Gamification in eHealth for Chronic Disease Self-Management in Youth: A Systematic Review.

This systematic review primarily aims to provide a summary of the game mechanics implemented in eHealth tools supporting young people's self-management of their chronic diseases. This review secondarily investigates the rationale for implementing game mechanics and the effects of these tools. A systematic search was conducted in Embase, Medline, PsycINFO, and Web of Science, from inception until August 30, 2022. Studies were eligible if focus was on the utilization of gamification in eHealth self-management interventions for young people (age = 10-25 years) with chronic diseases. Primary quantitative, qualitative, and mixed-method studies written in English were included. We identified 34 eHealth tools, of which 20 (59%) were gamified tools and 14 (41%) were serious games. We found that 55 unique game mechanics were implemented. The most commonly used were rewards (50%), score (44%), creative control (41%), and social interaction (32%). In comparison with gamified tools, the number and diversity of game mechanics applied were higher in serious games. For most tools (85%), a general rationale was provided for utilizing gamification, which often was to promote engaging experiences. A rationale for using specific game mechanics was less commonly provided (only for 45% of the game mechanics). The limited availability of experimental research precludes to test the effectiveness of using gamification in eHealth to support self-management in young people with chronic diseases. In this study, we highlight the importance of reporting the rationale for utilizing specific game mechanics in eHealth tools to ensure a proper alignment with evidence-based practice and the need of conducting experimental research. PROSPERO: CRD42021293037.

The Frequency of Design Studies Targeting People With Psychotic Symptoms and Features in Mental Health Care Innovation: Secondary Analysis of a Systematic Review.

This study examined and reflected on the frequency of people with psychotic symptoms and features as the target population in design studies for mental health care innovation.

The Involvement of Service Users and People With Lived Experience in Mental Health Care Innovation Through Design: Systematic Review.

BACKGROUND: Mental health care faces challenges that not only necessitate innovation but also require the involvement of service users and people with lived experience in developing and evaluating mental health care services. As the development of digital interventions is becoming more prevalent, design approaches are increasingly finding their way into mental health. There is evidence that these approaches can successfully integrate user experience into mental health services. However, there is no clear overview of the studies conducted and the lessons learned concerning the involvement of service users and people with lived experience. OBJECTIVE: In this systematic review, we aimed to provide an overview of the involvement of service users and people with lived experience in mental health care services through design approaches and to synthesize the advantages of design approaches in mental health care. METHODS: The following 5 databases were searched for relevant abstracts: PsycINFO, PubMed, Web of Science, Scopus, and Embase. In addition, 2 health design journal archives, Design for Health and The Journal of Health Design, were searched. To categorize the results, we collected the reported added value from the included articles and conducted a thematic synthesis in which the themes were developed from the retrieved data. The themes were discussed, revised, and checked until saturation was achieved. RESULTS: We included and categorized 33 papers. Most studies involved service users, primarily adults, and used various design approaches. Most of these studies aimed to design or evaluate digital interventions. Service users and people with lived experience were involved in different roles but never as decision makers. Studies that used co-design approaches exhibited the highest levels of involvement. Various added values were reported, including tailoring and testing interventions and digital interventions, improving engagement and collaboration, gathering the needs of stakeholders, and empowering participants as resourceful actors. The challenges reported were maintaining participants' continued participation throughout the study, managing the iterative nature of design, providing a safe space, balancing insights from design and medical science, and navigating design processes in medical environments. CONCLUSIONS: This systematic review provides an overview of the studies that used design approaches to involve service users and people with lived experience in mental health care innovation. Design approaches have advantages in mental health care innovation, offering added value and having manageable challenges. Future studies using design approaches in mental health care should involve participants as partners and decision makers and report on collaboration in a systematic and clear manner.

Game mechanics in eHealth interventions promoting self-management in young people with chronic diseases: a protocol for a systematic review and meta-analyses from the eHealth Junior Consortium.

INTRODUCTION: Young people (aged 10-25 years) with chronic diseases are vulnerable to have reduced social participation and quality of life. It is important to empower young people to engage in their chronic diseases self-management. In comparison with traditional face-to-face care, interventions delivered through the internet and related technologies (eHealth) are less stigmatising and more accessible. Gamified eHealth self-management interventions may be particularly promising for young people. This systematic review aims at identifying (1) the game mechanics that have been implemented in eHealth interventions to support young people's self-management of their chronic (somatic or psychiatric) diseases, (2) the investigators' rationale for implementing such game mechanics and, if possible, (3) the effects of these interventions. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic reviews and Meta-Analysis statement guidelines will be followed. A systematic search of the literature will be conducted in Embase, Psycinfo and Web of Science from inception until 30 August 2022. Studies will be eligible if focused on (1) young people (aged 10-25 years) with chronic diseases and (2) describing gamified eHealth self-management interventions. When possible, the effects of the gamified interventions will be compared with non-gamified interventions or care-as-usual. Primary quantitative, qualitative or mixed-method studies written in English will be included. Two independent reviewers will (1) select studies, (2) extract and summarise the implemented game mechanics as well as the characteristics of the intervention and study, (3) evaluate their methodological quality and (4) synthesise the evidence. The reviewers will reach a consensus through discussion, and if required, a third researcher will be consulted. ETHICS AND DISSEMINATION: As systematic reviews use publicly available data, no formal ethical review and approval are needed. Findings will be published in peer-reviewed journals, presented at conferences and communicated to relevant stakeholders including patient organisations via the eHealth Junior Consortium. PROSPERO REGISTRATION NUMBER: CRD42021293037.

Boundary Objects as Dialogical Learning Accelerators for Social Change in Design for Health: Systematic Review.

BACKGROUND: Boundary objects can add value for innovative design and implementation research in health care through their organizational focus and the dynamic structure between ill-structured and tailored use. However, when innovation is approached as a boundary object, more attention will need to be paid to the preimplementation phase. Research and design thinking pay attention to the preimplementation stage but do not have a social or organizational focus per se. The integration of boundary objects in design methodologies can provide a more social and organizational focus in innovative design projects by mapping out the mechanisms that occur at boundaries during design. Four dialogical learning mechanisms that can be triggered at boundaries have been described in the literature: identification, coordination, reflection, and transformation. These mechanisms seem suitable for integration in innovative design research on health. OBJECTIVE: Focusing on innovation in health, this study aims to find out whether the different learning mechanisms can be linked to studies on health innovation that mention boundary objects as a concept and assess whether the related mechanisms provide insight into the stage of the design and implementation or change process. METHODS: The following 6 databases were searched for relevant abstracts: PubMed, Scopus, Education Resources Information Center, PsycINFO, Information Science and Technology Abstracts, and Embase. These databases cover a wide range of published studies in the field of health. RESULTS: Our initial search yielded 3102 records; after removing the duplicates, 2186 (70.47%) records were screened on the title and abstract, and 25 (0.81%) papers were included; of the 13 papers where we identified 1 mechanism, 5 (38%) described an innovation or innovative project, and of the 12 papers where we identified more mechanisms, 9 (75%) described the development or implementation of an innovation. The reflective mechanism was not identified solely but was present in papers describing a more successful development or implementation project of innovation. In these papers, the predetermined goals were achieved, and the process of integration was relatively smoother. CONCLUSIONS: The concept of boundary objects has found its way into health care. Although the idea of a boundary object was introduced to describe how specific artifacts can fulfill a bridging function between different sociocultural sites and thus have a social focus, the focus in the included papers was often on the boundary object itself rather than the social effect. The reflection and transformation mechanisms were underrepresented in the included studies but based on the findings in this review, pursuing to trigger the reflective mechanism in design, development, and implementation projects can lead to a more fluid and smooth integration of innovation into practice.

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.

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.

Design of a Digital Comic Creator (It's Me) to Facilitate Social Skills Training for Children With Autism Spectrum Disorder: Design Research Approach.

BACKGROUND: Children with autism spectrum disorder (ASD) often face difficulties in social situations and are often lagging in terms of social skills. Many interventions designed for children with ASD emphasize improving social skills. Although many interventions demonstrate that targeted social skills can be improved in clinical settings, developed social skills are not necessarily applied in children's daily lives at school, sometimes because classmates continue to show negative bias toward children with ASD. Children with ASD do not blame the difficult social situations they encounter on their lack of social skills; their main goal is to be accepted by peers. OBJECTIVE: This study aims to design a comic creator-It's me-that would create comics to serve as transformational boundary objects to facilitate and enact a horizontal interaction structure between high-functioning children with ASD and their peers, aiming to increase mutual understanding between children at school. METHODS: This research project and this study are structured around the Design Research Framework in order to develop the comic through an iterative-incremental process. Three test sessions, which included 13, 6, and 47 children, respectively, were initiated where the focus shifted in time from usability during the first two tests to the initial assessment of acceptance and feasibility in the third session. A stakeholder review, which included six experts, took place after the second test session. RESULTS: A digital comic creator, It's me, was produced within this study. Children can create their own personal comic by filling in a digital questionnaire. Based on concepts of peer support, psychoeducation, and horizontal interaction, It's me has a rigorous base of underlying concepts that have been translated into design. Based on the first test sessions, the comic has shown its potential to initiate personal conversations between children. Teachers are convinced that It's me can be of added value in their classrooms. CONCLUSIONS: It's me aims to initiate more in-depth conversations between peers, which should lead to more mutual understanding and better relationships between children with ASD and their peers. The first test sessions showed that It's me has the potential to enact horizontal interaction and greater understanding among peers. It's me was designed as a boundary object, aiming to connect the objectives of different stakeholders, and to trigger reflection and transformation learning mechanisms. The applied design research approach might be of added value in the acceptance and adoption of the intervention because children, professionals, and teachers see added value in the tool, each from their own perspectives.

The Role of Transfer in Designing Games and Simulations for Health: Systematic Review.

BACKGROUND: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. OBJECTIVE: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. METHODS: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. RESULTS: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. CONCLUSIONS: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health.

iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare.

OBJECTIVE: Lower back problems are a common cause of sick leave of employees in Dutch care homes and hospitals. In the Netherlands over 40% of reported sick leave is due to back problems, mainly caused by carrying out heavy work. The goal of the iLift project was to develop a game for nursing personnel to train them in lifting and transfer techniques. The main focus was not on testing for the effectiveness of the game itself, but rather on the design of the game as an autogenous trigger and its place in a behavioral change support system. In this article, the design and development of such a health behavior change support system is addressed, describing cycles of design and evaluation. METHODS: (a) To define the problem space, use context and user context, focus group interviews were conducted with Occupational Therapists (n=4), Nurses (n=10) and Caregivers (n=12) and a thematic analysis was performed. We interviewed experts (n=5) on the subject of lifting and transferring techniques. (b) A design science research approach resulted in a playable prototype. An expert panel conducted analysis of video-recorded playing activities. (c) Field experiment: We performed a dynamic analysis in order to investigate the feasibility of the prototype through biometric data from player sessions (n=620) by healthcare professionals (n=37). RESULTS: (a) Occupational Therapists, Nurses and Caregivers did not recognise a lack of knowledge with training in lifting and transferring techniques. All groups considered their workload, time pressure and a culturally determined habit to place the patient's well being above their own as the main reason not to apply appropriate lifting and transferring techniques. This led to a shift in focus from a serious game teaching lifting and transferring techniques to a health behavior change support system containing a game with the intention to influence behavior. (b) Building and testing (subcomponents of) the prototype resulted in design choices regarding players perspective, auditory and visual feedback, overall playability and perceived immersiveness. This design process also addressed the behavior shaping capacities of the game and its place within the health behavior change support system. An expert panel on lifting and transferring techniques validated the provoked in-game activities as being authentic. (c) Regression analysis showed an increase of the game score and dashboard score when more sessions were played, indicating an in-game training effect. A post-hoc test revealed that from an average of 10 playing sessions or more, the dashboard score and the game score align, which indicates behavioral change towards executing appropriate static lifting and transferring techniques. CONCLUSIONS: Data gathered in the final field test shows an in-game training effect, causing players to exhibit correct techniques for static lifting and transferring techniques but also revealed the necessity for future social system development and especially regarding intervention acceptance. Social system factors showed a strong impact on the games persuasive capacities and its autogenous intent.

Determinants that shape public attitudes towards the mentally ill: a Dutch public study.

BACKGROUND: The stigmatisation of the mentally ill is considered a well-established fact. To improve negative attitudes among the general public, we need to identify the factors that cause them. Drawing from previous studies, we combined a variety of variables to examine a comprehensive explanative model. OBJECTIVES: We examined a sample of the Dutch public on their willingness to interact with mental patients. We examined a number of determinants concerning their influence on levels of social distance: demographical characteristics of the public, their beliefs about stereotypes of mental patients, their beliefs about causes of mental problems, their familiarity with mental illness. METHODS: We employed a questionnaire survey among two sub-samples of the Dutch public (n = 812, response 33%). RESULTS: Attributing psychiatric problems to structural causes (i.e. causes beyond patients' control and responsibility, such as genetic transmission) is associated with less social distance. Conversely, attribution to individual factors (e.g. drug abuse) related to more distant attitudes. Stereotypical beliefs about mental patients (e.g. untrustworthiness, aggressiveness, causing disturbances) relate to more social distance from mental patients. CONCLUSIONS: Results implied that our comprehensive model explains only a modest amount of variance, but shows that to improve public mental health literacy and attitudes should first deal with the most negative stereotypical beliefs.