ReviewA meta-analysis of serious digital games for healthy lifestyle promotion
Introduction
Healthy 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). Healthy lifestyle adoption and maintenance, however, are often hindered by motivational issues, lack of time to participate in health promotion programs, and the interventions' low reach into the target group (Baert et al., 2011, Mcguire et al., 2013, Toobert et al., 2002). Computer-delivered and computer-tailored interventions have been successfully designed to overcome these obstacles by tailoring to motivational stage, being accessible whenever the individual has time, and ensuring high availability at lower cost (Krebs et al., 2010, Portnoy et al., 2008).
Serious digital games are a type of computer-delivered intervention considered to be both educational and fun. Games differ from computer-delivered interventions by aspiring to be highly enjoyable, attention-captivating and intrinsically motivating (Graesser et al., 2009, Prensky, 2007). Serious games differ from mere entertainment games in their aim to educate or promote behavior change. In the context of health promotion programs, this may be achieved via the provision of health-related information, modeling of positive health behaviors, the creation of opportunities to practice healthy lifestyle skills (Kato, 2010), by changing mediators (e.g. self-regulatory skill development), and by applying change procedures (e.g. tailoring and goal-setting) (Thompson et al., 2010, Thompson et al., 2012). Serious games may furthermore create sustained effects by being intrinsically motivating to play longer and repeatedly (Sitzmann, 2011, Wouters et al., 2013).
Serious games are theorized to derive their learning effects from at least three sources: 1) by creating immersion or transportation, a state in which the player becomes absorbed in the play without disbelief, while creating personally relevant experiences and deep affection for the characters; 2) by establishing flow, a state of high concentration in which the player experiences a balance between skills and challenge; and 3) by meeting the individuals' needs for mastery, autonomy, connectedness, arousal, diversion, fantasy, or challenge (Annetta, 2010, Boyle et al., 2012, Connolly et al., 2012, Kapp, 2012, Lu et al., 2012). Several narrative systematic reviews have described health-promoting effects of serious games. These included health games relating to diverse behaviors and populations, including games for treatment, prevention, and professional education (Rahmani and Boren, 2012). Reviews on healthy lifestyles mostly focused on a single health behavior (e.g. Guy et al, 2011, on obesity prevention) or focused on one specific age group (e.g. Guse et al, 2012, on sexual health among adolescents). An exception was the review of Baranowski et al. which included games for healthy diet, physical activity and illness self-management (Baranowski et al., 2008). All reviews noted large differences between studies, and concluded that reasons for these differences are as yet unclear (Baranowski et al., 2008, Deshazo et al., 2010, Gamberini et al., 2008, Guse et al., 2012, Guy et al., 2011, Kato, 2010, Kharrazi et al., 2012, Lu et al., 2012, Papastergiou, 2009, Primack et al., 2012, Rahmani and Boren, 2012, Wilkinson et al., 2008).
As yet, no meta-analysis of serious games for healthy lifestyle promotion has been reported. Meta-analysis overcomes the problem of small sample sizes in individual studies, which make it hard to determine a treatment's effectiveness. Furthermore, quantifying and comparing heterogeneity across studies by game characteristics permits tests of hypotheses reported in previous reviews (Borenstein et al., 2009). These insights may guide professionals in developing future evidence-based serious games (Ritterfeld et al., 2009).
This meta-analysis of the effectiveness of serious games for healthy lifestyle promotion addressed the following questions: 1) How effective are serious games in changing health behaviors, their determinants and clinical outcomes?; and 2) What is the influence of moderators, such as study characteristics, sample characteristics, theoretical basis, tailoring, and implementation method, on intervention effectiveness?
Section snippets
Inclusion and exclusion criteria
Healthy lifestyles were defined as the ability to adapt and self manage mental, social and physical health, in line with a recent conceptualization of health (Huber et al., 2011). Four categories of health behaviors were studied: 1) healthy diet and physical activity, 2) health responsibility/maintenance, 3) social behavior, and 4) mental health promotion. Healthy diet and physical activity/exercise were grouped because they frequently co-occurred in games for health promotion. Examples within
Results
The database search yielded 7192 hits, from which 1473 duplicates were removed. Next, 5719 articles were deleted after reading the abstract and title. After reading the full texts, fifty-one games were retained. Sixteen studies were added from other sources, such as a search in specialized journals mentioned above and requests via professional networks, such as the Digital Games Research Association. This resulted in a total of 67 studies. Thirteen studies were removed because they did not
Discussion
This was the first article to conduct a meta-analysis of serious games for healthy lifestyle promotion. Overall, serious games increased healthy lifestyle adoption (g = 0.260, 95% CI 0.148; 0.373) and improved antecedents that determine adoption (g = 0.334, 95% CI 0.260; 0.407), and this applied across the several included health domains.
Overall, effect sizes were small. The effect sizes on behavior were however in line with findings of two meta-analyses on computer-delivered interventions (range
Limitations
Some limitations to this meta-analysis need to be noted. First, ‘no evidence for an effect’ does not equal ‘evidence for no effect’. In some areas, analyses were likely statistically underpowered (e.g. mental health, social behavior, clinical outcomes). Second, other factors (e.g. game features), may partially explain the high heterogeneity which indicates results should be treated with caution. These features were not included here. Third, publication bias is always a concern: reported effect
Conclusions
Findings indicated that serious games had positive effects on healthy lifestyles and their determinants, especially for knowledge, and on clinical outcomes. Long-term effects were maintained for knowledge, but not for behavior. Serious games were best individually tailored to both socio-demographic and change need information and benefited from a theoretical foundation in both behavioral prediction and game theories. They were effective either as a stand-alone or multi-component program and
Conflict of interest statement
The authors declare that there are no conflicts of interests.
Acknowledgments
This study received a grant (no. 110051) from the Flemish agency for Innovation by Science and Technology.
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