Examining the characteristics of health-related gaming interventions among congenital heart disease patients: A scoping review

Citation:

Fredericks, S., Lapum, J. & Goroscope, F. (Feb, 2018). Examining the characteristics of health-related gaming among congenital heart disease patients: A scoping review.  Online Journal of Nursing Informatics (OJNI), 22(1), Available at http://www.himss.org/ojni

Abstract

Resources to support persons living with congenital heart disease are limited, and consist primarily of patient education booklets. However, these resources fail to provide opportunities for social and/or group interaction. Health related gaming is an alternative medium for the delivery of patient education materials. To date, these types of interventions have been used throughout the healthcare environment, however no extensive review has been conducted to determine the characteristics of these interventions.

The aim of this scoping review was to summarize and disseminate research findings, to identify research gaps, and to make recommendations for future intervention design and evaluation.  Forty-two articles were included in this review. None of the studies used interventions that incorporated individuals living with congenital heart disease or the use of multi-player online gaming options. Additional testing of these interventions using a variety of populations, in a number of settings, and incorporating multi-player options is required. 

Background

Congenital heart disease (CHD) is a condition present at birth that encompasses a number of diseases involving the heart (Oliver et al., 2017). It consists of defects that may compromise the functioning of the heart and can affect the interior lining of its walls, valves, arteries, and veins (Oliver et al., 2017). CHD manifests in a number of forms which can range from simple defects that can have minimal symptoms and are more easily treated when diagnosed (e.g., narrowed valve, hole in septum) to multifaceted defects that can have life altering complications and require complex treatment (e.g., improper location of vessels leading to and from the heart, multiple defects that influence how the heart develops) (Opic et al., 2015). Over the years, the diagnosis and treatment of CHD has significantly advanced, allowing individuals to live into adulthood (Heery, Sheehan, While, Coyne, 2015). Consequently, lifelong complications exist, leading to individuals requiring additional care throughout their lives. Their capacity to partake in employment is sometimes limited, as many of these individuals tend to be too sick to work, and thus are more likely to be on permanent disability. Furthermore, the reoccurrence and/or exacerbation of symptoms results in increased use of the health care system, which often times is significantly higher than that of the average individual (Masoudi et al., 2017). Accordingly, the combination of the onset and/or aggravation of symptoms and limited work connections has led to decrease social interactions among these individuals.

Age and context appropriate interventions should be designed for the adult cohort with congenital heart disease since current resources are not optimal. Resources to support persons with CHD are limited and consist primarily of patient education booklets (Triedman & Newburger, 2016). However, these resources fail to provide opportunities for social and/or group interaction. Health related gaming interventions are an alternative resource for patient education interventions. They consist of online games that are created using a variety of health scenarios in which, players interact with a specific scenario to move through a gaming situation. As they proceed through the game, they acquire knowledge and health information. The player will then use this information to change their behavior within the game to engage in activities that are considered healthy in order to complete the game. It is anticipated that with increased involvement in health related gaming interventions; actual behavioral change leading to reduce complications will occur. Health related gaming interventions can also be designed to create a forum for social interaction and engagement, as well as entertainment (Triedman & Newburger, 2016). Accordingly, health related gaming interventions are online, in that a connection to the internet is required. This allows for the use of chat rooms and discussion forums throughout the gaming experience.

To date, online gaming interventions have been used throughout the healthcare environment, and has been shown to be beneficial to individuals living with various chronic diseases that include: obesity (Kharrazi et al., 2009), diabetes (Kharrazi et al., 2009), chronic kidney disease (Goldstein et al., 2013), and cognitive impairment (Yuan et al., 2013). The beneficial impact of gaming on memory and retention (Yuan et al., 2013), enhanced social capital and interactions (Beaudoin & Tao, 2007), increased engagement in physical and psychological therapy, improved performance of self-management skills, and improved physical activity (Primack et al., 2012) have been routinely identified throughout the literature (Primack et al., 2012). However no extensive review has been conducted to determine the characteristics of these interventions, such as specific features, length of time for delivery, process related to how it is delivered, who can access it, type of content delivered, and how often gaming intervention can be accessed, in addition to its effectiveness. This information is needed to effectively design, implement, and begin to evaluate the effectiveness of online gaming interventions delivered to adults diagnosed and living with CHD.

The purpose of this scoping review was to identify the body of literature pertaining to health related gaming interventions and to describe the characteristics associated with its delivery and implementation.

Method

Design

A scoping review was selected as opposed to a systematic review, as online gaming has not been thoroughly examined, described, or reviewed in the health related literature. Scoping reviews are typically used to present a broad overview of the evidence pertaining to a topic, irrespective of the quality of the study, and are useful when examining areas that are emerging, to clarify key concepts and identify gaps (Peters et al., 2015). The protocol for this study was developed using the scoping review methodological framework described by Peterson, Pearce, Ferguson, and Langford, (2017), which has since been revised by the Joanna Briggs Institute (Peters et al., 2015). The aim of this scoping review was to summarize and disseminate research findings, to identify research gaps, and to make recommendations for future intervention design and evaluation. For the purposes of this scoping review, we included studies based on their relevancy and contribution of evidence rather than their methodological rigor, thus we also included non-empirical papers. The body of literature surrounding online gaming will be mapped with a relevance to time (year published), source (empirical, theoretical, or grey literature), intervention characteristics, and type of outcome assessed.  

Inclusion Criteria

The search was limited to articles written in English, as this study was being conducted in English. Additionally, articles published between 1997 and 2017 were included. This timeframe was selected, as there has been a significant increase in the development, application, and evaluation of online gaming interventions in health care settings during this period. Studies that included individuals receiving ongoing healthcare were included in this review. This classification of study participant was intentionally kept broad to ensure the largest segment of the literature was reviewed. All studies included in this review had to discuss and/or evaluate an online gaming intervention. Furthermore, studies that used either qualitative or quantitative designs were also included in this review. Additionally, all outcomes were included, to determine the type of outcome that is typically evaluated with online gaming interventions. The search was conducted on a monthly basis and began August 2016 and concluded April 2017.

Initially, the search for articles that addressed the characteristics of health-related gaming interventions for adults living with congenital heart disease was conducted. No articles and/or reports of health gaming with the congenital heart population was found. Consequently, articles, reports, and studies that examined health-related gaming throughout healthcare was conducted.

Search Strategy

The search strategy began by consulting with university research librarians and online gaming experts. Their involvement allowed us to collect feedback about the study purpose and sources of literature. The librarian helped to develop a list of the most appropriate search terms and strategies.
Search terms that were used included: gaming and patient education, general medicine, gaming and healthcare, virtual gaming, computer gaming, online gaming, and simulated online gaming. Boolean operands such as AND/OR were used throughout the search. We began by searching electronic literature databases: ABI Inform, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Cochrane Library, EMBASE, Ovid MEDLine, PsycINFO, HealthStar, and Eric. We then searched relevant websites that included: https://medlineplus.gov/games.html, www.silvergames.com/t/patient, www.surgerysquad.com, www.dentalsolutions.ca/dentistry-for-kids/online-games/, and smartbrain.com. Furthermore, Universal Resource Locator (URL) and reference lists of key materials were also reviewed, as were primary and secondary sources, synthesis documents, technical reports, theoretical papers, and narrative papers.

Extracting and Charting the Results

All articles retrieved were reviewed independently by both the first author and two trained research assistants. The screening process consisted of the research assistants reviewing the title, abstract, and then the full text. In case of any uncertainty about a paper based on its title and the abstract, the first author reviewed the full text. No discrepancies appeared at the final stage of screening. The search initially yielded 2380 articles. In order to refine the search, only articles that were available via electronic medium were considered. This allowed for a more in-depth analysis of the articles that examined or described online gaming in healthcare, in a timely manner. Thus, 73 abstracts were assessed, with the final screening process yielding a total of 42 papers for inclusion (Figure 1). Of the 34 articles that were excluded, 27 were reports of the same study and 7 were irrelevant reports.

Data Collection
A multi-stage process to chart the data was enacted in which common descriptive demographic information was extracted from individual articles based on specified categories: author(s), publication date (year), condition of study participants, type of published document (research/theory/commentary/summary of literature), type of study design (experimental, quasi-experimental, non-experimental), setting for data collection (rehabilitation/school/home/other inclusive of cardiologist and pediatric settings), type of data collected (self-reported/ observational), type of gaming intervention, length of time for intervention delivery, process for delivery, number of times intervention can be accessed, format for content delivery, type of content delivered, type of outcome measured, and with which outcome gaming interventions were deemed to be most effective.

View Data Extraction

Data Analysis

Following the data extraction, we conducted a narrative synthesis, grouping the findings by data type of health gaming intervention. Descriptive analyses were also conducted to describe the demographic characteristics of the articles retrieved.

Results

The articles included in this review were published between 1997 and 2016, with the majority of papers being published in 2015 (n = 9, 21.4%). The condition of the participants included in the studies included varied from healthy (n = 10, 23.8%), having had a stroke (n = 10, 23.8%), or undergoing general rehabilitation following surgery (n = 6, 14.3%). For the most part, research studies (n = 36, 85.7%) were included, that contained quasi-experimental (n = 17, 40.5%), randomized controlled trials (n = 11, 26.2 %), and non-experimental, descriptive (n = 8, 19.0%) based designs. Rehabilitation (n = 16, 38.1%), home (n = 12, 28.6%), and school (n = 10, 23.8 %) were the most common settings, with self-reported data (n = 42, 100%) being included.

The interventions were typically designed for healthy individuals (n = 10, 23.8%), with the twofold purpose of providing self-care information and promoting behavioral change within the home environment. Data collection ranged between once (n = 10, 23.8%) to multiple times (n = 32, 76.1%). All interventions were designed with the intent to be used as health care interventions to promote and/or maintain health status.

The most common type of gaming intervention consisted of Nintendo Wii (https://www.nintendo.com/corp/history.jsp) gaming console (n = 28, 67%), computer simulations (n = 5, 11.9%), and web based games question and answer images embedded into the program (n = 3, 7.1%). The length of time for the online games ranged between 10 minutes (n = 1, 2.4%) to 5 hours (n = 1, 2.4%), with the most frequent length of time for interaction with the gaming intervention being 30 minutes (n = 9, 21.9%). The three most common methods for delivering online gaming interventions were through sensor motion detection devices (n = 16, 38.1%), hand held wireless controllers with motion detection (n = 12, 28.6%), and hand held wireless controllers (n = 4, 9.5%). On average, online gaming interventions were accessed at least twice a week (n = 6, 14.3%) in the form of virtual reality with motion sensors (n = 17, 40.5%), virtual sports games (n = 12, 28.6%), or virtual dance simulations (n = 6, 14.3% 9.5%). The majority of the online gaming simulations focused on educational content (n = 41, 97.6%), with data on bio physiological measures (i.e. range of motion, myocardial oxygenation, motor function, and strength) (n = 30, 71.4%) being collected, along with subjective data (n = 9, 21.4%) that measured emotion and mood, and learning outcomes (n = 1, 2.4%). Study findings suggested all (n = 42, 100%) outcomes had enhanced following exposure to online gaming interventions.

Discussion

There is a lack of research in the area of online gaming throughout the congenital heart disease population. As such, prior to implementing an intervention with this cohort, the conduct of a scoping review was undertaken as a first step in navigating the use of online gaming throughout healthcare.
Findings from this review suggest, even though much of the online gaming interventions were designed with the intent that they be used with individuals experiencing chronic illnesses, many of these interventions were evaluated using healthy, young adults, and in many cases adolescents. Additional testing of these interventions using a variety of populations, that include individuals living with congenital heart disease, is required, across a number of settings that include: home, rehabilitation, long term care facilities, and nursing homes. The congenital heart disease population tend to be under the age of 50, and are more likely to have an increase awareness and familiarity with technology (Triedman & Newburger, 2016). Furthermore, even though the majority of the studies were evaluated using randomized controlled trials, their findings cannot be inferred or even associated with individuals diagnosed and living with CHD, as the samples used were significantly different.

Use of Nintendo Wii (https://www.nintendo.com/corp/history.jsp) consoles, twice a week, for an average of 30 minutes each session, with motion sensor detection devices embedded into the consoles appear to be the most common form of online gaming intervention designed for use within the healthcare arena. Findings reported suggest these interventions are effective in producing desired changes in outcomes related to biophysiological, subjective, and learning outcomes. However, no study used interventions that incorporated multi-player online gaming. Furthermore, no study has examined the effect of web based multi-player online gaming that may involve an online fee.

Multi-player gaming provides individuals with the opportunity to engage with each other via a computer interface, allowing for the creation of a parallel world in which social interactions most frequently occur (Huang et al., 2017). Within this parallel domain, individuals are confined by technical restrictions and are sanctioned by formalized gaming rules (Huang et al., 2017). As such, individuals are able to express themselves in an unguarded setting, without appearance, symptoms, or perceived disabilities influencing their social interactions (Huang et al., 2017). As well, due to the highly interactive environment created by multi-player gaming interventions, opportunities for individuals to not only exchange information, (Park & Lee, 2017) but to create "strong friendships and emotional relationships” (Park & Lee, 2017)  have been shown to occur. This is of significance to the CHD population as these individuals tend to be more socially isolated due to symptoms associated with their condition. Engagement in a world that is perceived as providing a sense of anonymity and escape from daily health related routines can be empowering for many individuals diagnosed and living with CHD.

Conclusion

As a result, it is recommended multi-player gaming interventions should be designed, implemented, and evaluated within the CHD population. The nature and structure of the social interactions that develop within this population and the effect of these interactions on the overall quality of life of CHD individuals should also be examined further. The design and application of multi-player gaming interventions is not only innovative for this particular population but may have a positive effect on the healthcare system, as it can function as a medium for social support, repertoire of information, and an escape from the experience of living with CHD, as well as other chronic illnesses.

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Brief Biographies

Dr. Suzanne Fredericks is a Professor and the Graduate Program Director at the Daphne Cockwell School of Nursing at Ryerson University. Her research focus is on supporting patients following invasive procedures. Dr. Fredericks teaches in the undergraduate and graduate Nursing Programs, with an emphasis on Research Methods. Dr. Fredericks also acts as a graduate faculty adviser, student thesis supervisor, and student thesis committee member. Dr. Fredericks’ educational background consists of a Bachelor of Science in Nursing, a Masters of Nursing, and a PhD in Nursing.

Dr. Jennifer Lapum is an Associate Professor, a poet and an arts-based, narrative researcher at the Daphne Cockwell School of Nursing at Ryerson University. She is a registered nurse with extensive clinical background in critical care nursing, particularly in intensive care including cardiovascular intensive care nursing. In her research, she is focused on enhancing patients’ overall health and well-being and ensuring that no patient feels like “the 7,024th patient” when they enter and exit the health care system. As a scientist and artist, her focus is on the development of an arts-informed program of research in the health sciences to advance the capacity for humanistic approaches to health care. Dr. Lapum’s educational background consists of a Bachelor of Science in Nursing, a Masters of Nursing, and a PhD in Nursing.

Mr. Franklin Gorospe is an Instructor at the Daphne Cockwell School of Nursing at Ryerson University and a Registered Nurse. He was the Research Assistant for this study. Mr. Gorospe’s educational background consists of a Bachelor of Science in Nursing and a Masters of Nursing degree.