A meta-analysis of serious digital games for healthy lifestyle promotion

“Other studies have indeed reported that the terminology of theories is not used in a consistent manner across interventions and that one term may be used to represent different techniques, as well as that different labels may be used for the same technique (Michie et al., 2011a).”

“Random-effects Hedges' g was applied to indicate effect size, correcting for small sample sizes (Hedges, 1981).”

“…lifestyles comprise an array of potentially modifiable behaviors that can prevent a wide range of diseases, such as some cancers, cardiovascular diseases, stroke, dementia, mental illness, and diabetes (Fratiglioni et al., 2004; Kim et al., 2012; Lopez et al., 2006; Peel et al., 2005).”

“Meta-regression (methods-of-moments procedure) was performed for continuous moderators (Thompson and Higgins, 2002), where the slope ( β ) and its p-value indicated the importance of this moderator in understanding linear changes in effect sizes.”

“A recent meta-analysis of 64 games promoting healthy lifestyles revealed games had statistically significant effects on behaviors, stronger effects on behavior determinants, and even effects on health outcomes, although these effects were weaker.(33) A systematic review of 11 videogames for diabetes education revealed…”

“Unlike other teaching methods, game-based teaching can be designed with specific socio-cultural content when delivered in countries where sex education discussions in public are taboo [30].”

“Thus far, eHealth and mHealth research related to physical activity, sedentary behavior, and diet has been summarized in several studies that focused on use and effectiveness of different technologies such as mobile phone and/or SMS (short message service) text messaging [15-18], digital games [19,20], the Internet [2…”

“Although the scientific evaluation of serious games precludes making conclusive statements about their impact on “real-world” behaviors, several controlled trials of serious games have shown to affect these behaviors in diverse patient groups [42].”

“Researchers should (1) assess intrinsic and extrinsic motivations, (2) distinguish between intrinsic motivators to play the game or change behaviors, (3) analyze the effect of the reward system as well as the gamified intervention on motivation, (4) evaluate their effects across population ages, and (5) evaluate their…”

“…(King and Tester 1999), promote personal wellness and engage in preventive behaviors (Grimes et al. 2010; Consolvo et al. 2009; Orji et al. 2013; DeSmet et al. 2014), avoid risky sexual behavior (Jemmott et al. 1992; Duncan et al. 2014), and manage chronic diseases (Brownson and Kumanyika 2007;…”

“The recent meta-analysis of serious games for healthy lifestyle promotion, which showed games were effective, also investigated the role of theory, individual tailoring, and sample and study characteristics in game effectiveness [2].”

“Additionally, the same methodological problems of ecological invalidity and prescriptive, lab-based play evaluations in the 1970s [2] are apparent in some contemporary Serious Games evaluative studies [6, 7].”

“This article is part of a larger project on the effectiveness of serious digital games on healthy lifestyles.(29) The present article focused on the subset of games that aimed to improve sexual health behavior (e.”

“Serious games can be designed to modify user attitudes, perceptions, knowledge and skills (9), and needs to be tailored to the targeted sociodemographic group (10).”

“Overall, despite occasional critique, existing evidence has shown that digital games are a promising and capable medium for instruction and learning across contexts and age groups (Clark et al. 2016; DeSmet et al. 2014; Merchant et al. 2014).”

“A zeitgeist has emerged in the medical and educational fields for applied or “serious” games as tools for enhancing medical care [58-61].”

“For instance, a study [40] found that adolescents consumed fewer unhealthy munchies after playing a serious game designed to improve dietary habits.”

“Although the research on gaming approaches to addressing daily life functioning of children is limited, several controlled trials of serious games developed for other patient groups have been shown promise of impacting ‘‘real world’’ behaviors.(21)”

“26 As the development of SGs can be quite expensive and time consuming, describing which DEs have been integrated in the development of SGs for healthcare professionals and students, as well as their impact on engagement and educational outcomes, could help in the efficient development of future…”

“[87]) or including game-like features, which might also increase the likelihood of habit formation [88].”

“19 Consistently, in the present review, most of the included serious games had some form of positive effect on mental disorder symptoms.”

“17–20 The grand picture is still missing.”

“Additional design elements were included to explore other potentially engaging elements supporting behavior change and to facilitate the creative process related to users’ requirements, preferences, and ideas to meet their needs [23,86-90].”

“This in line with the results of other reviews which also reported unexpectedly small effects of SGs on self-efficacy (46, 50).”

“The effect of social norms specifically on the intention to use LSP has been demonstrated in the context of learning healthy habits (DeSmet et al., 2014) and learning improvement (Hanus & Fox, 2014; Mekler, Brühlmann, Tuch & Opwis, 2017).”

“unter Einbezug von 54 Studien die größten Effekte beim Wissenserwerb feststellen, während Connolly und Kollegen in ihrer Literaturübersicht zudem empirische Belege für die positiven Auswirkungen auf kognitive, wahrnehmungsbezogene, verhaltensbezogene, affektive und motivationale Aspekte fanden [27, 28].”

“Indeed, a recent meta-analyses examining the role of video games in the promotion of lifestyle changes, suggested that serous gaming is effective, albeit to a limited extend (126, 127).”

“Yet, using serious games (ie, games with the goal to educate people rather than merely entertain them) [24,25] to change health behaviors could lead to more attraction and participation [26,27], increased knowledge, and changed attitudes and behavior [24,25].”

“…of SGs, and developers in different fields and different research have different understanding and definition of SGs. Special games are different from common games for entertainment that are added to at least one explicit reality simulation additional motivation, also called serious purpose (3).”

“26,40 However, it is unclear whether other studies assessed these psychosocial outcomes or found negative results and did not report them.”

“A potential aid in correcting this lies in serious games, which have been shown to be able to educate and guide the behaviours of players [7].”

“…Altamimi and Skinner, 2012, Biddiss and Irwin, 2010, DeSmet et al., 2014, Gekker, 2012, Mark et al., 2008, Papastergiou, 2009, Peng et al., 2012], however, they have mostly focused on specific aspects, such as health objectives [DeSmet et al., 2014, Mark et al., 2008, Papastergiou, 2009], promoting”

“20 While several systematic reviews and/or meta-analyses have appeared on games for health, 6,21–24 and even included a few nutrition education games as a subcomponent, no review has appeared devoted to the consideration of games for nutrition education or dietary behavior change alone.”

“Ameta-analysis(DeSmet et al., 2014) using research on 64 different videogames targeting improvements in lifestyle indicatedthatusinggameshadbeneficialconsequencesforhealth.”

“Several available electronic empowerment-promoting tools, including compact disk read-only memory, web/Internet-based interventions, and video game technology provide informative sources for education and empowerment with widespread appeal (6, 21, 29, 34, 116, 117).”

“A metaanalysis of the research published on 54 games for healthy lifestyle promotion revealed small positive effects on healthy lifestyles, their determinants, and even on some clinical outcomes.(3) Similar benefits have been documented for nutrition education,(4) mental health,(5) and knowledge in regard to asthma,(6…”

“8 42 For all qualifying articles, relevant studies were identified independently by screening titles and abstracts, by one re-searcher and one-third by a second researcher.”

“Also consistent with DeSmet et al. (2014), our study found that NGBIs that were informed by narrative and learning theories yielded greater effect sizes than those informed by behavioral change theories.”

“Serious games, that is, games designed to achieve an outcome in addition to entertainment, have been developed to enhance health outcomes(8) and have been demonstrated to yield broad positive effects.(9) Serious games have influenced selfefficacy, or confidence, for doing a behavior (e.”

“These findings argue for continued efforts to utilize virtual scenarios to promote public health (see Baranowski, Buday, Thompson, & Baranowski, 2008; DeSmet et al., 2014), but they each share a limitation that the current project seeks to address.”

“This agrees with a meta-analysis of serious digital games for healthy lifestyle promotion [46].”

“Similarly, DeSmet et al.(23) emphasized the effectiveness of serious digital games either as a standalone or as a component of a multidimensional program to increase knowledge and encourage behaviors that might lead to a healthy lifestyle.”

“These reviews have also included a wide range of delivery modalities outside of what would be considered ‘games’ and delivered across a wide range of age groups (DeSmet et al., 2014).”

“18,19 Given that no research has yet been conducted into the effectiveness of serious games on the TPB predictors of cybersecurity behavior, and no study has yet investigated the effectiveness of serious games on all TPB factors, this study attempts to fill this gap in the literature.”

“…al., 2011) Tailoring related to higher effects, but only when tailored to socio-demographics, in a meta-analysis of 54 serious health game studies (DeSmet, Van Ryckeghem, et al., 2014) Tailoring is assumed to increase the extent to which game-based learning is experienced as fun (Lieberman, 2009).”

“The use of ‘serious games’ is an increasingly effective method in educating health professionals, and improving engagement, user retention, knowledge, and cooperation [10]–[11].”

“Previous reviews suggested that serious games had small positive effects on health-related behaviors and their determinants.(4) For example, exergaming, which requires rigorous physical exercise, was effective in increasing or substituting physical activity in adults in the short VC The Author(s) 2020.”

“Previous reviews which, however, did not concentrate on health promotion and disease prevention, underline our findings in a very general way [11, 12, 40, 41].”

“A meta-analysis of serious games for healthy lifestyle promotion was found to be appealing to individuals regardless of age or gender, showing this could be an intervention suitable for a more general audience than just children [20].”

“DeSmet et al [19] advocate the use of dual theoretical frameworks, stressing the importance of a theoretical foundation in both behavioral prediction and game theories.”

“Although there is a burgeoning literature on digital games that aims to promote a healthy lifestyle (DeSmet et al., 2014; Van ’ t Riet, Crutzen, & Lu, 2014) and digital games that are used in education and training contexts (Wouters, van Nimwegen, van Oostendorp, & Van der Spek, 2013), research on…”

“…differ in their interpretation of leisure (Churchill et al., 2007), and also that the choice of leisure activities improves family functioning and communications (Shaw & Dawson, 2001; Zabriskie & McCormick, 2001) or when serious leisure is performed has healthy results (DeSmet et al., 2014).”

“Further, in 2014, a meta-analysis of 54 serious digital game studies for healthy lifestyle promotion reviewed the overall effectiveness of serious digital games on healthy lifestyle [15], and demonstrated small positive effects on healthy lifestyle promotion outcomes.”

“[38] found that the average effect size for behaviour change was positive but small, indicating overall improvement in the adoption of healthy lifestyle practices as a result of engagement.”

“A recent meta-analysis of research in which this method was used for healthy lifestyle promotion concluded digital gaming is effective as stand-alone or a multi-component program and appeals to diverse population regardless of age or gender [9].”

“encouraging users to adopt a healthier lifestyle ( [19]).”

“A meta-analysis identified 64 serious games that promote healthy life styles, revealing that the games had a statistically significant effect on behavior(34).”

“Finally, feedback may have undermined nurses’ intrinsic motivation to perform PA because providing social pressures and rewards can give rise to extrinsic motivation (Deci and Ryan, 2012; DeSmet et al., 2014).”

“Some factors that could justify this result is the rather brief duration of the interventions, a higher resistance of less physically active players to the PA messages diffused in interventions [52], or the need to integrate the game intervention in a broader multi-component program [16].”

“A meta-analysis showed that serious games have a small but positive effect on healthy lifestyles and knowledge improvement [15].”

“Gamification techniques are especially effective when they are tailored toward an individual’s particular preferences and needs (ie, personalized) [12] because behavior change techniques that motivate one person may not appeal to someone else [16].”

“promotion [27] focused on four categories of health behaviour: 1) diet and physical activity, 2) health responsibility and maintenance, 3) social behaviour, and 4) and mental health.”

“Literature reviews show that there are several studies implying the benefit of serious games in general [3,6,25] or regarding different aspects, for instance as a tool to support learning processes or to induce health-related behaviour changes [4,7,9,11,26].”

“Threats to pediatric health risk from the double burden of overweight and malnutrition or undernutrition heightens the need to influence children’s dietary lifestyle habit formation through evidence-based, scalable, digital therapeutic methods [3].”

“This risks unclear game mechanisms, conflicting frameworks of action, and questionable results wrought from unclear study designs [45,48,49].”

“Academia and industry have recently grasped QoE’s value in applications’ performance and have gone from a purely QoS-to a QoE-based analysis [25, 26].”

“Previous review articles have noted a need for improved research methods and expanded clinical applicability [14-17].”

“47,51 The topics included dental caries prevention, 11,47,48 diet, 11,38,47,49,50 oral hygiene, 12,45– 47,50,51,53 other oral health habits, 12,48 dental eruption, and dentition.”

“While a significant portion of studies (38%) did not report any theoretical foundation, some studies may only mention a theory, but not report theory application to game design [37].”

“It is well known that health promotion and disease prevention programs suffer from poor adherence and compliance by participants, often because they are designed without addressing the target group [14,53].”

“Exergames offer promises because they provide high motivation and engagement while delivering more “healthy” gaming experiences [4] than the classic handheldbased sedentary scenario.”

“There is a gap in the literature regarding maintenance of health behaviours, with few studies assessing the prolonged impact of digital games on health promotion(48,49).”

“These digital tools can not only be inexpensively and widely deployed, but also offer the potential to transfer knowledge and educate users in an interactive and engaging manner, which can lead to behavior change [34-36].”

“Already, there are several examples of video games successfully teaching youth health knowledge and skills (eg, in cancer treatment specifically [31] and healthy lifestyles in general [32]) and changing mental health stigma [33].”