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Abstract

Introduction:

The use of serious games is a popular approach to help children with Type 1 diabetes (T1D) learn how to self-manage. Many different game mechanisms exist. However, it is unclear which game mechanisms a serious game should include to teach self-management to children with T1D. Therefore, the aim of this scoping review is to map and describe the game mechanisms used in serious games that teach children with T1D how to self-manage and explain how they contribute to teaching self-management.

Methods:

A systematic scoping review was conducted to map and describe the important game mechanisms published before 23 September 2020. A comprehensive search was performed in the PubMed, CINAHL, Embase, PsycINFO, Scopus, and Education Database. Relevant literature was selected, synthesized, and reported.

Results:

Of the 800 articles identified, 18 were included in this systematic scoping review. The game mechanisms used in serious games that teach self-management included narrative contexts, feedback, avatars, simulations, goals, levels, and social interactions.

Discussion:

This review identified 7 game mechanisms used in serious games that teach children how to self-manage. A serious game is most effective in teaching self-management when it is T1D-oriented and when multiple game mechanisms are combined. However, the most effective combination of game mechanisms has yet to be determined.

Keywords

children game mechanisms scoping review self-management serious game type 1 diabetes

Introduction

Type 1 diabetes (T1D) is one of the most common chronic diseases diagnosed in children younger than 15 years of age.^1,2 Living with T1D requires a high degree of self-management,^3,4 which is tasks an individual must undertake to control the disease and/or minimize the risk of short- and long-term complications.^5,6 For T1D self-management is complex and includes constant balancing of food (carbohydrates), physical activity, and insulin.^2,7 Due to the complexity of self-management, children may not be able to comprehend it.^2,8 However, involving children in self-management from preadolescence (aged 8-14) is crucial for maintaining optimal glycemic control.^1,2,7,9 For this to happen, he/she needs to learn how to self-manage, which involves the acquisition of knowledge, skills, self-efficacy, and motivation.¹⁰

Serious games, which are defined as digital games in which design element characteristics are used in nongame contexts,¹¹ are increasingly used as a learning platform for children with T1D in T1D education.^12
-15 Serious games are an effective tool because they are particularly appealing and engaging^13,16 compared to traditional methods for education which rely heavily on written materials.¹⁵ Serious games stimulate problem-solving, reflections on behavior, and improvements in short- and long-term memory.^12,14,17
-19 Studies have demonstrated that serious games developed for children with T1D entail a significant learning gain¹⁷ and induce the acquisition of knowledge, skills, self-efficacy, and motivation, which teaches children self-management.^18,20

When developing a serious game, game mechanisms (GMs) are used to entertain players as they educate and change behavior.^15,16,21
-23 GMs are mechanisms that relate to games. GMs can be implemented in a given thing or activity and thus make it playable.²⁴ GMs can be treated as building blocks,¹¹ and a wide variety of potential GMs exist. To the best of the authors’ knowledge, no previous study has examined which GMs a serious game should contain to teach children with T1D how to self-manage. Therefore, the aim of the present scoping review is to map GMs used in serious games that teach children with T1D aged 8 to 14 how to self-manage. Moreover, it aims to provide a description of the mapped GMs and explain how they contribute to teaching self-management.

Methods

Protocol

A systematic scoping review was conducted to provide a comprehensive narrative synthesis of the previously published literature regarding the GMs used in serious games that teach children with T1D aged 8 to 14 how to self-manage. Both Green et al²⁵ and the PRISMA statement were used as guidelines throughout the review process.²⁶

The Search Strategy

The PubMed, CINAHL, Embase, PsycINFO, Scopus, and Education Database were systematically searched for eligible articles published before September 23, 2020. Combinations of the following search terms were used: (1) children, (2) diabetes, (3) learning/education, and (4) (serious/video) games. To broaden the search, synonyms and near synonyms were included. The search terms included a combination of thesaurus terms and additional, appropriate free-form text. An additional chain search was conducted, including a search in Web of Science.

Study Selection

This systematic scoping review includes articles on GMs and descriptions of these in serious games that teach children with T1D (aged 8-14) how to self-manage. No methodological restrictions or date limitations were applied to include all known literature. Publications in the English and Scandinavian languages were included. Articles were excluded if the full text was not available (Table 1).

Table 1.

In- and Exclusion Criteria.

Inclusion criteria	Articles that focused on children (aged 8-14) diagnosed with T1D
Inclusion criteria	Articles that focused on and described the GMs used in serious games that teach self-management
Exclusion criteria	Articles that included GMs without describing them
	Articles not written in the English or Scandinavian languages
	Articles for which full text was not available

The study selection process encompassed multiple screenings by 3 authors (JN, KS, and CD). First, all of the eligible literature was identified, followed by a manual removal of duplicates. Next, the titles and abstracts of the remaining articles were screened to clarify their relevance. If neither the title nor the abstract treated serious games or GMs and self-management, the article was excluded. In uncertain cases, the article was included for full review. The remaining articles were included for full critical review. If an article was excluded during the full review, the reason was registered. All cases of disagreement between the authors during the study selection process was resolved through discussion.

The Synthesis

Three authors (JN, KS, and CD) validated and thoroughly read the final sample. Notes on the aims of the articles as well as the names, types and aims of the serious games; the target populations; the results; and the GMs used were organized into a table (Appendix 1). GMs described in the articles were identified and discussed until agreement was reached among the 3 authors (JN, KS, and CD). Each identified GM was described and the related effect on self-management was summarized.

Results

As illustrated in Figure 1, 800 articles were identified and screened. Subsequently, 87 articles were excluded as duplicates, and 638 articles were excluded after reviewing the titles and abstracts, leaving 75 full-text articles. A final sample of 18 articles was included (Appendix 1).

Figure 1.

Selection of articles. The process included several steps leading to the final sample of articles (n = 18) included in this systematic scoping review.

Based on the synthesis of the reviewed literature, 7 GMs emerged: (1) narrative contexts, (2) feedback, (3) avatars, (4) simulations, (5) goals, (6) levels, and (7) social interactions. The GMs are presented in decreasing order according to the number of articles including a given GM (Table 2).

Table 2.

Game Mechanisms Used in the Articles Included in This Scoping Review.

No.	Game mechanism	No. (%) of articles (n = 18)
1	Narrative contexts	18 (100)
2	Feedback	18 (100)
3	Avatars	16 (89)
4	Simulations	14 (78)
5	Goals	14 (78)
6	Levels	12 (67)
7	Social interactions	10 (56)

Narrative Contexts

Narrative contexts were described in all 18 articles (Table 3). Narrative contexts are stories that form the background of the game.²⁷ These revolved around T1D and simulated meaningful and recognizable self-management situations^28
-45 and were attractive, funny and happy.^28,41,44 Settings were described as both realistic medical^28,39 and fantasy themed.^{31,33,34,36,37,40
-42} In more than half of the articles, the narratives revolved around helping a character with T1D self-management.^{30,32
-34,36,37,39,41
-43} In other articles, the narratives were about a health professional who helps patients with T1D.^28,38,39 Health-based narratives were also designed as either action-adventure^{31,33,34,37,40,44} or more realistic.^28
-30,39

Table 3.

The GM Narrative Contexts. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Ebrahimpour et al²⁸	Related to T1D and options in the real world (story: a nurse who helps with self-management)	Transfers knowledge, skills, and abilities
	Medical setting, eg, a hospital	Increases motivation for learning
	Attractive, funny and happy scenario	Demystifies and reduces distress and fear
	Storytelling	Demystifies and reduces distress and fear
Calle-Bustos et al²⁹	Realistic and related to a self-management situation (story: count carbohydrates in food)	Transfers knowledge
Calle-Bustos et al²⁹	Augmented reality	Transfers knowledge
Glasemann et al³⁰	Realistic and related to T1D and self-management situations (stories: 1) everyday situation (meal), 2) take care of a monster with T1D)	Transfers knowledge
	Represent food children know and like	Motivates to learn
	Represent food children know and like	Creates a sense of virtual responsibility
Brox et al³¹	Related to T1D (story: glucose race with race representations)	Tricks the user into unknowingly using knowledge about T1D and self-management
Brox et al³¹	Typical action adventure	Learns and trains understanding
Thompson et al³²	Realistic; appealing to intended audience; representing structures, fears, concerns and behavioral issues (story: take care of a character with T1D)	Transfers skills and knowledge
Liberman³³	T1D-oriented and models game challenges after T1D challenges (story: help an elephant with T1D self-manage)
Liberman³³	Fantasy theme (summer camp)
Liberman³⁴	Related to T1D (story: make self-management decisions and see realistic health consequences)
Liberman³⁴	Action adventure
Peters et al³⁵	T1D related (story: help self-manage challenging, relevant daily life events)
Rønningen et al³⁶	T1D related (story: a fish with T1D living in an aquarium; the child becomes an assistant that helps with meals and medicine)
Rønningen et al³⁶	Fantasy theme
Baghaei et al³⁷	Represents T1D problems (story: Super Mario with T1D must save a princess)	Increases engagement
Baghaei et al³⁷	Typical action adventure	Increases engagement
Pesare et al³⁸	Simulates real T1D situations and outcomes (story: be a doctor helping a patient with self-management)	Corrects wrong attitudes and increases understanding of T1D
Pesare et al³⁸		Trains the user to handle daily activities
Lauritzen et al³⁹	Relates to T1D and simulate real T1D situations and outcomes (story: a diabetes nurse who helps patients do self-management)	Provides better insights into T1D, improves self-management, and increases adherence to treatment
Bomark et al⁴⁰	Relates to T1D (a glucose race in which the child controls the avatar with T1D)	Tricks the user into unknowingly using T1D knowledge
	Typical action-adventure	Learns and trains the understanding of T1D
	Typical action-adventure	Improves problem-solving and planning
D’Aprile et al⁴¹	Relates to real T1D and self-management situations (story: little Takos get fit together in a special gym, in which they learn useful techniques to control levels of Energy-G)	Trains in useful techniques to control blood glucose levels
	Attractive narrative metaphor or storytelling	Actively engages users
	A fantasy world inspired by Japanese culture	Supports critical thinking on the nutrition-related blood glucose changes and lifestyle habits
Brown et al⁴²	Simulates real T1D situations and outcomes (story: help two elephants with T1D in a summer camp do self-management)
Brown et al⁴²	Fantasy theme (summer camp)
Moosa et al⁴³	Relates to T1D and self-management (story: manage a character’s blood glucose level by distinguishing between different foods)	Keeps users engaged, motivated and relaxed
Moosa et al⁴³	Arcade game	Keeps users playing for a longer time
Sparapani et al⁴⁴	Meaningful for children with T1D and related to T1D (story: a person with T1D on an adventure with friends, experiencing unprecedented situations in a leisure setting)	Allows users to practice skills/behavior and demonstrate knowledge in real-world situations
	Stories that are entertaining and funny	Convinces users that change is possible
	Stories that are entertaining and funny	Motivates users to continue playing the game and encourages them to engage in healthy behaviors
Kamel Boulos et al⁴⁵	Related to real T1D and self-management situations	Reframes T1D as a challenge that can be overcome
Kamel Boulos et al⁴⁵	Relevant, recognizable	Reframes T1D as a challenge that can be overcome

The outcomes of T1D-oriented narratives were demystification,²⁸ increased understanding of self-management,^31,38
-41 and an easier transfer of knowledge and skills from serious games to real-world situations.^28
-30,32,38 Furthermore, they contributed to engagement and motivation.⁴⁵

Feedback

Feedback was included in all 18 articles (Table 4). Feedback is all kinds of output from the game, which informs about progression and/or performance.²⁷ Feedback was given on performance^{28,32-34,37,42} and/or the (correct/incorrect) choices and actions made.^{28-30,33,34,36,44} Feedback was informative and explanatory^30,33,44 and served as updates on progression.^34,35 Feedback assumed various forms, including (a) rewards^{28,30,31,34-37,39-45}; (b) encouragement and acknowledgment^29,32,35-37; (c) onscreen performance indicators^36-38,42,43; (d) character interactions,^32-34,37,44 eg, facial expression changes³⁶; realistic health consequences for the character^34,36,44; (e) message boxes^36-38,43; and (f) voice messages.^28,36

Table 4.

The GM Feedback. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Ebrahimpour et al²⁸	Given for (correct/incorrect) performance, behaviors, choices	Increases confidence, gives the ability to overcome fears and control emotions in the real world
Ebrahimpour et al²⁸	Type(s): verbal and visual encouragement	Encourages, provides motivation, and enhances self-confidence
Calle-Bustos et al²⁹	Given for correct/wrong answers
Calle-Bustos et al²⁹	Type(s): score—number of correct answers
Glasemann et al³⁰	Given for correct/wrong answers, completion of all tasks, solving of tasks in specific times	Users see improvements and compete with others
	Type(s): explanations, points, bonus points, magic points
	Score list
Brox et al³¹	Given for completion	Offers incentives to keep playing
	Type(s): achievements, rewards	Offers social learning (leaderboard)
	Leaderboard	Offers social learning (leaderboard)
Thompson et al³²	Given for performance	Demonstrates consequences of being in poor control
Thompson et al³²	Type(s): changes in the character, encouragement	Demonstrates consequences of being in poor control
Liberman³³	Given for health choices, performance	Offers motivating factors for improving health behavior
	Type(s): support, information, health consequences on avatars	Offers knowledge gains
	Personalized, individualized	Offers knowledge gains
Liberman³⁴	Given for actions, choices, performance	Motivates, engages, and appeals
	Type(s): realistic health consequences for the characters, points, continuous updates on progress toward the goals, remediation	Corrects mistakes and improves performance
	Immediate, cumulative
	Individualized, constructive
Peters et al³⁵	Type(s): encouragement, personalized achievements, points, badges, visualization of progress	Enhances intrinsic motivation, offers learning gain, and induces the feeling of competence
	Leaderboards	Increases productivity and effort
	Leaderboards	Offers extrinsic motivation (rewards)
Rønningen et al³⁶	Given for opening the game, correct behavior, performance. Wrong behavior leads to loss of previously earned rewards	Explicitly assures users that an action is managed correctly, resulting in learning
	Type(s): gold coins, free goldfish, medicinal packets (advantage in the game), praise, resources for progression, written updates on progression, glucose barometer, acknowledgment, changes in the goldfish’s facial expression	Extends playing time; users complete all tasks and thereby progress and learn (rewards)
	High-score list
Baghaei et al³⁷	Given for performance	Promotes understanding of blood sugar level changes
	Type(s): rewards, knowledge-rich visual information (on how they perform and what to do to perform better), cheering, onscreen performance indicators	Increases the motivation to learn
	Cannot lose any rewards	Enhances engagement and increases the chance that users repeats the game (rewards)
Pesare et al³⁸	Given for performance	Promotes understanding and reflections on the relationship between actions and blood sugar levels
Pesare et al³⁸	Type(s): glucometer to visualize a sliding bar with the glycemia values, useful tips during the game
Lauritzen et al³⁹	Given for performance
	Type(s): points and achievements, virtual patients are happy/unsatisfied
	Leaderboard
Bomark et al⁴⁰	Given for performance and progress	Offers incentives to repeat a task and continue playing until the task is mastered
	Type(s): achievements (represent progress)
	Leaderboards
D’Aprile et al⁴¹	Given for completion of a task	Promotes an understanding of good practices and motivates users to behave in a healthy and responsible way
	Type(s): Tako points	Stimulates the formal learning process
	Ranking based on scored points	Stimulates the formal learning process
Brown et al⁴²	Given for performance, appropriate self-care choices	Promotes an understanding of users’ choices on blood glucose
	Type(s): blood glucose meter, points
	Instant
Moosa et al⁴³	Given for performance, correct item collection (decreased for incorrect item collection)	Promotes an understanding of what is required to make correct decisions about insulin collection to avoid the risks of hypo- and hyperglycemia
Moosa et al⁴³	Type(s): messages, glucose level bar, points
Sparapani et al⁴⁴	Given for decisions	Promotes learning, understanding and feelings of competence, alerting users whether they are on the right track
Sparapani et al⁴⁴	Type(s): points, prizes, tokens to exchange, immediate reflections on health condition, informational positive comments	Provides extrinsic motivation/incentives (to perform tasks that do not bring pleasure) (rewards)
Kamel Boulos et al⁴⁵	Given for completing a task, for progressing toward the goal	Keeps users engaged in self-management
Kamel Boulos et al⁴⁵	Type(s): experience points	Keeps users engaged in self-management

Feedback contributed to learning, reflection, understanding of T1D and self-management, and it corrected misunderstandings.^{33-35,37,38,42-44} Furthermore, feedback led to increased confidence, induced the feeling of competence^28,35,36,44 and increased the motivation both to play, learn, and engage in self-management.^{28,33-35,37,44,45}

Rewards

Rewards emerged as a subcategory of feedback. Different types of rewards were included: (a) points,^{30,34,35,39,41-45} (b) badges,³⁵ (c) coins,³⁶ (d) prizes,⁴⁴ (e) tokens,⁴⁴ (f) advantages,³⁶ and (g) praise.³⁶ Rønningen et al³⁶ also included rewards when the game was opened to motivate players to play repeatedly. In 2 articles, it was argued that earned rewards should be lost when the character does something wrong,^36,43 while Baghaei et al³⁷ were opposed to losing earned rewards. The accumulation of rewards, especially points, was used to place users on a high-score list,^{30,31,35,36,39-41,43} which motivated them to improve performance.^30,40

Rewards primarily served as motivators to extend play time and thereby gain intended learning.^{28,31,35-37,40,44,45} Other outcomes included explicit assurance that an action was managed correctly,^36,41 enhancement of confidence,²⁸ and understanding of what was required to make correct decisions.⁴³

Avatars

Avatars refer to a (virtual) representation of a person controlled by the player.⁴⁶ The GM was commonly identified^28,30-44 (Table 5). The majority of the articles described avatars as (fantasy) characters with T1D^{30-37,39,41-44} who demonstrated appropriate self-management^{32-34,36,37,39,41,42,44} and thereby served as trustworthy and positive role models.^32-34,42,44 Role model avatars increased the likelihood that the child would emulate the avatars’ behaviors, making it easier to learn self-management.^32-34,44 Avatars could also be a health professional taking care of a person with T1D.^28,38,39 These types of avatars taught the concepts of T1D and T1D-related skills^28,39 and helped resolve misunderstandings while correcting incorrect behaviors.^28,38

Table 5.

The GM Avatars. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Ebrahimpour et al²⁸	Avatar(s): nurse who teaches about T1D	Teaches the concepts of T1D
	Cartoon characters, human-like animation	Helps clear up misunderstandings
	Cartoon characters, human-like animation	Provides observational learning
Glasemann et al³⁰	Avatar(s): sweet monster with T1D	Teaches virtual responsibility
Glasemann et al³⁰	Selects own monster and assigns a name	Teaches virtual responsibility
Brox et al³¹	Avatar(s): fantasy character with T1D	Engages users
	Cannot die	Allows users to identify with the avatar(s)
	Cannot die	Promotes social learning
Thompson et al³²	Avatar(s): realistic, appealing, and trustworthy “expert” role model with T1D	Conveys knowledge and refines skills
Thompson et al³²		Enhances self-efficacy and competence
Liberman³³	Avatars(s): Packy and Marlon, two elephants with T1D	Reduces stigmatization and enhances confidence, making it easier to engage in self-management
Liberman³³	Customize the self-care regimen of the character to match that of the user
Liberman³⁴	Avatar(s): Captain Novolin, a superhero with T1D	Boosts self-esteem, increases attention, optimizes credibility, and increase the likelihood that users will emulate the character’s behaviors
Liberman³⁴	Customizable to match the user’s health status
Peters et al³⁵	Avatar(s): robot with T1D
Rønningen et al³⁶	Avatar(s): Otis, a fish with T1D
Baghaei et al³⁷	Avatar(s): Super Mario with T1D; customizable according to preferences and abilities	Sustains engagement and encourages exploration
Pesare et al³⁸	Avatar(s): a doctor (coach)	Corrects wrong behaviors
Lauritzen et al³⁹	Avatar(s): a T1D nurse/specialist and a person with T1D
Bomark et al⁴⁰	Avatar(s): -	Hides identity (important when the target users are children)
Bomark et al⁴⁰	The user creates his or her own avatar (options to choose from)
D’Aprile et al⁴¹	Avatar(s): Takos, little polyps with T1D
D’Aprile et al⁴¹	Users create their own personal avatars
Brown et al⁴²	Avatar(s): two elephants with T1D
Moosa et al⁴³	Avatar(s): Aboud, a child with T1D
Sparapani et al⁴⁴	Avatar(s): a superhero with T1D

Avatars’ appearances could be customized and personalized according to the user’s preferences.^{30,33,34,37,40,41} Customization enhanced the enjoyment and individualized the learning experience.^33,34,37

Simulations

Simulations were included in 14 articles (Table 6). Simulations refer to exploration and experimentation in a risk-free, controlled, and simulated environment. Simulations made it possible to practice (and master) different self-management situations^{28,31-34,36-44} and observe realistic outcomes without real-life consequences.^{32-34,36-39,42-44} This mechanism helped users make meaningful connections between events and understand the effects of one’s choices^{31,32,34,36,38,41,43,44} and thereby increased the likelihood that the knowledge and skills attained would be retained and applied in real-world situations.^{28,32,33,37,42,44} When experiencing successful outcomes as a result of the users’ decisions, confidence and/or self-efficacy increased and promoted the intrinsic motivation to self-manage.^{33,34,40,42,44}

Table 6.

The GM Simulations. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Ebrahimpour et al²⁸	Simulates different real T1D-situations	Allows for the acquisition and transfer of skills and knowledge
	Provides medical information in a simulated, pleasant, and fun environment	Increases the motivation for learning
		Helps reduce distress and fear
		Improves the adherence to insulin therapy, resulting in better glycemic control and the prevention of complications
Brox et al³¹	Offers practice and experiments with all the main self-management tasks	Creates learning gains and train understanding
Thompson et al³²	Offers realistic T1D problems and solutions	Promotes situated learning and increases the likelihood that the knowledge/skills attained will be retained and applied
Thompson et al³²	Offers choices for the characters and consequences to observe without putting users in harm’s way	Stimulates meaningful connections between events and develops an understanding of the short- and long-term effects of choices
Liberman³³	Rehearses self-management, makes health decisions, and sees the health consequences in a simulated environment	Creates motivating factors for improving T1D-behavior
		Improves self-efficacy
		Makes it easier to enact behaviors in real life
Liberman³⁴	Simulates self-management and scenarios in which users can rehearse self-management and see realistic outcomes for the character until they succeed	Increases attention, involvement, learning, and retention
		Allows the acquisition of skills
		Increases self-efficacy
Rønningen et al³⁶	Creates a simulated environment with realistic outcomes	Enhances knowledge in respect to interactions regarding food, insulin, emotions, and blood glucose levels
Baghaei et al³⁷	Provides exploration tasks to manage the character’s blood sugar level	Offers the opportunity to gradually learn skills and essential T1D knowledge to remain healthy
Pesare et al³⁸	Creates a controlled environment in which to practice and experience self-management by making the right choices during everyday life and seeing the health consequences	Trains users to handle normal activities
Pesare et al³⁸		Prevents anxiety and fear of consequences
Lauritzen et al³⁹	Follows the character for a virtual day/week and offers control of the measuring of blood glucose, eating, use of insulin, and physical activity
Bomark et al⁴⁰	Provides the opportunity to experiment and learn-by-doing content	Builds self-esteem and knowledge
Bomark et al⁴⁰	Correlates game mechanics with insulin and blood sugar mechanics	Builds self-esteem and knowledge
D’Aprile et al⁴¹	Offers simulations in which users can self-manage and control blood glucose levels and observe the outcomes	Supports critical thinking for nutrition-related blood glucose changes and lifestyle habits
D’Aprile et al⁴¹		Provides a motivational lever to involve users in healthy and responsible behaviors
Brown et al⁴²	Creates an interactive environment in which users experiment and observe consequences and benefits while helping the character eat the right food to keep blood glucose in the normal range	Offers learning and habit formation
		Increases self-efficacy
		Transfers knowledge and skills to daily lives, resulting in improved self-management
Moosa et al⁴³	Simulates real T1D-situations and outcomes	Helps users understand why blood glucose levels change and how they are affected by insulin injections and food types
Sparapani et al⁴⁴	Offers simulations in which users make and practice choices that immediately reflect on the character’s health condition	Promotes gradual learning and progressive improvement in practical skills
		Promotes confidence and self-efficacy
		Helps users overcome barriers to treatment or eases them

Goals

Goals define a direction and set up the challenges that the player faces⁴⁷ and were described in 13 articles (Table 7). Goals were designed as meaningful learning goals related to T1D and self-management^{28,29,32-35,37,38,42-45} and represented the desired end state of attaining specific knowledge, skills, or attitudes.^29,32-36,43 Learning goals were broken into incremental, progressively small steps⁴⁵ and were short term.²⁸ Simple learning goals were embedded early in a serious game, and complex goals were reserved for later.³⁷ Goals were adjusted to match the child’s T1D knowledge.³⁷

Table 7.

The GM Goals. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Ebrahimpour et al²⁸	T1D-related (make correct choices regarding insulin injection)	Offers the feeling of victory and gains in confidence to overcome fears
Ebrahimpour et al²⁸	Achievable and short-termed
Calle-Bustos et al²⁹	T1D-related (make correct carb choices)
Calle-Bustos et al²⁹	Winning condition: obtain 70% correct answers
Brox et al³¹	Goal: finish the race first using T1D-knowledge	Effectively changes behavior
Brox et al³¹	Goal: finish the race first using T1D-knowledge	Persuades
Thompson et al³²	T1D-related (eg, monitor blood glucose)	Enhances competence, self-efficacy and internal motivation
Thompson et al³²	Connected to personal values	Enhances competence, self-efficacy and internal motivation
Liberman³³	Models game challenges and goals after real T1D-challenges	Contributes to making the game fun
Liberman³⁴	Creates cognitive challenges and goals related to T1D	Increases attention, involvement, learning, and retention
Liberman³⁴	Clear, intriguing and challenging	Motivates and appeals
Peters et al³⁵	Learning goals about T1D	Enhances motivation and learning gain through attainments
	Represents the desired end state of specific knowledge, skill or attitude to be attained
	Individualization: goals are selected matching the device users use for insulin intake
Baghaei et al³⁷	Goal: control blood glucose levels to save a princess (T1D-related)	Offers an enduring and fun-filled learning experience
	Structure allows the discovery of essential T1D-knowledge to be progressive and experimental, users obtain increasingly complex information/knowledge about different aspects of managing T1D	Encourages proactive knowledge discovery and, therefore, enhances engaged learning
		Facilitates progressive learning
Pesare et al³⁸	Specific learning goals related to T1D
Bomark et al⁴⁰	Leaderboards provide a goal	Offers incentives to repeat a task until it is mastered
Brown et al⁴²	Challenges based on T1D-challenges
Moosa et al⁴³	Best score concept
Moosa et al⁴³	Meaningful T1D learning goals
Sparapani et al⁴⁴	T1D-related tasks that help the child to overcome barriers to treatment, or even make them easier
Kamel Boulos et al⁴⁵	Break difficult T1D goals into incremental, progressively difficult small steps

Achieving T1D-related goals made the child feel victorious and caused gain of knowledge and confidence to overcome barriers in self-management.^{28,32,34,35,44} Furthermore, achieving a goal enhanced the internal motivation for learning^32,35,37 and contributed to making the game fun and engaging.^33,34,37

Levels

Eight articles outlined levels (Table 8), which includes information about the stage of the game and/or the player’s skills.²⁷ Rønningen et al³⁶ suggested a never-ending game with no levels to extend playtime, while other articles used several levels, each becoming increasingly more difficult to complete.^{29,30,32,33,37,42} The level of difficulty could be adjusted to match the current or expected level of T1D knowledge.^33,35,37,44 Through levels, difficult health goals were broken into incremental, progressively difficult small steps allowing the progressive gain of new knowledge.^{29,30,35,37,45} A level should be achievable³³ but challenging enough so it will be repeated and the child is exposed to the content until it is understood thoroughly,^29,34 ensuring that the information and skills learned in the game were retained.³⁴ Experimenting, failing, and ultimately succeeding resulted in enhanced competence, self-confidence, and internal motivation.^32,33,35 Baghaei et al³⁷ noted that a serious game should include the ability to save progression, so a child will not have to start from level 1 each time.

Table 8.

The GM Levels. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Calle-Bustos et al²⁹	3 levels	Reviews the material until the users understand it thoroughly
	Increasing difficulty	Teaches progressively
	Must correctly guess 70% in each level to move to the next level; otherwise, the user returns to the training phase of that level	Teaches progressively
Glasemann et al³⁰	Tasks at lower levels are easier to solve; tasks at higher levels are more complex	Teaches progressively
Brox et al³¹	Several levels	Makes learning enjoyable
Thompson et al³²	Gradually increases in difficulty	Enhances competence, self-efficacy, and internal motivation
Liberman³³	Challenging but achievable levels with difficulty levels increasing from easy to difficult	Provides an environment in which to experiment, fail, develop skills, and ultimately succeed
Liberman³³	Proceed at own ability and pace	Bolsters self-concepts
Liberman³⁴	Difficult enough that players will repeat levels dozens of times and thus be exposed repeatedly to the same content	Ensures the retention of information and skills learned in the game
Peters et al³⁵	Can progress faster or slower on certain topics	Facilitates nonlinear learning
Peters et al³⁵	The salient difficulty level is adapted to the child’s current level of knowledge	Encourages the acquisition of self-management skills
Rønningen et al³⁶	No levels—a never-ending game with increasing difficulty	Offers continuous play, which extends playtime
Baghaei et al³⁷	The challenge of maintaining appropriate blood sugar levels increases as users progress. Simple educational features in early stages; complex features in later stages	Provides flow and engagement
	Adjusts to match users’ T1D-knowledge	Teaches new knowledge progressively as users progress from one level to another
	Can save interaction sessions
Brown et al⁴²	24 levels, each increasingly in difficulty
Sparapani et al⁴⁴	Difficulty levels are adapted to the expected knowledge levels
Kamel Boulos et al⁴⁵	Through levels, difficult health goals are broken into incremental, progressively difficult small steps	Teaches progressively

Social Interactions

Social interactions were described in 10 articles (Table 9) and include communication and/or interaction.²⁷ The included articles described social interactions as communications or chats^{30,31,34,36,40,41} with other children with T1D,^31,36 health professionals, family, and/or friends.⁴¹ Communications consisted of context-sensitive predefined dialogs either to enable cross-language communications between players³¹ or to reduce the risk of bullying and foul language.⁴⁰ The GM resulted in (a) social learning,^30,31,41 (b) peer support,⁴⁰ (c) the building of self-esteem and knowledge,^34,40 (d) enhanced personalization and interactivity,³⁶ and (e) the stimulation of discussion and collaboration.³⁰

Table 9.

The GM Social Interactions. Description of the GM, Its Effect and Specifically How It Contributes to Teaching Self-Management.

Author(s)	Description of the game mechanism	Effect and specific contribution to teaching self-management
Glasemann et al³⁰	Assistance from a more capable peer	Stimulates discussion and collaboration
	Real-time competition	Offers enjoyment
	Cooperation through shared displays	Offers shared learning
	Distance communication	Offers shared learning
Brox et al³¹	Chat and socialize with others with T1D through predefined dialog and peer support	Teaches skills crucial to cope with T1D
	Competition and cooperation; also possible to play alone	Teaches from the examples of others
	Competition and cooperation; also possible to play alone	Provides users the incentive and motivation to learn
Thompson et al³²	Multiplayer in which parent and child work together to win	Reduces family conflict
Liberman³³	Two-player option	Enhances the motivation to self-manage
		Stimulates discussion/communication about T1D with friends, family and caregivers
		Boosts confidence
Liberman³⁴	Two-player option	Encourages social interactions that can increase peer tutoring, learning and retention
Liberman³⁴	Communication and social support
Rønningen et al³⁶	Chat and communicate with others	Enhances play personalization and interactivity
Lauritzen et al³⁹	Interactions (ask other players for help and help others)	Offers users better insight into T1D, improved self-management, and increased adherence to treatment
Lauritzen et al³⁹	Competition to be better regulated
Bomark et al⁴⁰	A social platform with social feedback	Helps to cope with T1D
Bomark et al⁴⁰	Communication with predefined context-sensitive dialog and comments and tips	Builds self-esteem and knowledge
D’Aprile et al⁴¹	Communication and interactions with health professionals, family and friends	Develops the dynamics of social learning
Brown et al⁴²	Two-player option	Teaches that it is advantageous to communicate and support each other to win the game as a team
Brown et al⁴²	Two-player option	Stimulates discussion about T1D and self-management and encourages users to seek support and advice when needed

Social interactions were also described as multiplayer options in which players competed against each other^30,31,39 and/or cooperated to win.^30-33,39,42 The outcomes of competition and cooperation included (a) stimulation of discussions about T1D,^30,33,42 (b) better insights into T1D and increased adherence to treatment,³⁹ (c) enhanced motivations to improve health behavior and for learning,^31,33 (d) boosted confidence,³³ and (e) reduced conflict.³²

Discussion

This scoping review aimed to systematically map the GMs used in serious games that teach children with T1D how to self-manage and to provide a description of the mapped GMs, including an explanation of how they contributed to teaching self-management. Seven GMs were identified: (1) narrative contexts, (2) feedback, (3) avatars, (4) simulations, (5) goals, (6) levels, and (7) social interactions.

Each GM can be treated as a building block,¹¹ and according to Swartwout et al⁴⁶ serious games are most effective when multiple GMs are combined. However, since this review does not examine how the GMs are interrelated, no GMs should be dismissed at this point without a study of their impact. Future research should determine which GMs are best to combine for teaching self-management. Furthermore, as suggested by Deterding et al¹¹ game genres are associated with the use of GMs. Avatars are common in action and role-playing games but not necessarily in strategy or card games. Therefore, the inclusion of GMs in a serious game to promote self-management should align with the game genre.¹¹

To ensure the effective transfer of knowledge and skills from a serious game to the real world, a serious game and its GMs should be related to T1D and self-management. This fact is consistent with previous findings.^18,19,46 When combined with risk-free trial-and-error simulations in which the decisions and actions match the choices available to a child with T1D, players are more likely to learn self-management skills.^18,46,48 Furthermore, several studies have found that children gain knowledge and develop skills simply by observing avatars that model behaviors, making this an effective approach for learning how to self-manage.^46-51

The GM social interactions was the least used in this review (n = 10) but should be a key feature, according to Klopfer⁵² and previously published literature.^46,53,54 Social interactions allow a child with T1D to socialize with other children with T1D their own age, which many children do not otherwise have the opportunity to do. Increased social networking and support have been associated with promoted self-management in children with T1D.^46,53,54 Furthermore, D’Aprile et al⁴¹ described communication with health professionals. This factor is supported by studies by Zang et al⁵⁵ and Åsand et al⁵⁶ because it prompts the child to become an active participant in self-management. However, Glasemann et al³⁰ found that children do not like health professionals to check up on them. Therefore, it cannot be confirmed that a serious game would be more effective if such features are included.

Levels were the only GM with conflicting findings. Rønningen et al³⁶ described a never-ending game without levels, while the remaining articles used levels.^{24-35,37,42,44,45} Both solutions resulted in the promotion of self-management, which is why using levels in serious games seems to be optional. However, according to Zichermann and Cunningham⁵⁷ (pp. 45-49), using levels where complexity transitions from one level to the next has proven extremely engaging. Well-designed levels result in confidence and experience gains, so they may be beneficial in a serious game.

Engagement and motivation are important aspects when designing a serious game to help the child learn from the game.³⁶ According to the results of this review, feedback (including rewards), narrative contexts, and goals are key components to motivate and thereby extend play time and increase the likelihood that serious games result in learning.^{28,31,35-37,40,44,45} This finding is supported by similar findings,^16,58,59 which show that these GMs lead to increased engagement and motivation, reducing the risk that the child stops playing and thereby misses potential learning.

A limitation of the present scoping review is that only articles in English and Scandinavian languages were included. A general limitation of using the scoping review is that the included articles were not assessed for quality, which is why the strength of the articles was not considered.⁶⁰ However, this scoping review was conducted based on the guidelines of Green et al²⁵ and the PRISMA statement²⁶ in the systematic literature search, which ensured a systematic methodological approach that contributes to the strength of the results. Another strength is that the search of the literature was performed in 6 databases using an extensive number of search terms, which makes the literature search systematic and exhaustive. Additionally, the validation of the sample by 3 authors contributes to further increasing the strength of this scoping review.

Conclusions

The findings of this review suggest that 7 GMs can be included in serious games to teach self-management. Serious games seem most effective in teaching self-management when they are T1D-oriented and when multiple GMs are combined. However, the ideal combination of GMs has yet to be determined and serious games may also teach self-management when not all game mechanisms are included. The game genre influences the choice of GMs. Future studies could focus on determining which combination and/or genre is the most effective in teaching children with T1D self-management.

Footnotes

Appendix

Appendix 1

Presentation of Included Articles in the Scoping Review.

Reference number	Author(s), country	Title	Aim of article	Method(s)	Serious game (SG)	Aim of serious game	Target population	Results of playing SG	Game mechanisms used
28	Ebrahimpour et al²⁸, Iran	The design and development of a computer game on insulin injection	Design and develop an educational computer game for diabetic children to teach them about T1D, insulin injections, and insulin injection skills (to decrease fear and anxiety)	Literature review	Koodak-e-Tavana, (computer game CD)	To teach children with T1D about diabetes, insulin injections, and insulin injection skills (to decrease fear and anxiety)	3 to 12 years w/T1D	Gain of knowledge, acquaintance with the correct method of insulin injection, and reduction in anxiety and fear	Narrative context
				Expert and user involvement	Seven different minigames				Feedback
				Pilot study for evaluation					Avatar
									Simulation
									Goals
29	Calle-Bustos et al²⁹, Spain	An augmented reality game to support therapeutic education for children with diabetes	To determine the effectiveness of the game in terms of learning and perceived satisfaction and usability	Pre- and post-questionnaire	Argumented reality game (mobile Android Game)	Help children learn carbohydrate content of different foods	5 to 14 years w/T1D	Knowledge gain about carb choices (independent of gender and age)	Narrative context
					An quiz with 3 levels, each of which focuses on a food group			Transfer of knowledge	Feedback
									Goals
									Levels
30	Glasemann et al³⁰, Denmark	Making chocolate-covered broccoli: designing a mobile learning game about food for young people with diabetes	Present the design process and prototype of an educational mobile game about carbohydrate counting	Participatory design methods (inclding design workshops)	The food quiz game (mobile phone game)	Help children and adolescents with diabetes to learn about carbohydrate counting in a motivating way	>10 years w/T1D	Encourages users to practice knowledge and skills and holds potential to motivate to learn about carbohydrate counting	Narrative context
				User test	Mini games with quiz like tasks				Feedback
				Interview with dieticians					Avatar
									Levels
									Social interaction
31	Brox et al³¹, Norway, Sweden, Finland	User centric social diabetes game design for children	Present a concept for a social learning game that is engaging and fun for diabetic children	User centric design process including review, interview, questionnaires, and surveys	A social learning platform (web-based game)	Motivating children with T1D to form lasting good habits in their daily treatment and disperse knowledge	8 to 12 years w/1D	Improved understanding of T1D and self-management	Narrative context
				Focus-testing of game mechanics and visual designs	Minigames (inclusive The Glucose Race)			Social games/multiplayer games provide extra incentive and motivation	Feedback
								Helps to master T1D better	Avatar
									Simulation
									Goals
									Levels
									Social interaction
32	Thompson et al³², USA	Conceptual model for the design of a serious video game promoting self-management among youth with type 1 diabetes	Present a conceptual model of how video games	Presentation of conceptual model	A self-management serious game (video game)	Promote self-management through mediating variables (knowledge, skills, self-efficacy, and motivation)	Youth w/T1D	Promotes self-management among children with T1D	Narrative context
					Virtual responsibility game				Feedback
									Avatar
									Simulation
									Goals
									Levels
									Social interaction
33	Liberman³³, USA	Management of chronic pediatric diseases with interactive health games: theory and research findings	Report clinical report findings and discuss psychological theory underlying the design of SG	Review of clinical report findings	Packy & Marlon (home video game system)	Improve self-management and self-care	8 to 16 years w/T1D	A 77% drop in diabetes-related urgent care and emergency medical visits, an annualized decrease of two urgent visits per patient per year.	Narrative context
					A side-scrolling action-adventure game			Improved knowledge and self-management	Feedback
								Increased confidence and self-efficacy for carrying out SM	Avatar
								Better communication with parents about diabetes, and in daily diabetes self-care	Simulation
									Goals
									Levels
									Social interaction
34	Liberman³⁴, USA	Interactive video games for health promotion: Effects on knowledge, self-efficacy, social support, and health	Consider how multimedia instructional design principles integrated into video games can contribute to health promotion targeted to young people and how to design health promotion learning activities when games are accessible on networks online	Review (of research findings)	Health hero games including Captain Novolin and Packy & Marlon (home video game)	Help players learn about prevention and self-care and improve skills and behaviors	8 to 14 years w/T1D	Encourages to self-manage, knowledge gain and enhanced skills	Narrative context
					Action-adventure game			Improved self-management	Feedback
									Avatar
									Simulation
									Goals
									Levels
									Social interaction
35	Peters et al³⁵, Italy and The Netherlands	Usability of the PAL objectives dashboard for children’s diabetes self-management education	Present The PAL system and evaluate the usability	Usability evaluation (GQM-Model including usability, effectiveness, and first time learnability)	The PAL system (web-based game)	Motivate to complete educational tasks and thereby improve SM skills by providing relevant, challenging educational objectives and facilitate monitoring of progress	8 to 10 years w/T1D	Learning gain	Narrative context
					Dashboards for caretakers, a medical diary, quiz and several mini games for children, and a virtual robot “pal”				Feedback
									Avatar
									Goals
									Levels
36	Rønningen et al³⁶, Norway	Exploring in-game reward mechanisms in diaquarium—a serious game for children with type 1 diabetes	Develop an educational game for children with T1D, concerning suitable in-game reward techniques	Development of prototype based on data collection (literature review, workshop, discussions with experts)	Diaquarium (computer game)	Increase self-management skills to prevent possible consequences of incorrect care of diabetes	>9 years w/T1D	Enhance knowledge regarding how nutrition, blood glucose levels, and insulin interplay	Narrative context
				Online questionnaire	Adventure game, virtual diabetes care				Feedback
				Evaluation					Avatar
									Simulation
									Levels (never-ending game)
									Social interaction
37	Baghaei et al³⁷, New Zealand	Diabetic mario: designing and evaluating mobile games for diabetes education	Determine the effects of playing the game on enhancing children’s knowledge of healthy diet and lifestyle	Pre-post pilot study with questionnaire and survey	Mario Brothers (2D Mobile Android game)	Help the player gain the requisite knowledge to better manage T1D	9 to 13 years w/T1D	SG is engaging and improved knowledge of healthy diet and lifestyle	Narrative context
					Action-adventure game				Feedback
									Avatar
									Simulation
									Goals
									Levels
38	Pesare et al³⁸, Italy	Intelligent agent and virtual game to support education in e-health	Present a SG that is addressed to young children with T1D and measure the learning effectiveness and usability of the game	A first pilot test—one group pre-test post-test study	Virtual Coach (video game)	Educate to adopt an adequate lifestyle and to control the glycemic balance and to train to handle the normal activities, such as breakfast, homework, play, and so on	8 to 12 years w/T1D	Effective for learning, positive learnability and usability	Narrative context
					Virtual diabetes care; coaching strategy with an intelligent agent				Feedback
									Avatar
									Simulation
									Goals
39	Lauritzen et al³⁹, Norway, Germany, Denmark	Social media and games as self-management tools for children and adolescents with type 1 diabetes mellitus	Develop and present an educational video game, with social media interface for children and adolescents with T1D	Literature review	No name (web-based social game)	To learn and improve self-management and treatment adherence, by performing virtual diabetes care, partaking in quizzes of diabetes related knowledge and competing with other players, using their own treatment data	7 to 12 years w/T1D	Combining video games and social media to make a social game that educates and motivates conduct SM and achieve better clinical results and lowering the risk of complications	Narrative context
				Analysis of popular social games	Minigames (counselling, virtual diabetes care, quizzes, mixed reality)				Feedback
									Avatar
									Simulation
									Social interaction
40	Bomark et al⁴⁰, Norway, Sweden and Finland	A prototype social learning platform for children with diabetes type 1	Describe the social learning platform and a minigame	Demonstration proposal	No name (a web-based iOS game)	Learn how to self-manage through the opportunity to experiment and peer support	8 to 12 years w/T1D	Opportunity to experiment and find peer support resulting in promoted self-management	Narrative context
					Learning mini games				Feedback
									Avatar
									Simulation
									Goals
									social interaction
41	D’Aprile et al⁴¹, Italy	How serious games for health enhance empowerment-related patient education: the impact of gender	Explore how SG influences empowerment processes and health behavior change, and whether and how gender affects the learning process	Usability test	Tako Dojo (Digital game)	To support and foster experiential and social dynamics, metacognition, problem solving skills, knowledge acquisition and building in order to help children in managing diabetes responsibly	11 to 17 years w/T1D	SG directly supported empowerment and indirectly supported therapeutic adherence	Narrative context
				Questionnaires (Game Experience Questionnaire, Diabetes Empowerment Scale, and Adherence in Diabetes Questionnaire)	Fantasy educational game			Stimulates the acquisition of expert knowledge, self-management skills, self-control and self-efficacy	Feedback
									Avatar
									Simulation
									Social interaction
42	Brown et al⁴², USA	Educational video game for juvenile diabetes: results of a controlled trial	Investigate the effects of Packy & Marlon on self-care and medical outcomes	A controlled trial	Packy & Marlon (Interactive video game for Super Nintendo)	To improve self-confidence, ability, and motivation to undertake the rigorous self-care necessary to control insulin-dependent diabetes	8 to 16 years w/T1D	A well-designed, educational video game can be an effective intervention	Narrative context
				Interviews	Action-adventure game			Improvement in diabetes related self-efficacy, communication with parents, self-care behaviors and decrease in urgent doctor visits	Feedback
				Questionnaires				No significant difference in knowledge about T1D	Avatar
									Simulation
									Goals
									Levels
									Social interaction
43	Moosa et al⁴³, Qatar	A simple health-based game for children	Design a serious game and evaluate the serious game	A comparative study to perform usability and user experience test	Qare and Qure (mobile game)	Teach about T1D and give an understanding of changes in blood glucose level and how it is affected by insulin injections and types of food so children can adapt themselves to the disease and have a healthy life style	8 to 11 years w/T1D	Raised up the awareness of diabetic children and convinced them to adapt a healthy life style	Narrative context
					A best score-based arcade diabetes raising awareness game				Feedback
									Avatar
									Simulation
									Goals
44	Sparapani et al⁴⁴, Brazil and Canada	Conceptual framework for designing video games for children with type 1 diabetes	To present a theoretically based conceptual framework for designing video games for children with T1D and what are the designing principles for a SG based on the framework	Methodological study that describes the steps for the development of the conceptual framework	No name (video game)	Enhance and facilitate self-management	7 to 12 years w/T1D	Shows the applicability of the framework by developing a video game for promoting SM and highlights GMs to be used	Narrative context
					T1D-oriented game				Feedback
									Avatar
									Simulation
									Goals
									Levels
45	Kamel Boulos et al⁴⁵, UK	Digital games for type 1 and type 2 diabetes: underpinning theory with three illustrative examples	Provide illustrative examples of game apps for T1D and type 2 diabetes in order to discuss gamification and digital game mechanisms as adherence tools in SM and how the mechanisms work	Review	Monster manor (mobile game apps)	To help managing T1D	6 to 10 years w/T1D	SG serves as adherence tools in SM and suggest three GM to be used	Narrative contextFeedbackGoalsLevels

Abbreviations: SG, serious game; T1D, type 1 diabetes.

Abbreviations

GM, game mechanism; GMs, game mechanisms; T1D, type 1 diabetes.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jannie Nørlev

Stine Hangaard

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Game Mechanisms in Serious Games That Teach Children with Type 1 Diabetes How to Self-Manage: A Systematic Scoping Review

Abstract

Introduction:

Methods:

Results:

Discussion:

Keywords

Introduction

Methods

Protocol

The Search Strategy

Study Selection

The Synthesis

Results

Narrative Contexts

Feedback

Rewards

Avatars

Simulations

Goals

Levels

Social Interactions

Discussion

Conclusions

Footnotes

Appendix

Abbreviations

Declaration of Conflicting Interests

Funding

ORCID iDs

References