Games in Health

António Sousa 1,2 *, Diogo Lajas 1,2, Lígia Sousa 1,2 and Maria Pinto 1,2 *

1 CIDES, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200 - 319 Porto, Portugal, 2 DCC, Faculdade de Ciências da Universidade do Porto, Rua do Campo Alegre 1055, 4169-007 Porto, Portugal

• {up201501635, up200901560, up198600733, up201402092, }@med.up.pt

What´s the role of games in health?

Abstract— The use of games in the health context is not a current and widespread practice by actors in various areas of health. However, over the past two decades have been conducted numerous reviews, meta-analyzes and specific studies on the use of games, and respective types, in various contexts of medicine and health care in order to assess the scientific evidence the benefits of its use. This article aims to determine whether, in the context of the types of games applied to the health context, there is some kind that denotes promising results regarding its use as a tool or learning.

Keywords— health, games, exergames, serious games, casual games, educational games, persuasive games, therapy, psychotherapy, rehabilitation, treatment.

Introduction

Technological developments have led to a new dynamic in the use of games that goes beyond mere entertainment. Its use has been extended to various areas, such as in the health field. There has been the accession of users of various age groups ("from 8 to 80"), of both genders and various socio-economic conditions, increasing the number of families who acquires personal consoles or computers to run entertainment software [1].

The offer is varied, providing various types that allow the increasing of motivation, attention and knowledge, promoting physical activity and allowing to evaluate the effectiveness of the game through immediate feedback to the user. Thus, according to their characteristics and objectives, the games can be classified into the following types: exergames, serious games, persuasive games, educational games and casual games. Each game type can have valences which intersect with the other. In other words, beyond its main objective has consonants side effects with other types of game. The existence of these types of games coupled with the current technology allows doctors and therapists new opportunities for intervention and interaction with the respective patients. At this juncture there have been changes in the attempt to use games for purposes related to health, especially in the context of disease risk prevention, self-management of the disease, therapy and physical rehabilitation, behavioral intervention and in the context of health education [2].

In this context, in the present article we propose, with a systematic review, to assess the existence of some kind of game that by its scope, in terms of implementation and results thereof, might be used as therapy or learning tool. For such, an analysis of systematic review articles and articles resulting from specific studies of the application of certain game in certain areas of health was conducted. This article will be carried out to characterize each type of game, with examples of their application in one or more areas, as well as presenting a summary table with the application of the results of the various types of games in the health areas presented. Finally we present the discussion of this analysis and future work suggestions.

Methods

To become aware of new ideas and the most current guidelines to satisfy the scientific question is "which the state of the art of games for health?" a systematic review of the literature was performed. As search strategy were executed online literature searches. A preliminary investigation was carried out to choose the nomenclature of the terms for the implementation of the research information and what kind of studies were available. Adopting for the selection the following databases: PubMed, Scopus, IEEE Xplore, Google Scholar and Research Gate. As search strategy was used the following combination of terms and keywords: “games for health”, “exergames”, “serious games”, “casual games”, “educational games”, “persuasive games” with “therapy”, “psychotherapy”, “rehabilitation” and “treatment”.

The inclusion criteria were scientific articles in English and from 2010 to the present. Mendeley software was used to archive the articles found and to check for duplicates. The selection of items for study in question was performed manually in four different steps based on the inclusion criteria. In the first stage the researchers conducted a screening by title that demonstrate the use of specific games in a specific area of health, or review of articles that focus on the use of games in health.

In a second step, after a title selection, some articles have generated doubts, whereby the respective abstracts were read. They were then sought the full articles so far chosen. Was downloaded articles, using Pubmed, Scopus, IEEE Xplore, Google Scholar and Research Gate (there has been some requests to transfer to the authors, who sent them then by e-mail). Subsequently the full reading of the various documents was carried out, this reading were added a few items that were emerging in the citations that the reviewers found relevant to include in this study.

Figure 1 – Selection of studies

Game Types

A. Exergames

Are games designed to encourage physical exercise requiring physical activity of users ([3]and [4]). Does not include traditional video games that use only hand movement. They are regarded as synonyms of exergames terms: exertainment, video games with exercise, interactive video games with physical activity or active video games. In this type of game are applied technologies able to monitor the movement and body functioning, such as accelerometer, gyroscope, ergometer, pressure sensors as the dance pad and balance boards [5], heart rate monitors, cameras, (ex. eyeToy) and muscle activity detection sensors. The evolution in this type of game is sustained in the user's physical performance [5]. These types of games are immersive as it transforms the user as an integral character in the game [6]. The target audience of the generality of this type of games (Kinect Sports, WiiFit, DanceDanceRevolution®) comprises the various age groups, and some may be limited to people over 10 years (Just Dance) or specific to adolescents (DanceCentral) ([5], [4] and [7]).

The high popularity and the rapid spread of such games makes them easily accessible by various stakeholders in medical procedures and therapeutic. They have the ability to provide data on the physical location of the patient, to understand where the user is pointing with hand, finger or manipulated equipment. Allow to measure the amount of inferring motion, the amount of energy expended in an activity and allow capture the stability of movement during its execution.

Have as main advantages: motivation, immediate feedback, providing information about the game's progress, foster socialization in that allow sharing and dissemination of results and achievement of objectives ([4] and [7]). The progress in the game is based on the user's actual motion, allows the user registration information, the possibility of exercising/home therapy, possibility of measurement results, the promotion of cognitive function [8] and with attractive interfaces and easy to use.

Presents as main disadvantages some insecurity issues, injuries caused by very fast movements or requiring flexibility, balance and strength that are not consistent with the user, requiring monitoring during exercise ([8] and [7]), physical exercise in insufficient amount and quality [9], the lack of structured treatment plans [8] , there is some resistance to the use of the devices and consequently poor adhesion ([5] and [4]).

B. Serious games

Games whose goals go beyond mere entertainment. They have some entertaining features but have as main objective the educational aspect or training in various areas (such as health, education, military and medicine) subsequently applied in real contexts. Some of its features are the possibility of practical training, simulation, development techniques, the development of clinical reasoning [10], the acquisition of good practices and specific behaviors [11]. These types of games have already been applied in surgical practice, ethics, nursing, cardiology, nutrition, psychology and first aid. Allow the continued training of technicians in the areas of health at low cost, where it will slowly introduce content to assimilate rather than charge a large amount of information. Examples of games in this context are Oncology game, Burn Center or Pulse! [11] and [10]). The serious games facilitate the immersion of the player [12], have many difficulty levels with clear objectives. Typically the target audience is the group of health professionals. Its main advantages are the low cost of training, better results in learning relative to conventional methods, useful technology to train professionals and teach students in a safe environment, with greater confidence and less ethical problems ([13], The impact of video games on training surgeons in the 21st century, [11], [12] and [14]).

The main drawbacks are the lack of updates in technologies and content, loss of the interaction between the former-student or therapist-patient, longer learning times or longer therapy times, potential accessing inappropriate content and uncontrolled access, loss of social component [15] illusion of learning and reduced likelihood ([13] and [16]).

C. Educational games

Are games with a strong integrated educational component, launching alerts and reminders to signs, problems and solutions in various areas, including health, business or military area [16]. Enhance the creation of opportunities to practice innovative techniques and improve the technical capabilities inherent in working in health. Here game is used as a generic term that includes electronic devices, cards or specialized activities that provide frameworks for the integration of content and creating learning activities [17]. Examples of these types of games are The hypos at school, Lunch Crunch or Heart Sense [18].

Learning is centered on the student, increasing the self-evaluation capacity, developing fine motor skills, eye-hand coordination, improved visual attention, depth perception [19], increased memory in the short and long term [13], recognition and problem solving [13]. It reinforces the knowledge, bridges the gap between what is learned, their use involves students, challenges them and motivates them to learn hard and compact materials and helps them to become more responsible for their own learning process [17]. Some games require users to have some technical skills related to computers ([13], [16] and [14]).

Some disadvantages are related to the illusion of learning, ill-defined learning objectives [16] loss of interaction with teachers and peers and, in most of these types of games, some inefficiency of learning ([13] and [16]). The games have a positive impact on teaching and learning issues, however, the evaluation methodology does not capture the learning benefits that these games can provide [17].

D. Casual games

Are games with simple and affordable concepts, most of them free to use and a quick and simple onboarding to the end user. Able to attract very wide audience and of various age groups, with however the children and young people the preferred target audience [20]and [12]). Thus achieving a greater coverage in terms of audience, more potential and popularity, it is spread by ubiquitous platforms such as the internet sites and applications for mobile devices. It allows the game can be used in various locations such as the hospital, at home or in school, fostering the interaction of the patients themselves with their family and friends [20]. In this type of game, the history and its mechanics can be used to convey information about diseases, clarify the importance and mechanisms of disease and treatment to promote adherence to the same, as is the case With Cytarius [20] or OrderUp [12].

Presents as main advantages its simplistic nature, conducive to integration of users in processes of change, good usability and accessibility, positive feedback enables high responsiveness to the game and is appealing to large audiences [12].
Some disadvantages inferred from reading the article M.Ellis et al. Indicate that child aesthetics of most games of this type can be inappropriate for older audience, too simplistic, short playing time, not brings concepts or complex stories and simple game mechanics limiting its application to convey complex content [12].

E. Persuasive games

The persuasive games are aimed at changing habits of underhanded way of the players ([21], [12] and [22]) most of the times based on behavioral theories [21] and theories about the kinds of game users ([21] and [12]), for example, the theory Bartle's that ranks the players in 4 types (Achiever, Explorer, Socializer and Killer) [21]. Some of these games seek to take advantage of the motivation patterns of the players to be able to translate that motivation into behavioral changes and attitudes in real life, voluntary and beneficial to the health of the player. An example of this type of game is My Healthy Foods.
When this type of game is developed based on behavioral theories has a higher success rate compared to developed without such theoretical or based on general guidelines [21].

The main disadvantage lies in the fact that most of these games have not based on theories about what motivates behavioral changes in patients so that they acquire healthy behaviors. Most of these games have not take into account the heterogeneity of players and lack of methodologies for the practical application of persuasion mechanisms at play [21].
The main advantage lies in the fact that induce changes in habits and attitudes, subtly and less intrusive, without the users are aware of them [12].

Health Application Areas

A. Prevention of disease risk

For this line were analyzed and collected the results aimed at promoting healthy lifestyles and behavior, working mainly in the prevention of specific diseases. The scope of these games are at-risk populations and are aimed at promoting a healthy diet [23], physical exercise ([5] and [15]), safe sexual behavior, anti- smoking, injury prevention, early prevention of heart attack [2], obesity prevention [10], prevention of oral health [11] and maintenance of cognitive performance ([3], [24] and [25]).

B. Self-management of disease

In this context were collected data from articles results whose main focus was self-management of the disease to develop in patient’s ability to handle chronic diseases such as asthma, diabetes, cancer, cardiovascular or psychiatric disorders. The games used in this aspect also allow greater adherence to treatment since they have elements that enhance the distraction of the disease and better management of pain in medical treatments and procedures ([11] and [2]), a better understanding of the disease and acceptance thereof [15], increased levels of motivation [23] and a decrease in anxiety levels in medical procedures [26].

C. Therapy and physical rehabilitation

With regard to physical rehabilitation therapy, were analyzed and collected results from articles intended to demonstrate the application of games in patients with specific pathologies related with reduced physical ability, or none, resulting from physical or neurological injuries. The use of games is an aid in physical therapy and cognitive rehabilitation ([11], [26], [4], [23], [10], [27], [7]). , improves the levels of cardiovascular fitness and coordination ([20] e [25]), allows also improve motor-sensory function ([28], [29] and [30]). One of the interesting aspects is that the various types of games that can be applied in this context are designed to transmit the patient's motivation to play, in a systematic and repetitive manner over a period of time sufficient to allow the achievement of concrete results in its therapy.

D. Behavioral intervention

On behavioral intervention were collected results in studies where emphasis is given to the use of games as a mechanism of habits and behavior changes. The various types of games are applicable to patients with risk behavior, encouraging the acquisition of healthy habits such as physical activity and healthy eating ([3], [6], [25], [23] and [10]). The application of these games featuring improvements in communication and teamwork, improves socialization skills and increases the motivation of patients ([11] and [23]), allowing them to internalize the good and bad practice in order to instill behavioral change [25].

E. Health education

In terms of medical education were analyzed and collected results of studies that focus on the use of games as medical training tools and training for medical students and health professionals. The types of games available in this context typically have low-cost approaches, absent of risk and easy and active training [2]. Allows a gradual learning [25], the acquisition of clinical skills, surgical and medical practice ([13], [11], [23] and [17]) as well as the reduction in learning time for some traditional methods [14]. It also allows increase motivation and improve academic results ([31] and [26]). In this type of games, the learning outcomes are affected by how teaching methods are integrated into the games, not by the games themselves [17].

On table I are shown concrete results deriving from the collection of information from various articles analyzed, where it considered the application of each type of games and the results achieved under each of the health issue addressed. As can be seen, there are results common to many types of games, regardless of their primary objective, especially the acquisition of habits and healthy lifestyles, including the promotion of physical activity habits and proper nutrition, both adjusted to the characteristics of patient condition. Thus, combining the playful aspect of the game to your particular goal is possible to achieve various results related to behavioral changes and a better knowledge of the disease (by the patient) that facilitate self-management of chronic diseases, prevent or delay the onset of diseases in certain risk age groups, allowing the reduction of the therapeutic, medical or hospital interventions and consequently a better patient quality of life.

Table 1 – Summary table

Discussion

In the performed reading there is a change in the interpretation and application of the games. Gradually have been losing a negative reputation, where its use was associated with poorer school performance, aggressive behavior, low socialization of players, childhood obesity, musculoskeletal disorders, increased blood pressure, heart rate and high levels of stress hormones. Over the years the use of games in various contexts, including in the areas of health has to deconstruct these ideas and providing new opportunities for interaction between patients and health professionals.

It notes that each type of game promotes health, although this objective is achieved in different ways. For example, casual games are best suited to users and patients with high mobility and low availability of time, since they are easily accessible from mobile devices and do not require much attention span. On the other hand, serious games and exergames that require more usage time to take advantage of the game. The attention span needed to assimilate the logic of the game in conjunction with other factors determines the target audience. For example, children have a preference for exergames at the expense of serious games because they are more fun and less pedagogic. Senior value the knowledge and learning of serious games. The casual games are enjoyed across the board by the various age groups. Typically the educational games are targeted to specific groups, to acquire certain technical skills, so its use and the related effects do not have a considerable impact. On the other hand, the persuasive games, with its enticing features, but subtle, tend to have greater acceptance and use in risk groups.

From the survey conducted there is some evidence that exergames and serious games are more acceptable and enjoyable games, where the greater engagement with doctors or therapists are associated with better results. There is also a greater investment in terms of studies and reviews, both for its appealing features, whether the therapeutic effects that start to show and the greater scope in terms of audience and application areas. However despite some evidence is found of their use as efficient tools and potential for improved health in a variety of areas and to a variety of demographic groups, yet there is no guarantee that games can influence behavior or improve the health status of patients. The absence of evidence in scientific studies and reviews analyzed due to the fact that use little controlled study methods, with reduced size groups, bit monitoring time during and after treatment and evaluation parameters ambiguous. On the other side it is not easy to compare and conclude that a game approach is comparable with the other in terms of being different content, in terms of objectives and results.

Taking into account the wide dissemination, growth and popularity of the games is necessary to evaluate effectively the potential benefits of health games. Therefore it is essential that in future are made more rigorous studies which apply theoretical and structured models with standard tools for measuring the parameters under study, data selection criteria well defined and the application of optimized quality measures such as randomized studies and case-control studies.

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