Serious games can be custom or noncustom, each offering advantages for rehabilitation. Custom serious games developed specifically for rehabilitation allow control over feedback and adjustment of game speed and difficulty. Alternatively, noncustom games do not offer these controls but provide attractive graphics, sounds, and engaging game mechanics. The differences between these systems may affect users' exercise intensity, quality of movement, and experience during gameplay, which have implications for system and game selection in rehabilitation. This study compared movement performance and user experience of patients after a stroke while playing custom and noncustom virtual reality balance games that were either game-paced or self-paced. A group of community-dwelling patients in the chronic phase post stroke participated in a cross-sectional repeated measures study. They were familiarized with 12 games; half were played using the custom system (Equio, Kinestica) and half with the noncustom system (Nintendo Wii Balance Board, Wii Fit games). Over 2 gameplay sessions with randomized blocks of game type (self-paced and game-paced) and the order of the system (custom and noncustom), participants played games requiring comparable movement of the center of pressure for each system. Movement performance (weight-shift repetitions and movement amplitude) was extracted from video recordings using the Kinovea software. User enjoyment (Modified Physical Activity Enjoyment Scale), flow (Flow State Scale for Occupational Tasks), and likability were assessed twice in each study block. Comparisons between the systems were conducted using paired t tests or Wilcoxon tests. Effect sizes (ES) were calculated using Cohen d. Twenty-six participants (aged 27-70 years) were included in the analysis. Repetitions and movement amplitude were significantly greater (repetitions: P˂.001-.003; amplitude: P=.002-.03) with large ES for all noncustom game-paced games and for half of the noncustom self-paced games (repetitions: ES 0.8-2.5; amplitude: ES 0.6-0.9). Perception of exertion was greater for noncustom game-paced games (ES 0.6; P=.005). In contrast, users' flow state (total and subdomains of sense of control and emotional experience; ES 0.6-0.8; P≤.03) and user preference were significantly greater for custom game-paced games. There was no significant difference between custom and noncustom games for enjoyment. Serious gameplay was influenced by customization and type of game pacing, both of which should be considered when selecting serious games for balance training. Repetitions, movement amplitude, and perception of effort were greatest for the noncustom game-paced games, indicating greater intensity, while also addressing the difficulty patients after a stroke have with weight-shifting to the affected side. In contrast, custom games provided a sense of control and increased flow state, which may promote better adherence. Findings from this study have implications for clinicians and game designers. Both custom and noncustom games offer training features that support stroke rehabilitation.
Inadequate health literacy and low engagement challenge public health education. Digital serious games show potential to enhance health knowledge and attitudes. However, the comparative effectiveness of different game formats is unclear. This study aimed to evaluate and compare the effectiveness of different digital serious game formats in improving public health knowledge and attitudes. This systematic review and Bayesian network meta-analysis followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Seven databases (PubMed, CINAHL, Embase, PsycINFO, Cochrane Library, Scopus, and Web of Science) were searched from January 2000 to October 2025. An updated search in February 2026 identified no additional studies. Eligible studies were randomized controlled trials (RCTs) involving nonprofessional participants comparing digital serious games with traditional or noninteractive education. Standardized mean differences and 95% credible intervals were pooled using Bayesian network models with random effects. Subgroup analyses examined population characteristics, intervention duration, health topic, and delivery format. Risk of bias was assessed using the Cochrane risk-of-bias tool, and evidence certainty was rated using the Grading of Recommendations Assessment, Development and Evaluation. Forty randomized controlled trials from 19 countries (N=8764 participants) were included. Digital serious games significantly improved knowledge (standardized mean difference 0.66, 95% CI 0.32-0.99; I²=89.1%) and attitudes (standardized mean difference 0.50, 95% CI 0.27-0.76; I²=80.7%) compared with traditional education. Multisession interventions showed larger effects than single-session interventions for knowledge (0.76 vs 0.43) and attitudes (0.53 vs 0.30), with greater improvements among adolescents, nonpatient populations, and Asian studies. Network meta-analysis showed low heterogeneity (I²=8% for knowledge; 3% for attitudes). Mobile app-based, computer-offline, and web-based games ranked highest for knowledge; computer-offline, web-based, and virtual reality games ranked highest for attitudes. Evidence certainty was moderate for knowledge and low-to-moderate for attitudes. Digital serious games improve public health knowledge and attitudes across diverse contexts. Using a Bayesian network meta-analysis of randomized controlled trials, this review compares the relative effectiveness of different game formats. Mobile app-based, computer-offline, and web-based games most improved knowledge; computer-offline, web-based, and virtual reality formats most improved attitudes. Multisession interventions were more effective than single-session ones, particularly for adolescents and nonpatient populations. These findings guide scalable digital health education strategies. Future research requires adequately powered trials, longer follow-up, and standardized frameworks.
Serious games are increasingly recognized as effective tools in adolescent mental health interventions, providing engaging platforms for emotional regulation, skill development, and behavioral change. However, the ways in which core theoretical concepts such as transfer, boundary crossing, and models of reality are incorporated into serious game designs are not consistently described in the literature. Clarifying how these concepts are addressed is important for understanding how game-based learning may connect to real-world health care practice. This systematic review aims to examine how serious games for adolescent health care are designed to support learning and facilitate outcomes. Specifically, it examines how the design incorporates constructs of transfer, boundary crossing, and models of reality, and how these elements are represented across published studies. We conducted a systematic search across 5 databases (PubMed, Scopus, ERIC, PsycINFO, and EMBASE) covering publications up to 2023. Studies were included if they involved serious games targeting adolescents with behavioral or developmental health concerns. Titles and abstracts were screened independently by 2 reviewers, with disagreements resolved by a third party. A qualitative analytical framework was applied to identify elements of design, with a particular focus on transfer, boundary crossing, and models of reality. Thirty-three studies met the inclusion criteria. Figural transfer was identified in 24 studies, while literal transfer was identified in 10 studies. Among boundary-crossing mechanisms, reflection occurred most frequently (22 studies), whereas transformation was observed in 3 studies. Causal and procedural models of reality were most commonly identified as primary model types, whereas relational and structural models were more often reported as secondary. Explicit design rationales were infrequently reported across studies. This review demonstrates that serious games for adolescent mental health most frequently emphasize reflective and representational forms of learning. Across the reviewed studies, theoretical constructs related to transfer, boundary crossing, and models of reality were often implicitly embedded rather than explicitly articulated. The proposed analytical framework offers a structured approach for analyzing these design characteristics and may support designers, researchers, and health care professionals in more explicitly aligning design choices with intended learning mechanisms and real-world applications.
Serious games have become an alternative support for traditional physical therapy. However, many of these games do not address the emotional needs of patients. People with disabilities often experience emotions such as sadness, frustration, and even anger, which can create a barrier to their rehabilitation treatment. This review presents a comprehensive overview of technologies, techniques, and methods in affective computing as applied to serious games for physical rehabilitation and identifies key gaps to guide future research in this field. A scoping review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the databases PubMed, ScienceDirect, IEEE Xplore, ACM Digital Library, PEDro, Springer, and Google Scholar. The initial search yielded 5293 records, of which 9 papers met the inclusion criteria. Data were systematically extracted from these papers based on predefined research questions. Notably, engagement, tiredness, and pain were the most identified emotions, reported in 4 of 9 (50%) studies. Only 3 studies applied theoretical frameworks for emotion classification. Facial expression analysis and gesture recognition were the most frequently used affective computing techniques, yet only 2 studies implemented adaptive gameplay based on affective feedback. The integration of affective computing into serious games represents a promising approach for detecting affective states in patients undergoing rehabilitation. However, the limited number of primary studies, methodological limitations, and potential selection and reference-standard biases limit the reliability and generalizability of the current findings. Future research should prioritize rigorous multicenter designs, standardized evaluation protocols, and multidisciplinary collaboration. Developing these areas is essential to establishing clinical effectiveness.
Serious games (SGs) have emerged as a promising tool in nursing education, providing interactive learning environments for clinical simulation, skill development, and feedback. These games enhance knowledge, clinical reasoning, and psychomotor skills. However, evidence on their effectiveness is dispersed across various platforms and outcome measures, making it difficult to derive clear guidelines for their integration into nursing curricula. This scoping review aimed to systematically identify and map existing evidence on the use of SGs in nursing education, analyze game characteristics, and identify critical gaps to inform future research and practice development. This scoping review followed the JBI framework and the PRISMA-ScR checklist. Nine databases (PubMed, Web of Science, Embase, CINAHL, the Cochrane Library, CBM, Wanfang Data, CNKI, and VIP) were searched from inception to January 15, 2026. Eligible studies were those reporting on original research on SGs in nursing education. Two reviewers screened titles, abstracts, and full texts. Risk of bias was assessed using a standardized checklist. The extracted data encompassed study characteristics, study design, participant information, sample sizes, application context, teaching content, and SG characteristics. Data were extracted and synthesized with descriptive statistics and content analysis. An evidence gap map was created to show the study distribution across course categories and outcome domains. We screened 6078 records and included 24 studies. Publications were from 2021 to 2025 (n=13, 54%), with the majority conducted in Europe (n=13, 54%). Quasi-experimental designs (n=10, 42%) and randomized controlled trials (n=8, 33%) were predominant. SGs were mainly used in fundamental or skills training and adult nursing courses. Scenario-based decision points (n=20, 83%) and points, badges, or leaderboards (n=20, 83%) were the most common game mechanics, while progression or unlocking and collaborative elements were less frequent. Outcomes most often assessed were knowledge (n=16, 67%), skills (n=10, 42%), and engagement or usability (n=13, 54%). Objective use metrics were rarely reported (n=1, 4%), indicating limited data on in-platform learning behaviors. Most SGs were delivered as digital non-virtual reality applications or computer-based simulation games. Follow-up assessment beyond immediate postintervention outcomes was infrequent. An evidence gap map showed studies concentrated in skills-based training and adult nursing, with fewer studies in maternity or neonatal nursing, critical care, and foundational sciences. This review extends earlier work on SGs in nursing education by mapping evidence across curricular areas, intervention reporting, and outcome assessment, rather than focusing mainly on effectiveness or specific formats. It shows where evidence is concentrated and where important gaps remain, particularly in underrepresented course areas, intervention descriptions, follow-up assessments, and objective use data. These findings provide a clearer picture of the evidence base and can inform curriculum planning; the use of SGs in skills-based and clinical training; and future decisions about their design, implementation, and evaluation.
Interprofessional education (IPE) is essential for developing teamwork and communication skills in health care training. Building interprofessional competency involves acquiring knowledge, cultivating readiness to engage in teamwork, and fostering effective collaboration. However, challenges include geographical barriers and faculty resistance that can hinder progress. Innovative solutions to enhance engagement and collaboration include serious games played using immersive virtual reality (IVR) and web-based platforms. Despite their potential, research comparing the effectiveness of these approaches for IPE remains limited. This study aimed to identify effective implementation methods by evaluating the impact of IVR and web-based serious games on health care students' interprofessional competencies and learning experiences. A multimethod approach was used to evaluate students' pre- and postlearning outcomes and experiences. Nursing and physiotherapy students were randomly assigned to either the IVR group or web-based group. The Readiness for Interprofessional Learning Scale (RIPLS), Brief Sense of Community Scale (BSCS), and Intrinsic Motivation Inventory (IMI) were used to measure learning experiences. Learning outcomes were examined through multiple-choice questions (MCQs). After the outcome assessments, groups switched modalities to allow all students to experience both learning approaches. Four focus groups (n=34) provided qualitative insights into learning experiences. The study included 271 students (IVR group: 125; web-based group: 146). Both groups showed significant improvements in community building (BSCS; IVR: r=-0.29, 95% CI 0.06-0.31; P=.001; web-based: r=-0.27, 95% CI 0.07-0.31; P=.001). The IVR group showed improvements in only the pressure/tension subscale of the IMI (r=-0.45, 95% CI -0.05 to -0.25; P<.001), while the web-based group showed improvements across all IMI subscales, including interest/enjoyment (r=-0.17, 95% CI 0.00-0.30; P=.043), perceived competence (r=-0.19, 95% CI 0.00-0.50; P=.02), and pressure/tension (r=-0.46, 95% CI -0.75 to -0.50; P<.001). Both groups showed significant improvements in knowledge-checking MCQ scores (IVR: r=-0.64, 95% CI 2.00-3.00; P<.001; web-based: r=-0.80, 95% CI 4.50-6.00; P<.001), with the web-based group outperforming the IVR group (r=-0.34, 95% CI -3.00 to -2.00; P<.001). RIPLS scores showed no significant difference in both groups, suggesting that greater exposure is required to enhance IPE readiness. A qualitative analysis revealed 6 themes: valuing collaboration opportunities, fostering trust and shared learning, promoting engagement and authenticity, enhancing knowledge retention, balancing innovation with practicality, and improving realism and inclusivity. No adverse events were noted. To our knowledge, this is the first study to compare the effects of 2 different modalities (IVR and web-based approaches) on a technology-enabled IPE program. These findings highlight the practical potential of both approaches in supporting IPE. The web-based approach's superior performance in enhancing learning outcomes and motivation suggests that its flexible format better accommodates diverse learning preferences. These findings support technology-enhanced IPE, offering educators scalable, evidence-based strategies to develop collaborative, patient-centered professionals who are equipped for real-world practice.
Serious games (SGs) are increasingly used to study and enhance team performance in organizational and educational settings. While prior research has explored leadership and communication as isolated factors, the multivariate interactions between behavioral indicators remain poorly understood. A deeper understanding of these relationships can reveal which behavioral and demographic factors most strongly predict successful outcomes, offering insights relevant to both scientific research and practical training design. This study aimed to develop machine learning (ML) models to predict team success in SGs. Specifically, it sought to identify the behavioral and demographic predictors that most strongly influence team performance outcomes. This study used a cross-sectional retrospective design. Behavioral and demographic data were analyzed from 233 teams participating in escape room-based SGs delivered by JGM Serious eXperiences in The Netherlands. Teams of 2-8 players (mean age 25.8 y; 53 all-male, 55 all-female, and 125 mixed-gender) were scored by trained observers across collaboration, communication, and leadership constructs using Likert-scale indicators. Exploratory data analysis compared winning (n=141) and losing teams (n=92) using descriptive statistics, Pearson correlations, and significance testing (independent-samples t tests and Mann-Whitney U tests). Mean differences were interpreted with 95% CIs. A total of 4 ML models: logistic regression, random forest, multilayer perceptron, and support vector classifier, were trained using 5-fold cross-validation (F1-score). The best model was interpreted using SHAP (Shapley Additive Explanations). Winning teams scored higher on several behavioral constructs, but only 4: knowledge sharing, leadership, guidance, and extraversion, showed statistically significant differences between winners and losing teams. These effects were supported by 95% CIs, Shapiro-Wilk tests for normality, and Mann-Whitney U tests where assumptions were violated, indicating that only a subset of behavioral indicators meaningfully distinguishes successful teams. Among the ML models, logistic regression achieved the highest accuracy (88%), followed by multilayer perceptron (87%), random forest (87%), and support vector classifier (85%). SHAP analysis showed that gender composition and prior escape-room experience were the strongest demographic predictors of success, while "celebrating progress" (extern5) and "taking initiative when the team is stuck" (sturing5) were the most influential behavioral indicators. This work demonstrates the usefulness of multivariate analysis in studying and understanding complex human behavior in SG environments as opposed to studying isolated behavioral indicators, often described in previous studies. The ML models developed using behavioral and demographic features of participating teams showed promising accuracies, and their interpretation led to unveiling a set of demographic and behavioral components as the most decisive factors leading to team success. This improved understanding of what makes a team win can be potentially translated into terms of improved productivity in business and organizational settings.
Unicompartmental knee arthroplasty (UKA) requires precise intraoperative coordination from operating room nurses. Conventional teaching may be insufficient for junior nurses learning complex UKA surgical cooperation, particularly regarding self-efficacy and cognitive demands. Serious games have emerged as a promising educational tool for nursing training. This study evaluated whether adding a WeChat-based serious game to conventional UKA training was associated with improved theoretical knowledge, self-efficacy, preoperative preparation, intraoperative performance, and perceived cognitive load among junior operating room nurses. This quasi-historical controlled study compared 2 sequential, noncontemporaneous cohorts of newly recruited junior operating room nurses from a tertiary hospital in Xuzhou, China. Nurses recruited in 2023 were assigned to the conventional training group (n=21, 50%), whereas nurses recruited in 2024 were assigned to the serious game-assisted training group (n=21, 50%). Both groups received the same UKA curriculum, including theoretical teaching and supervised intraoperative practice, while the intervention group additionally used a mobile serious game. Outcomes included theoretical test scores, General Self-Efficacy Scale scores, National Aeronautics and Space Administration Task Load Index (NASA-TLX) cognitive load scores, and assessments of preoperative preparation and intraoperative performance. Data from all 42 eligible participants were included. Compared with conventional training, serious game-assisted training was associated with higher theoretical knowledge scores (mean 96.86, SD 3.09 vs mean 92.38, SD 4.32; P<.001; Cohen d=1.19), preoperative preparedness (mean 4.19, SD 0.33 vs mean 3.49, SD 0.29; P<.001; Cohen d=2.27), intraoperative performance (mean 4.00, SD 0.30 vs mean 3.41, SD 0.28; P<.001; Cohen d=2.03), and overall preparedness and performance (mean 4.10, SD 0.23 vs mean 3.45, SD 0.20; P<.001; Cohen d=3.02). Self-efficacy was higher in the unadjusted analysis (mean 34.05, SD 2.87 vs mean 31.57, SD 3.43; P=.02; Cohen d=0.78), but this difference was attenuated after adjustment for age and education (adjusted mean difference 2.45, 95% CI -0.26 to 5.15; P=.08). The serious game-assisted group also reported higher NASA-TLX total cognitive load (mean 65.44, SD 12.00 vs mean 58.21, SD 6.05; P=.02; Cohen d=0.76). Serious game-assisted training was associated with better theoretical knowledge and procedural performance but higher perceived cognitive load among junior operating room nurses learning UKA coordination. The adjusted self-efficacy result, as well as the overall findings, should be interpreted cautiously rather than as definitive causal evidence because the study used a quasi-historical design without a contemporaneous control group.
Adolescents' internet adaptability (IA) is crucial for their online behavior and mental health. Serious games (SGs), as an emerging educational tool, hold promise for enhancing this adaptability through engaging, goal-oriented learning. Yet, direct evidence in this area remains limited. This viewpoint aims to clarify the mechanisms through which SGs enhance adolescents' IA and to derive corresponding design principles that can inform educational practice and game development. Drawing on insights from both Chinese and international studies, this study adopts a cross-contextual perspective to explore how SGs can foster IA in varied educational environments. Beyond synthesizing existing findings, this viewpoint provides an integrated account of why IA is essential in contemporary digital life and how SGs can support its development. It proposes a 3-stage framework, illustrating how contextualized design, real-time feedback, and dynamic tasks promote experiential learning, self-regulation, and the transfer of online skills. Based on this framework, the study further articulates 6 core design principles: clear goal definition, interaction diversity, contextual authenticity, immediate, scaffolding and explanatory feedback, a dynamically adaptive learning environment, and safety-by-design for digital well-being. These principles translate the core characteristics and mechanisms of SGs into actionable guidance for developing effective IA interventions. By synthesizing theoretical insights with practical considerations, this viewpoint highlights how SGs can serve as accessible and scalable tools to support adolescents in navigating increasingly complex digital environments. Together, these insights provide practical implications for educators, curriculum designers, and digital game developers seeking to foster adolescents' safe, responsible, and adaptive engagement in online environments.
Digital games are increasingly influential in shaping public perceptions of mental health due to their interactive and narrative nature. While serious games designed for therapeutic use have been studied, less is known about how mental health challenges are portrayed in mainstream video games for leisure and the impact of these portrayals on players. This scoping review aims to explore how academic studies address the representation of mental health challenges in contemporary video games for leisure, with particular attention to game design features, depictions of coping or living with a mental health condition, recovery, and intervention. The review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) methodology and applies the population, concept, and context framework. A comprehensive literature search was conducted across 6 databases (PubMed, Scopus, ProQuest, ERIC, IEEE Xplore, and Web of Science) in July 2024 and will be updated to include studies published until November 2025. Eligible studies include peer-reviewed original research on the portrayal of mental health in mainstream digital games. Screening and data extraction were conducted independently by 2 reviewers using Rayyan and NVivo software. Data synthesis will be narrative, focusing on themes of representation, game mechanics, recovery, and audience impact. As this is a protocol, no empirical results are available. The completed review will map how scholarly studies conceptualize and analyze portrayals of mental health in video games, identify recurring thematic and design patterns, and synthesize trends in how researchers frame the relationship between gameplay and mental health representation. By systematically mapping the current literature, this review will contribute to a deeper understanding of how mental health is depicted in mainstream games and will highlight areas for future research, including ethical considerations and opportunities for more informed, empathetic, and responsible game design.
Planning deficits are a common and functionally significant executive function difficulty in children with autism, affecting everyday activities such as organizing tasks, prioritizing goals, and monitoring progress. Traditional neuropsychological assessments often lack ecological validity and may not capture these skills in real-world contexts. Serious games offer promising alternatives by simulating everyday scenarios and enabling observation of planning behaviors during interactive tasks. However, most existing systems focus on training rather than theory-driven assessment, and are rarely evaluated for usability before deployment with children with autism. This study aimed to design and evaluate ShopAutiPlan, a supermarket-based serious game intended to assess executive planning skills in children with ASD by conducting a formative expert evaluation before its use in clinical or research settings. The evaluation sought to identify usability strengths and limitations, ensuring that the system aligns with planning theory and accommodates the unique needs of autistic users. A theory-driven design approach grounded in the Hayes-Roth cognitive model of planning was used to map planning subcomponents-including goal formulation, strategy generation, sequencing, execution, and monitoring-to in-game tasks and logged behavioral metrics. A cross-sectional, formative expert-based usability evaluation was conducted using inspection and think-aloud protocols. Six domain experts (2 psychologists, 2 human-computer interaction researchers, and 2 game developers) participated in individual evaluation sessions. Usability assessment was guided by ASD-specific usability heuristics, and experts completed the System Usability Scale (SUS). SUS scores were summarized using descriptive statistics, and qualitative feedback was analyzed through deductive coding mapped to heuristic categories. Across experts, 45 usability issues were identified, spanning cognitive accessibility, feedback clarity, realism, and technical performance. Severity ratings varied according to disciplinary perspectives: psychologists highlighted cognitive load, sensory accessibility, and task clarity, whereas developers focused on system responsiveness, interaction consistency, and technical reliability. The overall SUS score (mean 70.4, 95% CI 45.2-95.7) exceeded the standard benchmark of 68, supporting the acceptability of the system and complementing the qualitative findings from the heuristic evaluation. Recommendations from the evaluation informed iterative refinements to interface design, interaction flow, and task representation to enhance alignment between planning constructs and user experience. To the best of our knowledge, this study introduces the first shopping-based serious game specifically designed to assess executive planning skills in children with autism. Unlike many existing autism-related serious games that primarily focus on intervention or training, ShopAutiPlan adopts a theory-driven assessment-oriented design grounded in a cognitive model of planning and supported by gameplay-based behavioral measures. By integrating cognitive theory, serious game design, and interdisciplinary usability evaluation, the study proposes a structured framework for developing ecologically valid digital assessment tools that may complement conventional neuropsychological approaches in autism research and clinical practice.
Serious games are increasingly used in professional health education and maternal health promotion. However, most pregnancy-related digital interventions target specific behaviors and do not provide a comprehensive, longitudinal simulation of the pregnancy journey that incorporates psychosocial and administrative aspects. This study aimed to develop and evaluate a narrative-based serious game that simulates the chronological course of pregnancy and to assess its perceived educational usefulness, accessibility, and user acceptance across multiple platforms. We developed a 9-chapter interactive serious game covering pregnancy recognition, partner communication, public health consultation, mid-pregnancy and late-pregnancy checkups, and home preparation for childbirth. The game was collaboratively created by a pediatrician, 6 medical students, and a student illustrator using a low-cost visual novel engine (TyranoBuilder). It was released in April 2025 on iOS, Android, and Steam. A voluntary, anonymous postgame survey was conducted between April 2025 and January 2026. Descriptive statistics were used to summarize survey responses and platform analytics. This study was approved by the Ethics Committee of Shinshu University Hospital. A total of 65 users completed the postgame questionnaire. Most respondents were aged 10 to 19 years (38/65, 58.5%) and female (55/65, 84.6%). Nearly half of the participants (30/65, 46.2%) completed the game within 1 hour. Gameplay evaluation scores (5-point Likert scale; 3=neutral or appropriate) were balanced: game length (mean 3.37, SD 0.96), difficulty (mean 2.84, SD 0.85), and interactivity (mean 3.31, SD 1.10). Educational outcomes were rated highly (5-point Likert scale; higher=more favorable): reduced anxiety (mean 3.84, SD 0.96), perceived educational usefulness (mean 3.98, SD 1.02), perceived knowledge acquisition (mean 4.06, SD 1.06), story empathy (mean 3.80, SD 1.11), and overall satisfaction (mean 4.05, SD 1.04). Across all platforms, the game achieved 925 cumulative downloads. iOS and Android downloads were predominantly from Japan, whereas Steam downloads were geographically diverse. Of the 21 Steam reviews, 20 (95.2%) were positive. A serious pregnancy education game developed through a low-cost clinician-student collaborative model demonstrated high perceived educational usefulness, balanced gameplay characteristics, and broad user acceptance, including substantial engagement among teenagers and international users. Narrative-based serious games represent an accessible and scalable approach to maternal health education. Further research using more rigorous evaluation designs is warranted to assess long-term educational and behavioral impacts.
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Cognitive impairment is a core and enduring deficit in schizophrenia, severely affecting social functioning and quality of life. Traditional assessments such as the MATRICS Consensus Cognitive Battery face limitations in validity and engagement. Virtual reality (VR) serious games may offer an immersive alternative, and machine learning (ML) can uncover complex behavioral patterns. However, integrating VR-based assessment with ML for discriminating stable-phase schizophrenia remains unexplored. This prospective cohort study aimed to examine whether a VR serious game ("Fruit Pioneer") can effectively assess cognitive function in stable schizophrenia, verify its correlation with the standard Brief Cognitive Assessment Tool for Schizophrenia (B-CATS), and test the discriminative capacity using ML models. We hypothesize that (1) patients with schizophrenia will show poorer VR game performance than healthy controls (HCs), (2) VR metrics will correlate with B-CATS scores, and (3) ML models will help classify patients with schizophrenia and HCs using VR data. A total of 42 patients with stable schizophrenia and 65 HCs (aged 18-40 years) were enrolled. Exclusion criteria included color blindness, visual impairment, substance abuse, and comorbid chronic physical diseases. Finally, 39 patients with schizophrenia and 64 HCs were included. Materials included the VR serious game "Fruit Pioneer," B-CATS (Digital Symbol Substitution Test, Trail Making Test Part A, Trail Making Test Part B, and Animal Fluency), Simulator Sickness Questionnaire, and Game Experience Questionnaire. Data were collected via standardized VR gameplay and paper-based assessments. Logistic regression and a support vector machine (SVM) model were built using VR metrics. Patients with schizophrenia performed worse on all B-CATS subtests (all P<.001). They also showed lower VR total scores (median 467, IQR 376-544 vs median 683, IQR 616-753; P<.001), longer reaction times (median 1.11, IQR 0.995-1.23 vs median 1.03, IQR 0.96-1.1; P=.006), lower gaze hit rates (median 0.515, IQR 0.442-0.554 vs median 0.552, IQR 0.497-0.592; P=.01), and higher bomb penalty scores (median 150, IQR 95-170 vs median 108, IQR 85-131; P=.002). In the schizophrenia group, VR metrics correlated with B-CATS results, whereas this relationship was minimal in HCs. Classification performance of the SVM (average area under the curve [AUC]=0.874, 95% CI 0.860-0.888) was comparable to logistic regression (average AUC=0.854, 95% CI 0.838-0.870). This study demonstrates the innovative integration of a VR serious game with ML to assess cognitive function in stable schizophrenia. Unlike prior VR studies focused mainly on validation, our approach combines behavioral metrics with an SVM model, achieving effective classification. The findings support the potential of a scalable digital assessment correlated with standard tests. In clinical practice, this system may serve as an engaging alternative to traditional methods, facilitating long-term cognitive monitoring and personalized rehabilitation strategies.
Loneliness has been linked to reduced mental and physical health. The "loneliness epidemic" is recognized as a public health crisis. However, questions remain about the potential of video games, which people play by themselves, to help reduce perceived loneliness. This study explored the extent to which open-world games (eg, The Legend of Zelda: Breath of the Wild) and fun, accessible games (eg, Yoshi's Crafted World) can help reduce loneliness in adults. We examined how such gameplay can foster a stoic approach to life and how stoicism mediates the reduction of perceived loneliness. A cross-sectional survey was conducted using convenience sampling near a video game store. The sample comprised 2252 adults aged 21 years and older (women: n=966, 42.90%; men: n=1281, 56.90%; prefer not to disclose: n=5, 0.20%). Participants completed a questionnaire to measure perceived loneliness and stoicism, as well as their gameplay habits. Data were analyzed using ANOVA and moderated mediation with the PROCESS macro (bootstrapped samples=5000; 95% CI) to examine the effects of video gameplay on stoicism and loneliness, with the α level set at .05. Zelda players indicated higher stoicism (mean 4.87, SD 0.11; 95% CI 4.66-5.08) than nonplayers (mean 3.23, SD 0.07; 95% CI 3.09-3.37; F1,2252=164.95; P<.001). Yoshi players also noted significantly higher stoicism (mean 4.49, SD 0.12; 95% CI 4.27-4.72) than nonplayers (mean 3.61, SD 0.05; 95% CI 3.50-3.71; F1, 2252=48.33; P<.001), with a significant interaction effect (F1,2252=7.89; P=.005) on stoicism. Furthermore, Zelda players indicated lower loneliness (mean 3.02, SD 0.11; 95% CI 2.81-3.22) than nonplayers (mean 4.28, SD 0.07; 95% CI 4.14-4.42; F1, 2252=98.32; P<.001). Yoshi players also noted significantly lower loneliness (mean 3.09, SD 0.12; 95% CI 2.86-3.32) than nonplayers (mean 4.21, SD 0.05; 95% CI 4.10-4.32; F1, 2252=76.32; P<.001). Moderated mediation analysis demonstrated that Zelda gameplay was positively associated with stoicism (β=1.28, 95% CI 1.07-1.50; P<.001), and stoicism was negatively associated with perceived loneliness (β=-0.49, 95% CI -0.52 to -0.45; P<.001). This study is innovative in identifying stoicism as a potential emotional pathway through which video games may reduce loneliness. Moving beyond views of gaming as passive escapism, our findings suggest that specific gameplay experiences may serve as active spaces for cultivating resilience. We introduce a "digital diet" framework, indicating that balancing open-world challenges (eg, Zelda) with low-stakes restoration (Yoshi) produces synergistic psychological support. Practically, thoughtfully curated gaming experiences may serve as scalable and cost-effective digital adjuncts for public mental health interventions addressing the loneliness epidemic.
Serious digital games have been proposed as a novel approach to support diabetes education and self-management, but evidence regarding their effectiveness remains limited. This study aimed to evaluate the effects of SugarVita, a serious game for people with type 2 diabetes, on diabetes-related knowledge, self-confidence, and self-management. Secondary outcomes included hemoglobin A1c (HbA1c), engagement, and user evaluation. In this pilot randomized controlled trial, 30 adults with type 2 diabetes were randomized to SugarVita plus standard care or standard care alone for 8 weeks. Outcomes were assessed before and after the intervention using validated questionnaires and laboratory HbA1c values. Within-group changes were analyzed using Wilcoxon signed-rank tests and between-group differences using Mann-Whitney U tests. Bonferroni correction was applied for multiple primary outcomes. No statistically significant between-group differences were observed for diabetes-related knowledge, self-confidence, or self-management after correction for multiple testing. Both groups showed numerical improvements over time. HbA1c decreased significantly within the intervention group (median 73.0, IQR 70.8-81.5 to median 64.5, IQR 60.8-72.0 mmol/mol; P=.007), whereas no significant change was observed in the control group. Greater total playtime was moderately associated with HbA1c reduction. User evaluations indicated high perceived educational value. Participants reported positive experiences with SugarVita and perceived the game as educational and user-friendly. No statistically significant between-group differences were observed for the primary outcomes. These findings support the feasibility and acceptability of SugarVita as a digital educational intervention and warrant further evaluation in larger studies.
Few game-based digital mental health interventions have been adopted in clinical practice, where mental health professionals (MHPs) play a critical role in the uptake of new technologies. Existing evidence suggests that MHPs' views on game-based interventions and entertainment video games are mixed, reflecting broader tensions surrounding video games, which are perceived as both harmful and beneficial. However, the underlying reasons for these perceptions have remained unclear, even though they may substantially influence MHPs' willingness to adopt or refuse new clinical solutions. This qualitative cross-sectional study investigates how MHPs view entertainment video games and gaming in clinical contexts. By examining these perceptions, the study aims to inform the implementation of game-based digital mental health interventions in health care. This study combined 3 qualitative interview datasets (n=19, n=16, and n=6) capturing Finnish MHPs' views on video games and gaming, resulting in a combined sample of 41 participants, of whom 56% (n=23) were women and 59% (n=24) reported playing games. The interview data were analyzed using reflexive thematic analysis. Additionally, 2 post hoc analyses were conducted with complementary qualitative questionnaire data (n=80) collected alongside the first dataset. In total, 3 themes were generated to reflect the MHPs' views. First, personal recreation, clinically harmful: MHPs demonstrated a self-client attitude asymmetry, describing their own gaming primarily as positive and recreational, while associating clients' gaming with problems. Second, adverse technology and meaningful culture: MHPs expressed attitudinal ambivalence, making sense of gaming through conflicting frames as both potentially harmful technology and meaningful culture. Third, holistic exploration of clients' gaming: MHPs evaluated their clients' gaming within the broader context of the clients' lives. The first post hoc analysis reinforced the observed self-client attitude asymmetry, showing that MHPs associated their own gaming experiences with more positive and fewer negative meanings compared to their clients' gaming. The second post hoc analysis suggested that MHPs expected game-based interventions to be approachable, motivating, and complementary to other treatments, and particularly suited for children and youth, people with strong digital competencies, and clients who were withdrawn. Existing qualitative research on MHPs' perceptions of video games remains limited and has not examined clinicians' broader sense-making of gaming to inform the implementation of game-based interventions. This study identifies how clinician education can build on MHPs' existing perceptions while addressing potential misconceptions by clearly differentiating game-based interventions from entertainment games, clarifying their clinical aims and mechanisms of action, situating them within clients' broader care and recovery processes, and challenging narrow assumptions about their target audience. Together, these contributions address a critical gap in the literature and inform strategies to improve clinician education, communication, and the adoption of game-based interventions in mental health care.
Pediatric dental behavior management is difficult to teach because learners need safe opportunities to practice. Digital simulation tools offer new opportunities for safer and more structured training. However, the use of these approaches in pediatric dental behavior management education has not been systematically synthesized. This systematic review aimed to synthesize the evidence on digital simulation tools in pediatric dental behavior management education, focusing on their design, implementation, and educational outcomes, and the extent to which virtual reality (VR) and serious game-based approaches have been studied. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Scopus, Web of Science, Embase, the Cochrane Library, and the CNKI were searched for studies published between January 1, 2015, and December 10, 2025. An updated search using the same strategy across all 6 databases was performed on June 5, 2026. Only original research studies were eligible. Study characteristics, intervention design, implementation approaches, and educational outcomes were extracted, including technical skill acquisition, soft-skill and affective competency development, and learner experience and acceptability. Risk of bias was assessed independently by 2 reviewers using design-specific appraisal tools. Due to substantial heterogeneity in study designs, interventions, and outcome measures, findings were synthesized narratively rather than through meta-analysis. A total of 21 studies were included, including 20 studies identified in the original search and 1 study identified in the updated search. The identified evidence focused mainly on VR, haptic virtual reality simulation systems, augmented reality, 3D-printed models, and AI-driven chatbots. No eligible studies on gamification or serious games were identified, despite the inclusion of serious games and gamification terms in the search strategy. VR scenario simulations enhanced learners' empathy and self-efficacy in communicating with child patients, although these effects appeared to require reinforcement through repeated use. Haptic virtual reality simulation showed advantages in supporting specific procedural skills. Augmented reality improved local anesthesia training efficiency. The 3D-printed models and role-playing with professional actors enhanced clinical realism and communication skills, while AI-driven chatbots improved caregiver oral health knowledge and behaviors. Across studies, these tools were positioned as complements, rather than replacements for, traditional teaching. Evidence suggests that digital simulation tools, especially VR-based approaches, may support pediatric dental behavior management education by enhancing procedural practice, empathy, communication, confidence, and caregiver-related learning. However, substantial heterogeneity, reliance on self-reported measures, and the rapid evolution of digital simulation technologies limit the strength and currency of the evidence. The absence of eligible serious game studies indicates an important research gap. This review highlights their practical value for curriculum development and future educational tool design. Future work should evaluate VR and serious game-based approaches using stronger study designs, standardized outcomes, longer follow-up, and implementation strategies.
Cognitive decline in aging populations underscores the need for early interventions in mild cognitive impairment (MCI), where pharmacological treatments show limited benefit. Eye-movement metrics serve as sensitive markers of cognitive deficits in MCI, and digital programs integrating these tasks offer scalable, data-driven training approaches. This study aimed to evaluate the effectiveness of a digital cognitive training program incorporating eye-movement tasks in individuals with MCI, and to determine whether eye-movement indicators can serve as objective markers of cognitive improvement. A total of 12 participants aged 60-85 years with MCI (Korean version of the Montreal Cognitive Assessment [K-MoCA] score of ≤22) completed baseline and postintervention assessments using the K-MoCA and Mini-Mental State Examination-Korean version (MMSE-K). Longitudinal changes in visuospatial attention and oculomotor performance were examined using Spearman correlations across sessions, and pre-post comparisons of eye-tracking metrics were conducted to assess training-related improvements. Cognitive scores improved significantly, with K-MoCA increasing by 1.5 points (from mean 20.3, SD 1.1 to mean 21.8, SD 1.7; P=.004; Cohen d=1.38) and MMSE-K by 1.3 points (from mean 21.9, SD 2.0 to mean 23.2, SD 2.2; P=.002; Cohen d=1.29). Fixation duration decreased (r=0.248; P=.003), and saccade velocity increased (r=0.258; P=.002), indicating enhanced visual processing efficiency and faster attentional shifts, whereas fixation count and saccade amplitude showed no consistent changes. In addition, saccade duration decreased by 21.72 ms, and saccade velocity increased by 114.54 °/s. Digital cognitive training yielded measurable gains in visuospatial attention and oculomotor efficiency in MCI, with optimized fixation and saccade patterns indicating enhanced attentional control and information processing. These findings support eye-movement metrics as sensitive indicators of cognitive change and highlight digital interventions as scalable, noninvasive tools for cognitive support in aging populations.
Visuospatial neglect (VSN) is a cognitive disorder following a stroke, where individuals fail to perceive or respond to stimuli on the contralesional side of space. Visual scanning training (VST) is the recommended treatment in clinical guidelines. This qualitative study explored how patients (N=10) and informal caregivers (N=8) perceived the usability and potential implementation of 3 extended reality (XR)-based serious games to enhance VST-1 in virtual reality and 2 in augmented reality-as tools for VST. These technologies not only enhance patient engagement but also enable detailed data collection to monitor therapeutic progress. The themes and feedback were compared with themes and feedback from VSN therapists from a previous study: (1) suitability for VSN rehabilitation, (2) applicability, (3) motivation, (4) guidance, (5) versatility, and (6) detailed insights in game performance. Highlights were that patients reported high engagement and enjoyment, with many expressing willingness to use the games in both clinical and home settings. Informal caregivers supported these findings and emphasized the motivational value of the games. Additionally, both groups noted the importance of accessible instructions and technical support. Although XR technology offers potential in neurorehabilitation, a uniform solution may not suit all users. This study showed the importance of including diverse end-user groups in development for usability, acceptance, and implementation. Successful integration of XR in rehabilitation requires customizable features, structured support, and attention to the differing roles of caregivers. Further research is needed to evaluate the clinical effectiveness and optimize patient-tailored applications of XR in VSN treatment.