarding sessions for the game’s interface, storylines, and options. To validate the application’s prototype, 32 parents (females: n=18, 56%; males: n=14, 44%) of children aged 3-5 years and 5 children (females: n=2, 40%; males: n=3, 60%) of the same age group played the game for half an hour on average. The parents undertook a pre-post intervention assessment on confidence and ability to engage in CSAP education conversations, as well as exit surveys on the usability and sociocultural acceptability of the game, while children were quizzed on the topics covered and their enjoyment of the game. Results: Parents and caregivers showed interest in the developed game during the conducted surveys, and each parent on average navigated through all the parts of the game. The confidence level of parents in talking about CSAP increased from an average of 3.56 (neutral) before using the game to 4.9 (confident) after using the game. The ability scores, calculated based on a range of topics included in CSAP education talks with children, also increased from 5.67 (out of 10) to 8.8 (out of 10) after the game was played. Both confidence level and ability scores were statistically significant (P<.001). All 5 children were interested in the game and enjoyed the game-provided activities. Conclusions: The HappyToto game can thus be an effective technology-based intervention for improving the knowledge and skills of parents and children in CSAP education. %M 34747703 %R 10.2196/30350 %U https://games.jmir.org/2021/4/e30350 %U https://doi.org/10.2196/30350 %U http://www.ncbi.nlm.nih.gov/pubmed/34747703 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29044 %T Feasibility of a Sensor-Controlled Digital Game for Heart Failure Self-management: Randomized Controlled Trial %A Radhakrishnan,Kavita %A Julien,Christine %A Baranowski,Tom %A O'Hair,Matthew %A Lee,Grace %A Sagna De Main,Atami %A Allen,Catherine %A Viswanathan,Bindu %A Thomaz,Edison %A Kim,Miyong %+ School of Nursing, The University of Texas Austin, 1710 Red River St, Austin, TX, 78701, United States, 1 512 471 7936, Kradhakrishnan@mail.nur.utexas.edu %K heart failure %K digital game %K sensor %K self-management %K older adults %K weight monitoring %K physical activity %K behaviors %K mobile phone %D 2021 %7 8.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Poor self-management of heart failure (HF) contributes to devastating health consequences. Our innovative sensor-controlled digital game (SCDG) integrates data from sensors to trigger game rewards, progress, and feedback based on the real-time behaviors of individuals with HF. Objective: The aim of this study is to compare daily weight monitoring and physical activity behavior adherence by older adults using an SCDG intervention versus a sensors-only intervention in a feasibility randomized controlled trial. Methods: English-speaking adults with HF aged 55 years or older who owned a smartphone and could walk unassisted were recruited from Texas and Oklahoma from November 2019 to August 2020. Both groups were given activity trackers and smart weighing scales to track behaviors for 12 weeks. The feasibility outcomes of recruitment, retention, intervention engagement, and satisfaction were assessed. In addition to daily weight monitoring and physical activity adherence, the participants’ knowledge, functional status, quality of life, self-reported HF behaviors, motivation to engage in behaviors, and HF-related hospitalization were also compared between the groups at baseline and at 6, 12, and 24 weeks. Results: A total of 38 participants with HF—intervention group (IG; 19/38, 50%) and control group (CG; 19/38, 50%)—were enrolled in the study. Of the 38 participants, 18 (47%) were women, 18 (47%) were aged 65 years or older, 21 (55%) had been hospitalized with HF in the past 6 months, and 29 (76%) were White. Furthermore, of these 38 participants, 31 (82%)—IG (15/19, 79%) and CG (16/19, 84%)—had both weight monitoring and physical activity data at the end of 12 weeks, and 27 (71%)—IG (14/19, 74%) and CG (13/19, 68%)—participated in follow-up assessments at 24 weeks. For the IG participants who installed the SCDG app (15/19, 79%), the number of days each player opened the game app was strongly associated with the number of days the player engaged in weight monitoring (r=0.72; P=.04) and the number of days with physical activity step data (r=0.9; P<.001). The IG participants who completed the satisfaction survey (13/19, 68%) reported that the SCDG was easy to use. Trends of improvement in daily weight monitoring and physical activity in the IG, as well as within-group improvements in HF functional status, quality of life, knowledge, self-efficacy, and HF hospitalization in both groups, were observed in this feasibility trial. Conclusions: Playing an SCDG on smartphones was feasible and acceptable for older adults with HF for motivating daily weight monitoring and physical activity. A larger efficacy trial of the SCDG intervention will be needed to validate trends of improvement in daily weight monitoring and physical activity behaviors. Trial Registration: ClinicalTrials.gov NCT03947983; https://clinicaltrials.gov/ct2/show/NCT03947983 %M 34747701 %R 10.2196/29044 %U https://games.jmir.org/2021/4/e29044 %U https://doi.org/10.2196/29044 %U http://www.ncbi.nlm.nih.gov/pubmed/34747701 %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 e18359 %T Dissecting Digital Card Games to Yield Digital Biomarkers for the Assessment of Mild Cognitive Impairment: Methodological Approach and Exploratory Study %A Gielis,Karsten %A Vanden Abeele,Marie-Elena %A De Croon,Robin %A Dierick,Paul %A Ferreira-Brito,Filipa %A Van Assche,Lies %A Verbert,Katrien %A Tournoy,Jos %A Vanden Abeele,Vero %+ e-Media Research Lab, Katholieke Universiteit Leuven, Andreas Vesaliusstraat 13, Leuven, 3000, Belgium, 32 16376866, karsten.gielis@kuleuven.be %K mild cognitive impairment %K Klondike Solitaire %K card games %K generalized linear mixed effects analysis %K expert study %K monitoring %K screening %K cognition %K dementia %K older adults %K mobile phone %D 2021 %7 4.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Mild cognitive impairment (MCI), the intermediate cognitive status between normal cognitive decline and pathological decline, is an important clinical construct for signaling possible prodromes of dementia. However, this condition is underdiagnosed. To assist monitoring and screening, digital biomarkers derived from commercial off-the-shelf video games may be of interest. These games maintain player engagement over a longer period of time and support longitudinal measurements of cognitive performance. Objective: This paper aims to explore how the player actions of Klondike Solitaire relate to cognitive functions and to what extent the digital biomarkers derived from these player actions are indicative of MCI. Methods: First, 11 experts in the domain of cognitive impairments were asked to correlate 21 player actions to 11 cognitive functions. Expert agreement was verified through intraclass correlation, based on a 2-way, fully crossed design with type consistency. On the basis of these player actions, 23 potential digital biomarkers of performance for Klondike Solitaire were defined. Next, 23 healthy participants and 23 participants living with MCI were asked to play 3 rounds of Klondike Solitaire, which took 17 minutes on average to complete. A generalized linear mixed model analysis was conducted to explore the differences in digital biomarkers between the healthy participants and those living with MCI, while controlling for age, tablet experience, and Klondike Solitaire experience. Results: All intraclass correlations for player actions and cognitive functions scored higher than 0.75, indicating good to excellent reliability. Furthermore, all player actions had, according to the experts, at least one cognitive function that was on average moderately to strongly correlated to a cognitive function. Of the 23 potential digital biomarkers, 12 (52%) were revealed by the generalized linear mixed model analysis to have sizeable effects and significance levels. The analysis indicates sensitivity of the derived digital biomarkers to MCI. Conclusions: Commercial off-the-shelf games such as digital card games show potential as a complementary tool for screening and monitoring cognition. Trial Registration: ClinicalTrials.gov NCT02971124; https://clinicaltrials.gov/ct2/show/NCT02971124 %M 34734825 %R 10.2196/18359 %U https://games.jmir.org/2021/4/e18359 %U https://doi.org/10.2196/18359 %U http://www.ncbi.nlm.nih.gov/pubmed/34734825 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e27761 %T A Telehealth System Incorporating a Serious Game Intervention to Aid Occupational Therapists in Identifying and Treating Children With Difficulty Crossing the Body’s Midline: Key Informant Interviews Among Occupational Therapists %A Jacobs,Jonathan %A Heymann,Reolyn %A Greeff,Jacob Jacobus %+ Centre for Collaborative Digital Networks, Department of Electrical and Electronic Engineering Science, University of Johannesburg, Engineering Building, Corner of Kingsway and University Road, Auckland Park, Johannesburg, South Africa, 27 741550219, jonty.jacobs@gmail.com %K serious games %K input device %K telehealth %K occupational therapy %K midline crossing %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The midline is an imaginary line that isolates the left and right parts of the body. Crossing the midline infers that a body part (eg, hand or foot) can spontaneously move over to the opposite side of the body to perform an action. A child who has difficulty crossing the midline can physically perform actions that cross the center of the body; however, they do not intuitively cross the midline when challenged with a task that requires this movement, as their perceptual components prevent them from engaging on the contralateral side. This requires treatment from an occupational therapist. Owing to the recent COVID-19 pandemic, access to therapeutic sessions was not possible or reduced, putting the responsibility for treatment on caretakers at home. Caretakers do not have the knowledge and skills to provide treatment, and occupational therapists do not receive adequate feedback from caretakers on the child’s progress. Objective: The first objective is to adapt a simple serious game, or applied game, into a telehealth solution. Children will play the game at home under the supervision of a caretaker, and the results will be stored on the web. Occupational therapists can monitor progress via a web-based dashboard, receive additional valuable feedback about the child’s behavior during treatment, and easily adapt the game to target specific needs. The second objective is to evaluate whether the implemented telehealth solution is feasible as a treatment option for midline crossing difficulties and thus fit for purpose. Methods: To meet the first objective, engineering and game development stakeholders formed a team with an occupational therapist, and through a collaborative design process combined with an agile programming approach, a telehealth solution was designed to assist remote monitoring of the serious gameplay. For the second objective, 6 different occupational therapists were introduced to the game, had the opportunity to play the game, and then provided feedback regarding the feasibility, benefits, and applicability of the system during structured interviews. Results: A telehealth system was designed aimed to address this problem. All results are saved on the web and accessed by occupational therapists via a dashboard. In addition, observed behavioral information is also saved. During the interviews, occupational therapists indicated that the dashboard would support their treatment plan and was indeed a feasible solution. Conclusions: The feedback from the occupational therapists for this telehealth solution suggests a feasible method to treat midline crossing problems remotely. The therapists commented on the convenience of integrating both assessment and treatment into the same application, as it assists them when grading a child. The therapists collectively agreed that the quantitative aspect the serious game creates by providing measurable and standardized data proves advantageous when compared with traditional methods of assessment and treatment. %M 34723821 %R 10.2196/27761 %U https://games.jmir.org/2021/4/e27761 %U https://doi.org/10.2196/27761 %U http://www.ncbi.nlm.nih.gov/pubmed/34723821 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e26810 %T Impulsivity, Self-control, Interpersonal Influences, and Maladaptive Cognitions as Factors of Internet Gaming Disorder Among Adolescents in China: Cross-sectional Mediation Study %A Yu,Yanqiu %A Mo,Phoenix Kit-Han %A Zhang,Jianxin %A Li,Jibin %A Lau,Joseph Tak-Fai %+ Center for Health Behaviours Research, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Ngan Shing St, Sha Tin, Hong Kong, Hong Kong, 852 2252 8713, jlau@cuhk.edu.hk %K cognition %K adolescent health %K health risk behaviors %K internet %K self-control %K China %D 2021 %7 27.10.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Gaming disorder, including internet gaming disorder (IGD), was recently defined by the World Health Organization as a mental disease in the 11th Revision of the International Classification of Diseases (ICD-11). Thus, reducing IGD is warranted. Maladaptive cognitions related to internet gaming (MCIG) have been associated with IGD, while impulsivity, self-control, parental influences, and peer influences are key risk factors of IGD. Previous literature suggests that MCIG is associated with the aforementioned 4 risk factors and IGD, and may thus mediate between these risk factors and IGD. These potential mediations, if significant, imply that modification of MCIG may possibly alleviate these risk factors’ harmful impacts on increasing IGD. These mediation hypotheses were tested in this study for the first time. Objective: This study tested the mediation effects of MCIG between intrapersonal factors (impulsivity and self-control) and IGD, and between interpersonal factors (parental influences and peer influences) and IGD among adolescents in China. Methods: An anonymous, cross-sectional, and self-administered survey was conducted among secondary school students in classroom settings in Guangzhou and Chengdu, China. All grade 7 to 9 students (7 to 9 years of formal education) of 7 secondary schools were invited to join the study, and 3087 completed the survey. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) checklist was used to assess IGD. MCIG was assessed by using the Chinese version of the Revised Internet Gaming Cognition Scale. Impulsivity, self-control, and parental or peer influences were measured by using the motor subscale of the Barratt Impulsiveness Scale, the Brief Self-Control Scale, and the modified interpersonal influence scale, respectively. Structural equation modeling was conducted to examine the mediation effects of MCIG between these risk factors and IGD. Results: The prevalence of IGD was 13.57% (418/3081) and 17.67% (366/2071) among all participants and adolescent internet gamers, respectively. The 3 types of MCIG (perceived rewards of internet gaming, perceived urges for playing internet games, and perceived unwillingness to stop playing without completion of gaming tasks) were positively associated with IGD. Impulsivity, self-control, parental influences, and peer influences were all significantly associated with the 3 types of MCIG and IGD. The 3 types of MCIG partially mediated the associations between the studied factors and IGD (effect size of 30.0% to 37.8%). Conclusions: Impulsivity, self-control, and interpersonal influences had both direct and indirect effects via MCIG on IGD. Modifications of the 3 types of MCIG can potentially reduce the harmful impacts of impulsivity and interpersonal influences on IGD and enhance the protective effect of self-control against IGD. Future longitudinal studies are warranted. %M 34704960 %R 10.2196/26810 %U https://www.jmir.org/2021/10/e26810 %U https://doi.org/10.2196/26810 %U http://www.ncbi.nlm.nih.gov/pubmed/34704960 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e27848 %T An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study %A Kamnardsiri,Teerawat %A Phirom,Kochaphan %A Boripuntakul,Sirinun %A Sungkarat,Somporn %+ Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, 9th Floor, Faculty of Associated Medical Sciences, 110 Intawaroros Rd, Sripoom, Chiang Mai, 50200, Thailand, 66 53936042, somporn.sungkarat@cmu.ac.th %K digital game %K interactive game-based training %K physical-cognitive training %K exergaming %K Kinect sensors %K older adults %K falls %K PACES %K user-centered design %K game-based exercise %D 2021 %7 27.10.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults. Objective: The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults. Methods: In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants’ characteristics and PACES scores. Results: The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided. Conclusions: These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined. %M 34704953 %R 10.2196/27848 %U https://games.jmir.org/2021/4/e27848 %U https://doi.org/10.2196/27848 %U http://www.ncbi.nlm.nih.gov/pubmed/34704953 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e26821 %T Psychometric Properties of the Internet Gaming Disorder Scale–Short-Form (IGDS9-SF): Systematic Review %A Poon,Lok Y J %A Tsang,Hector W H %A Chan,Tsan Y J %A Man,Sze W T %A Ng,Lok Y %A Wong,Yi L E %A Lin,Chung-Ying %A Chien,Chi-Wen %A Griffiths,Mark D %A Pontes,Halley M %A Pakpour,Amir H %+ Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan, 886 6 2353535 ext 5106, cylin36933@gmail.com %K psychometrics %K IGDS9-SF %K gaming addiction %K gaming disorder %K problematic gaming %K internet %K gaming %K internet gaming %D 2021 %7 18.10.2021 %9 Review %J J Med Internet Res %G English %X Background: The Internet Gaming Disorder Scale–Short-Form (IGDS9-SF) is among the best with regard to its psychometric properties. Therefore, clinical psychologists are likely guided to use the IGDS9-SF if they want to assess or screen the disordered gaming in their practice. However, the information, especially psychometric evidence, concerning the IGDS9-SF has not been fully examined and summarized. Objective: This systematic review evaluated the psychometric properties of different language versions of the IGDS9-SF and assessed its methodological quality in order to improve the clinicians’ understanding of the IGDS9-SF and facilitate its use. Methods: Systematic literature searches were carried out using Embase, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science. The review included English-language studies of any research design that have reported at least one psychometric property of the IGDS9-SF, as defined by the COnsensus-based Standards for the selection of health status Measurement INstrument (COSMIN), and have aimed at testing the psychometric properties of the IGDS9-SF. Results: In total, 21 studies comprising 15 language versions of the IGDS9-SF were included. Overall, the IGDS9-SF showed adequate internal consistency (although some items did not have satisfactory item-total correlation [IT]), excellent criterion validity, and the ability to distinguish different subgroups with measurement invariance being supported across gender and age. In terms of factor structure, the IGDS9-SF was shown to have a unidimensional factor structure across all 21 studies. Conclusions: Although there is insufficient evidence regarding the responsiveness and properties of the IGDS9-SF using item response theory, the existing evidence supports its use in assessing disordered gaming among individuals. %M 34661543 %R 10.2196/26821 %U https://www.jmir.org/2021/10/e26821 %U https://doi.org/10.2196/26821 %U http://www.ncbi.nlm.nih.gov/pubmed/34661543 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29981 %T Effects of Active Video Games on Health-Related Physical Fitness and Motor Competence in Children and Adolescents With Overweight or Obesity: Systematic Review and Meta-Analysis %A Comeras-Chueca,Cristina %A Marin-Puyalto,Jorge %A Matute-Llorente,Angel %A Vicente-Rodriguez,German %A Casajus,Jose Antonio %A Gonzalez-Aguero,Alex %+ Department of Physiatry and Nursing, Faculty of Health and Sport Science, University of Zaragoza, Despacho nº 8, Pabellón polideportivo río Isuela, Ronda de la misericordia 5, Huesca, 22001, Spain, 34 876553755, alexgonz@unizar.es %K active videogames %K exergaming %K BMI %K body fat %K motor skills %K cardiorespiratory fitness %K muscle %D 2021 %7 18.10.2021 %9 Review %J JMIR Serious Games %G English %X Background: Childhood obesity is one of the most important public health problems. Active video games (AVGs) have been proposed as an attractive alternative to increase energy expenditure and are being investigated to determine their effectiveness against childhood obesity. Objective: The aim of this study is to summarize the existing research and draw conclusions about the effects of AVGs on health-related physical fitness and motor competence in children and adolescents with overweight and obesity. Methods: The search strategy was applied to PubMed, MEDLINE, Web of Science, and SPORTDiscus, including randomized and nonrandomized controlled trials investigating the effects of AVG programs on health-related physical fitness and motor competence in children and adolescents with overweight and obesity. To measure the risk of bias in randomized and nonrandomized controlled trials, 2 different quality assessment tools were used. In total, 15 articles met the inclusion criteria, and the variables of interest were BMI, body fat percentage, cardiorespiratory fitness (CRF), waist circumference, fat-free mass, muscular fitness, and motor competence. A meta-analysis was performed. Results: Positive effects were found for BMI and body fat percentage, favoring the AVG group compared with a control group with no intervention (mean difference −0.209; 95% CI −0.388 to −0.031 vs mean difference −0.879; 95% CI −1.138 to −0.602). Positive effects seem to be observed for CRF. The effects of AVG interventions on muscular fitness, fat-free mass, waist circumference, and motor competence are unclear. Conclusions: AVG programs showed positive effects on BMI, body fat percentage, and CRF. AVG could be a good strategy to combat childhood obesity. %M 34661549 %R 10.2196/29981 %U https://games.jmir.org/2021/4/e29981 %U https://doi.org/10.2196/29981 %U http://www.ncbi.nlm.nih.gov/pubmed/34661549 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e32729 %T Kinesiotherapy With Exergaming as a Potential Modulator of Epigenetic Marks and Clinical Functional Variables of Older Women: Protocol for a Mixed Methods Study %A Henrique,Patrícia Paula Bazzanello %A Perez,Fabrízzio Martin Pelle %A Becker,Osvaldo Henrique Cemin %A Bellei,Ericles Andrei %A Biduski,Daiana %A Korb,Arthiese %A Pochmann,Daniela %A Dani,Caroline %A Elsner,Viviane Rostirola %A De Marchi,Ana Carolina Bertoletti %+ Institute of Exact Sciences and Geosciences, University of Passo Fundo, B5 Building, São José, Highway BR-285, Km 292, Passo Fundo, 99052-900, Brazil, 55 5433168354, 168729@upf.br %K elderly women %K exergame %K epigenome %K cognition %K kinesiotherapy %D 2021 %7 13.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Kinesiotherapy is an option to mitigate worsening neuropsychomotor function due to human aging. Moreover, exergames are beneficial for the practice of physical therapy by older patients. Physical exercise interventions are known to alter the epigenome, but little is known about their association with exergames. Objective: We aim to evaluate the effects of kinesiotherapy with exergaming on older women’s epigenetic marks and cognitive ability, as well as on their clinical functional variables. Our hypothesis states that this kind of therapy can elicit equal or even better outcomes than conventional therapy. Methods: We will develop a virtual clinic exergame with 8 types of kinesiotherapy exercises. Afterward, we will conduct a 1:1 randomized clinical trial to compare the practice of kinesiotherapy with exergames (intervention group) against conventional kinesiotherapy (control group). A total of 24 older women will be enrolled for 1-hour sessions performed twice a week, for 6 weeks, totaling 12 sessions. We will assess outcomes using epigenetic blood tests, the Montreal Cognitive Assessment test, the Timed Up and Go test, muscle strength grading in a hydraulic dynamometer, and the Game Experience Questionnaire at various stages. Results: The project was funded in October 2019. Game development took place in 2020. Patient recruitment and a clinical trial are planned for 2021. Conclusions: Research on this topic is likely to significantly expand the understanding of kinesiotherapy and the impact of exergames. To the best of our knowledge, this may be one of the first studies exploring epigenetic outcomes of exergaming interventions. Trial Registration: Brazilian Clinical Trials Registry/Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-9tdrmw; https://ensaiosclinicos.gov.br/rg/RBR-9tdrmw. International Registered Report Identifier (IRRID): DERR1-10.2196/32729 %M 34643543 %R 10.2196/32729 %U https://www.researchprotocols.org/2021/10/e32729 %U https://doi.org/10.2196/32729 %U http://www.ncbi.nlm.nih.gov/pubmed/34643543 %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 %@ 2369-2529 %I JMIR Publications %V 8 %N 4 %P e29763 %T A Virtual Smash Room for Venting Frustration or Just Having Fun: Participatory Design of Virtual Environments in Digitally Reinforced Cancer Rehabilitation %A Persson,Johanna %A Clifford,Douglas %A Wallergård,Mattias %A Sandén,Ulrika %+ Department of Design Sciences, Lund University, Box 118, Lund, 22100, Sweden, 46 462224358, johanna.persson@design.lth.se %K virtual reality %K virtual environment %K cancer rehabilitation %K emotions %K participatory design %K virtual smash room %K human factors %D 2021 %7 7.10.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Cancer rehabilitation is central for helping patients and relatives create a functional everyday life based on the changes in life conditions. The needs are highly individual and include physical, mental, and social challenges. Cancer rehabilitation programs offer coping strategies, including guidelines on how to handle emotions. Objective: This paper presents a participatory design activity where patients in cancer rehabilitation use a virtual smash room, which is a virtual environment where the user can break things, mainly porcelain or glass items such as vases or plates. The objective is to understand attitudes to, and some effects of, using this application, as well as eliciting ideas of other virtual environments that would be desired. Methods: The virtual environment presented here, the virtual smash room, was designed at the request of a patient with cancer who wanted a tool for venting frustration. In this virtual environment, the user can break porcelain, vases, and plates. Patients participating in a week-long cancer rehabilitation program tested the virtual smash room and reported their experiences through a questionnaire. The questionnaire comprised three sections: (1) a subset of the Intrinsic Motivation Inventory (IMI), (2) a subset of the Virtual Reality Symptoms Questionnaire (VRSQ), and (3) a free-text response section. Results: A total of 101 responses were gathered. The results from the IMI questions showed that the participants found the virtual experience enjoyable (mean 4.52, maximum 5, SD 0.73), and it helped them retain their focus (mean 4.44, maximum 5, SD 0.74). The VRSQ revealed that there were only minor symptoms related to general discomfort (5.9%, n=6), fatigue (5.9%, n=6), nausea (3.0%, n=3), and tired eyes (8.9%, n=9), while several participants experienced dizziness (22.8%, n=23). Since only postmeasurements were gathered, nothing could be concluded about the prevalence of these symptoms before testing. The free-text responses indicated that the user group had many ideas for other virtual environments to use in cancer rehabilitation. Conclusions: This study presents a concept of using virtual reality in the cancer rehabilitation process and exemplifies activities of patient participation in the design process. Virtual reality has potential in being both distracting and enjoyable, while certain aspects of cybersickness might be especially important to consider for a user group already experiencing physical and mental issues. The results will act as input in the process of further designing virtual applications in digitally reinforced cancer rehabilitation. %M 34617913 %R 10.2196/29763 %U https://rehab.jmir.org/2021/4/e29763 %U https://doi.org/10.2196/29763 %U http://www.ncbi.nlm.nih.gov/pubmed/34617913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28037 %T Acceptability Evaluation of the Use of Virtual Reality Games in Smoking-Prevention Education for High School Students: Prospective Observational Study %A Guo,Jong-Long %A Hsu,Hsiao-Pei %A Lai,Tzu-Ming %A Lin,Mei-Ling %A Chung,Chih-Ming %A Huang,Chiu-Mieh %+ Institute of Clinical Nursing, College of Nursing, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, 886 2 28267362, cmhuang2021@nycu.edu.tw %K behavioral intention %K ARCS motivation model %K persuasiveness %K smoking prevention %K educational games %D 2021 %7 28.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Alternative forms of cigarettes, such as electronic cigarettes (e-cigarettes), are becoming increasingly common among adolescents. Many high schools now provide smoking-prevention education in an attempt to minimize the potential negative health effects and illness burdens e-cigarettes may induce in adolescents. However, it is often difficult to motivate young students to engage with traditional education regarding the harmful effects of tobacco; thus, the development of alternative approaches may be required. Objective: In this study, we aimed to conduct an acceptability evaluation of educational virtual reality games designed to support smoking-prevention measures. We based the acceptability evaluation on the following two experience types: game-playing and content-learning experiences. The paths by which these experience types affect the intention to abstain from smoking were also examined. Methods: We applied a prospective observational study design. We developed educational games based on three-dimensional virtual reality technology, in which participants operated joysticks to complete challenge tasks. To increase the possibility of the games fostering motivation to abstain from smoking, the ARCS motivational model (comprising attention, relevance, confidence, and satisfaction) was used as a framework during the games’ design. We measured the participants’ game-playing experiences by inquiring about the strength of the ARCS elements; content-learning experiences were measured using overall knowledge improvement and the perceived persuasiveness of the content. A total of 130 students participated in the program. Study hypotheses for this evaluation were derived from a literature review. We used partial least squares structural equation modeling to examine the proposed hypotheses. Results: Based on the responses of the students to questionnaire items concerning attention, relevance, confidence, and satisfaction in the context of the games, most students agreed or strongly agreed that the educational games were motivational, and that their game-playing experiences were positive. Regarding content-learning experiences, there was a significant improvement in knowledge (t129=25.67, P<.001), and most students perceived themselves as being persuaded to abstain from smoking. Attention, relevance, and satisfaction significantly influenced perceived persuasiveness (t=3.19, P<.001; t=4.28, P<.001; and t=3.49, P<.001, respectively); however, confidence did not (t=0.42, P=.67). Perceived persuasiveness, relevance, and satisfaction significantly influenced the intention to abstain from smoking (t=3.57, P<.001). In addition to directly affecting the intention to abstain from smoking, indirect effects were observed from both relevance and satisfaction to intention via perceived persuasiveness (t=2.87, P=.004 and t=2.11, P=.04, respectively). However, intention was not significantly influenced by knowledge improvement. Conclusions: Our findings revealed that the educational games were positively accepted by the participating students. This indicates that the integration of the ARCS framework and persuasive strategies is applicable for smoking-prevention education. We recommend that the games be included as teaching materials for smoking-prevention education. %M 34581679 %R 10.2196/28037 %U https://www.jmir.org/2021/9/e28037 %U https://doi.org/10.2196/28037 %U http://www.ncbi.nlm.nih.gov/pubmed/34581679 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26084 %T A Cognitive Behavioral Therapy–, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial %A Thabrew,Hiran %A Stasiak,Karolina %A Kumar,Harshali %A Naseem,Tarique %A Frampton,Christopher %A Merry,Sally %+ Department of Psychological Medicine, University of Auckland, Building 507, School of Medicine, Level 3, 22-30 Park Avenue, Grafton, Auckland, 1011, New Zealand, 64 21 402 055, h.thabrew@auckland.ac.nz %K long-term physical conditions %K chronic illness %K anxiety %K eHealth %K gaming %K young people %K treatment %K cognitive behavioral therapy %K biofeedback %D 2021 %7 24.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues. Objective: This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. Methods: Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale. Results: Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (−4.6; P<.001), Spence Child Anxiety Scale (−9.6; P=.005), and the Likert visual analog scales (−2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up. Conclusions: This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443 %M 34559053 %R 10.2196/26084 %U https://games.jmir.org/2021/3/e26084 %U https://doi.org/10.2196/26084 %U http://www.ncbi.nlm.nih.gov/pubmed/34559053 %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 %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e25922 %T Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial %A Moskowitz,Judith Tedlie %A Addington,Elizabeth L %A Shiu,Eva %A Bassett,Sarah M %A Schuette,Stephanie %A Kwok,Ian %A Freedman,Melanie E %A Leykin,Yan %A Saslow,Laura R %A Cohn,Michael A %A Cheung,Elaine O %+ Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, 625 N Michigan Ave, Suite 2700, Chicago, IL, 60611, United States, 1 3125037712, judith.moskowitz@northwestern.edu %K mHealth %K adherence %K depression %K discussion board %K gamification %K positive psychological intervention %K mobile phone %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another. Objective: The aim of our study is to test whether 3 enhancements—facilitator contact (FC), an online discussion board, and virtual badges (VB)—alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence. Methods: Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions—the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed. Results: A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline. Conclusions: The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence. Trial Registration: ClinicalTrials.gov NCT02861755; http://clinicaltrials.gov/ct2/show/NCT02861755 %M 34550076 %R 10.2196/25922 %U https://www.jmir.org/2021/9/e25922 %U https://doi.org/10.2196/25922 %U http://www.ncbi.nlm.nih.gov/pubmed/34550076 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e22942 %T Comparing a Virtual Reality–Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial %A Stunden,Chelsea %A Stratton,Kirsten %A Zakani,Sima %A Jacob,John %+ Department of Pediatrics, Faculty of Medicine, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada, 1 604 875 2345 ext 2393, john.jacob@cw.bc.ca %K virtual reality %K magnetic resonance imaging simulation %K certified child life specialists %K pediatrics %K magnetic resonance imaging procedures %K alternatives to sedation %K preparing children for MRI %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed. Objective: This study aims to compare the effectiveness of a virtual reality (VR)—based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers’ reported anxiety, procedural data, caregiver usability, child satisfaction, and fun. Methods: This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers’ reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales). Results: A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36%; SPM: 24/84, 29%; and CLP: 30/84, 36%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children’s reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r84=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37). Conclusions: Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting. Trial Registration: Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382 %M 34550072 %R 10.2196/22942 %U https://www.jmir.org/2021/9/e22942 %U https://doi.org/10.2196/22942 %U http://www.ncbi.nlm.nih.gov/pubmed/34550072 %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 e28796 %T A Computer-Based Interactive Narrative and a Serious Game for Children With Asthma: Development and Content Validity Analysis %A Sarasmita,Made Ary %A Larasanty,Luh Putu Febryana %A Kuo,Li-Na %A Cheng,Kuei-Ju %A Chen,Hsiang-Yin %+ Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Health and Science Building, 7th Floor, 250 Wuxing Street, Taipei, 110, Taiwan, 886 02 2736 1661 ext 6175, shawn@tmu.edu.tw %K asthma %K computer %K children %K interactive narrative %K serious game %K digital education %K mobile phone %D 2021 %7 13.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Nonadherence to medications, failure to prevent exposure to asthma triggers, lack of knowledge about using medications, and fixed mindsets contribute to poor asthma control in children. Digital learning could provide a new strategy for improving health-related outcomes in children with asthma. Objective: The aim of this study is to develop and design a digital educational program, titled Module of Inhaler and Asthma Triggers for Children (MIRACLE), for Indonesian children with asthma. The program comprises an interactive narrative and a serious game. It was proposed to increase the understanding of asthma self-management, instruct on proper inhaler techniques, improve asthma control, and promote a growth mindset for children with asthma. Methods: Two phases of research were conducted to develop the program. In the first phase, a literature search and two rounds of the Delphi technique were conducted to obtain agreement from an expert panel regarding elements of asthma self-management and the design of interactive narratives and a serious game. The expert panel item statements were evaluated using the content validity index (CVI). In the second phase, the SERES framework, Norma Engaging Multimedia Design, and Psychological Theory of Growth Mindset were applied to create a storyline, learn objectives, and game challenges. Results: In the first phase, 40 experts were invited to participate in Delphi round 1. Forty responses were collected to generate 38 item statements that consisted of part 1, elements of asthma self-management (25 items), and part 2, design of an interactive narrative and a serious game (13 items); 38 experts were involved in Delphi round 2. In total, 24 statements in part 1 and 13 items in part 2 had item-CVI values >0.80. The average CVI was 0.9, which was considered acceptable. Four narrative plots and five game sessions were developed during the second phase. Challenges with the scenario, scoring, and feedback on asthma difficulties were designed to promote a growth mindset for learners. Conclusions: We developed a culture-specific, computer-based asthma program containing an interactive narrative and a serious game to deliver asthma self-management and promote a growth mindset among Indonesian children. %M 34515641 %R 10.2196/28796 %U https://www.jmir.org/2021/9/e28796 %U https://doi.org/10.2196/28796 %U http://www.ncbi.nlm.nih.gov/pubmed/34515641 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e26802 %T Mechanism Design of Health Care Blockchain System Token Economy: Development Study Based on Simulated Real-World Scenarios %A Jung,Se Young %A Kim,Taehyun %A Hwang,Hyung Ju %A Hong,Kyungpyo %+ Department of Mathematics, Pohang University of Science and Technology, 77, Cheongam-ro, Nam-gu, Pohang-si, 37673, Republic of Korea, 82 054 279 2056, hjhwang@postech.ac.kr %K mechanism design %K optimization %K blockchain %K token economy %K eHealth %K electronic health records %K healthcare %K economy %K health records %D 2021 %7 13.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the fact that the adoption rate of electronic health records has increased dramatically among high-income nations, it is still difficult to properly disseminate personal health records. Token economy, through blockchain smart contracts, can better distribute personal health records by providing incentives to patients. However, there have been very few studies regarding the particular factors that should be considered when designing incentive mechanisms in blockchain. Objective: The aim of this paper is to provide 2 new mathematical models of token economy in real-world scenarios on health care blockchain platforms. Methods: First, roles were set for the health care blockchain platform and its token flow. Second, 2 scenarios were introduced: collecting life-log data for an incentive program at a life insurance company to motivate customers to exercise more and recruiting participants for clinical trials of anticancer drugs. In our 2 scenarios, we assumed that there were 3 stakeholders: participants, data recipients (companies), and data providers (health care organizations). We also assumed that the incentives are initially paid out to participants by data recipients, who are focused on minimizing economic and time costs by adapting mechanism design. This concept can be seen as a part of game theory, since the willingness-to-pay of data recipients is important in maintaining the blockchain token economy. In both scenarios, the recruiting company can change the expected recruitment time and number of participants. Suppose a company considers the recruitment time to be more important than the number of participants and rewards. In that case, the company can increase the time weight and adjust cost. When the reward parameter is fixed, the corresponding expected recruitment time can be obtained. Among the reward and time pairs, the pair that minimizes the company’s cost was chosen. Finally, the optimized results were compared with the simulations and analyzed accordingly. Results: To minimize the company’s costs, reward–time pairs were first collected. It was observed that the expected recruitment time decreased as rewards grew, while the rewards decreased as time cost grew. Therefore, the cost was represented by a convex curve, which made it possible to obtain a minimum—an optimal point—for both scenarios. Through sensitivity analysis, we observed that, as the time weight increased, the optimized reward increased, while the optimized time decreased. Moreover, as the number of participants increased, the optimization reward and time also increased. Conclusions: In this study, we were able to model the incentive mechanism of blockchain based on a mechanism design that recruits participants through a health care blockchain platform. This study presents a basic approach to incentive modeling in personal health records, demonstrating how health care organizations and funding companies can motivate one another to join the platform. %M 34515640 %R 10.2196/26802 %U https://www.jmir.org/2021/9/e26802 %U https://doi.org/10.2196/26802 %U http://www.ncbi.nlm.nih.gov/pubmed/34515640 %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 e23050 %T The Effect of a Serious Health Game on Children’s Eating Behavior: Cluster-Randomized Controlled Trial %A Folkvord,Frans %A Haga,Gosse %A Theben,Alexandra %+ Tilburg School of Humanities and Digital Sciences, Warrandelaan 2, Tilburg, 5000 LE, Netherlands, 31 +31610948122, fransfolkvord@Gmail.com %K children %K eating behavior %K food-cues %K serious health game %K health intervention %D 2021 %7 2.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Currently, children’s dietary intake patterns do not meet prescribed dietary guidelines. Consequently, childhood obesity is one of the most serious health concerns. Therefore, innovative methods need to be developed and tested in order to effectively improve the dietary intake of children. Teaching children how to cope with the overwhelming number of unhealthy food cues could be conducted effectively by serious health games. Objective: The main aim of this study was to examine the effect of a serious health computer game on young children’s eating behavior and attitudes toward healthy and unhealthy foods. Methods: A cluster-randomized controlled trial with a between-group design was conducted (n=157; 8-12 years), wherein children played a game that promoted a healthy lifestyle or attended regular classes and did not play a game (control). The game was designed in collaboration with researchers and pilot-tested among a group of children repeatedly before conducting the experiment. After 1 week of playing, attitudes toward food snacks and actual intake (children could eat ad libitum from fruits or energy-dense snacks) was assessed. Results: The results showed that playing a serious health game did not have an effect on attitude toward fruits or energy-dense snacks or on the intake of fruits or less energy-dense snacks. Additional Bayesian analyses supported these findings. Conclusions: Serious health games are increasingly considered to be a potential effective intervention when it comes to behavior change. The results of the current study stress the importance of tailoring serious health games in order to be effective, because no effect was found on attitude or eating behavior. Trial Registration: ClinicalTrials.gov NCT05025995; https://tinyurl.com/mdd7wrjd %M 34473061 %R 10.2196/23050 %U https://games.jmir.org/2021/3/e23050 %U https://doi.org/10.2196/23050 %U http://www.ncbi.nlm.nih.gov/pubmed/34473061 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26824 %T A Virtual Reality Game (The Secret Trail of Moon) for Treating Attention-Deficit/Hyperactivity Disorder: Development and Usability Study %A Rodrigo-Yanguas,Maria %A Martin-Moratinos,Marina %A Menendez-Garcia,Angela %A Gonzalez-Tardon,Carlos %A Royuela,Ana %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana-Puerta de Hierro University Hospital, Avenida, Manuel de Falla 1, Majadahonda, 28222, Spain, 34 655214857, hmblasco@yahoo.es %K attention-deficit/hyperactivity disorder %K chess %K virtual reality %K serious video game %K psychotherapy %K cognitive training %K usability %K new technologies %K transfer %K randomized controlled trial %D 2021 %7 1.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed for cognitive training related to core ADHD symptoms and executive dysfunction. Objective: We aimed to describe the development and usability of TSTM. Methods: The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion) of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation). Results: A total of 31/37 (86%) and 30/37 (83%) of participants liked playing TSTM and wanted to continue playing TSTM, respectively. Further, 5/37 (14%) of participants reported that they experienced either perceived dizziness or virtual reality motion sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype and frequent video game players to infrequent video game players. Conclusions: Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD. Trial Registration: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065 %M 34468332 %R 10.2196/26824 %U https://games.jmir.org/2021/3/e26824 %U https://doi.org/10.2196/26824 %U http://www.ncbi.nlm.nih.gov/pubmed/34468332 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26976 %T Feasibility of Virtual Reality Audiological Testing: Prospective Study %A Seol,Hye Yoon %A Kang,Soojin %A Lim,Jihyun %A Hong,Sung Hwa %A Moon,Il Joon %+ Department of Otolaryngology-Head & Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea, 82 2 3410 3579, moonij@skku.edu %K hearing loss %K virtual reality %K speech performance %K real-world performance %K hearing %K audiology %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: It has been noted in the literature that there is a gap between clinical assessment and real-world performance. Real-world conversations entail visual and audio information, yet there are not any audiological assessment tools that include visual information. Virtual reality (VR) technology has been applied to various areas, including audiology. However, the use of VR in speech-in-noise perception has not yet been investigated. Objective: The purpose of this study was to investigate the impact of virtual space (VS) on speech performance and its feasibility to be used as a speech test instrument. We hypothesized that individuals’ ability to recognize speech would improve when visual cues were provided. Methods: A total of 30 individuals with normal hearing and 25 individuals with hearing loss completed pure-tone audiometry and the Korean version of the Hearing in Noise Test (K-HINT) under three conditions—conventional K-HINT (cK-HINT), VS on PC (VSPC), and VS head-mounted display (VSHMD)—at –10 dB, –5 dB, 0 dB, and +5 dB signal-to-noise ratios (SNRs). Participants listened to target speech and repeated it back to the tester for all conditions. Hearing aid users in the hearing loss group completed testing under unaided and aided conditions. A questionnaire was administered after testing to gather subjective opinions on the headset, the VSHMD condition, and test preference. Results: Provision of visual information had a significant impact on speech performance between the normal hearing and hearing impaired groups. The Mann-Whitney U test showed statistical significance (P<.05) between the two groups under all test conditions. Hearing aid use led to better integration of audio and visual cues. Statistical significance through the Mann-Whitney U test was observed for –5 dB (P=.04) and 0 dB (P=.02) SNRs under the cK-HINT condition, as well as for –10 dB (P=.007) and 0 dB (P=.04) SNRs under the VSPC condition, between hearing aid and non–hearing aid users. Participants reported positive responses across almost all items on the questionnaire except for the weight of the headset. Participants preferred a test method with visual imagery, but found the headset to be heavy. Conclusions: Findings are in line with previous literature that showed that visual cues were beneficial for communication. This is the first study to include hearing aid users with a more naturalistic stimulus and a relatively simple test environment, suggesting the feasibility of VR audiological testing in clinical practice. %M 34463624 %R 10.2196/26976 %U https://games.jmir.org/2021/3/e26976 %U https://doi.org/10.2196/26976 %U http://www.ncbi.nlm.nih.gov/pubmed/34463624 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26153 %T A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study %A Allegue,Dorra Rakia %A Kairy,Dahlia %A Higgins,Johanne %A Archambault,Philippe S %A Michaud,Francois %A Miller,William C %A Sweet,Shane N %A Tousignant,Michel %+ The Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, 6363 Chemin Hudson (fifth floor), Montreal, QC, H3S1M9, Canada, 1 4389901309, dorra.rakia.allegue@umontreal.ca %K stroke %K rehabilitation %K virtual reality %K video games %K telerehabilitation %K upper extremity %K motivation %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment–upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID): RR2-10.2196/14629 %M 34132649 %R 10.2196/26153 %U https://games.jmir.org/2021/3/e26153 %U https://doi.org/10.2196/26153 %U http://www.ncbi.nlm.nih.gov/pubmed/34132649 %0 Journal Article %@ 2562-0959 %I JMIR Publications %V 4 %N 2 %P e30325 %T Gamification and Game-Based Strategies for Dermatology Education: Narrative Review %A Szeto,Mindy D %A Strock,Daniel %A Anderson,Jarett %A Sivesind,Torunn E %A Vorwald,Victoria M %A Rietcheck,Hope R %A Weintraub,Gil S %A Dellavalle,Robert P %+ Department of Dermatology, University of Colorado Anschutz Medical Campus, 1665 Aurora Court, 3rd Floor, Mailstop F703, Aurora, CO, 80045, United States, 1 7208480500, mindy.szeto@cuanschutz.edu %K games %K game-playing %K gamification %K serious games %K simulations %K education %K medical education %K dermatology education %K patient education %K review %D 2021 %7 30.8.2021 %9 Review %J JMIR Dermatol %G English %X Background: Game-based approaches, or gamification, are popular learning strategies in medical education for health care providers and patients alike. Gamification has taken the form of serious educational games and simulations to enable learners to rehearse skills and knowledge in a safe environment. Dermatology learners in particular may benefit from gamification methods, given the visual and procedural nature of the field. Objective: This narrative review surveys current applications of gamification within general medical training, in the education of dermatology students, and in dermatology patient outreach. Methods: A literature search was performed using PubMed, Google Scholar, and ResearchGate to access and review relevant medical education- and dermatology-related gamification studies published in peer-reviewed journals. Two independent researchers with education and experience in dermatology screened publications to select studies featuring a diversity of gamification approaches and study subjects for in-depth examination. Results: A total of 6 general medical education–related and 7 dermatology-specific gamification studies were selected. Gamification generally increased motivation and engagement, improved reinforcement of learning objectives, and contributed to more enjoyable and positive educational experiences compared to traditional modes of instruction. Enhancing examination scores, building confidence, and developing stronger team dynamics were additional benefits for medical trainees. Despite the abundance of gamification studies in general medical education, comparatively few instances were specific to dermatology learning, although large organizations such as the American Academy of Dermatology have begun to implement these strategies nationally. Gamification may also a provide promising alternative means of diversifying patient education and outreach methods, especially for self-identification of malignant melanoma. Conclusions: Serious games and simulations in general medical education have successfully increased learner motivation, enjoyment, and performance. In limited preliminary studies, gamified approaches to dermatology-specific medical education enhanced diagnostic accuracy and interest in the field. Game-based interventions in patient-focused educational pilot studies surrounding melanoma detection demonstrated similar efficacy and knowledge benefits. However, small study participant numbers and large variability in outcome measures may indicate decreased generalizability of findings regarding the current impact of gamification approaches, and further investigation in this area is warranted. Additionally, some relevant studies may have been omitted by the simplified literature search strategy of this narrative review. This could be expanded upon in a secondary systematic review of gamified educational platforms. %M 37632819 %R 10.2196/30325 %U https://derma.jmir.org/2021/2/e30325 %U https://doi.org/10.2196/30325 %U http://www.ncbi.nlm.nih.gov/pubmed/37632819 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e27195 %T Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach %A McClincy,Michael %A Seabol,Liliana G %A Riffitts,Michelle %A Ruh,Ethan %A Novak,Natalie E %A Wasilko,Rachel %A Hamm,Megan E %A Bell,Kevin M %+ Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA, 15224, United States, 1 412 692 5530, mcclincymp@upmc.edu %K IHT %K pediatric %K sports medicine %K ACL %K orthopaedics %K rehabilitation %K health technology %K gamification %D 2021 %7 27.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements. Objective: This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior. Methods: In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post–ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants. Results: The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity. Conclusions: The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting. %M 34448715 %R 10.2196/27195 %U https://games.jmir.org/2021/3/e27195 %U https://doi.org/10.2196/27195 %U http://www.ncbi.nlm.nih.gov/pubmed/34448715 %0 Journal Article %@ 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 %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e28150 %T Commercial Off-The-Shelf Video Games for Reducing Stress and Anxiety: Systematic Review %A Pallavicini,Federica %A Pepe,Alessandro %A Mantovani,Fabrizia %+ Department of Human Sciences for Education “Riccardo Massa”, University of Milano Bicocca, Piazza dell'Ateneo Nuovo 1, Milano, 20126, Italy, 39 0264484903, federica.pallavicini@gmail.com %K commercial off-the-shelf video games %K video games %K stress %K anxiety %K relaxation %D 2021 %7 16.8.2021 %9 Review %J JMIR Ment Health %G English %X Background: Using commercial off-the-shelf video games rather than custom-made computer games could have several advantages for reducing stress and anxiety, including their low cost, advanced graphics, and the possibility to reach millions of individuals worldwide. However, it is important to emphasize that not all commercial video games are equal, and their effects strongly depend on specific characteristics of the games. Objective: The aim of this systematic review was to describe the literature on the use of commercial off-the-shelf video games for diminishing stress and anxiety, examining the research outcomes along with critical variables related to computer game characteristics (ie, genre, platform, time of play). Methods: A systematic search of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The search databases were PsycINFO, Web of Science, Medline, IEEExplore, and the Cochrane Library. The search string was: [(“video game*”) OR (“computer game*”)] AND [(“stress”) OR (“anxiety”) OR (“relaxation”)] AND [(“study”) OR (“trial”) OR (“training”)]. Results: A total of 28 studies met the inclusion criteria for the publication period 2006-2021. The findings demonstrate the benefit of commercial off-the-shelf video games for reducing stress in children, adults, and older adults. The majority of the retrieved studies recruited young adults, and fewer studies have involved children, middle-aged adults, and older adults. In addition to exergames and casual video games, other genres of commercial off-the-shelf games helped to reduce stress and anxiety. Conclusions: Efficacy in reducing stress and anxiety has been demonstrated not only for exergames and casual video games but also for other genres such as action games, action-adventure games, and augmented reality games. Various gaming platforms, including consoles, PCs, smartphones, mobile consoles, and virtual reality systems, have been used with positive results. Finally, even single and short sessions of play had benefits in reducing stress and anxiety. Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202130081; https://inplasy.com/?s=INPLASY202130081 %M 34398795 %R 10.2196/28150 %U https://mental.jmir.org/2021/8/e28150 %U https://doi.org/10.2196/28150 %U http://www.ncbi.nlm.nih.gov/pubmed/34398795 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e24546 %T The Impact of Gamification-Induced Users' Feelings on the Continued Use of mHealth Apps: A Structural Equation Model With the Self-Determination Theory Approach %A Wang,Tong %A Fan,Lingye %A Zheng,Xu %A Wang,Wei %A Liang,Jun %A An,Kai %A Ju,Mei %A Lei,Jianbo %+ Institute of Medical Technology, Health Science Center, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, China, 86 82805901, jblei@hsc.pku.edu.cn %K mHealth app %K continued use %K continuance intention %K gamification %K self-determination theory (SDT) %K expectation confirmation model of information system continuance (ECM-ISC) %K PLS-SEM %D 2021 %7 12.8.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Continued use of mHealth apps can achieve better effects in health management. Gamification is an important factor in promoting users’ intention to continue using mHealth apps. Past research has rarely explored the factors underlying the continued use of mobile health (mHealth) apps and gamification’s impact mechanism or path on continued use. Objective: This study aimed to explore the factors influencing mHealth app users’ intention to continue using mHealth apps and the impact mechanism and path of users’ feelings induced by gamification on continued mHealth app use. Methods: First, based on the expectation confirmation model of information system continuance, we built a theoretical model for continued use of mHealth apps based on users’ feelings toward gamification. We used self-determination theory to analyze gamification’s impact on user perceptions and set the resulting feelings (competence, autonomy, and relatedness) as constructs in the model. Second, we used the survey method to validate the research model, and we used partial least squares to analyze the data. Results: A total of 2988 responses were collected from mHealth app users, and 307 responses were included in the structural equation model after passing the acceptance criteria. The intrinsic motivation for using mHealth apps is significantly affected by autonomy (β=.312; P<.001), competence (β=.346; P<.001), and relatedness (β=.165; P=.004) induced by gamification. The intrinsic motivation for using mHealth apps has a significant impact on satisfaction (β=.311, P<.001) and continuance intention (β=.142; P=.045); furthermore, satisfaction impacts continuance intention significantly (β=.415; P<.001). Confirmation has a significant impact on perceived usefulness (β=.859; P<.001) and satisfaction (β=.391; P<.001), and perceived usefulness has a significant impact on satisfaction (β=.269; P<.001) and continuance intention (β=.273; P=.001). The mediating effect analysis showed that in the impact path of the intrinsic motivation for using the mHealth apps on continuance intention, satisfaction plays a partial mediating role (β=.129; P<.001), with a variance accounted for of 0.466. Conclusions: This study explored the impact path of users’ feelings induced by gamification on the intention of continued mHealth app use. We confirmed that perceived usefulness, confirmation, and satisfaction in the classical continued use theory for nonmedical information systems positively affect continuance intention. We also found that the path and mechanism of users' feelings regarding autonomy, competence, and relatedness generated during interactions with different gamification elements promote the continued use of mHealth apps. %M 34387550 %R 10.2196/24546 %U https://www.jmir.org/2021/8/e24546 %U https://doi.org/10.2196/24546 %U http://www.ncbi.nlm.nih.gov/pubmed/34387550 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e31588 %T A Casual Video Game With Psychological Well-being Concepts for Young Adolescents: Protocol for an Acceptability and Feasibility Study %A Pine,Russell %A Mbinta,James %A Te Morenga,Lisa %A Fleming,Theresa %+ School of Health, Victoria University of Wellington, Kelburn, Wellington, 6032, New Zealand, 64 02040864377, Russell.pine@vuw.ac.nz %K digital mental health tools %K casual video games %K young people %D 2021 %7 12.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Many face-to-face and digital therapeutic supports are designed for adolescents experiencing high levels of psychological distress. However, promoting psychological well-being among adolescents is often neglected despite significant short-term and long-term benefits. Objective: This research has 3 main objectives: (1) to assess the acceptability of Match Emoji, a casual video game with psychological well-being concepts among 13-15-year-old students in a New Zealand secondary school; (2) to identify the feasibility of the research process; and (3) to explore the preliminary well-being and therapeutic potential of Match Emoji. Methods: Approximately 40 participants aged 13-15 years from a local secondary college in Wellington, New Zealand, will be invited to download and play Match Emoji 3-4 times a week for 5-15 minutes over a 2-week period. Participants will complete 4 assessments at baseline, postintervention, and 3 weeks later to assess psychological well-being and therapeutic changes. Statistical analysis will be used to synthesize data from interviews and triangulated with assessment changes and game analytics. This synthesis will help to assess the acceptability and feasibility of the Match Emoji. Results: The key outputs from the project will include the acceptability, feasibility, and therapeutic potential of Match Emoji. It is anticipated that participants will have finished playing the recommended game play regimen by August 2021 with analysis of results completed by October 2021. Conclusions: Data from the study are expected to inform future research on Match Emoji including a randomized controlled trial and further adjustments to the design and development of the game. International Registered Report Identifier (IRRID): PRR1-10.2196/31588 %M 34387558 %R 10.2196/31588 %U https://www.researchprotocols.org/2021/8/e31588 %U https://doi.org/10.2196/31588 %U http://www.ncbi.nlm.nih.gov/pubmed/34387558 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26449 %T The Making and Evaluation of Digital Games Used for the Assessment of Attention: Systematic Review %A Wiley,Katelyn %A Robinson,Raquel %A Mandryk,Regan L %+ Department of Computer Science, University of Saskatchewan, Room 373, Thorvaldson Bldg, University of Saskatchewan, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 306 966 5186, katelyn.wiley@usask.ca %K cognitive assessment %K attention %K serious games %K gamification %K systematic review %K mobile phone %D 2021 %7 9.8.2021 %9 Review %J JMIR Serious Games %G English %X Background: Serious games are now widely used in many contexts, including psychological research and clinical use. One area of growing interest is that of cognitive assessment, which seeks to measure different cognitive functions such as memory, attention, and perception. Measuring these functions at both the population and individual levels can inform research and indicate health issues. Attention is an important function to assess, as an accurate measure of attention can help diagnose many common disorders, such as attention-deficit/hyperactivity disorder and dementia. However, using games to assess attention poses unique problems, as games inherently manipulate attention through elements such as sound effects, graphics, and rewards, and research on adding game elements to assessments (ie, gamification) has shown mixed results. The process for developing cognitive tasks is robust, with high psychometric standards that must be met before these tasks are used for assessment. Although games offer more diverse approaches for assessment, there is no standard for how they should be developed or evaluated. Objective: To better understand the field and provide guidance to interdisciplinary researchers, we aim to answer the question: How are digital games used for the cognitive assessment of attention made and measured? Methods: We searched several databases for papers that described a digital game used to assess attention that could be deployed remotely without specialized hardware. We used Rayyan, a systematic review software, to screen the records before conducting a systematic review. Results: The initial database search returned 49,365 papers. Our screening process resulted in a total of 74 papers that used a digital game to measure cognitive functions related to attention. Across the studies in our review, we found three approaches to making assessment games: gamifying cognitive tasks, creating custom games based on theories of cognition, and exploring potential assessment properties of commercial games. With regard to measuring the assessment properties of these games (eg, how accurately they assess attention), we found three approaches: comparison to a traditional cognitive task, comparison to a clinical diagnosis, and comparison to knowledge of cognition; however, most studies in our review did not evaluate the game’s properties (eg, if participants enjoyed the game). Conclusions: Our review provides an overview of how games used for the assessment of attention are developed and evaluated. We further identified three barriers to advancing the field: reliance on assumptions, lack of evaluation, and lack of integration and standardization. We then recommend the best practices to address these barriers. Our review can act as a resource to help guide the field toward more standardized approaches and rigorous evaluation required for the widespread adoption of assessment games. %M 34383674 %R 10.2196/26449 %U https://games.jmir.org/2021/3/e26449 %U https://doi.org/10.2196/26449 %U http://www.ncbi.nlm.nih.gov/pubmed/34383674 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28400 %T Feasibility and Effects of Virtual Reality Motor-Cognitive Training in Community-Dwelling Older People With Cognitive Frailty: Pilot Randomized Controlled Trial %A Kwan,Rick Yiu Cho %A Liu,Justina Yat Wa %A Fong,Kenneth Nai Kuen %A Qin,Jing %A Leung,Philip Kwok-Yuen %A Sin,Olive Suk Kan %A Hon,Pik Yuen %A Suen,Lydia W %A Tse,Man-Kei %A Lai,Claudia KY %+ Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, GH502, Hung Hom, Kowloon, Hong Kong, , China (Hong Kong), 852 2766 6546, rick.kwan@polyu.edu.hk %K virtual reality %K motor-cognitive training %K cognitive frailty %K game %K feasibility %K VR %K training %K older adults %K frail %K pilot study %K randomized controlled trial %D 2021 %7 6.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive frailty refers to the coexistence of physical frailty and cognitive impairment, and is associated with many adverse health outcomes. Although cognitive frailty is prevalent in older people, motor-cognitive training is effective at enhancing cognitive and physical function. We proposed a virtual reality (VR) simultaneous motor-cognitive training program, which allowed older people to perform daily activities in a virtual space mimicking real environments. Objective: We aimed to (1) explore the feasibility of offering VR simultaneous motor-cognitive training to older people with cognitive frailty and (2) compare its effects with an existing motor-cognitive training program in the community on the cognitive function and physical function of older people with cognitive frailty. Methods: A two-arm (1:1), assessor-blinded, parallel design, randomized controlled trial was employed. The eligibility criteria for participants were: (1) aged ≥60 years, (2) community dwelling, and (3) with cognitive frailty. Those in the intervention group received cognitive training (ie, cognitive games) and motor training (ie, cycling on an ergometer) simultaneously on a VR platform, mimicking the daily living activities of older people. Those in the control group received cognitive training (ie, cognitive games) on tablet computers and motor training (ie, cycling on the ergometer) sequentially on a non-VR platform. Both groups received a 30-minute session twice a week for 8 weeks. Feasibility was measured by adherence, adverse outcomes, and successful learning. The outcomes were cognitive function, physical frailty level, and walking speed. Results: Seventeen participants were recruited and randomized to either the control group (n=8) or intervention group (n=9). At baseline, the median age was 74.0 years (IQR 9.5) and the median Montreal Cognitive Assessment score was 20.0 (IQR 4.0). No significant between-group differences were found in baseline characteristics except in the number of chronic illnesses (P=.04). At postintervention, the intervention group (Z=–2.67, P=.01) showed a significantly larger improvement in cognitive function than the control group (Z=–1.19, P=.24). The reduction in physical frailty in the intervention group (Z=–1.73, P=.08) was similar to that in the control group (Z=–1.89, P=.06). Improvement in walking speed based on the Timed Up-and-Go test was moderate in the intervention group (Z=–0.16, P=.11) and greater in the control group (Z=–2.52, P=.01). The recruitment rate was acceptable (17/33, 52%). Both groups had a 100% attendance rate. The intervention group had a higher completion rate than the control group. Training was terminated for one participant (1/9, 11%) due to minimal VR sickness (Virtual Reality Sickness Questionnaire score=18.3/100). Two participants (2/8, 25%) in the control group withdrew due to moderate leg pain. No injuries were observed in either group. Conclusions: This study provides preliminary evidence that the VR simultaneous motor-cognitive training is effective at enhancing the cognitive function of older people with cognitive frailty. The effect size on frailty was close to reaching a level of significance and was similar to that observed in the control group. VR training is feasible and safe for older people with cognitive frailty. Trial Registration: ClinicalTrials.gov NCT04467216; https://clinicaltrials.gov/ct2/show/NCT04467216 %M 34383662 %R 10.2196/28400 %U https://games.jmir.org/2021/3/e28400 %U https://doi.org/10.2196/28400 %U http://www.ncbi.nlm.nih.gov/pubmed/34383662 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 8 %P e24112 %T Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study %A Derksen,Marloes E %A Jaspers,Monique WM %A van Strijp,Sander %A Fransen,Mirjam P %+ Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 20 5664494, m.e.derksen@amsterdamumc.nl %K think aloud %K heuristic evaluation %K usability %K mHealth %K game elements %K smoking prevention %K user-centered design %K mobile phone %D 2021 %7 4.8.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation. Objective: This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation. Methods: Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society. Results: Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon). Conclusions: The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing. %M 34346895 %R 10.2196/24112 %U https://formative.jmir.org/2021/8/e24112 %U https://doi.org/10.2196/24112 %U http://www.ncbi.nlm.nih.gov/pubmed/34346895 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P 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 %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e22920 %T Resuscitating Cardiopulmonary Resuscitation Training in a Virtual Reality: Prospective Interventional Study %A Perron,Janaya Elizabeth %A Coffey,Michael Jonathon %A Lovell-Simons,Andrew %A Dominguez,Luis %A King,Mark E %A Ooi,Chee Y %+ Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Centre for Child Health Research & Innovation, Level 8, Bright Alliance Building, Corner of Avoca & High Streets, Randwick, Australia, 61 2 9382 5500, j.perron@unswalumni.com %K pediatrics %K cardiopulmonary resuscitation %K virtual reality %K medical education %D 2021 %7 29.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulation-based technologies are emerging to enhance medical education in the digital era. However, there is limited data for the use of virtual reality simulation in pediatric medical education. We developed Virtual Doc as a highly immersive virtual reality simulation to teach pediatric cardiopulmonary resuscitation skills to medical students. Objective: The primary objectives of this study were to evaluate participant satisfaction and perceived educational efficacy of Virtual Doc. The secondary aim of this study was to assess the game play features of Virtual Doc. Methods: We conducted a prospective closed beta-testing study at the University of New South Wales (Sydney, Australia) in 2018. All medical students from the 6-year undergraduate program were eligible to participate and were recruited through voluntary convenience sampling. Participants attended a 1-hour testing session and attempted at least one full resuscitation case using the virtual reality simulator. Following this, participants were asked to complete an anonymous postsession questionnaire. Responses were analyzed using descriptive statistics. Results: A total of 26 participants were recruited, consented to participate in this study, and attended a 1-hour in-person closed beta-testing session, and 88% (23/26) of participants completed the anonymous questionnaire and were included in this study. Regarding participant satisfaction, Virtual Doc was enjoyed by 91% (21/23) of participants, with 74% (17/23) intending to recommend the simulation to a colleague and 66% (15/23) intending to recommend the simulation to a friend. In assessment of the perceived educational value of Virtual Doc, 70% (16/23) of participants agreed they had an improved understanding of cardiopulmonary resuscitation, and 78% (18/23) agreed that Virtual Doc will help prepare for and deal with real-life clinical scenarios. Furthermore, 91% (21/23) of participants agreed with the development of additional Virtual Doc cases as beneficial for learning. An evaluation of the game play features as our secondary objective revealed that 70% (16/23) of participants agreed with ease in understanding how to use Virtual Doc, and 74% (17/23) found the game play elements useful in understanding cardiopulmonary resuscitation. One-third (7/23, 30%) found it easy to work with the interactive elements. In addition, 74% (17/23) were interested in interacting with other students within the simulation. Conclusions: Our study demonstrates a positive response regarding trainee satisfaction and perceived educational efficacy of Virtual Doc. The simulation was widely accepted by the majority of users and may have the potential to improve educational learning objectives. %M 34326040 %R 10.2196/22920 %U https://www.jmir.org/2021/7/e22920 %U https://doi.org/10.2196/22920 %U http://www.ncbi.nlm.nih.gov/pubmed/34326040 %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 e25637 %T Medical Students’ Perceptions of Play and Learning: Qualitative Study With Focus Groups and Thematic Analysis %A Van Gaalen,A E J %A Jaarsma,A D C %A Georgiadis,J R %+ Department of Biomedical Sciences of Cells and Systems, Section Anatomy & Medical Physiology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, Groningen, 9713AV, Netherlands, 31 640994891, a.e.j.van.gaalen@umcg.nl %K gamification %K serious games %K game-based learning %K medical education %K computers %K new technology %K focus group %K play %K qualitative %D 2021 %7 28.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In times where distance learning is becoming the norm, game-based learning (GBL) is increasingly applied to health profession education. Yet, decisions for if, when, how, and for whom GBL should be designed cannot be made on a solid empirical basis. Though the act of play seems to be intertwined with GBL, it is generally ignored in the current scientific literature. Objective: The objective of our study was to explore students’ perceptions of play in leisure time and of GBL as part of a mechanistic, bottom-up approach towards evidence-informed design and implementation of GBL in health profession education. Methods: We conducted 6 focus group discussions with medical and dentistry students, which were analyzed using thematic analysis. Results: A total of 58 students participated. We identified 4 major themes based on the students’ perception of play in leisure time and on the combination of play and learning. Our results indicate that, while play preferences were highly various in our health profession student cohort, pleasure was the common ground reported for playing. Crucially, play and the serious act of learning seemed paradoxical, indicating that the value and meaning of play are strongly context-dependent for students. Conclusions: Four key points can be constructed from our study. First, students play for pleasure. Perceptions of pleasure vary considerably among students. Second, students consider play as inefficient. Inefficiency will only be justified when it increases learning. Third, play should be balanced with the serious and only be used for difficult or tedious courses. Fourth, GBL activities should not be made compulsory for students. We provide practical implications and directions for future research. %M 34319237 %R 10.2196/25637 %U https://games.jmir.org/2021/3/e25637 %U https://doi.org/10.2196/25637 %U http://www.ncbi.nlm.nih.gov/pubmed/34319237 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26520 %T Extended Reality for Enhanced Telehealth During and Beyond COVID-19: Viewpoint %A Ong,Triton %A Wilczewski,Hattie %A Paige,Samantha R %A Soni,Hiral %A Welch,Brandon M %A Bunnell,Brian E %+ Doxy.me, LLC, 3445 Winton Place, Suite #114, Rochester, NY, 14623, United States, 1 1844436996, triton.ong@doxy.me %K extended reality %K virtual reality %K augmented reality %K mixed reality %K telehealth %K telemedicine %K COVID-19 %K telepresence %D 2021 %7 26.7.2021 %9 Viewpoint %J JMIR Serious Games %G English %X The COVID-19 pandemic caused widespread challenges and revealed vulnerabilities across global health care systems. In response, many health care providers turned to telehealth solutions, which have been widely embraced and are likely to become standard for modern care. Immersive extended reality (XR) technologies have the potential to enhance telehealth with greater acceptability, engagement, and presence. However, numerous technical, logistic, and clinical barriers remain to the incorporation of XR technology into telehealth practice. COVID-19 may accelerate the union of XR and telehealth as researchers explore novel solutions to close social distances. In this viewpoint, we highlight research demonstrations of XR telehealth during the COVID-19 pandemic and discuss future directions to make XR the next evolution of remote health care. %M 34227992 %R 10.2196/26520 %U https://games.jmir.org/2021/3/e26520 %U https://doi.org/10.2196/26520 %U http://www.ncbi.nlm.nih.gov/pubmed/34227992 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e27884 %T The Effects of Exergaming on Sensory Reweighting and Mediolateral Stability of Women Aged Over 60: Usability Study %A Sápi,Mariann %A Fehér-Kiss,Anna %A Csernák,Krisztina %A Domján,Andrea %A Pintér,Sándor %+ Department of Physiotherapy, Faculty of Health Sciences and Social Studies, University of Szeged, Temesvári krt. 31, Szeged, 6726, Hungary, 36 62 54 6411, domjan.andrea.agnes@szte.hu %K exergaming %K sensory reweighting %K older women %K mediolateral sway %K vestibular %D 2021 %7 21.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Older adults tend to experience difficulties in switching quickly between various reliable sensory inputs, which ultimately may contribute to an increased risk of falls and injuries. Sideward falls are the most frequent cause of hip fractures among older adults. Recently, exergame programs have been confirmed as beneficial tools for enhancing postural control, which can reduce the risk of falls. However, studies to explore more precisely which mechanism of exergaming directly influences older women’s ability to balance are still needed. Objective: Our aim was to evaluate, in a single-group pretest/posttest/follow-up usability study, whether Kinect exergame balance training might have a beneficial impact on the sensory reweighting in women aged over 60. Methods: A total of 14 healthy women (mean age 69.57 [SD 4.66] years, mean body mass index 26.21 [SD 2.6] kg/m2) participated in the study. The volunteers trained with the commercially available games of Kinect for Xbox 360 console 3 times (30 minutes/session) a week over a 6-week period (total of 18 visits). Participants’ postural sway in both the anteroposterior (AP) and mediolateral (ML) directions was recorded with NeuroCom Balance Master 6.0. To assess and measure postural sensory reweighting, the Modified Clinical Test of Sensory Interaction in Balance was used, where volunteers were exposed to various changes in visual (eyes open or eyes closed) and surface conditions (firm or foam surface). Results: In the ML direction, the Kinect exergame training caused a significant decrease in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P=.001), and on the foam surface with the eyes open (P=.001) and eyes closed (P<.001) conditions compared with baseline data. The follow-up measurements when compared with the baseline data showed a significant change in the sway path on the firm surface with the eyes open (P<.001) and eyes closed (P<.001) conditions, as well as on the foam surface with the eyes open (P=.003) and eyes closed (P<.001) conditions. Besides, on the firm surface, there were no significant differences in sway path values in the AP direction between the baseline and the posttraining measurements (eyes open: P=.49; eyes closed: P=.18). Likewise, on the foam surface, there were no significant differences in sway path values in the AP direction under both eyes open (P=.24) and eyes closed (P=.84) conditions. Conclusions: The improved posturography measurements of the sway path in the ML direction might suggest that the Kinect exergame balance training may have effects on sensory reweighting, and thus on the balance of women aged over 60. Based on these results, Kinect exergaming may provide a safe and potentially useful tool for improving postural stability in the crucial ML direction, and thus it may help reduce the risk of falling. %M 34287215 %R 10.2196/27884 %U https://games.jmir.org/2021/3/e27884 %U https://doi.org/10.2196/27884 %U http://www.ncbi.nlm.nih.gov/pubmed/34287215 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 7 %P e25437 %T Evaluating Quality, Usability, Evidence-Based Content, and Gamification Features in Mobile Learning Apps Designed to Teach Children Basic Life Support: Systematic Search in App Stores and Content Analysis %A Fijačko,Nino %A Masterson Creber,Ruth %A Gosak,Lucija %A Štiglic,Gregor %A Egan,Dominic %A Chaka,Brian %A Debeljak,Nika %A Strnad,Matej %A Skok,Pavel %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, 2000, Slovenia, 386 23004764, nino.fijacko@um.si %K cardiopulmonary resuscitation %K basic life support %K mobile learning %K mobile phone %K gamification %K schoolchildren %D 2021 %7 20.7.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the Kids Save Lives statements, initiatives to train school-age children in basic life support (BLS) have been widespread. Mobile phone apps, combined with gamification, represent an opportunity for including mobile learning (m-learning) in teaching schoolchildren BLS as an additional teaching method; however, the quality of these apps is questionable. Objective: This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children. Methods: We searched the Google Play Store and Apple iOS App Store using multiple terms (eg, cardiopulmonary resuscitation [CPR] or BLS). Apps meeting the inclusion criteria were evaluated by 15 emergency health care professionals using the user version of the Mobile Application Rating Scale and System Usability Scale. We modified a five-finger mnemonic for teaching schoolchildren BLS and reviewed the apps’ BLS content using standardized criteria based on three CPR guidelines. GFs in the apps were evaluated using a gamification taxonomy. Results: Of the 1207 potentially relevant apps, only 6 (0.49%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95% CI 3.0-3.4) and 47.1/100 points (95% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the personal and fictional, educational, and performance gamification groups represented most GFs. Conclusions: Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills. %M 34283034 %R 10.2196/25437 %U https://mhealth.jmir.org/2021/7/e25437 %U https://doi.org/10.2196/25437 %U http://www.ncbi.nlm.nih.gov/pubmed/34283034 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 7 %P e16643 %T A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial %A Lukas,Christian Aljoscha %A Eskofier,Bjoern %A Berking,Matthias %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nuremberg, Naegelsbachstr 25a, Erlangen, 91052, Germany, 49 176 80526686, christian.aljoscha.lukas@fau.de %K smartphone technology %K depression %K cognitive behavioral therapy %K approach/avoidance %K gamification %D 2021 %7 20.7.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Available smartphone-based interventions for depression predominantly use evidence-based strategies from cognitive-behavioral therapy (CBT), but patient engagement and reported effect sizes are small. Recently, studies have demonstrated that smartphone-based interventions combining CBT with gamified approach-avoidance bias modification training (AAMT) can foster patient engagement and reduce symptoms of several mental health problems. Objective: Based on these findings, we developed a gamified smartphone-based intervention, mentalis Phoenix (MT-Phoenix), and hypothesized the program would both engage patients and produce preliminary evidence for the reduction of depressive symptoms. Methods: To test this hypothesis, we evaluated MT-Phoenix in a randomized controlled pilot trial including 77 individuals with elevated depression scores (Patient Health Questionnaire-9 scores ≥5). Participants were either instructed to train for 14 days with MT-Phoenix or assigned to a waitlist control condition. Engagement with the intervention was measured by assessing usage data. The primary outcome was reduction in depressive symptom severity at postassessment. Results: Data from this pilot trial shows that participants in the intervention group used the smartphone-based intervention for 46% of all days (6.4/14) and reported a significantly greater reduction of depressive symptoms than did participants in the control condition (F1,74=19.34; P=.001), with a large effect size (d=1.02). Effects were sustained at a 3-month follow-up. Conclusions: A gamified smartphone-based intervention combining CBT with AAMT may foster patient engagement and effectively target depressive symptoms. Future studies should evaluate the effectiveness of this intervention in a phase 3 trial using clinical samples. Moreover, the intervention should be compared to active control conditions. Trial Registration: German Clinical Trial Registry DRKS00012769; https://tinyurl.com/47mw8du7 %M 34283037 %R 10.2196/16643 %U https://mental.jmir.org/2021/7/e16643 %U https://doi.org/10.2196/16643 %U http://www.ncbi.nlm.nih.gov/pubmed/34283037 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e29080 %T Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review %A Barteit,Sandra %A Lanfermann,Lucia %A Bärnighausen,Till %A Neuhann,Florian %A Beiersmann,Claudia %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 62215634030, barteit@uni-heidelberg.de %K virtual reality %K augmented reality %K global health %K income-limited countries %K medical education %D 2021 %7 8.7.2021 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment. Objective: We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs). Methods: We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD). Results: A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs. Conclusions: The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education. %M 34255668 %R 10.2196/29080 %U https://games.jmir.org/2021/3/e29080 %U https://doi.org/10.2196/29080 %U http://www.ncbi.nlm.nih.gov/pubmed/34255668 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28282 %T The Influence of Gamification and Information Technology Identity on Postadoption Behaviors of Health and Fitness App Users: Empirical Study in the United States %A Esmaeilzadeh,Pouyan %+ Department of Information Systems and Business Analytics, College of Business, Florida International University, Modesto A Maidique Campus 11200 SW 8th St, RB 261 B, Miami, FL, 33199, United States, 1 3053483302, pesmaeil@fiu.edu %K gamification %K health and fitness apps %K IT identity %K continued intention to use %K information-sharing tendency %K mHealth %K app design %K user interaction %D 2021 %7 5.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of health and fitness apps has been on the rise to monitor personal fitness and health parameters. However, recent research discovered that many users discontinue using these apps after only a few months. Gamification has been suggested as a technique to increase users’ interactions with apps. Nevertheless, it is still not clear how gamification mechanisms encourage continued use and inspire user self-management. Objective: The main objective of this study was to articulate how gamification mechanisms in studies of designing and using health and fitness apps can contribute to the realization of information technology (IT) identity and positive behavioral outcomes. The broader goal was to shed light on how gamification mechanisms will translate into positive use behaviors in the context of mobile health apps. Methods: Data were collected from 364 users of health and fitness apps through an online survey to empirically examine the proposed model. Results: Based on identity theories, this study suggests the fully mediating role of IT identity to describe how gamification elements can lead to continued intention to use health and fitness apps, and increase users’ tendency for information sharing through the apps. The findings indicate that perceived gamification can increase users’ IT identity. In turn, a higher IT identity would encourage users to continue using the apps and share more personal health information with others through the apps. Conclusions: The results of this study can have practical implications for app designers to use gamification elements to increase users’ dependency, relatedness, and emotional energy associated with health apps. Moreover, the findings can have theoretical contributions for researchers to help better articulate the process in which gamification can be translated into positive use behaviors. %M 34812736 %R 10.2196/28282 %U https://games.jmir.org/2021/3/e28282/ %U https://doi.org/10.2196/28282 %U http://www.ncbi.nlm.nih.gov/pubmed/34812736 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e29182 %T Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study %A Knobel,Samuel Elia Johannes %A Kaufmann,Brigitte Charlotte %A Gerber,Stephan Moreno %A Urwyler,Prabitha %A Cazzoli,Dario %A Müri,René M %A Nef,Tobias %A Nyffeler,Thomas %+ Neurocenter, Luzerner Kantonsspital, Spitalstrasse, Lucerne, 6004, Switzerland, 41 205 56 86, thomas.nyffeler@luks.ch %K virtual reality %K serious game %K search task %K stroke %K neglect %K usability %K development %K immersion %K concept %K gaming %D 2021 %7 2.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. Objective: This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. Methods: In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. Results: In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. Conclusions: The developed iVR serious game, “bird search task,” was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task. %M 34255653 %R 10.2196/29182 %U https://games.jmir.org/2021/3/e29182 %U https://doi.org/10.2196/29182 %U http://www.ncbi.nlm.nih.gov/pubmed/34255653 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 7 %P e20658 %T Executive Function After Prenatal Alcohol Exposure in Children in a South African Population: Cross-sectional Study %A Louw,Jacobus Gidion %A van Heerden,Alastair %A Olivier,Leana %A Lambrechts,Tersius %A Broodryk,Mandi %A Bunge,Liska %A Vosloo,Martlé %A Tomlinson,Mark %+ Foundation for Alcohol Related Research, 42 Bloemhof Street, Bellville, Cape Town, 7535, South Africa, 27 216862646, jl@farrsa.org.za %K fetal alcohol spectrum disorders %K FASD %K cognitive %K executive function %K experimental games %K brain drug effects %K child development %K serious games %K games %K alcohol %K training %D 2021 %7 2.7.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Alcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol. Objective: The aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol. Methods: Children both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low–socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable. Results: No significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms. Conclusions: We expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low–socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development. International Registered Report Identifier (IRRID): RR2-10.2196/14489 %M 34255647 %R 10.2196/20658 %U https://formative.jmir.org/2021/7/e20658 %U https://doi.org/10.2196/20658 %U http://www.ncbi.nlm.nih.gov/pubmed/34255647 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 6 %P e29792 %T A Digital Gaming Intervention to Improve HIV Testing for Adolescents and Young Adults: Protocol for Development and a Pilot Randomized Controlled Trial %A Castel,Amanda D %A Wilbourn,Brittany %A Trexler,Connie %A D'Angelo,Lawrence D %A Greenberg,Daniel %+ Department of Epidemiology, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW, Suite 500, Washington, DC, 20052, United States, 1 2029944392, blewis1@gwu.edu %K HIV testing %K pre-exposure prophylaxis (PrEP) %K youth %K mobile phone %D 2021 %7 14.6.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC. Objective: This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a randomized controlled study with AYAs at risk for HIV in Washington, DC. Methods: This research protocol will be conducted in 3 phases. A formative phase will involve surveys and focus groups (n=64) with AYAs living in the DC area. These focus groups will allow researchers to understand youth preferences for game enhancement. The second phase will consist of a pilot test (n=10) of the gaming intervention. This pilot test will allow researchers to modify the game based on formative results and test the planned recruitment and data collection strategy with intended end users. The third phase will consist of a randomized controlled study among 300 AYAs to examine the efficacy of the life-simulation game compared with app-based HIV educational materials on HIV and PrEP in changing HIV testing, knowledge, risk behaviors, and PrEP access. Participants will have unlimited access to either the life-simulation game or the educational app for 3 months from the time of enrollment. Study assessments will occur at enrollment and at 1, 3, and 6 months post enrollment via e-surveys. At 6 months, a subset of intervention participants (n=25) will participate in in-depth exit interviews regarding their experience being in the study. Results: Institutional review board approval was received on February 5, 2020. This project is currently recruiting participants for the formative phase. Conclusions: This interactive life-simulation intervention aims to increase HIV testing and PrEP access among AYAs in the DC area. In this intervention, players can enact real-life behaviors and receive their HIV risk profile to promote HIV testing and PrEP seeking. Such an intervention has great potential to improve knowledge of HIV and PrEP among AYAs, increase motivation and self-efficacy related to HIV testing and PrEP use, and decrease individual and structural barriers that often preclude engagement in HIV prevention services. Trial Registration: ClinicalTrials.gov NCT04917575; https://clinicaltrials.gov/ct2/show/NCT04917575 International Registered Report Identifier (IRRID): PRR1-10.2196/29792 %M 34185022 %R 10.2196/29792 %U https://www.researchprotocols.org/2021/6/e29792 %U https://doi.org/10.2196/29792 %U http://www.ncbi.nlm.nih.gov/pubmed/34185022 %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 e26575 %T Gaming Your Mental Health: A Narrative Review on Mitigating Symptoms of Depression and Anxiety Using Commercial Video Games %A Kowal,Magdalena %A Conroy,Eoin %A Ramsbottom,Niall %A Smithies,Tim %A Toth,Adam %A Campbell,Mark %+ Lero, The Science Foundation Ireland Research Centre for Software, Physical Education and Sport Sciences Department, University of Limerick, p1041 PESS building, Castletroy, Limerick, Ireland, 353 061234944, mark.campbell@ul.ie %K commercial video games %K mobile phone %K clinical %K mental health disorders %K psychotherapy %K pandemic %K accessibility %K health care %D 2021 %7 16.6.2021 %9 Viewpoint %J JMIR Serious Games %G English %X Globally, depression and anxiety are the two most prevalent mental health disorders. They occur both acutely and chronically, with various symptoms commonly expressed subclinically. The treatment gap and stigma associated with such mental health disorders are common issues encountered worldwide. Given the economic and health care service burden of mental illnesses, there is a heightened demand for accessible and cost-effective methods that prevent occurrence of mental health illnesses and facilitate coping with mental health illnesses. This demand has been exacerbated post the advent of the COVID-19 pandemic and the subsequent increase in incidence of mental health disorders. To address these demands, a growing body of research is exploring alternative solutions to traditional mental health treatment methods. Commercial video games have been shown to impart cognitive benefits to those playing regularly (ie, attention control, cognitive flexibility, and information processing). In this paper, we specifically focus on the mental health benefits associated with playing commercial video games to address symptoms of depression and anxiety. In light of the current research, we conclude that commercial video games show great promise as inexpensive, readily accessible, internationally available, effective, and stigma-free resources for the mitigation of some mental health issues in the absence of, or in addition to, traditional therapeutic treatments. %M 34132648 %R 10.2196/26575 %U https://games.jmir.org/2021/2/e26575 %U https://doi.org/10.2196/26575 %U http://www.ncbi.nlm.nih.gov/pubmed/34132648 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25151 %T Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study %A Maharaj,Alita %A Lim,David %A Murphy,Rinki %A Serlachius,Anna %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand, 64 9 923 3073, a.serlachius@auckland.ac.nz %K type 2 diabetes %K mobile apps %K diabetes %K self-management %K user engagement %K app %K mHealth %K randomized controlled trial %K intervention %K efficacy %D 2021 %7 16.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Diabetes apps represent a promising addition to face-to-face self-management interventions, which can be time and resource intensive. However, few randomized controlled trials have evaluated the efficacy of diabetes apps, in particular as a stand-alone intervention without additional clinical support. Objective: We used a feasibility randomized trial design to investigate differences in user engagement between 2 commercially available apps (free versions of Glucose Buddy and mySugr) over 2 weeks in adults with type 2 diabetes. Feasibility was assessed based on recruitment uptake, adherence to the diabetes apps, and follow-up rates. We also hypothesized that the diabetes app mySugr would demonstrate higher user engagement at follow-up due to its use of gamification. We also predicted higher user engagement would be associated with improved self-care behaviors and illness beliefs. Methods: Adults with type 2 diabetes attending outpatient diabetes clinics in Auckland were recruited and randomized (1:1 without blinding) to use either the Glucose Buddy or mySugr diabetes apps. User engagement, self-care behaviors, and illness beliefs were measured 2 weeks after baseline. Spearman rank correlations, Mann-Whitney tests, and Wilcoxon signed-rank tests were used to explore associations between the outcome measures and to investigate possible changes between and within groups. Six participants were interviewed to further explore acceptability and usability. Results: In total, 58 participants (29 per group) completed the 2-week follow-up, of whom only 38 reported using the apps (Glucose Buddy: n=20; mySugr: n=18). Both groups reported low engagement (Glucose Buddy: median 4 days; mySugr: median 6.5 days; P=.06; use for both groups: median 10 minutes). No changes were observed in self-care or illness beliefs in either group. Out of the self-care behaviors, only blood glucose testing was significantly associated with minutes of app use (P=.02). The interviews suggested that although both apps were deemed acceptable, they were generally viewed as time-consuming and too complicated to use. Conclusions: Low engagement with both Glucose Buddy and mySugr reflect the challenges associated with engaging users with diabetes apps. Due to low engagement and loss to follow-up, the changes in outcome measures should be interpreted with caution. The results highlight the need for more clinical support as well as involvement from end users and behavior change specialists in order to incorporate evidence-based behavior change techniques to motivate and provide value to users. Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12618000424202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374671 %M 34132640 %R 10.2196/25151 %U https://formative.jmir.org/2021/6/e25151 %U https://doi.org/10.2196/25151 %U http://www.ncbi.nlm.nih.gov/pubmed/34132640 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e26872 %T Brain Exercising Games With Consumer-Grade Single-Channel Electroencephalogram Neurofeedback: Pre-Post Intervention Study %A Israsena,Pasin %A Jirayucharoensak,Suwicha %A Hemrungrojn,Solaphat %A Pan-Ngum,Setha %+ National Electronics and Computer Technology Center, National Science and Technology Development Agency, 112 Thailand Science Park, Klong Luang, Pathumthani, 12120, Thailand, 66 25646900 ext 2471, pasin.israsena@nectec.or.th %K neurofeedback %K serious gaming %K serious game %K brain exercise %K cognition training %K EEG %K aging %K cognition %K cognitive %K brain game %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The aging population is one of the major challenges affecting societies worldwide. As the proportion of older people grows dramatically, so does the number of age-related illnesses such as dementia-related illnesses. Preventive care should be emphasized as an effective tool to combat and manage this situation. Objective: The aim of this pilot project was to study the benefits of using neurofeedback-based brain training games for enhancing cognitive performance in the elderly population. In particular, aiming for practicality, the training games were designed to operate with a low-cost consumer-grade single-channel electroencephalogram (EEG) headset that should make the service scalable and more accessible for wider adoption such as for home use. Methods: Our training system, which consisted of five brain exercise games using neurofeedback, was serviced at 5 hospitals in Thailand. Participants were screened for cognitive levels using the Thai Mental State Examination and Montreal Cognitive Assessment. Those who passed the criteria were further assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB) computerized cognitive assessment battery. The physiological state of the brain was also assessed using 16-channel EEG. After 20 sessions of training, cognitive performance and EEG were assessed again to compare pretraining and posttraining results. Results: Thirty-five participants completed the training. CANTAB results showed positive and significant effects in the visual memory (delayed matching to sample [percent correct] P=.04), attention (median latency P=.009), and visual recognition (spatial working memory [between errors] P=.03) domains. EEG also showed improvement in upper alpha activity in a resting state (open-eyed) measured from the occipital area (P=.04), which similarly indicated improvement in the cognitive domain (attention). Conclusions: Outcomes of this study show the potential use of practical neurofeedback-based training games for brain exercise to enhance cognitive performance in the elderly population. %M 34128816 %R 10.2196/26872 %U https://games.jmir.org/2021/2/e26872 %U https://doi.org/10.2196/26872 %U http://www.ncbi.nlm.nih.gov/pubmed/34128816 %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 e26820 %T Virtual Reality Human–Human Interface to Deliver Psychotherapy to People Experiencing Auditory Verbal Hallucinations: Development and Usability Study %A Brander,Mischa %A Egger,Stephan T %A Hürlimann,Noa %A Seifritz,Erich %A Sumner,Robert W %A Vetter,Stefan %A Magnenat,Stéphane %+ Psychotherapy and Psychosomatics, Department of Psychiatry, Psychiatric University Hospital of Zurich, University of Zürich, Lenggstrasse 31, Zurich, 8032, Switzerland, 41 523049340, stephan.egger@pukzh.ch %K system usability %K virtual reality psychotherapy %K verbal auditory hallucinations %D 2021 %7 1.6.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital technologies have expanded the options for delivering psychotherapy, permitting for example, the treatment of schizophrenia using Avatar Therapy. Despite its considerable potential, this treatment method has not been widely disseminated. As a result, its operability and functionality remain largely unknown. Objective: We aimed to study the usability of a therapeutic virtual reality human–human interface, created in a game engine. Methods: Participants were psychiatric hospital staff who were introduced to the therapeutic platform in a hands-on session. The System Usability Scale (SUS) was employed for evaluation purposes. Statistical evaluation was conducted using descriptive statistics, the chi-square test, analysis of variance, and multilevel factor analysis. Results: In total, 109 staff members were introduced to the therapeutic tool and completed the SUS. The mean SUS global score was 81.49 (SD 11.1). Psychotherapists (mean 86.44, SD 8.79) scored significantly higher (F2,106=6.136; P=.003) than nursing staff (mean 79.01, SD 13.30) and administrative personnel (mean 77.98, SD 10.72). A multilevel factor analysis demonstrates a different factor structure for each profession. Conclusions: In all professional groups in this study, the usability of a digital psychotherapeutic tool developed using a game engine achieved the benchmark for an excellent system, scoring highest among the professional target group (psychotherapists). The usability of the system seems, to some extent, to be dependent on the professional background of the user. It is possible to create and customize novel psychotherapeutic approaches with gaming technologies and platforms. Trial Registration: Clinicaltrials.gov NCT04099940; http://clinicaltrials.gov/ct2/show/NCT04099940 %M 33769295 %R 10.2196/26820 %U https://games.jmir.org/2021/2/e26820 %U https://doi.org/10.2196/26820 %U http://www.ncbi.nlm.nih.gov/pubmed/33769295 %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 %@ 2369-2529 %I JMIR Publications %V 8 %N 2 %P e24337 %T Parents' Perspectives on a Computer Game–Assisted Rehabilitation Program for Manual Dexterity in Children With Cerebral Palsy: Qualitative Analysis of Expectations, Child Engagement, and Benefits %A Kanitkar,Anuprita %A Parmar,Sanjay Tejraj %A Szturm,Tony J %A Restall,Gayle %A Rempel,Gina %A Sepehri,Nariman %+ University of Manitoba, 800 Sherbrook Street, RR327, Winnipeg, MB, Canada, 1 2048813112, anuprita.kan@gmail.com %K cerebral palsy %K parents' expectations %K fine motor function %K object manipulation %K computer game–based treatment protocol %K parents %K motor function %K computer games, rehabilitation %K game-based rehabilitation %K gross movement %K children %D 2021 %7 31.5.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Children with motor impairments affecting the upper extremity benefit from task-specific therapy, such as constraint-induced movement therapy. However, there is a need to improve engagement and compliance with task-specific exercise programs that target manual dexterity for children with cerebral palsy (CP). A computer game–based rehabilitation (GRP) platform was developed that combines fine manipulation and gross movement exercises with engaging game activities appropriate for young children with CP. Objective: The objectives of this qualitative analysis were to compare parents’ perspectives and opinions about expectations, challenges, and benefits between 2 interventions. Methods: A mixed methods, randomized controlled trial (RCT) was conducted to examine the feasibility and estimate the effect size of 2 exercise programs for rehabilitation of manual dexterity of children with CP using either GRP or conventional therapy. Parents of 26 of the children who completed the GRP program (n=33) and parents of 15 of the children who completed the conventional therapy program (n=27) participated in the interviews. A general conductive approach was used to analyze the data recorded during the parents’ interviews. Results: Five themes captured the range of the parent’s experiences, viewpoints, and ideas: (1) parents’ expectations, (2) child’s engagement with therapy, (3) positive effects of the interventions, (4) challenges, and (5) improving the protocol. Conclusions: Parents from both groups recognized that their expectations related to improving children’s object handling and manipulation skills including participation in activities of daily life were addressed during the 16-week therapy program. Parents perceived a change in the children’s level of independence in their daily tasks at home, school, and leisure activities. Trial Registration: ClinicalTrials.gov NCT02728375; https://clinicaltrials.gov/ct2/show/NCT02728375 %M 34057424 %R 10.2196/24337 %U https://rehab.jmir.org/2021/2/e24337 %U https://doi.org/10.2196/24337 %U http://www.ncbi.nlm.nih.gov/pubmed/34057424 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 2 %P e28210 %T Examining the Feasibility of Early Mobilization With Virtual Reality Gaming Using Head-Mounted Display and Adaptive Software With Adolescents in the Pediatric Intensive Care Unit: Case Report %A Lai,Byron %A Powell,Maegen %A Clement,Anne Grace %A Davis,Drew %A Swanson-Kimani,Erin %A Hayes,Leslie %+ Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 2056389790 ext 8 9725, byronlai@uab.edu %K physical activity %K active video gaming %K exergaming %K early mobility %K rehabilitation %D 2021 %7 27.5.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Early rehabilitative mobilization for adolescents is safe and feasible. However, there is a lack of published rehabilitation strategies and treatments that can maximize engagement and outcomes among adolescents in the pediatric intensive care unit (PICU). Virtual reality (VR) gaming using a head-mounted display (HMD) and adaptive software can allow active and nonactive gameplay at the bedside for people with limited arm mobility, making it a potentially inclusive and enjoyable treatment modality for adolescents in the PICU. Objective: The purpose of this brief case study is to report on the preliminary feasibility of incorporating adaptive VR gaming using an HMD with 2 adolescents who received early mobility treatment within the PICU. Methods: This study was a mini-ethnographic investigation of 2 adolescents (a 15-year-old male and a 13-year old male) in the PICU who underwent VR gaming sessions as part of their early mobilization care, using an Oculus Rift HMD and adaptive software (WalkinVR) that promoted full gameplay in bed. The Rift was plugged into a gaming laptop that was set up on a table within the patient’s room before each session. The intervention was delivered by an adapted exercise professional and supervised by a physical therapist. Patients had access to a variety of active games (eg, boxing, rhythmic movement to music, and exploratory adventure) and nonactive games (eg, racing and narrative adventure). Gaming sessions were scheduled between usual care, when tolerable and requested by the participant. The interventionist and therapists took audio-recorded and written notes after completing each gaming session. These data were analyzed and presented in a narrative format from the perspective of the research team. Results: Case 1 participated in 4 gaming sessions, with an average of 18 minutes (SD 11) per session. Case 2 participated in 2 sessions, with an average of 35 minutes (SD 7) per session. Both cases were capable of performing active gaming at a moderate level of exercise intensity, as indicated by their heart rate. However, their health and symptoms fluctuated on a daily basis, which prompted the gameplay of adventure or nonactive games. Gameplay appeared to improve participants’ affect and alertness and motivate them to be more engaged in early mobilization therapy. Gameplay without the WalkinVR software caused several usability issues. There were no serious adverse events, but both cases experienced symptoms based on their condition. Conclusions: The findings of this study suggest that VR gaming with HMDs and adaptive software is likely a feasible supplement to usual care for adolescents within the PICU, and these findings warrant further investigation. Recommendations for future studies aimed at incorporating VR gaming during early mobilization are presented herein. %M 34042602 %R 10.2196/28210 %U https://rehab.jmir.org/2021/2/e28210 %U https://doi.org/10.2196/28210 %U http://www.ncbi.nlm.nih.gov/pubmed/34042602 %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 %@ 2369-3762 %I JMIR Publications %V 7 %N 2 %P e22992 %T Using a Web-Based Quiz Game as a Tool to Summarize Essential Content in Medical School Classes: Retrospective Comparative Study %A Yuenyongviwat,Varah %A Bvonpanttarananon,Jongdee %+ Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Hatyai, 90110, Thailand, 66 74451601, varahortho@gmail.com %K medical education %K medical students %K computer games %K gaming %K web-based %K interface %K perception %K retrospective %D 2021 %7 29.4.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: Kahoot! is a web-based technology quiz game in which teachers can design their own quizzes via provided game templates. The advantages of these games are their attractive interfaces, which contain stimulating music, moving pictures, and colorful, animated shapes to maintain students’ attentiveness while they perform the quizzes. Objective: The aim of this study was to evaluate the use of Kahoot! compared with a traditional teaching approach as a tool to summarize the essential content of a medical school class in the aspects of final examination scores and the perception of students regarding aspects of their learning environment and of process management. Methods: This study used an interrupted time series design, and retrospective data were collected from 85 medical students. Of these 85 students, 43 completed a Kahoot! quiz, while 42 students completed a paper quiz. All students attended a lecture on the topic of bone and joint infection and participated in a short case discussion. Students from both groups received the same content and study material, with the exception that at the end of the lesson, students in the Kahoot! group completed a quiz summarizing the essential content from the lecture, whereas the other group received a paper quiz with the same questions and the teacher provided an explanation after the students had finished. The students’ satisfaction was evaluated after the class, and their final examination was held 2 weeks after the class. Results: The mean final examination score in the Kahoot! group was 62.84 (SD 8.79), compared to 60.81 (SD 9.25) in the control group (P=.30). The students’ satisfaction with the class environment, learning process management, and teacher were not significantly different between the 2 groups (all P>.05). Conclusions: In this study, it was found that using Kahoot! as a tool to summarize the essential content in medical school classes involving a lecture and case discussion did not affect the students’ final examination scores or their satisfaction with the class environment, learning process management, or teacher. %M 33913813 %R 10.2196/22992 %U https://mededu.jmir.org/2021/2/e22992 %U https://doi.org/10.2196/22992 %U http://www.ncbi.nlm.nih.gov/pubmed/33913813 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e27290 %T Impact of Gamification on the Self-Efficacy and Motivation to Quit of Smokers: Observational Study of Two Gamified Smoking Cessation Mobile Apps %A Rajani,Nikita B %A Mastellos,Nikolaos %A Filippidis,Filippos T %+ Department of Primary Care and Public Health, Imperial College London, School of Public Health, St. Dunstan's Road, London, W6 8RP, United Kingdom, 44 7427615928, nikita.rajani14@imperial.ac.uk %K gamification %K smoking cessation %K mobile applications %K self-efficacy %K motivation to quit %K mHealth %K mobile phone %D 2021 %7 27.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The proportion of smokers making quit attempts and the proportion of smokers successfully quitting have been decreasing over the past few years. Previous studies have shown that smokers with high self-efficacy and motivation to quit have an increased likelihood of quitting and staying quit. Consequently, further research on strategies that can improve the self-efficacy and motivation of smokers seeking to quit could lead to substantially higher cessation rates. Some studies have found that gamification can positively impact the cognitive components of behavioral change, including self-efficacy and motivation. However, the impact of gamification in the context of smoking cessation and mobile health has been sparsely investigated. Objective: This study aims to examine the association between perceived usefulness, perceived ease of use, and frequency of use of gamification features embedded in smoking cessation apps on self-efficacy and motivation to quit smoking. Methods: Participants were assigned to use 1 of the 2 mobile apps for a duration of 4 weeks. App-based questionnaires were provided to participants before app use and 2 weeks and 4 weeks after they started using the app. Gamification was quantitatively operationalized based on the Cugelman gamification framework and concepts from the technology acceptance model. The mean values of perceived frequency, ease of use, and usefulness of gamification features were calculated at midstudy and end-study. Two linear regression models were used to investigate the impact of gamification on self-efficacy and motivation to quit. Results: A total of 116 participants completed the study. The mean self-efficacy increased from 37.38 (SD 13.3) to 42.47 (SD 11.5) points and motivation to quit increased from 5.94 (SD 1.4) to 6.32 (SD 1.7) points after app use. Goal setting was perceived to be the most useful gamification feature, whereas sharing was perceived to be the least useful. Participants self-reported that they used the progress dashboards the most often, whereas they used the sharing feature the least often. The average perceived frequency of gamification features was statistically significantly associated with change in self-efficacy (β=3.35; 95% CI 0.31-6.40) and change in motivation to quit (β=.54; 95% CI 0.15-0.94) between baseline and end-study. Conclusions: Gamification embedded in mobile apps can have positive effects on self-efficacy and motivation to quit smoking. The findings of this study can provide important insights for tobacco control policy makers, mobile app developers, and smokers seeking to quit. %M 33904824 %R 10.2196/27290 %U https://games.jmir.org/2021/2/e27290 %U https://doi.org/10.2196/27290 %U http://www.ncbi.nlm.nih.gov/pubmed/33904824 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e24237 %T Assessing Children’s Fine Motor Skills With Sensor-Augmented Toys: Machine Learning Approach %A Brons,Annette %A de Schipper,Antoine %A Mironcika,Svetlana %A Toussaint,Huub %A Schouten,Ben %A Bakkes,Sander %A Kröse,Ben %+ Digital Life Center, Amsterdam University of Applied Sciences, Wibautstraat 2-4, Amsterdam, 1091 GM, Netherlands, 31 621156976, a.e.brons@hva.nl %K motor development %K fine motor function %K gamification %K playful %K motor skill assessment %K Movement ABC (MABC) %K machine learning %K motor function %K motor skills %K toys %K children %K game %K movement assessment %D 2021 %7 22.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Approximately 5%-10% of elementary school children show delayed development of fine motor skills. To address these problems, detection is required. Current assessment tools are time-consuming, require a trained supervisor, and are not motivating for children. Sensor-augmented toys and machine learning have been presented as possible solutions to address this problem. Objective: This study examines whether sensor-augmented toys can be used to assess children’s fine motor skills. The objectives were to (1) predict the outcome of the fine motor skill part of the Movement Assessment Battery for Children Second Edition (fine MABC-2) and (2) study the influence of the classification model, game, type of data, and level of difficulty of the game on the prediction. Methods: Children in elementary school (n=95, age 7.8 [SD 0.7] years) performed the fine MABC-2 and played 2 games with a sensor-augmented toy called “Futuro Cube.” The game “roadrunner” focused on speed while the game “maze” focused on precision. Each game had several levels of difficulty. While playing, both sensor and game data were collected. Four supervised machine learning classifiers were trained with these data to predict the fine MABC-2 outcome: k-nearest neighbor (KNN), logistic regression (LR), decision tree (DT), and support vector machine (SVM). First, we compared the performances of the games and classifiers. Subsequently, we compared the levels of difficulty and types of data for the classifier and game that performed best on accuracy and F1 score. For all statistical tests, we used α=.05. Results: The highest achieved mean accuracy (0.76) was achieved with the DT classifier that was trained on both sensor and game data obtained from playing the easiest and the hardest level of the roadrunner game. Significant differences in performance were found in the accuracy scores between data obtained from the roadrunner and maze games (DT, P=.03; KNN, P=.01; LR, P=.02; SVM, P=.04). No significant differences in performance were found in the accuracy scores between the best performing classifier and the other 3 classifiers for both the roadrunner game (DT vs KNN, P=.42; DT vs LR, P=.35; DT vs SVM, P=.08) and the maze game (DT vs KNN, P=.15; DT vs LR, P=.62; DT vs SVM, P=.26). The accuracy of only the best performing level of difficulty (combination of the easiest and hardest level) achieved with the DT classifier trained with sensor and game data obtained from the roadrunner game was significantly better than the combination of the easiest and middle level (P=.046). Conclusions: The results of our study show that sensor-augmented toys can efficiently predict the fine MABC-2 scores for children in elementary school. Selecting the game type (focusing on speed or precision) and data type (sensor or game data) is more important for determining the performance than selecting the machine learning classifier or level of difficulty. %M 33885371 %R 10.2196/24237 %U https://www.jmir.org/2021/4/e24237 %U https://doi.org/10.2196/24237 %U http://www.ncbi.nlm.nih.gov/pubmed/33885371 %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 %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e25504 %T “Doc McStuffins: Doctor for a Day” Virtual Reality (DocVR) for Pediatric Preoperative Anxiety and Satisfaction: Pediatric Medical Technology Feasibility Study %A Gold,Jeffrey I %A Annick,Erin T %A Lane,Arianna S %A Ho,Katherine %A Marty,Ryan T %A Espinoza,Juan C %+ Department of Anesthesiology Critical Care Medicine, The Saban Research Institute, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, United States, 1 13233616341, JGold@chla.usc.edu %K virtual reality (VR) %K pediatric %K anxiety %K preoperative %K satisfaction %K Doc McStuffins %D 2021 %7 19.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Preoperative anxiety is a common occurrence among children and is associated with a host of maladaptive postoperative behaviors. Consequently, increased attention has been placed on interventions to reduce preoperative anxiety and its associated outcomes. Child Life preparation prior to surgery includes evidence-based practices such as age-appropriate distraction and therapeutic play. Virtual reality (VR) is a promising addition to the Child Life toolbox to address anxiety prior to surgery. The current study evaluates the implementation and feasibility of a VR experience, “Doc McStuffins: Doctor for a Day Virtual Reality Experience” (DocVR), developed by Disney Junior in collaboration with Children’s Hospital Los Angeles, to target pediatric preoperative anxiety. Objective: The primary aim of this study was to examine the feasibility and efficacy of DocVR for preoperative anxiety. A secondary aim was to improve patient, caregiver, and health care provider satisfaction with the preoperative experience. Methods: In this study, 51 patients (age 6-14 years) scheduled for surgery in the ambulatory surgery center and the main operating room at Children’s Hospital Los Angeles were approached to participate in Disney’s DocVR experience. The patients played the DocVR experience for an average of 18 minutes (3-55 minutes). Irrespective of surgical procedure, patients and their families were eligible, as long as they had no known marked cognitive or visual impairments that would interfere with completing the survey and engaging in the DocVR experience. Results: Patients who tried the DocVR experience (n=51) responded overwhelmingly positively to both the VR technology and to the game itself. Patients experienced a statistically significant decrease in anxiety following DocVR game play (Z=–3.26, P=.001). On the Facial Affective Scale, the percentage of patients who chose the face with the most positive facial expression to represent their affect increased from 23% (12/51) pre-VR to 49% (25/47) post-VR. Furthermore, 97% (38/39) of patients reported feeling more comfortable at the hospital, and 74% (28/38) reported feeling less scared at the hospital after playing the game. The game was enjoyed by 94% (46/49) of patients, and 88% (30/34) of patients reported feeling both “Interested” and “Involved” in the game. Conclusions: DocVR is a feasible and beneficial VR experience to relieve pediatric preoperative anxiety and improve satisfaction in the preoperative area. The VR experience resulted in a decrease in overall anxiety and an increase in overall positive affect during the preoperative time. Patients also responded positively to the game, confirming their interest in the content and affirming the quality of the DocVR experience. The positive response to the game indicates that DocVR has the potential to make the overall preoperative experience less anxiety-producing and more comfortable, which leads to improved patient satisfaction. Naturally, improved patient outcomes lead to improved caregiver and health care provider satisfaction. %M 33730687 %R 10.2196/25504 %U https://www.jmir.org/2021/4/e25504 %U https://doi.org/10.2196/25504 %U http://www.ncbi.nlm.nih.gov/pubmed/33730687 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e24647 %T A Gamified, Social Media–Inspired, Web-Based Personalized Normative Feedback Alcohol Intervention for Lesbian, Bisexual, and Queer-Identified Women: Protocol for a Hybrid Trial %A Boyle,Sarah C %A LaBrie,Joseph W %+ HeadsUp Labs, Department of Psychology, Loyola Marymount University, 1 LMU Drive, Suite 3787, Los Angeles, CA, 90045, United States, 1 8182909940, sarah.boyle@lmu.edu %K sexual minority women %K alcohol %K intervention %K social norms %K gamification %K protocol %K mobile phone %D 2021 %7 16.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Sexual minority women are more likely to drink alcohol, engage in heavy drinking, and experience alcohol-related problems than heterosexual women. However, culturally tailored interventions for this population have been slow to emerge. Objective: This type 1 effectiveness-implementation trial examines the feasibility and efficacy of a gamified, culturally tailored, personalized normative feedback (PNF) alcohol intervention for sexual minority women who psychologically identify as lesbian, bisexual, or queer (LBQ). Methods: The core components of a PNF intervention were delivered within LezParlay, a fun, social media–inspired, digital competition designed to challenge negative stereotypes about LBQ women and increase visibility. The competition was advertised on the web through social media platforms and collaboration with LBQ community organizations. After 2 rounds of play by a large cohort of LBQ women, a subsample of 500 drinkers already taking part in the competition were invited to participate in the evaluation study. Study participants were randomized to receive 1 of 3 unique sequences of PNF (ie, alcohol and stigma coping, alcohol and control, or control topics only) over 2 intervention rounds. Randomization was fully automated by the web app, and both researchers and participants were blinded. Results: Analyses will evaluate whether PNF on alcohol use reduces participants’ drinking and negative consequences at 2 and 4 months postintervention; examine whether providing PNF on stigma-coping behaviors, in addition to alcohol use, further reduces alcohol use and consequences beyond PNF on alcohol alone; identify mediators and moderators of intervention efficacy; and examine broader LezParlay app engagement, acceptability, and perceived benefits. Conclusions: This incognito intervention approach is uniquely oriented toward engaging and preventing alcohol-related risks among community populations of LBQ women who may view their heavy drinking as normative and not in need of change because of the visibility of alcohol use in sexual minority community spaces. Thus, this intervention strategy diverges from, and is intended to complement, more intensive programs being developed to meet the needs of LBQ women already motivated to reduce their consumption. Trial Registration: ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478 International Registered Report Identifier (IRRID): DERR1-10.2196/24647 %M 33861212 %R 10.2196/24647 %U https://www.researchprotocols.org/2021/4/e24647 %U https://doi.org/10.2196/24647 %U http://www.ncbi.nlm.nih.gov/pubmed/33861212 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e24998 %T Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study %A Langlet,Billy Sundström %A Odegi,Dorothy %A Zandian,Modjtaba %A Nolstam,Jenny %A Södersten,Per %A Bergh,Cecilia %+ Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Hälsovägen 7, 3rd floor, Stockholm, 141 52, Sweden, 46 852488034, billy.langlet@ki.se %K feeding and eating disorders %K anorexia nervosa %K bulimia nervosa %K binge eating disorder %K immersive virtual reality %K eating disorders %K virtual reality %D 2021 %7 13.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall “good” rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the “accuracy” item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. %M 33847593 %R 10.2196/24998 %U https://games.jmir.org/2021/2/e24998 %U https://doi.org/10.2196/24998 %U http://www.ncbi.nlm.nih.gov/pubmed/33847593 %0 Journal Article %@ 2563-6316 %I JMIR Publications %V 2 %N 2 %P e20461 %T A Physical Activity Mobile Game for Hematopoietic Stem Cell Transplant Patients: App Design, Development, and Evaluation %A Cerbas,Shannon %A Kelemen,Arpad %A Liang,Yulan %A Sik-Lanyi,Cecilia %A Van de Castle,Barbara %+ University of Maryland, Baltimore, 655 W Lombard St, Baltimore, MD, 21201, United States, 1 410 706 4812, liang@umaryland.edu %K cancer %K mobile app %K gamification %K bone marrow transplant %K alpha testing %K physical activity %D 2021 %7 13.4.2021 %9 Original Paper %J JMIRx Med %G English %X Background: Physical activity mobile apps may encourage patients with cancer to increase exercise uptake, consequently decreasing cancer-related fatigue. While many fitness apps are currently available for download, most are not suitable for patients with cancer due to the unique barriers these patients face, such as fatigue, pain, and nausea. Objective: The aim of this study is to design, develop, and perform alpha testing of a physical activity mobile health game for hematopoietic stem cell transplant (HSCT) patients. The ultimate future goal of this project is to motivate HSCT patients to increase physical activity and provide them with a safe and fun way to exercise. Methods: A mobile health game called Walking Warrior was designed as a puzzle game where tiles are moved and matched. Walking Warrior interfaces with an open-source step counter and communicates with a central online MySQL database to record game play and walking performance. The game came to fruition after following an iterative process model with several prototypes. Game developers and bone marrow transplant nurses were recruited to perform an expert usability evaluation of the Walking Warrior prototype by completing a heuristic questionnaire and providing qualitative suggestions for improvement. Experts also made qualitative recommendations for improvements on speed, movement of tiles, appearance, and accuracy of the step counter. We recruited 5 additional usability evaluators who searched for and compared 4 open-source step counter programs, then qualitatively compared them for accuracy, robustness, cheat proofing, ease of use, and battery drain issues. Patient recruitment is planned at a later stage in this project. This paper only describes software design, development, and evaluation, rather than behavioral evaluation (ie, impact on physical activity), which is the long-term goal of this project. Results: Internal consistency and the instrument’s reliability evaluation results from 1 clinical expert and 4 technical experts were deemed excellent (Cronbach α=.933). A hierarchical cluster analysis of the questionnaire item responses for similarity/dissimilarity among the experts indicated that the two expert groups were not clustered into two separate groups in the dendrogram. This indicates that the item responses were not affected by profession. Factor analyses indicate that responses from the 40-item questionnaire were classified into five primary factors. The associated descriptive statistics for each of these categories were as follows (on a scale of 1 to 5): clarity and ease (median 4; mean 3.7, SD 0.45), appropriateness (median 4; mean 3.7, SD 0.49), game quality (median 3.5; mean 3.3, SD 0.42), motivation to walk (median 3; mean 3.1, SD 0.58), and mental effort (median 3.5; mean 3.1, SD 1.27). Conclusions: The evaluation from experts and clinicians provided qualitative information to further improve game design and development. Findings from the expert usability evaluation suggest the game’s assets of clarity, ease of use, appropriateness, quality, motivation to walk, and mental effort were all favorable. This mobile game could ultimately help patients increase physical activity as an aid to recovery. %M 37725560 %R 10.2196/20461 %U https://xmed.jmir.org/2021/2/e20461 %U https://doi.org/10.2196/20461 %U http://www.ncbi.nlm.nih.gov/pubmed/37725560 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e19875 %T Combining Web-Based Gamification and Physical Nudges With an App (MoveMore) to Promote Walking Breaks and Reduce Sedentary Behavior of Office Workers: Field Study %A Mamede,André %A Noordzij,Gera %A Jongerling,Joran %A Snijders,Merlijn %A Schop-Etman,Astrid %A Denktas,Semiha %+ Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Burgemeester Oudlaan 50, Rotterdam, 3062 PA, Netherlands, 31 10 408 8789, mamedesoaresbraga@essb.eur.nl %K internet %K eHealth %K mHealth %K mobile phone %K lifestyle %K obesity %K social network %K multilevel analysis %K physical exercise %D 2021 %7 12.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Sedentary behavior (SB) and lack of physical activity (PA) have been associated with poorer health outcomes and are increasingly prevalent in individuals working in sedentary occupations such as office jobs. Gamification and nudges have attracted attention as promising strategies to promote changes in health behavior. However, most effectiveness studies thus far lacked active controls, and few studies have tested interventions combining these strategies. Objective: This study investigates the effectiveness of combining a gamified digital app with physical nudges to increase PA and reduce SB in Dutch office workers. Methods: Employees in the municipality of Rotterdam (N=298) from two office locations were randomized at the location level to either a 10-week intervention, combining a 5-week gamification phase encompassing a gamified digital app with social support features and a 5-week physical nudges phase, or to an active control (ie, basic digital app with self-monitoring and goal setting). The primary outcome was the daily step count, objectively measured via accelerometers. Secondary outcomes were self-reported PA and SB measured at baseline and at 5, 10, and 14 weeks. Mixed effects models were used to analyze the effects of the intervention on the outcome measures. Results: A total of 78.5% (234/298) of participants completed the study and provided accelerometer data, whereas 36.9% (110/298) participants completed the self-report measures at 14 weeks. In the gamification phase, step count data were missing for 13.5% (473/3492) of observations in the control and 11.4% (445/3888) in the intervention condition; however, these percentages increased to 39.6% (1154/2910) and 59.6% (1932/3492) at follow-up, respectively. During the gamification phase, intervention participants increased their number of daily steps by 634 (95% CI 154.2-1113.8; P=.01) more than participants in the control group, after controlling for relevant factors. Improvements were not sustained during the physical nudges phase (P=.76) or follow-up (P=.88). Conclusions: A digital intervention with gamification and social support features significantly increased the step count of office workers compared with an active control. Physical nudges in the workplace were insufficient to promote the maintenance of behavioral changes achieved in the gamification phase. Future research should explore the long-term effectiveness of similar gamified digital interventions. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 49129401; https://www.isrctn.com/ISRCTN14881571 %M 33843593 %R 10.2196/19875 %U https://www.jmir.org/2021/4/e19875 %U https://doi.org/10.2196/19875 %U http://www.ncbi.nlm.nih.gov/pubmed/33843593 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e23635 %T The Current Situation and Future Prospects of Simulators in Dental Education %A Li,Yaning %A Ye,Hongqiang %A Ye,Fan %A Liu,Yunsong %A Lv,Longwei %A Zhang,Ping %A Zhang,Xiao %A Zhou,Yongsheng %+ Department of Prosthodontics, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Avenue, Haidian District, Beijing, 100081, China, 86 010 82195070, kqzhouysh@hsc.pku.edu.cn %K dental simulator %K dental education %K virtual reality %D 2021 %7 8.4.2021 %9 Viewpoint %J J Med Internet Res %G English %X The application of virtual reality has become increasingly extensive as this technology has developed. In dental education, virtual reality is mainly used to assist or replace traditional methods of teaching clinical skills in preclinical training for several subjects, such as endodontics, prosthodontics, periodontics, implantology, and dental surgery. The application of dental simulators in teaching can make up for the deficiency of traditional teaching methods and reduce the teaching burden, improving convenience for both teachers and students. However, because of the technology limitations of virtual reality and force feedback, dental simulators still have many hardware and software disadvantages that have prevented them from being an alternative to traditional dental simulators as a primary skill training method. In the future, when combined with big data, cloud computing, 5G, and deep learning technology, dental simulators will be able to give students individualized learning assistance, and their functions will be more diverse and suitable for preclinical training. The purpose of this review is to provide an overview of current dental simulators on related technologies, advantages and disadvantages, methods of evaluating effectiveness, and future directions for development. %M 33830059 %R 10.2196/23635 %U https://www.jmir.org/2021/4/e23635 %U https://doi.org/10.2196/23635 %U http://www.ncbi.nlm.nih.gov/pubmed/33830059 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e26216 %T How Gameful Experience Affects Public Knowledge, Attitudes, and Practices Regarding COVID-19 Among the Taiwanese Public: Cross-sectional Study %A Peng,Li-Hsun %A Bai,Ming-Han %+ Graduate School of Design, National Yunlin University of Science and Technology, 123 University Road, Section 3, Douliou, Yunlin, 640301, Taiwan, 886 961055900, minghan.bai@gmail.com %K COVID-19 %K knowledge %K attitude %K practice %K serious game %K gameful experience %D 2021 %7 6.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In 2019, with the COVID-19 pandemic sweeping across the globe, public health systems worldwide faced severe challenges. Amid the pandemic, one simulation game, Plague Inc., has received substantial attention. This game has indirectly drawn greater public attention to public health issues by simulating pathogen transmission and disease symptoms. Objective: Against this backdrop, this research investigates whether the gameful experience of Plague Inc. has indirectly affected public knowledge, attitudes, and practices (KAP) regarding COVID-19. Methods: An online survey was conducted through social networking services in Taiwan from May 6-28, 2020. Results: A total of 486 subjects participated in this study, of which 276 (56.8%) had played Plague Inc. This study had several findings. First, participants who had played Plague Inc. demonstrated higher levels of knowledge (P=.03, median 7, IQR 7-8) and attitudes (P=.007, median 8, IQR 7-8) than participants who had not played Plague Inc. (knowledge: median 7, IQR 6-8; attitude: median 7, IQR 6-8). Second, there was a significant correlation between creative thinking (ρ=.127, P=.04) and dominance (ρ=.122, P=.04) in attitude. Finally, there was a significant correlation between creative thinking (ρ=.126, P<.001) and dominance (ρ=.119, P=.049) in practice. Conclusions: Serious games highlighting the theme of pathogen transmission may enhance public knowledge and attitudes regarding COVID-19. Furthermore, the creative thinking and dominance involved in gameful experiences may act as critical factors in public attitudes and practices regarding COVID-19. These findings should be further verified through experimental research in the future. %M 33737262 %R 10.2196/26216 %U https://games.jmir.org/2021/2/e26216 %U https://doi.org/10.2196/26216 %U http://www.ncbi.nlm.nih.gov/pubmed/33737262 %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 %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e27443 %T Impact of a Serious Game (Escape COVID-19) on the Intention to Change COVID-19 Control Practices Among Employees of Long-term Care Facilities: Web-Based Randomized Controlled Trial %A Suppan,Mélanie %A Abbas,Mohamed %A Catho,Gaud %A Stuby,Loric %A Regard,Simon %A Achab,Sophia %A Harbarth,Stephan %A Suppan,Laurent %+ Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, Geneva, 1211, Switzerland, 41 223723311, melanie.suppan@hcuge.ch %K COVID-19 %K transmission %K serious game %K infection prevention %K health care worker %K SARS-CoV-2 %K nursing homes %K randomized controlled trial %K long-term care facilities %K impact %K game %K intention %K control %K elderly %D 2021 %7 25.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Most residents of long-term care facilities (LTCFs) are at high risk of complications and death following SARS-CoV-2 infection. In these facilities, viral transmission can be facilitated by shortages of human and material resources, which can lead to suboptimal application of infection prevention and control (IPC) procedures. To improve the dissemination of COVID-19 IPC guidelines, we developed a serious game called “Escape COVID-19” using Nicholson’s RECIPE for meaningful gamification, as engaging serious games have the potential to induce behavioral change. Objective: As the probability of executing an action is strongly linked to the intention of performing it, the objective of this study was to determine whether LTCF employees were willing to change their IPC practices after playing “Escape COVID-19.” Methods: This was a web-based, triple-blind, randomized controlled trial, which took place between November 5 and December 4, 2020. The health authorities of Geneva, Switzerland, asked the managers of all LTCFs under their jurisdiction to forward information regarding the study to all their employees, regardless of professional status. Participants were unaware that they would be randomly allocated to one of two different study paths upon registration. In the control group, participants filled in a first questionnaire designed to gather demographic data and assess baseline knowledge before accessing regular online IPC guidelines. They then answered a second questionnaire, which assessed their willingness to change their IPC practices and identified the reasons underlying their decision. They were then granted access to the serious game. Conversely, the serious game group played “Escape COVID-19” after answering the first questionnaire but before answering the second one. This group accessed the control material after answering the second set of questions. There was no time limit. The primary outcome was the proportion of LTCF employees willing to change their IPC practices. Secondary outcomes included the factors underlying participants’ decisions, the domains these changes would affect, changes in the use of protective equipment items, and attrition at each stage of the study. Results: A total of 295 answer sets were analyzed. Willingness to change behavior was higher in the serious game group (82% [119/145] versus 56% [84/150]; P<.001), with an odds ratio of 3.86 (95% CI 2.18-6.81; P<.001) after adjusting for professional category and baseline knowledge, using a mixed effects logistic regression model with LTCF as a random effect. For more than two-thirds (142/203) of the participants, the feeling of playing an important role against the epidemic was the most important factor explaining their willingness to change behavior. Most of the participants unwilling to change their behavior answered that they were already applying all the guidelines. Conclusions: The serious game “Escape COVID-19” was more successful than standard IPC material in convincing LTCF employees to adopt COVID-19–safe IPC behavior. International Registered Report Identifier (IRRID): RR2-10.2196/25595 %M 33685854 %R 10.2196/27443 %U https://www.jmir.org/2021/3/e27443 %U https://doi.org/10.2196/27443 %U http://www.ncbi.nlm.nih.gov/pubmed/33685854 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e24652 %T A Virtual Reality Game to Change Sun Protection Behavior and Prevent Cancer: User-Centered Design Approach %A Horsham,Caitlin %A Dutton-Regester,Ken %A Antrobus,Jodie %A Goldston,Andrew %A Price,Harley %A Ford,Helen %A Hacker,Elke %+ School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Brisbane, 4059, Australia, 61 731389674, elke.hacker@qut.edu.au %K virtual reality %K gamification %K primary prevention %K health promotion %K skin cancer %K mobile phone %D 2021 %7 25.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Public health sun safety campaigns introduced during the 1980s have successfully reduced skin cancer rates in Australia. Despite this success, high rates of sunburn continue to be reported by youth and young adults. As such, new strategies to reinforce sun protection approaches in this demographic are needed. Objective: This study aims to develop a virtual reality (VR) game containing preventive skin cancer messaging and to assess the safety and satisfaction of the design based on end user feedback. Methods: Using a two-phase design approach, we created a prototype VR game that immersed the player inside the human body while being confronted with growing cancer cells. The first design phase involved defining the problem, identifying stakeholders, choosing the technology platform, brainstorming, and designing esthetic elements. In the second design phase, we tested the prototype VR experience with stakeholders and end users in focus groups and interviews, with feedback incorporated into refining and improving the design. Results: The focus groups and interviews were conducted with 18 participants. Qualitative feedback indicated high levels of satisfaction, with all participants reporting the VR game as engaging. A total of 11% (2/8) of participants reported a side effect of feeling nauseous during the experience. The end user feedback identified game improvements, suggesting an extended multistage experience with visual transitions to other environments and interactions involving cancer causation. The implementation of the VR game identified challenges in sharing VR equipment and hygiene issues. Conclusions: This study presents key findings highlighting the design and implementation approaches for a VR health intervention primarily aimed at improving sun protection behaviors. This design approach can be applied to other health prevention programs in the future. %M 33764308 %R 10.2196/24652 %U https://games.jmir.org/2021/1/e24652 %U https://doi.org/10.2196/24652 %U http://www.ncbi.nlm.nih.gov/pubmed/33764308 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e26007 %T Game-Based Learning Outcomes Among Physiotherapy Students: Comparative Study %A Molina-Torres,Guadalupe %A Rodriguez-Arrastia,Miguel %A Alarcón,Raquel %A Sánchez-Labraca,Nuria %A Sánchez-Joya,María %A Roman,Pablo %A Requena,Mar %+ Department of Nursing, Physical Therapy and Medicine, University of Almeria, Carretera de Sacramento s/n, Almeria, 04120, Spain, 34 950 21 45 63, pablo.roman@ual.es %K gamification %K board game–based approach %K health sciences %K physiotherapy %K teaching innovation %D 2021 %7 24.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: University teaching methods are changing, and in response to a classical teacher-centered approach, new methods continue to strengthen knowledge acquisition by involving students more actively in their learning, thus achieving greater motivation and commitment. Objective: This study aimed to analyze the degree of satisfaction of physiotherapy students who used a board game–based approach, as well as to compare the difference between traditional and gamification teaching methods and their influence on the final evaluation of these students. Methods: A comparative study was conducted. Participants were physiotherapy students who were enrolled in the subject of “physiotherapy in geriatric and adult psychomotricity” (n=59). They were divided into two groups (experimental [n=29] and control [n=30] groups) through convenience sampling. The experimental group received gamification lessons, where the students performed different tests adapted from Party&Co, and the control group received traditional lessons. A total of 16 theoretical lessons were received in both groups. Results: The scores in the final examination of the subject were higher in the experimental group (mean 7.53, SD 0.95) than in the control group (mean 6.24, SD 1.34), showing a statistically significant difference between the two groups (P=.001). Conclusions: Overall, the “Physiotherapy Party” game not only stimulated learning and motivated students, but also improved learning outcomes among participants, and the improvements were greater than those among students who received traditional teaching. %M 33759800 %R 10.2196/26007 %U https://games.jmir.org/2021/1/e26007 %U https://doi.org/10.2196/26007 %U http://www.ncbi.nlm.nih.gov/pubmed/33759800 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e24170 %T Α Virtual Reality App for Physical and Cognitive Training of Older People With Mild Cognitive Impairment: Mixed Methods Feasibility Study %A Hassandra,Mary %A Galanis,Evangelos %A Hatzigeorgiadis,Antonis %A Goudas,Marios %A Mouzakidis,Christos %A Karathanasi,Eleni Maria %A Petridou,Niki %A Tsolaki,Magda %A Zikas,Paul %A Evangelou,Giannis %A Papagiannakis,George %A Bellis,George %A Kokkotis,Christos %A Panagiotopoulos,Spyridon Rafail %A Giakas,Giannis %A Theodorakis,Yannis %+ School of Physical Education, Sport Science and Dietetics, Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, 42100, Greece, 30 24310 4700, mxasad@uth.gr %K virtual reality %K elderly %K mild cognitive impairment %K combined physical and cognitive function %K dual task %D 2021 %7 24.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Therapeutic virtual reality (VR) has emerged as an effective treatment modality for cognitive and physical training in people with mild cognitive impairment (MCI). However, to replace existing nonpharmaceutical treatment training protocols, VR platforms need significant improvement if they are to appeal to older people with symptoms of cognitive decline and meet their specific needs. Objective: This study aims to design and test the acceptability, usability, and tolerability of an immersive VR platform that allows older people with MCI symptoms to simultaneously practice physical and cognitive skills on a dual task. Methods: On the basis of interviews with 20 older people with MCI symptoms (15 females; mean age 76.25, SD 5.03 years) and inputs from their health care providers (formative study VR1), an interdisciplinary group of experts developed a VR system called VRADA (VR Exercise App for Dementia and Alzheimer’s Patients). Using an identical training protocol, the VRADA system was first tested with a group of 30 university students (16 females; mean age 20.86, SD 1.17 years) and then with 27 older people (19 females; mean age 73.22, SD 9.26 years) who had been diagnosed with MCI (feasibility studies VR2a and VR2b). Those in the latter group attended two Hellenic Association Day Care Centers for Alzheimer’s Disease and Related Disorders. Participants in both groups were asked to perform a dual task training protocol that combined physical and cognitive exercises in two different training conditions. In condition A, participants performed a cycling task in a lab environment while being asked by the researcher to perform oral math calculations (single-digit additions and subtractions). In condition B, participants performed a cycling task in the virtual environment while performing calculations that appeared within the VR app. Participants in both groups were assessed in the same way; this included questionnaires and semistructured interviews immediately after the experiment to capture perceptions of acceptability, usability, and tolerability, and to determine which of the two training conditions each participant preferred. Results: Participants in both groups showed a significant preference for the VR condition (students: mean 0.66, SD 0.41, t29=8.74, P<.001; patients with MCI: mean 0.72, SD 0.51, t26=7.36, P<.001), as well as high acceptance scores for intended future use, attitude toward VR training, and enjoyment. System usability scale scores (82.66 for the students and 77.96 for the older group) were well above the acceptability threshold (75/100). The perceived adverse effects were minimal, indicating a satisfactory tolerability. Conclusions: The findings suggest that VRADA is an acceptable, usable, and tolerable system for physical and cognitive training of older people with MCI and university students. Randomized controlled trial studies are needed to assess the efficacy of VRADA as a tool to promote physical and cognitive health in patients with MCI. %M 33759797 %R 10.2196/24170 %U https://games.jmir.org/2021/1/e24170 %U https://doi.org/10.2196/24170 %U http://www.ncbi.nlm.nih.gov/pubmed/33759797 %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 e24151 %T Application of Eye Tracking in Puzzle Games for Adjunct Cognitive Markers: Pilot Observational Study in Older Adults %A Krebs,Christine %A Falkner,Michael %A Niklaus,Joel %A Persello,Luca %A Klöppel,Stefan %A Nef,Tobias %A Urwyler,Prabitha %+ Gerontechnology & Rehabilitation group, University of Bern, Murtenstrasse 50, Bern, 3008, Switzerland, 41 316327607, prabitha.urwyler@artorg.unibe.ch %K eye tracking %K puzzle games %K aging %K cognitive assessment %K cognition, attention, executive functions, visual search, fixations %D 2021 %7 22.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Recent studies suggest that computerized puzzle games are enjoyable, easy to play, and engage attentional, visuospatial, and executive functions. They may help mediate impairments seen in cognitive decline in addition to being an assessment tool. Eye tracking provides a quantitative and qualitative analysis of gaze, which is highly useful in understanding visual search behavior. Objective: The goal of the research was to test the feasibility of eye tracking during a puzzle game and develop adjunct markers for cognitive performance using eye-tracking metrics. Methods: A desktop version of the Match-3 puzzle game with 15 difficulty levels was developed using Unity 3D (Unity Technologies). The goal of the Match-3 puzzle was to find configurations (target patterns) that could be turned into a row of 3 identical game objects (tiles) by swapping 2 adjacent tiles. Difficulty levels were created by manipulating the puzzle board size (all combinations of width and height from 4 to 8) and the number of unique tiles on the puzzle board (from 4 to 8). Each level consisted of 4 boards (ie, target patterns to match) with one target pattern each. In this study, the desktop version was presented on a laptop computer setup with eye tracking. Healthy older subjects were recruited to play a full set of 15 puzzle levels. A paper-pencil–based assessment battery was administered prior to the Match-3 game. The gaze behavior of all participants was recorded during the game. Correlation analyses were performed on eye-tracking data correcting for age to examine if gaze behavior pertains to target patterns and distractor patterns and changes with puzzle board size (set size). Additionally, correlations between cognitive performance and eye movement metrics were calculated. Results: A total of 13 healthy older subjects (mean age 70.67 [SD 4.75] years; range 63 to 80 years) participated in this study. In total, 3 training and 12 test levels were played by the participants. Eye tracking recorded 672 fixations in total, 525 fixations on distractor patterns and 99 fixations on target patterns. Significant correlations were found between executive functions (Trail Making Test B) and number of fixations on distractor patterns (P=.01) and average fixations (P=.005). Conclusions: Overall, this study shows that eye tracking in puzzle games can act as a supplemental source of data for cognitive performance. The relationship between a paper-pencil test for executive functions and fixations confirms that both are related to the same cognitive processes. Therefore, eye movement metrics might be used as an adjunct marker for cognitive abilities like executive functions. However, further research is needed to evaluate the potential of the various eye movement metrics in combination with puzzle games as visual search and attentional marker. %M 33749607 %R 10.2196/24151 %U https://games.jmir.org/2021/1/e24151 %U https://doi.org/10.2196/24151 %U http://www.ncbi.nlm.nih.gov/pubmed/33749607 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e25063 %T Preserved Inhibitory Control Deficits of Overweight Participants in a Gamified Stop-Signal Task: Experimental Study of Validity %A Schroeder,Philipp Alexander %A Lohmann,Johannes %A Ninaus,Manuel %+ Department of Psychology, Clinical Psychology and Psychotherapy, University of Tübingen, Schleichstr 4, Tübingen, , Germany, 49 07071 297 7435, philipp.schroeder@uni-tuebingen.de %K gamification %K inhibitory control %K response inhibition %K overweight %K BMI %K stop-signal task %K mental health %K games %K overweight %D 2021 %7 12.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification in mental health could increase training adherence, motivation, and transfer effects, but the external validity of gamified tasks is unclear. This study documents that gamified task variants can show preserved associations between markers of behavioral deficits and health-related variables. We draw on the inhibitory control deficit in overweight populations to investigate effects of gamification on performance measures in a web-based experimental task. Objective: This study tested whether associations between inhibitory control and overweight were preserved in a gamified stop-signal task (SST). Methods: Two versions of an adaptive SST were developed and tested in an online experiment. Participants (n=111) were randomized to 1 of the 2 task variants and completed a series of questionnaires along with either the gamified SST or a conventional SST. To maximize its possible effects on participants’ inhibitory control, the gamified SST included multiple game elements in addition to the task itself and the stimuli. Both variants drew on the identical core mechanics, but the gamified variant included an additional narrative, graphical theme, scoring system with visual and emotional feedback, and the presence of a companion character. In both tasks, food and neutral low-poly stimuli were classified based on their color tone (go trials), but responses were withheld in 25% of the trials (stop trials). Mean go reaction times and stop-signal reaction times (SSRT) were analyzed as measures of performance and inhibitory control. Results: Participants in the gamified SST had longer reaction times (803 [SD 179] ms vs 607 [SD 90] ms) and worse inhibitory control (SSRT 383 [SD 109] ms vs 297 [SD 45] ms). The association of BMI with inhibitory control was relatively small (r=.155, 95% CI .013-.290). Overweight participants had longer reaction times (752 [SD 217] ms vs 672 [SD 137] ms) and SSRTs (363 [SD 116] ms vs 326 [SD 77] ms). Gamification did not interact with the effect of overweight on mean performance or inhibitory control. There were no effects of gamification on mood and user experience, despite a negative effect on perceived efficiency. Conclusions: The detrimental effects of heightened BMI on inhibitory control were preserved in a gamified version of the SST. Overall, the effects of overweight were smaller than in previously published web-based and laboratory studies. Gamification elements can impact behavioral performance, but gamified tasks can still assess inhibitory control deficits. Although our results are promising, according validations may differ for other types of behavior, gamification, and health variables. %M 33709936 %R 10.2196/25063 %U https://games.jmir.org/2021/1/e25063 %U https://doi.org/10.2196/25063 %U http://www.ncbi.nlm.nih.gov/pubmed/33709936 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e22370 %T Exergaming Platform for Older Adults Residing in Long-Term Care Homes: User-Centered Design, Development, and Usability Study %A Chu,Charlene H %A Biss,Renée K %A Cooper,Lara %A Quan,Amanda My Linh %A Matulis,Henrique %+ Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada, 1 416 946 0217, charlene.chu@utoronto.ca %K user-centered design %K aged %K long-term care %K nursing homes %D 2021 %7 9.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Older adults (OAs) residing in long-term care (LTC) homes are often unable to engage in adequate amounts of physical activity because of multiple comorbidities, including frailty and severe cognitive impairments. This level of physical inactivity is associated with declines in cognitive and functional abilities and can be further compounded by social isolation. Exergaming, defined as a combination of exercise and gaming, has the potential to engage OAs in exercise and encourage social interaction. However, previously used systems such as the Nintendo Wii are no longer commercially available, and the physical design of other exergames is not suitable for OAs (ie, fall risks, accessibility issues, and games geared toward a younger population) with diverse physical and cognitive impairments. Objective: This study aims to design and develop a novel, user-centered, evidence-based exergaming system for use among OAs in LTC homes. In addition, we aim to identify facilitators and barriers to the implementation of our exergaming intervention, the MouvMat, into LTC homes according to staff input. Methods: This study used a user-centered design (UCD) process that consisted of 4 rounds of usability testing. The exergame was developed and finalized based on existing evidence, end user and stakeholder input, and user testing. Semistructured interviews and standardized and validated scales were used iteratively to evaluate the acceptability, usability, and physical activity enjoyment of the MouvMat. Results: A total of 28 participants, 13 LTC residents, and 15 staff and family members participated in the UCD process for over 18 months to design and develop the novel exergaming intervention, the MouvMat. The iterative use of validated scales (System Usability Scale, 8-item Physical Activity Enjoyment Scale, and modified Treatment Evaluation Inventory) indicated an upward trend in the acceptability, usability, and enjoyment scores of MouvMat over 4 rounds of usability testing, suggesting that identified areas for refinement and improvement were appropriately addressed by the team. A qualitative analysis of semistructured interview data found that residents enjoyed engaging with the prototype and appreciated the opportunity to increase their PA. In addition, staff and stakeholders were drawn to MouvMat’s ability to increase residents’ autonomous PA. The intended and perceived benefits of MouvMat use, that is, improved physical and cognitive health, were the most common facilitators of its use identified by study participants. Conclusions: This study was successful in applying UCD to collaborate with LTC residents, despite the high number of physical and sensory impairments that this population experiences. By following a UCD process, an exergaming intervention that meets diverse requirements (ie, hardware design features and motivation) and considers environmental barriers and residents’ physical and cognitive needs was developed. The effectiveness of MouvMat in improving physical and cognitive abilities should be explored in future multisite randomized controlled trials. %M 33687337 %R 10.2196/22370 %U https://games.jmir.org/2021/1/e22370 %U https://doi.org/10.2196/22370 %U http://www.ncbi.nlm.nih.gov/pubmed/33687337 %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 %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e18161 %T A Virtual Reality Exergame to Engage Adolescents in Physical Activity: Mixed Methods Study Describing the Formative Intervention Development Process %A Farič,Nuša %A Smith,Lee %A Hon,Adrian %A Potts,Henry W W %A Newby,Katie %A Steptoe,Andrew %A Fisher,Abi %+ Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 207 7679 4466 ext 419, nusa.faric.11@ucl.ac.uk %K adolescent %K adult %K exercise %K leisure activities %K obesity %K sports %K video games %K mobile phone %K virtual reality %K motivation %D 2021 %7 4.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Early adolescence (13-17 years) is a critical developmental stage for physical activity promotion. Virtual reality (VR) exergaming is a promising intervention strategy to engage adolescents in physical activity. Objective: The vEngage project aims to develop a physical activity intervention for adolescents using VR exergaming. Here, we describe the formative intervention development work and process of academic-industry collaboration. Methods: The formative development was guided by the Medical Research Council framework and included recruiting an adolescent user group to provide iterative feedback, a literature review, a quantitative survey of adolescents, qualitative interviews with adolescents and parents, inductive thematic analysis of public reviews of VR exergames, a quantitative survey and qualitative interviews with users of the augmented reality running app Zombies, Run!, and building and testing a prototype with our adolescent user group. Results: VR exergaming was appealing to adolescents and acceptable to parents. We identified behavior change techniques that users would engage with and features that should be incorporated into a VR exergame, including realistic body movements, accurate graphics, stepped levels of gameplay difficulty, new challenges, in-game rewards, multiplayer options, and the potential to link with real-world aspects such as physical activity trackers. We also identified some potential barriers to use, such as cost, perceived discomfort of VR headsets, and motion sickness concerns. A prototype game was developed and user-tested with generally positive feedback. Conclusions: This is the first attempt to develop a VR exergame designed to engage adolescents in physical activity that has been developed within a public health intervention development framework. Our formative work suggests that this is a very promising avenue. The benefit of the design process was the collaborative parallel work between academics and game designers and the involvement of the target population in the game (intervention) design from the outset. Developing the game within an intervention framework allowed us to consider factors, such as parental support, that would be important for future implementation. This study also serves as a call to action for potential collaborators who may wish to join this endeavor for future phases and an example of how academic-industry collaboration can be successful and beneficial. %M 33538697 %R 10.2196/18161 %U http://www.jmir.org/2021/2/e18161/ %U https://doi.org/10.2196/18161 %U http://www.ncbi.nlm.nih.gov/pubmed/33538697 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e23710 %T Perception of Game-Based Rehabilitation in Upper Limb Prosthetic Training: Survey of Users and Researchers %A Garske,Christian Alexander %A Dyson,Matthew %A Dupan,Sigrid %A Nazarpour,Kianoush %+ Intelligent Sensing Laboratory, School of Engineering, Newcastle University, Merz Court, Newcastle upon Tyne, NE1 7RU, United Kingdom, 44 191 20 86682, c.a.garske2@ncl.ac.uk %K upper limb %K rehabilitation %K arm prosthesis %K serious games %K engagement %K transfer %D 2021 %7 1.2.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have been investigated for their use in multiple forms of rehabilitation for decades. The rising trend to use games for physical fitness in more recent years has also provided more options and garnered more interest for their use in physical rehabilitation and motor learning. In this study, we report the results of an opinion survey of serious games in upper limb prosthetic training. Objective: This study investigates and contrasts the expectations and preferences for game-based prosthetic rehabilitation of people with limb difference and researchers. Methods: Both participant groups answered open and closed questions as well as a questionnaire to assess their user types. The distribution of the user types was compared with a Pearson chi-square test against a sample population. The data were analyzed using the thematic framework method; answers fell within the themes of usability, training, and game design. Researchers shared their views on current challenges and what could be done to tackle these. Results: A total of 14 people with limb difference and 12 researchers participated in this survey. The open questions resulted in an overview of the different views on prosthetic training games between the groups. The user types of people with limb difference and researchers were both significantly different from the sample population, with χ25=12.3 and χ25=26.5, respectively. Conclusions: We found that the respondents not only showed a general willingness and tentative optimism toward the topic but also acknowledged hurdles limiting the adoption of these games by both clinics and users. The results indicate a noteworthy difference between researchers and people with limb difference in their game preferences, which could lead to design choices that do not represent the target audience. Furthermore, focus on long-term in-home experiments is expected to shed more light on the validity of games in upper limb prosthetic rehabilitation. %M 33522975 %R 10.2196/23710 %U http://games.jmir.org/2021/1/e23710/ %U https://doi.org/10.2196/23710 %U http://www.ncbi.nlm.nih.gov/pubmed/33522975 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e25052 %T Validation of a Portable Game Controller to Assess Peak Expiratory Flow Against Conventional Spirometry in Children: Cross-sectional Study %A Chelabi,Khadidja %A Balli,Fabio %A Bransi,Myriam %A Gervais,Yannick %A Marthe,Clement %A Tse,Sze Man %+ Division of Respiratory Medicine, Department of Pediatrics, Sainte-Justine University Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada, 1 (514) 345 4931 ext 5409, sze.man.tse@umontreal.ca %K asthma %K pediatrics %K serious game %K peak expiratory flow %K pulmonary function test, adherence, self-management %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: International asthma guidelines recommend the monitoring of peak expiratory flow (PEF) as part of asthma self-management in children and adolescents who poorly perceive airflow obstruction, those with a history of severe exacerbations, or those who have difficulty controlling asthma. Measured with a peak flow meter, PEF represents a person’s maximum speed of expiration and helps individuals to follow their disease evolution and, ultimately, to prevent asthma exacerbations. However, patient adherence to regular peak flow meter use is poor, particularly in pediatric populations. To address this, we developed an interactive tablet-based game with a portable game controller that can transduce a signal from the user’s breath to generate a PEF value. Objective: The purpose of this study was to evaluate the concordance between PEF values obtained with the game controller and various measures derived from conventional pulmonary function tests (ie, spirometry) and to synthesize the participants’ feedback. Methods: In this cross-sectional multicenter study, 158 children (aged 8-15 years old) with a diagnosis or suspicion of asthma performed spirometry and played the game in one of two hospital university centers. We evaluated the correlation between PEF measured by both the game controller and spirometry, forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25%-75% of pulmonary volume (FEF25-75), using Spearman correlation. A Bland-Altman plot was generated for comparison of PEF measured by the game controller against PEF measured by spirometry. A post-game user feedback questionnaire was administered and analyzed. Results: The participants had a mean age of 10.9 (SD 2.5) years, 44% (71/158) were female, and 88% (139/158) were White. On average, the pulmonary function of the participants was normal, including FEV1, PEF, and FEV1/forced vital capacity (FVC). The PEF measured by the game controller was reproducible in 96.2% (152/158) of participants according to standardized criteria. The PEF measured by the game controller presented a good correlation with PEF measured by spirometry (r=0.83, P<.001), with FEV1 (r=0.74, P<.001), and with FEF25-75 (r=0.65, P<.001). The PEF measured by the game controller presented an expected mean bias of –36.4 L/min as compared to PEF measured by spirometry. The participants’ feedback was strongly positive, with 78.3% (123/157) reporting they would use the game if they had it at home. Conclusions: The game controller we developed is an interactive tool appreciated by children with asthma, and the PEF values measured by the game controller are reproducible, with a good correlation to values measured by conventional spirometry. Future studies are necessary to evaluate the clinical impact this novel tool might have on asthma management and its potential use in an out-of-hospital setting. %M 33512326 %R 10.2196/25052 %U http://games.jmir.org/2021/1/e25052/ %U https://doi.org/10.2196/25052 %U http://www.ncbi.nlm.nih.gov/pubmed/33512326 %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 %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e24356 %T Application of an Adaptive, Digital, Game-Based Approach for Cognitive Assessment in Multiple Sclerosis: Observational Study %A Hsu,Wan-Yu %A Rowles,William %A Anguera,Joaquin A %A Zhao,Chao %A Anderson,Annika %A Alexander,Amber %A Sacco,Simone %A Henry,Roland %A Gazzaley,Adam %A Bove,Riley %+ Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, United States, 1 415 595 2795, riley.bove@ucsf.edu %K cognition %K digital health %K mHealth %K multiple sclerosis %K cognitive assessment %K video game %D 2021 %7 20.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive impairment is one of the most debilitating manifestations of multiple sclerosis. Currently, the assessment of cognition relies on a time-consuming and extensive neuropsychological examination, which is only available in some centers. Objective: To enable simpler, more accessible cognitive screening, we sought to determine the feasibility and potential assessment sensitivity of an unsupervised, adaptive, video game–based digital therapeutic to assess cognition in multiple sclerosis. Methods: A total of 100 people with multiple sclerosis (33 with cognitive impairment and 67 without cognitive impairment) and 24 adults without multiple sclerosis were tested with the tablet game (EVO Monitor) and standard measures, including the Brief International Cognitive Assessment for Multiple Sclerosis (which included the Symbol Digit Modalities Test [SDMT]) and Multiple Sclerosis Functional Composite 4 (which included the Timed 25-Foot Walk test). Patients with multiple sclerosis also underwent neurological evaluations and contributed recent structural magnetic resonance imaging scans. Group differences in EVO Monitor performance and the association between EVO Monitor performance and standard measures were investigated. Results: Participants with multiple sclerosis and cognitive impairment showed worse performance in EVO Monitor compared with participants without multiple sclerosis (P=.01) and participants with multiple sclerosis without cognitive impairment (all P<.002). Regression analyses indicated that participants with a lower SDMT score showed lower performance in EVO Monitor (r=0.52, P<.001). Further exploratory analyses revealed associations between performance in EVO Monitor and walking speed (r=–0.45, P<.001) as well as brain volumetric data (left thalamic volume: r=0.47, P<.001; right thalamic volume: r=0.39, P=.002; left rostral middle frontal volume: r=0.28, P=.03; right rostral middle frontal volume: r=0.27, P=.03). Conclusions: These findings suggest that EVO Monitor, an unsupervised, video game–based digital program integrated with adaptive mechanics, is a clinically valuable approach to measuring cognitive performance in patients with multiple sclerosis. Trial Registration: ClinicalTrials.gov NCT03569618; https://clinicaltrials.gov/ct2/show/NCT03569618 %M 33470940 %R 10.2196/24356 %U http://www.jmir.org/2021/1/e24356/ %U https://doi.org/10.2196/24356 %U http://www.ncbi.nlm.nih.gov/pubmed/33470940 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 1 %P e16054 %T Electromyography-Driven Exergaming in Wheelchairs on a Mobile Platform: Bench and Pilot Testing of the WOW-Mobile Fitness System %A Enciso,James %A Variya,Dhruval %A Sunthonlap,James %A Sarmiento,Terrence %A Lee,Ka Mun %A Velasco,James %A Pebdani,Roxanna N %A de Leon,Ray D %A Dy,Christine %A Keslacy,Stefan %A Won,Deborah Soonmee %+ Department of Electrical and Computer Engineering, California State University, Los Angeles, 5151 State University Dr., Los Angeles, CA, 90032, United States, 1 323 343 5908, dwon@calstatela.edu %K exergaming %K gamercising %K mobile health %K wheelchair exercises %K wireless electromyography %K mobile phone %D 2021 %7 19.1.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Implementing exercises in the form of video games, otherwise known as exergaming, has gained recent attention as a way to combat health issues resulting from sedentary lifestyles. However, these exergaming apps have not been developed for exercises that can be performed in wheelchairs, and they tend to rely on whole-body movements. Objective: This study aims to develop a mobile phone app that implements electromyography (EMG)-driven exergaming, to test the feasibility of using this app to enable people in wheelchairs to perform exergames independently and flexibly in their own home, and to assess the perceived usefulness and usability of this mobile health system. Methods: We developed an Android mobile phone app (Workout on Wheels, WOW-Mobile) that senses upper limb muscle activity (EMG) from wireless body-worn sensors to drive 3 different video games that implement upper limb exercises designed for people in wheelchairs. Cloud server recordings of EMG enabled long-term monitoring and feedback as well as multiplayer gaming. Bench testing of data transmission and power consumption were tested. Pilot testing was conducted on 4 individuals with spinal cord injury. Each had a WOW-Mobile system at home for 8 weeks. We measured the minutes for which the app was used and the exergames were played, and we integrated EMG as a measure of energy expended. We also conducted a perceived usefulness and usability questionnaire. Results: Bench test results revealed that the app meets performance specifications to enable real-time gaming, cloud storage of data, and live cloud server transmission for multiplayer gaming. The EMG sampling rate of 64 samples per second, in combination with zero-loss data communication with the cloud server within a 10-m range, provided seamless control over the app exergames and allowed for offline data analysis. Each participant successfully used the WOW-Mobile system at home for 8 weeks, using the app for an average of 146 (range 89-267) minutes per week with the system, actively exergaming for an average of 53% of that time (39%-59%). Energy expenditure, as measured by integrated EMG, was found to be directly proportional to the time spent on the app (Pearson correlation coefficient, r=0.57-0.86, depending on the game). Of the 4 participants, 2 did not exercise regularly before the study; these 2 participants increased from reportedly exercising close to 0 minutes per week to exergaming 58 and 158 minutes on average using the WOW-Mobile fitness system. The perceived usefulness of WOW-Mobile in motivating participants to exercise averaged 4.5 on a 5-point Likert scale and averaged 5 for the 3 participants with thoracic level injuries. The mean overall ease of use score was 4.25 out of 5. Conclusions: Mobile app exergames driven by EMG have promising potential for encouraging and facilitating fitness for individuals in wheelchairs who have maintained arm and hand mobility. %M 33464221 %R 10.2196/16054 %U http://rehab.jmir.org/2021/1/e16054/ %U https://doi.org/10.2196/16054 %U http://www.ncbi.nlm.nih.gov/pubmed/33464221 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e16458 %T Promoting Physical Activity in Japanese Older Adults Using a Social Pervasive Game: Randomized Controlled Trial %A Santos,Luciano Henrique De Oliveira %A Okamoto,Kazuya %A Otsuki,Ryo %A Hiragi,Shusuke %A Yamamoto,Goshiro %A Sugiyama,Osamu %A Aoyama,Tomoki %A Kuroda,Tomohiro %+ Department of Social Informatics, Graduate School of Informatics, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan, 81 75 366 7701, lhsantos@kuhp.kyoto-u.ac.jp %K aged %K physical activity %K pervasive games %K social interaction %D 2021 %7 6.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pervasive games aim to create more fun and engaging experiences by mixing elements from the real world into the game world. Because they intermingle with players’ lives and naturally promote more casual gameplay, they could be a powerful strategy to stimulate physical activity among older adults. However, to use these games more effectively, it is necessary to understand how design elements of the game affect player behavior. Objective: The aim of this study was to evaluate how the presence of a specific design element, namely social interaction, would affect levels of physical activity. Methods: Participants were recruited offline and randomly assigned to control and intervention groups in a single-blind design. Over 4 weeks, two variations of the same pervasive game were compared: with social interaction (intervention group) and with no social interaction (control group). In both versions, players had to walk to physical locations and collect virtual cards, but the social interaction version allowed people to collaborate to obtain more cards. Changes in the weekly step counts were used to evaluate the effect on each group, and the number of places visited was used as an indicator of play activity. Results: A total of 20 participants were recruited (no social interaction group, n=10; social interaction group, n=10); 18 participants remained active until the end of the study (no social interaction group, n=9; social interaction group, n=9). Step counts during the first week were used as the baseline level of physical activity (no social interaction group: mean 46,697.2, SE 7905.4; social interaction group: mean 45,967.3, SE 8260.7). For the subsequent weeks, changes to individual baseline values (absolute/proportional) for the no social interaction group were as follows: 1583.3 (SE 3108.3)/4.6% (SE 7.2%) (week 2), 591.5 (SE 2414.5)/2.4% (SE 4.7%) (week 3), and −1041.8 (SE 1992.7)/0.6% (SE 4.4%) (week 4). For the social interaction group, changes to individual baseline values were as follows: 11520.0 (SE 3941.5)/28.0% (SE 8.7%) (week 2), 9567.3 (SE 2631.5)/23.0% (SE 5.1%) (week 3), and 7648.7 (SE 3900.9)/13.9% (SE 8.0%) (week 4). The result of the analysis of the group effect was significant (absolute change: η2=0.31, P=.04; proportional change: η2=0.30, P=.03). Correlations between both absolute and proportional change and the play activity were significant (absolute change: r=0.59, 95% CI 0.32 to 0.77; proportional change: r=0.39, 95% CI 0.08 to 0.64). Conclusions: The presence of social interaction design elements in pervasive games appears to have a positive effect on levels of physical activity. Trial Registration: Japan Medical Association Clinical Trial Registration Number JMA-IIA00314; https://tinyurl.com/y5nh6ylr (Archived by WebCite at http://www.webcitation.org/761a6MVAy) %M 33404507 %R 10.2196/16458 %U https://games.jmir.org/2021/1/e16458 %U https://doi.org/10.2196/16458 %U http://www.ncbi.nlm.nih.gov/pubmed/33404507 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e24078 %T Emotional Bias Modification for Individuals With Attention Deficit Hyperactivity Disorder: Protocol for a Co-Design Study %A Zhang,Melvyn %A Vallabhajosyula,Ranganath %A Fung,Daniel %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Level 18 Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 63892000, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K ADHD %K child psychiatry %D 2020 %7 23.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a worldwide prevalence rate of 5%. Individuals with ADHD often tend to have difficulties with emotional regulation. The advances in experimental psychology have led to the discovery of emotional biases. Targeting emotional biases could potentially help improve the core symptoms of irritability and short-temperedness among these individuals. Emotional biases refer to the preferential allocation of attention toward emotional stimuli. A recent study reported the presence of emotional biases among individuals with ADHD when they compared individuals with ADHD with those without. Gamification technologies have been explored to help diminish the repetitiveness of the task and increase the intrinsic motivation to train. These inconsistent findings of the impact of gaming on the effectiveness of mobile interventions call for further work to better understand the needs of patients (users) and health care professionals. Objective: The aim of this research study is to collate health care professionals’ perspectives on the limitations of the existing task, and to determine if gamification elements could be incorporated, to refine the conventional intervention. Methods: A qualitative research approach, that of a focus group, will be used. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore will be invited to participate in this qualitative research. During the focus group, participants are to comment on the limitations of the existing emotional bias intervention; recommend strategies to improve the intervention; and provide their perspectives pertaining to the use of gamification to improve the intervention. Results: We expect that the study will be completed in 12 months from the publication of this protocol. Conclusions: To our best knowledge, this is perhaps one of the only few studies that have attempted to explore emotional biases among adolescents with ADHD. International Registered Report Identifier (IRRID): PRR1-10.2196/24078 %M 33355536 %R 10.2196/24078 %U http://www.researchprotocols.org/2020/12/e24078/ %U https://doi.org/10.2196/24078 %U http://www.ncbi.nlm.nih.gov/pubmed/33355536 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e25226 %T A Mobile Serious Game About the Pandemic (COVID-19 - Did You Know?): Design and Evaluation Study %A Gaspar,Juliano De Souza %A Lage,Eura Martins %A Silva,Fernando José Da %A Mineiro,Érico %A Oliveira,Isaias José Ramos De %A Oliveira,Igor %A Souza,Rayner Guilherme De %A Gusmão,Juan Rodrigues Oliveira %A De Souza,Camila Fernanda Donadoni %A Reis,Zilma Silveira Nogueira %+ Faculdade de Medicina, Universidade Federal de Minas Gerais, Rua Alfredo Balena, 190, Belo Horizonte, 30130-100, Brazil, 55 313409 0000, julianogaspar@gmail.com %K coronavirus %K COVID-19 %K e-learning %K mHealth %K digital health %K gamification %K serious game %K mobile apps %K public health %K informatics %D 2020 %7 22.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: No treatment for COVID-19 is yet available; therefore, providing access to information about SARS-CoV-2, the transmission route of the virus, and ways to prevent the spread of infection is a critical sanitary measure worldwide. Serious games have advantages in the dissemination of reliable information during the pandemic; they can provide qualified content while offering interactivity to the user, and they have great reach over the internet. Objective: This study aimed to develop a serious game with the purpose of providing science-based information on the prevention of COVID-19 and personal care during the pandemic while assessing players’ knowledge about COVID-19–related topics. Methods: The study was conducted with the interdisciplinary collaboration of specialists in health sciences, computing, and design at the Federal University of Minas Gerais, Brazil. The health recommendations were grouped into six thematic blocks, presented in a quiz format. The software languages were based on the progressive web app development methodology with the Ionic framework, JavaScript, HTML5, cascading style sheets, and TypeScript (Angular). Open data reports of how users interact with the serious game were obtained using the Google Analytics application programming interface. The visual identity, logo, infographics, and icons were carefully developed by considering a selection of colors, typography, sounds, and images that are suitable for young audiences. Cards with cartoon characters were introduced at the end of each thematic topic to interact with the player, reinforcing their correct answers or alerting them to the need to learn more about the disease. The players’ performance was assessed by the rate of incorrect and correct answers and analyzed by linear correlation coefficient over 7 weeks. The agile SCRUM development methodology enabled quick and daily interactions of developers through a webchat and sequential team meetings. Results: The game “COVID-19–Did You Know?” was made available for free on a public university website on April 1, 2020. The game had been accessed 17,571 times as of September 2020. Dissemination actions such as reports on social media and television showed a temporal correspondence with the access number. The players’ error rate in the topic “Mask” showed a negative trend (r=–.83; P=.01) over the weeks of follow-up. The other topics showed no significant trend over the weeks. Conclusions: The gamification strategy for health education content on the theme of COVID-19 reached a young audience, which is considered to be a priority in the strategy of orientation toward social distancing. Specific educational reinforcement measures were proposed and implemented based on the players’ performance. The improvement in the users’ performance on the topic about the use of masks may reflect an increase in information about or adherence to mask use over time. %M 33301416 %R 10.2196/25226 %U http://games.jmir.org/2020/4/e25226/ %U https://doi.org/10.2196/25226 %U http://www.ncbi.nlm.nih.gov/pubmed/33301416 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e16883 %T Evaluation of a Serious Video Game to Facilitate Conversations About Human Papillomavirus Vaccination for Preteens: Pilot Randomized Controlled Trial %A Cates,Joan R %A Fuemmeler,Bernard F %A Stockton,Laurie L %A Diehl,Sandra J %A Crandell,Jamie L %A Coyne-Beasley,Tamera %+ Massey Cancer Center, Virginia Commonwealth University, 830 E. Main St., Rm 4-128, P.O. Box 980149, Richmond, VA, 23219, United States, 1 804 828 8892, Bernard.Fuemmeler@vcuhealth.org %K video games %K papillomavirus vaccines %K adolescent health %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the United States, the most common sexually transmitted infection, human papillomavirus (HPV), causes genital warts and is associated with an estimated 33,700 newly diagnosed cancer cases annually. HPV vaccination, especially for preteens aged 11 to 12 years, is effective in preventing the acquisition of HPV and HPV-associated cancers. However, as of 2018, completion of the 2- or 3-dose HPV vaccination series increased only from 48.6% to 51.1% in teens aged 13 to 17 years, and this increase was observed only in boys. By comparison, 88.7% of teens had more than one dose of the recommended vaccine against tetanus, diphtheria, and acellular pertussis (Tdap), and 85.1% of teens had more than one dose of meningococcal vaccine. Immunizations for Tdap, meningococcal disease, and HPV can occur at the same clinical visit but often do not. Objective: Vaccination against HPV is recommended for routine use in those aged 11 to 12 years in the United States, yet it is underutilized. We aimed to develop an educational video game to engage preteens in the decision to vaccinate. Methods: Land of Secret Gardens is a metaphor for protecting seedlings (body) with a potion (vaccine). We screened 131 dyads of parents and preteens from 18 primary practices in North Carolina who had not initiated HPV vaccination. We measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. A total of 55 dyads were enrolled, and we randomly assigned 28 (21 completed) to play the game and 27 (26 completed) to the comparison group. Results: In total, 18 preteens reported playing the game. The vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant.. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant. Conclusions: Video games help preteens in the decision to pursue HPV vaccination. A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification is effective in increasing preteen interest in HPV vaccination, as game features support decision making for HPV vaccination. Trial Registration: ClinicalTrials.gov NCT04627298; https://www.clinicaltrials.gov/ct2/show/NCT04627298 %M 33270028 %R 10.2196/16883 %U https://games.jmir.org/2020/4/e16883 %U https://doi.org/10.2196/16883 %U http://www.ncbi.nlm.nih.gov/pubmed/33270028 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18528 %T Using Serious Games for Antismoking Health Campaigns: Experimental Study %A Kim,Jihyun %A Song,Hayeon %A Merrill Jr,Kelly %A Jung,Younbo %A Kwon,Remi Junghuem %+ Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul, 03063, Republic of Korea, 82 2 740 1870, Hayeon.song@gmail.com %K fear appeals %K serious games %K smoking %K entertainment education %K susceptibility %D 2020 %7 2.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games for health have been gaining in popularity among scholars and practitioners. However, there remain a few questions to be addressed. Objective: This study tests the effects of a serious game and fear appeals on smoking-related outcomes. More specifically, this research aims to understand how serious games function as a more effective vehicle for a health campaign than a traditional medium, such as a print-based pamphlet. Further, while serious games utilize a variety of persuasive strategies in the game’s content, it is not clear whether fear appeals, which are widely used persuasive-message strategies for health, can be an effective strategy in serious games. Thus, we are testing the effect of fear appeals in a serious game. Methods: We created a computer game and a print brochure to educate participants about the risks of smoking. More specifically, a flash-based single-player game was developed in which players were asked to avoid cigarettes in the gameplay context. We also developed an online brochure based on existing smoking-related brochures at a university health center; antismoking messages on the computer game and in the brochure were comparable. Then, an experiment using a 2 (media type: game vs. print) x 2 (fearful image: fear vs. no-fear) between-subjects design was conducted. The study recruitment was announced to undergraduate students enrolled in a large, public Midwestern university in the United States. After a screening test, a total of 72 smokers, who reported smoking in the past 30 days, participated in the experiment. Results: Overall, gameplay, when compared to print-based pamphlets, had greater impacts on attitudes toward smoking and the intention to quit smoking. Further, the game’s persuasive effects were especially pronounced when messages contained fear appeals. When fearful images were presented, participants in the game condition reported significantly more negative attitudes toward social smoking than those in the print condition [F(1,67)=7.28; P=.009; ηp2=0.10]. However, in the no-fear condition, there was no significant difference between the conditions [F(1,67)=0.25; P=.620]. Similarly, the intention to quit smoking [F(1,67)=4.64; P=.035; ηp2=0.07] and susceptibility [F(1,67)=6.92; P=.011; ηp2=0.09] were also significantly different between the conditions, but only when fear appeals were used. Conclusions: This study extends fear appeal research by investigating the effects of different media types. It offers empirical evidence that a serious game can be an effective vehicle for fear appeals. %M 33263549 %R 10.2196/18528 %U http://games.jmir.org/2020/4/e18528/ %U https://doi.org/10.2196/18528 %U http://www.ncbi.nlm.nih.gov/pubmed/33263549 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e21652 %T The Role of Enjoyment in a Serious Game for Binge Drinking Prevention: Pretest-Posttest Quasi-Experimental Study %A Hong,Traci %A Cabrera,Joshua %A Beaudoin,Christopher E %+ College of Communication, Boston University, 640 Commonwealth Ave, Boston, MA, 02215, United States, 1 6173533450, tjhong@bu.edu %K alcohol prevention %K binge drinking %K serious game %D 2020 %7 30.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although binge drinking peaks at age 21 to 25 years, there is limited research on the effects of serious games in this population, as well as on the process by which playing serious games impacts alcohol-related outcomes. Designed with both health behavioral theory and game theory, One Shot is an online serious game that aims to prevent binge drinking. Objective: This study utilized a conceptual model for serious video game processes. Using One Shot, the model assessed the following process stages: (1) Alcohol Use Disorders Identification Test-Concise (AUDIT-C); (2) in-game factors of game time and risky alcohol decisions; (3) game enjoyment; and (4) postgame outcomes of intention to drink less and drinking refusal self-efficacy. Methods: In a one-group pretest-posttest quasi-experimental design, a sample (N=550) of young adults (age 21-25 years) who reported recent binge drinking played the One Shot game. Intention to drink less and drinking refusal self-efficacy were measured at pregame and postgame, with their effects lagged in statistical analysis. Participants were presented with various scenarios in the game that pertained to risky alcohol decisions, which, along with game time, were unobtrusively recorded by the server. A structural equation model (SEM) was used to test the conceptual model, with assessments made to determine if enjoyment mediated the effects of game time and risky alcohol decisions on the 2 postgame alcohol-related outcomes. Results: A well-fitting SEM demonstrated support for the multistep model, with AUDIT-C predicting risky alcohol decisions (β=.30). Risky alcohol decisions (β=−.22) and game time (β=.18) predicted enjoyment, which, in turn, predicted intention to drink less (β=.21) and drinking refusal self-efficacy (β=.16). Enjoyment significantly (P<.001) mediated the effects of game time and risky alcohol decision on intention to drink less and drinking refusal self-efficacy. Conclusions: The results support a conceptual model in which staggered individual and in-game factors influence alcohol-related outcomes. Enjoyment is important for participants’ intentions to drink less and beliefs that they can refuse alcohol. %M 33252348 %R 10.2196/21652 %U http://www.jmir.org/2020/11/e21652/ %U https://doi.org/10.2196/21652 %U http://www.ncbi.nlm.nih.gov/pubmed/33252348 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e15717 %T Impact of Pediatric Mobile Game Play on Healthy Eating Behavior: Randomized Controlled Trial %A Kato-Lin,Yi-Chin %A Kumar,Uttara Bharath %A Sri Prakash,Bhargav %A Prakash,Bhairavi %A Varadan,Vasini %A Agnihotri,Sanjeeta %A Subramanyam,Nrutya %A Krishnatray,Pradeep %A Padman,Rema %+ The Heinz College of Information Systems and Public Policy, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, , United States, 1 412 268 2180, rpadman@cmu.edu %K pediatric obesity %K mobile games %K implicit learning %K healthy eating behavior evaluation %K game telemetry analysis %D 2020 %7 18.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Video and mobile games have been shown to have a positive impact on behavior change in children. However, the potential impact of game play patterns on outcomes of interest are yet to be understood, especially for games with implicit learning components. Objective: This study investigates the immediate impact of fooya!, a pediatric dietary mobile game with implicit learning components, on food choices. It also quantifies children’s heterogeneous game play patterns using game telemetry and determines the effects of these patterns on players’ food choices. Methods: We analyzed data from a randomized controlled trial (RCT) involving 104 children, aged 10 to 11 years, randomly assigned to the treatment group (played fooya!, a dietary mobile game developed by one of the authors) or the control group (played Uno, a board game without dietary education). Children played the game for 20 minutes each in two sessions. After playing the game in each session, the children were asked to choose 2 out of 6 food items (3 healthy and 3 unhealthy choices). The number of healthy choices in both sessions was used as the major outcome. We first compared the choice and identification of healthy foods between treatment and control groups using statistical tests. Next, using game telemetry, we determined the variability in game play patterns by quantifying game play measures and modeled the process of game playing at any level across all students as a Markov chain. Finally, correlation tests and regression models were used to establish the relationship between game play measures and actual food choices. Results: We saw a significant main effect of the mobile game on number of healthy foods actually chosen (treatment 2.48, control 1.10; P<.001; Cohen d=1.25) and identified (treatment 7.3, control 6.94; P=.048; Cohen d=.25). A large variation was observed in children’s game play patterns. Children played an average of 15 game levels in 2 sessions, with a range of 2 to 23 levels. The greatest variation was noted in the proportion of scoring activities that were highly rewarded, with an average of 0.17, ranging from 0.003 to 0.98. Healthy food choice was negatively associated with the number of unhealthy food facts that children read in the game (Kendall τ=–.32, P=.04), even after controlling for baseline food preference. Conclusions: A mobile video game embedded with implicit learning components showed a strong positive impact on children’s food choices immediately following the game. Game telemetry captured children’s different play patterns and was associated with behavioral outcomes. These results have implications for the design and use of mobile games as an intervention to improve health behaviors, such as the display of unhealthy food facts during game play. Longitudinal RCTs are needed to assess long-term impact. Trial Registration: ClinicalTrials.gov NCT04082195; https://clinicaltrials.gov/ct2/show/NCT04082195, registered retrospectively. %M 33206054 %R 10.2196/15717 %U http://mhealth.jmir.org/2020/11/e15717/ %U https://doi.org/10.2196/15717 %U http://www.ncbi.nlm.nih.gov/pubmed/33206054 %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 %@ 2291-9694 %I JMIR Publications %V 8 %N 11 %P e23626 %T Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study %A Rantala,Arja %A Jansson,Miia M %A Helve,Otto %A Lahdenne,Pekka %A Pikkarainen,Minna %A Pölkki,Tarja %+ Research Group of Medical Imaging, Physics and Technology, Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Pentti Kaiteran katu 1, Oulu, FI-90014, Finland, 358 504340424, arja.rantala@oulu.fi %K anxiety %K children %K day surgery %K delivery of health care %K digital solution %K gamification %K nursing %K pain %K qualitative study %K technology %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative pain relief, and postoperative guidance. Parents’ experiences help care providers to provide effective, family-centered care that responds to parents’ needs throughout the day surgery pathway. Objective: The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs for a digital gaming solution in order to facilitate the digitalization of these pathways. Methods: This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to the hospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: Parental experiences of the children’s day surgery pathway included 3 main categories: (1) needs for parental guidance, (2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparation of child for treatment). The needs for a digital gaming solution were identified as 1 main category—the digital gaming solution for children and families to support care. This main category included 3 upper categories: (1) preparing children and families for the day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution. Conclusions: Parents need guidance and support for their children’s day surgery care pathways. A digital gaming solution may be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to digital gaming solutions that provide support and guidance and engage children in the day surgery pathways. %M 33185556 %R 10.2196/23626 %U http://medinform.jmir.org/2020/11/e23626/ %U https://doi.org/10.2196/23626 %U http://www.ncbi.nlm.nih.gov/pubmed/33185556 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19723 %T Use of a Low-Cost Portable 3D Virtual Reality Simulator for Psychomotor Skill Training in Minimally Invasive Surgery: Task Metrics and Score Validity %A Alvarez-Lopez,Fernando %A Maina,Marcelo Fabián %A Arango,Fernando %A Saigí-Rubió,Francesc %+ Faculty of Health Sciences, Universitat Oberta de Catalunya, Avinguda Tibidabo, 39-43, Barcelona, 08035, Spain, 34 933 263 622, fsaigi@uoc.edu %K simulation training %K minimally invasive surgical procedures %K medical education %K user-computer interface %K computer-assisted surgery %K Leap Motion Controller %D 2020 %7 27.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery. Objective: The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality). Methods: In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability. Results: Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures. Conclusions: The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery. %M 33107833 %R 10.2196/19723 %U http://games.jmir.org/2020/4/e19723/ %U https://doi.org/10.2196/19723 %U http://www.ncbi.nlm.nih.gov/pubmed/33107833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e19840 %T Exergaming With Beat Saber: An Investigation of Virtual Reality Aftereffects %A Szpak,Ancret %A Michalski,Stefan Carlo %A Loetscher,Tobias %+ University of South Australia, St Bernards Road, Magill, South Australia, Adelaide, 5072, Australia, 61 08 8302 ext 4336, ancret.szpak@unisa.edu.au %K virtual reality %K motion sickness %K exercise %K sedentary behavior %K depth perception %D 2020 %7 23.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) exergaming has the potential to target sedentary behavior. Immersive environments can distract users from the physical exertion of exercise and can motivate them to continue exergaming. Despite the recent surge in VR popularity, numerous users still experience VR sickness from using head-mounted displays (HMDs). Apart from the commonly assessed self-reported symptoms, depth perception and cognition may also be affected. Considering the potential benefits of VR exergaming, it is crucial to identify the adverse effects limiting its potential and continued uptake. Objective: This study aims to investigate the consequences of playing one of the most popular VR exergames for 10 and 50 min on aspects of vision, cognition, and self-reported VR sickness. Methods: A total of 36 participants played an exergame, called Beat Saber, using an HMD. A repeated measures within-subject design was conducted to assess changes in vision, cognition, and well-being after short (10 min) and long (50 min) durations of VR exposure. We measured accommodation, convergence, decision speed, movement speed, and self-reported sickness at 3 test periods—before VR, immediately after VR, and 40 min after VR (late). Results: Beat Saber was well tolerated, as there were no dropouts due to sickness. For most participants, any immediate aftereffects were short-lived and returned to baseline levels after 40 min of exiting VR. For both short and long exposures, there were changes in accommodation (F1,35=8.424; P=.006) and convergence (F1,35=7.826; P=.008); however, in the late test period, participants returned to baseline levels. Measures on cognition revealed no concern. The total simulator sickness questionnaire (SSQ) scores increased immediately after VR (F1,35=26.515; P<.001) and were significantly higher for long compared with short exposures (t35=2.807; P=.03), but there were no differences in exposure duration in the late test period, with scores returning to baseline levels. Although at a group level, participants’ sickness levels returned to baseline 40 min after VR exposure, approximately 14% of the participants still reported high levels of sickness in the late test period after playing 50 min of Beat Saber. We also showed that the participants who experienced a high level of sickness after a short exposure were almost certain to experience a high level of symptoms after a longer exposure. Conclusions: Irrespective of the duration of exposure, this study found no strong evidence for adverse symptoms 40 min after exiting VR; however, some individuals still reported high levels of VR sickness at this stage. We recommend that users commit to a waiting period after exiting VR to ensure that any aftereffects have deteriorated. Exergames in HMDs have the potential to encourage people to exercise but are understudied, and the aftereffects of exergaming need to be closely monitored to ensure that VR exergames can reach their full potential. %M 33095182 %R 10.2196/19840 %U http://www.jmir.org/2020/10/e19840/ %U https://doi.org/10.2196/19840 %U http://www.ncbi.nlm.nih.gov/pubmed/33095182 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e14322 %T Use of a Smartphone App to Increase Physical Activity Levels in Insufficiently Active Adults: Feasibility Sequential Multiple Assignment Randomized Trial (SMART) %A Gonze,Bárbara De Barros %A Padovani,Ricardo Da Costa %A Simoes,Maria Do Socorro %A Lauria,Vinicius %A Proença,Neli Leite %A Sperandio,Evandro Fornias %A Ostolin,Thatiane Lopes Valentim Di Paschoale %A Gomes,Grace Angélica De Oliveira %A Castro,Paula Costa %A Romiti,Marcello %A Gagliardi,Antonio %A Arantes,Rodolfo Leite %A Dourado,Victor Zuniga %+ Laboratory of Epidemiology and Human Movement (EPIMOV), Department of Human Movement Sciences, Federal University of São Paulo, Rua Silva Jardim 136, Vila Mathias, Santos, 11015-020, Brazil, 55 1332290203, victor.dourado@unifesp.br %K tailored messages %K gamification %K steps per day %D 2020 %7 23.10.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The sequential multiple assignment randomized trial (SMART) design allows for changes in the intervention during the trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has not been utilized in a smartphone/gamified intervention for physical activity. Objective: We aimed to investigate the feasibility of the SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively. Methods: We conducted a feasibility 24-week/two-stage SMART in which 18 insufficiently active participants (<10,000 steps/day) were first randomized to group 1 (smartphone app only), group 2 (smartphone app + tailored messages), and a control group (usual routine during the protocol). Participants were motivated to increase their step count by at least 2000 steps/day each week. Based on the 12-week intermediate outcome, responders continued the intervention and nonresponders were rerandomized to subsequent treatment, including a new group 3 (smartphone app + tailored messages + gamification) in which they were instructed to form groups to use several game elements available in the chosen app (Pacer). We considered responders as those with any positive slope in the linear relationship between weeks and steps per day at the end of the first stage of the intervention. We compared the accelerometer-based steps per day before and after the intervention, as well as the slopes of the app-based steps per day between the first and second stages of the intervention. Results: Twelve participants, including five controls, finished the intervention. We identified two responders in group 1. We did not observe relevant changes in the steps per day either throughout the intervention or compared with the control group. However, the rerandomization of five nonresponders led to a change in the slope of the steps per day (median −198 steps/day [IQR −279 to −103] to 20 steps/day [IQR −204 to 145]; P=.08). Finally, in three participants from group 2, we observed an increase in the number of steps per day up to the sixth week, followed by an inflection to baseline values or even lower (ie, a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into the following: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals. Conclusions: The SMART design was feasible and changed the behavior of steps per day after rerandomization. Rerandomization should be implemented earlier to take advantage of tailored messages. Additionally, difficulties with technology and realistic and individualized goals should be considered in interventions for physical activity using smartphones. Trial Registration: Brazilian Registry of Clinical Trials RBR-8xtc9c; http://www.ensaiosclinicos.gov.br/rg/RBR-8xtc9c/. %M 33094733 %R 10.2196/14322 %U https://www.researchprotocols.org/2020/10/e14322 %U https://doi.org/10.2196/14322 %U http://www.ncbi.nlm.nih.gov/pubmed/33094733 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19280 %T Archetypes of Gamification: Analysis of mHealth Apps %A Schmidt-Kraepelin,Manuel %A Toussaint,Philipp A %A Thiebes,Scott %A Hamari,Juho %A Sunyaev,Ali %+ Department of Economics and Management, Karlsruhe Institute of Technology, Kaiserstraße 89, Karlsruhe, D-76133, Germany, 49 72160846037, sunyaev@kit.edu %K mHealth %K smartphones %K mobile phones %K gamification %K quantified-self %K exergames, persuasive technology %D 2020 %7 19.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Nowadays, numerous health-related mobile apps implement gamification in an attempt to draw on the motivational potential of video games and thereby increase user engagement or foster certain health behaviors. However, research on effective gamification is still in its infancy and researchers increasingly recognize methodological shortcomings of existing studies. What we actually know about the phenomenon today stems from fragmented pieces of knowledge, and a variety of different perspectives. Existing research primarily draws on conceptual knowledge that is gained from research prototypes, and isolated from industry best practices. We still lack knowledge on how gamification has been successfully designed and implemented within the industry and whether certain gamification approaches have shown to be particularly suitable for certain health behaviors. Objective: We address this lack of knowledge concerning best practices in the design and implementation of gamification for health-related mobile apps by identifying archetypes of gamification approaches that have emerged in pertinent health-related mobile apps and analyzing to what extent those gamification approaches are influenced by the underlying desired health-related outcomes. Methods: A 3-step research approach is employed. As a first step, a database of 143 pertinent gamified health-related mobile apps from the Apple App Store and Google Play Store is set up. Second, the gamification approach of each app within the database is classified based on an established taxonomy for gamification in health-related apps. Finally, a 2-step cluster analysis is conducted in order to identify archetypes of the most dominant gamification approaches in pertinent gamified health-related mobile apps. Results: Eight archetypes of gamification emerged from the analysis of health-related mobile apps: (1) competition and collaboration, (2) pursuing self-set goals without rewards, (3) episodical compliance tracking, (4) inherent gamification for external goals, (5) internal rewards for self-set goals, (6) continuous assistance through positive reinforcement, (7) positive and negative reinforcement without rewards, and (8) progressive gamification for health professionals. The results indicate a close relationship between the identified archetypes and the actual health behavior that is being targeted. Conclusions: By unveiling salient best practices and discussing their relationship to targeted health behaviors, this study contributes to a more profound understanding of gamification in mobile health. The results can serve as a foundation for future research that advances the knowledge on how gamification may positively influence health behavior change and guide practitioners in the design and development of highly motivating and effective health-related mobile health apps. %M 33074155 %R 10.2196/19280 %U https://mhealth.jmir.org/2020/10/e19280 %U https://doi.org/10.2196/19280 %U http://www.ncbi.nlm.nih.gov/pubmed/33074155 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e20979 %T Evaluation of the Effectiveness of a Novel Brain-Computer Interface Neuromodulative Intervention to Relieve Neuropathic Pain Following Spinal Cord Injury: Protocol for a Single-Case Experimental Design With Multiple Baselines %A Hesam-Shariati,Negin %A Newton-John,Toby %A Singh,Avinash K %A Tirado Cortes,Carlos A %A Do,Tien-Thong Nguyen %A Craig,Ashley %A Middleton,James W %A Jensen,Mark P %A Trost,Zina %A Lin,Chin-Teng %A Gustin,Sylvia M %+ Centre for Pain IMPACT, Neuroscience Research Australia, 139 Barker St, Randwick NSW, Sydney , Australia, 61 413278336, s.gustin@unsw.edu.au %K EEG neurofeedback %K neuropathic pain %K spinal cord injury %K thalamus %K serious games %K brain-machine interface %K brain-computer interface %K single-case experimental design %D 2020 %7 29.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Neuropathic pain is a debilitating secondary condition for many individuals with spinal cord injury. Spinal cord injury neuropathic pain often is poorly responsive to existing pharmacological and nonpharmacological treatments. A growing body of evidence supports the potential for brain-computer interface systems to reduce spinal cord injury neuropathic pain via electroencephalographic neurofeedback. However, further studies are needed to provide more definitive evidence regarding the effectiveness of this intervention. Objective: The primary objective of this study is to evaluate the effectiveness of a multiday course of a brain-computer interface neuromodulative intervention in a gaming environment to provide pain relief for individuals with neuropathic pain following spinal cord injury. Methods: We have developed a novel brain-computer interface-based neuromodulative intervention for spinal cord injury neuropathic pain. Our brain-computer interface neuromodulative treatment includes an interactive gaming interface, and a neuromodulation protocol targeted to suppress theta (4-8 Hz) and high beta (20-30 Hz) frequency powers, and enhance alpha (9-12 Hz) power. We will use a single-case experimental design with multiple baselines to examine the effectiveness of our self-developed brain-computer interface neuromodulative intervention for the treatment of spinal cord injury neuropathic pain. We will recruit 3 participants with spinal cord injury neuropathic pain. Each participant will be randomly allocated to a different baseline phase (ie, 7, 10, or 14 days), which will then be followed by 20 sessions of a 30-minute brain-computer interface neuromodulative intervention over a 4-week period. The visual analog scale assessing average pain intensity will serve as the primary outcome measure. We will also assess pain interference as a secondary outcome domain. Generalization measures will assess quality of life, sleep quality, and anxiety and depressive symptoms, as well as resting-state electroencephalography and thalamic γ-aminobutyric acid concentration. Results: This study was approved by the Human Research Committees of the University of New South Wales in July 2019 and the University of Technology Sydney in January 2020. We plan to begin the trial in October 2020 and expect to publish the results by the end of 2021. Conclusions: This clinical trial using single-case experimental design methodology has been designed to evaluate the effectiveness of a novel brain-computer interface neuromodulative treatment for people with neuropathic pain after spinal cord injury. Single-case experimental designs are considered a viable alternative approach to randomized clinical trials to identify evidence-based practices in the field of technology-based health interventions when recruitment of large samples is not feasible. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000556943; https://bit.ly/2RY1jRx International Registered Report Identifier (IRRID): PRR1-10.2196/20979 %M 32990249 %R 10.2196/20979 %U http://www.researchprotocols.org/2020/9/e20979/ %U https://doi.org/10.2196/20979 %U http://www.ncbi.nlm.nih.gov/pubmed/32990249 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e19881 %T Game-Based Meditation Therapy to Improve Posttraumatic Stress and Neurobiological Stress Systems in Traumatized Adolescents: Protocol for a Randomized Controlled Trial %A Schuurmans,Angela A T %A Nijhof,Karin S %A Scholte,Ron %A Popma,Arne %A Otten,Roy %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 24 361 61 61, angela.anna.schuurmans@gmail.com %K Adolescents %K Autonomic nervous system %K Cortisol %K Meditation %K Neurofeedback %K Posttraumatic stress %K Randomized controlled trial %K Trauma %D 2020 %7 23.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Many adolescents in residential care have been exposed to prolonged traumatic experiences such as violence, neglect, or abuse. Consequently, they suffer from posttraumatic stress. This not only negatively affects psychological and behavioral outcomes (eg, increased anxiety, depression, and aggression) but also has adverse effects on physiological outcomes, in particular on their neurobiological stress systems. Although current evidence-based treatment options are effective, they have their limitations. An alternative to traditional trauma treatment is meditation-based treatment that focuses on stress regulation and relaxation. Muse is a game-based meditation intervention that makes use of adolescents’ intrinsic motivation. The neurofeedback element reinforces relaxation abilities. Objective: This paper describes the protocol for a randomized controlled trial in which the goal is to examine the effectiveness of Muse (InteraXon Inc) in reducing posttraumatic stress and normalizing neurobiological stress systems in a sample of traumatized adolescents in residential care. Methods: This will be a multicenter, multi-informant, and multimethod randomized controlled trial. Participants will be adolescents (N=80), aged 10 to 18 years, with clinical levels of posttraumatic symptoms, who are randomized to receive either the Muse therapy sessions and treatment as usual (intervention) or treatment as usual alone (control). Data will be collected at 3 measurement instances: pretest (T1), posttest (T2), and at 2-month follow-up. Primary outcomes will be posttraumatic symptoms (self-report and mentor report) and stress (self-report) at posttest. Secondary outcomes will be neurobiological stress parameters under both resting and acute stress conditions, and anxiety, depression, and aggression at posttest. Secondary outcomes also include all measures at 2-month follow-up: posttraumatic symptoms, stress, anxiety, depression aggression, and neurobiological resting parameters. Results: The medical-ethical committee Arnhem-Nijmegen (NL58674.091.16) approved the trial on November 15, 2017. The study was registered on December 2, 2017. Participant enrollment started in January 2018, and the results of the study are expected to be published in spring or summer 2021. Conclusions: Study results will demonstrate whether game-based meditation therapy improves posttraumatic stress and neurobiological stress systems, and whether it is more effective than treatment as usual alone for traumatized adolescents. Trial Registration: Netherlands Trial Register NL6689 (NTR6859); https://www.trialregister.nl/trial/6689 International Registered Report Identifier (IRRID): DERR1-10.2196/19881 %M 32965226 %R 10.2196/19881 %U http://www.researchprotocols.org/2020/9/e19881/ %U https://doi.org/10.2196/19881 %U http://www.ncbi.nlm.nih.gov/pubmed/32965226 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e18640 %T A Mobile Gaming Intervention for Persons on Pre-Exposure Prophylaxis: Protocol for Intervention Development and Randomized Controlled Trial %A Whiteley,Laura %A Olsen,Elizabeth %A Mena,Leandro %A Haubrick,Kayla %A Craker,Lacey %A Hershkowitz,Dylan %A Brown,Larry K %+ Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, 700 Butler Drive, Providence, RI, , United States, 1 401 455 6430, laura_whiteley@brown.edu %K pre-exposure prophylaxis (PrEP) %K adherence %K mobile gaming intervention %K HIV prevention %K men who have sex with men (MSM) %D 2020 %7 14.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: In the United States, young minority men who have sex with men (MSM) are the most likely to become infected with HIV. Pre-exposure prophylaxis (PrEP) is an efficacious and promising prevention strategy. However, PrEP’s safety and effectiveness can be greatly compromised by suboptimal adherence to treatment. To maximize the positive impact of PrEP, it is necessary to combine its prescription with cost-effective behavioral interventions that promote adherence and decrease HIV risk behaviors. In this project, we developed a theoretically informed app/gaming intervention to engage young MSM in learning information, practicing behaviors, and improving motivation for HIV preventative behaviors and PrEP adherence. Objective: The goal of this project was to develop and test a cutting-edge, engaging, and entertaining app/gaming intervention for improving adherence to PrEP and building HIV prevention knowledge, skills, and behavior. Methods: This study was conducted in two phases. In the developmental phase, we conducted qualitative interviews with young MSM (n=20) to guide the development of the gaming intervention. In the randomized controlled trial, we tested the preliminary efficacy of the gaming intervention compared to a comparison condition among young MSM. Subjects were recruited from the University of Mississippi Medical Center HIV/STI testing clinics (n=60). Results: Institutional review board approval was received in February 2015. Research activities began in June 2015 and are still ongoing. Conclusions: This app/gaming intervention aimed to improve PrEP adherence and HIV preventative behaviors in young MSM. Engaging young MSM in learning information, practicing behaviors, and improving motivation for increased adherence to PrEP has the potential to decrease HIV seroconversion. It is important to develop interventions that are enjoyable, engaging, and easily incorporated into clinical settings. Trial Registration: ClinicalTrials.gov RCT02611362; https://tinyurl.com/y65gkuwr International Registered Report Identifier (IRRID): DERR1-10.2196/18640 %M 32924954 %R 10.2196/18640 %U http://www.researchprotocols.org/2020/9/e18640/ %U https://doi.org/10.2196/18640 %U http://www.ncbi.nlm.nih.gov/pubmed/32924954 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e20667 %T Feasibility of a Commercially Available Virtual Reality System to Achieve Exercise Guidelines in Youth With Spina Bifida: Mixed Methods Case Study %A Lai,Byron %A Davis,Drew %A Narasaki-Jara,Mai %A Hopson,Betsy %A Powell,Danielle %A Gowey,Marissa %A Rocque,Brandon G %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, School of Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 2052001724, byronlai@uab.edu %K physical activity %K active video gaming %K exergaming %K disability %K Oculus Quest %D 2020 %7 3.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Access to physical activity among youth with spina bifida (SB) is much lower than it is for children without disability. Enjoyable home-based exercise programs are greatly needed. Objective: Our objective is to examine the feasibility of a virtual reality (VR) active video gaming system (ie, bundle of consumer-available equipment) to meet US physical activity guidelines in two youth with SB. Methods: Two youth with SB—a 12-year-old female and a 13-year-old male; both full-time wheelchair users—participated in a brief, 4-week exercise program using a popular VR head-mounted display: Oculus Quest (Facebook Technologies). The system included a Polar H10 (Polar Canada) Bluetooth heart rate monitor, a no-cost mobile phone app (VR Health Exercise Tracker [Virtual Reality Institute of Health and Exercise]), and 13 games. The intervention protocol was conducted entirely in the homes of the participants due to the coronavirus disease 2019 (COVID-19) pandemic. The VR system was shipped to participants and they were instructed to do their best to complete 60 minutes of moderate-intensity VR exercise per day. Exercise duration, intensity, and calories expended were objectively monitored and recorded during exercise using the heart rate monitor and a mobile app. Fatigue and depression were measured via self-report questionnaires at pre- and postintervention. Participants underwent a semistructured interview with research staff at postintervention. Results: Across the intervention period, the total average minutes of all exercise performed each week for participants 1 and 2 were 281 (SD 93) and 262 (SD 55) minutes, respectively. The total average minutes of moderate-intensity exercise performed per week for participants 1 and 2 were 184 (SD 103) (184/281, 65.4%) and 215 (SD 90) (215/262, 82.1%) minutes, respectively. One participant had a reduction in their depression score, using the Quality of Life in Neurological Disorders (Neuro-QoL) test, from baseline to postintervention, but no other changes were observed for fatigue and depression scores. Participants reported that the amount of exercise they completed was far higher than what was objectively recorded, due to usability issues with the chest-worn heart rate monitor. Participants noted that they were motivated to exercise due to the enjoyment of the games and VR headset as well as support from a caregiver. Conclusions: This study demonstrated that two youth with SB who used wheelchairs could use a VR system to independently and safely achieve exercise guidelines at home. Study findings identified a promising protocol for promoting exercise in this population and this warrants further examination in future studies with larger samples. %M 32880577 %R 10.2196/20667 %U http://games.jmir.org/2020/3/e20667/ %U https://doi.org/10.2196/20667 %U http://www.ncbi.nlm.nih.gov/pubmed/32880577 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e17297 %T Impact of Co-Designed Game Learning on Cultural Safety in Colombian Medical Education: Protocol for a Randomized Controlled Trial %A Pimentel,Juan %A Cockcroft,Anne %A Andersson,Neil %+ CIET-PRAM, Department of Family Medicine, McGill University, 3rd Floor, Suite 300, 5858 Chemin de la Côte-des-Neiges, Montreal, QC, H3S1P1, Canada, 1 514 398 7375, juan.pimentel@mail.mcgill.ca %K transformative learning %K medical education %K cultural safety %K participatory research %K game jam %D 2020 %7 31.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cultural safety encourages practitioners to examine how their own culture shapes their clinical practice and to respect their patients’ worldviews. Lack of cultural safety in health care is linked to stigma and discrimination toward culturally diverse patients. Training in cultural safety poses considerable challenges. It is an unappealing subject for medical students and requires behavioral changes in their clinical practice. Game jams—collaborative workshops to create and play games—have recently shown effectiveness and engaging potential in university-level education. Objective: The trial aims to determine if medical students’ participation in a game jam to design an educational game on cultural safety is more effective than a standard lesson on cultural safety in terms of change in the students’ self-reported intended patient-oriented behavior. Methods: A parallel-group, 2-arm randomized controlled trial with a 1:1 allocation ratio will randomize 340 medical students and 60 medical interns (n=400) at the Faculty of Medicine at La Sabana University, Colombia (170 students and 30 medical interns to each arm). The intervention group will participate in an 8-hour game jam comprising (1) a preliminary lecture on cultural safety and game design, (2) a game building session where groups of students will create educational games about cultural safety, and (3) a play-test session in which students will play and learn from each other’s games. The control group will receive a standard lesson, including a 2-hour lecture on cultural safety, followed by a 6-hour workshop to create posters about cultural safety. Web-based self-administered 30-item Likert-type questionnaires will assess cultural safety self-reported intended behavior before, immediately after, and 6 months after the intervention. An intention-to-treat approach will use a t-test with 95% CIs to determine the significance of the effect of the intervention, including within- and between-group comparisons. The qualitative most significant change technique will explore the impact of the intervention on the clinical experience of the students. Results: Study enrollment began in July 2019. A total of 531 students completed the baseline survey and were randomized. Data collection is expected to be complete by July 2020, and results are expected in October 2020. The study was approved by the institutional review board of the Faculty of Medicine at McGill University (May 31, 2017) and by the Subcommittee for Research of the Faculty of Medicine at La Sabana University (approval number 445). Conclusions: The research will develop participatory methods in game-based learning co-design that might be relevant to other subjects. Ultimately, it should foster improved cultural safety skills for medical students, improve the quality of health services for diverse cultural groups, and contribute to enhanced population health. Game learning may provide an innovative solution to a long-standing and neglected problem in medical education, helping to meet the educational expectations and needs of millennial medical students. Trial Registration: ISRCTN Registry ISRCTN14261595; http://www.controlled-trials.com/ISRCTN14261595 %M 32442146 %R 10.2196/17297 %U https://www.researchprotocols.org/2020/8/e17297 %U https://doi.org/10.2196/17297 %U http://www.ncbi.nlm.nih.gov/pubmed/32442146 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e16947 %T Virtual Reality–Based Executive Function Rehabilitation System for Children With Traumatic Brain Injury: Design and Usability Study %A Shen,Jiabin %A Xiang,Henry %A Luna,John %A Grishchenko,Alice %A Patterson,Jeremy %A Strouse,Robert V %A Roland,Maxwell %A Lundine,Jennifer P %A Koterba,Christine H %A Lever,Kimberly %A Groner,Jonathan I %A Huang,Yungui %A Lin,En-Ju Deborah %+ Research Information Solutions and Innovation, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States, 1 6143553071, deborah.lin@nationwidechildrens.org %K traumatic brain injury %K virtual reality %K neurological rehabilitation %K executive function %K cognitive rehabilitation %D 2020 %7 25.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. Objective: This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. Methods: The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. Results: Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. Conclusions: This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI. %M 32447275 %R 10.2196/16947 %U http://games.jmir.org/2020/3/e16947/ %U https://doi.org/10.2196/16947 %U http://www.ncbi.nlm.nih.gov/pubmed/32447275 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e14920 %T Parents of Adolescents Perspectives of Physical Activity, Gaming and Virtual Reality: Qualitative Study %A McMichael,Lucy %A Farič,Nuša %A Newby,Katie %A Potts,Henry W W %A Hon,Adrian %A Smith,Lee %A Steptoe,Andrew %A Fisher,Abi %+ Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, United Kingdom, 44 020776794466 ext 41914, nfaric@gmail.com %K exercise %K obesity %K video games %K adolescent %K adolescence %K sports %K health %K leisure activities %K virtual reality %D 2020 %7 25.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) exergaming may be a promising avenue to engage adolescents with physical activity. Since parental support is a consistent determinant of physical activity in adolescents, it is crucial to gather the views of parents of adolescents about this type of intervention. Objective: This study aimed to interview parents of younger adolescents (13-17 years old) about physical activity, gaming, and VR as part of the larger vEngage study. Methods: Semistructured interviews were conducted with 18 parents of adolescents. Data were synthesized using framework analysis. Results: Parents believed that encouraging physical activity in adolescents was important, particularly for mental health. Most parents felt that their children were not active enough. Parents reported their adolescents regularly gamed, with mostly negative perceptions of gaming due to violent content and becoming addicted. Parents discussed an inability to relate to gaming due to “generational differences,” but an exception was exergaming, which they had played with their children in the past (eg, Wii Fit). Specific recommendations for promoting a VR exergaming intervention were provided, but ultimately parents strongly supported harnessing gaming for any positive purpose. Conclusions: The current study suggests promise for a VR exergaming intervention, but this must be framed in a way that addresses parental concerns, particularly around addiction, violence, and safety, without actively involving their participation. While parents would rather their children performed “real-world” physical activity, they believed the key to engagement was through technology. Overall, there was the perception that harnessing gaming and sedentary screen time for a positive purpose would be strongly supported. %M 32840487 %R 10.2196/14920 %U http://games.jmir.org/2020/3/e14920/ %U https://doi.org/10.2196/14920 %U http://www.ncbi.nlm.nih.gov/pubmed/32840487 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18888 %T Effects of Avatar Perspective on Joint Excursions Used to Play Virtual Dodgeball: Within-Subject Comparative Study %A van der Veen,Susanne M %A Stamenkovic,Alexander %A Applegate,Megan E %A Leitkam,Samuel T %A France,Christopher R %A Thomas,James S %+ Virginia Commonwealth University, 900 E Leigh St, 4th Floor, Richmond, VA, 23298, United States, 1 7405416324, smvanderveen@vcu.edu %K virtual reality %K avatar perspective %K reaching %K joint excursion %K exergaming %K exercise rehabilitation %K head mounted display %D 2020 %7 19.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Visual representation of oneself is likely to affect movement patterns. Prior work in virtual dodgeball showed greater excursion of the ankles, knees, hips, spine, and shoulder occurs when presented in the first-person perspective compared to the third-person perspective. However, the mode of presentation differed between the two conditions such that a head-mounted display was used to present the avatar in the first-person perspective, but a 3D television (3DTV) display was used to present the avatar in the third-person. Thus, it is unknown whether changes in joint excursions are driven by the visual display (head-mounted display versus 3DTV) or avatar perspective during virtual gameplay. Objective: This study aimed to determine the influence of avatar perspective on joint excursion in healthy individuals playing virtual dodgeball using a head-mounted display. Methods: Participants (n=29, 15 male, 14 female) performed full-body movements to intercept launched virtual targets presented in a game of virtual dodgeball using a head-mounted display. Two avatar perspectives were compared during each session of gameplay. A first-person perspective was created by placing the center of the displayed content at the bridge of the participant’s nose, while a third-person perspective was created by placing the camera view at the participant’s eye level but set 1 m behind the participant avatar. During gameplay, virtual dodgeballs were launched at a consistent velocity of 30 m/s to one of nine locations determined by a combination of three different intended impact heights and three different directions (left, center, or right) based on subject anthropometrics. Joint kinematics and angular excursions of the ankles, knees, hips, lumbar spine, elbows, and shoulders were assessed. Results: The change in joint excursions from initial posture to the interception of the virtual dodgeball were averaged across trials. Separate repeated-measures ANOVAs revealed greater excursions of the ankle (P=.010), knee (P=.001), hip (P=.0014), spine (P=.001), and shoulder (P=.001) joints while playing virtual dodgeball in the first versus third-person perspective. Aligning with the expectations, there was a significant effect of impact height on joint excursions. Conclusions: As clinicians develop treatment strategies in virtual reality to shape motion in orthopedic populations, it is important to be aware that changes in avatar perspective can significantly influence motor behavior. These data are important for the development of virtual reality assessment and treatment tools that are becoming increasingly practical for home and clinic-based rehabilitation. %M 32812885 %R 10.2196/18888 %U http://games.jmir.org/2020/3/e18888/ %U https://doi.org/10.2196/18888 %U http://www.ncbi.nlm.nih.gov/pubmed/32812885 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e16655 %T A Serious Game on the First-Aid Procedure in Choking Scenarios: Design and Evaluation Study %A Boada,Imma %A Rodriguez Benitez,Antonio %A Thió-Henestrosa,Santiago %A Soler,Josep %+ Graphics and Imaging Laboratory, Escola Politècnica Superior, Edifici Politècnica IV, C/ de la Universitat de Girona, 6, Campus Montilivi, 17003 Girona, Spain, 34 618334786, imma.boada@udg.edu %K choking %K prevention %K first-aid procedure %K first-aid education %D 2020 %7 19.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Choking is one of the causes of unintentional injury death. Gaining the knowledge of the first-aid procedure that has to be applied in case of choking can increase the chances of survival of persons with choking. Serious games can be a good channel for educating people about choking scenarios and the actions to be taken to save the persons with choking. Objective: The objective of this study is to present and evaluate the effectiveness of a serious game designed to prevent choking and to promote the first-aid procedure that needs to be applied in case of choking. Methods: In this study, we present a serious game as a set of minigames that reproduces the main steps of the protocol for the first-aid performed in choking. In the proposed game, the player acquires the role of a helper who has to save the person in a choking emergency by applying the main steps of the protocol. Time and score restrictions are imposed to pass each minigame. To test this game, we performed a pilot study with 48 high school students. Different tests were performed to assess the students’ preferences and their knowledge on choking before and after playing the proposed game. The obtained results were analyzed using Mann-Whitney U test when a grade variable was involved and by using Fisher exact test when 2 categorical variables were involved. Results: The findings of our study showed that the players enjoyed the game. No statistical differences were detected when considering the gender of the player, their preferences for video games, or their previous experience in choking emergencies. By comparing the knowledge of these students before and after playing the game, we found that all the indicators of the knowledge about how to act in case of a choking emergency were improved through this serious game. Conclusions: The findings of our study show that the proposed game is a good strategy for promoting and teaching first-aid procedures in choking emergencies to nonexperts in this field. %M 32812882 %R 10.2196/16655 %U http://games.jmir.org/2020/3/e16655/ %U https://doi.org/10.2196/16655 %U http://www.ncbi.nlm.nih.gov/pubmed/32812882 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18637 %T Augmented Reality System for Digital Rectal Examination Training and Assessment: System Validation %A Muangpoon,Theerapat %A Haghighi Osgouei,Reza %A Escobar-Castillejos,David %A Kontovounisios,Christos %A Bello,Fernando %+ Faculty of Medicine, Department of Surgery and Cancer, Imperial College London, Rm H38, ICCESS, 3rd Floor, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, United Kingdom, 44 7940419331, r.haghighi-osgouei@imperial.ac.uk %K Augmented Reality %K Digital Rectal Examination (DRE) %K Magnetic Tracker %K Pressure Sensor %K Medical Education %K Usability %D 2020 %7 13.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital rectal examination is a difficult examination to learn and teach because of limited opportunities for practice; however, the main challenge is that students and tutors cannot see the finger when it is palpating the anal canal and prostate gland inside the patients. Objective: This paper presents an augmented reality system to be used with benchtop models commonly available in medical schools with the aim of addressing the problem of lack of visualization. The system enables visualization of the examining finger, as well as of the internal organs when performing digital rectal examinations. Magnetic tracking sensors are used to track the movement of the finger, and a pressure sensor is used to monitor the applied pressure. By overlaying a virtual finger on the real finger and a virtual model on the benchtop model, students can see through the examination and finger maneuvers. Methods: The system was implemented in the Unity game engine (Unity Technologies) and uses a first-generation HoloLens (Microsoft Inc) as an augmented reality device. To evaluate the system, 19 participants (9 clinicians who routinely performed digital rectal examinations and 10 medical students) were asked to use the system and answer 12 questions regarding the usefulness of the system. Results: The system showed the movement of an examining finger in real time with a frame rate of 60 fps on the HoloLens and accurately aligned the virtual and real models with a mean error of 3.9 mm. Users found the movement of the finger was realistic (mean 3.9, SD 1.2); moreover, they found the visualization of the finger and internal organs were useful for teaching, learning, and assessment of digital rectal examinations (finger: mean 4.1, SD 1.1; organs: mean 4.6, SD 0.8), mainly targeting a novice group. Conclusions: The proposed augmented reality system was designed to improve teaching and learning of digital rectal examination skills by providing visualization of the finger and internal organs. The initial user study proved its applicability and usefulness. %M 32788146 %R 10.2196/18637 %U https://www.jmir.org/2020/8/e18637 %U https://doi.org/10.2196/18637 %U http://www.ncbi.nlm.nih.gov/pubmed/32788146 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17367 %T The Acceptability and Impact of the Xploro Digital Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study %A Bray,Lucy %A Sharpe,Ashley %A Gichuru,Phillip %A Fortune,Peter-Marc %A Blake,Lucy %A Appleton,Victoria %+ Faculty of Health, Social Care and Medicine, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, United Kingdom, 44 01695 657231, brayl@edgehill.ac.uk %K health literacy %K augmented reality %K children %K procedure %K health %K artificial intelligence %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. Objective: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent’s procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. Methods: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children’s hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. Results: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=−2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=−4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. Conclusions: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use. %M 32780025 %R 10.2196/17367 %U http://www.jmir.org/2020/8/e17367/ %U https://doi.org/10.2196/17367 %U http://www.ncbi.nlm.nih.gov/pubmed/32780025 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18633 %T Effect of Computer Debriefing on Acquisition and Retention of Learning After Screen-Based Simulation of Neonatal Resuscitation: Randomized Controlled Trial %A Michelet,Daphne %A Barre,Jessy %A Truchot,Jennifer %A Piot,Marie-Aude %A Cabon,Philippe %A Tesniere,Antoine %+ Ilumens Platform of Simulation in Healthcare, Université de Paris, 45 rue des Saints Pères, Paris, 75006, France, 33 326832537, daphnemichelet@gmail.com %K screen-based simulation %K debriefing %K neonatal resuscitation %K simulation %K medical education %K midwifery %K neonatal %D 2020 %7 11.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Debriefing is key in a simulation learning process. Objective: This study focuses on the impact of computer debriefing on learning acquisition and retention after a screen-based simulation training on neonatal resuscitation designed for midwifery students. Methods: Midwifery students participated in 2 screen-based simulation sessions, separated by 2 months, session 1 and session 2. They were randomized in 2 groups. Participants of the debriefing group underwent a computer debriefing focusing on technical skills and nontechnical skills at the end of each scenario, while the control group received no debriefing. In session 1, students participated in 2 scenarios of screen-based simulation on neonatal resuscitation. During session 2, the students participated in a third scenario. The 3 scenarios had an increasing level of difficulty, with the first representing the baseline level. Assessments included a knowledge questionnaire on neonatal resuscitation, a self-efficacy rating, and expert evaluation of technical skills as per the Neonatal Resuscitation Performance Evaluation (NRPE) score and of nontechnical skills as per the Anaesthetists’ Non-Technical Skills (ANTS) system. We compared the results of the groups using the Mann-Whitney U test. Results: A total of 28 midwifery students participated in the study. The participants from the debriefing group reached higher ANTS scores than those from the control group during session 1 (13.25 vs 9; U=47.5; P=.02). Their scores remained higher, without statistical difference during session 2 (10 vs 7.75; P=.08). The debriefing group had higher self-efficacy ratings at session 2 (3 vs 2; U=52; P=.02). When comparing the knowledge questionnaires, the significant baseline difference (13 for debriefing group vs 14.5 for control group, P=.05) disappeared at the end of session 1 and in session 2. No difference was found for the assessment of technical skills between the groups or between sessions. Conclusions: Computer debriefing seems to improve nontechnical skills, self-efficacy, and knowledge when compared to the absence of debriefing during a screen-based simulation. This study confirms the importance of debriefing after screen-based simulation. Trial Registration: ClinicalTrials.gov NCT03844009; https://clinicaltrials.gov/ct2/show/NCT03844009 %M 32780021 %R 10.2196/18633 %U http://games.jmir.org/2020/3/e18633/ %U https://doi.org/10.2196/18633 %U http://www.ncbi.nlm.nih.gov/pubmed/32780021 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18687 %T Mapping Behavioral Health Serious Game Interventions for Adults With Chronic Illness: Scoping Review %A Thomas,Teresa Hagan %A Sivakumar,Varshini %A Babichenko,Dmitriy %A Grieve,Victoria L B %A Klem,Mary Lou %+ School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, United States, 1 4126243799, t.thomas@pitt.edu %K review %K chronic disease %K behavioral sciences %K video games %D 2020 %7 30.7.2020 %9 Review %J JMIR Serious Games %G English %X Background: Serious games for health are increasingly being used to address health outcomes in patients with chronic illnesses. These studies vary in their study designs, patient populations, frameworks, outcome variables, and degree of specificity of the serious game intervention. Objective: This scoping review aims to clarify the conceptual features of the existing research related to serious games designed to improve cognitive and behavioral outcomes in adults with chronic illness. Methods: We applied the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for scoping reviews (PRISMA-ScR) methodology, including an a priori research question. We searched 4 electronic databases to identify articles published through November 2019. Inclusion criteria encompassed (1) adults 18 years or older; (2) patients with a diagnosis of chronic illness; (3) a serious game intervention; and (4) defined patient outcomes that assess patients’ behavioral, cognitive, or health outcomes. Results: Of the 3305 articles identified, 38 were included in the review. We charted and analyzed the theoretical frameworks, key concepts, and outcome variables of these studies with summaries of features across articles. The majority of studies used a randomized controlled trial design (23/38, 61%), included a custom serious game intervention (22/38, 58%), and lacked a theoretical framework (25/38, 66%). Common outcome variables included quality of life (16/38, 42%), mood (15/38, 39%), cognitive function (13/38, 34%), symptoms (12/38, 32%), and physical activity (9/38, 24%). Key differences between studies included whether or not serious games aimed to train versus teach patients, be widely accessible versus tailored interventions, or replace versus complement current treatments. Conclusions: This scoping review defines the current landscape of research in serious games for health research targeting behavioral and cognitive outcomes in adults with chronic disease. Studies have addressed a variety of patient populations and diverse patient outcomes. Researchers wanting to build on the current research should integrate theoretical frameworks into the design of the intervention and trial to more clearly articulate the active ingredients and mechanisms of serious games. %M 32729836 %R 10.2196/18687 %U http://games.jmir.org/2020/3/e18687/ %U https://doi.org/10.2196/18687 %U http://www.ncbi.nlm.nih.gov/pubmed/32729836 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14861 %T An Internet-Based Psychological Intervention With a Serious Game to Improve Vitality, Psychological and Physical Condition, and Immune Function in Healthy Male Adults: Randomized Controlled Trial %A Schakel,Lemmy %A Veldhuijzen,Dieuwke S %A van Middendorp,Henriët %A Prins,Corine %A Drittij,Anne M H F %A Vrieling,Frank %A Visser,Leo G %A Ottenhoff,Tom H M %A Joosten,Simone A %A Evers,Andrea W M %+ Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, Leiden, Netherlands, 31 715273627, a.evers@fsw.leidenuniv.nl %K BCG vaccination %K cognitive behavioral therapy %K immune system %K stress %K ICBT %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Recently, internet-based cognitive behavioral therapy (ICBT) and serious gaming interventions have been suggested to enhance accessibility to interventions and engagement in psychological interventions that aim to promote health outcomes. Few studies, however, have investigated their effectiveness in the context of simulated real-life challenges. Objective: We aimed to examine the effectivity of a guided ICBT combined with a serious gaming intervention in improving self-reported psychophysiological and immunological health endpoints in response to psychophysiological and immune-related challenges. Methods: Sixty-nine healthy men were randomly assigned to the intervention condition, receiving ICBT combined with serious gaming for 6 weeks, or the control condition, receiving no intervention. Self-reported vitality was the primary endpoint. Other self-reported psychophysiological and immunological endpoints were assessed following various challenges, including a bacillus Calmette-Guérin vaccination evoking pro-inflammatory responses, 1 and 4 weeks after the intervention period. Results: Although the intervention did not affect vitality-associated parameters, self-reported sleep problems (P=.027) and bodily sensations (P=.042) were lower directly after the intervention compared with controls. Furthermore, wellbeing (P=.024) was higher in the intervention group after the psychophysiological challenges. Although no significant group differences were found for the psychophysiological and immunological endpoints, the data provided preliminary support for increased immunoglobulin antibody responses at the follow-up time points (P<.05). Differential chemokine endpoints between conditions were observed at the end of the test day. Conclusions: The present study provides some support for improving health endpoints with an innovative ICBT intervention. Future research should replicate and further extend the present findings by consistently including challenges and a wide range of immune parameters into the study design. Trial Registration: Nederlands Trial Register NTR5610; https://www.trialregister.nl/trial/5466 %M 32706667 %R 10.2196/14861 %U https://www.jmir.org/2020/7/e14861 %U https://doi.org/10.2196/14861 %U http://www.ncbi.nlm.nih.gov/pubmed/32706667 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14865 %T Habits and Attitudes of Video Gaming and Information Technology Use in People with Schizophrenia: Cross-Sectional Survey %A Choi,William TH %A Yu,Dan KS %A Wong,Terry %A Lantta,Tella %A Yang,Min %A Välimäki,Maritta %+ Department of Nursing Science, Faculty of Medicine, University of Turku, ICT-City, A-wing, 5th floor, Joukahaisenkatu 3–5, Turku, 20520, Finland, 358 29 450 236, maritta.valimaki@polyu.edu.hk %K video gaming %K internet %K information technology %K schizophrenia %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information technology and video gaming have potential advantages in the treatment of schizophrenia. However, information regarding the habits and attitudes related to internet use and video gaming in people with schizophrenia is limited. Objective: The aim of this study was to explore the habits and attitudes regarding video gaming and information technology usage and their associated factors in people with schizophrenia in Hong Kong. Methods: In this cross-sectional survey, service users with schizophrenia were recruited from 6 halfway hostels and 7 integrated centers for mental wellness in Hong Kong. A 79-item self-report questionnaire was utilized to explore the habits of internet use and video gaming in these people with schizophrenia. The attitude toward video gaming was assessed using the Gaming Attitudes, Motivations, and Experiences Scales. Of the 148 individuals in a convenience sample who were invited to participate in this study, 110 willingly participated (a response rate of 74.3%). The data were analyzed using descriptive statistics, a two-tailed independent t test, Pearson correlation, and principal analysis with 3 methods of rotation (varimax, equimax, and promax). Results: Most participants (100/110, 90.9%) had access to the internet and half of them (54/110, 49.1%) used the internet daily mostly to watch videos (66/110, 60.0%) or read news or books, etc (42/110, 38.2%). One-third of the participants (36/110, 32.7%) used the internet to play web-based games, and most of them (88/110, 80.0%) had played a video game in the past year. The most favorable gaming platforms were cellular phones (43/88, 49%) followed by computers (19/88, 22%) and arcade cabinets (6/88, 7%). The most favorable game genre was action games (34/145, 23.4%). Those who had a bachelor’s degree or higher scored lower in social interaction than those with a lower education level (P=.03). Those who played video games daily scored higher in the category of story than those who did not play daily (t86=2.03, P=.05). The most popular gaming category was autonomy and the least popular categories were violent catharsis and violent reward. Two motives, “social playing” and “evasive playing,” were formed to describe the characteristics of playing video games. Conclusions: Our data showed a high internet utilization rate among people with schizophrenia in Hong Kong. Only a few of them used the internet to search for health-related information. Our study also exemplified the unique habits of gaming among the participants. Health care professionals could utilize video games to engage people with schizophrenia and promote coping with stress and provide social skills training to such people with schizophrenia. Identification of the gaming attitudes can contribute to the development of serious games for the schizophrenic population. Further investigation is vital for the promotion of mental health through web-based platforms. %M 32459646 %R 10.2196/14865 %U http://www.jmir.org/2020/7/e14865/ %U https://doi.org/10.2196/14865 %U http://www.ncbi.nlm.nih.gov/pubmed/32459646 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16365 %T The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps %A Fijačko,Nino %A Gosak,Lucija %A Cilar,Leona %A Novšak,Alenka %A Creber,Ruth Masterson %A Skok,Pavel %A Štiglic,Gregor %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, Slovenia, 386 23004764, nino.fijacko@um.si %K mobile health %K oral health care %K gamification %K mobile store %K evidence-based dentistry %K behavior change technique %K Mobile Application Rating Scale user version %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches. Objective: The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene. Methods: We searched six online app stores using four search terms (“oral hygiene game,” “oral hygiene gamification,” “oral hygiene brush game,” and “oral hygiene brush gamification”). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change. Results: Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94%), virtual characters (14/17, 82%), and fantasy (13/17, 76%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app. Conclusions: The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement. %M 32673235 %R 10.2196/16365 %U https://mhealth.jmir.org/2020/7/e16365 %U https://doi.org/10.2196/16365 %U http://www.ncbi.nlm.nih.gov/pubmed/32673235 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17100 %T Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers’ Learning Gain: Randomized Controlled Trial %A Tuti,Timothy %A Winters,Niall %A Edgcombe,Hilary %A Muinga,Naomi %A Wanyama,Conrad %A English,Mike %A Paton,Chris %+ Kellogg College, University of Oxford, 60 Banbury Road, Oxford, OX2 6PN, United Kingdom, 44 7501966958, timothy.tuti@kellogg.ox.ac.uk %K neonatal mortality %K education %K emergency medical services %K global health %K smartphone %K feedback %K health workforce %K developing countries %K mobile phone %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. Objective: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. Methods: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants’ personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. Results: The effect of adaptive feedback on care providers’ learning gain was found to be g=0.09 (95% CI −0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. Conclusions: There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). Trial Registration: Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836 International Registered Report Identifier (IRRID): RR2-10.2196/13034 %M 32628115 %R 10.2196/17100 %U https://www.jmir.org/2020/7/e17100 %U https://doi.org/10.2196/17100 %U http://www.ncbi.nlm.nih.gov/pubmed/32628115 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18781 %T A Web-Based Mobile App (INTERACCT App) for Adolescents Undergoing Cancer and Hematopoietic Stem Cell Transplantation Aftercare to Improve the Quality of Medical Information for Clinicians: Observational Study %A Lawitschka,Anita %A Buehrer,Stephanie %A Bauer,Dorothea %A Peters,Konrad %A Silbernagl,Marisa %A Zubarovskaya,Natalia %A Brunmair,Barbara %A Kayali,Fares %A Hlavacs,Helmut %A Mateus-Berr,Ruth %A Riedl,David %A Rumpold,Gerhard %A Peters,Christina %+ Stem Cell Transplantation-Outpatient and Aftercare Clinic, St. Anna Children’s Hospital, Medical University Vienna, Kinderspitalgasse 15, 1090 Vienna, Vienna, Austria, 43 1 40 170 ext 2900, anita.lawitschka@stanna.at %K mobile app %K adolescents %K cancer %K stem cell transplant %K self-reported heath status %K medical information exchange %K mobile phone %D 2020 %7 30.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A growing number of cancer and hematopoietic stem cell transplant (HSCT) survivors require long-term follow-up with optimal communication schemes, and patients' compliance is crucial. Adolescents have various unmet needs. Regarding self-report of symptoms and health status, users of mobile apps showed enhanced compliance. Currently, HSCT aftercare at the HSCT outpatient clinic of the St. Anna Children’s Hospital in Vienna, Austria, is based on handwritten diaries, carrying various disadvantages. Recently, we developed the prototype of a web-based, self-monitoring gamified mobile app tailored for adolescents: the INTERACCT (Integrating Entertainment and Reaction Assessment into Child Cancer Therapy) app. Objective: This observational, prospective study evaluated the usability of the INTERACCT app for tracking real-time self-reported symptoms and health status data in adolescent HSCT patients and a healthy matched control group. The primary outcome of the study was the quality of the self-reported medical information. We hypothesized that the mobile app would provide superior medical information for the clinicians than would the handwritten diaries. Methods: Health data were reported via paper diary and mobile app for 5 consecutive days each. The quality of medical information was rated on a 5-point scale independently and blinded by two HSCT clinicians, and the duration of use was evaluated. A total of 52 participant questionnaires were assessed for gaming patterns and device preferences, self-efficacy, users’ satisfaction, acceptability, and suggestions for improvement of the mobile app. Interrater reliability was calculated with the intraclass correlation coefficient, based on a two-way mixed model; one-way repeated-measures analysis of variance and t tests were conducted post hoc. Descriptive methods were used for correlation with participants’ demographics. For users’ satisfaction and acceptability of the mobile app, the median and the IQR were calculated. Results: Data from 42 participants—15 patients and 27 healthy students—with comparable demographics were evaluated. The results of our study indicated a superiority of the quality of self-reported medical data in the INTERACCT app over traditional paper-and-pencil assessment (mobile app: 4.14 points, vs paper-based diary: 3.77 points, P=.02). The mobile app outperformed paper-and-pencil assessments mainly among the patients, in particular among patients with treatment-associated complications (mobile app: 4.43 points, vs paper-based diary: 3.73 points, P=.01). The mobile app was used significantly longer by adolescents (≥14 years: 4.57 days, vs ≤13 years: 3.14 days, P=.03) and females (4.76 days for females vs 2.95 days for males, P=.004). This corresponds with a longer duration of use among impaired patients with comorbidities. User satisfaction and acceptability ratings for the mobile app were high across all groups, but adherence to entering a large amount of data decreased over time. Based on our results, we developed a case vignette of the target group. Conclusions: Our study was the first to show that the quality of patient-reported medical information submitted via the INTERACCT app embedded in a serious game is superior to that submitted via a handwritten diary. In light of these results, a refinement of the mobile app supported by a machine learning approach is planned within an international research project. %M 32602847 %R 10.2196/18781 %U http://mhealth.jmir.org/2020/6/e18781/ %U https://doi.org/10.2196/18781 %U http://www.ncbi.nlm.nih.gov/pubmed/32602847 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 4 %N 1 %P e16354 %T Assisting Home-Based Resistance Training for Normotensive and Prehypertensive Individuals Using Ambient Lighting and Sonification Feedback: Sensor-Based System Evaluation %A Radha,Mustafa %A den Boer,Niels %A Willemsen,Martijn C %A Paardekooper,Thom %A IJsselsteijn,Wijnand A %A Sartor,Francesco %+ Royal Philips, High Tech Campus 34, Eindhoven, 5656 AE, Netherlands, 31 681497376, francesco.sartor@philips.com %K hypertension %K sonification %K respiratory guidance %K intrinsic motivation %K physical exertion %D 2020 %7 29.6.2020 %9 Original Paper %J JMIR Cardio %G English %X Background: Physical exercise is an effective lifestyle intervention to improve blood pressure. Although aerobic sports can be performed anywhere, resistance exercises are traditionally performed at the gym; extending the latter to the home setting may promote an increase in the number of practitioners. Objective: This study aims to evaluate a sensor-based system that guides resistance exercises through ambient lighting and sonification (A/S) feedback in a home setting in 34 study participants who were normotensive and prehypertensive. Methods: Participants took part in a 1.5-hour exercise session in which they experienced the A/S feedback (ie, experimental condition) as well as a control condition (ie, no feedback) and a reference condition (ie, verbal feedback through a human remote coach). The system was evaluated for improving exercise form (range of motion, timing, and breathing patterns) as well as psychophysiological experience (perceived exertion, attentional focus, competence, and motivation). Results: A/S feedback was significantly better than the control for concentric (mean 2.48, SD 0.75 seconds; P<.001) and eccentric (mean 2.92, SD 1.05 seconds; P<.001) contraction times, concentric range of motion consistency (mean 15.64, SD 8.31 cm vs mean 17.94, SD 9.75 cm; P<.001), and perceived exertion (mean 3.37, SD 0.78 vs mean 3.64, SD 0.76; P<.001). However, A/S feedback did not outperform verbal feedback on any of these measures. The breathing technique was best in the control condition (ie, without any feedback). Participants did not show more positive changes in perceived competence with A/S feedback or verbal feedback. Conclusions: The system seemed to improve resistance exercise execution and perception in comparison with the control, but did not outperform a human tele-coach. Further research is warranted to improve the breathing technique. %M 32597789 %R 10.2196/16354 %U https://cardio.jmir.org/2020/1/e16354 %U https://doi.org/10.2196/16354 %U http://www.ncbi.nlm.nih.gov/pubmed/32597789 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14030 %T Controlling for Placebo Effects in Computerized Cognitive Training Studies With Healthy Older Adults From 2016-2018: Systematic Review %A Masurovsky,Alexander %+ Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Unter den Linden 6, Berlin, 10099, Germany, 49 30 2093 89768, masurova@student.hu-berlin.de %K computerized cognitive training %K brain training %K placebo %K active control %K elderly %K older adults %D 2020 %7 26.6.2020 %9 Review %J JMIR Serious Games %G English %X Background: Computerized cognitive training has been proposed as a potential solution to age-related cognitive decline. However, published findings from evaluation studies of cognitive training games, including metastudies and systematic reviews, provide evidence both for and against transferability from trained tasks to untrained cognitive ability. There continues to be no consensus on this issue from the scientific community. Some researchers have proposed that the number of results supporting the efficacy of cognitive training may be inflated due to placebo effects. It has been suggested that placebo effects need to be better controlled by using an active control and measuring participant expectations for improvement in outcome measures. Objective: This review examined placebo control methodology for recent evaluation studies of computerized cognitive training programs with older adult subjects, specifically looking for the use of an active control and measurement of expectations. Methods: Data were extracted from PubMed. Evaluation studies of computerized cognitive training with older adult subjects (age ≥50 years) published between 2016 and 2018 were included. Methods sections of studies were searched for (1) control type (active or passive) and subtype (active: active-ingredient or similar-form; passive: no-contact or passive-task); (2) if expectations were measured, how were they measured, and whether they were used in analysis; and (3) whether researchers acknowledged a lack of active control and lack of expectation measurement as limitations (where appropriate). Results: Of the 19 eligible studies, 4 (21%) measured expectations, and 9 (47%) included an active control condition, all of which were of the similar-form type. The majority of the studies (10/19, 53%) used only a passive control. Of the 9 studies that found results supporting the efficacy of cognitive training, 5 were for far transfer effects. Regarding the limitations, due to practical considerations, the search was limited to one source (PubMed) and to search results only. The search terms may have been too restrictive. Recruitment methods were not analyzed, although this aspect of research may play a critical role in systematically forming groups with different expectations for improvement. The population was limited to healthy older adults, while evaluation studies include other populations and cognitive training types, which may exhibit better or worse placebo control than the studies examined in this review. Conclusions: Poor placebo control was present in 47% (9/19) of the reviewed studies; however, the studies still published results supporting the effectiveness of cognitive training programs. Of these positive results, 5 were for far transfer effects, which form the basis for broad claims by cognitive training game makers about the scientific validity of their product. For a minimum level of placebo control, future evaluation studies should use a similar-form active control and administer a questionnaire to participants at the end of the training period about their own perceptions of improvement. Researchers are encouraged to think of more methods for the valid measure of expectations at other time points in the training. %M 32589159 %R 10.2196/14030 %U http://games.jmir.org/2020/2/e14030/ %U https://doi.org/10.2196/14030 %U http://www.ncbi.nlm.nih.gov/pubmed/32589159 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e13834 %T Digital Game Interventions for Youth Mental Health Services (Gaming My Way to Recovery): Protocol for a Scoping Review %A Ferrari,Manuela %A McIlwaine,Sarah V %A Reynolds,Jennifer Ann %A Archie,Suzanne %A Boydell,Katherine %A Lal,Shalini %A Shah,Jai L %A Henderson,Joanna %A Alvarez-Jimenez,Mario %A Andersson,Neil %A Boruff,Jill %A Nielsen,Rune Kristian Lundedal %A Iyer,Srividya N %+ Douglas Mental Health University Institute, 6875 Boulevard LaSalle, Perry C3 E-3102, Montreal, QC, H4H 1R3, Canada, 1 514 761 6131 ext 3445, manuela.ferrari@douglas.mcgill.ca %K mental health %K mental disorders %K biomedical technology %K video games %K virtual reality %K mental health services %D 2020 %7 24.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Digital or video games are played by millions of adolescents and young adults around the world and are one of the technologies used by youths to access mental health services. Youths with mental health problems strongly endorse the use of technologies, including mobile and online platforms, to receive information, support their treatment journeys (eg, decision-making tools), and facilitate recovery. A growing body of literature explores the advantages of playing digital games for improving attention span and memory, managing emotions, promoting behavior change, and supporting treatment for mental illness (eg, anxiety, depression, or posttraumatic stress disorder). The research field has also focused on the negative impact of video games, describing potential harms related to aggression, addiction, and depression. To promote clarity on this matter, there is a great need for knowledge synthesis offering recommendations on how video games can be safely and effectively adopted and integrated into youth mental health services. Objective: The Gaming My Way to Recovery scoping review project assesses existing evidence on the use of digital game interventions within the context of mental health services for youths (aged 11-29 years) using the stepped care model as the conceptual framework. The research question is as follows: For which youth mental health conditions have digital games been used and what broad objectives (eg, prevention, treatment) have they addressed? Methods: Using the methodology proposed by Arksey and O’Malley, this scoping review will map the available evidence on the use of digital games for youths between 11 and 29 years old with mental health or substance use problems, or both. Results: The review will bring together evidence-based knowledge to assist mental health providers and policymakers in evaluating the potential benefits and risks of these interventions. Following funding of the project in September 2018, we completed the search in November 2018, and carried out data screening and stakeholder engagement activities during preparation of the protocol. We will conduct a knowledge synthesis based on specific disorders, treatment level and modality, type of service, population, settings, ethical practices, and user engagement and offer recommendations concerning the integration of video game technologies and programs, future research and practice, and knowledge dissemination. Conclusions: Digital game interventions employ unique, experiential, and interactive features that potentially improve skills and facilitate learning among players. Digital games may also provide a new treatment platform for youths with mental health conditions. Assessing current knowledge on video game technology and interventions may potentially improve the range of interventions offered by youth mental health services while supporting prevention, intervention, and treatment. International Registered Report Identifier (IRRID): PRR1-10.2196/13834 %M 32579117 %R 10.2196/13834 %U http://www.researchprotocols.org/2020/6/e13834/ %U https://doi.org/10.2196/13834 %U http://www.ncbi.nlm.nih.gov/pubmed/32579117 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15635 %T Virtual Reality Games and the Role of Body Involvement in Enhancing Positive Emotions and Decreasing Anxiety: Within-Subjects Pilot Study %A Pallavicini,Federica %A Pepe,Alessandro %+ Department of Human Sciences for Education, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milan, 20100, Italy, 39 0264484903, federica.pallavicini@gmail.com %K virtual reality %K virtual reality gaming %K video games %K emotions %K positive emotions %K anxiety %K state anxiety %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the last few years, the introduction of immersive technologies, especially virtual reality, into the gaming market has dramatically altered the traditional concept of video games. Given the unique features of virtual reality in terms of interaction and its ability to completely immerse the individual into the game, this technology should increase the propensity for video games to effectively elicit positive emotions and decrease negative emotions and anxiety in the players. However, to date, few studies have investigated the ability of virtual reality games to induce positive emotions, and the possible effect of this new type of video game in diminishing negative emotions and anxiety has not yet been tested. Furthermore, given the critical role of body movement in individuals’ well-being and in emotional responses to video games, it seems critical to investigate how body involvement can be exploited to modulate the psychological benefits of virtual reality games in terms of enhancing players’ positive emotions and decreasing negative emotions and anxiety. Objective: This within-subjects study aimed to explore the ability of commercial virtual reality games to induce positive emotions and diminish negative emotions and state anxiety of the players, investigating the effects of the level of body involvement requested by the game (ie, high vs low). Methods: A total of 36 young adults played a low body-involvement (ie, Fruit Ninja VR) and a high body-involvement (ie, Audioshield) video game in virtual reality. The Visual Analogue Scale (VAS) and the State-Trait Anxiety Inventory, Form-Y1 (STAI-Y1) were used to assess positive and negative emotions and state anxiety. Results: Results of the generalized linear model (GLM) for repeated-measures multivariate analysis of variance (MANOVA) revealed a statistically significant increase in the intensity of happiness (P<.001) and surprise (P=.003) and, in parallel, a significant decrease in fear (P=.01) and sadness (P<.001) reported by the users. Regarding the ability to improve anxiety in the players, the results showed a significant decrease in perceived state anxiety after game play, assessed with both the STAI-Y1 (P=.003) and the VAS-anxiety (P=.002). Finally, the results of the GLM MANOVA showed a greater efficacy of the high body-involvement game (ie, Audioshield) compared to the low body-involvement game (ie, Fruit Ninja VR), both for eliciting positive emotions (happiness, P<.001; and surprise, P=.01) and in reducing negative emotions (fear, P=.05; and sadness, P=.05) and state anxiety, as measured by the STAI-Y1 (P=.05). Conclusions: The two main principal findings of this study are as follows: (1) virtual reality video games appear to be effective tools to elicit positive emotions and to decrease negative emotions and state anxiety in individuals and (2) the level of body involvement of the virtual video game has an important effect in determining the ability of the game to improve positive emotions and decrease negative emotions and state anxiety of the players. %M 32554371 %R 10.2196/15635 %U http://games.jmir.org/2020/2/e15635/ %U https://doi.org/10.2196/15635 %U http://www.ncbi.nlm.nih.gov/pubmed/32554371 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16261 %T Development and Validation of the Reasons to Exergame (RTEX) Scale in Young Adults: Exploratory Factors Analysis %A O'Loughlin,Erin %A Sabiston,Catherine M %A Kakinami,Lisa %A McGrath,Jennifer J %A Consalvo,Mia %A O'Loughlin,Jennifer L %A Barnett,Tracie A %+ Centre de Recherche du CHUM, Concordia University, 850 rue Saint-Denis, Bureau S02-370, Montreal, QC, H2X 0A9, Canada, 1 514 890 8000 ext 15853, erin_oloughlin@hotmail.com %K exergaming %K youth %K young adults %K motivation %K scale %D 2020 %7 15.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergaming is associated with positive health benefits; however, little is known about what motivates young people to exergame. Objective: This study aimed to develop a new Reasons to Exergame (RTEX) scale and describe its psychometric properties (Study 1) including test-retest reliability (Study 2). We also examined the test-retest reliability of self-report exergaming behavior measures (Study 2). Methods: We identified scale items in consultation with experts. In Study 1, we conducted an Exploratory Factor Analysis of RTEX and examined how the factors identified relate to exergaming frequency and intensity in a population-based sample of 272 young adults. In Study 2, we examined the test-retest reliability of RTEX factors and self-report measures of past-week exergaming frequency and intensity among 147 college students. Results: We identified four factors in RTEX: exergaming for fitness, exergaming for enjoyment, preferring exergaming over other gaming options, and choosing exergaming over competing interests (eg, sports). Test-retest reliability of RTEX factors (ICC 0.7-0.8) and self-report exergaming frequency (ICC 0.4-0.9) was adequate. Exergaming for fitness and enjoyment were positively associated with the frequency of exergaming with friends and family, and with exergaming intensity. Preferring exergaming over other gaming options and choosing exergaming over competing interests (eg, sports) were not related to exergaming behavior. Conclusions: RTEX is a psychometrically sound scale with four factors that measure reasons to exergame. Replication of these findings is needed in larger, more diverse samples. %M 32538792 %R 10.2196/16261 %U http://games.jmir.org/2020/2/e16261/ %U https://doi.org/10.2196/16261 %U http://www.ncbi.nlm.nih.gov/pubmed/32538792 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e17756 %T A Mobile Game (Safe City) Designed to Promote Children’s Safety Knowledge and Behaviors: Protocol for a Randomized Controlled Trial %A Wong,Rosa S %A Tung,Keith TS %A Wong,Hiu Tung %A Ho,Frederick KW %A Wong,Hing Sang %A Fu,King-Wa %A Pong,Ting Chuen %A Chan,Ko Ling %A Chow,Chun Bong %A Ip,Patrick %+ Department of Paediatrics & Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, China (Hong Kong), 852 2255 4090, patricip@hku.hk %K serious game %K safety training %K mobile game %K mobile phone %K injury prevention %K randomized controlled trial %K game-based intervention %D 2020 %7 12.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Children have high levels of curiosity and eagerness to explore. This makes them more vulnerable to danger and hazards, and they thus have a higher risk of injury. Safety education such as teaching safety rules and tips is vital to prevent children from injuries. Although game-based approaches have the potential to capture children’s attention and sustain their interest in learning, whether these new instructional approaches are more effective than traditional approaches in delivering safety messages to children remains uncertain. Objective: The aim of this study is to test the effectiveness of a game-based intervention in promoting safety knowledge and behaviors among Hong Kong school children in Grades 4-6. It will also examine the potential effect of the game-based intervention on these children’s functioning and psychosocial difficulties. Methods: This study comprises the development of a city-based role-playing game Safe City, where players are immersed as safety inspectors to prevent dangerous situations and promote safety behavior in a virtual city environment. The usability and acceptability tests will be conducted with children in Grades 4-6 who will trial the gameplay on a mobile phone. Adjustments will be made based on their feedback. A 4-week randomized controlled trial with children studying in Grades 4-6 in Hong Kong elementary schools will be conducted to assess the effectiveness of the Safe City game–based intervention. In this trial, 504 children will play Safe City, and 504 children will receive traditional instructional materials (electronic and printed safety information). The evaluation will be conducted using both child self-report and parent proxy-report data. Specifically, child safety knowledge and behaviors will be assessed by a questionnaire involving items on knowledge and behaviors, respectively, for home safety, road safety, and sport-related safety; child functioning will be assessed by PedsQL Generic Core Scales; and psychosocial difficulties will be assessed by the Strength and Difficulties Questionnaire. These questionnaires will be administered at 3 time points: before, 1 month, and 3 months after the intervention. Game usage statistics will also be reviewed. Results: This project was funded in September 2019. The design and development of the Safe City game are currently under way. Recruitment and data collection will begin from September 2020 and will continue up to March 1, 2021. Full analysis will be conducted after the end of the data collection period. Conclusions: If the Safe City game is found to be an effective tool to deliver safety education, it could be used to promote safety in children in the community and upgraded to incorporate more health-related topics to support education and empowerment for the larger public. Trial Registration: ClinicalTrials.gov NCT04096196; https://clinicaltrials.gov/ct2/show/NCT04096196 International Registered Report Identifier (IRRID): PRR1-10.2196/17756 %M 32530436 %R 10.2196/17756 %U http://www.researchprotocols.org/2020/6/e17756/ %U https://doi.org/10.2196/17756 %U http://www.ncbi.nlm.nih.gov/pubmed/32530436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15339 %T Using Geocaching to Promote Active Aging: Qualitative Study %A Fornasini,Silvia %A Dianti,Marco %A Bacchiega,Alessandro %A Forti,Stefano %A Conforti,Diego %+ Fondazione Bruno Kessler, Via Sommarive 18, Trento, 38123, Italy, 39 0461 314140, s.fornasini@fbk.eu %K geocaching %K active ageing %K elderly empowerment %K qualitative methods %D 2020 %7 11.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the past few years, the development of technologies supporting active aging has been increasing. Among the activities that promote physical exercise by using technologies is geocaching—a treasure hunt of sorts in which participants use a receiver GPS to hide or find real or virtual objects. Although this activity is particularly suited to the promotion of healthy lifestyles in older people, geocaching remains to be unexplored in this area. Objective: This study aimed to investigate the effectiveness of activities combining geocaching and self-tracking technologies to promote active aging, evaluate the usability of technologies, and explore the ways in which technologies have been integrated in the organizational context under examination to determine the user experience of participants. Methods: A group of individuals aged 65 years and older (N=14) attending a senior center managed by a social cooperative was involved in the study. Some of them created the geocaching contents, and others, split into 2 teams, participated in the game. Each participant was given a pedometer bracelet and the geocaching app. The steps taken by individual participants along with the number of caches found by each group translated into team scores. Results: The main results of the study were as follows: (1) activities in favor of active aging that involve the use of new technologies can foster the participation of elderly people; in particular, adding gamification to self-tracking can be a valid strategy to promote physical exercise among the elderly; (2) for this to happen, involvement of older people firsthand is crucial, and there must be a focus on their active involvement and empowerment in every phase of the project; and (3) the mediation of conflicts and competition that arise from the gamification could only take place because of the strong support of the organization in the form of social workers. Conclusions: The results show that promoting active aging through technologies requires more effort than simply using these tools; it requires a wider process that involves an articulated organizational network with heterogeneous actors, technologies, and relations. %M 32525486 %R 10.2196/15339 %U http://www.jmir.org/2020/6/e15339/ %U https://doi.org/10.2196/15339 %U http://www.ncbi.nlm.nih.gov/pubmed/32525486 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e16506 %T The Model of Gamification Principles for Digital Health Interventions: Evaluation of Validity and Potential Utility %A Floryan,Mark %A Chow,Philip I %A Schueller,Stephen M %A Ritterband,Lee M %+ Department of Computer Science, University of Virginia, 85 Engineer's Way, Charlottesville, VA, 22904, United States, 1 4342433087, mrf8t@virginia.edu %K gamification %K internet interventions %K eHealth %K mHealth %K digital health %D 2020 %7 10.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although gamification continues to be a popular approach to increase engagement, motivation, and adherence to behavioral interventions, empirical studies have rarely focused on this topic. There is a need to empirically evaluate gamification models to increase the understanding of how to integrate gamification into interventions. Objective: The model of gamification principles for digital health interventions proposes a set of five independent yet interrelated gamification principles. This study aimed to examine the validity and reliability of this model to inform its use in Web- and mobile-based apps. Methods: A total of 17 digital health interventions were selected from a curated website of mobile- and Web-based apps (PsyberGuide), which makes independent and unbiased ratings on various metrics. A total of 133 independent raters trained in gamification evaluation techniques were instructed to evaluate the apps and rate the degree to which gamification principles are present. Multiple ratings (n≥20) were collected for each of the five gamification principles within each app. Existing measures, including the PsyberGuide credibility score, mobile app rating scale (MARS), and the app store rating of each app were collected, and their relationship with the gamification principle scores was investigated. Results: Apps varied widely in the degree of gamification implemented (ie, the mean gamification rating ranged from 0.17≤m≤4.65 out of 5). Inter-rater reliability of gamification scores for each app was acceptable (κ≥0.5). There was no significant correlation between any of the five gamification principles and the PsyberGuide credibility score (P≥.49 in all cases). Three gamification principles (supporting player archetypes, feedback, and visibility) were significantly correlated with the MARS score, whereas three principles (meaningful purpose, meaningful choice, and supporting player archetypes) were significantly correlated with the app store rating. One gamification principle was statistically significant with both the MARS and the app store rating (supporting player archetypes). Conclusions: Overall, the results support the validity and potential utility of the model of gamification principles for digital health interventions. As expected, there was some overlap between several gamification principles and existing app measures (eg, MARS). However, the results indicate that the gamification principles are not redundant with existing measures and highlight the potential utility of a 5-factor gamification model structure in digital behavioral health interventions. These gamification principles may be used to improve user experience and enhance engagement with digital health programs. %M 32519965 %R 10.2196/16506 %U https://www.jmir.org/2020/6/e16506 %U https://doi.org/10.2196/16506 %U http://www.ncbi.nlm.nih.gov/pubmed/32519965 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15647 %T Gamifying Parenting Education Using an App Developed for Pacific and Other New Zealand Families (Play Kindly): Qualitative Study %A Mairs,Rebecca A %A Bekker,Marthinus J %A Patolo,Tony %A Hopkins,Sarah A %A Cowley-Malcolm,Esther T %A Perese,Lana M %A Sundborn,Gerhard B %A Merry,Sally N %+ Department of Psychological Medicine, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand, 64 9 373 7599 ext 92019, marthinus.bekker@auckland.ac.nz %K parenting %K mHealth %K Pacific peoples %D 2020 %7 10.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Play Kindly is a gamified animated app designed to address common behavioral problems in childhood. The interface is designed to appeal to Pacific people, a population group with a higher risk of developing clinically significant behavioral problems than most other ethnic groups in New Zealand. Objective: The aim of this study is to explore the opinions of parents and professionals about the acceptability, usability, and content of Play Kindly. Methods: We used qualitative and Pacific and Māori research methodologies. A total of five focus groups with 45 parents and 12 individual interviews with professionals were conducted. The five focus groups consisted of 2 pan-Pacific groups, 1 Māori group, 1 open group, and 1 group of young Pacific adults or prospective parents. The professionals were from a range of disciplines, and the majority had expertise in early childhood, parenting interventions, or research in this field. Results: Play Kindly appealed to both parents and professionals. Participants related to the scenarios, which were created in collaboration with a playwright and animator. Although most participants liked the Pacific feel, there was some disagreement about how culturally specific the app should be. A range of issues with usability and gamification techniques were highlighted, likely attributed to the low budget and lack of initial co-design with parents as well as professionals with specific expertise in parenting. A number of parents and professionals felt that the parenting strategies were overly simplified and did not take into account the context in which the behavior occurred. Professionals suggested narrowing the focus of the app to deliver two important parenting messages: playing with your child and positively reinforcing desired behaviors. Conclusions: Play Kindly is the first culturally adapted parenting app of its kind designed for Pacific parents and other New Zealanders with children 2-5 years of age. This app has potential in Pacific communities where there are limited culturally specific parenting resources. The results of this study will guide improvements of the app prior to testing it in an open trial. %M 32519973 %R 10.2196/15647 %U http://games.jmir.org/2020/2/e15647/ %U https://doi.org/10.2196/15647 %U http://www.ncbi.nlm.nih.gov/pubmed/32519973 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17884 %T Prediction of (Non)Participation of Older People in Digital Health Research: Exergame Intervention Study %A Poli,Arianna %A Kelfve,Susanne %A Klompstra,Leonie %A Strömberg,Anna %A Jaarsma,Tiny %A Motel-Klingebiel,Andreas %+ Division Ageing and Social Change, Department of Culture and Society, Linköping University, Campus Norrköping, Bredgatan 33, Norrköping, 60174, Sweden, 46 700850634, arianna.poli@liu.se %K technology %K exclusion %K recruitment %K self-selection %K nonparticipation %D 2020 %7 5.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of digital technologies is increasing in health care. However, studies evaluating digital health technologies can be characterized by selective nonparticipation of older people, although older people represent one of the main user groups of health care. Objective: We examined whether and how participation in an exergame intervention study was associated with age, gender, and heart failure (HF) symptom severity. Methods: A subset of data from the HF-Wii study was used. The data came from patients with HF in institutional settings in Germany, Italy, the Netherlands, and Sweden. Selective nonparticipation was examined as resulting from two processes: (non)recruitment and self-selection. Baseline information on age, gender, and New York Heart Association Functional Classification of 1632 patients with HF were the predictor variables. These patients were screened for HF-Wii study participation. Reasons for nonparticipation were evaluated. Results: Of the 1632 screened patients, 71% did not participate. The nonrecruitment rate was 21%, and based on the eligible sample, the refusal rate was 61%. Higher age was associated with lower probability of participation; it increased both the probabilities of not being recruited and declining to participate. More severe symptoms increased the likelihood of nonrecruitment. Gender had no effect. The most common reasons for nonrecruitment and self-selection were related to physical limitations and lack of time, respectively. Conclusions: Results indicate that selective nonparticipation takes place in digital health research and that it is associated with age and symptom severity. Gender effects cannot be proven. Such systematic selection can lead to biased research results that inappropriately inform research, policy, and practice. Trial Registration: ClinicalTrial.gov NCT01785121, https://clinicaltrials.gov/ct2/show/NCT01785121 %M 32501275 %R 10.2196/17884 %U http://www.jmir.org/2020/6/e17884/ %U https://doi.org/10.2196/17884 %U http://www.ncbi.nlm.nih.gov/pubmed/32501275 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16216 %T Serious Games for Nutritional Education: Online Survey on Preferences, Motives, and Behaviors Among Young Adults at University %A Holzmann,Sophie Laura %A Schäfer,Hanna %A Plecher,David Alexander %A Stecher,Lynne %A Klinker,Gudrun Johanna %A Groh,Georg %A Hauner,Hans %A Holzapfel,Christina %+ Institute for Nutritional Medicine, Else Kröner-Fresenius-Center for Nutritional Medicine, School of Medicine, Technical University of Munich, Georg-Brauchle-Ring 62, Munich, , Germany, 49 89 289 249 23, christina.holzapfel@tum.de %K nutrition %K information sources %K serious games %K digital gameplay %K preferences %K motives %K behavior %K university students %K survey %D 2020 %7 3.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Data on nutritional information and digital gameplay are limited among young adults in Germany. Objective: This survey aimed to gather data on nutritional information sources and digital games for nutritional education (preferences, motives, and behaviors) among young adults at both Munich universities in Germany. Methods: An online survey was developed by an multidisciplinary research group using EvaSys, an in-house survey software. The questionnaire (47 items) covered questions about baseline characteristics (eg, housing situation and weight), nutrition (eg, nutritional information sources), and digital (nutritional) gameplay (eg, preferences, motives, and behaviors). A feedback field was also provided. This publication is based on a selection of 20 questions (7 baseline characteristics, 2 nutrition, 11 gameplay). Young adults, primarily Munich university students aged from 18 to 24 years, were invited to participate by digital and nondigital communication channels between 2016 and 2017. Statistical analyses were performed using Excel 2013 (Microsoft Corp) and R version 3.1.3 (R Foundation for Statistical Computing). Results: In total, 468 young adults (342/468, 73.1% women; 379/468, 81.0% university students) participated. Most of the participants (269/468, 57.5%) were aged 18 to 24 years with a BMI in the normal weight range (346/447, 77.4%). Mean body weight was 65.5 [SD 14.0] kg. Most participants reported getting nutritional information from the internet (372/467, 79.7%) and printed media (298/467, 63.8%), less than 1.0% (2/467, 0.4%) named digital games. Apps (100/461, 21.7%) and university/workplace (146/461, 31.7%) were the most desired sources for additional information about nutrition, while 10.0% (46/461, 10.0%) of participants stated wanting digital games. Almost two-thirds (293/468, 62.6%) of participants played digital games, while one-fifth (97/456, 21.3%) played digital games daily using smartphones or tablets. Finally, most respondents (343/468, 73.3%), mainly women, expressed interest in obtaining nutritional information during digital gameplay. However, significant gender differences were shown for nutritional acquisition behaviors and digital gameplay preferences, motives, and behaviors. Conclusions: Our survey population reported playing digital games (especially men) and wanting nutritional information during digital gameplay (especially women). Furthermore, university or workplace are named as preferred settings for nutritional information. Therefore, a digital game app might have the potential to be a tool for nutritional education among young adults within the university or workplace environment. %M 32490847 %R 10.2196/16216 %U https://games.jmir.org/2020/2/e16216 %U https://doi.org/10.2196/16216 %U http://www.ncbi.nlm.nih.gov/pubmed/32490847 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e13170 %T Toward Gamified Pain Management Apps: Mobile Application Rating Scale–Based Quality Assessment of Pain-Mentor’s First Prototype Through an Expert Study %A Hoffmann,Alexandra %A Faust-Christmann,Corinna A %A Zolynski,Gregor %A Bleser,Gabriele %+ Junior Research Group wearHEALTH, Department of Computer Science, Technische Universität Kaiserslautern, Gottlieb-Daimler-Straße 48, Kaiserslautern, 67663, Germany, 49 631 205 3456, hoffmann@cs.uni-kl.de %K mHealth %K chronic pain %K stress management %K pain management %K health app %K gamification %K health professional %D 2020 %7 26.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The use of health apps to support the treatment of chronic pain is gaining importance. Most available pain management apps are still lacking in content quality and quantity as their developers neither involve health experts to ensure target group suitability nor use gamification to engage and motivate the user. To close this gap, we aimed to develop a gamified pain management app, Pain-Mentor. Objective: To determine whether medical professionals would approve of Pain-Mentor’s concept and content, this study aimed to evaluate the quality of the app’s first prototype with experts from the field of chronic pain management and to discover necessary improvements. Methods: A total of 11 health professionals with a background in chronic pain treatment and 2 mobile health experts participated in this study. Each expert first received a detailed presentation of the app. Afterward, they tested Pain-Mentor and then rated its quality using the mobile application rating scale (MARS) in a semistructured interview. Results: The experts found the app to be of excellent general (mean 4.54, SD 0.55) and subjective quality (mean 4.57, SD 0.43). The app-specific section was rated as good (mean 4.38, SD 0.75). Overall, the experts approved of the app’s content, namely, pain and stress management techniques, behavior change techniques, and gamification. They believed that the use of gamification in Pain-Mentor positively influences the patients’ motivation and engagement and thus has the potential to promote the learning of pain management techniques. Moreover, applying the MARS in a semistructured interview provided in-depth insight into the ratings and concrete suggestions for improvement. Conclusions: The experts rated Pain-Mentor to be of excellent quality. It can be concluded that experts perceived the use of gamification in this pain management app in a positive manner. This showed that combining pain management with gamification did not negatively affect the app’s integrity. This study was therefore a promising first step in the development of Pain-Mentor. %M 32452803 %R 10.2196/13170 %U http://formative.jmir.org/2020/5/e13170/ %U https://doi.org/10.2196/13170 %U http://www.ncbi.nlm.nih.gov/pubmed/32452803 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16983 %T Digital Gamification to Enhance Vaccine Knowledge and Uptake: Scoping Review %A Montagni,Ilaria %A Mabchour,Inass %A Tzourio,Christophe %+ Bordeaux Population Health U1219, Inserm-University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 0547304281, ilaria.montagni@u-bordeaux.fr %K gamification %K vaccination %K vaccine hesitancy %K digital tools %K scoping review %D 2020 %7 18.5.2020 %9 Review %J JMIR Serious Games %G English %X Background: Vaccine hesitancy is a growing threat to population health, and effective interventions are needed to reduce its frequency. Digital gamification is a promising new approach to tackle this public health issue. Objective: The purpose of this scoping review was to assess the amount and quality of outcomes in studies evaluating gamified digital tools created to increase vaccine knowledge and uptake. Methods: We searched for peer-reviewed articles published between July 2009 and August 2019 in PubMed, Google Scholar, Journal of Medical Internet Research, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, and SocINDEX. Studies were coded by author, year of publication, country, journal, research design, sample size and characteristics, type of vaccine, theory used, game content, game modality, gamification element(s), data analysis, type of outcomes, and mean quality score. Outcomes were synthesized through the textual narrative synthesis method. Results: A total of 7 articles met the inclusion criteria and were critically reviewed. Game modalities and gamification elements were diverse, but role play and a reward system were present in all studies. These articles included a mixture of randomized controlled trials, quasi-experimental studies, and studies comprising quantitative and qualitative measures. The majority of the studies were theory-driven. All the identified gamified digital tools were highly appreciated for their usability and were effective in increasing awareness of vaccine benefits and motivation for vaccine uptake. Conclusions: Despite the relative paucity of studies on this topic, this scoping review suggests that digital gamification has strong potential for increasing vaccination knowledge and, eventually, vaccination coverage. %M 32348271 %R 10.2196/16983 %U http://games.jmir.org/2020/2/e16983/ %U https://doi.org/10.2196/16983 %U http://www.ncbi.nlm.nih.gov/pubmed/32348271 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17807 %T Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia: Qualitative Study %A Lindner,Philip %A Rozental,Alexander %A Jurell,Alice %A Reuterskiöld,Lena %A Andersson,Gerhard %A Hamilton,William %A Miloff,Alexander %A Carlbring,Per %+ Department of Psychology, Stockholm University, Frescati hagväg 8, 104 05, Stockholm, , Sweden, 46 704522587, philip.lindner@ki.se %K virtual reality %K gamification %K serious game %K exposure therapy %K phobia %K user experience %D 2020 %7 29.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention. Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods. Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis. Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal. Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences. %M 32347803 %R 10.2196/17807 %U http://games.jmir.org/2020/2/e17807/ %U https://doi.org/10.2196/17807 %U http://www.ncbi.nlm.nih.gov/pubmed/32347803 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e16096 %T Investigating Serious Games That Incorporate Medication Use for Patients: Systematic Literature Review %A Abraham,Olufunmilola %A LeMay,Sarah %A Bittner,Sarah %A Thakur,Tanvee %A Stafford,Haley %A Brown,Randall %+ Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin–Madison, 777 Highland Ave, 2515 Rennebohm Hall, Madison, WI, 53705, United States, 1 6082634498, olufunmilola.abraham@wisc.edu %K games %K medication adherence %K patient safety %K video games %K systematic review %D 2020 %7 29.4.2020 %9 Review %J JMIR Serious Games %G English %X Background: The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use. Objective: This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use. Methods: PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection. Results: Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies. Conclusions: Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives. %M 32347811 %R 10.2196/16096 %U http://games.jmir.org/2020/2/e16096/ %U https://doi.org/10.2196/16096 %U http://www.ncbi.nlm.nih.gov/pubmed/32347811 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e15344 %T Design, Development, and Testing of an App for Dual-Task Assessment and Training Regarding Cognitive-Motor Interference (CMI-APP) in People With Multiple Sclerosis: Multicenter Pilot Study %A Tacchino,Andrea %A Veldkamp,Renee %A Coninx,Karin %A Brulmans,Jens %A Palmaers,Steven %A Hämäläinen,Päivi %A D'hooge,Mieke %A Vanzeir,Ellen %A Kalron,Alon %A Brichetto,Giampaolo %A Feys,Peter %A Baert,Ilse %+ Scientific Research Area, Italian Multiple Sclerosis Foundation, Via Operai 40, Genoa, 16149, Italy, 39 3491403917, andrea.tacchino@aism.it %K tablet %K mobile device %K cognitive rehabilitation %K cognitive impairment %K dual-task training %K cognitive-motor interference %K dual-task cost %K adherence %K multiple sclerosis %K walking %D 2020 %7 16.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Dual tasking constitutes a large portion of most activities of daily living; in real-life situations, people need to not only maintain balance and mobility skills, but also perform other cognitive or motor tasks at the same time. Interest toward dual-task training (DTT) is increasing as traditional interventions may not prepare patients to adequately face the challenges of most activities of daily living. These usually involve simultaneous cognitive and motor tasks, and they often show a decline in performance. Cognitive-motor interference (CMI) has been investigated in different neurological populations, but limited evidence is present for people with multiple sclerosis (MS). The use of computerized tools is mandatory to allow the application of more standardized assessment and rehabilitation intervention protocols and easier implementation of multicenter and multilanguage studies. Objective: To describe the design and development of CMI-APP, an adaptive and interactive technology tablet-based app, and to present the preliminary results of a multicenter pilot study involving people with MS performed in several European centers for evaluating the feasibility of and adherence to a rehabilitation program based on CMI-APP. Methods: CMI-APP includes user-friendly interfaces for personal data input and management, assessment of CMI, and DTT. A dedicated team developed CMI-APP for Android tablets above API level 14 (version 4.0), using C# as the programming language and Unity and Visual Studio as development tools. Three cognitive assessment tests for working memory, information processing speed, and sustained attention and four motor assessment tests for walking at different difficulty levels were implemented. Dual cognitive-motor tasks were performed by combining single cognitive and motor tasks. CMI-APP implements exercises for DTT involving the following 12 cognitive functions: sustained attention, text comprehension, verbal fluency, auditory discrimination, visual discrimination, working memory, information processing speed, auditory memory, visual memory, verbal analog reasoning, visual analog reasoning, and visual spatial planning, which can be performed during walking or stepping on the spot. Fifteen people with MS (mean age 52.6, SD 8.6 years; mean disease duration 9.4, SD 8.4 years; mean Expanded Disability Status Scale score 3.6, SD 1.1) underwent DTT (20 sessions). Adherence to the rehabilitation program was evaluated according to the percentage of performed sessions, perceived exertion during the training (Borg 15-point Ratings of Perceived Exertion [RPE] Scale), and subjective experience of the training (Intrinsic Motivation Inventory [IMI]). Results: The adherence rate was 91%. DTT was perceived as “somewhat difficult” (mean RPE Scale score 12.6, SD 1.9). IMI revealed that participants enjoyed the training and felt that it was valuable and, to some extent, important, without feelings of pressure. They felt competent, although they did not always feel they could choose the exercises, probably because the therapist chose the exercises and many exercises had few difficulty levels. Conclusions: CMI-APP is safe, highly usable, motivating, and well accepted for DTT by people with MS. The findings are fundamental for the preparation of future large-sample studies examining CMI and the effectiveness of DTT interventions with CMI-APP in people with MS. %M 32343258 %R 10.2196/15344 %U http://mhealth.jmir.org/2020/4/e15344/ %U https://doi.org/10.2196/15344 %U http://www.ncbi.nlm.nih.gov/pubmed/32343258 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e15725 %T The Kids Obesity Prevention Program: Cluster Randomized Controlled Trial to Evaluate a Serious Game for the Prevention and Treatment of Childhood Obesity %A Mack,Isabelle %A Reiband,Nadine %A Etges,Carolin %A Eichhorn,Sabrina %A Schaeffeler,Norbert %A Zurstiege,Guido %A Gawrilow,Caterina %A Weimer,Katja %A Peeraully,Riyad %A Teufel,Martin %A Blumenstock,Gunnar %A Giel,Katrin Elisabeth %A Junne,Florian %A Zipfel,Stephan %+ Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Osianderstraße 5, Tübingen, 72076, Germany, 49 70712985614, isabelle.mack@uni-tuebingen.de %K children %K serious game %K nutrition %K stress %K energy density %D 2020 %7 24.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Health games provide opportunities for the treatment and prevention of childhood obesity. We developed a motion-controlled serious game for children that addresses 3 core topics of nutrition, physical activity, and stress coping. It is the first serious game that extensively targets the dietary energy density principle (DED-P) in relation to nutrition. The game is intended to provide an additional educational component for the prevention and treatment of obesity in children. Objective: The Kids Obesity Prevention study aimed to evaluate the newly developed game and to evaluate how well children are able to understand and apply the DED-P. Methods: This cluster randomized controlled trial collected data from 82 primary school children aged 9 to 12 years and their parents at baseline (T0), at 2 weeks after study commencement (T1), and at the 4-week follow-up (T2). The dropout rate was 3.6%. The intervention group (IG) played the game within 2 weeks (2 sessions with different game modules). One part of the game involves selection of food with the lower energy density when presented with a pair of foods. This allows assessment of whether the children have understood the DED-P and whether they can apply it to unknown foods under time pressure. The control group (CG) received a brochure about the food pyramid concept and physical activity. The primary outcome was the gain in knowledge (nutrition and stress coping) and measured with a pretested questionnaire. The secondary outcomes were the maintenance of knowledge, application of the DED-P, feelings during game play, game acceptance, and behavioral measures (physical activity, media consumption, and dietary intake). Results: The knowledge score ranging from 0 to 100 increased from T0 (IG: 53 [SD 10], CG: 50 [SD 11]) to T1 (IG: 69 [SD 11], CG: 52 [SD 12]) in IG versus CG (P<.001). At T2, the knowledge score of IG remained at the same level as that of T1. Game data showed that after DED-P education, the classification under time pressure of unknown versus known food pairs according to their DED category was similar (hit rate around 70%). Overall, 95% of the children liked the game very much or much. No group changes were observed at the behavioral level. Conclusions: The Kids Obesity Prevention program sustainably increased knowledge in the areas of nutrition and stress coping, and children were able to apply the DED-P. Trial Registration: ClinicalTrials.gov NCT02551978; https://clinicaltrials.gov/ct2/show/NCT02551978 %M 32329742 %R 10.2196/15725 %U https://www.jmir.org/2020/4/e15725 %U https://doi.org/10.2196/15725 %U http://www.ncbi.nlm.nih.gov/pubmed/32329742 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 4 %P e15534 %T Optimizing Child Nutrition Education With the Foodbot Factory Mobile Health App: Formative Evaluation and Analysis %A Brown,Jacqueline Marie %A Savaglio,Robert %A Watson,Graham %A Kaplansky,Allison %A LeSage,Ann %A Hughes,Janette %A Kapralos,Bill %A Arcand,JoAnne %+ Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science Building Rm 3016, Oshawa, ON, L1G 0C5, Canada, 1 (905) 7218668 ext 3796, joanne.arcand@uoit.ca %K mHealth %K children %K child nutrition sciences %K mobile apps %K health education %D 2020 %7 17.4.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Early nutrition interventions to improve food knowledge and skills are critical in enhancing the diet quality of children and reducing the lifelong risk of chronic disease. Despite the rise of mobile health (mHealth) apps and their known effectiveness for improving health behaviors, few evidence-based apps exist to help engage children in learning about nutrition and healthy eating. Objective: This study aimed to describe the iterative development and user testing of Foodbot Factory, a novel nutrition education gamified app for children to use at home or in the classroom and to present data from user testing experiments conducted to evaluate the app. Methods: An interdisciplinary team of experts in nutrition, education (pedagogy), and game design led to the creation of Foodbot Factory. First, a literature review and an environmental scan of the app marketplace were conducted, and stakeholders were consulted to define the key objectives and content of Foodbot Factory. Dietitian and teacher stakeholders identified priority age groups and learning objectives. Using a quasi-experimental mixed method design guided by the Iterative Convergent Design for Mobile Health Usability Testing approach, five app user testing sessions were conducted among students (ages 9-12 years). During gameplay, engagement and usability were assessed via direct observations with a semistructured form. After gameplay, qualitative interviews and questionnaires were used to assess user satisfaction, engagement, usability, and knowledge gained. Results: The environmental scan data revealed that few evidence-based nutrition education apps existed for children. A literature search identified key nutrients of concern for Canadian children and techniques that could be incorporated into the app to engage users in learning. Foodbot Factory included characters (2 scientists and Foodbots) who initiate fun and engaging dialogue and challenges (minigames), with storylines incorporating healthy eating messages that align with the established learning objectives. A total of five modules were developed: drinks, vegetables and fruit, grain foods, animal protein foods, and plant protein foods. Seven behavior change techniques and three unique gamified components were integrated into the app. Data from each user testing session were used to inform and optimize the next app iteration. The final user testing session demonstrated that participants agreed that they wanted to play Foodbot Factory again (12/17, 71%), that the app is easy to use (12/17, 71%) and fun (14/17, 88%), and that the app goals were clearly presented (15/17, 94%). Conclusions: Foodbot Factory is an engaging and educational mHealth intervention for the Canadian public that is grounded in evidence and developed by an interdisciplinary team of experts. The use of an iterative development approach is a demonstrated method to improve engagement, satisfaction, and usability with each iteration. Children find Foodbot Factory to be fun and easy to use, and can engage children in learning about nutrition. %M 32301743 %R 10.2196/15534 %U http://formative.jmir.org/2020/4/e15534/ %U https://doi.org/10.2196/15534 %U http://www.ncbi.nlm.nih.gov/pubmed/32301743 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e15164 %T Gamified Mobile Computerized Cognitive Behavioral Therapy for Japanese University Students With Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Yokomitsu,Kengo %A Irie,Tomonari %A Sekiguchi,Mayu %A Shimizu,Ayako %A Matsuoka,Hirofumi %A Merry,Sally Nicola %A Stasiak,Karolina %+ College of Comprehensive Psychology, Ritsumeikan University, 2-150 Iwakura-cho, Ibaraki, Osaka, 567-8570, Japan, 81 72 665 2490, k-yoko@fc.ritsumei.ac.jp %K SPARX %K Japan %K university students %K depressive symptoms %D 2020 %7 7.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence shows that computerized self-help interventions are effective for reducing symptoms of depression. One such intervention, SPARX, is a gamified mobile computerized cognitive behavioral therapy (cCBT) developed for adolescents in New Zealand, which was shown to be as effective as usual care for young people with mild-to-moderate symptoms of depression. However, gamified cCBT has not yet been tested in Japan. Objective: This trial is designed to investigate whether a Japanese-adapted version of SPARX improves depressive symptoms in Japanese university students with mild-to-moderate depressive symptoms. Methods: In this 7-week, multicenter, stratified, parallel-group, superiority randomized trial, participants will be allocated to either a treatment condition (SPARX) or a wait-list control condition. SPARX is a fully automated program, which will be delivered to the mobile phone or tablet device of the participants. SPARX is designed as an interactive fantasy game to guide the user through seven modules that teach key CBT strategies. All participants will be recruited from universities via advertisements on online bulletin boards, the campus newspaper, and posters. Participants in the treatment condition will use the SPARX program weekly. The primary outcome is the reduction of depressive symptoms (using Patient Health Questionnaires-9) measured at baseline and weekly: once after the 7-week intervention and once at a 1-month follow-up. Secondary outcomes include satisfaction with the program and satisfaction with life, measured by the Satisfaction With Life Scale; positive and negative moods, measured by the Profile of Mood States Second Edition; social functioning, measured by the EuroQol Instrument; rumination, measured by the Ruminative Responses Scale; and coping, measured by the Brief Coping Orientation to Problem Experienced Inventory. Results: This study received funding from The Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, and obtained institutional review board approval in September 2019. Data collection began in April 2019. Conclusions: Results of this trial may provide further evidence for the efficacy of gamified cCBT for the treatment of depression and, specifically, provide support for using SPARX with Japanese university students. Trial Registration: Japan Primary Registries Network UMIN000034354; https://tinyurl.com/uu7xd77 International Registered Report Identifier (IRRID): DERR1-10.2196/15164 %M 32254045 %R 10.2196/15164 %U https://www.researchprotocols.org/2020/4/e15164 %U https://doi.org/10.2196/15164 %U http://www.ncbi.nlm.nih.gov/pubmed/32254045 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 4 %P e13174 %T The Performance of Emotion Classifiers for Children With Parent-Reported Autism: Quantitative Feasibility Study %A Kalantarian,Haik %A Jedoui,Khaled %A Dunlap,Kaitlyn %A Schwartz,Jessey %A Washington,Peter %A Husic,Arman %A Tariq,Qandeel %A Ning,Michael %A Kline,Aaron %A Wall,Dennis Paul %+ Department of Pediatrics, Stanford University, 450 Serra Mall, Stanford, CA, 94305, United States, 1 (650) 7232300, dpwall@stanford.edu %K mobile phone %K emotion %K autism %K digital data %K mobile app %K mHealth %K affect %K machine learning %K artificial intelligence %K digital health %D 2020 %7 1.4.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Autism spectrum disorder (ASD) is a developmental disorder characterized by deficits in social communication and interaction, and restricted and repetitive behaviors and interests. The incidence of ASD has increased in recent years; it is now estimated that approximately 1 in 40 children in the United States are affected. Due in part to increasing prevalence, access to treatment has become constrained. Hope lies in mobile solutions that provide therapy through artificial intelligence (AI) approaches, including facial and emotion detection AI models developed by mainstream cloud providers, available directly to consumers. However, these solutions may not be sufficiently trained for use in pediatric populations. Objective: Emotion classifiers available off-the-shelf to the general public through Microsoft, Amazon, Google, and Sighthound are well-suited to the pediatric population, and could be used for developing mobile therapies targeting aspects of social communication and interaction, perhaps accelerating innovation in this space. This study aimed to test these classifiers directly with image data from children with parent-reported ASD recruited through crowdsourcing. Methods: We used a mobile game called Guess What? that challenges a child to act out a series of prompts displayed on the screen of the smartphone held on the forehead of his or her care provider. The game is intended to be a fun and engaging way for the child and parent to interact socially, for example, the parent attempting to guess what emotion the child is acting out (eg, surprised, scared, or disgusted). During a 90-second game session, as many as 50 prompts are shown while the child acts, and the video records the actions and expressions of the child. Due in part to the fun nature of the game, it is a viable way to remotely engage pediatric populations, including the autism population through crowdsourcing. We recruited 21 children with ASD to play the game and gathered 2602 emotive frames following their game sessions. These data were used to evaluate the accuracy and performance of four state-of-the-art facial emotion classifiers to develop an understanding of the feasibility of these platforms for pediatric research. Results: All classifiers performed poorly for every evaluated emotion except happy. None of the classifiers correctly labeled over 60.18% (1566/2602) of the evaluated frames. Moreover, none of the classifiers correctly identified more than 11% (6/51) of the angry frames and 14% (10/69) of the disgust frames. Conclusions: The findings suggest that commercial emotion classifiers may be insufficiently trained for use in digital approaches to autism treatment and treatment tracking. Secure, privacy-preserving methods to increase labeled training data are needed to boost the models’ performance before they can be used in AI-enabled approaches to social therapy of the kind that is common in autism treatments. %M 32234701 %R 10.2196/13174 %U https://mental.jmir.org/2020/4/e13174 %U https://doi.org/10.2196/13174 %U http://www.ncbi.nlm.nih.gov/pubmed/32234701 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17994 %T The Effect of Narrative on Physical Activity via Immersion During Active Video Game Play in Children: Mediation Analysis %A Sousa,Caio Victor %A Fernandez,Austin %A Hwang,Jungyun %A Lu,Amy Shirong %+ College of Arts, Media, and Design, Bouvé College of Health Sciences, Health Technology Lab, Northeastern University, 360 Huntington Ave, 212A Lake Hall, Boston, MA, 02115, United States, 1 6173735795, a.lu@northeastern.edu %K video games %K exercise %K fitness trackers %K narration %K physical activity %K exercise %D 2020 %7 31.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Active video games (AVGs) can increase physical activity (PA) and help produce higher physiological expenditure. Animated narrative videos (NVs) possess unique immersive and motivational properties. When added to AVGs, they have been found to increase moderate-to-vigorous physical activity (MVPA) as opposed to the original no video condition. However, there is no evidence of whether that was due to the NV or the addition of an animated video to an AVG. Objective: This study aimed to investigate the differential effect of adding an NV versus a nonnarrative video (NNV) to an AVG on PA parameters and physiological responses and to explore the mediating role of immersion. Methods: A total of 22 children aged 8 to 12 years were randomly assigned to the NV or NNV condition. They were instructed to play an AVG (on Xbox Kinect) for as long as they wanted. We used accelerometers to estimate the time spent (in minutes) in MVPA. Heart rate (HR) and rate of perceived exertion (RPE) were measured before, during, and after the AVG play session. The participants then reported their experience of narrative immersion via a questionnaire. Results: The NV group had significantly higher narrative immersion (mean 3.50, SD 0.55 vs mean 2.91, SD 0.59; P=.03) and MVPA (mean 19.46, SD 13.31 vs mean 7.85, SD 5.83; P=.02) than the NNV group. Narrative immersion was positively correlated with MVPA (r=0.52; P=.01) and average HR during AVG (r=0.43; P=.05). Mediation analysis indicated that narrative immersion mediated the effect of NV (NV vs NNV) on MVPA (direct effect: beta=7.51; P=.01). The indirect effect was that NV was positively correlated with the mediator variable narrative immersion (beta=.59; P=.03), which was itself marginally associated with MVPA (beta=6.95; P=.09); when narrative immersion was included in the model, the regression coefficient was attenuated. Conclusions: AVG with added narratives elicits more narrative immersion, resulting in more minutes in MVPA. Narrative immersion served as a mediator between NV and MVPA via its elicitation of an elevated HR without increasing RPE. The inclusion of immersive narratives in AVG could be helpful for inducing MVPA, to enhance AVG engagement without additional exertion. %M 32229466 %R 10.2196/17994 %U http://www.jmir.org/2020/3/e17994/ %U https://doi.org/10.2196/17994 %U http://www.ncbi.nlm.nih.gov/pubmed/32229466 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16013 %T The Association Between Pain Relief Using Video Games and an Increase in Vagal Tone in Children With Cancer: Analytic Observational Study With a Quasi-Experimental Pre/Posttest Methodology %A Alonso Puig,Mario %A Alonso-Prieto,Mercedes %A Miró,Jordi %A Torres-Luna,Raquel %A Plaza López de Sabando,Diego %A Reinoso-Barbero,Francisco %+ Pediatric Pain Unit, Anesthesiology-Critical Care Service, University La Paz Hospital, Paseo de la Castellana, 261, Madrid, 28046, Spain, 34 676687569 ext 676687569, meme27@hotmail.es %K hematology oncology %K pediatric patient %K acute pain %K patient-controlled analgesia %K video pupilometer %K analgesia nociception index %D 2020 %7 30.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients with secondary pain due to mucositis after chemotherapy require treatment with morphine. Use of electronic video games (EVGs) has been shown to be an effective method of analgesia in other clinical settings. Objective: The main objective of this study was to assess the association between the use of EVGs and the intensity of pain caused by chemotherapy-induced mucositis in pediatric patients with cancer. The secondary objective was to assess the association between changes in pain intensity and sympathetic-parasympathetic balance in this sample of pediatric patients. Methods: Clinical records were compared between the day prior to the use of EVGs and the day after the use of EVGs. The variables were variations in pupil size measured using the AlgiScan video pupilometer (IDMed, Marseille, France), heart rate variability measured using the Analgesia Nociception Index (ANI) monitor (Mdoloris Medical Systems, Loos, France), intensity of pain measured using the Numerical Rating Scale (score 0-10), and self-administered morphine pump parameters. Results: Twenty patients (11 girls and nine boys; mean age 11.5 years, SD 4.5 years; mean weight 41.5 kg, SD 20.7 kg) who met all the inclusion criteria were recruited. EVGs were played for a mean of 2.3 (SD 1.3) hours per day, resulting in statistically significant changes. After playing EVGs, there was significantly lower daily morphine use (before vs after playing EVGs: 35.9 vs 28.6 µg/kg/day, P=.003), lower demand for additional pain relief medication (17 vs 9.6 boluses in 24 hours, P=.001), lower scores of incidental pain intensity (7.7 vs 5.4, P=.001), lower scores of resting pain (4.8 vs 3.2, P=.01), and higher basal parasympathetic tone as measured using the ANI monitor (61.8 vs 71.9, P=.009). No variation in pupil size was observed with the use of EVGs. Conclusions: The use of EVGs in pediatric patients with chemotherapy-induced mucositis has a considerable analgesic effect, which is associated physiologically with an increase in parasympathetic vagal tone despite lower consumption of morphine. %M 32224482 %R 10.2196/16013 %U http://www.jmir.org/2020/3/e16013/ %U https://doi.org/10.2196/16013 %U http://www.ncbi.nlm.nih.gov/pubmed/32224482 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e12388 %T Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study %A Khalili-Mahani,Najmeh %A Assadi,Atousa %A Li,Kate %A Mirgholami,Mahsa %A Rivard,Marie-Eve %A Benali,Habib %A Sawchuk,Kim %A De Schutter,Bob %+ PERFORM Centre, Concordia University, , Montreal, QC, , Canada, 1 5148482424 ext 5370, najmeh.khalili-mahani@concordia.ca %K silver gaming %K serious games %K stress %K cognitive training %K brain training games %K exercise games %K ICT %D 2020 %7 26.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants’ motivations to adopt these technologies. Objective: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. Methods: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S1-BrainGame, S2-CarRace, and S3-Exergame). Each session included an identical sequence of activities (t1-Baseline, t2-Picture encode, t3-Play, t4-Stroop test, t5-Play, and t6-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire. Results: Session×activity effects were significant on all ambulatory measures (χ210>20; P<.001) other than cortisol (P=.37). Compared with S1 and S2, S3 was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S1, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S3. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (χ21>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. Conclusions: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed. %M 32213474 %R 10.2196/12388 %U http://mental.jmir.org/2020/3/e12388/ %U https://doi.org/10.2196/12388 %U http://www.ncbi.nlm.nih.gov/pubmed/32213474 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e14568 %T Prevention of HIV and Other Sexually Transmitted Infections by Geofencing and Contextualized Messages With a Gamified App, UBESAFE: Design and Creation Study %A Besoain,Felipe %A Perez-Navarro,Antoni %A Jacques Aviñó,Constanza %A Caylà,Joan A %A Barriga,Nicolas A %A Garcia de Olalla,Patricia %+ Faculty of Computer Sciences, Multimedia and Telecommunication, Universitat Oberta de Catalunya, Rambla del Poblenou, 156, Barcelona, 08018, Spain, 34 619963691, aperezn@uoc.edu %K human immunodeficiency virus %K mobile apps %K sexually transmitted infection %K recreational games %D 2020 %7 17.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Advances in the development of information and communication technologies have facilitated social and sexual interrelationships, thanks to the websites and apps created to this end. However, these resources can also encourage sexual contacts without appropriate preventive measures in relation to HIV and other sexually transmitted infections (STIs). How can users be helped to benefit from the advantages of these apps while keeping in mind those preventive measures? Objective: This study aimed to prevent STIs by helping users to remember preventive measures in the risky situations. Methods: We have used the design and creation methodology and have developed a software system. This system has two parts: an Android operating system app with emphasis on ubiquitous computing and gamification as well as a server with a webpage. First, a functional test with 5 men who have sex with men (MSM) allowed us to test the app with end users. In addition, a feasibility test with 4 MSM for a month allowed us to try the UBESAFE system with all its functionalities. Results: The main output is a system called UBESAFE that is addressed to MSM. The system has two main parts: (1) an app that sends preventive contextualized messages to users when they use a contact app or when they are near a point where sexual contacts are likely and (2) a server part that was managed by the public health agency of Barcelona (ASPB), which preserves the quality and pertinence of messages and places and offers instant help to users. To increase users’ adherence, UBESAFE uses a gamified system to engage users in the creation of preventive messages. Users increased the initial pool of messages by more than 100% (34/30) and created more than 56% (9/16) of places (named hot zones). Conclusions: The system helped MSM who used it to become conscious about HIV and other STIs. The system also helped the ASPB to stay in contact with MSM and to detect behaviors that could benefit from preventive measures. All functions were performed in a nonintrusive manner because users used the app privately. Furthermore, the system has shown how important it is to make users a part of the creation process as well as to develop apps that work by themselves and thus become useful to the users. %M 32181752 %R 10.2196/14568 %U http://mhealth.jmir.org/2020/3/e14568/ %U https://doi.org/10.2196/14568 %U http://www.ncbi.nlm.nih.gov/pubmed/32181752 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16987 %T Precourse Preparation Using a Serious Smartphone Game on Advanced Life Support Knowledge and Skills: Randomized Controlled Trial %A Phungoen,Pariwat %A Promto,Songwoot %A Chanthawatthanarak,Sivit %A Maneepong,Sawitree %A Apiratwarakul,Korakot %A Kotruchin,Praew %A Mitsungnern,Thapanawong %+ Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparb Rd Muang, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand, 66 43366869, thapanawong@hotmail.com %K CPR training %K gamified learning %K medical education %K serious game learning %D 2020 %7 9.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the past several years, gamified learning has been growing in popularity in various medical educational contexts including cardiopulmonary resuscitation (CPR) training. Furthermore, prior work in Basic Life Support (BLS) training has demonstrated the benefits of serious games as a method for pretraining among medical students. However, there is little evidence to support these benefits with regard to Advanced Life Support (ALS) training. Objective: We compare the effects of a brief precourse ALS preparation using a serious smartphone game on student knowledge, skills, and perceptions in this area with those of conventional ALS training alone. Methods: A serious game (Resus Days) was developed by a Thai physician based on global ALS clinical practice guidelines. Fifth-year medical students were enrolled and randomized to either the game group or the control group. Participants in both groups attended a traditional ALS lecture, but the game group was assigned to play Resus Days for 1 hour before attending the lecture and were allowed to play as much as they wished during the training course. All students underwent conventional ALS training, and their abilities were evaluated using multiple-choice questions and with hands-on practice on a mannequin. Subject attitudes and perceptions about the game were evaluated using a questionnaire. Results: A total of 105 students participated in the study and were randomly assigned to either the game group (n=52) or the control group (n=53). Students in the game group performed better on the ALS algorithm knowledge posttest than those in the control group (17.22 [SD 1.93] vs 16.60 [SD 1.97], P=.01; adjusted mean difference [AMD] 0.93; 95% CI 0.21-1.66). The game group’s pass rate on the skill test was also higher but not to a statistically significant extent (79% vs 66%, P=.09; adjusted odds ratio [AOR] 2.22; 95% CI 0.89-5.51). Students indicated high satisfaction with the game (9.02 [SD 1.11] out of 10). Conclusions: Engaging in game-based preparation prior to an ALS training course resulted in better algorithm knowledge scores for medical students than attending the course alone. Trial Registration: Thai Clinical Trials Registry HE611533; https://tinyurl.com/wmbp3q7 %M 32149711 %R 10.2196/16987 %U http://www.jmir.org/2020/3/e16987/ %U https://doi.org/10.2196/16987 %U http://www.ncbi.nlm.nih.gov/pubmed/32149711 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e14766 %T Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation %A Vugts,Miel AP %A Zedlitz,Aglaia MEE %A Joosen,Margot CW %A Vrijhoef,Hubertus JM %+ Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 134664294, m.a.p.vugts@uvt.nl %K serious gaming %K eHealth %K chronic pain %K medically unexplained symptoms %K implementation %K realist evaluation %D 2020 %7 9.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens. Objective: To realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances. Methods: Following a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing—with regression models—routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results. Results: Qualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a “confrontation with yourself,” which reflected self-discrepancies. Important characteristics of serious gaming in the study’s context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07.10) Patients with lower levels of activation exhibited positive, short-term benefits in increased intent and confidence to discuss their needs and ask questions in the clinic visit, positive attitudes regarding participation in SDM with their provider, and accurate beliefs about the use of antibiotics (P<.10). The results also suggest small immediate gains in providers’ attitudes about SDM (mean change 0.20; F1,33= 8.03, P=.01). Conclusions: This pilot study provided preliminary evidence on the efficacy of the use of simulated conversations with virtual humans as a tool to improve patient-provider communication (ie, through increasing patient confidence to actively participate in the visit and physician attitudes about SDM) for engaging in conversations about antibiotic use. Future research should explore if repeated opportunities to use the 15-min simulation as well as providing users with several different conversations to practice with would result in sustained improvements in antibiotics beliefs and knowledge and communication behaviors over time. The results of this pilot study offered several opportunities to improve on the simulation in order to bolster communication skills and knowledge retention. %M 28428160 %R 10.2196/mededu.6305 %U http://mededu.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/mededu.6305 %U http://www.ncbi.nlm.nih.gov/pubmed/28428160 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e8 %T What Older People Like to Play: Genre Preferences and Acceptance of Casual Games %A Chesham,Alvin %A Wyss,Patric %A Müri,René Martin %A Mosimann,Urs Peter %A Nef,Tobias %+ ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, Bern, 3008, Switzerland, 41 31 632 75 79, tobias.nef@artorg.unibe.ch %K games, recreational %K genre preference %K mobile applications %K aged %K core elements of the gaming experience %D 2017 %7 18.04.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent computerized cognitive training studies, video games have emerged as a promising tool that can benefit cognitive function and well-being. Whereas most video game training studies have used first-person shooter (FPS) action video games, subsequent studies found that older adults dislike this type of game and generally prefer casual video games (CVGs), which are a subtype of video games that are easy to learn and use simple rules and interfaces. Like other video games, CVGs are organized into genres (eg, puzzle games) based on the rule-directed interaction with the game. Importantly, game genre not only influences the ease of interaction and cognitive abilities CVGs demand, but also affects whether older adults are willing to play any particular genre. To date, studies looking at how different CVG genres resonate with older adults are lacking. Objective: The aim of this study was to investigate how much older adults enjoy different CVG genres and how favorably their CVG characteristics are rated. Methods: A total of 16 healthy adults aged 65 years and above playtested 7 CVGs from 4 genres: casual action, puzzle, simulation, and strategy video games. Thereafter, they rated casual game preference and acceptance of casual game characteristics using 4 scales from the Core Elements of the Gaming Experience Questionnaire (CEGEQ). For this, participants rated how much they liked the game (enjoyment), understood the rules of the game (game-play), learned to manipulate the game (control), and make the game their own (ownership). Results: Overall, enjoyment and acceptance of casual game characteristics was high and significantly above the midpoint of the rating scale for all CVG genres. Mixed model analyses revealed that ratings of enjoyment and casual game characteristics were significantly influenced by CVG genre. Participants’ mean enjoyment of casual puzzle games (mean 0.95 out of 1.00) was significantly higher than that for casual simulation games (mean 0.75 and 0.73). For casual game characteristics, casual puzzle and simulation games were given significantly higher game-play ratings than casual action games. Similarly, participants’ control ratings for casual puzzle games were significantly higher than that for casual action and simulation games. Finally, ownership was rated significantly higher for casual puzzle and strategy games than for casual action games. Conclusions: The findings of this study show that CVGs have characteristics that are suitable and enjoyable for older adults. In addition, genre was found to influence enjoyment and ratings of CVG characteristics, indicating that puzzle games are particularly easy to understand, learn, and play, and are enjoyable. Future studies should continue exploring the potential of CVG interventions for older adults in improving cognitive function, everyday functioning, and well-being. We see particular potential for CVGs in people suffering from cognitive impairment due to dementia or brain injury. %M 28420601 %R 10.2196/games.7025 %U http://games.jmir.org/2017/2/e8/ %U https://doi.org/10.2196/games.7025 %U http://www.ncbi.nlm.nih.gov/pubmed/28420601 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e7 %T Who Is Still Playing Pokémon Go? A Web-Based Survey %A Rasche,Peter %A Schlomann,Anna %A Mertens,Alexander %+ Institute of Industrial Engineering and Ergonomics, Department of Mechanical Engineering, RWTH Aachen University, Bergdriesch 27, Aachen, 52062, Germany, 49 2418099477, p.rasche@iaw.rwth-aachen.de %K games %K recreational %K mobile apps %K cell phones %K Pokémon Go %D 2017 %7 05.04.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Poor physical activity is one of the major health care problems in Western civilizations. Various digital gadgets aiming to increase physical activity, such as activity trackers or fitness apps, have been introduced over recent years. The newest products are serious games that incorporate real-life physical activity into their game concept. Recent studies have shown that such games increase the physical activity of their users over the short term. Objective: In this study, we investigated the motivational effects of the digital game “Pokémon Go” leading to continued use or abandonment of the game. The aim of the study was to determine aspects that motivate individuals to play augmented reality exergames and how this motivation can be used to strengthen the initial interest in physical activity. Methods: A total of 199 participants completed an open self-selected Web-based survey. On the basis of their self-indicated assignment to one of three predefined user groups (active, former, and nonuser of Pokémon Go), participants answered various questions regarding game experience, physical activity, motivation, and personality as measured by the Big Five Inventory. Results: In total, 81 active, 56 former, and 62 nonusers of Pokémon Go were recruited. When asked about the times they perform physical activity, active users stated that they were less physically active in general than former and nonusers. However, based on a subjective rating, active users were more motivated to be physically active due to playing Pokémon Go. Motivational aspects differed for active and former users, whereas fan status was the same within both groups. Active users are more motivated by features directly related to Pokémon, such as catching all possible Pokémon and reaching higher levels, whereas former users stress the importance of general game quality, such as better augmented reality and more challenges in the game. Personality did not affect whether a person started to play Pokémon Go nor their abandonment of the game. Conclusions: The results show various motivating elements that should be incorporated into augmented reality exergames based on the game Pokémon Go. We identified different user types for whom different features of the game contribute to maintained motivation or abandonment. Our results show aspects that augmented reality exergame designers should keep in mind to encourage individuals to start playing their game and facilitate long-term user engagement, resulting in a greater interest in physical activity. %M 28381393 %R 10.2196/games.7197 %U http://games.jmir.org/2017/2/e7/ %U https://doi.org/10.2196/games.7197 %U http://www.ncbi.nlm.nih.gov/pubmed/28381393 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 2 %P e6 %T A Blended Web-Based Gaming Intervention on Changes in Physical Activity for Overweight and Obese Employees: Influence and Usage in an Experimental Pilot Study %A Kouwenhoven-Pasmooij,Tessa A %A Robroek,Suzan JW %A Ling,Sui Wai %A van Rosmalen,Joost %A van Rossum,Elisabeth FC %A Burdorf,Alex %A Hunink,MG Myriam %+ Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Na2818, Postbus 2040, Rotterdam, 3000CA, Netherlands, 31 107043489, t.kouwenhoven@erasmusmc.nl %K eHealth %K gamification %K physical activity %K fitness tracker %K body mass index %K engagement %K social support %K blended care %D 2017 %7 03.04.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Addressing the obesity epidemic requires the development of effective interventions aimed at increasing physical activity (PA). eHealth interventions with the use of accelerometers and gaming elements, such as rewarding or social bonding, seem promising. These eHealth elements, blended with face-to-face contacts, have the potential to help people adopt and maintain a physically active lifestyle. Objective: The aim of this study was to assess the influence and usage of a blended Web-based gaming intervention on PA, body mass index (BMI), and waist circumference among overweight and obese employees. Methods: In an uncontrolled before-after study, we observed 52 health care employees with BMI more than 25 kg/m2, who were recruited via the company’s intranet and who voluntarily participated in a 23-week Web-based gaming intervention, supplemented (blended) with non-eHealth components. These non-eHealth components were an individual session with an occupational health physician involving motivational interviewing and 5 multidisciplinary group sessions. The game was played by teams in 5 time periods, aiming to gain points by being physically active, as measured by an accelerometer. Data were collected in 2014 and 2015. Primary outcome was PA, defined as length of time at MET (metabolic equivalent task) ≥3, as measured by the accelerometer during the game. Secondary outcomes were reductions in BMI and waist circumference, measured at baseline and 10 and 23 weeks after the start of the program. Gaming elements such as “compliance” with the game (ie, days of accelerometer wear), “engagement” with the game (ie, frequency of reaching a personal monthly target), and “eHealth teams” (ie, social influence of eHealth teams) were measured as potential determinants of the outcomes. Linear mixed models were used to evaluate the effects on all outcome measures. Results: The mean age of participants was 48.1 years; most participants were female (42/51, 82%). The mean PA was 86 minutes per day, ranging from 6.5 to 223 minutes, which was on average 26.2 minutes per day more than self-reported PA at baseline and remained fairly constant during the game. Mean BMI was reduced by 1.87 kg/m2 (5.6%) and waist circumference by 5.6 cm (4.8%). The univariable model showed that compliance, engagement, and eHealth team were significantly associated with more PA, which remained significant for eHealth team in the multivariable model. Conclusions: This blended Web-based gaming intervention was beneficial for overweight workers in becoming physically active above the recommended activity levels during the entire intervention period, and a favorable influence on BMI and waist circumference was observed. Promising components in the intervention, and thus targets for upscaling, are eHealth teams and engagement with the game. Broader implementation and long-term follow-up can provide insights into the sustainable effects on PA and weight loss and into who benefits the most from this approach. %M 28373157 %R 10.2196/games.6421 %U http://games.jmir.org/2017/2/e6/ %U https://doi.org/10.2196/games.6421 %U http://www.ncbi.nlm.nih.gov/pubmed/28373157 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 4 %P e86 %T Pedestrian Inattention Blindness While Playing Pokémon Go as an Emerging Health-Risk Behavior: A Case Report %A Barbieri,Stefania %A Vettore,Gianna %A Pietrantonio,Vincenzo %A Snenghi,Rossella %A Tredese,Alberto %A Bergamini,Mauro %A Previato,Sara %A Stefanati,Armando %A Gaudio,Rosa Maria %A Feltracco,Paolo %+ Department of Urgent and Emergency Care, University of Padova, Via Giustiniani 2, Padova, Padova,, Italy, 39 0498074414, stefibarbieri118@gmail.com %K Pokémon Go %K videogames %K pedestrians %K multiple trauma %K traffic accidents %K motor vehicle collisions %K road injuries %D 2017 %7 01.04.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street. Objective: We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage. Methods: We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient’s history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital’s privacy policy. Results: The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game. Conclusions: Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims. %M 28365563 %R 10.2196/jmir.6596 %U http://www.jmir.org/2017/4/e86/ %U https://doi.org/10.2196/jmir.6596 %U http://www.ncbi.nlm.nih.gov/pubmed/28365563 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e5 %T Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach %A Hale,Alexander R %A Young,Vicki Louise %A Grand,Ann %A McNulty,Cliodna Ann Miriam %+ Public Health England, Primary Care Unit, Gloucestershire Royal Hospital, Gloucester, GL1 3NN, United Kingdom, 44 300 422 5062, vicki.young@phe.gov.uk %K antibiotic resistance %K computer games %K children %K education %K e-Bug %D 2017 %7 24.03.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of 3 antibiotic games on the e-Bug student website, exploring children’s views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed. Results: The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game “Body Busters” was the most popular, closely followed by “Doctor Doctor,” and “Microbe Mania” the least popular. Conclusions: This study shows that 2 of the e-Bug antibiotic educational games are valuable. “Body Busters” effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. “Doctor Doctor” also resulted in increased knowledge, but was less enjoyable. “Microbe Mania” had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games. %M 28341618 %R 10.2196/games.6420 %U http://games.jmir.org/2017/1/e5/ %U https://doi.org/10.2196/games.6420 %U http://www.ncbi.nlm.nih.gov/pubmed/28341618 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 3 %P e72 %T InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians %A Diehl,Leandro Arthur %A Souza,Rodrigo Martins %A Gordan,Pedro Alejandro %A Esteves,Roberto Zonato %A Coelho,Izabel Cristina Meister %+ Internal Medicine Department, Health Sciences Center, Londrina State University (UEL), Depto Clinica Medica/CCS, Av Robert Koch 60, Londrina PR, 86038350, Brazil, 55 4333712234, drgaucho@yahoo.com %K diabetes mellitus %K insulin %K video games %K medical education %K continuing medical education %K educational technology %D 2017 %7 09.03.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated. Objective: The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity. Methods: Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively. Results: Subjects’ characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as “fun or pleasant,” “useful,” and “practice-changing.” Conclusions: The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients. Trial Registration: Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf) %M 28279950 %R 10.2196/jmir.6944 %U http://www.jmir.org/2017/3/e72/ %U https://doi.org/10.2196/jmir.6944 %U http://www.ncbi.nlm.nih.gov/pubmed/28279950 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 1 %P e8 %T Effects of Video Game Training on Behavioral and Electrophysiological Measures of Attention and Memory: Protocol for a Randomized Controlled Trial %A Ballesteros,Soledad %A Mayas,Julia %A Ruiz-Marquez,Eloisa %A Prieto,Antonio %A Toril,Pilar %A Ponce de Leon,Laura %A de Ceballos,Maria L %A Reales Avilés,José Manuel %+ Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Facultad de Psicología, Juan del Rosal, 10, Madrid,, Spain, 34 91398 62 27, mballesteros@psi.uned.es %K attention %K C-reactive protein %K cognitive training %K healthy aging %K inflammation %K electrophysiology %K video games %K working memory %D 2017 %7 24.01.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Neuroplasticity-based approaches seem to offer promising ways of maintaining cognitive health in older adults and postponing the onset of cognitive decline symptoms. Although previous research suggests that training can produce transfer effects, this study was designed to overcome some limitations of previous studies by incorporating an active control group and the assessment of training expectations. Objective: The main objectives of this study are (1) to evaluate the effects of a randomized computer-based intervention consisting of training older adults with nonaction video games on brain and cognitive functions that decline with age, including attention and spatial working memory, using behavioral measures and electrophysiological recordings (event-related potentials [ERPs]) just after training and after a 6-month no-contact period; (2) to explore whether motivation, engagement, or expectations might account for possible training-related improvements; and (3) to examine whether inflammatory mechanisms assessed with noninvasive measurement of C-reactive protein in saliva impair cognitive training-induced effects. A better understanding of these mechanisms could elucidate pathways that could be targeted in the future by either behavioral or neuropsychological interventions. Methods: A single-blinded randomized controlled trial with an experimental group and an active control group, pretest, posttest, and 6-month follow-up repeated measures design is used in this study. A total of 75 cognitively healthy older adults were randomly distributed into experimental and active control groups. Participants in the experimental group received 16 1-hour training sessions with cognitive nonaction video games selected from Lumosity, a commercial brain training package. The active control group received the same number of training sessions with The Sims and SimCity, a simulation strategy game. Results: We have recruited participants, have conducted the training protocol and pretest assessments, and are currently conducting posttest evaluations. The study will conclude in the first semester of 2017. Data analysis will take place during 2017. The primary outcome is transfer of benefit from training to attention and working memory functions and the neural mechanisms underlying possible cognitive improvements. Conclusions: We expect that mental stimulation with video games will improve attention and memory both at the behavioral level and in ERP components promoting brain and mental health and extending independence among elderly people by avoiding the negative personal and economic consequences of long-term care. Trial Registration: Clinicaltrials.gov NCT02796508; https://clinicaltrials.gov/ct2/show/NCT02796508 (archived by WebCite at http://www.webcitation.org/6nFeKeFNB) %M 28119279 %R 10.2196/resprot.6570 %U http://www.researchprotocols.org/2017/1/e8/ %U https://doi.org/10.2196/resprot.6570 %U http://www.ncbi.nlm.nih.gov/pubmed/28119279 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 1 %P e3 %T The Use of Motion-Based Technology for People Living With Dementia or Mild Cognitive Impairment: A Literature Review %A Dove,Erica %A Astell,Arlene J %+ Research & Academics, Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, ON, L1N 5S9, Canada, 1 905 430 4055 ext 6313, dovee@ontarioshores.ca %K dementia %K mild cognitive impairment %K technology %K review %D 2017 %7 11.01.2017 %9 Review %J J Med Internet Res %G English %X Background: The number of people living with dementia and mild cognitive impairment (MCI) is increasing substantially. Although there are many research efforts directed toward the prevention and treatment of dementia and MCI, it is also important to learn more about supporting people to live well with dementia or MCI through cognitive, physical, and leisure means. While past research suggests that technology can be used to support positive aging for people with dementia or MCI, the use of motion-based technology has not been thoroughly explored with this population. Objective: The aim of this study was to identify and synthesize the current literature involving the use of motion-based technology for people living with dementia or MCI by identifying themes while noting areas requiring further research. Methods: A systematic review of studies involving the use of motion-based technology for human participants living with dementia or MCI was conducted. Results: A total of 31 articles met the inclusion criteria. Five questions are addressed concerning (1) context of use; (2) population included (ie, dementia, MCI, or both); (3) hardware and software selection; (4) use of motion-based technology in a group or individual setting; and (5) details about the introduction, teaching, and support methods applied when using the motion-based technology with people living with dementia or MCI. Conclusions: The findings of this review confirm the potential of motion-based technology to improve the lives of people living with dementia or MCI. The use of this technology also spans across several contexts including cognitive, physical, and leisure; all of which support multidimensional well-being. The literature provides evidence that people living with dementia or MCI can learn how to use this technology and that they enjoy doing so. However, there is a lack of information provided in the literature regarding the introduction, training, and support methods applied when using this form of technology with this population. Future research should address the appropriate introduction, teaching, and support required for people living with dementia or MCI to use the motion-based technology. In addition, it is recommended that the diverse needs of these specific end-users be considered in the design and development of this technology. %M 28077346 %R 10.2196/jmir.6518 %U http://www.jmir.org/2017/1/e3/ %U https://doi.org/10.2196/jmir.6518 %U http://www.ncbi.nlm.nih.gov/pubmed/28077346 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 1 %P e1 %T Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology %A Paim,Crislaine Pires Padilha %A Goldmeier,Silvia %+ Institute of Cardiology of Rio Grande do Sul, University Foundation of Cardiology, 395 Princesa Isabel Avenue, Porto Alegre, 90620-001, Brazil, 55 51 32303600, sgoldmeier@gmail.com %K nursing education research %K educational technology %K perioperative nursing %D 2017 %7 10.01.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Existing research suggests that digital games can be used effectively for educational purposes at any level of training. Perioperative nursing educators can use games to complement curricula, in guidance and staff development programs, to foster team collaboration, and to give support to critical thinking in nursing practice because it is a complex environment. Objective: To describe the process of developing an educational game to set up surgical instruments on the Mayo stand or back table as a resource to assist the instructor in surgical instrumentation training for students and nursing health professionals in continued education. Methods: The study was characterized by applied research in production technology. It included the phases of analysis and design, development, and evaluation. The objectives of the educational game were developed through Bloom’s taxonomy. Parallel to the physical development of the educational game, a proposed model for the use of digital elements in educational game activities was applied to develop the game content. Results: The development of the game called “Playing with Tweezers” was carried out in 3 phases and was evaluated by 15 participants, comprising students and professional experts in various areas of knowledge such as nursing, information technology, and education. An environment was created with an initial screen, menu buttons containing the rules of the game, and virtual tour modes for learning and assessment. Conclusions: The “digital” nursing student needs engagement, stimulation, reality, and entertainment, not just readings. “Playing with Tweezers” is an example of educational gaming as an innovative teaching strategy in nursing that encourages the strategy of involving the use of educational games to support theoretical or practical classroom teaching. Thus, the teacher does not work with only 1 type of teaching methodology, but with a combination of different methodologies. In addition, we cannot forget that skill training in an educational game does not replace curricular practice, but helps. %M 28073736 %R 10.2196/games.6048 %U http://games.jmir.org/2017/1/e1/ %U https://doi.org/10.2196/games.6048 %U http://www.ncbi.nlm.nih.gov/pubmed/28073736 %0 Journal Article %@ 2369-6893 %I JMIR Publications %V 2 %N 1 %P e29 %T Health eRide: Outcomes of a Pilot Program Leveraging Principles of Gamification and SMS Messaging to Help Veterans Self-Manage Chronic Pain %A Johnson,Sara %A Levesque,Deborah %A Broderick,Lynne %+ Pro-Change Behavior Systems, Inc, 1174 Kingstown Road, Suite 101, South Kingstown, RI, 02879, United States, 1 401 360 2978, lbroderick@prochange.com %K gamification %K intervention %K veterans %K serious games %K pain management %D 2016 %7 29.12.2016 %9 Poster %J iproc %G English %X Background: Chronic pain creates a significant public health burden and disproportionately affects veterans. Over 56% of Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans have a diagnosis of chronic pain. The frequency and extent of pain, posttraumatic stress disorder (PTSD), traumatic brain injury, and the co-occurrence of all three conditions (post-deployment multi-symptom disorder, PMD) can complicate and reduce the effectiveness of traditional treatments for pain. Taken in combination with the opioid crisis in the United States, there is an urgent need for innovative and integrative approaches to non-medical pain management. However, readiness to engage in pain self-management varies. Objective: The objective of this Phase I pilot was to design, develop, and establish the feasibility of a theoretically-grounded, mobile-optimized, interactive pain self-management intervention for veterans that leverages principles of gamification. Methods: The development of Health eRide: Your Journey to Managing Pain included extensive end-user input including a veteran advisory panel (n=5), formative focus groups (n=20), and iterative usability testing (n=20). Health eRide is tailored not only to veterans’ preference for pain self-management strategies but also their readiness to adopt those strategies as measured by a Transtheoretical Model-based stage of change assessment. The program incorporates core components of promising treatments for PMD by intervening on sleep hygiene and stress management. Health eRide includes (1) an online computer-tailored intervention that provides tailored behavior change guidance and (2) an individually tailored subway-themed “map” of their pain management journey. Stops along the map include stage-based interactive activities designed to further users along in their journey to self-managing pain. The program also included optional text messaging and a Facebook page. A pilot study with a 30-day follow-up was conducted with 69 veterans (81% male, 58% Caucasian, average age=50) to examine the acceptability and preliminary effectiveness of Health eRide. Users completed stage of change algorithms and pain rating scales at baseline and follow-up and completed a measure of acceptability and the System Usability Scale (SUS) at follow-up. Results: A total of 44 veterans (64%) completed the follow-up assessment (no significant differences on baseline demographics between those who completed the follow-up assessment and those who did not). The mean rating of acceptability for Health eRide was 3.20 on a 4 point scale, indicating that users found the program useful, informative, reliable, and easy to navigate. Likewise, the mean score on the SUS was 65.4, indicating the program meets standards for usability. The results show significant changes in movement to readiness to adopt strategies to self-manage pain (54.5% at baseline vs 79.5% at follow-up, P=.007) and effectively manage stress (50% vs 88.6%, P<.001). While there was movement to readiness to adopt healthy sleep habits (25% vs 38.6%), the change was not significant. There were significant improvements in ratings of pain: “How would you rate your pain right now?” (partial η2=.205, P=.002) and “How would you rate your usual pain in the last week?” (partial η2=.378, P<.001). Conclusions: Findings provide encouraging evidence of the acceptability and effectiveness of incorporating principles of gamification into a theoretically grounded intervention for veterans at all levels of readiness for self-managing chronic pain. %R 10.2196/iproc.6155 %U http://www.iproc.org/2016/1/e29/ %U https://doi.org/10.2196/iproc.6155 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e22 %T Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students’ Experiences Using a Multiplayer Virtual World %A Creutzfeldt,Johan %A Hedman,Leif %A Felländer-Tsai,Li %+ Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K32, Karolinska University Hospital, Stockholm, 14186, Sweden, 46 8 585 82102, johan.creutzfeldt@ki.se %K avatars %K cardiopulmonary resuscitation %K educational technology %K medical students %K experiences %K multiplayer virtual worlds %K patient simulation %K virtual learning environments %D 2016 %7 16.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners’ reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students’ perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students’ experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. %M 27986645 %R 10.2196/games.6448 %U http://games.jmir.org/2016/2/e22/ %U https://doi.org/10.2196/games.6448 %U http://www.ncbi.nlm.nih.gov/pubmed/27986645 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 12 %P e315 %T Influence of Pokémon Go on Physical Activity: Study and Implications %A Althoff,Tim %A White,Ryen W %A Horvitz,Eric %+ Computer Science Department, Stanford University, 94 Thoburn Ct., Apt 108, Stanford, CA, 94305, United States, 1 6504850758, althoff@cs.stanford.edu %K physical activity %K Pokémon Go %K mobile health %K mHealth %K wearable devices %K mobile applications %K games %K exergames %K public health %D 2016 %7 06.12.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity helps people maintain a healthy weight and reduces the risk for several chronic diseases. Although this knowledge is widely recognized, adults and children in many countries around the world do not get recommended amounts of physical activity. Although many interventions are found to be ineffective at increasing physical activity or reaching inactive populations, there have been anecdotal reports of increased physical activity due to novel mobile games that embed game play in the physical world. The most recent and salient example of such a game is Pokémon Go, which has reportedly reached tens of millions of users in the United States and worldwide. Objective: The objective of this study was to quantify the impact of Pokémon Go on physical activity. Methods: We study the effect of Pokémon Go on physical activity through a combination of signals from large-scale corpora of wearable sensor data and search engine logs for 32,000 Microsoft Band users over a period of 3 months. Pokémon Go players are identified through search engine queries and physical activity is measured through accelerometers. Results: We find that Pokémon Go leads to significant increases in physical activity over a period of 30 days, with particularly engaged users (ie, those making multiple search queries for details about game usage) increasing their activity by 1473 steps a day on average, a more than 25% increase compared with their prior activity level (P<.001). In the short time span of the study, we estimate that Pokémon Go has added a total of 144 billion steps to US physical activity. Furthermore, Pokémon Go has been able to increase physical activity across men and women of all ages, weight status, and prior activity levels showing this form of game leads to increases in physical activity with significant implications for public health. In particular, we find that Pokémon Go is able to reach low activity populations, whereas all 4 leading mobile health apps studied in this work largely draw from an already very active population. Conclusions: Mobile apps combining game play with physical activity lead to substantial short-term activity increases and, in contrast to many existing interventions and mobile health apps, have the potential to reach activity-poor populations. Future studies are needed to investigate potential long-term effects of these applications. %M 27923778 %R 10.2196/jmir.6759 %U http://www.jmir.org/2016/12/e315/ %U https://doi.org/10.2196/jmir.6759 %U http://www.ncbi.nlm.nih.gov/pubmed/27923778 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e19 %T Quittr: The Design of a Video Game to Support Smoking Cessation %A Bindoff,Ivan %A de Salas,Kristy %A Peterson,Gregory %A Ling,Tristan %A Lewis,Ian %A Wells,Lindsay %A Gee,Peter %A Ferguson,Stuart G %+ University of Tasmania, Private Bag 87, Hobart, 7001, Australia, 61 3 62266220, Kristy.deSalas@utas.edu.au %K smoking cessation %K video games %K mobile phone %K motivation %D 2016 %7 01.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking is recognized as the largest, single, preventable cause of death and disease in the developed world. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term abstinence. Behavioral support, such as education, advice, goal-setting, and encouragement, is known to be beneficial in improving the likelihood of succeeding in a quit attempt, but it remains difficult to effectively deliver this behavioral support and keep the patient engaged with the process for a sufficient duration. In an attempt to solve this, there have been numerous mobile apps developed, yet engagement and retention have remained key challenges that limit the potential effectiveness of these interventions. Video games have been clearly linked with the effective delivery of health interventions, due to their capacity to increase motivation and engagement of players. Objective: The objective of this study is to describe the design and development of a smartphone app that is theory-driven, and which incorporates gaming characteristics in order to promote engagement with content, and thereby help smokers to quit. Methods: Game design and development was informed by a taxonomy of motivational affordances for meaningful gamified and persuasive technologies. This taxonomy describes a set of design components that is grounded in well-established psychological theories on motivation. Results: This paper reports on the design and development process of Quittr, a mobile app, describing how game design principles, game mechanics, and game elements can be used to embed education and support content, such that the app actually requires the user to access and engage with relevant educational content. The next stage of this research is to conduct a randomized controlled trial to determine whether the additional incentivization game features offer any value in terms of the key metrics of engagement–how much content users are consuming, how many days users are persisting with using the app, and what proportion of users successfully abstain from smoking for 28 days, based on user-reported data and verified against a biochemical baseline using cotinine tests. Conclusions: We describe a novel, and theoretically-informed mobile app design approach that has a broad range of potential applications. By using the virtual currency approach, we remove the need for the game to comprehensively integrate the healthy activity as part of its actual play mechanics. This opens up the potential for a wide variety of health problems to be tackled through games where no obvious play mechanic presents itself. The implications of this app are that similar approaches may be of benefit in areas such as managing chronic conditions (diabetes, heart disease, etc), treating substance abuse (alcohol, illicit drugs, etc), diet and exercise, eating disorders (anorexia, bulimia, and binge eating), and various phobias. %M 27908844 %R 10.2196/games.6258 %U http://games.jmir.org/2016/2/e19/ %U https://doi.org/10.2196/games.6258 %U http://www.ncbi.nlm.nih.gov/pubmed/27908844 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e224 %T Efficacy of Mobile Serious Games in Increasing HIV Risk Perception in Swaziland: A Randomized Control Trial (SGprev Trial) Research Protocol %A Lukhele,Bhekumusa Wellington %A Musumari,Patou %A El-Saaidi,Christina %A Techasrivichien,Teeranee %A Suguimoto,S. Pilar %A Ono Kihara,Masako %A Kihara,Masahiro %+ Department of Global Health and Socio Epidemiology, Frontier Laboratory Bldg, 2nd Fl., Kyoto University School of Public Health Yoshida Konoe-cho, Sakyo-ku, Kyoto, 6068501, Japan, 81 757534350 ext 4350, bhekumusa.lukhele.36x@st.kyoto-u.ac.jp %K eHealth %K mHealth %K gamification %K Internet %K HIV prevention %K innovation %D 2016 %7 22.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: The human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) continue to be a major public health problem in Sub-Saharan Africa (SSA), particularly in Swaziland, which has the highest HIV prevalence in this region. A wide range of strategies and interventions have been used to promote behavior change, though almost all such interventions have involved mass media. Therefore, innovative behavior change strategies beyond mass media communication are urgently needed. Serious games have demonstrated effectiveness in advancing health in the developed world; however, no rigorous serious games interventions have been implemented in HIV prevention in SSA. Objective: We plan to test whether a serious game intervention delivered on mobile phones to increase HIV risk perception, increase intention to reduce sexual partnerships, and increase intention to know own and partners HIV status will be more effective compared with current prevention efforts. Methods: This is a two-arm randomized intervention trial. We will recruit 380 participants who meet the following eligibility criteria: 18-29 years of age, own a smartphone running an Android-based operating system, have the WhatsApp messaging app, live in Swaziland, and can adequately grant informed consent. Participants will be allocated into a smartphone interactive, educational story game, and a wait-list control group in a 1:1 allocation ratio. Subsequently, a self-administered Web-based questionnaire will be issued at baseline and after 4 weeks of exposure to the game. We hypothesize that the change in HIV risk perception between pre- and post-intervention assessment is greater in the intervention group compared with the change in the control group. Our primary hypothesis is based on the assumption that increased perceived risk of HIV provides cues to engage in protective behavior. Our primary outcome measure is HIV risk perceived mean change between pre- and post-intervention compared with the mean change in the wait-list control group at 4-weeks post-intervention. We will use standardized regression coefficients to calculate the effect of the intervention on our primary outcome with P values. We will conduct both intention to treat and as treated analysis. Results: This study is funded by Hayao Nakayama Foundation for Science & Technology and Culture; Grant number H26-A2-41. The research and development approval has been obtained from Kyoto University Graduate School and Faculty of Medicine Ethics Committee, Japan, and Swaziland’s Ministry of Health Ethics and Scientific committee. Results are expected in February 2017. Conclusions: This study will provide evidence on the efficiency of a mobile phone interactive game in increasing HIV risk perception in Swaziland. Our findings may also be generalizable to similar settings in SSA. Trial Registration: University Hospital Medical Information Network Clinical Trial Registry ID number (UMIN-CTR):UMIN000021781; URL:https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000025103 (Archived by WebCite at http://www.webcitation.org/6hOphB11a). %M 27876685 %R 10.2196/resprot.6543 %U http://www.researchprotocols.org/2016/4/e224/ %U https://doi.org/10.2196/resprot.6543 %U http://www.ncbi.nlm.nih.gov/pubmed/27876685 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e18 %T Game On? Smoking Cessation Through the Gamification of mHealth: A Longitudinal Qualitative Study %A El-Hilly,Abdulrahman Abdulla %A Iqbal,Sheeraz Syed %A Ahmed,Maroof %A Sherwani,Yusuf %A Muntasir,Mohammed %A Siddiqui,Sarim %A Al-Fagih,Zaid %A Usmani,Omar %A Eisingerich,Andreas B %+ Airway Disease, National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, Dovehouse Street, London, SW3 6LY, United Kingdom, 44 (0)20 7351 8051, o.usmani@imperial.ac.uk %K gamification %K mhealth %K mobile health %K smoking cessation %K health behavior %K health policy %K public health %K behavioral support %D 2016 %7 24.10.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Finding ways to increase and sustain engagement with mHealth interventions has become a challenge during application development. While gamification shows promise and has proven effective in many fields, critical questions remain concerning how to use gamification to modify health behavior. Objective: The objective of this study is to investigate how the gamification of mHealth interventions leads to a change in health behavior, specifically with respect to smoking cessation. Methods: We conducted a qualitative longitudinal study using a sample of 16 smokers divided into 2 cohorts (one used a gamified intervention and the other used a nongamified intervention). Each participant underwent 4 semistructured interviews over a period of 5 weeks. Semistructured interviews were also conducted with 4 experts in gamification, mHealth, and smoking cessation. Interviews were transcribed verbatim and thematic analysis undertaken. Results: Results indicated perceived behavioral control and intrinsic motivation acted as positive drivers to game engagement and consequently positive health behavior. Importantly, external social influences exerted a negative effect. We identified 3 critical factors, whose presence was necessary for game engagement: purpose (explicit purpose known by the user), user alignment (congruency of game and user objectives), and functional utility (a well-designed game). We summarize these findings in a framework to guide the future development of gamified mHealth interventions. Conclusions: Gamification holds the potential for a low-cost, highly effective mHealth solution that may replace or supplement the behavioral support component found in current smoking cessation programs. The framework reported here has been built on evidence specific to smoking cessation, however it can be adapted to health interventions in other disease categories. Future research is required to evaluate the generalizability and effectiveness of the framework, directly against current behavioral support therapy interventions in smoking cessation and beyond. %M 27777216 %R 10.2196/games.5678 %U http://games.jmir.org/2016/2/e18/ %U https://doi.org/10.2196/games.5678 %U http://www.ncbi.nlm.nih.gov/pubmed/27777216 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 10 %P e272 %T The Narrative Impact of Active Video Games on Physical Activity Among Children: A Feasibility Study %A Lu,Amy Shirong %A Baranowski,Tom %A Hong,S Lee %A Buday,Richard %A Thompson,Debbe %A Beltran,Alicia %A Dadabhoy,Hafza Razak %A Chen,Tzu-An %+ College of Arts, Media & Design, Department of Communication Studies, Northeastern University, 360 Huntington Ave, 204 Lake Hall, Boston, MA, 02115, United States, 1 6173737839, a.lu@northeastern.edu %K video games %K narration %K behavior %K child health %K child obesity %K motivation %D 2016 %7 14.10.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Active video games (AVGs) capable of inducing physical activity offer an innovative approach to combating childhood obesity. Unfortunately, children’s AVG game play decreases quickly, underscoring the need to identify novel methods for player engagement. Narratives have been demonstrated to influence behaviors. Objective: The objective of this study was to test the hypothesis that a narrative would motivate increased AVG play, though a feasibility study that investigated the motivational effect of adding a previously developed narrative cutscene to an originally nonnarrative AVG, Nintendo Wii Sports Resort: Swordplay Showdown. Methods: A total of 40 overweight and obese 8- to 11-year-olds equally divided by sex played the AVG. Half (n=20) were randomly assigned to a narrative group that watched the narrative cutscene before game play. The other half played the game without watching it. Results: Children in the narrative group had significantly (P<.05) more steps per 10-second period (mean 3.2, SD 0.7) and overall (mean 523, SD 203) during game play compared with the nonnarrative group (10-second period: mean 2.7, SD 0.7; overall: mean 366, SD 172). Conclusions: The AVG with narrative induced increased physical activity. Additional research is needed to understand the mechanisms through which narrative increases physical activity during AVG game play. %M 27742605 %R 10.2196/jmir.6538 %U http://www.jmir.org/2016/10/e272/ %U https://doi.org/10.2196/jmir.6538 %U http://www.ncbi.nlm.nih.gov/pubmed/27742605 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e46 %T Evaluation of a Digital Game-Based Learning Program for Enhancing Youth Mental Health: A Structural Equation Modeling of the Program Effectiveness %A Huen,Jenny MY %A Lai,Eliza SY %A Shum,Angie KY %A So,Sam WK %A Chan,Melissa KY %A Wong,Paul WC %A Law,YW %A Yip,Paul SF %+ Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong, China (Hong Kong), 852 39174375, sfpyip@hku.hk %K digital game-based learning %K mental health %K program evaluation %K Internet %D 2016 %7 07.10.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital game-based learning (DGBL) makes use of the entertaining power of digital games for educational purposes. Effectiveness assessment of DGBL programs has been underexplored and no attempt has been made to simultaneously model both important components of DGBL: learning attainment (ie, educational purposes of DGBL) and engagement of users (ie, entertaining power of DGBL) in evaluating program effectiveness. Objective: This study aimed to describe and evaluate an Internet-based DGBL program, Professor Gooley and the Flame of Mind, which promotes mental health to adolescents in a positive youth development approach. In particular, we investigated whether user engagement in the DGBL program could enhance their attainment on each of the learning constructs per DGBL module and subsequently enhance their mental health as measured by psychological well-being. Methods: Users were assessed on their attainment on each learning construct, psychological well-being, and engagement in each of the modules. One structural equation model was constructed for each DGBL module to model the effect of users' engagement and attainment on the learning construct on their psychological well-being. Results: Of the 498 secondary school students that registered and participated from the first module of the DGBL program, 192 completed all 8 modules of the program. Results from structural equation modeling suggested that a higher extent of engagement in the program activities facilitated users’ attainment on the learning constructs on most of the modules and in turn enhanced their psychological well-being after controlling for users’ initial psychological well-being and initial attainment on the constructs. Conclusions: This study provided evidence that Internet intervention for mental health, implemented with the technologies and digital innovations of DGBL, could enhance youth mental health. Structural equation modeling is a promising approach in evaluating the effectiveness of DGBL programs. %M 27717921 %R 10.2196/mental.5656 %U http://mental.jmir.org/2016/4/e46/ %U https://doi.org/10.2196/mental.5656 %U http://www.ncbi.nlm.nih.gov/pubmed/27717921 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e17 %T Usability Evaluation Methods for Gesture-Based Games: A Systematic Review %A Simor,Fernando Winckler %A Brum,Manoela Rogofski %A Schmidt,Jaison Dairon Ebertz %A Rieder,Rafael %A De Marchi,Ana Carolina Bertoletti %+ Universidade de Passo Fundo, BR 285 KM 292.7, Passo Fundo, RS, 99052-900, Brazil, 55 5433168354, rieder@upf.br %K usability testing %K evaluation %K computer games %K gestural input %K usability evaluation %K method %K gesture-based games %D 2016 %7 04.10.2016 %9 Review %J JMIR Serious Games %G English %X Background: Gestural interaction systems are increasingly being used, mainly in games, expanding the idea of entertainment and providing experiences with the purpose of promoting better physical and/or mental health. Therefore, it is necessary to establish mechanisms for evaluating the usability of these interfaces, which make gestures the basis of interaction, to achieve a balance between functionality and ease of use. Objective: This study aims to present the results of a systematic review focused on usability evaluation methods for gesture-based games, considering devices with motion-sensing capability. We considered the usability methods used, the common interface issues, and the strategies adopted to build good gesture-based games. Methods: The research was centered on four electronic databases: IEEE, Association for Computing Machinery (ACM), Springer, and Science Direct from September 4 to 21, 2015. Within 1427 studies evaluated, 10 matched the eligibility criteria. As a requirement, we considered studies about gesture-based games, Kinect and/or Wii as devices, and the use of a usability method to evaluate the user interface. Results: In the 10 studies found, there was no standardization in the methods because they considered diverse analysis variables. Heterogeneously, authors used different instruments to evaluate gesture-based interfaces and no default approach was proposed. Questionnaires were the most used instruments (70%, 7/10), followed by interviews (30%, 3/10), and observation and video recording (20%, 2/10). Moreover, 60% (6/10) of the studies used gesture-based serious games to evaluate the performance of elderly participants in rehabilitation tasks. This highlights the need for creating an evaluation protocol for older adults to provide a user-friendly interface according to the user’s age and limitations. Conclusions: Through this study, we conclude this field is in need of a usability evaluation method for serious games, especially games for older adults, and that the definition of a methodology and a test protocol may offer the user more comfort, welfare, and confidence. %M 27702737 %R 10.2196/games.5860 %U http://games.jmir.org/2016/2/e17/ %U https://doi.org/10.2196/games.5860 %U http://www.ncbi.nlm.nih.gov/pubmed/27702737 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e225 %T Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (“Balance It”): A Pilot Study %A Spook,Jorinde %A Paulussen,Theo %A Kok,Gerjo %A van Empelen,Pepijn %+ Wageningen University and Research, Department of Communication, Philosophy and Technology: Centre for Integrative Development, PO Box 8130, 6700 EW, Wageningen,, Netherlands, 31 0317481446, jorinde.spook@wur.nl %K Balance It %K effect evaluation %K serious game %K self-regulation %K prevention and control %K health promotion %K dietary intake %K physical activity %D 2016 %7 26.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA). Objective: We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA. Methods: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. Results: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. Conclusions: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight. %M 27670222 %R 10.2196/jmir.4964 %U http://www.jmir.org/2016/9/e225/ %U https://doi.org/10.2196/jmir.4964 %U http://www.ncbi.nlm.nih.gov/pubmed/27670222 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e237 %T Impact of Game-Inspired Infographics on User Engagement and Information Processing in an eHealth Program %A Comello,Maria Leonora G %A Qian,Xiaokun %A Deal,Allison M %A Ribisl,Kurt M %A Linnan,Laura A %A Tate,Deborah F %+ School of Media and Journalism, University of North Carolina at Chapel Hill, Carroll Hall, CB 3365, Chapel Hill, NC, 27599, United States, 1 919 928 2440, comello@email.unc.edu %K infographics %K game design %K eHealth %K personalized feedback %K visuals %D 2016 %7 22.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Online interventions providing individual health behavior assessment should deliver feedback in a way that is both understandable and engaging. This study focused on the potential for infographics inspired by the aesthetics of game design to contribute to these goals. Objective: We conducted formative research to test game-inspired infographics against more traditional displays (eg, text-only, column chart) for conveying a behavioral goal and an individual’s behavior relative to the goal. We explored the extent to which the display type would influence levels of engagement and information processing. Methods: Between-participants experiments compared game-inspired infographics with traditional formats in terms of outcomes related to information processing (eg, comprehension, cognitive load) and engagement (eg, attitudes toward the information, emotional tone). We randomly assigned participants (N=1162) to an experiment in 1 of 6 modules (tobacco use, alcohol use, vegetable consumption, fruit consumption, physical activity, and weight management). Results: In the tobacco module, a game-inspired format (scorecard) was compared with text-only; there were no differences in attitudes and emotional tone, but the scorecard outperformed text-only on comprehension (P=.004) and decreased cognitive load (P=.006). For the other behaviors, we tested 2 game-inspired formats (scorecard, progress bar) and a traditional column chart; there were no differences in comprehension, but the progress bar outperformed the other formats on attitudes and emotional tone (P<.001 for all contrasts). Conclusions: Across modules, a game-inspired infographic showed potential to outperform a traditional format for some study outcomes while not underperforming on other outcomes. Overall, findings support the use of game-inspired infographics in behavioral assessment feedback to enhance comprehension and engagement, which may lead to greater behavior change. %M 27658469 %R 10.2196/jmir.5976 %U http://www.jmir.org/2016/9/e237/ %U https://doi.org/10.2196/jmir.5976 %U http://www.ncbi.nlm.nih.gov/pubmed/27658469 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e14 %T Gamifying Self-Management of Chronic Illnesses: A Mixed-Methods Study %A AlMarshedi,Alaa %A Wills,Gary %A Ranchhod,Ashok %+ University of Southampton, School of Electronics and Computer Science, aaa3g12@soton.ac.uk, Southampton,, United Kingdom, 44 (0)23 8059 4506, aaa3g12@soton.ac.uk %K gamification %K healthcare %K self-management %K chronic illnesses %K diabetes %K motivation %K behavioral change %D 2016 %7 09.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Self-management of chronic illnesses is an ongoing issue in health care research. Gamification is a concept that arose in the field of computer science and has been borrowed by many other disciplines. It is perceived by many that gamification can improve the self-management experience of people with chronic illnesses. This paper discusses the validation of a framework (called The Wheel of Sukr) that was introduced to achieve this goal. Objective: This research aims to (1) discuss a gamification framework targeting the self-management of chronic illnesses and (2) validate the framework by diabetic patients, medical professionals, and game experts. Methods: A mixed-method approach was used to validate the framework. Expert interviews (N=8) were conducted in order to validate the themes of the framework. Additionally, diabetic participants completed a questionnaire (N=42) in order to measure their attitudes toward the themes of the framework. Results: The results provide a validation of the framework. This indicates that gamification might improve the self-management of chronic illnesses, such as diabetes. Namely, the eight themes in the Wheel of Sukr (fun, esteem, socializing, self-management, self-representation, motivation, growth, sustainability) were perceived positively by 71% (30/42) of the participants with P value <.001. Conclusions: In this research, both the interviews and the questionnaire yielded positive results that validate the framework (The Wheel of Sukr). Generally, this study indicates an overall acceptance of the notion of gamification in the self-management of diabetes. %M 27612632 %R 10.2196/games.5943 %U http://games.jmir.org/2016/2/e14/ %U https://doi.org/10.2196/games.5943 %U http://www.ncbi.nlm.nih.gov/pubmed/27612632 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e39 %T Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review %A Brown,Menna %A O'Neill,Noelle %A van Woerden,Hugo %A Eslambolchilar,Parisa %A Jones,Matt %A John,Ann %+ Swansea University, Medical School, ILS2, Singleton Park, Swansea, SA2 8PP, United Kingdom, 44 179260 ext 6312, menna.brown@swansea.ac.uk %K adherence %K Web-based mental health interventions %K well-being %K gamification %K engagement %K dropout %K patient compliance %K patient nonadherence %D 2016 %7 24.08.2016 %9 Review %J JMIR Ment Health %G English %X Background: Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of “active” technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being. Objective: This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being. Methods: A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched. Results: A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration. Conclusions: Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data. %M 27558893 %R 10.2196/mental.5710 %U http://mental.jmir.org/2016/3/e39/ %U https://doi.org/10.2196/mental.5710 %U http://www.ncbi.nlm.nih.gov/pubmed/27558893 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e13 %T A Video Game Promoting Cancer Risk Perception and Information Seeking Behavior Among Young-Adult College Students: A Randomized Controlled Trial %A Khalil,Georges Elias %A Beale,Ivan L %A Chen,Minxing %A Prokhorov,Alexander V %+ The M.D. Anderson Cancer Center, Department of Behavioral Science, University of Texas, 1155 Pressler St. Unit 1330, Houston, TX,, United States, 1 713 563 2605, gekhalil@mdanderson.org %K cancer %K risk %K information seeking %K perceived risk %K perceived susceptibility %K perceived severity %K cancer prevention %K games for health %K serious games %D 2016 %7 28.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Risky behaviors tend to increase drastically during the transition into young adulthood. This increase may ultimately facilitate the initiation of carcinogenic processes at a young age, highlighting a serious public health problem. By promoting information seeking behavior (ISB), young adults may become aware of cancer risks and potentially take preventive measures. Objective: Based on the protection motivation theory, the current study seeks to evaluate the impact of challenge in a fully automated video game called Re-Mission on young adult college students' tendency to perceive the severity of cancer, feel susceptible to cancer, and engage in ISB. Methods: A total of 216 young adults were recruited from a university campus, consented, screened, and randomized in a single-blinded format to 1 of 3 conditions: an intervention group playing Re-Mission at high challenge (HC; n=85), an intervention group playing Re-Mission at low challenge (LC; n=81), and a control group with no challenge (NC; presented with illustrated pictures of Re-Mission; n=50). Measurement was conducted at baseline, immediate posttest, 10-day follow-up, and 20-day follow-up. Repeated-measures mixed-effect models were conducted for data analysis of the main outcomes. Results: A total of 101 young adults continued until 20-day follow-up. Mixed-effect models showed that participants in the HC and LC groups were more likely to increase in perceived susceptibility to cancer (P=.03), perceived severity of cancer (P=.02), and ISB (P=.01) than participants in the NC group. The LC group took until 10-day follow-up to show increase in perceived susceptibility (B=0.47, standard error (SE) 0.16, P=.005). The HC group showed an immediate increase in perceived susceptibility at posttest (B=0.43, SE 0.14, P=.002). The LC group exhibited no changes in perceived severity (B=0.40, SE 0.33, P=.24). On the other hand, the HC group showed a significant increase from baseline to posttest (B=0.39, SE 0.14, P=.005), maintaining this increase until 20-day follow-up (B=−0.007, SE 0.26, P=.98). Further analyses indicated that perceived threat from virtual cancer cells in the game is related to the increase in perceived severity (B=0.1, SE 0.03, P=.001), and perceived susceptibility is related to changes in ISB at 10-day follow-up (B=0.21, SE 0.08, P=.008). Conclusions: The feature of challenge with cancer cells in a virtual environment has the potential to increase cancer risk perception and ISB. The results are promising considering that the Re-Mission intervention was neither designed for cancer risk communication, nor applied among healthy individuals. Further research is needed to understand the theoretical framework underlying the effects of Re-Mission on ISB. The findings call for the development of a Web-based, game-based intervention for cancer risk communication and information seeking among young adults. ClinicalTrial: International Standard Randomized Controlled Trial Number (ISRCTN): 15789289; http://www.controlled-trials.com/ISRCTN15789289 (Archived by WebCite at http://www.webcitation.org/6jGYZC3lZ) %M 27470927 %R 10.2196/games.5793 %U http://games.jmir.org/2016/2/e13/ %U https://doi.org/10.2196/games.5793 %U http://www.ncbi.nlm.nih.gov/pubmed/27470927 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 7 %P e196 %T Possible Biases of Researchers’ Attitudes Toward Video Games: Publication Trends Analysis of the Medical Literature (1980–2013) %A Segev,Aviv %A Rovner,Mitchell %A Appel,David Ian %A Abrams,Aaron W %A Rotem,Michal %A Bloch,Yuval %+ Shalvata Mental Health Center, 1st Aliyat Hanoar St, POB 94, Hod Hasharon,, Israel, 972 9 7478 554, segev_a@netvision.net.il %K video games %K publication trends %K bias %D 2016 %7 18.07.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The study of video games is expanding, and so is the debate regarding their possible positive and deleterious effects. As controversies continue, several researchers have expressed their concerns about substantial biases existing in the field, which might lead to the creation of a skewed picture, both in the professional and in the lay literature. However, no study has tried to examine this issue quantitatively. Objective: The objective of our study was to examine possible systematic biases in the literature, by analyzing the publication trends of the medical and life sciences literature regarding video games. Methods: We performed a complete and systematic PubMed search up to December 31, 2013. We assessed all 1927 articles deemed relevant for their attitude toward video games according to the focus, hypothesis, and authors’ interpretation of the study results, using a 3-category outcome (positive, negative, and neutral). We assessed the prevalence of different attitudes for possible association with year of publication, location of researchers, academic discipline, methodological research, and centrality of the publishing journals. Results: The attitude toward video games presented in publications varied by year of publication, location, academic discipline, and methodological research applied (P<.001 for all). Moreover, representation of different attitudes differed according to centrality of the journals, as measured by their impact factor (P<.001). Conclusions: The results suggest that context, whether scientific or social, is related to researchers’ attitudes toward video games. Readers, both lay and professional, should weigh these contextual variables when interpreting studies’ results, in light of the possible bias they carry. The results also support a need for a more balanced, open-minded approach toward video games, as it is likely that this complex phenomenon carries novel opportunities as well as new hazards. %M 27430187 %R 10.2196/jmir.5935 %U http://www.jmir.org/2016/7/e196/ %U https://doi.org/10.2196/jmir.5935 %U http://www.ncbi.nlm.nih.gov/pubmed/27430187 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e12 %T Validation of a Computerized, Game-based Assessment Strategy to Measure Training Effects on Motor-Cognitive Functions in People With Dementia %A Wiloth,Stefanie %A Lemke,Nele %A Werner,Christian %A Hauer,Klaus %+ AGAPLESION Bethanien Hospital, Geriatric Centre at the University of Heidelberg, Heidelberg, Germany, Research Department, Rohrbacher Straße 149, Heidelberg, 69126, Germany, 49 1739471446, stefanie.wiloth@gmail.com %K serious games %K computerized assessment %K validation %K motor-cognitive functions %K elderly %K older adults %K cognitive impairment %K dementia %D 2016 %7 18.7.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exergames often used for training purpose can also be applied to create assessments based on quantitative data derived from the game. A number of studies relate to these use functionalities developing specific assessment tasks by using the game software and provided good data on psychometric properties. However, (1) assessments often include tasks other than the original game task used for training and therefore relate to similar but not to identical or integrated performances trained, (2) people with diagnosed dementia have insufficiently been addressed in validation studies, and (3) studies did commonly not present validation data such as sensitivity to change, although this is a paramount objective for validation to evaluate responsiveness in intervention studies. Objective: Specific assessment parameters have been developed using quantitative data directly derived from the data stream during the game task of a training device (Physiomat). The aim of this study was to present data on construct validity, test–retest reliability, sensitivity to change, and feasibility of this internal assessment approach, which allows the quantification of Physiomat training effects on motor-cognitive functions in 105 multimorbid patients with mild-to-moderate dementia (mean age 82.7±5.9). Methods: Physiomat assessment includes various tasks at different complexity levels demanding balance and cognitive abilities. For construct validity, motor-cognitive Physiomat assessment tasks were compared with established motor and cognitive tests using Spearman’s rank correlations (rs). For test–retest reliability, we used intra-class correlations (ICC3,1) and focused on all Physiomat tasks. Sensitivity to change of trained Physiomat tasks was tested using Wilcoxon statistic and standardized response means (SRMs). Completion rate and time were calculated for feasibility. Results: Analyses have mostly shown moderate-to-high correlations between established motor as well as cognitive tests and simple (rs=−.22 to .68, P ≤.001-.03), moderate (rs=−.33 to .71, P ≤.001-.004), and complex motor-cognitive Physiomat tasks (rs=−.22 to .83, P ≤.001-.30) indicating a good construct validity. Moderate-to-high correlations between test and retest assessments were found for simple, moderate, and complex motor-cognitive tasks (ICC=.47-.83, P ≤.001) indicating good test–retest reliability. Sensitivity to change was good to excellent for Physiomat assessment as it reproduced significant improvements (P ≤.001) with mostly moderate-to-large effect sizes (SRM=0.5-2.0) regarding all trained tasks. Completion time averaged 25.8 minutes. Completion rate was high for initial Physiomat measures. No adverse events occurred during assessment. Conclusions: Overall, Physiomat proved to have good psychometric qualities in people with mild-to-moderate dementia representing a reliable, valid, responsive, and feasible assessment strategy for multimorbid older adults with or without cognitive impairment, which relates to identical and integrated performances trained by using the game. %M 27432746 %R 10.2196/games.5696 %U http://games.jmir.org/2016/2/e12/ %U https://doi.org/10.2196/games.5696 %U http://www.ncbi.nlm.nih.gov/pubmed/27432746 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e11 %T Gamification of Cognitive Assessment and Cognitive Training: A Systematic Review of Applications and Efficacy %A Lumsden,Jim %A Edwards,Elizabeth A %A Lawrence,Natalia S %A Coyle,David %A Munafò,Marcus R %+ UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, 12a Priory rd, Bristol, BS8 1TU, United Kingdom, 44 117 92 88450, jim.lumsden@bristol.ac.uk %K gamification %K gamelike %K cognition %K computer games %K review %D 2016 %7 15.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive tasks are typically viewed as effortful, frustrating, and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or reduce intervention effects. However, gamification may provide a possible solution. If game design features can be incorporated into cognitive tasks without undermining their scientific value, then data quality, intervention effects, and participant engagement may be improved. Objectives: This systematic review aims to explore and evaluate the ways in which gamification has already been used for cognitive training and assessment purposes. We hope to answer 3 questions: (1) Why have researchers opted to use gamification? (2) What domains has gamification been applied in? (3) How successful has gamification been in cognitive research thus far? Methods: We systematically searched several Web-based databases, searching the titles, abstracts, and keywords of database entries using the search strategy (gamif* OR game OR games) AND (cognit* OR engag* OR behavi* OR health* OR attention OR motiv*). Searches included papers published in English between January 2007 and October 2015. Results: Our review identified 33 relevant studies, covering 31 gamified cognitive tasks used across a range of disorders and cognitive domains. We identified 7 reasons for researchers opting to gamify their cognitive training and testing. We found that working memory and general executive functions were common targets for both gamified assessment and training. Gamified tests were typically validated successfully, although mixed-domain measurement was a problem. Gamified training appears to be highly engaging and does boost participant motivation, but mixed effects of gamification on task performance were reported. Conclusions: Heterogeneous study designs and typically small sample sizes highlight the need for further research in both gamified training and testing. Nevertheless, careful application of gamification can provide a way to develop engaging and yet scientifically valid cognitive assessments, and it is likely worthwhile to continue to develop gamified cognitive tasks in the future. %M 27421244 %R 10.2196/games.5888 %U http://games.jmir.org/2016/2/e11/ %U https://doi.org/10.2196/games.5888 %U http://www.ncbi.nlm.nih.gov/pubmed/27421244 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e81 %T Acceptance, Usability and Health Applications of Virtual Worlds by Older Adults: A Feasibility Study %A Cook,Nicole %A Winkler,Sandra L %+ Master of Public Health program, College of Osteopathic Medicine, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, FL, 33314, United States, 1 9542621505, nc570@nova.edu %K Second Life %K virtual worlds %K older adults %K seniors %K health care %K training %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Virtual worlds allow users to communicate and interact across various environments, scenarios, and platforms. Virtual worlds present opportunities in health care to reduce the burden of illness and disability by supporting education, rehabilitation, self-management, and social networking. The application of virtual worlds to older adults who bear the burden and cost of health conditions associated with age has not been evaluated. Objective: The aim of this study is to explore the usability, ease of use, and enjoyment of a virtual world by older adults, the types of virtual world activities that older adults may engage in, and the perceptions of older adults regarding the application of virtual worlds in health care. Methods: This quasi-experimental pre-post design research was guided by the Technology Acceptance Model (TAM). Participants were recruited from a Lifelong Learning Institute (LLI) program at Nova Southeastern University. Participants attended four training sessions over a 5-week period in the Second Life (SL) virtual world. Subjects were surveyed before and after the training on perceived ease of use, attitudes towards technology, behavioral intention to use the system, facilitating conditions, effort expectancy, and self-efficacy. Results: Older adults (N=19) completed the informed consent and attended the first training session, and 11 participants (58%, 11/19) completed the full training and the post survey. Completers (82%, 9/11) were more likely than non-completers (37%, 3/8) to consider themselves technologically savvy (P=.048), and to express confidence in being able to use the virtual world (100%, 11/11 vs 37%, 3/8; P=.002). All completers (100%, 11/11) perceived that SL has application in health behaviors and disease and reducing social isolation among people who are homebound. Of the completers, 10 (91%, 10/11) responded that they enjoyed learning how to use SL. Completers suggested that future trainings include more assistants and smaller groups. Conclusions: This pilot study suggests that virtual worlds can be both a feasible and an applicable method to promote health among some seniors. Future research on virtual worlds with older populations should consider using state-of-the art technology including large monitors, providing a minimum of one trainer for every two to three participants, and distributing a comprehensive training manual at the start of the training to support organization and recall. %M 27256457 %R 10.2196/resprot.5423 %U http://www.researchprotocols.org/2016/2/e81/ %U https://doi.org/10.2196/resprot.5423 %U http://www.ncbi.nlm.nih.gov/pubmed/27256457 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e8 %T Effects of Playing a Serious Computer Game on Body Mass Index and Nutrition Knowledge in Women %A Shiyko,Mariya %A Hallinan,Sean %A Seif El-Nasr,Magy %A Subramanian,Shree %A Castaneda-Sceppa,Carmen %+ Northeastern University, Applied Psychology, 360 Huntington Ave, 404 INV, Boston, MA, 02115, United States, 1 6173737527, m.shiyko@neu.edu %K serious games %K games for health %K weight loss %K body mass index %K nutritional knowledge %K game play %K self-determination theory %K Player Experience of Need Satisfaction (PENS) model %K women %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Obesity and weight gain is a critical public health concern. Serious digital games are gaining popularity in the context of health interventions. They use persuasive and fun design features to engage users in health-related behaviors in a non-game context. As a young field, research about effectiveness and acceptability of such games for weight loss is sparse. Objective: The goal of this study was to evaluate real-world play patterns of SpaPlay and its impact on body mass index (BMI) and nutritional knowledge. SpaPlay is a computer game designed to help women adopt healthier dietary and exercise behaviors, developed based on Self-Determination theory and the Player Experience of Need Satisfaction (PENS) model. Progress in the game is tied to real-life activities (e.g., eating a healthy snack, taking a flight of stairs). Methods: We recruited 47 women to partake in a within-subject 90-day longitudinal study, with assessments taken at baseline, 1-, 2-, and 3- months. Women were on average, 29.8 years old (±7.3), highly educated (80.9% had BA or higher), 39% non-White, baseline BMI 26.98 (±5.6), who reported at least contemplating making changes in their diet and exercise routine based on the Stages of Change Model. We computed 9 indices from game utilization data to evaluate game play. We used general linear models to examine inter-individual differences between levels of play, and multilevel models to assess temporal changes in BMI and nutritional knowledge. Results: Patterns of game play were mixed. Participants who reported being in the preparation or action stages of behavior change exhibited more days of play and more play regularity compared to those who were in the contemplation stage. Additionally, women who reported playing video games 1-2 hours per session demonstrated more sparse game play. Brief activities, such as one-time actions related to physical activity or healthy food, were preferred over activities that require a longer commitment (e.g., taking stairs every day for a week). BMI decreased significantly (P<.001) from baseline to 3-month follow-up, yielding a large effect size of 1.28. Nutritional knowledge increased significantly (P<.001) from first to third month follow-ups, with an effect size of .86. The degree of change in both outcomes was related to game play, baseline readiness to change, and the extent of video game play in general. Conclusions: This work demonstrates initial evidence of success for using a serious game as an intervention for health behavior change in real world settings. Our findings also highlight the need to understand not only game effectiveness but also inter-individual differences. Individualizing content and the intervention medium appears to be necessary for a more personalized and long-lasting impact. %M 27255497 %R 10.2196/games.4977 %U http://games.jmir.org/2016/1/e8/ %U https://doi.org/10.2196/games.4977 %U http://www.ncbi.nlm.nih.gov/pubmed/27255497 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e9 %T Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play %A Levac,Danielle %A Nawrotek,Joanna %A Deschenes,Emilie %A Giguere,Tia %A Serafin,Julie %A Bilodeau,Martin %A Sveistrup,Heidi %+ Northeastern University, Department of Physical Therapy, Movement and Rehabilitation Sciences, 407c Robinson Hall, 360 Huntington Avenue, Boston, MA, 02115, United States, 1 6173735198, d.levac@neu.edu %K active video games, virtual reality, physical therapy, movement, reliability %D 2016 %7 01.06.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality active video games are increasingly popular physical therapy interventions for children with cerebral palsy. However, physical therapists require educational resources to support decision making about game selection to match individual patient goals. Quantifying the movements elicited during virtual reality active video game play can inform individualized game selection in pediatric rehabilitation. Objective: The objectives of this study were to develop and evaluate the feasibility and reliability of the Movement Rating Instrument for Virtual Reality Game Play (MRI-VRGP). Methods: Item generation occurred through an iterative process of literature review and sample videotape viewing. The MRI-VRGP includes 25 items quantifying upper extremity, lower extremity, and total body movements. A total of 176 videotaped 90-second game play sessions involving 7 typically developing children and 4 children with cerebral palsy were rated by 3 raters trained in MRI-VRGP use. Children played 8 games on 2 virtual reality and active video game systems. Intraclass correlation coefficients (ICCs) determined intra-rater and interrater reliability. Results: Excellent intrarater reliability was evidenced by ICCs of >0.75 for 17 of the 25 items across the 3 raters. Interrater reliability estimates were less precise. Excellent interrater reliability was achieved for far reach upper extremity movements (ICC=0.92 [for right and ICC=0.90 for left) and for squat (ICC=0.80) and jump items (ICC=0.99), with 9 items achieving ICCs of >0.70, 12 items achieving ICCs of between 0.40 and 0.70, and 4 items achieving poor reliability (close-reach upper extremity-ICC=0.14 for right and ICC=0.07 for left) and single-leg stance (ICC=0.55 for right and ICC=0.27 for left). Conclusions: Poor video quality, differing item interpretations between raters, and difficulty quantifying the high-speed movements involved in game play affected reliability. With item definition clarification and further psychometric property evaluation, the MRI-VRGP could inform the content of educational resources for therapists by ranking games according to frequency and type of elicited body movements. %M 27251029 %R 10.2196/games.5528 %U http://games.jmir.org/2016/1/e9/ %U https://doi.org/10.2196/games.5528 %U http://www.ncbi.nlm.nih.gov/pubmed/27251029 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e7 %T A Serious Game for Clinical Assessment of Cognitive Status: Validation Study %A Tong,Tiffany %A Chignell,Mark %A Tierney,Mary C. %A Lee,Jacques %+ Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, 5 King's College Road, Toronto, ON,, Canada, 1 416 978 7581, tiffany.tong@mail.utoronto.ca %K cognitive assessments %K cognitive screening tools %K computerized assessments %K games %K human computer interaction %K human factors %K neuropsychological tests %K screening %K serious games %K tablet computers %K technology assessment %K usability %K validation studies %K video games %D 2016 %7 27.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: We propose the use of serious games to screen for abnormal cognitive status in situations where it may be too costly or impractical to use standard cognitive assessments (eg, emergency departments). If validated, serious games in health care could enable broader availability of efficient and engaging cognitive screening. Objective: The objective of this work is to demonstrate the feasibility of a game-based cognitive assessment delivered on tablet technology to a clinical sample and to conduct preliminary validation against standard mental status tools commonly used in elderly populations. Methods: We carried out a feasibility study in a hospital emergency department to evaluate the use of a serious game by elderly adults (N=146; age: mean 80.59, SD 6.00, range 70-94 years). We correlated game performance against a number of standard assessments, including the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). Results: After a series of modifications, the game could be used by a wide range of elderly patients in the emergency department demonstrating its feasibility for use with these users. Of 146 patients, 141 (96.6%) consented to participate and played our serious game. Refusals to play the game were typically due to concerns of family members rather than unwillingness of the patient to play the game. Performance on the serious game correlated significantly with the MoCA (r=–.339, P <.001) and MMSE (r=–.558, P <.001), and correlated (point-biserial correlation) with the CAM (r=.565, P <.001) and with other cognitive assessments. Conclusions: This research demonstrates the feasibility of using serious games in a clinical setting. Further research is required to demonstrate the validity and reliability of game-based assessments for clinical decision making. %M 27234145 %R 10.2196/games.5006 %U http://games.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/games.5006 %U http://www.ncbi.nlm.nih.gov/pubmed/27234145 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e3 %T Crave-Out: A Distraction/Motivation Mobile Game to Assist in Smoking Cessation %A DeLaughter,Kathryn L %A Sadasivam,Rajani S %A Kamberi,Ariana %A English,Thomas M %A Seward,Greg L %A Chan,S Wayne %A Volkman,Julie E %A Amante,Daniel J %A Houston,Thomas K %+ CHOIR ENRM VAMC, 200 Springs Rd., Bedford, MA,, United States, 1 781 687 2559, kathryn.delaughter@va.gov %K smoking cessation %K Internet %K secondary prevention %K health behavior %D 2016 %7 26.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Smoking is still the number one preventable cause of death. Cravings—an intense desire or longing for a cigarette—are a major contributor to quit attempt failure. New tools to help smokers’ manage their cravings are needed. Objective: To present a case study of the development process and testing of a distraction/motivation game (Crave-Out) to help manage cravings. Methods: We used a phased approach: in Phase 1 (alpha testing), we tested and refined the game concept, using a Web-based prototype. In Phase 2 (beta testing), we evaluated the distraction/motivation potential of the mobile game prototype, using a prepost design. After varying duration of abstinence, smokers completed the Questionnaire of Smoking Urge-Brief (QSU-Brief) measurement before and after playing Crave-Out. Paired t tests were used to compare pregame and postgame QSU-Brief levels. To test dissemination potential, we released the game on the Apple iTunes App Store and tracked downloads between December 22, 2011, and May 5, 2014. Results: Our concept refinement resulted in a multilevel, pattern memory challenge game, with each level increasing in difficulty. Smokers could play the game as long as they wanted. At the end of each level, smokers were provided clear goals for the next level and rewards (positive reinforcement using motivational tokens that represented a benefit of quitting smoking). Negative reinforcement was removed in alpha testing as smokers felt it reminded them of smoking. Measurement of QSU-Brief (N=30) resulted in a pregame mean of 3.24 (SD 1.65) and postgame mean of 2.99 (SD 1.40) with an overall decrease of 0.25 in cravings (not statistically significant). In a subset analysis, the QSU-Brief decrease was significant for smokers abstinent for more than 48 hours (N=5) with a pregame mean of 2.84 (SD 1.16) and a postgame mean of 2.0 (SD 0.94; change=0.84; P =.03). Between December 22, 2011, and May 29, 2014, the game was downloaded 3372 times from the App-Store, with 1526 smokers visiting the online resource www.decide2quit.org linked to the game. Conclusions: Overall, playing the game resulted in small, but nonsignificant decreases in cravings, with changes greater for those had already quit for more than 48 hours. Lessons learned can inform further development. Future research could incorporate mHealth games in multicomponent cessation interventions. Trial Registration: Clinicaltrials.gov NCT00797628; https://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/6hbJr6LWG) %M 27229772 %R 10.2196/games.4566 %U http://games.jmir.org/2016/1/e3/ %U https://doi.org/10.2196/games.4566 %U http://www.ncbi.nlm.nih.gov/pubmed/27229772 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e5 %T A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment %A Pasquier,Pierre %A Mérat,Stéphane %A Malgras,Brice %A Petit,Ludovic %A Queran,Xavier %A Bay,Christian %A Boutonnet,Mathieu %A Jault,Patrick %A Ausset,Sylvain %A Auroy,Yves %A Perez,Jean Paul %A Tesnière,Antoine %A Pons,François %A Mignon,Alexandre %+ Percy Military Teaching Hospital, Department of anesthesiology and intensive care, French Military Health Service, 101 avenue Henri Barbusse, Clamart, 92141, France, 33 141466000, pasquier9606@me.com %K serious games %K forward combat casualty care %K care under fire %K interdisciplinary collaboration %K simulation %K medical simulation %K virtual simulation %K training %K education %K assessment %D 2016 %7 18.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: The French Military Health Service has standardized its military prehospital care policy in a ‘‘Sauvetage au Combat’’ (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC. Objectives: The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment. Methods: A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance. Results: The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi–operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months. Conclusions: The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations. %M 27194369 %R 10.2196/games.5340 %U http://games.jmir.org/2016/1/e5/ %U https://doi.org/10.2196/games.5340 %U http://www.ncbi.nlm.nih.gov/pubmed/27194369 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e6 %T Epic Allies: Development of a Gaming App to Improve Antiretroviral Therapy Adherence Among Young HIV-Positive Men Who Have Sex With Men %A LeGrand,Sara %A Muessig,Kathryn Elizabeth %A McNulty,Tobias %A Soni,Karina %A Knudtson,Kelly %A Lemann,Alex %A Nwoko,Nkechinyere %A Hightow-Weidman,Lisa B %+ Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, 310 Trent Drive, Room 305, Durham, NC, 27710, United States, 1 9194380448, sara.legrand@duke.edu %K mobile applications %K video games %K serious games %K HIV %K medication adherence %K health knowledge, attitudes, practice %K youth %K men who have sex with men %D 2016 %7 13.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the United States, the human immunodeficiency virus (HIV) disproportionately affects young men who have sex with men (YMSM). For HIV-positive individuals, adherence to antiretroviral therapy (ART) is critical for achieving optimal health outcomes and reducing secondary transmission of HIV. However, YMSM often struggle with ART adherence. Novel mobile phone apps that incorporate game-based mechanics and social networking elements represent a promising intervention approach for improving ART adherence among YMSM. Objective: This study used a multiphase, iterative development process to create an ART adherence app for YMSM. Methods: The three-phase development process included: (1) theory-based concept development jointly by public health researchers and the technology team, (2) assessment of the target population’s ART adherence needs and app preferences and development and testing of a clickable app prototype, and (3) development and usability testing of the final app prototype. Results: The initial theory-based app concept developed in Phase One included medication reminders, daily ART adherence tracking and visualization, ART educational modules, limited virtual interactions with other app users, and gamification elements. In Phase Two, adherence needs, including those related to information, motivation, and behavioral skills, were identified. Participants expressed preferences for an ART adherence app that was informational, interactive, social, and customizable. Based on the findings from Phase Two, additional gaming features were added in Phase Three, including an interactive battle, superhero app theme, and app storyline. Other features were modified to increase interactivity and customization options and integrate the game theme. During usability testing of the final prototype, participants were able to understand and navigate the app successfully and rated the app favorably. Conclusions: An iterative development process was critical for the development of an ART adherence game app that was viewed as highly acceptable, relevant, and useful by YMSM. %M 27178752 %R 10.2196/games.5687 %U http://games.jmir.org/2016/1/e6/ %U https://doi.org/10.2196/games.5687 %U http://www.ncbi.nlm.nih.gov/pubmed/27178752 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 4 %P e94 %T Is Participatory Design Associated with the Effectiveness of Serious Digital Games for Healthy Lifestyle Promotion? A Meta-Analysis %A DeSmet,Ann %A Thompson,Debbe %A Baranowski,Tom %A Palmeira,Antonio %A Verloigne,Maïté %A De Bourdeaudhuij,Ilse %+ Ghent University, Department of Movement and Sport Sciences, Watersportlaan 2, Ghent, 9000, Belgium, 32 92646311, ilse.debourdeaudhuij@ugent.be %K serious games %K video games %K computer games %K games %K health promotion %K meta-analysis %K review %K design %K community-based participatory research %D 2016 %7 29.04.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious digital games can be effective at changing healthy lifestyles, but large differences in their effectiveness exist. The extent of user involvement in game design may contribute to game effectiveness by creating a better fit with user preferences. Participatory design (PD), which represents active user involvement as informant (ie, users are asked for input and feedback) or codesigner (ie, users as equal partners in the design) early on and throughout the game development, may be associated with higher game effectiveness, as opposed to no user involvement or limited user involvement. Objective: This paper reports the results of a meta-analysis examining the moderating role of PD in the effectiveness of serious digital games for healthy lifestyle promotion. Methods: Four databases were searched for peer-reviewed papers in English that were published or in press before October 2014, using a (group-) randomized controlled trial design. Effectiveness data were derived from another meta-analysis assessing the role of behavior change techniques and game features in serious game effectiveness. Results: A total of 58 games evaluated in 61 studies were included. As previously reported, serious digital games had positive effects on healthy lifestyles and their determinants. Unexpectedly, PD (g=0.075, 95% CI 0.017 to 0.133) throughout game development was related to lower game effectiveness on behavior (Q=6.74, P<.05) than when users were only involved as testers (g=0.520, 95% CI 0.150 to 0.890, P<.01). Games developed with PD (g=0.171, 95% CI 0.061 to 0.281, P<.01) were also related to lower game effectiveness on self-efficacy (Q=7.83, P<.05) than when users were not involved in game design (g=0.384, 95% CI 0.283 to 0.485, P<.001). Some differences were noted depending on age group, publication year of the study, and on the specific role in PD (ie, informant or codesigner), and depending on the game design element. Games developed with PD were more effective in changing behavioral determinants when they included users in design elements on game dynamics (beta=.215, 95% CI .075 to .356, P<.01) and, more specifically, as an informant (beta=.235, 95% CI .079 to .329, P<.01). Involving users as informants in PD to create game levels was also related to higher game effectiveness (Q=7.02, P<.01). Codesign was related to higher effectiveness when used to create the game challenge (Q=11.23, P<.01), but to lower game effectiveness when used to create characters (Q=4.36, P<.05) and the game world (Q=3.99, P<.05). Conclusions: The findings do not support higher effectiveness of games developed with PD. However, significant differences existed among PD games. More support was found for informant roles than for codesign roles. When PD was applied to game dynamics, levels, and game challenge, this was associated with higher effectiveness than when it was applied to game aesthetics. Since user involvement may have an important influence on reach, adoption, and implementation of the intervention, further research and design efforts are needed to enhance effectiveness of serious games developed with PD. %M 27129447 %R 10.2196/jmir.4444 %U http://www.jmir.org/2016/4/e94/ %U https://doi.org/10.2196/jmir.4444 %U http://www.ncbi.nlm.nih.gov/pubmed/27129447 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e4 %T The Relationship Between Engagement and Neurophysiological Measures of Attention in Motion-Controlled Video Games: A Randomized Controlled Trial %A Leiker,Amber M %A Miller,Matthew %A Brewer,Lauren %A Nelson,Monica %A Siow,Maria %A Lohse,Keith %+ Rehabilitation Informatics Lab, School of Kinesiolgy, Auburn University, 301 Wire Road, Auburn, AL, , United States, 1 334 844 1982, rehabinformatics@gmail.com %K games %K engagement %K motivation %K eP3a %K Kinect %K exergame %D 2016 %7 21.04.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Video games and virtual environments continue to be the subject of research in health sciences for their capacity to augment practice through user engagement. Creating game mechanics that increase user engagement may have indirect benefits on learning (ie, engaged learners are likely to practice more) and may also have direct benefits on learning (ie, for a fixed amount of practice, engaged learners show superior retention of information or skills). Objective: To manipulate engagement through the aesthetic features of a motion-controlled video game and measure engagement’s influence on learning. Methods: A group of 40 right-handed participants played the game under two different conditions (game condition or sterile condition). The mechanics of the game and the amount of practice were constant. During practice, event-related potentials (ERPs) to task-irrelevant probe tones were recorded during practice as an index of participants’ attentional reserve. Participants returned for retention and transfer testing one week later. Results: Although both groups improved in the task, there was no difference in the amount of learning between the game and sterile groups, countering previous research. A new finding was a statistically significant relationship between self-reported engagement and the amplitude of the early-P3a (eP3a) component of the ERP waveform, such that participants who reported higher levels of engagement showed a smaller eP3a (beta=−.08, P=.02). Conclusions: This finding provides physiological data showing that engagement elicits increased information processing (reducing attentional reserve), which yields new insight into engagement and its underlying neurophysiological properties. Future studies may objectively index engagement by quantifying ERPs (specifically the eP3a) to task-irrelevant probes. %M 27103052 %R 10.2196/games.5460 %U http://games.jmir.org/2016/1/e4/ %U https://doi.org/10.2196/games.5460 %U http://www.ncbi.nlm.nih.gov/pubmed/27103052 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e2 %T Feasibility of Applied Gaming During Interdisciplinary Rehabilitation for Patients With Complex Chronic Pain and Fatigue Complaints: A Mixed-Methods Study %A Vugts,Miel A P %A Joosen,Margot C W %A van Bergen,Alfonsus H M M %A Vrijhoef,Hubertus J M %+ Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, P.O. Box 90153, Tilburg, 5000 LE, Netherlands, 31 13 466 8271, m.a.p.vugts@tilburguniversity.edu %K behavioral medicine %K therapy %K computer-assisted %K computer games %K mind-body therapies %K patient acceptance of health care %K feasibility studies %K fatigue syndrome, chronic %K fibromyalgia %K musculoskeletal pain %D 2016 %7 01.04.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Applied gaming holds potential as a convenient and engaging means for the delivery of behavioral interventions. For developing and evaluating feasible computer-based interventions, policy makers and designers rely on limited knowledge about what causes variation in usage. Objective: In this study, we looked closely at why and by whom an applied game (LAKA) is demanded and whether it is feasible (with respect to acceptability, demand, practicality, implementation, and efficacy) and devised a complementary intervention during an interdisciplinary rehabilitation program (IRP) for patients with complex chronic pain and fatigue complaints. Methods: A mixed-methods design was used. Quantitative process analyses and assessments of feasibility were carried out with patients of a Dutch rehabilitation center who received access to LAKA without professional support during a 16-week interdisciplinary outpatient program. The quantitative data included records of routinely collected baseline variables (t0), additional surveys to measure technology acceptance before (t1) and after 8 weeks of access to LAKA (t2), and automatic log files of usage behavior (frequency, length, and progress). Subsequently, semistructured interviews were held with purposively selected patients. Interview codes triangulated and illustrated explanations of usage and supplemented quantitative findings on other feasibility domains. Results: Of the 410 eligible patients who started an IRP during the study period, 116 patients participated in additional data collections (108 with problematic fatigue and 47 with moderate or severe pain). Qualitative data verified that hedonic motivation was the most important factor for behavioral intentions to use LAKA (P<.001). Moreover, quotes illustrated a positive association between usage intentions (t1) and baseline level (t0) coping by active engagement (Spearman ρ=0.25; P=.008) and why patients who often respond by seeking social support were represented in a group of 71 patients who accessed the game (P=.034). The median behavioral intention to use LAKA was moderately positive and declined over time. Twenty patients played the game from start to finish. Behavioral change content was recognized and seen as potentially helpful by interview respondents who exposed themselves to the content of LAKA. Conclusions: Variation in the demand for applied gaming is generally explained by perceived enjoyment and effort and by individual differences in coping resources. An applied game can be offered as a feasible complementary intervention for more patients with complex chronic pain or fatigue complaints by embedding and delivering in alignment with patient experiences. Feasibility, effectiveness, and cost-effectiveness can be evaluated in a full-scale evaluation. New observations elicit areas of further research on the usage of computer-based interventions. %M 27036094 %R 10.2196/games.5088 %U http://games.jmir.org/2016/1/e2/ %U https://doi.org/10.2196/games.5088 %U http://www.ncbi.nlm.nih.gov/pubmed/27036094 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e26 %T Behavioral Outcome Effects of Serious Gaming as an Adjunct to Treatment for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial %A Bul,Kim CM %A Kato,Pamela M %A Van der Oord,Saskia %A Danckaerts,Marina %A Vreeke,Leonie J %A Willems,Annik %A van Oers,Helga JJ %A Van Den Heuvel,Ria %A Birnie,Derk %A Van Amelsvoort,Thérèse AMJ %A Franken,Ingmar HA %A Maras,Athanasios %+ Yulius Academy, Yulius Mental Health Care Organization, Dennenhout 1, Barendrecht, 2994 GC, Netherlands, 31 884056990, k.bul@yulius.nl %K attention deficit-hyperactivity disorder %K ADHD %K serious game %K Internet %K children %K treatment %K randomized controlled trial %D 2016 %7 16.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The need for accessible and motivating treatment approaches within mental health has led to the development of an Internet-based serious game intervention (called “Plan-It Commander”) as an adjunct to treatment as usual for children with attention-deficit/hyperactivity disorder (ADHD). Objective: The aim was to determine the effects of Plan-It Commander on daily life skills of children with ADHD in a multisite randomized controlled crossover open-label trial. Methods: Participants (N=170) in this 20-week trial had a diagnosis of ADHD and ranged in age from 8 to 12 years (male: 80.6%, 137/170; female: 19.4%, 33/170). They were randomized to a serious game intervention group (group 1; n=88) or a treatment-as-usual crossover group (group 2; n=82). Participants randomized to group 1 received a serious game intervention in addition to treatment as usual for the first 10 weeks and then received treatment as usual for the next 10 weeks. Participants randomized to group 2 received treatment as usual for the first 10 weeks and crossed over to the serious game intervention in addition to treatment as usual for the subsequent 10 weeks. Primary (parent report) and secondary (parent, teacher, and child self-report) outcome measures were administered at baseline, 10 weeks, and 10-week follow-up. Results: After 10 weeks, participants in group 1 compared to group 2 achieved significantly greater improvements on the primary outcome of time management skills (parent-reported; P=.004) and on secondary outcomes of the social skill of responsibility (parent-reported; P=.04), and working memory (parent-reported; P=.02). Parents and teachers reported that total social skills improved over time within groups, whereas effects on total social skills and teacher-reported planning/organizing skills were nonsignificant between groups. Within group 1, positive effects were maintained or further improved in the last 10 weeks of the study. Participants in group 2, who played the serious game during the second period of the study (weeks 10 to 20), improved on comparable domains of daily life functioning over time. Conclusions: Plan-It Commander offers an effective therapeutic approach as an adjunct intervention to traditional therapeutic ADHD approaches that improve functional outcomes in daily life. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 62056259; http://www.controlled-trials.com/ISRCTN62056259 (Archived by WebCite at http://www.webcitation.org/6eNsiTDJV). %M 26883052 %R 10.2196/jmir.5173 %U http://www.jmir.org/2016/2/e26/ %U https://doi.org/10.2196/jmir.5173 %U http://www.ncbi.nlm.nih.gov/pubmed/26883052 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 1 %P e6 %T Digital Gaming for Improving the Functioning of People With Traumatic Brain Injury: Protocol of a Feasibility Study %A Välimäki,Maritta %A Korkeila,Jyrki %A Kauppi,Kaisa %A Kaakinen,Johanna K %A Holm,Suvi %A Vahlo,Jukka %A Tenovuo,Olli %A Hämäläinen,Heikki %A Sarajuuri,Jaana %A Rantanen,Pekka %A Orenius,Tage %A Koponen,Aki %+ Faculty of Medicine, Department of Nursing Science, Lemminkäisenkatu 1, University of Turku, 20014, Finland, 358 23338495, mava@utu.fi %K digital games %K brain injury %K cognitive rehabilitation %D 2016 %7 09.02.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Traumatic brain injury (TBI) is a critical public health problem. The recovery process for people with TBI is typically slow and dependent on complex and intensive assisted rehabilitation programs. Objective: To evaluate the effects and feasibility of digital games for cognitive functioning and general well-being among people with traumatic brain injury. Methods: This is a single-site feasibility study conducted in Finland, which uses a pragmatic, randomized controlled trial with three arms, and will recruit patients from the Turku University Hospital, Division of Clinical Neurosciences in Finland. Participants must meet the following inclusion criteria: (1) a Finnish speaking adult, aged 18-65 years; (2) diagnosed with a traumatic brain injury (diagnostic criteria ICD-10, S06.X, T90.5) in the University Hospital; (3) access to a TV, a computer, and the Internet at home; (4) not an active digital gamer (5 hours or less a week); (5) willing to participate in the study. Participants must have been discharged from the neurologic treatment period for traumatic brain injury for over 12 months before the commencement of the trial, and they may not have actively participated in cognitive rehabilitation during the 3 months prior to the trial. Written informed consent will be mandatory for acceptance into the trial. Exclusion criteria are as follows: (1) sensory, cognitive, or physical impairment (eg, severe cognitive impairment); (2) a deficiency restricting the use of computers or computer game control system unaided (eg, impairment in vision, severe astigmatism, hemiplegia, disorder in visuospatial perception, dysfunction of the central vestibular system); (3) apathy identified in previous neuropsychological evaluations; (4) diagnosed severe mental disorders (eg, schizophrenia or severe depressive disorders to be identified in medical records as the secondary diagnosis). Results: The preparatory phase for the study is fulfilled. Recruitment started in June 2015 and finished November 2015. Results will be reported in 2016. Conclusions: The specific outcomes such as primary outcome measures were selected because they are widely used psychological tests and thought to be sensitive to changes in the cognitive functions related to TBI. Trial Registration: Clinicaltrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH) %M 26860741 %R 10.2196/resprot.4841 %U http://www.researchprotocols.org/2016/1/e6/ %U https://doi.org/10.2196/resprot.4841 %U http://www.ncbi.nlm.nih.gov/pubmed/26860741 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e29 %T Effects of a Web-Based Computer-Tailored Game to Reduce Binge Drinking Among Dutch Adolescents: A Cluster Randomized Controlled Trial %A Jander,Astrid %A Crutzen,Rik %A Mercken,Liesbeth %A Candel,Math %A de Vries,Hein %+ School for Public Health and Primary Care CAPHRI, Department of Health Promotion, Maastricht University, PO Box 616, Maastricht, 6200 MD, Netherlands, 31 433884279, astrid.jander@maastrichtuniversity.nl %K adolescents %K alcohol drinking %K binge drinking %K cluster randomized controlled trial %K serious games %K computer tailoring %D 2016 %7 03.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Binge drinking among Dutch adolescents is among the highest in Europe. Few interventions so far have focused on adolescents aged 15 to 19 years. Because binge drinking increases significantly during those years, it is important to develop binge drinking prevention programs for this group. Web-based computer-tailored interventions can be an effective tool for reducing this behavior in adolescents. Embedding the computer-tailored intervention in a serious game may make it more attractive to adolescents. Objective: The aim was to assess whether a Web-based computer-tailored intervention is effective in reducing binge drinking in Dutch adolescents aged 15 to 19 years. Secondary outcomes were reduction in excessive drinking and overall consumption during the previous week. Personal characteristics associated with program adherence were also investigated. Methods: A cluster randomized controlled trial was conducted among 34 Dutch schools. Each school was randomized into either an experimental (n=1622) or a control (n=1027) condition. Baseline assessment took place in January and February 2014. At baseline, demographic variables and alcohol use were assessed. Follow-up assessment of alcohol use took place 4 months later (May and June 2014). After the baseline assessment, participants in the experimental condition started with the intervention consisting of a game about alcohol in which computer-tailored feedback regarding motivational characteristics was embedded. Participants in the control condition only received the baseline questionnaire. Both groups received the 4-month follow-up questionnaire. Effects of the intervention were assessed using logistic regression mixed models analyses for binge and excessive drinking and linear regression mixed models analyses for weekly consumption. Factors associated with intervention adherence in the experimental condition were explored by means of a linear regression model. Results: In total, 2649 adolescents participated in the baseline assessment. At follow-up, 824 (31.11%) adolescents returned. The intervention was effective in reducing binge drinking among adolescents aged 15 years (P=.03) and those aged 16 years when they participated in at least 2 intervention sessions (P=.04). Interaction effects between excessive drinking and educational level (P=.08) and between weekly consumption and age (P=.09) were found; however, in-depth analyses revealed no significant subgroup effects for both interaction effects. Additional analyses revealed that prolonged use of the intervention was associated with stronger effects for binge drinking. Yet, overall adherence to the intervention was low. Analyses revealed that being Protestant, female, younger, a nonbinge drinker, and having a higher educational background were associated with adherence. Conclusions: The intervention was effective for adolescents aged 15 and 16 years concerning binge drinking. Prevention messages may be more effective for those at the start of their drinking career, whereas other methods may be needed for those with a longer history of alcohol consumption. Despite using game elements, intervention completion was low. Trial Registration: Dutch Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by WebCite® at http://www.webcitation.org/6eSJD3FiY) %M 26842694 %R 10.2196/jmir.4708 %U http://www.jmir.org/2016/2/e29/ %U https://doi.org/10.2196/jmir.4708 %U http://www.ncbi.nlm.nih.gov/pubmed/26842694 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 4 %N 1 %P e1 %T Behavioral Economics, Wearable Devices, and Cooperative Games: Results From a Population-Based Intervention to Increase Physical Activity %A van Mierlo,Trevor %A Hyatt,Douglas %A Ching,Andrew T %A Fournier,Rachel %A Dembo,Ron S %+ Evolution Health Systems Inc., 901 King Street West, Suite 400, Toronto, ON, M5V 3H5, Canada, 1 4166448476, tvanmierlo@evolutionhs.com %K behavioral economics, cooperative games, adherence, compliance, serious games, Superusers, health rewards, internet of things, wearable devices %D 2016 %7 28.01.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Health care literature supports the development of accessible interventions that integrate behavioral economics, wearable devices, principles of evidence-based behavior change, and community support. However, there are limited real-world examples of large scale, population-based, member-driven reward platforms. Subsequently, a paucity of outcome data exists and health economic effects remain largely theoretical. To complicate matters, an emerging area of research is defining the role of Superusers, the small percentage of unusually engaged digital health participants who may influence other members. Objective: The objective of this preliminary study is to analyze descriptive data from GOODcoins, a self-guided, free-to-consumer engagement and rewards platform incentivizing walking, running and cycling. Registered members accessed the GOODcoins platform through PCs, tablets or mobile devices, and had the opportunity to sync wearables to track activity. Following registration, members were encouraged to join gamified group challenges and compare their progress with that of others. As members met challenge targets, they were rewarded with GOODcoins, which could be redeemed for planet- or people-friendly products. Methods: Outcome data were obtained from the GOODcoins custom SQL database. The reporting period was December 1, 2014 to May 1, 2015. Descriptive self-report data were analyzed using MySQL and MS Excel. Results: The study period includes data from 1298 users who were connected to an exercise tracking device. Females consisted of 52.6% (n=683) of the study population, 33.7% (n=438) were between the ages of 20-29, and 24.8% (n=322) were between the ages of 30-39. 77.5% (n=1006) of connected and active members met daily-recommended physical activity guidelines of 30 minutes, with a total daily average activity of 107 minutes (95% CI 90, 124). Of all connected and active users, 96.1% (n=1248) listed walking as their primary activity. For members who exchanged GOODcoins, the mean balance was 4,000 (95% CI 3850, 4150) at time of redemption, and 50.4% (n=61) of exchanges were for fitness or outdoor products, while 4.1% (n=5) were for food-related items. Participants were most likely to complete challenges when rewards were between 201-300 GOODcoins. Conclusions: The purpose of this study is to form a baseline for future research. Overall, results indicate that challenges and incentives may be effective for connected and active members, and may play a role in achieving daily-recommended activity guidelines. Registrants were typically younger, walking was the primary activity, and rewards were mainly exchanged for fitness or outdoor products. Remaining to be determined is whether members were already physically active at time of registration and are representative of healthy adherers, or were previously inactive and were incentivized to change their behavior. As challenges are gamified, there is an opportunity to investigate the role of superusers and healthy adherers, impacts on behavioral norms, and how cooperative games and incentives can be leveraged across stratified populations. Study limitations and future research agendas are discussed. %M 26821955 %R 10.2196/games.5358 %U http://games.jmir.org/2016/1/e1/ %U https://doi.org/10.2196/games.5358 %U http://www.ncbi.nlm.nih.gov/pubmed/26821955 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e8 %T Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study %A Bird,Marie-Louise %A Clark,Brodie %A Millar,Johanna %A Whetton,Sue %A Smith,Stuart %+ Healthy Research Centre, Faculty of Health, University of Tasmania, Locked Bag 1322, Launceston, 7250, Australia, 61 408123433, birdm@utas.edu.au %K health care reform %K postural balance %K pleasure %K exercise %K perception %D 2015 %7 27.11.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (“exergames”), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perceptions of the use of technology to improve health are not known. Objective: The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods: Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (“Your Shape Fitness Evolved 2012”). Games scores, rates of game participation, and enjoyment were also recorded. Results: A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83%-100%) were recorded. Conclusions: Older adults’ have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults. %M 26614263 %R 10.2196/games.4275 %U http://games.jmir.org/2015/2/e8/ %U https://doi.org/10.2196/games.4275 %U http://www.ncbi.nlm.nih.gov/pubmed/26614263 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e130 %T Using an eHealth Intervention to Stimulate Health Behavior for the Prevention of Cognitive Decline in Dutch Adults: A Study Protocol for the Brain Aging Monitor %A Aalbers,Teun %A Baars,Maria AE %A Qin,Li %A de Lange,Annet %A Kessels,Roy PC %A Olde Rikkert,Marcel GM %+ Department of Geriatric Medicine, Radboud University Medical Center, PO Box 9101, Nijmegen, 6500 HB, Netherlands, 31 243619807, teun.aalbers@radboudumc.nl %K cognition %K healthy lifestyle %K eHealth %K internet %K prevention %K applied games %K protocol %D 2015 %7 10.11.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Internet-delivered intervention programs are an effective way of changing health behavior in an aging population. The same population has an increasing number of people with cognitive decline or cognitive impairments. Modifiable lifestyle risk factors such as physical activity, nutrition, smoking, alcohol consumption, sleep, and stress all influence the probability of developing neurodegenerative diseases such as Alzheimer’s disease. Objective: This study aims to answer two questions: (1) Is the use of a self-motivated, complex eHealth intervention effective in changing multiple health behaviors related to cognitive aging in Dutch adults in the work force, especially those aged 40 and over? and (2) Does this health behavior change result in healthier cognitive aging patterns and contribute to preventing or delaying future onset of neurodegenerative syndromes? Methods: The Brain Aging Monitor study uses a quasi-experimental 2-year pre-posttest design. The Brain Aging Monitor is an online, self-motivated lifestyle intervention program. Recruitment is done both in medium to large organizations and in the Dutch general population over the age of 40. The main outcome measure is the relationship between lifestyle change and cognitive aging. The program uses different strategies and modalities such as Web content, email, online newsletters, and online games to aid its users in behavior change. To build self-regulatory skills, the Brain Aging Monitor offers its users goal-setting activities, skill-building activities, and self-monitoring. Results: Study results are expected to be published in early 2016. Conclusions: This study will add to the body of evidence on the effectiveness of eHealth intervention programs with the combined use of state-of-the-art applied games and established behavior change techniques. This will lead to new insights on how to use behavior change techniques and theory in multidimensional lifestyle eHealth research, and how these techniques and theories apply when they are used in a setting where no professional back-end is available. Trial Registration: Nederlands Trial Register: NTR4144; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4144 (Archived by WebCite at http://www.webcitation.org/6cZzwZSg3) %M 26554496 %R 10.2196/resprot.4468 %U http://www.researchprotocols.org/2015/4/e130/ %U https://doi.org/10.2196/resprot.4468 %U http://www.ncbi.nlm.nih.gov/pubmed/26554496 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 10 %P e245 %T Using Videogame Apps to Assess Gains in Adolescents’ Substance Use Knowledge: New Opportunities for Evaluating Intervention Exposure and Content Mastery %A Montanaro,Erika %A Fiellin,Lynn E %A Fakhouri,Tamer %A Kyriakides,Tassos C %A Duncan,Lindsay R %+ Yale University, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT, 06510, United States, 1 203 764 4333, erika.montanaro@yale.edu %K video games %K intervention studies %K substance use %K HIV %K evaluation %K eHealth %D 2015 %7 28.10.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Videogame interventions are becoming increasingly popular as a means to engage people in behavioral interventions; however, strategies for examining data from such interventions have not been developed. Objective: The objective of this study was to describe how a technology-based intervention can yield meaningful, objective evidence of intervention exposure within a behavioral intervention. This study demonstrates the analysis of automatic log files, created by software from a videogame intervention, that catalog game play and, as proof of concept, the association of these data with changes in substance use knowledge as documented with standardized assessments. Methods: We analyzed 3- and 6-month follow-up data from 166 participants enrolled in a randomized controlled trial evaluating a videogame intervention, PlayForward: Elm City Stories (PlayForward). PlayForward is a videogame developed as a risk reduction and prevention program targeting HIV risk behaviors (substance use and sex) in young minority adolescents. Log files were analyzed to extract the total amount of time spent playing the videogame intervention and the total number of game levels completed and beaten by each player. Results: Completing and beating more of the game levels, and not total game play time, was related to higher substance use knowledge scores at the 3- (P=.001) and 6-month (P=.001) follow-ups. Conclusions: Our findings highlight the potential contributions a videogame intervention can make to the study of health behavior change. Specifically, the use of objective data collected during game play can address challenges in traditional human-delivered behavioral interventions. Trial Registration: Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6cV9fxsOg) %M 26510775 %R 10.2196/jmir.4377 %U http://www.jmir.org/2015/10/e245/ %U https://doi.org/10.2196/jmir.4377 %U http://www.ncbi.nlm.nih.gov/pubmed/26510775 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e118 %T Games and Telerehabilitation for Balance Impairments and Gaze Dysfunction: Protocol of a Randomized Controlled Trial %A Szturm,Tony %A Hochman,Jordan %A Wu,Christine %A Lisa,Lix %A Reimer,Karen %A Wonneck,Beth %A Giacobbo,Andrea %+ College of Rehabilitation Sciences, Department of Physical Therapy, University of Manitoba, R106, 771 McDermot Avenue,, Winnipeg, MB, R3E 0T6, Canada, 1 (204) 789 3897, tony.szturm@umanitoba.ca %K balance-exercises %K gaze-exercises %K home therapy %K telerehabilitation %K therapeutic-gaming %K vestibular rehabilitation %D 2015 %7 21.10.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Digital media and gaming have received considerable interest from researchers and clinicians as a model for learning a broad range of complex tasks and facilitating the transfer of skills to daily life. These emerging rehabilitation technologies have the potential to improve clinical outcomes and patient participation because they are engaging, motivating, and accessible. Our research goal is to develop preventative and therapeutic point-of-care eHealth applications that will lead to equivalent or better long-term health outcomes and health care costs than existing programs. We have produced a novel computer-aided tele-rehabilitation platform that combines computer game-based exercises with tele-monitoring. Objective: Compare the therapeutic effectiveness of an in-home, game-based rehabilitation program (GRP) to standard care delivered in an outpatient physical therapy clinic on measures of balance, gaze control, dizziness, and health-related quality of life. Methods: A randomized, controlled, single-blind pilot trial will be conducted. Fifty-six participants with a diagnosis of peripheral vestibular disorder will be randomly assigned to either usual physical therapy (comparator group) or to a game-based intervention (experimental group). Measures to be assessed will include gaze control, dynamic balance, and self-reported measures of dizziness. Results: The project was funded and enrollment was started in August 2014. To date, 36 participants have been enrolled. There have been 6 drop-outs. It is expected that the study will be completed January 2016 and the first results are expected to be submitted for publication in Spring of 2016. Conclusions: A successful application of this rehabilitation program would help streamline rehabilitation services, leverage therapist time spent with clients, and permit regular practice times at the client’s convenience. Trial Registration: Clinicaltrials.gov: NCT02134444; https://clinicaltrials.gov/ct2/show/NCT02134444 (Archived by WebCite at http://www.webcitation.org/6cE18bqqY) %M 26490109 %R 10.2196/resprot.4743 %U http://www.researchprotocols.org/2015/4/e118/ %U https://doi.org/10.2196/resprot.4743 %U http://www.ncbi.nlm.nih.gov/pubmed/26490109 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e7 %T Effects of Social Network Exposure on Nutritional Learning: Development of an Online Educational Platform %A Dagan,Noa %A Beskin,Daniel %A Brezis,Mayer %A Reis,Ben Y %+ Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital and Harvard Medical School, 1 Autumn St Room 540.1, Boston, MA, 02115, United States, 1 857 218 4561, ben.reis@childrens.harvard.edu %K nutrition requirements %K obesity %K public health %K social networking sites %D 2015 %7 05.10.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Social networking sites (SNSs) such as Facebook have the potential to enhance online public health interventions, in part, as they provide social exposure and reinforcement. Objective: The objective of the study was to evaluate whether social exposure provided by SNSs enhances the effects of online public health interventions. Methods: As a sample intervention, we developed Food Hero, an online platform for nutritional education in which players feed a virtual character according to their own nutritional needs and complete a set of virtual sport challenges. The platform was developed in 2 versions: a "private version" in which a user can see only his or her own score, and a "social version" in which a user can see other players’ scores, including preexisting Facebook friends. We assessed changes in participants’ nutritional knowledge using 4 quiz scores and 3 menu-assembly scores. Monitoring feeding and exercising attempts assessed engagement with the platform. Results: The 2 versions of the platform were randomly assigned between a study group (30 members receiving the social version) and a control group (33 members, private version). The study group's performance on the quizzes gradually increased over time, relative to that of the control group, becoming significantly higher by the fourth quiz (P=.02). Furthermore, the study group's menu-assembly scores improved over time compared to the first score, whereas the control group's performance deteriorated. Study group members spent an average of 3:40 minutes assembling each menu compared to 2:50 minutes in the control group, and performed an average of 1.58 daily sport challenges, compared to 1.21 in the control group (P=.03). Conclusions: This work focused on isolating the SNSs' social effects in order to help guide future online interventions. Our results indicate that the social exposure provided by SNSs is associated with increased engagement and learning in an online nutritional educational platform. %M 26441466 %R 10.2196/games.4002 %U http://games.jmir.org/2015/2/e7/ %U https://doi.org/10.2196/games.4002 %U http://www.ncbi.nlm.nih.gov/pubmed/26441466 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 3 %P e114 %T Using Video Games to Enhance Motivation States in Online Education: Protocol for a Team-Based Digital Game %A Janssen,Anna %A Shaw,Tim %A Goodyear,Peter %+ Sydney Medical School, University of Sydney, Level 2, Charles Perkins Centre D17, University of Sydney, Sydney, 2006, Australia, 61 02 9036 9406, anna.janssen@sydney.edu.au %K digital games %K medical education %K online learning %D 2015 %7 28.09.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Video and computer games for education have been of interest to researchers for several decades. Over the last half decade, researchers in the health sector have also begun exploring the value of this medium. However, there are still many gaps in the literature regarding the effective use of video and computer games in medical education, particularly in relation to how learners interact with the platform, and how the games can be used to enhance collaboration. Objective: The objective of the study is to evaluate a team-based digital game as an educational tool for engaging learners and supporting knowledge consolidation in postgraduate medical education. Methods: A mixed methodology will be used in order to establish efficacy and level of motivation provided by a team-based digital game. Second-year medical students will be recruited as participants to complete 3 matches of the game at spaced intervals, in 2 evenly distributed teams. Prior to playing the game, participants will complete an Internet survey to establish baseline data. After playing the game, participants will voluntarily complete a semistructured interview to establish motivation and player engagement. Additionally, metrics collected from the game platform will be analyzed to determine efficacy. Results: The research is in the preliminary stages, but thus far a total of 54 participants have been recruited into the study. Additionally, a content development group has been convened to develop appropriate content for the platform. Conclusions: Video and computer games have been demonstrated to have value for educational purposes. Significantly less research has addressed how the medium can be effectively utilized in the health sector. Preliminary data from this study would suggest there is an interest in games for learning in the medical student body. As such, it is beneficial to undertake further research into how these games teach and engage learners in order to evaluate their role in tertiary and postgraduate medical education in the future. %M 26416522 %R 10.2196/resprot.4016 %U http://www.researchprotocols.org/2002/3/e114/ %U https://doi.org/10.2196/resprot.4016 %U http://www.ncbi.nlm.nih.gov/pubmed/26416522 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 8 %P e210 %T Apps for IMproving FITness and Increasing Physical Activity Among Young People: The AIMFIT Pragmatic Randomized Controlled Trial %A Direito,Artur %A Jiang,Yannan %A Whittaker,Robyn %A Maddison,Ralph %+ Faculty of Medical and Health Sciences, National Institute for Health Innovation, University of Auckland, National Institute for Health Innovation, School of Population Health, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand, 64 9 373 7599 ext 85285, a.direito@auckland.ac.nz %K physical fitness %K motor activity %K exercise %K physical activity %K adolescent %K health promotion %K telemedicine %K mHealth %K mobile applications %K smartphone %D 2015 %7 27.08.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Given the global prevalence of insufficient physical activity (PA), effective interventions that attenuate age-related decline in PA levels are needed. Mobile phone interventions that positively affect health (mHealth) show promise; however, their impact on PA levels and fitness in young people is unclear and little is known about what makes a good mHealth app. Objective: The aim was to determine the effects of two commercially available smartphone apps (Zombies, Run and Get Running) on cardiorespiratory fitness and PA levels in insufficiently active healthy young people. A second aim was to identify the features of the app design that may contribute to improved fitness and PA levels. Methods: Apps for IMproving FITness (AIMFIT) was a 3-arm, parallel, randomized controlled trial conducted in Auckland, New Zealand. Participants were recruited through advertisements in electronic mailing lists, local newspapers, flyers posted in community locations, and presentations at schools. Eligible young people aged 14-17 years were allocated at random to 1 of 3 conditions: (1) use of an immersive app (Zombies, Run), (2) use of a nonimmersive app (Get Running), or (3) usual behavior (control). Both smartphone apps consisted of a fully automated 8-week training program designed to improve fitness and ability to run 5 km; however, the immersive app featured a game-themed design and narrative. Intention-to-treat analysis was performed using data collected face-to-face at baseline and 8 weeks, and all regression models were adjusted for baseline outcome value and gender. The primary outcome was cardiorespiratory fitness, objectively assessed as time to complete the 1-mile run/walk test at 8 weeks. Secondary outcomes were PA levels (accelerometry and self-reported), enjoyment, psychological need satisfaction, self-efficacy, and acceptability and usability of the apps. Results: A total of 51 participants were randomized to the immersive app intervention (n=17), nonimmersive app intervention (n=16), or the control group (n=18). The mean age of participants was 15.7 (SD 1.2) years; participants were mostly NZ Europeans (61%, 31/51) and 57% (29/51) were female. Overall retention rate was 96% (49/51). There was no significant intervention effect on the primary outcome using either of the apps. Compared to the control, time to complete the fitness test was –28.4 seconds shorter (95% CI –66.5 to 9.82, P=.20) for the immersive app group and –24.7 seconds (95% CI –63.5 to 14.2, P=.32) for the nonimmersive app group. No significant intervention effects were found for secondary outcomes. Conclusions: Although apps have the ability to increase reach at a low cost, our pragmatic approach using readily available commercial apps as a stand-alone instrument did not have a significant effect on fitness. However, interest in future use of PA apps is promising and highlights a potentially important role of these tools in a multifaceted approach to increase fitness, promote PA, and consequently reduce the adverse health outcomes associated with insufficient activity. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12613001030763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12613001030763 (Archived by WebCite at http://www.webcitation.org/6aasfJVTJ). %M 26316499 %R 10.2196/jmir.4568 %U http://www.jmir.org/2015/8/e210/ %U https://doi.org/10.2196/jmir.4568 %U http://www.ncbi.nlm.nih.gov/pubmed/26316499 %0 Journal Article %@ 2369-2529 %I JMIR Publications Inc. %V 2 %N 2 %P e8 %T Interchangeability of the Wii Balance Board for Bipedal Balance Assessment %A Bonnechère,Bruno %A Jansen,Bart %A Omelina,Lubos %A Rooze,Marcel %A Van Sint Jan,Serge %+ Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculty of Medicine, Université Libre de Bruxelles, Lennik Street 808, Brussels, 1070, Belgium, 32 25556262, bbonnech@ulb.ac.be %K force plate %K balance board %K balance performance %K validity %K repeatability %D 2015 %7 27.08.2015 %9 Short Paper %J JMIR Rehabil Assist Technol %G English %X Background: Since 2010, an increasing interest in more portable and flexible hardware for balance and posture assessment led to previously published studies determining whether or not the Wii Balance Board could be used to assess balance and posture, both scientifically and clinically. However, no previous studies aimed at comparing results from different Wii Balance Boards for clinical balance evaluation exist. Objective: The objective of this crossover study is to assess the interchangeability of the Wii Balance Board. Methods: A total of 6 subjects participated in the study and their balance was assessed using 4 different Wii Balance Boards. Trials were recorded simultaneously with Wii Balance Boards and with a laboratory force plate. Nine relevant clinical parameters were derived from center of pressure displacement data obtained from Wii Balance Board and force plate systems. Intraclass correlation coefficients (ICC), F tests, and Friedman tests were computed to assess the agreement between trials and to compare the Wii Balance Board and force plate results. Results: Excellent correlations were found between the Wii Balance Board and force plate (mean ρ =.83). With the exception of 2 parameters, strong to excellent agreements were found for the 7 remaining parameters (ICC=.96). No significant differences were found between trials recorded with different Wii Balance Boards. Conclusions: Our results indicate that for most of the parameters analyzed, balance and posture assessed with one Wii Balance Board were statistically similar to results obtained from another. Furthermore, the good correlation between the Wii Balance Board and force plate results shows that Wii Balance Boards can be reliably used for scientific assessment using most of the parameters analyzed in this study. These results also suggest that the Wii Balance Board could be used in multicenter studies and therefore, would allow for the creation of larger populations for clinical studies. Trial Registration: Ethical Committee of the Erasme Hospital (CCB B406201215142). %M 28582237 %R 10.2196/rehab.3832 %U http://rehab.jmir.org/2015/2/e8/ %U https://doi.org/10.2196/rehab.3832 %U http://www.ncbi.nlm.nih.gov/pubmed/28582237 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e6 %T Training Vegetable Parenting Practices Through a Mobile Game: Iterative Qualitative Alpha Test %A Brand,Leah %A Beltran,Alicia %A Buday,Richard %A Hughes,Sheryl %A O'Connor,Teresia %A Baranowski,Janice %A Dadabhoy,Hafza R %A Diep,Cassandra S %A Baranowski,Tom %+ Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St, Houston, TX, 77030, United States, 1 713 798 9319, lbrand@bcm.edu %K mobile games %K games for health %K serious games %K pediatric nutrition %K parenting %D 2015 %7 24.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Vegetable consumption protects against chronic diseases, but many young children do not eat vegetables. One quest within the mobile application Mommio was developed to train mothers of preschoolers in effective vegetable parenting practices, or ways to approach getting their child to eat and enjoy vegetables. A much earlier version of the game, then called Kiddio, was alpha tested previously, but the game has since evolved in key ways. Objective: The purpose of this research was to alpha test the first quest, substantiate earlier findings and obtain feedback on new game features to develop an effective, compelling parenting game. Methods: Mothers of preschool children (n=20) played a single quest of Mommio 2 to 4 times, immediately after which a semi-structured interview about their experience was completed. Interviews were transcribed and double coded using thematic analysis methods. Results: Mothers generally liked the game, finding it realistic and engaging. Some participants had difficulties with mechanics for moving around the 3-D environment. Tips and hints were well received, and further expansion and customization were desired. Conclusions: Earlier findings were supported, though Mommio players reported more enjoyment than Kiddio players. Continued development will include more user-friendly mechanics, customization, opportunities for environment interaction, and food parenting scenarios. %M 26208899 %R 10.2196/games.4081 %U http://games.jmir.org/2015/2/e6/ %U https://doi.org/10.2196/games.4081 %U http://www.ncbi.nlm.nih.gov/pubmed/26208899 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e4 %T Health Behavior Theory in Physical Activity Game Apps: A Content Analysis %A Payne,Hannah E %A Moxley,Victor BA %A MacDonald,Elizabeth %+ Computational Health Science Research Group, Department of Health Science, Brigham Young University, 3024 LSB, Provo, UT, 84604, United States, 1 530 919 5100, hannahp413@gmail.com %K health and fitness apps %K mobile phone %K behavioral health %K theory %K content analysis %K physical activity %D 2015 %7 13.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Physical activity games developed for a mobile phone platform are becoming increasingly popular, yet little is known about their content or inclusion of health behavior theory (HBT). Objective: The objective of our study was to quantify elements of HBT in physical activity games developed for mobile phones and to assess the relationship between theoretical constructs and various app features. Methods: We conducted an analysis of exercise and physical activity game apps in the Apple App Store in the fall of 2014. A total of 52 apps were identified and rated for inclusion of health behavior theoretical constructs using an established theory-based rubric. Each app was coded for 100 theoretical items, containing 5 questions for 20 different constructs. Possible total theory scores ranged from 0 to 100. Descriptive statistics and Spearman correlations were used to describe the HBT score and association with selected app features, respectively. Results: The average HBT score in the sample was 14.98 out of 100. One outlier, SuperBetter, scored higher than the other apps with a score of 76. Goal setting, self-monitoring, and self-reward were the most-reported constructs found in the sample. There was no association between either app price and theory score (P=.5074), or number of gamification elements and theory score (P=.5010). However, Superbetter, with the highest HBT score, was also the most expensive app. Conclusions: There are few content analyses of serious games for health, but a comparison between these findings and previous content analyses of non-game health apps indicates that physical activity mobile phone games demonstrate higher levels of behavior theory. The most common theoretical constructs found in this sample are known to be efficacious elements in physical activity interventions. It is unclear, however, whether app designers consciously design physical activity mobile phone games with specific constructs in mind; it may be that games lend themselves well to inclusion of theory and any constructs found in significant levels are coincidental. Health games developed for mobile phones could be potentially used in health interventions, but collaboration between app designers and behavioral specialists is crucial. Additionally, further research is needed to better characterize mobile phone health games and the relative importance of educational elements versus gamification elements in long-term behavior change. %M 26168926 %R 10.2196/games.4187 %U http://games.jmir.org/2015/2/e4/ %U https://doi.org/10.2196/games.4187 %U http://www.ncbi.nlm.nih.gov/pubmed/26168926 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 6 %P e150 %T A Virtual Emergency Telemedicine Serious Game in Medical Training: A Quantitative, Professional Feedback-Informed Evaluation Study %A Nicolaidou,Iolie %A Antoniades,Athos %A Constantinou,Riana %A Marangos,Charis %A Kyriacou,Efthyvoulos %A Bamidis,Panagiotis %A Dafli,Eleni %A Pattichis,Constantinos S %+ Department of Communication and Internet Studies, Cyprus University of Technology, P.O. Box 50329, Limassol, 3603, Cyprus, 357 99329897, iolie.nicolaidou@cut.ac.cy %K telemedicine %K emergency telemedicine %K serious games %K virtual patients %K medical education %K professional feedback-informed evaluation %K emergency assessment and management %D 2015 %7 17.06.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Serious games involving virtual patients in medical education can provide a controlled setting within which players can learn in an engaging way, while avoiding the risks associated with real patients. Moreover, serious games align with medical students’ preferred learning styles. The Virtual Emergency TeleMedicine (VETM) game is a simulation-based game that was developed in collaboration with the mEducator Best Practice network in response to calls to integrate serious games in medical education and training. The VETM game makes use of data from an electrocardiogram to train practicing doctors, nurses, or medical students for problem-solving in real-life clinical scenarios through a telemedicine system and virtual patients. The study responds to two gaps: the limited number of games in emergency cardiology and the lack of evaluations by professionals. Objective: The objective of this study is a quantitative, professional feedback-informed evaluation of one scenario of VETM, involving cardiovascular complications. The study has the following research question: “What are professionals’ perceptions of the potential of the Virtual Emergency Telemedicine game for training people involved in the assessment and management of emergency cases?” Methods: The evaluation of the VETM game was conducted with 90 professional ambulance crew nursing personnel specializing in the assessment and management of emergency cases. After collaboratively trying out one VETM scenario, participants individually completed an evaluation of the game (36 questions on a 5-point Likert scale) and provided written and verbal comments. The instrument assessed six dimensions of the game: (1) user interface, (2) difficulty level, (3) feedback, (4) educational value, (5) user engagement, and (6) terminology. Data sources of the study were 90 questionnaires, including written comments from 51 participants, 24 interviews with 55 participants, and 379 log files of their interaction with the game. Results: Overall, the results were positive in all dimensions of the game that were assessed as means ranged from 3.2 to 3.99 out of 5, with user engagement receiving the highest score (mean 3.99, SD 0.87). Users’ perceived difficulty level received the lowest score (mean 3.20, SD 0.65), a finding which agrees with the analysis of log files that showed a rather low success rate (20.6%). Even though professionals saw the educational value and usefulness of the tool for pre-hospital emergency training (mean 3.83, SD 1.05), they identified confusing features and provided input for improving them. Conclusions: Overall, the results of the professional feedback-informed evaluation of the game provide a strong indication of its potential as an educational tool for emergency training. Professionals’ input will serve to improve the game. Further research will aim to validate VETM, in a randomized pre-test, post-test control group study to examine possible learning gains in participants’ problem-solving skills in treating a patient’s symptoms in an emergency situation. %M 26084866 %R 10.2196/jmir.3667 %U http://www.jmir.org/2015/6/e150/ %U https://doi.org/10.2196/jmir.3667 %U http://www.ncbi.nlm.nih.gov/pubmed/26084866 %0 Journal Article %@ 2369-3762 %I JMIR Publications Inc. %V 1 %N 1 %P e2 %T Student Preferences on Gaming Aspects for a Serious Game in Pharmacy Practice Education: A Cross-Sectional Study %A Chang,Huan Ying %A Poh,David Yan Hong %A Wong,Li Lian %A Yap,John Yin Gwee %A Yap,Kevin Yi-Lwern %+ National University of Singapore, Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, 18 Science Drive 4, Singapore, , Singapore, 65 6601 3253, kevinyap.ehealth@gmail.com %K gaming aspects %K pharmacy-related serious game %K pharmacy practice education %K reward systems %K game settings %K storylines %K viewing perspectives %K gaming styles %D 2015 %7 11.05.2015 %9 Original Paper %J JMIR Medical Education %G English %X Background: Serious games are motivating and provide a safe environment for students to learn from their mistakes without experiencing any negative consequences from their actions. However, little is known about students’ gaming preferences and the types of serious games they like to play for education. Objective: This study aims to determine the types of gaming aspects that students would like to play in a pharmacy-related serious game. Methods: A cross-sectional study was conducted using a self-administered survey, which obtained students’ responses on their preferences regarding various gaming aspects (reward systems, game settings, storylines, viewing perspectives, and gaming styles) and for a hypothetical gaming scenario (authentic simulation or post-apocalyptic fantasy). Descriptive statistics, chi-square, and Fisher’s exact tests were used for statistical analyses. Results: Response rate was 72.7% (497/684 undergraduates). The most popular game reward systems were unlocking mechanisms (112/497, 22.5%) and experience points (90/497, 18.1%). Most students preferred fantasy/medieval/mythic (253/497, 50.9%) and modern (117/497, 23.5%) settings, but lower year undergraduates preferred modern settings less than upper year seniors (47/236, 19.9% vs 70/242, 28.9%, P=.022). Almost one-third (147/497, 29.6%) preferred an adventurer storyline or an authentic pharmacy-related plot (119/497, 23.9%), and a collaborative game style was most preferred by the students (182/497, 36.6%). Three-dimensional game perspectives (270/497, 54.3%) were more popular than two-dimensional perspectives (221/497, 44.5%), especially among males than females (126/185, 68.1% vs 142/303, 46.9%, P<.001). In terms of choice for a pharmacy-related serious game, a post-apocalyptic fantasy game (scenario B, 287/497, 57.7%) was more popular than an authentic simulation game (scenario A, 209/497, 42.1%). More males preferred the post-apocalyptic fantasy scenario than females (129/187, 69.0% vs 155/306, 50.7%, P<.001). Conclusions: In general, students want a three-dimensional, fantasy/medieval/mythic post-apocalyptic game, based on an adventurer storyline with an unlocking mechanism reward system. A balance between real-life and fantasy elements needs to be struck in order for the game to cater students towards health care practices. %M 27731304 %R 10.2196/mededu.3754 %U http://mededu.jmir.org/2015/1/e2/ %U https://doi.org/10.2196/mededu.3754 %U http://www.ncbi.nlm.nih.gov/pubmed/27731304 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 2 %N 2 %P e11 %T Integrating Health Behavior Theory and Design Elements in Serious Games %A Cheek,Colleen %A Fleming,Theresa %A Lucassen,Mathijs FG %A Bridgman,Heather %A Stasiak,Karolina %A Shepherd,Matthew %A Orpin,Peter %+ Rural Clinical School, School of Medicine, University of Tasmania, Private Bag 3513, Burnie, , Australia, 61 3 6430 5922, Colleen.Cheek@utas.edu.au %K depression %K adolescent %K cognitive behavior therapy %K online intervention %K user-centered %K self-efficacy %K motivation %K adherence %K SPARX %D 2015 %7 21.04.2015 %9 Original Paper %J JMIR Mental Health %G English %X Background: Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games. Objective: To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective. Methods: We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework. Results: A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model. Conclusions: This study’s method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user’s sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose. %M 26543916 %R 10.2196/mental.4133 %U http://mental.jmir.org/2015/2/e11/ %U https://doi.org/10.2196/mental.4133 %U http://www.ncbi.nlm.nih.gov/pubmed/26543916 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e3 %T Digital Games for Type 1 and Type 2 Diabetes: Underpinning Theory With Three Illustrative Examples %A Kamel Boulos,Maged N %A Gammon,Shauna %A Dixon,Mavis C %A MacRury,Sandra M %A Fergusson,Michael J %A Miranda Rodrigues,Francisco %A Mourinho Baptista,Telmo %A Yang,Stephen P %+ The Alexander Graham Bell Centre for Digital Health, Moray College UHI, University of the Highlands and Islands, AGBC210, Moray College UHI, Moray Street, Elgin, IV30 1JJ, United Kingdom, 44 1343576830, maged.kamelboulos@uhi.ac.uk %K diabetes mellitus %K video games %K self-care %D 2015 %7 18.03.2015 %9 Viewpoint %J JMIR Serious Games %G English %X Digital games are an important class of eHealth interventions in diabetes, made possible by the Internet and a good range of affordable mobile devices (eg, mobile phones and tablets) available to consumers these days. Gamifying disease management can help children, adolescents, and adults with diabetes to better cope with their lifelong condition. Gamification and social in-game components are used to motivate players/patients and positively change their behavior and lifestyle. In this paper, we start by presenting the main challenges facing people with diabetes—children/adolescents and adults—from a clinical perspective, followed by three short illustrative examples of mobile and desktop game apps and platforms designed by Ayogo Health, Inc. (Vancouver, BC, Canada) for type 1 diabetes (one example) and type 2 diabetes (two examples). The games target different age groups with different needs—children with type 1 diabetes versus adults with type 2 diabetes. The paper is not meant to be an exhaustive review of all digital game offerings available for people with type 1 and type 2 diabetes, but rather to serve as a taster of a few of the game genres on offer today for both types of diabetes, with a brief discussion of (1) some of the underpinning psychological mechanisms of gamified digital interventions and platforms as self-management adherence tools, and more, in diabetes, and (2) some of the hypothesized potential benefits that might be gained from their routine use by people with diabetes. More research evidence from full-scale evaluation studies is needed and expected in the near future that will quantify, qualify, and establish the evidence base concerning this gamification potential, such as what works in each age group/patient type, what does not, and under which settings and criteria. %M 25791276 %R 10.2196/games.3930 %U http://games.jmir.org/2015/1/e3/ %U https://doi.org/10.2196/games.3930 %U http://www.ncbi.nlm.nih.gov/pubmed/25791276 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e1 %T The Design and Relevance of a Computerized Gamified Depression Therapy Program for Indigenous Māori Adolescents %A Shepherd,Matthew %A Fleming,Theresa %A Lucassen,Mathijs %A Stasiak,Karolina %A Lambie,Ian %A Merry,Sally N %+ School of Counselling, Human Services and Social Work, Department of Education, University of Auckland, 5th floor, N Building, Epsom Campus, Epsom, Auckland, Private Bag 92601, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K computerized cognitive behavioral therapy %K Māori %K indigenous populations %K depression %K consumer opinions %K participatory design %D 2015 %7 03.03.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression. Objective: The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach. Methods: There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data. Results: SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery. Conclusions: SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people. Trial Registration: The New Zealand Northern Y Regional Ethics Committee; http://ethics.health.govt.nz/home; NTY/09/003; (Archived by WebCite at http://www.webcitation/6VYgHXKaR). %M 25736225 %R 10.2196/games.3804 %U http://games.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/games.3804 %U http://www.ncbi.nlm.nih.gov/pubmed/25736225 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 1 %P e14 %T The Effect of Social Support Features and Gamification on a Web-Based Intervention for Rheumatoid Arthritis Patients: Randomized Controlled Trial %A Allam,Ahmed %A Kostova,Zlatina %A Nakamoto,Kent %A Schulz,Peter Johannes %+ Institute of Communication and Health, Faculty of Communication Sciences, University of Lugano (Università della Svizzera italiana), Blue Building, 1st floor, 13 G Buffi street, Lugano, 6900, Switzerland, 41 41 58 666 4821, ahmed.allam@usi.ch %K social support %K gaming %K experimental games %K eHealth %K rheumatoid arthritis %K randomized controlled trial %K multilevel analysis %K patient empowerment %K physical activity %K health care utilization %D 2015 %7 09.01.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Rheumatoid arthritis (RA) is chronic systematic disease that affects people during the most productive period of their lives. Web-based health interventions have been effective in many studies; however, there is little evidence and few studies showing the effectiveness of online social support and especially gamification on patients’ behavioral and health outcomes. Objective: The aim of this study was to look into the effects of a Web-based intervention that included online social support features and gamification on physical activity, health care utilization, medication overuse, empowerment, and RA knowledge of RA patients. The effect of gamification on website use was also investigated. Methods: We conducted a 5-arm parallel randomized controlled trial for RA patients in Ticino (Italian-speaking part of Switzerland). A total of 157 patients were recruited through brochures left with physicians and were randomly allocated to 1 of 4 experimental conditions with different types of access to online social support and gamification features and a control group that had no access to the website. Data were collected at 3 time points through questionnaires at baseline, posttest 2 months later, and at follow-up after another 2 months. Primary outcomes were physical activity, health care utilization, and medication overuse; secondary outcomes included empowerment and RA knowledge. All outcomes were self-reported. Intention-to-treat analysis was followed and multilevel linear mixed models were used to study the change of outcomes over time. Results: The best-fit multilevel models (growth curve models) that described the change in the primary outcomes over the course of the intervention included time and empowerment as time-variant predictors. The growth curve analyses of experimental conditions were compared to the control group. Physical activity increased over time for patients having access to social support sections plus gaming (unstandardized beta coefficient [B]=3.39, P=.02). Health care utilization showed a significant decrease for patients accessing social support features (B=–0.41, P=.01) and patients accessing both social support features and gaming (B=–0.33, P=.03). Patients who had access to either social support sections or the gaming experience of the website gained more empowerment (B=2.59, P=.03; B=2.29, P=.05; respectively). Patients who were offered a gamified experience used the website more often than the ones without gaming (t91=–2.41, P=.02; U=812, P=.02). Conclusions: The Web-based intervention had a positive impact (more desirable outcomes) on intervention groups compared to the control group. Social support sections on the website decreased health care utilization and medication overuse and increased empowerment. Gamification alone or with social support increased physical activity and empowerment and decreased health care utilization. This study provides evidence demonstrating the potential positive effect of gamification and online social support on health and behavioral outcomes. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 57366516; http://www.controlled-trials. com/ISRCTN57366516 (Archived by webcite at http://www.webcitation.org/6PBvvAvvV). %M 25574939 %R 10.2196/jmir.3510 %U http://www.jmir.org/2015/1/e14/ %U https://doi.org/10.2196/jmir.3510 %U http://www.ncbi.nlm.nih.gov/pubmed/25574939 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 3 %N 4 %P e80 %T A Telehealth Intervention Using Nintendo Wii Fit Balance Boards and iPads to Improve Walking in Older Adults With Lower Limb Amputation (Wii.n.Walk): Study Protocol for a Randomized Controlled Trial %A Imam,Bita %A Miller,William C %A Finlayson,Heather C %A Eng,Janice J %A Payne,Michael WC %A Jarus,Tal %A Goldsmith,Charles H %A Mitchell,Ian M %+ Department of Occupational Science and Occupational Therapy, University of British Columbia, Koerner Pavilion, Room T314, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B3, Canada, 1 604 714 4108, bill.miller@ubc.ca %K amputation %K adult %K aged %K randomized controlled trial %K telemedicine %K walking %D 2014 %7 22.12.2014 %9 Protocol %J JMIR Res Protoc %G English %X Background: The number of older adults living with lower limb amputation (LLA) who require rehabilitation for improving their walking capacity and mobility is growing. Existing rehabilitation practices frequently fail to meet this demand. Nintendo Wii Fit may be a valuable tool to enable rehabilitation interventions. Based on pilot studies, we have developed “Wii.n.Walk”, an in-home telehealth Wii Fit intervention targeted to improve walking capacity in older adults with LLA. Objective: The objective of this study is to determine whether the Wii.n.Walk intervention enhances walking capacity compared to an attention control group. Methods: This project is a multi-site (Vancouver BC, London ON), parallel, evaluator-blind randomized controlled trial. Participants include community-dwelling older adults over the age of 50 years with unilateral transtibial or transfemoral amputation. Participants will be stratified by site and block randomized in triplets to either the Wii.n.Walk intervention or an attention control group employing the Wii Big Brain cognitive software. This trial will include both supervised and unsupervised phases. During the supervised phase, both groups will receive 40-minute sessions of supervised group training three times per week for a duration of 4 weeks. Participants will complete the first week of the intervention in groups of three at their local rehabilitation center with a trainer. The remaining 3 weeks will take place at participants’ homes using remote supervision by the trainer using Apple iPad technology. At the end of 4 weeks, the supervised period will end and the unsupervised period will begin. Participants will retain the Wii console and be encouraged to continue using the program for an additional 4 weeks’ duration. The primary outcome measure will be the “Two-Minute Walk Test” to measure walking capacity. Outcome measures will be evaluated for all participants at baseline, after the end of both the supervised and unsupervised phases, and after 1-year follow up. Results: Study staff have been hired and trained at both sites and recruitment is currently underway. No participants have been enrolled yet. Conclusions: Wii.n.Walk is a promising in-home telehealth intervention that may have useful applications for older adults with LLA who are discharged from rehabilitation or live in remote areas having limited or no access to existing rehabilitation programs. Trial Registration: Clinicaltrial.gov NCT01942798; http://clinicaltrials.gov/ct2/show/NCT01942798 (Archived by WebCite at http://www.webcitation.org/6V0w8baKP). %M 25533902 %R 10.2196/resprot.4031 %U http://www.researchprotocols.org/2014/4/e80/ %U https://doi.org/10.2196/resprot.4031 %U http://www.ncbi.nlm.nih.gov/pubmed/25533902 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e13 %T Active Fantasy Sports: Rationale and Feasibility of Leveraging Online Fantasy Sports to Promote Physical Activity %A Moller,Arlen C %A Majewski,Sara %A Standish,Melanie %A Agarwal,Pooja %A Podowski,Aleksandra %A Carson,Rebecca %A Eyesus,Biruk %A Shah,Aakash %A Schneider,Kristin L %+ Department of Psychology, Illinois Institute of Technology, Suite 252, 3105 S Dearborn, Chicago, IL, 60616, United States, 1 312 567 3505, amoller@iit.edu %K physical activity %K games for health %K active video game %K exergame %K asynchronous %K social support %K multiplayer %K enjoyment %K intrinsic motivation %K sports %D 2014 %7 25.11.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: The popularity of active video games (AVGs) has skyrocketed over the last decade. However, research suggests that the most popular AVGs, which rely on synchronous integration between players’ activity and game features, fail to promote physical activity outside of the game or for extended periods of engagement. This limitation has led researchers to consider AVGs that involve asynchronous integration of players’ ongoing physical activity with game features. Rather than build an AVG de novo, we selected an established sedentary video game uniquely well suited for the incorporation of asynchronous activity: online fantasy sports. Objective: The primary aim of this study was to explore the feasibility of a new asynchronous AVG—active fantasy sports—designed to promote physical activity. Methods: We conducted two pilot studies of an active fantasy sports game designed to promote physical activity. Participants wore a low cost triaxial accelerometer and participated in an online fantasy baseball (Study 1, n=9, 13-weeks) or fantasy basketball (Study 2, n=10, 17-weeks) league. Privileges within the game were made contingent on meeting weekly physical activity goals (eg, averaging 10,000 steps/day). Results: Across the two studies, the feasibility of integrating physical activity contingent features and privileges into online fantasy sports games was supported. Participants found the active fantasy sports game enjoyable, as or more enjoyable than traditional (sedentary) online fantasy sports (Study 1: t8=4.43, P<.01; Study 2: t9=2.09, P=.07). Participants in Study 1 increased their average steps/day, t8=2.63, P<.05, while participants in Study 2 maintained (ie, did not change) their activity, t9=1.57, P=.15). In postassessment interviews, social support within the game was cited as a key motivating factor for increasing physical activity. Conclusions: Preliminary evidence supports potential for the active fantasy sports system as a sustainable and scalable intervention for promoting adult physical activity. %M 25654304 %R 10.2196/games.3691 %U http://games.jmir.org/2014/2/e13/ %U https://doi.org/10.2196/games.3691 %U http://www.ncbi.nlm.nih.gov/pubmed/25654304 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e11 %T How to Systematically Assess Serious Games Applied to Health Care %A Graafland,Maurits %A Dankbaar,Mary %A Mert,Agali %A Lagro,Joep %A De Wit-Zuurendonk,Laura %A Schuit,Stephanie %A Schaafstal,Alma %A Schijven,Marlies %+ Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, 1100DD, Netherlands, 31 20 566 4207, m.p.schijven@amc.uva.nl %K consensus %K serious game %K applied game %K telehealth %K mobile health %K video game %D 2014 %7 11.11.2014 %9 Viewpoint %J JMIR Serious Games %G English %X The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game’s rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games. %M 25654163 %R 10.2196/games.3825 %U http://games.jmir.org/2014/2/e11/ %U https://doi.org/10.2196/games.3825 %U http://www.ncbi.nlm.nih.gov/pubmed/25654163 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 8 %P e183 %T Physiological and Brain Activity After a Combined Cognitive Behavioral Treatment Plus Video Game Therapy for Emotional Regulation in Bulimia Nervosa: A Case Report %A Fagundo,Ana Beatriz %A Via,Esther %A Sánchez,Isabel %A Jiménez-Murcia,Susana %A Forcano,Laura %A Soriano-Mas,Carles %A Giner-Bartolomé,Cristina %A Santamaría,Juan J %A Ben-Moussa,Maher %A Konstantas,Dimitri %A Lam,Tony %A Lucas,Mikkel %A Nielsen,Jeppe %A Lems,Peter %A Cardoner,Narcís %A Menchón,Jose M %A de la Torre,Rafael %A Fernandez-Aranda,Fernando %+ University Hospital of Bellvitge-IDIBELL, Department of Psychiatry, Feixa Llarga s/n, Barcelona, 08907, Spain, 34 93 2607227, ffernandez@bellvitgehospital.cat %K eating disorders %K bulimia nervosa %K emotional regulation %K impulsivity %K video game therapy %K neuroimaging %K fMRI %D 2014 %7 12.08.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: PlayMancer is a video game designed to increase emotional regulation and reduce general impulsive behaviors, by training to decrease arousal and improve decision-making and planning. We have previously demonstrated the usefulness of PlayMancer in reducing impulsivity and improving emotional regulation in bulimia nervosa (BN) patients. However, whether these improvements are actually translated into brain changes remains unclear. Objective: The aim of this case study was to report on a 28-year-old Spanish woman with BN, and to examine changes in physiological variables and brain activity after a combined treatment of video game therapy (VGT) and cognitive behavioral therapy (CBT). Methods: Ten VGT sessions were carried out on a weekly basis. Anxiety, physiological, and impulsivity measurements were recorded. The patient was scanned in a 1.5-T magnetic resonance scanner, prior to and after the 10-week VGT/CBT combined treatment, using two paradigms: (1) an emotional face-matching task, and (2) a multi-source interference task (MSIT). Results: Upon completing the treatment, a decrease in average heart rate was observed. The functional magnetic resonance imaging (fMRI) results indicated a post-treatment reduction in reaction time along with high accuracy. The patient engaged areas typically active in healthy controls, although the cluster extension of the active areas decreased after the combined treatment. Conclusions: These results suggest a global improvement in emotional regulation and impulsivity control after the VGT therapy in BN, demonstrated by both physiological and neural changes. These promising results suggest that a combined treatment of CBT and VGT might lead to functional cerebral changes that ultimately translate into better cognitive and emotional performances. %M 25116416 %R 10.2196/jmir.3243 %U http://www.jmir.org/2014/8/e183/ %U https://doi.org/10.2196/jmir.3243 %U http://www.ncbi.nlm.nih.gov/pubmed/25116416 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e10 %T Diabetes Island: Preliminary Impact of a Virtual World Self-Care Educational Intervention for African Americans With Type 2 Diabetes %A Ruggiero,Laurie %A Moadsiri,Ada %A Quinn,Lauretta T %A Riley,Barth B %A Danielson,Kirstie K %A Monahan,Colleen %A Bangs,Valerie A %A Gerber,Ben S %+ Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road (MC 275), Chicago, IL, 60608, United States, 1 312 413 9825, lruggier@uic.edu %K minority group %K type 2 diabetes mellitus %K self-management %D 2014 %7 08.08.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Diabetes is a serious worldwide public health challenge. The burden of diabetes, including prevalence and risk of complications, is greater for minorities, particularly African Americans. Internet-based immersive virtual worlds offer a unique opportunity to reach large and diverse populations with diabetes for self-management education and support. Objective: The objective of the study was to examine the acceptability, usage, and preliminary outcome of a virtual world intervention, Diabetes Island, in low-income African Americans with type 2 diabetes. The main hypotheses were that the intervention would: (1) be perceived as acceptable and useful; and (2) improve diabetes self-care (eg, behaviors and barriers) and self-care related outcomes, including glycemic control (A1C), body mass index (BMI), and psychosocial factors (ie, empowerment and distress) over six months. Methods: The evaluation of the intervention impact used a single-group repeated measures design, including three assessment time points: (1) baseline, (2) 3 month (mid intervention), and (3) 6 month (immediate post intervention). Participants were recruited from a university primary care clinic. A total of 41 participants enrolled in the 6 month intervention study. The intervention components included: (1) a study website for communication, feedback, and tracking; and (2) access to an immersive virtual world (Diabetes Island) through Second Life, where a variety of diabetes self-care education activities and resources were available. Outcome measures included A1C, BMI, self-care behaviors, barriers to adherence, eating habits, empowerment, and distress. In addition, acceptability and usage were examined. A series of mixed-effects analyses, with time as a single repeated measures factor, were performed to examine preliminary outcomes. Results: The intervention study sample (N=41) characteristics were: (1) mean age of 55 years, (2) 71% (29/41) female, (3) 100% (41/41) African American, and (4) 76% (31/41) reported annual incomes below US $20,000. Significant changes over time in the expected direction were observed for BMI (P<.02); diabetes-related distress (P<.02); global (P<.01) and dietary (P<.01) environmental barriers to self-care; one physical activity subscale (P<.04); and one dietary intake (P<.01) subscale. The participant feedback regarding the intervention (eg, ease of use, interest, and perceived impact) was consistently positive. The usage patterns showed that the majority of participants logged in regularly during the first two months, and around half logged in each week on average across the six month period. Conclusions: This study demonstrated promising initial results of an immersive virtual world approach to reaching underserved individuals with diabetes to deliver diabetes self-management education. This intervention model and method show promise and could be tailored for other populations. A large scale controlled trial is needed to further examine efficacy. %M 25584346 %R 10.2196/games.3260 %U http://games.jmir.org/2014/2/e10/ %U https://doi.org/10.2196/games.3260 %U http://www.ncbi.nlm.nih.gov/pubmed/25584346 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e5 %T Assessing Video Games to Improve Driving Skills: A Literature Review and Observational Study %A Sue,Damian %A Ray,Pradeep %A Talaei-Khoei,Amir %A Jonnagaddala,Jitendra %A Vichitvanichphong,Suchada %+ Lab for Agile Information Systems, School of Systems, Management, and Leadership, University of Technology, Sydney, CB10.04.346, PO Box 123, Broadway, Ultimo NSW 2007, Sydney, , Australia, 61 (02) 9514 3, amir.talaei@uts.edu.au %K video games %K driving %K motor skills %K health %K coordination %D 2014 %7 07.08.2014 %9 Review %J JMIR Serious Games %G English %X Background: For individuals, especially older adults, playing video games is a promising tool for improving their driving skills. The ease of use, wide availability, and interactivity of gaming consoles make them an attractive simulation tool. Objective: The objective of this study was to look at the feasibility and effects of installing video game consoles in the homes of individuals looking to improve their driving skills. Methods: A systematic literature review was conducted to assess the effect of playing video games on improving driving skills. An observatory study was performed to evaluate the feasibility of using an Xbox 360 Kinect console for improving driving skills. Results: Twenty–nine articles, which discuss the implementation of video games in improving driving skills were found in literature. On our study, it was found the Xbox 360 with Kinect is capable of improving physical and mental activities. Xbox Video games were introduced to engage players in physical, visual and cognitive activities including endurance, postural sway, reaction time, eyesight, eye movement, attention and concentration, difficulties with orientation, and semantic fluency. However, manual dexterity, visuo-spatial perception and binocular vision could not be addressed by these games. It was observed that Xbox Kinect (by incorporating Kinect sensor facilities) combines physical, visual and cognitive engagement of players. These results were consistent with those from the literature review. Conclusions: From the research that has been carried out, we can conclude that video game consoles are a viable solution for improving user’s physical and mental state. In future we propose to carry a thorough evaluation of the effects of video games on driving skills in elderly people. %M 25654355 %R 10.2196/games.3274 %U http://games.jmir.org/2014/2/e5/ %U https://doi.org/10.2196/games.3274 %U http://www.ncbi.nlm.nih.gov/pubmed/25654355 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e9 %T Just a Fad? Gamification in Health and Fitness Apps %A Lister,Cameron %A West,Joshua H %A Cannon,Ben %A Sax,Tyler %A Brodegard,David %+ LaughModel Health Communication Research Group, Department of Health Science, Brigham Young University, 213 RB, Provo, UT, 84604, United States, 1 9702316755, cameron@laughmodel.com %K gamification %K mobile phone %K behavioral health %K health and fitness apps %D 2014 %7 04.08.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Gamification has been a predominant focus of the health app industry in recent years. However, to our knowledge, there has yet to be a review of gamification elements in relation to health behavior constructs, or insight into the true proliferation of gamification in health apps. Objective: The objective of this study was to identify the extent to which gamification is used in health apps, and analyze gamification of health and fitness apps as a potential component of influence on a consumer’s health behavior. Methods: An analysis of health and fitness apps related to physical activity and diet was conducted among apps in the Apple App Store in the winter of 2014. This analysis reviewed a sample of 132 apps for the 10 effective game elements, the 6 core components of health gamification, and 13 core health behavior constructs. A regression analysis was conducted in order to measure the correlation between health behavior constructs, gamification components, and effective game elements. Results: This review of the most popular apps showed widespread use of gamification principles, but low adherence to any professional guidelines or industry standard. Regression analysis showed that game elements were associated with gamification (P<.001). Behavioral theory was associated with gamification (P<.05), but not game elements, and upon further analysis gamification was only associated with composite motivational behavior scores (P<.001), and not capacity or opportunity/trigger. Conclusions: This research, to our knowledge, represents the first comprehensive review of gamification use in health and fitness apps, and the potential to impact health behavior. The results show that use of gamification in health and fitness apps has become immensely popular, as evidenced by the number of apps found in the Apple App Store containing at least some components of gamification. This shows a lack of integrating important elements of behavioral theory from the app industry, which can potentially impact the efficacy of gamification apps to change behavior. Apps represent a very promising, burgeoning market and landscape in which to disseminate health behavior change interventions. Initial results show an abundant use of gamification in health and fitness apps, which necessitates the in-depth study and evaluation of the potential of gamification to change health behaviors. %M 25654660 %R 10.2196/games.3413 %U http://games.jmir.org/2014/2/e9/ %U https://doi.org/10.2196/games.3413 %U http://www.ncbi.nlm.nih.gov/pubmed/25654660 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e7 %T The Cure: Design and Evaluation of a Crowdsourcing Game for Gene Selection for Breast Cancer Survival Prediction %A Good,Benjamin M %A Loguercio,Salvatore %A Griffith,Obi L %A Nanis,Max %A Wu,Chunlei %A Su,Andrew I %+ The Scripps Research Institute, Department of Molecular and Experimental Medicine, MEM-216, 10550 North Torrey Pines Road, La Jolla, CA, 92037, United States, 1 619 261 2046, bgood@scripps.edu %K breast neoplasms %K gene expression %K artificial intelligence %K survival analysis %K crowdsourcing %K Web applications %K computer games %K collaborative and social computing systems and tools %K supervised learning %K feature selection %D 2014 %7 29.07.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Molecular signatures for predicting breast cancer prognosis could greatly improve care through personalization of treatment. Computational analyses of genome-wide expression datasets have identified such signatures, but these signatures leave much to be desired in terms of accuracy, reproducibility, and biological interpretability. Methods that take advantage of structured prior knowledge (eg, protein interaction networks) show promise in helping to define better signatures, but most knowledge remains unstructured. Crowdsourcing via scientific discovery games is an emerging methodology that has the potential to tap into human intelligence at scales and in modes unheard of before. Objective: The main objective of this study was to test the hypothesis that knowledge linking expression patterns of specific genes to breast cancer outcomes could be captured from players of an open, Web-based game. We envisioned capturing knowledge both from the player’s prior experience and from their ability to interpret text related to candidate genes presented to them in the context of the game. Methods: We developed and evaluated an online game called The Cure that captured information from players regarding genes for use as predictors of breast cancer survival. Information gathered from game play was aggregated using a voting approach, and used to create rankings of genes. The top genes from these rankings were evaluated using annotation enrichment analysis, comparison to prior predictor gene sets, and by using them to train and test machine learning systems for predicting 10 year survival. Results: Between its launch in September 2012 and September 2013, The Cure attracted more than 1000 registered players, who collectively played nearly 10,000 games. Gene sets assembled through aggregation of the collected data showed significant enrichment for genes known to be related to key concepts such as cancer, disease progression, and recurrence. In terms of the predictive accuracy of models trained using this information, these gene sets provided comparable performance to gene sets generated using other methods, including those used in commercial tests. The Cure is available on the Internet. Conclusions: The principal contribution of this work is to show that crowdsourcing games can be developed as a means to address problems involving domain knowledge. While most prior work on scientific discovery games and crowdsourcing in general takes as a premise that contributors have little or no expertise, here we demonstrated a crowdsourcing system that succeeded in capturing expert knowledge. %M 25654473 %R 10.2196/games.3350 %U http://games.jmir.org/2014/2/e7/ %U https://doi.org/10.2196/games.3350 %U http://www.ncbi.nlm.nih.gov/pubmed/25654473 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 3 %P e32 %T Attitudes and Preferences on the Use of Mobile Health Technology and Health Games for Self-Management: Interviews With Older Adults on Anticoagulation Therapy %A Lee,Jung-Ah %A Nguyen,Annie Lu %A Berg,Jill %A Amin,Alpesh %A Bachman,Mark %A Guo,Yuqing %A Evangelista,Lorraine %+ University of California, Irvine, Program in Nursing Science, Berk Hall 100A, Irvine, CA, 92697-3959, United States, 1 949 824 2855, jungahl@uci.edu %K anticoagulation therapy %K health apps %K health games %K mobile health technology %K self-management %D 2014 %7 23.07.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Older adults are at substantial risk for cardiovascular disorders that may require anticoagulation therapy. Those on warfarin therapy report dissatisfaction and reduced quality of life (QOL) resulting from the treatment. Advances in the area of mobile health (mHealth) technology have resulted in the design and development of new patient-centric models for the provision of personalized health care services to improve care delivery. However, there is a paucity of research examining the effectiveness of mHealth tools on knowledge, attitudes, and patient satisfaction with treatment, as well as self-management, adherence to therapy, and QOL in older adults with chronic illness conditions requiring long-term warfarin therapy. Objective: The objective of the study was to explore the attitudes and preferences of older adults on warfarin therapy regarding the use of mHealth technology and health games to gain skills for self-management. Methods: We conducted group and individual interviews with patients (60 years or older) on warfarin therapy at two anticoagulation clinics affiliated with an academic medical center. We held 4 group and 2 individual interviews, resulting in 11 patient participants and 2 family caregiver participants. We used structured questions on three topic areas including medication self-management strategies, mHealth technology use, and health games for exercise. We demonstrated some commercial health apps related to medication management, vitamin K content of food, and a videogame for balance exercise. Discussions were audiotaped and transcribed verbatim. Common themes were drawn using content analysis. Results: The participants reported awareness of the importance of staying on schedule with warfarin therapy. They also acknowledged that negative experiences of friends or family members who were taking warfarin influenced their desire to keep on schedule with warfarin therapy. In addition, the participants expressed that the use of mHealth technology may be helpful for medication management. They also expressed the need for family support in the use of health technology devices. Moreover, the participants discussed concerns and challenges to use health technology and health games, and provided suggestions on ways to make mHealth technology and health games elder-friendly. Conclusions: These findings indicate that our older adults on warfarin therapy are interested in mHealth technology specific to warfarin medication management and health games. Further research needs to be done to validate these findings. Elder-friendly designs, technology support, and physical safety using mHealth technology may be useful in this population. These findings can be used to inform a larger study to design and test an elder-centered mHealth technology in this target population. %M 25098413 %R 10.2196/mhealth.3196 %U http://mhealth.jmir.org/2014/3/e32/ %U https://doi.org/10.2196/mhealth.3196 %U http://www.ncbi.nlm.nih.gov/pubmed/25098413 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 2 %P e8 %T What Serious Video Games Can Offer Child Obesity Prevention %A Thompson,Debbe %+ USDA/ARS Children's Nutrition Research Center, Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston, TX, 77030, United States, 1 713 798 7076, dit@bcm.edu %K serious video games %K children %K teenagers %K obesity prevention %K formative research, qualitative research %D 2014 %7 16.07.2014 %9 Viewpoint %J JMIR Serious Games %G English %X Childhood obesity is a worldwide issue, and effective methods encouraging children to adopt healthy diet and physical activity behaviors are needed. This viewpoint addresses the promise of serious video games, and why they may offer one method for helping children eat healthier and become more physically active. Lessons learned are provided, as well as examples gleaned from personal experiences. %M 25654589 %R 10.2196/games.3480 %U http://games.jmir.org/2014/2/e8/ %U https://doi.org/10.2196/games.3480 %U http://www.ncbi.nlm.nih.gov/pubmed/25654589 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e6 %T A Functional Magnetic Resonance Imaging Assessment of Small Animals’ Phobia Using Virtual Reality as a Stimulus %A Clemente,Miriam %A Rey,Beatriz %A Rodriguez-Pujadas,Aina %A Breton-Lopez,Juani %A Barros-Loscertales,Alfonso %A Baños,Rosa M %A Botella,Cristina %A Alcañiz,Mariano %A Avila,Cesar %+ LabHuman, I3BH, Universitat Politecnica de Valencia, Ciudad Politécnica de la Innovación - Cubo Azul - Edif 8B - Acceso N, Camino de Vera s/n, Valencia, 46022, Spain, 34 96 387 75 18 ext 67042, yavanna12@gmail.com %K neuroimaging %K patient assessment %K virtual reality %K phobia %D 2014 %7 27.06.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: To date, still images or videos of real animals have been used in functional magnetic resonance imaging protocols to evaluate the brain activations associated with small animals’ phobia. Objective: The objective of our study was to evaluate the brain activations associated with small animals’ phobia through the use of virtual environments. This context will have the added benefit of allowing the subject to move and interact with the environment, giving the subject the illusion of being there. Methods: We have analyzed the brain activation in a group of phobic people while they navigated in a virtual environment that included the small animals that were the object of their phobia. Results: We have found brain activation mainly in the left occipital inferior lobe (P<.05 corrected, cluster size=36), related to the enhanced visual attention to the phobic stimuli; and in the superior frontal gyrus (P<.005 uncorrected, cluster size=13), which is an area that has been previously related to the feeling of self-awareness. Conclusions: In our opinion, these results demonstrate that virtual stimulus can enhance brain activations consistent with previous studies with still images, but in an environment closer to the real situation the subject would face in their daily lives. %M 25654753 %R 10.2196/games.2836 %U http://games.jmir.org/2014/1/e6/ %U https://doi.org/10.2196/games.2836 %U http://www.ncbi.nlm.nih.gov/pubmed/25654753 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e4 %T Personal, Social, and Game-Related Correlates of Active and Non-Active Gaming Among Dutch Gaming Adolescents: Survey-Based Multivariable, Multilevel Logistic Regression Analyses %A Simons,Monique %A de Vet,Emely %A Chinapaw,Mai JM %A de Boer,Michiel %A Seidell,Jacob C %A Brug,Johannes %+ EMGO Institute for Health and Care Research, Department of Health Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands, Amsterdam, , Netherlands, 31 205983670, m.simons@vu.nl %K video games %K interactive games %K active games %K adolescent %K sedentary lifestyle %K physical activity %K determinants %D 2014 %7 04.04.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Playing video games contributes substantially to sedentary behavior in youth. A new generation of video games—active games—seems to be a promising alternative to sedentary games to promote physical activity and reduce sedentary behavior. At this time, little is known about correlates of active and non-active gaming among adolescents. Objective: The objective of this study was to examine potential personal, social, and game-related correlates of both active and non-active gaming in adolescents. Methods: A survey assessing game behavior and potential personal, social, and game-related correlates was conducted among adolescents (12-16 years, N=353) recruited via schools. Multivariable, multilevel logistic regression analyses, adjusted for demographics (age, sex and educational level of adolescents), were conducted to examine personal, social, and game-related correlates of active gaming ≥1 hour per week (h/wk) and non-active gaming >7 h/wk. Results: Active gaming ≥1 h/wk was significantly associated with a more positive attitude toward active gaming (OR 5.3, CI 2.4-11.8; P<.001), a less positive attitude toward non-active games (OR 0.30, CI 0.1-0.6; P=.002), a higher score on habit strength regarding gaming (OR 1.9, CI 1.2-3.2; P=.008) and having brothers/sisters (OR 6.7, CI 2.6-17.1; P<.001) and friends (OR 3.4, CI 1.4-8.4; P=.009) who spend more time on active gaming and a little bit lower score on game engagement (OR 0.95, CI 0.91-0.997; P=.04). Non-active gaming >7 h/wk was significantly associated with a more positive attitude toward non-active gaming (OR 2.6, CI 1.1-6.3; P=.035), a stronger habit regarding gaming (OR 3.0, CI 1.7-5.3; P<.001), having friends who spend more time on non-active gaming (OR 3.3, CI 1.46-7.53; P=.004), and a more positive image of a non-active gamer (OR 2, CI 1.07–3.75; P=.03). Conclusions: Various factors were significantly associated with active gaming ≥1 h/wk and non-active gaming >7 h/wk. Active gaming is most strongly (negatively) associated with attitude with respect to non-active games, followed by observed active game behavior of brothers and sisters and attitude with respect to active gaming (positive associations). On the other hand, non-active gaming is most strongly associated with observed non-active game behavior of friends, habit strength regarding gaming and attitude toward non-active gaming (positive associations). Habit strength was a correlate of both active and non-active gaming, indicating that both types of gaming are habitual behaviors. Although these results should be interpreted with caution because of the limitations of the study, they do provide preliminary insights into potential correlates of active and non-active gaming that can be used for further research as well as preliminary direction for the development of effective intervention strategies for replacing non-active gaming by active gaming among adolescents. %M 25654657 %R 10.2196/games.3092 %U http://games.jmir.org/2014/1/e4/ %U https://doi.org/10.2196/games.3092 %U http://www.ncbi.nlm.nih.gov/pubmed/25654657 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 2 %P e61 %T Effect of a Kinect-Based Exercise Game on Improving Executive Cognitive Performance in Community-Dwelling Elderly: Case Control Study %A Kayama,Hiroki %A Okamoto,Kazuya %A Nishiguchi,Shu %A Yamada,Minoru %A Kuroda,Tomohiro %A Aoyama,Tomoki %+ Human Health Sciences, Graduate School of Medicine, Kyoto University, 53, Kawaharcho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan, 81 75 751 3909, kayama.hiroki.37r@st.kyoto-u.ac.jp %K fall prevention %K cognitive function %K dual-task %K training %K elderly %D 2014 %7 24.02.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: Decrease of dual-task (DT) ability is known to be one of the risk factors for falls. We developed a new game concept, Dual-Task Tai Chi (DTTC), using Microsoft’s motion-capture device Kinect, and demonstrated that the DTTC test can quantitatively evaluate various functions that are known risk factors for falling in elderly adults. Moreover, DT training has been attracting attention as a way to improve balance and DT ability. However, only a few studies have reported that it improves cognitive performance. Objective: The purpose of this study was to demonstrate whether or not a 12-week program of DTTC training would effectively improve cognitive functions. Methods: This study examined cognitive functions in community-dwelling older adults before and after 12 weeks of DTTC training (training group [TG]) or standardized training (control group [CG]). Primary end points were based on the difference in cognitive functions between the TG and the CG. Cognitive functions were evaluated using the trail-making test (part A and part B) and verbal fluency test. Results: A total of 41 elderly individuals (TG: n=26, CG: n=15) participated in this study and their cognitive functions were assessed before and after DTTC training. Significant differences were observed between the two groups with significant group × time interactions for the executive cognitive function measure, the delta-trail-making test (part B−part A; F1,36=4.94, P=.03; TG: pre mean 48.8 [SD 43.9], post mean 42.2 [SD 29.0]; CG: pre mean 49.5 [SD 51.8], post mean 64.9 [SD 54.7]). Conclusions: The results suggest that DTTC training is effective for improving executive cognitive functions. Trial Registration: Japan Medical Association Clinical Trial Registration Number: JMA-IIA00092; https://dbcentre3.jmacct.med.or.jp/jmactr/App/JMACTRS06/JMACTRS06.aspx?seqno=2682 (Archived by WebCite at http://www.webcitation.org/6NRtOkZFh). %M 24565806 %R 10.2196/jmir.3108 %U http://www.jmir.org/2014/2/e61/ %U https://doi.org/10.2196/jmir.3108 %U http://www.ncbi.nlm.nih.gov/pubmed/24565806 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e3 %T Views of Young People in Rural Australia on SPARX, a Fantasy World Developed for New Zealand Youth With Depression %A Cheek,Colleen %A Bridgman,Heather %A Fleming,Theresa %A Cummings,Elizabeth %A Ellis,Leonie %A Lucassen,Mathijs FG %A Shepherd,Matthew %A Skinner,Timothy %+ Rural Clinical School, University of Tasmania, Private Bag 3513, Burnie, 7320, Australia, 61 364305922, Colleen.Cheek@utas.edu.au %K mental health %K stigma %K computer games %K youth %K rural health, computerized CBT %D 2014 %7 18.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: A randomized control trial demonstrated that a computerized cognitive behavioral therapy (cCBT) program (Smart, Positive, Active, Realistic, X-factor thoughts [SPARX]) was an appealing and efficacious treatment for depression for adolescents in New Zealand. Little is known about the acceptability of computerized therapy programs for rural Australians and the suitability of computerized programs developed in one cultural context when used in another country. Issues such as accents and local differences in health care access might mean adjustments to programs are required. Objective: This study sought to explore the acceptability of SPARX by youth in rural Australia and to explore whether and how young people would wish to access such a program. Methods: Focus groups and semistructured interviews were conducted with 16 young people attending two youth-focused community services in a small, rural Tasmanian town. An inductive data-driven approach was used to identify themes using the interview transcripts as the primary data source. Interpretation was supported by demographic data, observer notes, and content analysis. Results: Participants reported that young people want help for mental health issues but they have an even stronger need for controlling how they access services. In particular, they considered protecting their privacy in their small community to be paramount. Participants thought computerized therapy was a promising way to increase access to treatment for youth in rural and remote areas if offered with or without therapist support and via settings other than school. The design features of SPARX that were perceived to be useful, included the narrative structure of the program, the use of different characters, the personalization of an avatar, “socialization” with the Guide character, optional journaling, and the use of encouraging feedback. Participants did not consider (New Zealand) accents off-putting. Young people believed the SPARX program would appeal to those who play computer games generally, but may be less appealing for those who do not. Conclusions: The findings suggest that computerized therapy offered in ways that support privacy and choice can improve access to treatment for rural youth. Foreign accents and style may not be off-putting to teenage users when the program uses a playful fantasy genre, as it is consistent with their expectation of fantasy worlds, and it is in a medium with which they already have a level of competence. Rather, issues of engaging design and confidential access appeared to be more important. These findings suggest a proven tool once formally assessed at a local level can be adopted cross-nationally. %M 25659116 %R 10.2196/games.3183 %U http://games.jmir.org/2014/1/e3/ %U https://doi.org/10.2196/games.3183 %U http://www.ncbi.nlm.nih.gov/pubmed/25659116 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 2 %P e47 %T A Decade of Research on the Use of Three-Dimensional Virtual Worlds in Health Care: A Systematic Literature Review %A Ghanbarzadeh,Reza %A Ghapanchi,Amir Hossein %A Blumenstein,Michael %A Talaei-Khoei,Amir %+ School of Information and Communication Technology, Griffith University, G23 2.32, Gold Coast Campus, Gold Coast, Queensland, 4222, Australia, 61 7 555 28502, reza.ghanbarzadeh@griffithuni.edu.au %K 3D virtual worlds %K 3DVW %K health care %D 2014 %7 18.02.2014 %9 Review %J J Med Internet Res %G English %X Background: A three-dimensional virtual world (3DVW) is a computer-simulated electronic 3D virtual environment that users can explore, inhabit, communicate, and interact with via avatars, which are graphical representations of the users. Since the early 2000s, 3DVWs have emerged as a technology that has much to offer the health care sector. Objective: The purpose of this study was to characterize different application areas of various 3DVWs in health and medical context and categorize them into meaningful categories. Methods: This study employs a systematic literature review on the application areas of 3DVWs in health care. Our search resulted in 62 papers from five top-ranking scientific databases published from 1990 to 2013 that describe the use of 3DVWs for health care specific purposes. We noted a growth in the number of academic studies on the topic since 2006. Results: We found a wide range of application areas for 3DVWs in health care and classified them into the following six categories: academic education, professional education, treatment, evaluation, lifestyle, and modeling. The education category, including professional and academic education, contains the largest number of papers (n=34), of which 23 are related to the academic education category and 11 to the professional education category. Nine papers are allocated to treatment category, and 8 papers have contents related to evaluation. In 4 of the papers, the authors used 3DVWs for modeling, and 3 papers targeted lifestyle purposes. The results indicate that most of the research to date has focused on education in health care. We also found that most studies were undertaken in just two countries, the United States and the United Kingdom. Conclusions: 3D virtual worlds present several innovative ways to carry out a wide variety of health-related activities. The big picture of application areas of 3DVWs presented in this review could be of value and offer insights to both the health care community and researchers. %M 24550130 %R 10.2196/jmir.3097 %U http://www.jmir.org/2014/2/e47/ %U https://doi.org/10.2196/jmir.3097 %U http://www.ncbi.nlm.nih.gov/pubmed/24550130 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e2 %T DietBet: A Web-Based Program that Uses Social Gaming and Financial Incentives to Promote Weight Loss %A Leahey,Tricia %A Rosen,Jamie %+ Brown Medical School, Department of Psychiatry and Human Behavior, The Miriam Hospital's Weight Control and Diabetes Research Center, 196 Richmond Street, Providence, RI, 02903, United States, 1 4017938947, tleahey@lifespan.org %K commercial weight loss %K Web-based intervention %K social gaming %K financial incentives %D 2014 %7 07.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: Web-based commercial weight loss programs are increasing in popularity. Despite their significant public health potential, there is limited research on the effectiveness of such programs. Objective: The objective of our study was to examine weight losses produced by DietBet and explore whether baseline and engagement variables predict weight outcomes. Methods: DietBet is a social gaming website that uses financial incentives and social influence to promote weight loss. Players bet money and join a game. All players have 4 weeks to lose 4% of their initial body weight. At enrollment, players can choose to share their participation on Facebook. During the game, players interact with one another and report their weight loss on the DietBet platform. At week 4, all players within each game who lose at least 4% of initial body weight are declared winners and split the pool of money bet at the start of the game. Official weigh-in procedures are used to verify weights at the start of the game and at the end. Results: From December 2012 to July 2013, 39,387 players (84.04% female, 33,101/39,387; mean weight 87.8kg, SD 22.6kg) competed in 1934 games. The average amount bet was US $27 (SD US $22). A total of 65.63% (25,849/39,387) provided a verified weight at the end of the 4-week competition. The average intention-to-treat weight loss was 2.6% (SD 2.3%). Winners (n=17,171) won an average of US $59 (SD US $35) and lost 4.9% (SD 1.0%) of initial body weight, with 30.68% (5268/17,171) losing 5% or more of their initial weight. Betting more money at game entry, sharing on Facebook, completing more weigh-ins, and having more social interactions during the game predicted greater weight loss and greater likelihood of winning (Ps<.001). In addition, weight loss clustered within games (P<.001), suggesting that players influenced each others’ weight outcomes. Conclusions: DietBet, a social gaming website, reached nearly 40,000 individuals in just 7 months and produced excellent 4-week weight loss results. Given its reach and potential public health impact, future research may consider examining whether a longer program promotes additional weight loss. %M 25658966 %R 10.2196/games.2987 %U http://games.jmir.org/2014/1/e2/ %U https://doi.org/10.2196/games.2987 %U http://www.ncbi.nlm.nih.gov/pubmed/25658966 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 12 %P e270 %T Puzzling With Online Games (BAM-COG): Reliability, Validity, and Feasibility of an Online Self-Monitor for Cognitive Performance in Aging Adults %A Aalbers,Teun %A Baars,Maria A E %A Olde Rikkert,Marcel G M %A Kessels,Roy P C %+ Radboud University Medical Center, Department of Geriatric Medicine, Reinier Postlaan 4, Nijmegen, 6500 HB, Netherlands, 31 243619807, teun.aalbers@radboudumc.nl %K cognitive testing %K brain aging %K games %K validity %K reliability %K self-monitoring %K Internet %K eHealth %D 2013 %7 03.12.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Online interventions are aiming increasingly at cognitive outcome measures but so far no easy and fast self-monitors for cognition have been validated or proven reliable and feasible. Objective: This study examines a new instrument called the Brain Aging Monitor–Cognitive Assessment Battery (BAM-COG) for its alternate forms reliability, face and content validity, and convergent and divergent validity. Also, reference values are provided. Methods: The BAM-COG consists of four easily accessible, short, yet challenging puzzle games that have been developed to measure working memory (“Conveyer Belt”), visuospatial short-term memory (“Sunshine”), episodic recognition memory (“Viewpoint”), and planning (“Papyrinth”). A total of 641 participants were recruited for this study. Of these, 397 adults, 40 years and older (mean 54.9, SD 9.6), were eligible for analysis. Study participants played all games three times with 14 days in between sets. Face and content validity were based on expert opinion. Alternate forms reliability (AFR) was measured by comparing scores on different versions of the BAM-COG and expressed with an intraclass correlation (ICC: two-way mixed; consistency at 95%). Convergent validity (CV) was provided by comparing BAM-COG scores to gold-standard paper-and-pencil and computer-assisted cognitive assessment. Divergent validity (DV) was measured by comparing BAM-COG scores to the National Adult Reading Test IQ (NART-IQ) estimate. Both CV and DV are expressed as Spearman rho correlation coefficients. Results: Three out of four games showed adequate results on AFR, CV, and DV measures. The games Conveyer Belt, Sunshine, and Papyrinth have AFR ICCs of .420, .426, and .645 respectively. Also, these games had good to very good CV correlations: rho=.577 (P=.001), rho=.669 (P<.001), and rho=.400 (P=.04), respectively. Last, as expected, DV correlations were low: rho=−.029 (P=.44), rho=−.029 (P=.45), and rho=−.134 (P=.28) respectively. The game Viewpoint provided less desirable results with an AFR ICC of .167, CV rho=.202 (P=.15), and DV rho=−.162 (P=.21). Conclusions: This study provides evidence for the use of the BAM-COG test battery as a feasible, reliable, and valid tool to monitor cognitive performance in healthy adults in an online setting. Three out of four games have good psychometric characteristics to measure working memory, visuospatial short-term memory, and planning capacity. %M 24300212 %R 10.2196/jmir.2860 %U http://www.jmir.org/2013/12/e270/ %U https://doi.org/10.2196/jmir.2860 %U http://www.ncbi.nlm.nih.gov/pubmed/24300212 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 10 %P e240 %T Design and Evaluation of a Simulation for Pediatric Dentistry in Virtual Worlds %A Papadopoulos,Lazaros %A Pentzou,Afroditi-Evaggelia %A Louloudiadis,Konstantinos %A Tsiatsos,Thrasyvoulos-Konstantinos %+ Laboratory of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Panepistimioupoli, Thessaloniki, 54124, Greece, 30 2310999272, lazapap@hotmail.gr %K virtual patient %K virtual world %K pediatric dentistry %K simulation %K Second Life %K OpenSim %K communication %K tell-show-do %K behavior management %D 2013 %7 29.10.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Three-dimensional virtual worlds are becoming very popular among educators in the medical field. Virtual clinics and patients are already used for case study and role play in both undergraduate and continuing education levels. Dental education can also take advantage of the virtual world’s pedagogical features in order to give students the opportunity to interact with virtual patients (VPs) and practice in treatment planning. Objective: The objective of this study was to design and evaluate a virtual patient as a supplemental teaching tool for pediatric dentistry. Methods: A child VP, called Erietta, was created by utilizing the programming and building tools that online virtual worlds offer. The case is about an eight-year old girl visiting the dentist with her mother for the first time. Communication techniques such as Tell-Show-Do and parents’ interference management were the basic elements of the educational scenario on which the VP was based. An evaluation of the simulation was made by 103 dental students in their fourth year of study. Two groups were formed: an experimental group which was exposed to the simulation (n=52) and a control group which did not receive the simulation (n=51). At the end, both groups were asked to complete a knowledge questionnaire and the results were compared. Results: A statistically significant difference between the two groups was found by applying a t test for independent samples (P<.001), showing a positive learning effect from the VP. The majority of the participants evaluated the aspects of the simulation very positively while 69% (36/52) of the simulation group expressed their preference for using this module as an additional teaching tool. Conclusions: This study demonstrated that a pediatric dentistry VP built in a virtual world offers significant learning potential when used as a supplement to the traditional teaching techniques. %M 24168820 %R 10.2196/jmir.2651 %U http://www.jmir.org/2013/10/e240/ %U https://doi.org/10.2196/jmir.2651 %U http://www.ncbi.nlm.nih.gov/pubmed/24168820 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 10 %P e232 %T Can a Novel Web-Based Computer Test Predict Poor Simulated Driving Performance? A Pilot Study With Healthy and Cognitive-Impaired Participants %A Nef,Tobias %A Müri,René M %A Bieri,Rahel %A Jäger,Michael %A Bethencourt,Nora %A Tarnanas,Ioannis %A Mosimann,Urs P %+ Gerontechnology and Rehabilitation Group, University of Bern, Murtenstrasse 50, Bern, 3010, Switzerland, 41 31 632 88 17, Rene.muri@insel.ch %K cognitive impairment %K Web-based cognitive test %K computer-based tests %K driving simulation %D 2013 %7 18.10.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Driving a car is a complex instrumental activity of daily living and driving performance is very sensitive to cognitive impairment. The assessment of driving-relevant cognition in older drivers is challenging and requires reliable and valid tests with good sensitivity and specificity to predict safe driving. Driving simulators can be used to test fitness to drive. Several studies have found strong correlation between driving simulator performance and on-the-road driving. However, access to driving simulators is restricted to specialists and simulators are too expensive, large, and complex to allow easy access to older drivers or physicians advising them. An easily accessible, Web-based, cognitive screening test could offer a solution to this problem. The World Wide Web allows easy dissemination of the test software and implementation of the scoring algorithm on a central server, allowing generation of a dynamically growing database with normative values and ensures that all users have access to the same up-to-date normative values. Objective: In this pilot study, we present the novel Web-based Bern Cognitive Screening Test (wBCST) and investigate whether it can predict poor simulated driving performance in healthy and cognitive-impaired participants. Methods: The wBCST performance and simulated driving performance have been analyzed in 26 healthy younger and 44 healthy older participants as well as in 10 older participants with cognitive impairment. Correlations between the two tests were calculated. Also, simulated driving performance was used to group the participants into good performers (n=70) and poor performers (n=10). A receiver-operating characteristic analysis was calculated to determine sensitivity and specificity of the wBCST in predicting simulated driving performance. Results: The mean wBCST score of the participants with poor simulated driving performance was reduced by 52%, compared to participants with good simulated driving performance (P<.001). The area under the receiver-operating characteristic curve was 0.80 with a 95% confidence interval 0.68-0.92. Conclusions: When selecting a 75% test score as the cutoff, the novel test has 83% sensitivity, 70% specificity, and 81% efficiency, which are good values for a screening test. Overall, in this pilot study, the novel Web-based computer test appears to be a promising tool for supporting clinicians in fitness-to-drive assessments of older drivers. The Web-based distribution and scoring on a central computer will facilitate further evaluation of the novel test setup. We expect that in the near future, Web-based computer tests will become a valid and reliable tool for clinicians, for example, when assessing fitness to drive in older drivers. %M 24144946 %R 10.2196/jmir.2943 %U http://www.jmir.org/2013/10/e232/ %U https://doi.org/10.2196/jmir.2943 %U http://www.ncbi.nlm.nih.gov/pubmed/24144946 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 1 %N 1 %P e2 %T Surgical Trainee Opinions in the United Kingdom Regarding a Three-Dimensional Virtual Mentoring Environment (MentorSL) in Second Life: Pilot Study %A Jaffer,Usman %A John,Nigel W %A Standfield,Nigel %+ Imperial College Healthcare Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom, 44 (0)7968872992, usman.jaffer@doctors.org.uk %K education %K Internet %K training %D 2013 %7 20.09.2013 %9 Original Paper %J JMIR Serious Games %G English %X Background: Medical mentoring is becoming increasingly complex with the evolving needs of trainees and the complexities of their personal and social lives. The Internet is an enabling technology, which increasingly facilitates interaction with multiple people at a distance. Web 2.0 and 3.0 technology shows promise in furthering this facilitation. Objective: The objective of our study was to establish opinions among doctors in postgraduate surgical training regarding mentoring and whether these doctors would readily accept virtual mentoring following a brief experience. Methods: On the 12th of February 2012, an introductory teaching class was arranged by The London Postgraduate School of Surgery for doctors in training. Participants were introduced to a novel virtual mentoring system and asked to complete a questionnaire regarding their opinions before and after the demonstration. Results: A total of 57 junior doctors attended. Among them, 35 completed questionnaires pre- and postdemonstration. Regarding usefulness of a 3D virtual environment for mentoring, 6/35 (17%) agreed or strongly agreed and 20/35 (57%) were unsure prior to the session. Following 20 minutes using MentorSL, this significantly increased to 14/35 (40%) agreeing or strongly agreeing with 11/35 (31%) unsure (P<.001). Prior to using MentorSL, regarding usefulness of voice communication for virtual mentoring, 11/35 (31%) agreed or strongly agreed and 18/35 (51%) were unsure. Following 20 minutes using MentorSL, 19/35 (54%) agreed or strongly agreed and 10/35 (29%) were unsure of usefulness. Regarding ease of use of navigation, search mentor, meeting scheduling, and voice communication features, 17/35 (49%), 13/35 (37%), 15/35 (43%), and 16/35 (46%) participants agreed or strongly agreed, respectively. Regarding usefulness of telementoring, 24/35 (69%) agreed or strongly agreed, increasing to 28/35 (80%) following the introduction. For usefulness of multiple mentors, initially 24/35 (69%) agreed or strongly agreed increasing to 29/35 (83%). For overall satisfaction, 30/35 (86%) reported good or adequate and 19/35 (54%) agreed or strongly agreed with using the system again. Conclusions: These data suggest that a short introduction on how to use virtual systems may result in significant participation and use of virtual mentoring systems. %M 25658652 %R 10.2196/games.2822 %U http://games.jmir.org/2013/1/e2/ %U https://doi.org/10.2196/games.2822 %U http://www.ncbi.nlm.nih.gov/pubmed/25658652 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 2 %N 2 %P e35 %T Development and Alpha Testing of QuitIT: An Interactive Video Game to Enhance Skills for Coping With Smoking Urges %A Krebs,Paul %A Burkhalter,Jack E %A Snow,Bert %A Fiske,Jeff %A Ostroff,Jamie S %+ Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, 641 Lexington Ave, 7th Floor, New York, NY, 10022, United States, 1 646 888 0041, ostroffj@mskcc.org %K smoking cessation %K health promotion game %K tobacco, quitting self efficacy %K behavioral medicine %K virtual reality %D 2013 %7 11.09.2013 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Despite many efforts at developing relapse prevention interventions, most smokers relapse to tobacco use within a few months after quitting. Interactive games offer a novel strategy for helping people develop the skills required for successful tobacco cessation. Objective: The objective of our study was to develop a video game that enables smokers to practice strategies for coping with smoking urges and maintaining smoking abstinence. Our team of game designers and clinical psychologists are creating a video game that integrates the principles of smoking behavior change and relapse prevention. We have reported the results of expert and end-user feedback on an alpha version of the game. Methods: The alpha version of the game consisted of a smoking cue scenario often encountered by smokers. We recruited 5 experts in tobacco cessation research and 20 current and former smokers, who each played through the scenario. Mixed methods were used to gather feedback on the relevance of cessation content and usability of the game modality. Results: End-users rated the interface from 3.0 to 4.6/5 in terms of ease of use and from 2.9 to 4.1/5 in terms of helpfulness of cessation content. Qualitative themes showed several user suggestions for improving the user interface, pacing, and diversity of the game characters. In addition, the users confirmed a high degree of game immersion, identification with the characters and situations, and appreciation for the multiple opportunities to practice coping strategies. Conclusions: This study highlights the procedures for translating behavioral principles into a game dynamic and shows that our prototype has a strong potential for engaging smokers. A video game modality exemplifies problem-based learning strategies for tobacco cessation and is an innovative step in behavioral management of tobacco use. %M 24025236 %R 10.2196/resprot.2416 %U http://www.researchprotocols.org/2013/2/e35/ %U https://doi.org/10.2196/resprot.2416 %U http://www.ncbi.nlm.nih.gov/pubmed/24025236 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 1 %N 1 %P e1 %T Ecological Validity of Virtual Reality Daily Living Activities Screening for Early Dementia: Longitudinal Study %A Tarnanas,Ioannis %A Schlee,Winfried %A Tsolaki,Magda %A Müri,René %A Mosimann,Urs %A Nef,Tobias %+ Gerontechnology and Rehabilitation Group, University of Bern, Murtenstrasse 50, Bern, 3010, Switzerland, 41 31 632 7582, ioannis.tarnanas@artorg.unibe.ch %D 2013 %7 06.08.2013 %9 Original Paper %J JMIR Serious Games %G English %X Background: Dementia is a multifaceted disorder that impairs cognitive functions, such as memory, language, and executive functions necessary to plan, organize, and prioritize tasks required for goal-directed behaviors. In most cases, individuals with dementia experience difficulties interacting with physical and social environments. The purpose of this study was to establish ecological validity and initial construct validity of a fire evacuation Virtual Reality Day-Out Task (VR-DOT) environment based on performance profiles as a screening tool for early dementia. Objective: The objectives were (1) to examine the relationships among the performances of 3 groups of participants in the VR-DOT and traditional neuropsychological tests employed to assess executive functions, and (2) to compare the performance of participants with mild Alzheimer’s-type dementia (AD) to those with amnestic single-domain mild cognitive impairment (MCI) and healthy controls in the VR-DOT and traditional neuropsychological tests used to assess executive functions. We hypothesized that the 2 cognitively impaired groups would have distinct performance profiles and show significantly impaired independent functioning in ADL compared to the healthy controls. Methods: The study population included 3 groups: 72 healthy control elderly participants, 65 amnestic MCI participants, and 68 mild AD participants. A natural user interface framework based on a fire evacuation VR-DOT environment was used for assessing physical and cognitive abilities of seniors over 3 years. VR-DOT focuses on the subtle errors and patterns in performing everyday activities and has the advantage of not depending on a subjective rating of an individual person. We further assessed functional capacity by both neuropsychological tests (including measures of attention, memory, working memory, executive functions, language, and depression). We also evaluated performance in finger tapping, grip strength, stride length, gait speed, and chair stands separately and while performing VR-DOTs in order to correlate performance in these measures with VR-DOTs because performance while navigating a virtual environment is a valid and reliable indicator of cognitive decline in elderly persons. Results: The mild AD group was more impaired than the amnestic MCI group, and both were more impaired than healthy controls. The novel VR-DOT functional index correlated strongly with standard cognitive and functional measurements, such as mini-mental state examination (MMSE; rho=0.26, P=.01) and Bristol Activities of Daily Living (ADL) scale scores (rho=0.32, P=.001). Conclusions: Functional impairment is a defining characteristic of predementia and is partly dependent on the degree of cognitive impairment. The novel virtual reality measures of functional ability seem more sensitive to functional impairment than qualitative measures in predementia, thus accurately differentiating from healthy controls. We conclude that VR-DOT is an effective tool for discriminating predementia and mild AD from controls by detecting differences in terms of errors, omissions, and perseverations while measuring ADL functional ability. %M 25658491 %R 10.2196/games.2778 %U http://games.jmir.org/2013/1/e1/ %U https://doi.org/10.2196/games.2778 %U http://www.ncbi.nlm.nih.gov/pubmed/25658491 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 6 %P e104 %T Silence is Golden: Effect of Encouragement in Motivating the Weak Link in an Online Exercise Video Game %A Irwin,Brandon C %A Feltz,Deborah L %A Kerr,Norbert L %+ Department of Kinesiology, Kansas State University, 1A Natatorium, Manhattan, KS, 66506, United States, 1 785 532 0660, bcirwin@k-state.edu %K active video games %K physical activity %K exercise %K Köhler effect %K partner exercise %K social influence %K group dynamics %K group exercise %K virtual partner %K intensity %K duration %K online video games %D 2013 %7 04.06.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the physical and mental health benefits, few adults meet US Department of Health and Human Services physical activity guidelines for exercise frequency, intensity, and duration. One strategy that may increase physical activity duration is exercising with an Internet partner (ie, someone who is virtually present, as in video chat). Internet partners help people overcome many barriers associated with face-to-face exercise groups (eg, time, coordinating schedules, social physique anxiety). Past research examining individual performance in groups suggests that an increase in effort occurs when performing a task conjunctively, ie, when a participant is (1) less capable than fellow group members, and (2) participants efforts are particularly indispensable for group success (ie, where the group’s potential productivity is equal to the productivity of its least capable member). This boost in effort is more commonly known as the Köhler effect, named after the German psychologist who first observed the effect. While encouragement between group members is common practice in face-to-face group exercise, the effect of encouragement between partners exercising conjunctively across the Internet is unknown. Objective: To examine the impact of exercising alone, compared to exercising conjunctively with an Internet partner, both with and without encouragement, on exercise persistence (primary outcomes) and secondary psychosocial outcomes (self-efficacy, enjoyment, exercise intention). Methods: Participants were recruited online and face-to-face from the campus of Michigan State University. With the assistance of the experimenter, participants (n=115) played an exercise video game in a laboratory, performing a series of five abdominal plank exercises where they were asked to hold the plank for as long as possible (Time 1). They were then randomized to a condition (Individual, Partner-without-encouragement, or Partner-with-encouragement), where they performed the exercises again (Time 2). The impact of condition on the primary outcome measures and secondary outcome measures were evaluated using a 2 (Gender) x 3 (Condition) ANOVA on change scores (Time 2-Time 1). Results: Those who exercised in online teams (n=80) exercised significantly longer (time=78.8s, P<.001) than those who worked individually (n=35). However, exercise duration was shorter when one’s more capable partner gave verbal encouragement (n=55) than when s/he did not (n=25) (a mean difference of 31.14s). These increases in effort were not accompanied by altered task self-efficacy, enjoyment of the task, or intention to exercise in the future. Conclusions: Exercising conjunctively with an Internet partner can boost one’s duration of exercise. However, encouragement from the stronger to the weaker member can mitigate these gains, especially if one perceives such comments being directed at someone other than themselves. To boost exercise duration, Internet-based physical activity interventions involving group interaction should make relative abilities of participants known and communication clear. %M 23732514 %R 10.2196/jmir.2551 %U http://www.jmir.org/2013/6/e104/ %U https://doi.org/10.2196/jmir.2551 %U http://www.ncbi.nlm.nih.gov/pubmed/23732514 %0 Journal Article %@ 1923-2195 %I Gunther Eysenbach %V 2 %N 1 %P e1 %T InSpire to Promote Lung Assessment in Youth: Evolving the Self-Management Paradigms of Young People With Asthma %A Elias,Pierre %A Rajan,Nithin O %A McArthur,Kara %A Dacso,Clifford C %+ The Abramson Center for the Future of Health, The Methodist Hospital Research Institute, 6565 Fannin, MGJ 3012, Houston, TX, 77030, United States, 1 713 202 2462, kmcarthur@tmhs.org %K pediatric asthma %K chronic disease management %K mobile phones %K spirometry %K gamification %D 2013 %7 21.05.2013 %9 Original Paper %J Med 2.0 %G English %X Background: Asthma is the most common chronic disease in childhood, disproportionately affecting urban, minority, and disadvantaged children. Individualized care plans supported by daily lung-function monitoring can reduce morbidity and mortality. However, despite 20 years of interventions to increase adherence, only 50% of US youth accurately follow their care plans, which leads to millions of preventable hospitalizations, emergency room visits, and sick days every year. We present a feasibility study of a novel, user-centered approach to increasing young people’s lung-function monitoring and asthma self-care. Promoting Lung Assessment in Youth (PLAY) helps young people become active managers of their asthma through the Web 2.0 principles of participation, cocreation, and information sharing. Specifically, PLAY combines an inexpensive, portable spirometer with the motivational power and convenience of mobile phones and virtual-community gaming. Objective: The objective of this study was to develop and pilot test InSpire, a fully functional interface between a handheld spirometer and an interactive game and individualized asthma-care instant-messaging system housed on a mobile phone. Methods: InSpire is an application for mobile smartphones that creates a compelling world in which youth collaborate with their physicians on managing their asthma. Drawing from design-theory on global timer mechanics and role playing, we incentivized completing spirometry maneuvers by making them an engaging part of a game young people would want to play. The data can be sent wirelessly to health specialists and return care recommendations to patients in real-time. By making it portable and similar to applications normally desired by the target demographic, InSpire is able to seamlessly incorporate asthma management into their lifestyle. Results: We describe the development process of building and testing the InSpire prototype. To our knowledge, the prototype is a first-of-its kind mobile one-stop shop for asthma management. Feasibility testing in children aged 7 to 14 with asthma assessed likability of the graphical user interface as well as young people’s interest in our incentivizing system. Nearly 100% of children surveyed said they would play games like those in PLAY if they involved breathing into a spirometer. Two-thirds said they would prefer PLAY over the spirometer alone, whereas 1/3 would prefer having both. No children said they would prefer the spirometer over PLAY. Conclusions: Previous efforts at home-monitoring of asthma in children have experienced rapid decline in adherence. An inexpensive monitoring technology combined with the computation, interactive communication, and display ability of a mobile phone is a promising approach to sustainable adherence to lung-function monitoring and care plans. An exciting game that redefines the way youth conduct health management by inviting them to collaborate in their health better can be an incentive and a catalyst for more far-reaching goals. %M 25075232 %R 10.2196/med20.2014 %U http://www.medicine20.com/2013/1/e1/ %U https://doi.org/10.2196/med20.2014 %U http://www.ncbi.nlm.nih.gov/pubmed/25075232 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 5 %P e80 %T Evaluation of a Web-Based Social Network Electronic Game in Enhancing Mental Health Literacy for Young People %A Li,Tim MH %A Chau,Michael %A Wong,Paul WC %A Lai,Eliza SY %A Yip,Paul SF %+ School of Business, The University of Hong Kong, 8/F K K Leung Building, Pokfulam Road, Hong Kong, , China (Hong Kong), 852 39171014, mchau@business.hku.hk %K digital game-based learning %K mental health literacy %K social networking sites %K motivation %D 2013 %7 15.05.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet-based learning programs provide people with massive health care information and self-help guidelines on improving their health. The advent of Web 2.0 and social networks renders significant flexibility to embedding highly interactive components, such as games, to foster learning processes. The effectiveness of game-based learning on social networks has not yet been fully evaluated. Objectives: The aim of this study was to assess the effectiveness of a fully automated, Web-based, social network electronic game on enhancing mental health knowledge and problem-solving skills of young people. We investigated potential motivational constructs directly affecting the learning outcome. Gender differences in learning outcome and motivation were also examined. Methods: A pre/posttest design was used to evaluate the fully automated Web-based intervention. Participants, recruited from a closed online user group, self-assessed their mental health literacy and motivational constructs before and after completing the game within a 3-week period. The electronic game was designed according to cognitive-behavioral approaches. Completers and intent-to-treat analyses, using multiple imputation for missing data, were performed. Regression analysis with backward selection was employed when examining the relationship between knowledge enhancement and motivational constructs. Results: The sample included 73 undergraduates (42 females) for completers analysis. The gaming approach was effective in enhancing young people’s mental health literacy (d=0.65). The finding was also consistent with the intent-to-treat analysis, which included 127 undergraduates (75 females). No gender differences were found in learning outcome (P=.97). Intrinsic goal orientation was the primary factor in learning motivation, whereas test anxiety was successfully alleviated in the game setting. No gender differences were found on any learning motivation subscales (P>.10). We also found that participants’ self-efficacy for learning and performance, as well as test anxiety, significantly affected their learning outcomes, whereas other motivational subscales were statistically nonsignificant. Conclusions: Electronic games implemented through social networking sites appear to effectively enhance users’ mental health literacy. %M 23676714 %R 10.2196/jmir.2316 %U http://www.jmir.org/2013/5/e80/ %U https://doi.org/10.2196/jmir.2316 %U http://www.ncbi.nlm.nih.gov/pubmed/23676714 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 5 %P e81 %T Prevalence of Behavior Changing Strategies in Fitness Video Games: Theory-Based Content Analysis %A Lyons,Elizabeth Jane %A Hatkevich,Claire %+ Institute for Translational Sciences, School of Medicine, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0342, United States, 1 409 772 1917, ellyons@utmb.edu %K video game %K theory %K content analysis %K fitness %K physical activity %K exergame %D 2013 %7 07.05.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Fitness video games are popular, but little is known about their content. Because many contain interactive tools that mimic behavioral strategies from weight loss intervention programs, it is possible that differences in content could affect player physical activity and/or weight outcomes. There is a need for a better understanding of what behavioral strategies are currently available in fitness games and how they are implemented. Objective: The purpose of this study was to investigate the prevalence of evidence-based behavioral strategies across fitness video games available for home use. Games available for consoles that used camera-based controllers were also contrasted with games available for a console that used handheld motion controllers. Methods: Fitness games (N=18) available for three home consoles were systematically identified and play-tested by 2 trained coders for at least 3 hours each. In cases of multiple games from one series, only the most recently released game was included. The Sony PlayStation 3 and Microsoft Xbox360 were the two camera-based consoles, and the Nintendo Wii was the handheld motion controller console. A coding list based on a taxonomy of behavioral strategies was used to begin coding. Codes were refined in an iterative process based on data found during play-testing. Results: The most prevalent behavioral strategies were modeling (17/18), specific performance feedback (17/18), reinforcement (16/18), caloric expenditure feedback (15/18), and guided practice (15/18). All games included some kind of feedback on performance accuracy, exercise frequency, and/or fitness progress. Action planning (scheduling future workouts) was the least prevalent of the included strategies (4/18). Twelve games included some kind of social integration, with nine of them providing options for real-time multiplayer sessions. Only two games did not feature any kind of reward. Games for the camera-based consoles (mean 12.89, SD 2.71) included a greater number of strategies than those for the handheld motion controller console (mean 10.00, SD 2.74, P=.04). Conclusions: Behavioral strategies for increasing self-efficacy and self-regulation are common in home console fitness video games. Social support and reinforcement occurred in approximately half of the studied games. Strategy prevalence varies by console type, partially due to greater feedback afforded by camera-based controllers. Experimental studies are required to test the effects of these strategies when delivered as interactive tools, as this medium may represent an innovative platform for disseminating evidence-based behavioral weight loss intervention components. %M 23651701 %R 10.2196/jmir.2403 %U http://www.jmir.org/2013/5/e81/ %U https://doi.org/10.2196/jmir.2403 %U http://www.ncbi.nlm.nih.gov/pubmed/23651701 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 15 %N 3 %P e51 %T Development and Testing of a Multidimensional iPhone Pain Assessment Application for Adolescents with Cancer %A Stinson,Jennifer N %A Jibb,Lindsay A %A Nguyen,Cynthia %A Nathan,Paul C %A Maloney,Anne Marie %A Dupuis,L Lee %A Gerstle,J Ted %A Alman,Benjamin %A Hopyan,Sevan %A Strahlendorf,Caron %A Portwine,Carol %A Johnston,Donna L %A Orr,Mike %+ The Hospital for Sick Children, 555 University Ave, Toronto, ON, , Canada, 1 416 813 8501 ext 4514, jennifer.stinson@sickkids.ca %K neoplasms %K pain %K child %K adolescent %K youth %K cellular phone %K game %D 2013 %7 08.03.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary. Objective: Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer. Methods: We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app. Results: Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete. Conclusions: A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing. %M 23475457 %R 10.2196/jmir.2350 %U http://www.jmir.org/2013/3/e51/ %U https://doi.org/10.2196/jmir.2350 %U http://www.ncbi.nlm.nih.gov/pubmed/23475457 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 2 %N 1 %P e5 %T InsuOnline, a Serious Game to Teach Insulin Therapy to Primary Care Physicians: Design of the Game and a Randomized Controlled Trial for Educational Validation %A Diehl,Leandro Arthur %A Souza,Rodrigo Martins %A Alves,Juliano Barbosa %A Gordan,Pedro Alejandro %A Esteves,Roberto Zonato %A Jorge,Maria Lúcia Silva Germano %A Coelho,Izabel Cristina Meister %+ Departamento de Clínica Médica, Centro de Ciências da Saúde (CCS), Universidade Estadual de Londrina (UEL), Av. Robert Koch, 60, Londrina, PR, 86038-350, Brazil, 55 4333712234, drgaucho@yahoo.com %K Diabetes Mellitus %K Insulin %K Video Games %K Medical Education %K Educational Technology %K Continuing Medical Education %D 2013 %7 21.01.2013 %9 Proposal %J JMIR Res Protoc %G English %X Background: Physicians´ lack of knowledge contributes to underuse of insulin and poor glycemic control in adults with diabetes mellitus (DM). Traditional continuing medical education have limited efficacy, and new approaches are required. Objective: We report the design of a trial to assess the educational efficacy of InsuOnline, a game for education of primary care physicians (PCPs). The goal of InsuOnline was to improve appropriate initiation and adjustment of insulin for the treatment of DM. InsuOnline was designed to be educationally adequate, self-motivating, and attractive. Methods: A multidisciplinary team of endocrinologists, experts in medical education, and programmers, was assembled for the design and development of InsuOnline. Currently, we are conducting usability and playability tests, with PCPs and medical students playing the game on a desktop computer. Adjustments will be made based on these results. An unblinded randomized controlled trial with PCPs who work in the city of Londrina, Brazil, will be conducted to assess the educational validity of InsuOnline on the Web. In this trial, 64 PCPs will play InsuOnline, and 64 PCPs will undergo traditional instructional activities (lecture and group discussion). Knowledge on how to initiate and adjust insulin will be assessed by a Web-based multiple choice questionnaire, and attitudes regarding diabetes/insulin will be assessed by Diabetes Attitude Scale 3 at 3 time points—before, immediately after, and 6 months after the intervention. Subjects´ general impressions on the interventions will be assessed by a questionnaire. Software logs will be reviewed. Results: To our knowledge, this is the first research with the aim of assessing the educational efficacy of a computer game for teaching PCPs about insulin therapy in DM. We describe the development criteria used for creating InsuOnline. Evaluation of the game using a randomized controlled trial design will be done in future studies. Conclusions: We demonstrated that the design and development of a game for PCPs education on insulin is possible with a multidisciplinary team. InsuOnline can be an attractive option for large-scale continuous medical education to help improving PCPs´ knowledge on insulin therapy and potentially improving DM patients´ care. Trial Registration: Clinicaltrials.gov: NCT01759953; http://clinicaltrials.gov/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6Dq8Vc7a6). %M 23612462 %R 10.2196/resprot.2431 %U http://www.researchprotocols.org/2013/1/e5/ %U https://doi.org/10.2196/resprot.2431 %U http://www.ncbi.nlm.nih.gov/pubmed/23612462 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 14 %N 6 %P e167 %T Crowdsourcing Malaria Parasite Quantification: An Online Game for Analyzing Images of Infected Thick Blood Smears %A Luengo-Oroz,Miguel Angel %A Arranz,Asier %A Frean,John %+ Biomedical Image Technologies group, DIE, ETSI Telecomunicación, Universidad Politécnica de Madrid, CEI Moncloa UPM-UCM, ETSIT, Av. Complutense 30, Madrid, 28040, Spain, 34 913366827, maluengo@die.upm.es %K Crowdsourcing %K Malaria %K Image Analysis %K Games for Health %K Telepathology %D 2012 %7 29.11.2012 %9 Original Paper %J J Med Internet Res %G English %X Background: There are 600,000 new malaria cases daily worldwide. The gold standard for estimating the parasite burden and the corresponding severity of the disease consists in manually counting the number of parasites in blood smears through a microscope, a process that can take more than 20 minutes of an expert microscopist’s time. Objective: This research tests the feasibility of a crowdsourced approach to malaria image analysis. In particular, we investigated whether anonymous volunteers with no prior experience would be able to count malaria parasites in digitized images of thick blood smears by playing a Web-based game. Methods: The experimental system consisted of a Web-based game where online volunteers were tasked with detecting parasites in digitized blood sample images coupled with a decision algorithm that combined the analyses from several players to produce an improved collective detection outcome. Data were collected through the MalariaSpot website. Random images of thick blood films containing Plasmodium falciparum at medium to low parasitemias, acquired by conventional optical microscopy, were presented to players. In the game, players had to find and tag as many parasites as possible in 1 minute. In the event that players found all the parasites present in the image, they were presented with a new image. In order to combine the choices of different players into a single crowd decision, we implemented an image processing pipeline and a quorum algorithm that judged a parasite tagged when a group of players agreed on its position. Results: Over 1 month, anonymous players from 95 countries played more than 12,000 games and generated a database of more than 270,000 clicks on the test images. Results revealed that combining 22 games from nonexpert players achieved a parasite counting accuracy higher than 99%. This performance could be obtained also by combining 13 games from players trained for 1 minute. Exhaustive computations measured the parasite counting accuracy for all players as a function of the number of games considered and the experience of the players. In addition, we propose a mathematical equation that accurately models the collective parasite counting performance. Conclusions: This research validates the online gaming approach for crowdsourced counting of malaria parasites in images of thick blood films. The findings support the conclusion that nonexperts are able to rapidly learn how to identify the typical features of malaria parasites in digitized thick blood samples and that combining the analyses of several users provides similar parasite counting accuracy rates as those of expert microscopists. This experiment illustrates the potential of the crowdsourced gaming approach for performing routine malaria parasite quantification, and more generally for solving biomedical image analysis problems, with future potential for telediagnosis related to global health challenges. %M 23196001 %R 10.2196/jmir.2338 %U http://www.jmir.org/2012/6/e167/ %U https://doi.org/10.2196/jmir.2338 %U http://www.ncbi.nlm.nih.gov/pubmed/23196001 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 13 %N 1 %P e4 %T Assessing the Acceptability and Usability of an Interactive Serious Game in Aiding Treatment Decisions for Patients with Localized Prostate Cancer %A Reichlin,Lindsey %A Mani,Nithya %A McArthur,Kara %A Harris,Amy M %A Rajan,Nithin %A Dacso,Clifford C %+ Abramson Center for the Future of Health, The Methodist Hospital Research Institute, 6550 Fannin, Suite 1011, Houston, TX 77030, 1 713 441 2750, CDacso@theabramsoncenter.org %K serious games %K prostate cancer %K shared decision-making %K usability %D 2011 %7 12.01.2011 %9 Original Paper %J J Med Internet Res %G English %X Background: Men diagnosed with localized prostate cancer face a potentially life-altering treatment decision that can be overwhelming. Enhancing patient knowledge through education can significantly reduce feelings of uncertainty while simultaneously increasing confidence in decision making. Serious games have been shown in other populations to increase health knowledge and assist with the health decision-making process. We developed an interactive serious game, Time After Time, which translates evidence-based treatment outcome data into an accessible and understandable format that men can utilize in their prostate cancer treatment decision-making process. The game specifically aims to raise men’s awareness and understanding of the impact of health-related quality of life issues associated with the major treatment options and to enrich their conversations with their health care providers. Objective: This study determined the acceptability and usability of the alpha version of Time After Time, an interactive decision aid for men diagnosed with localized prostate cancer, in order to inform future iterations of the serious game. Methods: The study employed a mixed methods approach to assess the acceptability and usability of the Time After Time serious game using qualitative focus groups and a quantitative Likert scale survey. Results: A total of 13 men who had already completed treatment for localized prostate cancer completed the survey and participated in focus group meetings. The majority of the study participants rated Time After Time as an appropriate decision tool for localized prostate cancer and verified that it meets its goals of increasing focus on side effects and generating questions for the patient’s health care team. However, participants also expressed concerns about game usability and the diversity of information covered regarding treatment options and potential treatment outcomes. Conclusions: Serious games are a promising approach to health education and decision support for older men. Participants were receptive to the idea of a serious game as a decision aid in localized prostate cancer. However, usability issues are a major concern for this demographic, as is clarity and transparency of data sources. %M 21239374 %R 10.2196/jmir.1519 %U http://www.jmir.org/2011/1/e4/ %U https://doi.org/10.2196/jmir.1519 %U http://www.ncbi.nlm.nih.gov/pubmed/21239374