Computer game for inner-city children does not improve asthma outcomes

Personality-targeted persuasive gamified systems: exploring the impact of application domain on the effectiveness of behaviour change strategies

Persuasive gamified systems for health are interventions that promote behaviour change using various persuasive strategies. While research has shown that these strategies are effective at motivating behaviour change, there is little knowledge on whether and how the effectiveness of these strategies vary across multiple domains for people of distinct personality traits. To bridge this gap, we conducted a quantitative study with 568 participants to investigate (a) whether the effectiveness of the persuasive strategies implemented vary within each domain (b) whether the effectiveness of various strategies vary across two distinct domains, (c) how people belonging to different personality traits respond to these strategies, and (d) if people high in a personality trait would be influenced by a persuasive strategy within one domain and not in the other. Our results show that there are significant differences in the effectiveness of various strategies across domains and that people's personality plays a significant role in the perceived persuasiveness of different strategies both within and across distinct domains. The Reward strategy (which involves incentivizing users for achieving specific milestones towards the desired behaviour) and the Competition strategy (which involves allowing users to compete with each other to perform the desired behaviour) were effective for promoting healthy eating but not for smoking cessation for people high in Conscientiousness. We provide design suggestions for developing persuasive gamified interventions for health targeting distinct domains and tailored to individuals depending on their personalities.

A Computer-Based Interactive Narrative and a Serious Game for Children With Asthma: Development and Content Validity Analysis

Background

Nonadherence to medications, failure to prevent exposure to asthma triggers, lack of knowledge about using medications, and fixed mindsets contribute to poor asthma control in children. Digital learning could provide a new strategy for improving health-related outcomes in children with asthma.

Objective

The aim of this study is to develop and design a digital educational program, titled Module of Inhaler and Asthma Triggers for Children (MIRACLE), for Indonesian children with asthma. The program comprises an interactive narrative and a serious game. It was proposed to increase the understanding of asthma self-management, instruct on proper inhaler techniques, improve asthma control, and promote a growth mindset for children with asthma.

Methods

Two phases of research were conducted to develop the program. In the first phase, a literature search and two rounds of the Delphi technique were conducted to obtain agreement from an expert panel regarding elements of asthma self-management and the design of interactive narratives and a serious game. The expert panel item statements were evaluated using the content validity index (CVI). In the second phase, the SERES framework, Norma Engaging Multimedia Design, and Psychological Theory of Growth Mindset were applied to create a storyline, learn objectives, and game challenges.

Results

In the first phase, 40 experts were invited to participate in Delphi round 1. Forty responses were collected to generate 38 item statements that consisted of part 1, elements of asthma self-management (25 items), and part 2, design of an interactive narrative and a serious game (13 items); 38 experts were involved in Delphi round 2. In total, 24 statements in part 1 and 13 items in part 2 had item-CVI values >0.80. The average CVI was 0.9, which was considered acceptable. Four narrative plots and five game sessions were developed during the second phase. Challenges with the scenario, scoring, and feedback on asthma difficulties were designed to promote a growth mindset for learners.

Conclusions

We developed a culture-specific, computer-based asthma program containing an interactive narrative and a serious game to deliver asthma self-management and promote a growth mindset among Indonesian children.

Play interventions for paediatric patients in hospital: a scoping review

OBJECTIVE

Play is a non-invasive, safe and inexpensive intervention that can help paediatric patients and their families manage difficult aspects of being ill or hospitalised. Although play has existed in hospitals for decades, research on hospital play interventions is scarce. This review aimed to categorise and synthesise the last 20 years of research on hospital play interventions.

DESIGN

Scoping review.

DATA SOURCES

PubMed, CINAHL, CENTRAL, ERIC and PsycINFO (1 January 2000- 9 September 2020).

STUDY SELECTION AND DATA EXTRACTION

We systematically searched for original peer-reviewed articles, written in English, on hospital play interventions in paediatric patients (0-18 years) in non-psychiatric settings. Two reviewers independently screened titles and abstracts, reviewed full text of relevant articles and extracted data. We thematically synthesised the data from the included studies, and a descriptive analysis, based on a developed framework, is presented.

RESULTS

Of the 297 included articles, 78% came from high-income countries and 56% were published within the last 5 years. Play interventions were carried out across all ages by various healthcare professionals. Play interventions served different roles within four clinical contexts: A) procedures and diagnostic tests, B) patient education, C) treatment and recovery and D) adaptation. Across these contexts, play interventions were generally facilitated and purpose-oriented and had positive reported effects on pain, stress, and anxiety.

CONCLUSIONS

Play in hospitals is an emerging interdisciplinary research area with a significant potential benefit for child and family health. Future research should further describe principles for play in hospitals. High-quality studies investigating short-term and long-term effects are needed to guide when and how to best integrate play in hospitals.

Investigating Serious Games That Incorporate Medication Use for Patients: Systematic Literature Review

Background

The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use.

Objective

This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use.

Methods

PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection.

Results

Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies.

Conclusions

Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player’s retention of learning objectives.

Therapeutic Patient Education with Learning Objects Improves Asthma Control in Mexican Children

One of the most common chronic diseases that causes missed school days and workdays is pediatric asthma, producing education, health and economic delays in low and middle-income countries. A patient-centered remarkable therapeutic strategy in the prevention and treatment of chronic diseases is the Therapeutic Patient Education (TPE) which denotes an outstanding difference in the outcomes, from the awareness, to the personal treatment adaption to prevent crises. In this paper, an intervention of TPE with learning objects (LOs) of a pediatric asthma course, designed to train the uncontrolled patient and the caregiver as a team on the specific knowledge to self-control the disease, was carried out at a health facility in Mexico. The Asthma Control Test (ACT) was used and the learning performance was evaluated with formative quizzes. A randomized controlled trial was designed, with pairs of children patients and caregivers during 60 days; the control group was trained with the usual approach, receiving general information about the disease. ACT measures showed statistical significance for the TPE group after the use of the LOs, achieving a controlled state, while the control group did not show difference. Also, the intervention group obtained a higher score in learning performance assessment. The users learned how to avoid risks, the personal triggers of the patient, how to correctly use the different treatments and accessories, consequently, they learned how to self-manage the disease. Our study also confirmed that control of asthma is not only a matter of knowledge, but financial issues to afford the treatment.

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review

BACKGROUND

Asthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.

OBJECTIVE

The study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.

RESULTS

Fourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.

CONCLUSIONS

These findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

Illness Experience, Self-Determination, and Recreational Activities in Pediatric Asthma

Although asthma self-management depends on ongoing and accurate self-assessment by the patient, pediatric asthma patients have weak skills in the area of symptom perception. Before developing an asthma game targeted to improving asthma self-management and improved symptom awareness, we sought to identify gaps in existing games. To clarify the role of relatedness and autonomy in asthma health game design, we investigated symptom awareness, vocabulary, and self-determination through a series of semi-structured interviews with children suffering from asthma. Using self-determination theory as a framework, interviews were oriented to patients' illness experience and vocabulary related to symptomatology, as well as to recreational activities. Formative analysis of the interviews reveals attitudes, perceptions, and motivational factors arising in the context of childhood asthma, and it elucidates the images and vocabulary associated with both illness experience and recreational activities. Qualitative assessment of patient perspectives leads to specific recommendations for game design ideas that will support market entry of a spirometer-controlled game for children with asthma.

Serious games for health: three steps forwards

Serious games are educational tools which are more and more used in patient and health professional education. In this article, we discuss three main points that developers and educators need to address during the development of a serious game for health. We first explain how to develop motivating serious games by finding a point where the intrinsic and extrinsic motivations of end users can converge. Then, we propose to identify the features of serious games which enhance their learning effectiveness on the basis of a framework derived from cognitive science and called "the four pillars of learning." Finally, we discuss issues and solutions related to the evaluation of serious games.

Developing a mobile application to better inform patients and enable effective consultation in implant dentistry

The field of dentistry lacks satisfactory tools to help visualize planned procedures and their potential results to patients. Dentists struggle to provide an effective image in their patient's mind of the end results of the planned treatment only through verbal explanations. Thus, verbal explanations alone often cannot adequately help the patients make a treatment decision. Inadequate attempts are frequently made by dentists to sketch the procedure for the patient in an effort to depict the treatment. These attempts however require an artistic ability not all dentists have. Real case photographs are sometimes of help in explaining and illustrating treatments. However, particularly in implant cases, real case photographs are often ineffective and inadequate. The purpose of this study is to develop a mobile application with an effective user interface design to support the dentist-patient interaction by providing the patient with illustrative descriptions of the procedures and the end result. Sketching, paper prototyping, and wire framing were carried out with the actual user's participation. Hard and soft dental tissues were modeled using three dimensional (3D) modeling programs and real cases. The application enhances the presentation to the patients of potential implants and implant supported prosthetic treatments with rich 3D illustrative content. The application was evaluated in terms of perceived ease of use and perceived usefulness through an online survey. The application helps improve the information sharing behavior of dentists to enhance the patients' right to make informed decisions. The paper clearly demonstrates the relevance of interactive communication technologies for dentist-patient communication.

The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories

BACKGROUND

To address the need for risk behavior reduction and human immunodeficiency virus prevention interventions that capture adolescents "where they live," we created a tablet-based videogame to teach skills and knowledge and influence psychosocial antecedents for decreasing risk and preventing human immunodeficiency virus infection in minority youth in schools, after-school programs, and summer camps.

METHODS

We developed PlayForward: Elm City Stories over a 2-year period, working with researchers, commercial game designers, and staff and teens from community programs. The videogame PlayForward provides an interactive world where players, using an avatar, "travel" through time, facing challenges such as peer pressure to drink alcohol or engage in risky sexual behaviors. Players experience how their choices affect their future and then are able to go back in time and change their choices, creating different outcomes. A randomized controlled trial was designed to evaluate the efficacy of PlayForward. Participants were randomly assigned to play PlayForward or a set of attention/time control games on a tablet at their community-based program. Assessment data were collected during face-to-face study visits and entered into a web-based platform and unique real-time "in-game" PlayForward data were collected as players engaged in the game. The innovative methods of this randomized controlled trial are described. We highlight the logistical issues of conducting a large-scale trial using mobile technology such as the iPad(®), and collecting, transferring, and storing large amounts of in-game data. We outline the methods used to analyze the in-game data alone and in conjunction with standardized assessment data to establish correlations between behaviors during gameplay and those reported in real life. We also describe the use of the in-game data as a measure of fidelity to the intervention.

RESULTS

In total, 333 boys and girls, aged 11-14 years, were randomized over a 14-month period: 166 were assigned to play PlayForward and 167 to play the control games. To date (as of 1 March 2016), 18 have withdrawn from the study; the following have completed the protocol-defined assessments: 6 weeks: 271 (83%), 3 months: 269 (84%), 6 months: 254 (79%), 12 months: 259 (82%), and 24 months: is ongoing with 152 having completed out of the 199 participants (76%) who were eligible to date (assessment windows were still open).

CONCLUSION

Videogames can be developed to address complex behaviors and can be subject to empiric testing using community-based randomized controlled trials. Although mobile technologies pose challenges in their use as interventions and in the collection and storage of data they produce, they provide unique opportunities as new sources of potentially valid data and novel methods to measure the fidelity of digitally delivered behavioral interventions.

Interactive media for parental education on managing children chronic condition: a systematic review of the literature

Background

Although some research has examined the use of games for the education of pediatric patients, the use of technology for parental education seems like an appropriate application as it has been a part of the popular culture for at least 30 years. The main objective of this systematic review is to examine the literature for research evaluating the use of interactive media in the education of parents of children with chronic conditions.

Methods

We searched the MEDLINE, PSYCHINFO, CINAHL, Cochrane database of systematic reviews and EMBASE databases from 1986 to 2014 seeking original investigations on the use of interactive media and video games to educate parents of children with chronic conditions. Cohort studies, randomized control trials, and observational studies were included in our search of the literature.

Two investigators reviewed abstracts and full texts as necessary. The quality of the studies was assessed using the GRADE guidelines.

Overall trend in the results and the degree of certainty in the results were considered when assessing the body of literature pertaining to our focused questions.

Results

Our initial search identified 4367 papers, but only 12 fulfilled the criterion established for final analysis, with the majority of the studies having flaws that reduced their quality. These papers reported mostly positive results supporting the idea that parent education is possible through interactive media.

Conclusion

We found limited evidence of the effectiveness of using serious games and or interactive media to educate parents of children with chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0517-2) contains supplementary material, which is available to authorized users.

Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials assessing the effectiveness of serious games in improving knowledge and/or self-management behaviors in young people with chronic conditions.

MATERIALS AND METHODS

The authors searched the databases PubMed, Cochrane Library, Web of Sciences, and PsychINFO for articles published between January 1990 and January 2014. Reference lists were hand-searched to retrieve additional studies. Randomized controlled trials that compared a digital game with either standard education or no specific education in a population of children and/or adolescents with chronic conditions were included.

RESULTS

The authors identified 9 studies in which the effectiveness of serious games in young people with chronic conditions was evaluated using a randomized controlled trials design. Six studies found a significant improvement of knowledge in the game group from pretest to posttest; 4 studies showed significantly better knowledge in the game group than in the control group after the intervention. Two studies reported significantly better self-management in the game group than in the control group after the intervention. Seven studies were included in the meta-analysis. For knowledge, pooled estimate of Hedges' gu was 0.361 (95% confidence intervals, 0.098-0.624), demonstrating that serious games improve knowledge in patients. For self-management, pooled estimate of Hedges' gu was 0.310 (95% confidence intervals, 0.122-0.497), showing that gaming improves self-management behaviors.

CONCLUSIONS

The authors' meta-analysis shows that educational video games can be effective in improving knowledge and self-management in young people with chronic conditions.

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

Several systematic reviews have described health-promoting effects of serious games but so far no meta-analysis has been reported. This paper presents a meta-analysis of 54 serious digital game studies for healthy lifestyle promotion, in which we investigated the overall effectiveness of serious digital games on healthy lifestyle promotion outcomes and the role of theoretically and clinically important moderators. Findings showed that serious games have small positive effects on healthy lifestyles (g=0.260, 95% CI 0.148; 0.373) and their determinants (g=0.334, 95% CI 0.260; 0.407), especially for knowledge. Effects on clinical outcomes were significant, but much smaller (g=0.079, 95% CI 0.038; 0.120). Long-term effects were maintained for all outcomes except for behavior. Serious games are best individually tailored to both socio-demographic and change need information, and benefit from a strong focus on game theories or a dual theoretical foundation in both behavioral prediction and game theories. They can be effective either as a stand-alone or multi-component programs, and appeal to populations regardless of age and gender. Given that effects of games remain heterogeneous, further explorations of which game features create larger effects are needed.

Digital asthma self-management interventions: a systematic review

BACKGROUND

Many people with asthma tolerate symptoms and lifestyle limitations unnecessarily by not utilizing proven therapies. Better support for self-management is known to improve asthma control, and increasingly the Internet and other digital media are being used to deliver that support.

OBJECTIVE

Our goal was to summarize current knowledge, evidenced through existing systematic reviews, of the effectiveness and implementation of digital self-management support for adults and children with asthma and to examine what features help or hinder the use of these programs.

METHODS

A comprehensive search strategy combined 3 facets of search terms: (1) online technology, (2) asthma, and (3) self-management/behavior change/patient experience. We undertook searches of 14 databases, and reference and citation searching. We included qualitative and quantitative systematic reviews about online or computerized interventions facilitating self-management. Title, abstract, full paper screening, and quality appraisal were performed by two researchers independently. Data extraction was undertaken using standardized forms.

RESULTS

A total of 3810 unique papers were identified. Twenty-nine systematic reviews met inclusion criteria: the majority were from the United States (n=12), the rest from United Kingdom (n=6), Canada (n=3), Portugal (n=2), and Australia, France, Spain, Norway, Taiwan, and Greece (1 each). Only 10 systematic reviews fulfilled pre-determined quality standards, describing 19 clinical trials. Interventions were heterogeneous: duration of interventions ranging from single use, to 24-hour access for 12 months, and incorporating varying degrees of health professional involvement. Dropout rates ranged from 5-23%. Four RCTs were aimed at adults (overall range 3-65 years). Participants were inadequately described: socioeconomic status 0/19, ethnicity 6/19, and gender 15/19. No qualitative systematic reviews were included. Meta-analysis was not attempted due to heterogeneity and inadequate information provision within reviews. There was no evidence of harm from digital interventions. All RCTs that examined knowledge (n=2) and activity limitation (n=2) showed improvement in the intervention group. Digital interventions improved markers of self care (5/6), quality of life (4/7), and medication use (2/3). Effects on symptoms (6/12) and school absences (2/4) were equivocal, with no evidence of overall benefits on lung function (2/6), or health service use (2/15). No specific data on economic analyses were provided. Intervention descriptions were generally brief making it impossible to identify which specific "ingredients" of interventions contribute most to improving outcomes.

CONCLUSIONS

Digital self-management interventions show promise, with evidence of beneficial effects on some outcomes. There is no evidence about utility in those over 65 years and no information about socioeconomic status of participants, making understanding the "reach" of such interventions difficult. Digital interventions are poorly described within reviews, with insufficient information about barriers and facilitators to their uptake and utilization. To address these gaps, a detailed quantitative systematic review of digital asthma interventions and an examination of the primary qualitative literature are warranted, as well as greater emphasis on economic analysis within trials.

A systematic review of interactive multimedia interventions to promote children's communication with health professionals: implications for communicating with overweight children

BACKGROUND

Interactive multimedia is an emerging technology that is being used to facilitate interactions between patients and health professionals. The purpose of this review was to identify and evaluate the impact of multimedia interventions (MIs), delivered in the context of paediatric healthcare, in order to inform the development of a MI to promote the communication of dietetic messages with overweight preadolescent children. Of particular interest were the effects of these MIs on child engagement and participation in treatment, and the subsequent effect on health-related treatment outcomes.

METHODS

An extensive search of 12 bibliographic databases was conducted in April 2012. Studies were included if: one or more child-participant was 7 to 11-years-of-age; a MI was used to improve health-related behaviour; child-participants were diagnosed with a health condition and were receiving treatment for that condition at the time of the study. Data describing study characteristics and intervention effects on communication, satisfaction, knowledge acquisition, changes in self-efficacy, healthcare utilisation, and health outcomes were extracted and summarised using qualitative and quantitative methods.

RESULTS

A total of 14 controlled trials, published between 1997 and 2006 met the selection criteria. Several MIs had the capacity to facilitate engagement between the child and a clinician, but only one sought to utilise the MI to improve communication between the child and health professional. In spite of concerns over the quality of some studies and small study populations, MIs were found useful in educating children about their health, and they demonstrated potential to improve children's health-related self-efficacy, which could make them more able partners in face-to-face communications with health professionals.

CONCLUSIONS

The findings of this review suggest that MIs have the capacity to support preadolescent child-clinician communication, but further research in this field is needed. Particular attention should be given to designing appropriate MIs that are clinically relevant.

Electronic media-based health interventions promoting behavior change in youth: a systematic review

IMPORTANCE

Little research has been done on the efficacy of electronic media-based interventions, especially on their effect on health or safety behavior. The current review systematically identified and evaluated electronic media-based interventions that focused on promoting health and safety behavior change in youth.

OBJECTIVE

To assess the type and quality of the studies evaluating the effects of electronic media-based interventions on health and safety behavior change.

EVIDENCE REVIEW

Studies were identified from searches in MEDLINE (1950 through September 2010) and PsycINFO (1967 through September 2010). The review included published studies of interventions that used electronic media and focused on changes in behavior related to health or safety in children aged 18 years or younger.

FINDINGS

Nineteen studies met the criteria and focused on at least 1 behavior change outcome. The focus was interventions related to physical activity and/or nutrition in 7 studies, on asthma in 6, safety behaviors in 3, sexual risk behaviors in 2, and diabetes mellitus in 1. Seventeen studies reported at least 1 statistically significant effect on behavior change outcomes, including an increase in fruit, juice, or vegetable consumption; an increase in physical activity; improved asthma self-management; acquisition of street and fire safety skills; and sexual abstinence. Only 5 of the 19 studies were rated as excellent.

CONCLUSIONS AND RELEVANCE

Our systematic review suggests that interventions using electronic media can improve health and safety behaviors in young persons, but there is a need for higher-quality, rigorous interventions that promote behavior change.

Role of video games in improving health-related outcomes: a systematic review

CONTEXT

Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it also may be useful for therapeutic purposes. The goal of this study was to determine whether video games may be useful in improving health outcomes.

EVIDENCE ACQUISITION

Literature searches were performed in February 2010 in six databases: the Center on Media and Child Health Database of Research, MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials. Reference lists were hand-searched to identify additional studies. Only RCTs that tested the effect of video games on a positive, clinically relevant health consequence were included. Study selection criteria were strictly defined and applied by two researchers working independently. Study background information (e.g., location, funding source); sample data (e.g., number of study participants, demographics); intervention and control details; outcomes data; and quality measures were abstracted independently by two researchers.

EVIDENCE SYNTHESIS

Of 1452 articles retrieved using the current search strategy, 38 met all criteria for inclusion. Eligible studies used video games to provide physical therapy, psychological therapy, improved disease self-management, health education, distraction from discomfort, increased physical activity, and skills training for clinicians. Among the 38 studies, a total of 195 health outcomes were examined. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. Study quality was generally poor; for example, two thirds (66%) of studies had follow-up periods of <12 weeks, and only 11% of studies blinded researchers.

CONCLUSIONS

There is potential promise for video games to improve health outcomes, particularly in the areas of psychological therapy and physical therapy. RCTs with appropriate rigor will help build evidence in this emerging area.

Application of biomedical informatics to chronic pediatric diseases: a systematic review

Background

Chronic diseases affect millions of children worldwide leading to substantial disease burden to the children and their families as well as escalating health care costs. The increasing trend in the prevalence of complex pediatric chronic diseases requires innovative and optimal delivery of care. Biomedical informatics applications play an important role in improving health outcomes while being cost-effective. However, their utility in pediatric chronic diseases has not been studied in a comprehensive and systematic way. The objective of this study was to conduct a systematic review of the effects of biomedical informatics applications in pediatric chronic diseases.

Methods

A comprehensive literature search was conducted using MEDLINE, the Cochrane Library and EMBASE databases from inception of each database to September 2008. We included studies of any methodological type and any language that applied biomedical informatics to chronic conditions in children and adolescents 18 years of age or younger. Two independent reviewers carried out study selection and data extraction. Quality assessment was performed using a study design evaluation instrument to appraise the strength of the studies and their methodological adequacy. Because of heterogeneity in the conditions and outcomes we studied, a formal meta-analysis was not performed.

Results

Based on our search strategy, 655 titles and abstracts were reviewed. From this set we identified 27 relevant articles that met our inclusion criteria. The results from these studies indicated that biomedical informatics applications have favourable clinical and patient outcomes including, but not limited to, reduced number of emergency room visits, improved knowledge on disease management, and enhanced satisfaction. Seventy percent of reviewed papers were published after year 2000, 89% of users were patients and 11% were either providers or caregivers. The majority (96%) of the selected studies reported improved outcomes.

Conclusion

Published studies suggested positive impacts of informatics predominantly in pediatric asthma. As electronic tools become more widely adopted, there will be opportunities to improve patient care in a wide range of chronic illnesses through informatics solutions.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

Playing for real: video games and stories for health-related behavior change

BACKGROUND

Video games provide extensive player involvement for large numbers of children and adults, and thereby provide a channel for delivering health behavior change experiences and messages in an engaging and entertaining format.

METHOD

Twenty-seven articles were identified on 25 video games that promoted health-related behavior change through December 2006.

RESULTS

Most of the articles demonstrated positive health-related changes from playing the video games. Variability in what was reported about the games and measures employed precluded systematically relating characteristics of the games to outcomes. Many of these games merged the immersive, attention-maintaining properties of stories and fantasy, the engaging properties of interactivity, and behavior-change technology (e.g., tailored messages, goal setting). Stories in video games allow for modeling, vicarious identifying experiences, and learning a story's "moral," among other change possibilities.

CONCLUSIONS

Research is needed on the optimal use of game-based stories, fantasy, interactivity, and behavior change technology in promoting health-related behavior change.

Internet telehealth for pediatric asthma case management: integrating computerized and case manager features for tailoring a Web-based asthma education program

This article reports on the development of a personalized, Web-based asthma-education program for parents whose 4- to 12-year-old children have moderate to severe asthma. Personalization includes computer-based tailored messages and a human coach to build asthma self-management skills. Computerized features include the Asthma Manager, My Calendar/Reminder, My Goals, and a tailored home page. These are integrated with monthly asthma-education phone calls from an asthma-nurse case manager. The authors discuss the development process and issues and describe the current randomized evaluation study to test whether the year-long integrated intervention can improve adherence to a daily asthma controller medication, asthma control, and parent quality of life to reduce asthma-related healthcare utilization. Implications for health education for chronic disease management are raised.

Biomedical informatics applications for asthma care: a systematic review

Asthma is a common condition associated with significant patient morbidity and health care costs. Although widely accepted evidence-based guidelines for asthma management exist, unnecessary variation in patient care remains. Application of biomedical informatics techniques is one potential way to improve care for asthmatic patients. We performed a systematic literature review to identify computerized applications for clinical asthma care. Studies were evaluated for their clinical domain, developmental stage and study design. Additionally, prospective trials were identified and analyzed for potential study biases, study effects, and clinical study characteristics. Sixty-four papers were selected for review. Publications described asthma detection or diagnosis (18 papers), asthma monitoring or prevention (13 papers), patient education (13 papers), and asthma guidelines or therapy (20 papers). The majority of publications described projects in early stages of development or with non-prospective study designs. Twenty-one prospective trials were identified, which evaluated both clinical and non-clinical impacts on patient care. Most studies took place in the outpatient clinic environment, with minimal study of the emergency department or inpatient settings. Few studies demonstrated evidence of computerized applications improving clinical outcomes. Further research is needed to prospectively evaluate the impact of using biomedical informatics to improve care of asthmatic patients.

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.