Sage Journals: Discover world-class research

Abstract

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

Introduction

Chronic diseases are health conditions that last for longer than 3 months (e.g., cancer, chronic fatigue, and depression).¹ Currently, 15%–25% of the young people (defined as 10–25 years old^2–4) from developed countries have chronic diseases.^5,6 In adolescence and young adulthood, growing up with chronic diseases impacts all developmental domains. Self-management, the process allowing young people to maintain satisfactory daily functioning despite their chronic diseases,⁷ is essential for alleviating the burden of these conditions, enhancing quality of life, and reducing health care utilization.^7–9 These behaviors are used to manage several aspects of chronic diseases (e.g., symptoms, treatments, and lifestyle changes).¹⁰ Examples of self-management are decision-making, taking action, and using resources, in order to take an active role in medical management, adoption of new behaviors, and coping emotionally.¹¹ Currently, there is a need for novel interventions in self-management that align with the interests of young people who grow up in a digital world.^12–14

For supporting chronic disease self-management needs in young people, eHealth interventions, which utilize the internet and related technologies, are promising. eHealth interventions have demonstrated efficacy in enhancing self-management.¹⁵ Particularly, these interventions have the potential to overcome barriers to care such as anonymity and accessibility, which may reduce stigma commonly experienced by the young people, as well as reduce treatment burden in terms of time and costs.¹⁶ Gamification is the utilization of game mechanics (e.g., badges, unlocking milestones, and narrative).¹⁷ In this context, there are two main possibilities. First, incorporating gamification into nongame contexts in eHealth interventions, that is, gamified eHealth tools, hereinafter referred to as gamified tools. Second, designing games for a primary purpose other than pure entertainment in eHealth tools, that is, serious games for eHealth, hereinafter referred to as serious games.¹⁸ Game mechanics align with young people’s natural interest in play, which is important for their healthy development.¹⁹ Although incorporating game mechanics into eHealth self-management interventions for young people with chronic diseases may be a particularly promising approach, previous systematic reviews focused on adults,^18,20–24 and thus, a summary of the prior available evidence in youth^18,20–24 is needed. Thus, it is important to provide an overview on game mechanics used in eHealth tools for youth and the reasons to use them, which will inform the development of new eHealth tools by the eHealth Junior Consortium (see, http://ehealthjunior.nl/). This consortium develops, evaluates, and implements eHealth tools for the well-being of young people with chronic diseases.

Objectives

Therefore, the primary aim of this systematic review is to provide an overview of gamified eHealth interventions supporting young people’s self-management of chronic diseases, with an emphasis on summarizing the game mechanics implemented in the interventions. The secondary aims are (1) to identify the developer’s rationale for implementing such game mechanics and (2) to investigate the effects of these interventions. To provide a comprehensive overview of the current state of the art, we included studies conducted in young people affected with a variety of chronic diseases (e.g., somatic and psychiatric) using gamified tools or serious games.

Research questions

The primary research question is as follows: Which game mechanics have been implemented in eHealth interventions aimed to support young people in their chronic diseases self-management? In addition, the secondary research questions are as follows: (1) What was the rationale behind the implementation of each game mechanic? and, if possible, (2) What were the effects of gamified eHealth interventions on self-management and health-related outcomes?

Materials and Methods

The protocol of this systematic review was approved by the steering committee of the eHealth Junior Consortium, preregistered (PROSPERO: CRD42021293037), and published.²⁵ Importantly, two independent reviewers, a medical doctor (M.D.S.) and a psychologist (L.L.), were trained to participate in the key processes of the present systematic review by the guarantor of the review (F.E.L.). One of the reviewers (L.L.) was involved in the conceptualization, methodology, and development of the protocol of the review. Both independent reviewers (M.D.S. and L.L.) received explanations on the aim of systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, protocol development, search strategy creation, screening, data extraction, quality assessment, synthesis, and reporting. They were provided with practice, feedback, and ongoing support by a highly multidisciplinary team including experts in systematic reviews, pediatrics, psychology, and psychiatry and game experts/designers. This support was particularly intense at the beginning of the training, including pilot testing and detailed consensus meetings to address discrepancies. Consensus meetings to address discrepancies were regularly arranged throughout the review process.

Inclusion criteria

Participants: Adolescents or young adults (between ages 10 and 25 years) with a chronic disease.

Interventions: Gamified eHealth tools or serious games for eHealth tools aiding self-management in young people with a chronic disease. Self-management behaviors are aimed at managing the disease and its effects (e.g., symptoms, treatment, physical and psychosocial consequences, and lifestyle adjustments).¹⁰ An intervention was considered intended for self-management if it addresses at least one of the following behaviors: problem solving, decision making, using resources, forming a relationship with a provider, or taking action,^26,27 performed in the domains of medical management, adopting new behaviors or roles, or psychosocial coping.²⁷

Comparator: For studies that included a comparison arm, we compared gamified interventions or serious games versus (1) usual care (comparator) or (2) nongamified (comparator) versions of eHealth interventions.

Outcome measures: To assess the effects of the interventions, we focused on three categories of outcomes: (1) self-management behaviors including problem solving, decision making, using resources, and forming a relationship with a provider and taking action²⁶; (2) effects of self-management on outcomes^27,28; and (3) antecedents of self-management such as adherence to the eHealth tool, acceptability, and user’s experience.^27,28

Studies: We included peer-reviewed articles and conference proceedings reporting primary data.

Search strategy

On August 30, 2022, we conducted an electronic search in Embase, Medline, PsycINFO Ovid, and Web of Science Core Collection. We used these databases because the topic of our review is at the intersection of biomedicine and psychology fields. Supplementary File S1 shows the search strategy. In brief, an experienced information specialist (W.M.B.) designed a search consisting of terms (both controlled thesaurus terms and terms in title or abstract) for chronic diseases such as asthma or diabetes, combined with gamification, eHealth or mobile phone applications, and self-care or coping behavior and limited to youth or adolescents. The search results were limited to articles in the English language only. To identify gray literature, the eHealth Junior Consortium members were emailed for unpublished eligible studies. To gain deeper insights in the tools identified from the included studies, we conducted a snowballing technique (using references and cites of the included studies) and a Google search (e.g., trailers and intervention websites).

Selection of studies

Metadata were imported into Mendeley Desktop, and duplicates were automatically deleted. Two researchers (M.D.S. and L.L.) independently screened records by title and abstract and then by full text for inclusion. Disagreements were resolved through discussion with a third researcher (F.E.L.).

Data extraction

The information to describe each of the eligible studies was extracted (1) by two researchers independently when presented in the main text (M.D.S. and L.L., or M.D.S. and M.M.H.; disagreements were resolved through discussion with a third researcher [F.E.L.]) or (2) by one researcher only when presented in supplementary files (M.D.S., who consulted with other researchers when needed). To guide the extraction of the game mechanics implemented in each eligible study, we used the framework of game design patterns by Björk and Holopainen²⁹ because it offers a comprehensive overview and description of game mechanics, including detailed definitions and examples. Thus, this framework was instrumental in guiding data extraction for the present review. Brief definitions of each game mechanic are provided in Supplementary File S2; for further details, readers are directed to the original source.²⁹ We carefully considered other frameworks, but we found that they were not adequate for this review because they focus on nonserious games,³⁰ the educational domain specifically³¹ or broad groups of game elements,³² or general drivers for engagement.³³ The rationale was extracted literally from the included study (see Supplementary File S3).

Risk of bias (quality) assessment

The Mixed-Methods Appraisal Tool³⁴ was used to assess the risk of bias of each eligible study (M.D.S. or L.L., who consulted with other researchers when needed).

Funding information

In line with the PRISMA statement, which advocates for transparent reporting and comprehensive documentation of the review process, we extracted the funding information from the included studies (M.D.S. or L.L., who consulted with other researchers when needed). This addition ensures transparency regarding potential additional sources of bias or conflict of interest in the included studies.

Data synthesis

A narrative (descriptive) synthesis was provided for the primary and secondary review questions. Gephi Graph Visualization and Manipulation software version 0.10 was used to create a network of game mechanics.

Results

Selection process

From 2357 records identified in the primary search, we included 34 studies.^{35–64,72–76} Using a snowballing technique, we included seven additional studies^65–71 (Fig. 1 for flowchart). From the 41 studies included in this review, 34 unique eHealth tools with gamification were identified. The main characteristics of these tools are summarized in Table 1. Of the 41 studies, 24 focused on developing tools or investigating their usability/feasibility^{36,39,41–47,49,51,53,58–62,64–67,69,72,73}, 15 on testing the effects of the interventions (eight were randomized controlled trials [RCTs]^{37,40,48,50,54,56,70,71}, two were protocols for RCTs^57,74, four had a pre-post design^38,52,55,75 and one had a single case experimental design [SCED⁶³] and two were descriptives^35,68). The quality assessment revealed that the different components within the mixed-method studies did not meet the quality criteria for each respective method, and none of the quantitative nonrandomized controlled trials adequately addressed confounders in design and analysis (see Supplementary File S4). A summary of the funding information from the included studies is presented in Supplementary File S5. When needed, a complementary Google search (e.g., trailers and intervention websites) was conducted to obtain additional information (see Supplementary File S6).

FIG. 1.

Flowchart of the selection process.

Table 1.

Overview of the eHealth Tools Identified from the Included Studies

	N gamified tools^*	N serious game tools^*
Total	20^{36,37,39,41,44–47,50,53–56,58,59,61,62,64–67,69,72–75}	14^{35,38,40,42,43,48,49,51,52,57,60,63,68,70,71}
Type of disease targeted
Somatic	16^{36,39,41,44–46,50,53–56,58,61,62,65,67,69,72–75}	10^{35,38,43,49,51,52,57,60}
Psychiatric	2^47,64,66	4^{40,42,48,63,68,70,71}
Intersection of somatic and psychiatric	2^37,59	—
Study design
Usability/feasibility	16^{36,39,41,44–47,53,55,58,59,61,62,64–67,69,72,73}	7^{42,43,49,51,60}
Randomized controlled trial	4^37,50,54,56	3^40,48,70,71
Pre-post design	2^55,75	2^38,52
Protocols for Randomized controlled trial	1⁷⁴	1⁵⁷
Descriptive	—	2^35,68
Single-case experimental	—	1⁶³
Type of tool and platform^**
Smartphone (and tablet) application	16^{36,37,39,41,44–47,50,53,55,56,58,61,62,65,67,69,73–75}	3^43,49,57
Website	2^54,64,66	1⁵²
Combination of smartphone application and website	1⁵⁹	2^48,68,70
Videogame on gaming device (Wii/Xbox/Nintendo/computer)	1⁷²	4^38,60
Videogame on computer or laptop with biofeedback	—	2^40,42,71
Virtual reality with biofeedback	—	1⁶³
Self-management domain targeted
Medical management	16^{36,37,41,44–47,50,53,55,56,58,61,62,67,69,72–75}	11^{35,38,42,43,48,49,51,52,60,68,70,71}
Adopting new behaviors/roles	11^{36,37,39,41,46,50,53,58,59,61,64–67}	7^{38,40,42,48,51,57,63,68,70,71}
Psychosocial coping	13^{36,39,41,45–47,50,53–55,59,61,64–66,69,74}	4^{40,42,51,63,71}
Self-management behavior targeted
Taking action	19^{6,37,39,41,44–47,50,53–56,58,59,61,62,64–66,67,69,72–74}	10^{38,40,42,43,49,51,60,63,71}
Using resources	18^{6,37,39,41,44–47,50,53–55,59,61,64–66,69,72–75}	9^{35,38,42,43,48,49,51,52,63,68,70,71}
Forming relationship with provider	9^{39,45,46,50,54,55,59,64–66,69,72,74}	1⁵¹
Decision-making	8^{36,39,46,53,56,58,59,62,65,67,73}	2^42,51,71
Problem solving	1⁴⁷	—

Note. ^*As some tools were described and evaluated in multiple studies (with different designs) and some studies described multiple tools, the number of supporting references does not always match the frequency of tools with specific characteristics.

The type and platform of one tool were unclear.³⁵

Characteristics of eHealth tools

Regarding the type of gamification, 20 tools were gamified^{36,37,39,41,44–47,50,53–56,58,59,61,62,64–67,69,72–75} and 14 tools were serious games.^{35,38,40,42,43,48,49,51,52,57,60,63,68,70,71} Tools were developed for a broad range of chronic diseases, including somatic,^{35,36,38,39,41,43–46,49–58,60–62,65,67,69,72–75} psychiatric,^{40,42,47,48,63,64,66,68,70,71} and those at the intersection of both (i.e., chronic pain).^37,59

Most tools (n = 26) aimed at multiple self-management domains and behaviors.^{36–42,44–51,53–56,58,59,61–73} Twenty-nine tools supported taking action,^{36–47,49–51,53–56,58–64,66,67,69,71–74} such as taking medication^44,49,60,73 or increasing physical activity.^36,48,50 Using resources was targeted in 27 tools,^{36–39,41–55,59,61,63,64,66,68–75} for example, through monitoring disease activity or self-management behaviors.^{37,44–46,56,59,61,62,65,72,73} Ten tools supported forming a relationship with a provider^{39,45,46,50,51,54,55,59,64-66,69,72,74} and decision making, respectively.^{36,39,42,46,51,53,56,58,59,62,65,67,73} Only the anorexia nervosa companionship app targeted problem solving directly, with a module on how to manage emotional dysregulation.⁴⁷

Implemented game mechanics (primary research question)

We identified 55 distinct game mechanics; Figure 2 presents an overview. The most commonly used were rewards (n = 17 [50%]), score (n = 15 [44%]), creative control (n = 14 [41%]), and social interaction (n = 11 [32%]). In comparison with gamified tools, the number and diversity of game mechanics applied were higher in serious games (Fig. 3). A small group of game mechanics was combined in several tools; for example, 11 tools combined rewards and score (Fig. 4, see Supplementary File S7 for the more detailed figure^{41,43–46,51,53,55,56,60–62,69}). Of the 55 distinct game mechanics, 51 were used in serious games compared with 27 in gamified tools, of which 23 were found in both.

FIG. 2.

Number of tools using specific game mechanics. The total number of tools and distinct game mechanics is included between brackets.

FIG. 3.

Number of game mechanics implemented per tool. The total number of tools per category is included between brackets. The median number (range) of game mechanics implemented per tool for gamified tools was 5 (1–10) and for serious games was 8 (4–20).

FIG. 4.

Combinations of game mechanics. All nodes represent a game mechanic (see label). Links between nodes represent common use in a tool. The thickness of the links represents the frequency of co-occurrence (the thicker the link, the more often the connected game mechanics are used in the same tool). For readability, we chose to filter out links with a weight of only 1 (see Supplementary File S7 for the unfiltered network). The color of the node reflects betweenness centrality (the frequency of the node being on the shortest path between other nodes; the darker the node, the larger the dependency of other nodes). The high betweenness centrality of some game mechanics (e.g., Games within Games, Puzzle Solving, and Characters) reflects their frequent use in serious games, causing co-occurrence in tools with a large variety of other rare game mechanics (e.g., Lives, Evade, and Units). This is contrasted by the relatively low betweenness centrality of the common game mechanics Rewards and Social Interaction, illustrating their main occurrence in gamified tools.

Rationale for gamification (secondary research question)

A rationale for implementing gamification in general was provided for 29 eHealth tools (85%, Table 2 depicts an overview, whereas Supplementary File S3 contains detailed information). The most common rationale for gamification was promoting engagement,^{37,38,40,41,44,45,47,49,55,57,59,62–64,67,68,72,75} behavioral change,^{43,46,47,60,64,68,75} and effectiveness.^{40,43,55,60,68,71} For serious games in specific, authors saw games as an effective tool to learn,^{35,38,42,48,60,68,70,71,76}, specifying special needs of children with specific psychiatric diseases^42,63 and explaining the preference for game-based learning by the young age of the users.³⁸ Moreover, in rationales within serious games, the young age was brought into connection with their interest in games⁶³ and technology⁶⁰ in general.³⁸ Games are tailored to the special needs of children with diseases^42,63 and intellectual and social maturation levels.³⁸ A rationale to use a specific game mechanic was provided for 97 instances (45%, Table 3). Most of these rationales were directly related to increasing engagement with the tool or the targeted self-management behavior. Although for more than half of the tools, the design of the self-management intervention was based on a behavioral change,^{36,39,44,46,50,51,54,58,60,61,65,67} learning theory,^40,52,63 or a psychological therapy,^{40,42,47,48,68,70,71} only seven tools^{36,40,46,48,50,51,58,67,68,70} directly linked the implementation of specific game mechanics to this theoretical basis. For instance, ATOMIC,³⁶ COOL Passport,⁵⁰ and Reactivate⁴⁶ were based on the social cognitive theory.⁷⁷ Consequently, they used game mechanics that were largely similar. However, how the mechanics were linked to theory constructs differed; for example, social interaction was used in all three tools but for different reasons: for self-efficacy and outcome expectations,³⁶ social support,^36,46 or self-judgment.⁵⁰

Table 2.

eHealth Tools with Gamification for Chronic Disease Self-Management in Youth and Their Rationale

Tool, chronic condition, country, year	System, aim, and description	Rationale for gamification
L’Affaire Birman, DM1, France, 2016⁵²	Web-based serious game to educate on flexible insulin therapy. The player manages the DM1 of character “Alex” during a playful investigation.	None given
Anorexia nervosa companionship app, anorexia nervosa, France, 2021⁴⁷	App, to evaluate and manage negative emotions and behaviors focused on weight loss, an unguided self-help program. Based on cognitive behavioral therapy it has the following modules: psychoeducation, symptoms management, and emotional evaluation.	Engagement for participation and behavioral change
Asthma self-management app, asthma, United States, 2017⁴⁴	App, wireframes, to increase asthma self-management by providing information, logging medications, symptoms, and triggers, and sending notifications and alerts.	Engagement
ASTHMAXcel Adventures, Asthma, United States, 2020⁷⁵	App, for smartphones and tablets on iOS and Android platform, to improve asthma control. It consists of short educational videos followed by games in which knowledge is tested.	Engagement to retain users User-friendly Behavior change
ATOMIC, multiple sclerosis, Canada, 2022³⁶	App, to promote physical activity in order to lower disease activity, perceived barriers, depression, and fatigue, as well as heighten self-efficacy and goal setting. Part of an intervention program. The app contains goal setting and facilitates social support through leader and discussion board, educational modules, and personalized feedback and coaching.	Reward, incentive
AYA STEPS, survivors of childhood cancer, United States, 2019⁴¹	App (Adolescent and Young Adult Self-management via Texting, Education, and Plans for Survivorship), to enhance health and well-being. It combines: Delivery and storage of tailored text messages to support adjustment and health after treatment; Digital survivorship care plans; Applets for facilitating survivorship self-management.	Engagement
Bant, DM1, Canada, 2012,⁶² 2017⁵⁶	App, iPhone-based, connected to glucometer, aims to improve health outcomes by increasing self-care behavior and treatment adherence. It prompts participants to improve blood glucose trends by warning if trends are out of range, providing trending screens and decision support.	Engagement⁶²
Bim, chronic kidney disease, Brazil, 2020⁴³	App, for phones and tablets on Android platform, to improve adherence to medical nutritional instructions by encouraging users to take care of a character “Bim” with daily self-management (e.g., food and water intake, hygiene, use of medication, dialysis at home and hospital) to be used during hemodialysis.	[about games] Effective for behavioral change; Increase access to information on the disease
DEEP, attention deficit hyperactivity disorder and/or autism spectrum disorder, Netherlands, 2020⁶³	Video reality biofeedback game, to cope with anxiety and as a result diminish disruptive classroom behavior (anxiety) by exploring an underwater fantasy world using the participant’s own breathing (measured with a waist belt) to control their movement.	[about videogames] Teach new strategies by their immersive emotional experience Suitable for population with special needs Motivate and engage children Practice skills Low cost
Diabetes self-management platform, DM1, United States, 2013⁴⁵	app, on Android platform, to increase diabetic self-management by recording key metrics per day. Social media component by ‘friending’ other users to track health progress of friend, comment on key metrics.	Engagement
Digital games (Adherence Warrior, Berry Match Game, Cat O’Polt), HIV, United States, 2018⁶⁰	Videogames, to be played on videogame device, connected to medication dispenser aimed at improving adherence to medication and teaching players about the effect of HIV by getting rewarded in the game when opening the pillbox on time.	Adherence Interest of youth in electronics. Effective for behavior change by making learning entertaining and by changing attitudes
Dojo, externalizing problems or anxiety, Netherlands, 2015⁴²; 2016⁷¹	Videogame, helps youths to recognize and control their physiological and emotional arousal. It incorporates relaxation tutorials and the teaching of emotion regulation techniques. Players are provided with real-time biofeedback (heart rate), reinforcing the relaxation abilities and helping them to master the techniques.Controlling physiological reactions facilitates success in the game, which encourages the player to learn to recognize the association between emotional arousal and physical reactivity and to regulate physiological arousal more effectively as the game progresses.	Learning by doing, suited for youth with intellectual disabilities⁴² Practice⁴² Engaging⁴² Training opportunity for emotions, electing behaviors⁴² Effectiveness⁷¹
FUN QUEST, childhood cancer survivors, Japan, 2022³⁸	Game-based learning program on computer, to improve adherence to survivorship care. Role-playing game in which the main character is requested to answer health-related questions after which he/she receives advice from other characters.	[about games] Accepted by youth Simulation Preference of learning of youth Learning on own initiative Engagement Tailored to social and intellectual maturation
Care & Organize Our Lifestyle (COOL) passport, congenital heart disease, 2021⁵⁰	App, self-regulation-based mHealth program that provides information on health management and policies coupled with gameplay. It is combined with the Health Promotion cloud, a Web-based interactive platform that facilitates communication between users, shows health promotion messages. The overall goal of the interventions is increasing disease knowledge and physical activity.	Pleasure Incentive
Home Telecare for monitoring CF, Australia, 2005⁷²	Computer-based measurement module/spirometer/measurement device connected to a computer, to monitor long function of patients with cystic fibrosis from home. It guides patients through conducting the measurements and gives instant feedback (represented by a boat race). Includes symptom diary.	Incentive
iManage, sickle cell disease, Canada, 2017⁶⁵; United States, 2021³⁹	App, accessible through smartphone and tablet, adjunct to a group intervention to increase self-management and self-efficacy. Functionalities: Track daily pain and mood Create, monitor, and complete self-management goals See progress of others	None given
JIApp, juvenile idiopathic arthritis, United Kingdom, 2017⁶¹	App, on smartphone, to monitor disease activity and side effects and support self-management (treatment adherence and engagement in health promoting behaviors). Functionalities: Provide general information Monitor symptoms, thoughts, and feelings Diary section for questions to ask in consultation Remind for treatment adherence	Reward
Kiss MyAsthma, asthma, Australia, 2018⁶⁷; 2021⁵⁸	A goal-setting app, on smartphone (cross-platform), to improve asthma self-management. Eight sections, including asthma history, goals, inspirations, reminder, and information.	Engagement⁶⁷
Mobile Asthma Action Plan (AAP), asthma, United States, 2015⁷³	App, for smartphone on iOS or Android platform, to support asthma control by daily prompts to symptoms or peak flow measurements and reminders for taking medication. Feedback consists of positive messaging or follow-up actions.	None given
MOST+, Mental health condition, Australia, 2017⁶⁶; 2020⁶⁴	Enhanced Moderated Online Social Therapy, Web-based, aims to increase mental health. It is a merge of interactive web therapy, peer-to-peer Web-based social networking, peer and clinical moderation, and on demand web chat with registered clinicians.	Engagement⁶⁶ Behavioral change⁶⁶
MyPainPal, chronic pain, Australia, 2021⁵⁹	App, cloud-based (cross-platform Web- and mobile-based), to support chronic pain self-management. Functionalities: Self-monitoring diary and calendar Goal setting Tips and strategies Social	Engagement
MyREADY Transition BBD, brain-based disabilities, Canada, 2021⁵⁷	App, to educate and empower for transition from pediatric to adult care. Journey in the city with a virtual coach that helps to navigate through buildings and introduces educational sections.	Engagement
MyT1DHero, DM1, United States, 2017⁶⁹, 2021⁵⁵	App, to facilitate diabetes-specific positive parent-adolescent communication and improve diabetes-related outcomes. It links an adolescent and their parent through 2 separate app interfaces and prompts adolescents to test blood glucose. Informs on how to address out-of-range blood glucose values.	Engagement⁵⁵ Effectiveness⁵⁵
Pain Squad+, Cancer, Canada, 2017⁵³	App, Web-based smartphone application, to give real-time pain support by giving self-management advice based on reported pain. Users play the role of law-enforcement officers investigating pain cases.	None given
PERGAMON, DM1, Netherlands, 2018⁵¹	Educational gaming and coaching platform that consists of a website, mobile app, and sensor device. It combines games with a virtual coach to enhance self-management. It consists of the main adventure and puzzle game “Mystery of TikoTako” and seven mini-games. Users complete in-game and real-world goals related to monitoring blood glucose levels, acquiring skills and knowledge, and social activities.	Adherence Reward
Power Defense, DM1, Canada, 2011³⁵	Videogame, to improve diabetes numeracy skills by controlling a power base station, symbolic for someone with DM1, training skills mainly implicitly. The player has to balance the amount of energy under challenging circumstances.	Interactivity of learning environment
Reactivate, obesity, Ireland, 2014⁴⁶	App, on android smartphone, as a remote treatment aid, consisting of self-monitoring, goal setting, rewards system, and peer support. It has tips for weight management (text, video, image) and encourages to engage in daily goal setting and goal review.	Behavioral change
RAGE-Control, anger dyscontrol, Germany, 2021⁴⁰	Videogame, coupled to a heart rate monitor, to train emotional regulation by practicing modulation of physiological arousal during a challenging task. In the game players maneuver a spaceship and fire at enemy spaceships. Firing is disabled when heart rate increases above a threshold.	Engagement, motivation, challenge Train emotional regulation skills Efficacy
SPARX, mild to moderate depression, New Zealand, 2012⁴⁸; The Netherlands, 2016⁷⁰; New Zealand, 2021⁶⁸	Interactive fantasy game on CD-ROM for the treatment of depression by delivering cognitive behavioral therapy in seven modules. A self-chosen avatar undertakes challenges to restore the balance in a fantasy world. A computerized guide opens and ends every module to put game into real-life perspective and give homework challenges.	Adherence⁴⁸ Learning⁶⁸ Behavioral change⁶⁸ Engagement⁶⁸ Effective⁶⁸
T1D, DM1, United Kingdom, 2017⁴⁹	App, on iOS platform, to increase disease knowledge and medication adherence. It has links to relevant websites, an educational game situated in the pancreas, and an avatar.	Engagement
TEENCOPE, DM1, United States, 2014⁵⁴	Web-based psychoeducational intervention, to train coping skills. Interactive lessons, tailored computer-generated feedback based upon user responses, video animations, and the ability for users to interact with each other using a discussion board and profile viewing.	None given
WebMAP Mobile, chronic pain, United States, 2020³⁷	App, on Android and iOS platform, to learn pain self-management skills, combined with parent program through website. Interactive, self-guided app with four components: Treatment modules Skills library (audio clips, videos of peers, infographics) Daily check-in (record and track pain, sleep, activity, mood) Skills tracker (record and track skills practice)	Engagement Encourage skills practice

Additional information on implemented game mechanics was found with Google search for the following tools: L’Affaire Birman, MyREADY Transition BBD, and Pain Squat+ (S6). CF, cystic fibrosis; DM1, diabetes mellitus type 1.

Table 3.

Rationale for the Use of Specific Game Mechanics

Game mechanic	Reported rationale for use	Tool
Rewards	Engagement	Asthma self-management app,⁴⁴ JIApp,⁶¹ WebMAP Mobile³⁷
	Incentive	Asthma self-management app,⁴⁴ AYA STEPS⁴¹
	Incentive to increase medication adherence	Cat O’Polt⁶⁰
	Pleasure as incentive to exercise more frequently	COOL Passport⁵⁰
	Encourage self-management behavior	Bant^56,62
	Encourage skills practice	WebMAP Mobile³⁷
	Rewards system as behavioral change tool	Reactivate⁴⁶
	Enjoyment	JIApp⁶¹
Score	Engagement, incentive	AYA STEPS⁴¹
	Encourage self-management behavior	Bant^56,62
	Learn to understand health needs	Bim⁴³
	Appealing to younger users	JIApp⁶¹
Creative control	Incentive, reward	ATOMIC³⁶
	Empowerment	PERGAMON⁵¹
	Create personal connection	T1D⁴⁹
	Wish of respondents to personalize	AYA STEPS⁴¹
Social interaction	Social support	ATOMIC,³⁶ MOST+,⁶⁴ MyPainPal⁵⁹
	Peer support as behavioral change tool	Reactivate⁴⁶
	Encourage self-disclosure	MyT1DHero⁶⁹
	Learn from each other	TEENCOPE⁵⁴
	Facilitate peer comparison in the self-judgment dimension	COOL Passport⁵⁰
	Motivate other user for self-management	Diabetes self-management platform⁴⁵
	Outcome Expectations, self-efficacy	ATOMIC³⁶
	Empowerment	PERGAMON⁵¹
	Engagement	MyPainPal⁵⁹
	Adherence, elicit positive health behavior	Bant⁶²
Games within games	Enhance learning	ASTHMAXcel Adventures,⁷⁵ Power Defense³⁵
	Trigger emotion to provide the opportunity to practice acquired techniques	Dojo⁴²
	Teach and test knowledge needed for disease self-management	PERGAMON⁵¹
	Stimulate motor coordination and memory	Bim⁴³
	Engagement, incentive	Asthma self-management app⁴⁴
	Interest participants	COOL Passport⁵⁰
	Encourage exploration of the app	MyREADY Transition BBD
Levels	Frequent rewards	Bant⁶²
Levels	Pleasure as incentive to exercise more frequently	COOL Passport⁵⁰
Resources	Incentive	ATOMIC³⁶
	Incentive to increase medication adherence	Berry Match⁶⁰
	Pleasure as incentive to exercise more frequently	COOL Passport⁵⁰
	Enjoyment	JIApp⁶¹
	Reward	ATOMIC³⁶
Characters	Making therapeutic concepts more accessible, engaging, and compelling	MOST+⁶⁴
Characters	Learn through virtual experiences	FUN QUEST³⁸
Avatars	Incentive	Asthma self-management app,⁴⁴ ATOMIC³⁶
	Engagement	Asthma self-management app⁴⁴
	Reward	ATOMIC³⁶
	Learn through virtual experiences	FUN QUEST³⁸
	Personal and interactive experience	T1D³⁸
Dedicated game facilitators	Engagement, novelty	Kiss MyAsthma⁶⁷
Dedicated game facilitators	Game into context, provide education	SPARX⁴⁸
High score lists	Encourage behavior change	ASTHMAXcel Adventures,⁷⁵ COOL Passport⁵⁰
	Paradigm to emulate, promote peer interaction	COOL Passport⁵⁰
	Social support, vicarious learning	ATOMIC³⁶
	Social comparison	Reactivate⁴⁶
Player-defined goals	Address motivation and confidence to change behavior, effectiveness, relevance	Kiss MyAsthma⁶⁷
	Goal setting as behavioral change tool, to stimulate practice and action planning, to act on antecedents	Reactivate⁴⁶
	Self-efficacy	ATOMIC³⁶
	Need of young people	MyPainPal
Progress indicators	Self-monitoring as behavioral change tool, feedback on progress	Reactivate
Puzzle solving	Discover and use CBT knowledge	SPARX⁶⁸
	Teach and test knowledge needed for disease self-management, repetition of playing the game to make best-practice behavior one’s own	PERGAMON⁵¹
	Evoke emotions to use newly acquired emotion regulation strategies	Dojo⁷¹
Cognitive immersion	Encourage memory	Bim⁴³
Maneuvering	Stimulate motor coordination	Bim⁴³
	Reinforce the practical use of the relaxation techniques	Dojo⁴²
	Creating physiological arousal	RAGE-Control⁴⁰
Narrative structures	Nonthreatening, easy to understand, making therapeutic concepts more accessible, engaging, and compelling	MOST+⁶⁴
Narrative structures	Learn through virtual experiences	FUN QUEST³⁸
Collecting	Metaphor for collecting positive thoughts	SPARX⁶⁸
Combat	Creating physiological arousal	RAGE-Control⁴⁰
Enemies	Analog to real-life DM1 management	Power Defense³⁵
Enemies	Creating physiological arousal	RAGE-Control⁴⁰
Overcome	Reinforce the practical use of the relaxation techniques	Dojo⁴²
Power-ups	Incentive to increase medication adherence	Berry Match⁶⁰
Team play	Desire for social interaction	iManage⁶⁵
Team play	Peer support as behavioral change tool	Reactivate⁴⁶
Tools	Incentive, reward	ATOMIC³⁶
Ability losses	Analog to real-life DM2 management	Power Defense³⁵
Ability losses	Penalty for not downregulating physiological arousal	RAGE-Control⁴⁰
Movement limitations	Effective for regulating anxiety	DEEP⁶³
Movement limitations	Reinforce the practical use of the relaxation techniques	Dojo⁴²
Outcome indicators	Incentive	Home Telecare for monitoring CF⁷²
Outcome indicators	Instruction	Mobile Asthma Action Plan (AAP)⁷³
Penalties	Reinforce the practical use of the relaxation techniques	Dojo⁴²
Renewable resources	Incentive to increase medication adherence	Adherence Warrior,⁶⁰ Cat O’Polt⁶⁰
Resource management	Representation to implicitly train numeracy skills, analog to real-life DM2 management	Power Defense³⁵
Resource management	Teach and test knowledge needed for disease self-management	PERGAMON⁵¹
Cards	Exercise (personal strengths to increase psychological well-being)	MOST+⁶⁴
Competition	Increase motivation for self-management tasks	iManage⁶⁵
Contest	Reinforce the practical use of the relaxation techniques	Dojo⁴²
Evade	Reinforce the practical use of the relaxation techniques	Dojo⁴²
Game pauses	Support learning process of young people, time to engage in practice activities	MyREADY Transition BBD⁵⁷
Game pauses	Novelty	COOL Passport⁵⁰
Goal indicators	Feedback on breathing	DEEP⁶³
Role-playing	Learn through virtual experiences	FUN QUEST³⁸
Time limits	Teach and test knowledge needed for disease self-management	PERGAMON⁵¹
Traverse	Reinforce the practical use of the relaxation techniques	Dojo⁴²

Rationales are summarised. For detailed rationales extracted directly from the included studies, see Supplementary File S3.

Importantly, involving patients in codesign processes yielded rationales for implementing certain game mechanics, as these were most appealing to the target population.^{41,50,59,61,65} In serious games, a broad range of game mechanics facilitated the practice of self-management skills. For this rationale, FUN QUEST, among others, included characters, avatars, roleplaying, and narrative structures.³⁸

Efficacy of gamification and serious games (secondary research question)

We did not perform meta-analyses because only eight RCTs were included and primary outcomes and control conditions were diverse (Supplementary File S8). There was no effect observed in six (75%) RCTs^{37,50,54,56,70,71} and positive effects in two RCTs, both testing a serious game.^40,48 A consistent finding across studies with and without control groups was that higher engagement was associated with larger effect sizes.^{37,39,55,56,64} Studies gave little insight on mediators for engagement. The effect of gamification in general could only be deduced from the study on TEENCOPE, which was compared with a nongamified eHealth intervention and did not perform better in engaging.⁵⁴ The effect of specific game mechanics on engagement or other outcomes was not assessed in any of the included studies.

Discussion

In this systematic review, we observed that 55 distinct game mechanics were implemented in 34 eHealth tools. The most used were rewards, score, creative control, and social interaction. We also showed that the most common rationale for gamifying eHealth tools was to provide young people with an engaging experience. Experimental research is scarce, precluding to quantify the effects of gamified eHealth interventions in improving young people’s self-management of chronic diseases.

Implemented game mechanics (primary research question)

A total of 55 distinct game mechanics were implemented in the included studies, 216 times in total altogether. Rewards, score, and social interaction were frequently used. A previous review also identified these game mechanics as common in eHealth tools for medical education.²⁴ The common use of the same game mechanics in diverse populations, with different characteristics and needs, may raise concerns,⁷⁸ particularly in relation to effectiveness and integration.^79,80 Tailoring the game mechanics in eHealth tools to support self-management, considering the age and specific needs associated with a particular chronic disease, may be important for optimal outcomes.^79–81 However, the present review does not allow us to determine which specific combination of game mechanics may best suit a particular disease, as the studies included involved a wide range of diseases.

From the 34 eHealth tools included in this review, 20 (59%) were gamified and 14 (41%) were serious games. Of the 55 game mechanics implemented, 4 were unique in gamified tools, 28 in serious games, and 23 were utilized in both types of tools. In general, the level of gamification (i.e., the number and diversity of implemented game mechanics) was higher in serious games in comparison with gamified tools. In line with prior literature,²⁴ the use of gamification for self-management purposes may have been insufficient in certain gamified eHealth tools, as it was solely based on point or reward systems.^37,61 However, other gamified eHealth tools integrated point or reward systems with additional mechanics such as creative control^{36,39,44,47,55,59,65,69} or social interaction.^{36,39,45,46,50,55,56,59,62,65,69} While these types of gamified tools may be more effective, the current state of the art does not provide firm conclusions. The lack of concrete insights might be explained by the paucity of efficacy studies. In addition, RCTs have been suggested to be unappropriated to assess complex interventions like mHealth.⁸² For gaining insight into the working mechanism of game mechanics, more adaptive study designs might be a solution. Examples are a SCED⁸³ (n = 1, 1 study found in this review⁶³) and a multiphase optimization strategy trial, which allows for testing individual intervention components and their combinations.⁸⁴ Even with these adaptive designs, it needs to be considered that a game mechanic is not a sole entity and depends on its integration in the tool and combination with other mechanics.

Rationale for gamification (secondary research question)

One of the secondary aims of this review was to identify the rationale for gamification in self-management facilitated by eHealth. This aim was conducted at two levels: the general rationale for using gamification in eHealth tools and the rationale for implementing a specific game mechanic. We found that providing a general rationale for using gamification or serious games was more common than for a specific game mechanic; 85% of the tools versus 45% of the times. The rationale most frequently given for both implementing game mechanics in general and for the choice of specific game mechanics was to provide young people with an engaging experience,^{37,38,40,41,44,45,47,49,55,57,59,62–64,67,68,75} which was robustly observed from previous reviews without age restrictions on eHealth interventions for mental health and well-being¹⁸ and chronic disease management and healthy lifestyle.²³ Collectively, for young people, incorporating game mechanics into eHealth self-management interventions seems appropriate because of their natural interest in play, which was reflected by the rationales for serious games.¹⁹

In some studies included in the present review, it was highlighted that involving young people with chronic diseases in codesign when gamifying eHealth tools for self-management may help to identify which game mechanics are the most appealing to the target population.^{41,50,59,61,65} However, this speculation remains to be corroborated in experimental research.⁸⁵ Indeed, a previous review concluded that gamification in mental health apps lacked a clear rationale.²² We additionally showed that the link between specific game mechanics and self-management theory was not explicitly stated for most of the tools included in the present review. Thus, on behalf of the eHealth Junior Consortium, we recommend that future research reports the rationale for utilizing specific game mechanics in eHealth tools to ensure a proper alignment with evidence-based practice, which is highly valued in healthcare.⁸⁰

Efficacy of gamification and serious games (secondary research question)

In this study, we found that experimental designs (i.e., RCT and SCED) were scarce and heterogeneous. This limitation does not seem to be specific to research on eHealth or young people, as it has also been observed in other reviews that do not focus on eHealth and do not have age restrictions.^86–89 In general, the limited experimental evidence makes it difficult to quantify the effects of gamification in the self-management of chronic diseases in young people. Only two (25%) of the eight RCTs included in this review showed that eHealth interventions utilizing gamification may improve self-management of chronic diseases. Consistent with previous reviews,^86,89,90 the studies that we included had small sample sizes and may have been underpowered. Consequently, it is challenging to draw quantitative conclusions from our review. Thus, future studies should be well-powered. In our risk of bias (quality) assessment, we also identified that future nonexperimental research should adequately control for confounders as is a common limitation in the available literature.

Limitations and strengths

This review has some limitations. First, the small number of RCTs included in this review precluded to conduct meta-analysis to quantify the effects of eHealth interventions using gamification. At least, we provided a qualitative synthesis, which was not conducted by previous reviews on different populations.²⁴ Second, the inclusion of studies published in English only may limit the generalizability of our results. Third, the rapidly evolving nature of eHealth terminology may have resulted in failing to identify relevant studies despite our carefully designed search term combinations. Fourth, common limitations in the field, such as incomplete descriptions of eHealth tools, may have negatively impacted our findings. Fifth, a deeper level of understanding on how specific game mechanics were used to engage users may be of interest,⁹¹ which would require to conduct qualitative studies in the targeted population. Sixth, we paid scarce attention to how well several game mechanics were integrated in each of the tools and if they aligned with the therapeutic goal(s) of the tools, which might impact the efficacy of game mechanics.^80,92

This review also has several strengths. First, the inclusion of heterogeneous samples and interventions, such as somatic and psychiatric diseases, as well as gamified tools and serious games, helped us to provide a comprehensive overview of the current state of the art. Our comprehensive overview may serve as a valuable resource for game developers, health professionals, and researchers offering starting points for further development and evaluation of gamified eHealth interventions. A priority of the eHealth Junior Consortium for further research is to identify both universal/transdiagnostic and individual/personal mechanisms promoting self-management acknowledging the importance of both types of mechanisms. Second, we carefully designed our search strategy, inclusion/exclusion criteria, and time span coverage, searching in four major databases (Embase, Medline, PsycINFO, and Web of Science). In addition, two independent researchers were involved in all the information provided in the main text of this review (e.g., electronic search, selection of studies, and extraction of information for main tables and figures). Third, this work is embedded within the eHealth Junior Consortium, providing a highly multidisciplinary vision from diverse fields including pediatrics, psychiatry, psychology, game design, and eHealth, among others.

Conclusions

This review provides an overview of the use of game mechanics in eHealth tools focusing on improving self-management of chronic diseases in youth. We identified 34 eHealth tools utilizing 55 distinct game mechanics; the most common were rewards, score, creative control, and social interaction. For most of the tools (85%), a general rationale for utilizing gamification was provided, which often was to facilitate engaging experiences. A rationale for using specific game mechanics was less commonly provided (only for 45% of the game mechanics). Thus, future research should report the rationale for utilizing specific game mechanics in eHealth tools. The scarce experimental research available precludes testing the effectiveness of using gamification in the eHealth tools identified in the present review. The general rationale for gamifying and the rationale for using specific game mechanics identified in this review may inform priorities for testing their effectiveness in future experimental research.

Footnotes

Acknowledgments

The protocol of the present systematic review was agreed in an online meeting of the eHealth Junior Consortium on 9/11/2021. Discussions about the findings were carried out in online meetings on 14/07/2022 and 19/01/2023. The authors thank all the participants for their active participation and valuable suggestions.

Authors’ Contributions

M.D.S.: search, study selection, data extraction, writing, visualization, and project administration. L.L.: conceptualization, methodology, search, study selection, data extraction, and writing. M.M.H.: conceptualization, data extraction, and review. J.v’t.V.: conceptualization and review. V.T.V.: conceptualization and review. W.M.B.: conceptualization, methodology, and review. M.H.J.H.: conceptualization, review, and project administration. R.C.V.: conceptualization and review. S.L.N.: conceptualization, review, and project administration. F.E.-L.: conceptualization, methodology, writing, supervision, and project administration. F.E.-L. is the guarantor of the review.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This publication is part of the “Feeling good, despite illness; Accessible eHealth supporting the well-being of chronically ill children.” The eHealth Junior Consortium project (with project number NWA.1292.19.226) of the NWA research program “Research on Routes by Consortia (ORC),” which is funded by the Netherlands Organization for Scientific Research (NWO) to M.H.J.H. F.E.-L. was supported by the Ramón y Cajal 2021 Excellence Research Grant action from the Spanish Ministry of Science and Innovation (FSE/AGENCIA ESTATAL DE INVESTIGACIÓN, RYC2021-034311-I to FE-L) and Alicia Koplowitz Foundation (grant number: N/A to FE-L).

Supplementary Material

References

Hal

, Tierolf

, Rooijen

, et al. Een actueel perspectief op kinderen en jongeren met een chronische aandoening in Nederland. Omvang, samenstelling en participatie. Verwey-Jonker Instituut: Utrecht; 2019.

Society for Adolescent Health and Medicine. Young adult health and well-being: A position statement of the Society for Adolescent Health and Medicine. J Adolesc Health, 2017; 60(6):758–759; doi: 10.1016/j.jadohealth.2017.03.021

World Health Organization. Adolescence: A period needing special attention. Health for the World’s Adolescents report. 2014. Available from: http://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html

United Nations. Global Issues: Youth. n.d. Available from: https://www.un.org/en/global-issues/youth

Van Der Lee

, Mokkink

, Grootenhuis

, et al. Definitions and measurement of chronic health conditions in childhood: A systematic review. JAMA, 2007; 297(24):2741–2751.

Cleave

, Gortmaker

, Perrin

. Dynamics of obesity and chronic health conditions among children and youth. Jama, 2010; 303(7):623–630.

Gauci

, Bloomfield

, Lawn

, et al. Effectiveness of self-management programmes for adolescents with a chronic illness: A systematic review. J Adv Nurs, 2021; 77(9):3585–3599; doi: 10.1111/jan.14801

Lozano

, Houtrow

. Supporting self-management in children and adolescents with complex chronic conditions. Pediatrics, 2018; 141(Suppl 3):S233–S241; doi: 10.1542/peds.2017-1284H

Allegrante

, Wells

, Peterson

. The annual review of public health is online at. Annu Rev Public Health, 2019; 40:127–146; doi: 10.1146/annurev-publhealth

10.

Lorig

. Self-management education: More than a nice extra. Med Care, 2003; 41(6):699–701; doi: 10.1097/01.MLR.0000072811.54551.38

11.

Corbin

, Strauss

. Unending Work and Care: Managing Chronic Illness at Home. Jossey-Bass; 1988.

12.

Camp-Spivey

, Logan

, Nichols

. Theoretical and contextual considerations for self-management strategies of children and adolescents with chronic diseases: An integrative review. J Child Health Care, 2022; 26(2):242–261; doi: 10.1177/13674935211013697

13.

Catarino

, Charepe

, Festas

. Promotion of self-management of chronic disease in children and teenagers: Scoping review. Healthcare (Basel), 2021; 9(12); doi: 10.3390/healthcare9121642

14.

Coe

, Doy

, Enomoto

, et al. Gen Z Mental Health: The Impact of Tech and Social Media. McKinsey Health Institute; 2023.

15.

Arsad

, Syed Soffian

, Nadira Megat Kamaruddin

, et al. The impact of eHealth applications in healthcare intervention: A systematic review. J Health Res, 2022; 37(3):178–189; doi: 10.56808/2586-940X.1020

16.

Thabrew

, Stasiak

, Kumar

, et al. A cognitive behavioral therapy-, biofeedback-, and game-based eHealth intervention to treat anxiety in children and young people with long-term physical conditions (starship rescue): Co-design and open trial. JMIR Serious Games, 2021; 9(3):e26084; doi: 10.2196/26084

17.

Deterding

, Dixon

, Khaled

, et al. From game design elements to gamefulness: Defining “Gamification”. In Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments, MindTrek 2011; Association for Computing Machinery: New York, NY; 2011; pp 9–15; doi: 10.1145/2181037.2181040

18.

Cheng

VWS

, Davenport

, Johnson

, et al. Gamification in apps and technologies for improving mental health and well-being: Systematic review. JMIR Ment Health, 2019; 6(6):e13717; doi: 10.2196/13717

19.

Nijhof

, Vinkers

, van Geelen

, et al. Healthy play, better coping: The importance of play for the development of children in health and disease. Neurosci Biobehav Rev, 2018; 95:421–429; doi: 10.1016/j.neubiorev.2018.09.024

20.

Muangsrinoon

, Boonbrahm

. Game elements from literature review of gamification in healthcare context. J Technol Sci Educ, 2019; 9(1):20–31; doi: 10.3926/jotse.556

21.

Pereira

, Duarte

, Rebelo

, et al. LNCS 8518—A review of Gamification for health-related contexts. Springer; 2014.

22.

Auf

, Dagman

, Renström

, et al. Gamification and nudging techniques for improving user engagement in mental health and well-being apps. In: Proceedings of the Design Society Cambridge University Press; 2021; pp. 1647–1656; doi: 10.1017/pds.2021.426

23.

Sardi

, Idri

, Fernández-Alemán

. A systematic review of gamification in e-Health. J Biomed Inform, 2017; 71:31–48; doi: 10.1016/J.JBI.2017.05.011

24.

Garett

, Young

. Health care gamification: A study of game mechanics and elements. Tech Know Learn, 2019; 24(3):341–353; doi: 10.1007/s10758-018-9353-4

25.

Estévez-López

, Levelt

, van ’t Veer

, et al. Game mechanics in eHealth interventions promoting self-management in young people with chronic diseases: A protocol for a systematic review and meta-analyses from the eHealth Junior Consortium. BMJ Open, 2022; 12(9):e059581; doi: 10.1136/bmjopen-2021-059581

26.

Lorig

, Ritter

, Stewart

, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care, 2001; 39(11):1217–1223; doi: 10.1097/00005650-200111000-00008

27.

Van De Velde

, De Zutter

, Satink

, et al. Delineating the concept of self-management in chronic conditions: A concept analysis. BMJ Open, 2019; 9(7):e027775; doi: 10.1136/bmjopen-2018-027775

28.

Gosak

, Vrbnjak

, Pajnkihar

. Self-management of chronic diseases: A concept analysis. Pielegniarstwo XXI Wieku/Nursing in the 21st Century, 2022; 21(2):115–121; doi: 10.2478/pielxxiw-2022-0006

29.

Björk

, Holopainen

. Patterns in Game Design. In: Game Development Series. Charles River Media; 2004.

30.

Hunicke

, Leblanc

, Zubek

. MDA: A Formal Approach to Game Design and Game Research. (AAAI workshop on Challenges in Game). AAAI Press; 2014.

31.

Toda

, Oliveira

, Klock

, et al. A taxonomy of game elements for gamification in educational contexts: Proposal and evaluation. Proceedings—IEEE 19th International Conference on Advanced Learning Technologies, ICALT 2019, Maceió; 2019; pp 84–88; doi: 10.1109/ICALT.2019.00028

32.

Tondello

, Mora

, Nacke

. Elements of gameful design emerging from user preferences. CHI PLAY 2017—Proceedings of the Annual Symposium on Computer-Human Interaction in Play; 2017; 129–140; doi: 10.1145/3116595.3116627

33.

Chou

Y-K

. Actionable Gamification: Beyond Points, Badges, and Leaderboards. Createspace Independent Publishing Platform: Scotts Valley; 2015.

34.

Hong

, Pluye

, Fàbregues

, et al. Improving the content validity of the mixed methods appraisal tool: A modified e-Delphi study. J Clin Epidemiol, 2019; 111:49–59.e1; doi: 10.1016/j.jclinepi.2019.03.008

35.

Bassilious

, DeChamplain

, McCabe

, et al. Power defense: A video game for improving diabetes numeracy. In: 2011 IEEE International Games Innovation Conference, 2011; pp. 124–125; doi: 10.1109/IGIC.2011.6115113

36.

Stephens

, Schneiderman

, Finlayson

, et al. Feasibility of a theory-informed mobile app for changing physical activity in youth with multiple sclerosis. Mult Scler Relat Disord, 2022; 58:103467; doi: 10.1016/j.msard.2021.103467

37.

Palermo

, de la Vega

, Murray

, et al. A digital health psychological intervention (WebMAP Mobile) for children and adolescents with chronic pain: Results of a hybrid effectiveness-implementation stepped-wedge cluster randomized trial. Pain, 2020; 161(12):2763–2774; doi: 10.1097/j.pain.0000000000001994

38.

Masumoto

, Nakagami-Yamaguchi

, Nambu

, et al. A pilot study of game-based learning programs for childhood cancer survivors. BMC Cancer, 2022; 22(1); doi: 10.1186/s12885-022-09359-w

39.

Hood

, Nwankwo

, Walton

, et al. Mobile health use predicts self-efficacy and self-management in adolescents with sickle cell disease. Transl Behav Med, 2021; 11(10):1823–1831; doi: 10.1093/tbm/ibab041

40.

Ducharme

, Kahn

, Vaudreuil

, et al. A “Proof of Concept” randomized controlled trial of a video game requiring emotional regulation to augment anger control training. Front Psychiatry, 2021; 12:591906; doi: 10.3389/fpsyt.2021.591906

41.

Schwartz

, Psihogios

, Henry-Moss

, et al. Iterative development of a tailored mHealth intervention for adolescent and young adult survivors of childhood cancer. Clin Pract Pediatr Psychol, 2019; 7(1):31–43; doi: 10.1037/cpp0000272

42.

Schuurmans

, Nijhof

, Vermaes

, et al. A pilot study evaluating “Dojo,” a videogame intervention for youths with Externalizing and Anxiety Problems. Games Health J, 2015; 4(5):401–408; doi: 10.1089/g4h.2014.0138

43.

Santana

, de Souza Freitas

ATV

, Barreto

, et al. Serious game on a smartphone for adolescents undergoing hemodialysis: Development and evaluation. JMIR Serious Games, 2020; 8(3):e17979; doi: 10.2196/17979

44.

Sage

, Roberts

, Geryk

, et al. A self-regulation theory-based asthma management mobile app for adolescents: A usability assessment. JMIR Hum Factors, 2017; 4(1):e5; doi: 10.2196/humanfactors.7133

45.

Padman

, Jaladi

, Kim

, et al. An evaluation framework and a pilot study of a mobile platform for diabetes self-management: Insights from pediatric users. Stud Health Technol Inform, 2013; 192:333–337.

46.

O’Malley

, Dowdall

, Burls

, et al. Exploring the usability of a mobile app for adolescent obesity management. JMIR Mhealth Uhealth, 2014; 2(2):e29; doi: 10.2196/mhealth.3262

47.

Naccache

, Mesquida

, Raynaud

J-P

, et al. Smartphone application for adolescents with anorexia nervosa: An initial acceptability and user experience evaluation. BMC Psychiatry, 2021; 21(1):467; doi: 10.1186/s12888-021-03478-7

48.

Merry

, Stasiak

, Shepherd

, et al. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial. BMJ, 2012; 344(7857):e2598; doi: 10.1136/bmj.e2598

49.

McCulloch

, Hope

, Loranger

, et al. How to effectively design and create a concept mobile application to aid in the management of type 1 diabetes in adolescents. J Vis Commun Med, 2017; 40(3):101–108; doi: 10.1080/17453054.2017.1366828

50.

Lin

P-J

, Fanjiang

Y-Y

, Wang

J-K

, et al. Long-term effectiveness of an mHealth-tailored physical activity intervention in youth with congenital heart disease: A randomized controlled trial. J Adv Nurs, 2021; 77(8):3494–3506; doi: 10.1111/jan.14924

51.

Klaassen

, Bul

KCM

, Op den Akker

, et al. Design and evaluation of a pervasive coaching and gamification platform for young diabetes patients. Sensors (Basel), 2018; 18(2); doi: 10.3390/s18020402

52.

Joubert

, Armand

, Morera

, et al. Impact of a serious videogame designed for flexible insulin therapy on the knowledge and behaviors of children with type 1 diabetes: The LUDIDIAB pilot study. Diabetes Technol Ther, 2016; 18(2):52–58; doi: 10.1089/dia.2015.0227

53.

Jibb

, Cafazzo

, Nathan

, et al. Development of a mHealth real-time pain self-management app for adolescents with cancer: An iterative usability testing study. J Pediatr Oncol Nurs, 2017; 34(4):283–294; doi: 10.1177/1043454217697022

54.

Jaser

, Whittemore

, Chao

, et al. Mediators of 12-month outcomes of two Internet interventions for youth with type 1 diabetes. J Pediatr Psychol, 2014; 39(3):306–315; doi: 10.1093/JPEPSY/JST081

55.

Holtz

, Mitchell

, Holmstrom

, et al. An mHealth-based intervention for adolescents with type 1 diabetes and their parents: Pilot feasibility and efficacy single-arm study. JMIR Mhealth Uhealth, 2021; 9(9):e23916–12; doi: 10.2196/23916

56.

Goyal

, Nunn

, Rotondi

, et al. A mobile app for the self-management of type 1 diabetes among adolescents: A randomized controlled trial. JMIR Mhealth Uhealth, 2017; 5(6):e82; doi: 10.2196/mhealth.7336

57.

Gorter

, Amaria

, Kovacs

, et al. CHILD-BRIGHT READYorNot Brain-Based Disabilities Trial: Protocol of a randomised controlled trial (RCT) investigating the effectiveness of a patient-facing e-health intervention designed to enhance healthcare transition readiness in youth. BMJ Open, 2021; 11(3):e048756; doi: 10.1136/bmjopen-2021-048756

58.

Davis

, Peters

, Calvo

, et al. A consumer designed smartphone app for young people with asthma: Pilot of engagement and acceptability. J Asthma, 2021; 58(2):253–261; doi: 10.1080/02770903.2019.1680997

59.

Cooke

, Richards

, Tjondronegoro

, et al. myPainPal: Co-creation of a mHealth app for the management of chronic pain in young people. Inform Health Soc Care, 2021; 46(3):291–305; doi: 10.1080/17538157.2021.1892697

60.

Castel

, Qasmieh

, Greenberg

, et al. Digital gaming to improve adherence among adolescents and young adults living with HIV: Mixed-methods study to test feasibility and acceptability. JMIR Serious Games, 2018; 6(4):e10213–18; doi: 10.2196/10213

61.

Cai

, Beste

, Chaplin

, et al. Developing and evaluating JIApp: Acceptability and usability of a smartphone app system to improve self-management in young people with juvenile idiopathic arthritis. JMIR Mhealth Uhealth, 2017; 5(8):e121; doi: 10.2196/mhealth.7229

62.

Cafazzo

, Casselman

, Hamming

, et al. Design of an mHealth app for the self-management of adolescent type 1 diabetes: A pilot study. J Med Internet Res, 2012; 14(3):e70; doi: 10.2196/jmir.2058

63.

Bossenbroek

, Wols

, Weerdmeester

, et al. Efficacy of a virtual reality biofeedback game (DEEP) to reduce anxiety and disruptive classroom behavior: Single-case study. JMIR Ment Health, 2020; 7(3):e16066; doi: 10.2196/16066

64.

Alvarez-Jimenez

, Rice

, D’Alfonso

, et al. A novel multimodal digital service (moderated online social therapy+) for help-seeking young people experiencing mental ill-health: Pilot evaluation within a national youth e-mental health service. J Med Internet Res, 2020; 22(8):e17155; doi: 10.2196/17155

65.

Crosby

, Ware

, Goldstein

, et al. Development and evaluation of iManage: A self-management app co-designed by adolescents with sickle cell disease. Pediatr Blood Cancer, 2017; 64(1):139–145; doi: 10.1002/PBC.26177

66.

D’Alfonso

, Santesteban-Echarri

, Rice

, et al. Artificial intelligence-assisted online social therapy for youth mental health. Front Psychol, 2017; 8(JUN):796; doi: 10.3389/fpsyg.2017.00796

67.

Davis

, Peters

, Calvo

, et al. “Kiss myAsthma”: Using a participatory design approach to develop a self-management app with young people with asthma. J Asthma, 2018; 55(9):1018–1027; doi: 10.1080/02770903.2017.1388391

68.

Fleming

, Lucassen

, Stasiak

, et al. Technology Matters: SPARX—computerised cognitive behavioural therapy for adolescent depression in a game format. Child Adolesc Ment Health, 2021; 26(1):92–94; doi: 10.1111/CAMH.12444

69.

Holtz

, Murray

, Hershey

, et al. Developing a patient-centered mHealth app: A tool for adolescents with type 1 diabetes and their parents. JMIR Mhealth Uhealth, 2017; 5(4):e53; doi: 10.2196/MHEALTH.6654

70.

Poppelaars

, Tak

, Lichtwarck-Aschoff

, et al. A randomized controlled trial comparing two cognitive-behavioral programs for adolescent girls with subclinical depression: A school-based program (Op Volle Kracht) and a computerized program (SPARX). Behav Res Ther, 2016; 80:33–42; doi: 10.1016/J.BRAT.2016.03.005

71.

Scholten

, Malmberg

, Lobel

, et al. A randomized controlled trial to test the effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PLoS One, 2016; 11(1):e0147763; doi: 10.1371/JOURNAL.PONE.0147763

72.

Magrabi

, Lovell

, Henry

, et al. Designing home telecare: A case study in monitoring cystic fibrosis. Telemed J E Health, 2005; 11(6):707–719.

73.

Burbank

, Lewis

, Hewes

, et al. Mobile-based asthma action plans for adolescents. J Asthma, 2015; 52(6):583–586.

74.

Holtz

, Mitchell

, Hershey

, et al. Using an mHealth app to transition care of type 1 diabetes from parents to teens: Protocol for a pilot study. JMIR Res Protoc, 2018; 7(10):e10803; doi: 10.2196/10803

75.

Hsia

, Singh

, Njeze

, et al. Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma. Ann Allergy Asthma Immunol, 2020; 125(5):581–588; doi: 10.1016/j.anai.2020.07.018

76.

Bassilious

. Numeracy in Adolescents with Type 1 Diabetes: Assessment and Gaming Intervention—A Pilot Project. University of Illinois: Chicago; 2013.

77.

Bandura

. Social cognitive theory: An agentic perspective. Annu Rev Psychol, 2001; 52:1–26.

78.

Wouters

, Van der Spek

, Van Oostendorp

. Current practices in serious game research: A review from a learning outcomes perspective. In Games-based learning advancements for multi-sensory human computer interfaces: techniques and effective practices. IGI Global; 2009; pp. 232–250.

79.

Fizek

. Why fun matters: In search of emergent playful experiences. In: Rethinking Gamification. Meson Press: Lüneburg, Germany; 2014.

80.

Siriaraya

, Visch

, Boffo

, et al. Game design in mental health care: Case study–based framework for integrating game design into therapeutic content. JMIR Serious Games, 2021; 9(4):e27953; doi: 10.2196/27953

81.

DeSmet

, Van Ryckeghem

, Compernolle

, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med, 2014; 69:95–107; doi: 10.1016/j.ypmed.2014.08.026

82.

Pham

, Wiljer

, Cafazzo

. Beyond the randomized controlled trial: A review of alternatives in mHealth clinical trial methods. JMIR Mhealth Uhealth, 2016; 4(3):e107; doi: 10.2196/mhealth.5720

83.

Michie

, Yardley

, West

, et al. Developing and evaluating digital interventions to promote behavior change in health and health care: Recommendations resulting from an international workshop. J Med Internet Res, 2017; 19(6):e232; doi: 10.2196/jmir.7126

84.

Baptist

, Gibson-Scipio

, Carcone

, et al. Asthma and technology in emerging African American adults (The ATHENA Project): Protocol for a trial using the multiphase optimization strategy framework. JMIR Res Protoc, 2022; 11(5):e37946; doi: 10.2196/37946

85.

DeSmet

, Thompson

, Baranowski

, et al. Is participatory design associated with the effectiveness of serious digital games for healthy lifestyle promotion? A meta-analysis. J Med Internet Res, 2016; 18(4):e94; doi: 10.2196/jmir.4444

86.

Holtz

, Murray

, Park

. Serious games for children with chronic diseases: A systematic review. Games Health J, 2018; 7(5):291–301; doi: 10.1089/g4h.2018.0024

87.

Thomas

, Sivakumar

, Babichenko

, et al. Mapping behavioral health serious game interventions for adults with chronic illness: Scoping review. JMIR Serious Games, 2020; 8(3):e18687; doi: 10.2196/18687

88.

Drummond

, Monnier

, Tesnière

, et al. A systematic review of serious games in asthma education. Pediatr Allergy Immunol, 2017; 28(3):257–265; doi: 10.1111/pai.12690

89.

Theng

, Lee

JWY

, Patinadan

, et al. The use of videogames, gamification, and virtual environments in the self-management of diabetes: A systematic review of evidence. Games Health J, 2015; 4(5):352–361; doi: 10.1089/g4h.2014.0114

90.

Charlier

, Zupancic

, Fieuws

, et al. Serious games for improving knowledge and self-management in young people with chronic conditions: A systematic review and meta-analysis. J Am Med Inform Assoc, 2016; 23(1):230–239; doi: 10.1093/jamia/ocv100

91.

van Dooren

MMM

, Visch

, Spijkerman

. The design and application of game rewards in youth addiction care. Information (Switzerland), 2019; 10(4):126; doi: 10.3390/info10040126

92.

Veldmeijer

, Terlouw

, van ’t Veer

, et al. Harnessing virtual reality simulation in training healthcare workers in handling patients with suspected COVID-19 infections: Results of training and lessons learned about design. Design for Health, 2022; 6(1):44–68; doi: 10.1080/24735132.2022.2059997

93.

Van der Kooij

, Hoogendoorn

, Spijkerman

, et al. Validation of serious games. IJSG, 2015; 2(3); doi: 10.17083/ijsg.v2i3.75

94.

Lansing

, Berg

. Topical Review: Adolescent self-regulation as a foundation for chronic illness self-management. J Pediatr Psychol, 2014; 39(10):1091–1096; doi: 10.1093/jpepsy/jsu067

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

1.34 MB

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

Abstract

Introduction

Objectives

Research questions

Materials and Methods

Inclusion criteria

Search strategy

Selection of studies

Data extraction

Risk of bias (quality) assessment

Funding information

Data synthesis

Results

Selection process

Characteristics of eHealth tools

Implemented game mechanics (primary research question)

Rationale for gamification (secondary research question)

Efficacy of gamification and serious games (secondary research question)

Discussion

Implemented game mechanics (primary research question)

Rationale for gamification (secondary research question)

Efficacy of gamification and serious games (secondary research question)

Limitations and strengths

Conclusions

Footnotes

Acknowledgments

Authors’ Contributions

Author Disclosure Statement

Funding Information

Supplementary Material

References

Supplementary Material