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Bond elements to create the building blocks of all matter.

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Worker Placement Engine-Builder in a Plant Cell

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DnD games improve young peoples mental health and behaviour

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DnD games improve young peoples mental health and behaviour

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Young Dragons programme shows promise in supporting emotional wellbeing and inclusion in London schools

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A new evaluation led by researchers at Imperial College London has found that an innovative role-playing game programme, known as Young Dragons, may…

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Playing boardgames helps dyslexic learners 

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Playing boardgames helps dyslexic learners 

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blog article

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Fun is a key factor for building engagement at school. When I was at school, my class re-enacted the Battle of Hastings. We found out about what the Normans and the Anglo Saxons wore in battle and we all made our own costumes and weapons and then had loads of fun exploring the history. I can picture it in my head now and remember some elements of the history lesson behind the activity. In much the same way, using board games to learn is fun and somehow reduces the barriers to engagement with learning.

3) Board games promote dyslexic strengths.

Big picture thinking, working with strategy and having great interpersonal skills have often been thought of as dyslexic strengths. With the inclusive nature of board games, they present an opportunity to develop those strengths in a safe and engaging environment.

4) Board games can be an essential part of multi-sensory learning.

We all know that board games can be used for learning. They all seem to have some topic at the centre of the game play so using board games with educational content that involves kinaesthetic, visual and audible experiences will only serve to help that all important learning content to be absorbed.

5) Board games can be used to revise in a fun way.

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How can playing board games help dyslexic learners? - The Studying With Dyslexia Blog

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With multi-sensory learning being a huge hit for dyslexic learners, it makes sense then that using board games to learn could well come with benefits. Let's look at five great reasons why this could be the case.

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Educational Intervention through a Board Game for the Teaching of Mathematics to Dyslexics

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Educational Intervention through a Board Game for the Teaching of Mathematics to Dyslexics

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Educational Intervention through a Board Game for the Teaching of Mathematics to Dyslexic Greek Students

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The main purpose of this study was to investigate the effectiveness of an intervention strategy in teaching mathematics based on a board game, using the curriculum of mathematics in Greece, called Adapted Analytical Programs (A.A.P.). This research was conducted on secondary students in Greek Genera…

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A Cooperative Learning Classroom Intervention for Increasing Peer's Acceptance of Children With ADHD 

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A Cooperative Learning Classroom Intervention for Increasing Peer's Acceptance of Children With ADHD 

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https://journals.sagepub.com/doi/full/10.1177/1087054716666952

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Objective: The hypothesis behind this study was that trained teachers using cooperative learning procedures with children in their classroom (aged from 6 to 10 years) can influence the social skills of children with ADHD symptoms and their acceptance by their peers. Method: The study involved 30 children with ADHD symptoms attending 12 different classes, where cooperative learning was adopted in some, and standard practices in others. ADHD children's symptoms, social skills, and cooperative behavior were assessed by means of a teacher's questionnaire, and the social preferences of the children in their class were collected. Results: Changes emerged in teachers' assessments of the children's cooperative behavior in the experimental classes. Improvements in the sociometric status of children with ADHD symptoms were only seen in the cooperative learning classes. Conclusion: These results show the importance of well-structured intervention in classes that include children with ADHD symptoms. Implications of these findings for future intervention are discussed.

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A Cooperative Learning Classroom Intervention for Increasing Peer's Acceptance of Children With ADHD - Agnese Capodieci, Thomas Rivetti, Cesare Cornoldi, 2019

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Objective: The hypothesis behind this study was that trained teachers using cooperative learning procedures with children in their classroom (aged from 6 to 10 years) can influence the social skills of children with ADHD symptoms and their acceptance by their peers.

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Attention-training based games proved to help students concentrate class

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Attention-training based games proved to help students concentrate class

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Adults and children with ADHD: New research 

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Adults and children with ADHD: New research 

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How common is ADHD? More than 6 million (9.4 percent) of children in the U.S. have an ADD diagnosis, according to the latest data. Read on for more ADHD statistics, facts, and information regarding attention deficit in kids and adults.

ADHD Statistics: How Common is ADHD?

ADHD Prevalence in Children

About 6.1 million children in the United States (9.4 percent) between ages 2 to 17 are estimated to have ever been diagnosed with attention deficit hyperactivity disorder ( ADHD or ADD), according to a 2016 study from the Centers for Disease Control and Prevention (CDC).

This figure includes:

388,000 (2.4 percent) of young children aged 2 to 5 years

2.4 million (9.6 percent) of school-age children aged 6 to 11 years

3.3 million (13.6 percent) of adolescents aged 12 to 17 years

The same study found that boys are more likely to have ever been diagnosed with ADHD than were girls (12.9 percent and 5.6 percent, respectively).

Research, however, suggests that ADHD affects a greater number of girls than typically and traditionally reported. ADHD may be missed in girls because of the way their symptoms tend to manifest compared to boys', which may reflect a general bias in the diagnostic process.

ADHD is among the most common neurodevelopmental disorders of childhood, per the DSM-5. While figures vary, the worldwide ADHD prevalence in children is estimated at about 5 percent.
[Could Your Child Have ADHD? Take This Symptoms Test]
ADHD Prevalence in Adults

The worldwide prevalence of adult ADHD is estimated at 2.8 percent, according to a 2016 study.

Prevalence estimates for adult ADHD in the U.S. vary. One 2019 study estimates an adult ADHD prevalence of 0.96 percent - doubling from 0.43 percent a decade prior.

Prior studies have placed adult ADHD prevalence rates in the U.S. between 2.5 percent and 4.4 percent, with a 5.4 percent diagnosis rate in men compared to 3.2 percent in women.
Estimates on the number of children diagnosed with ADHD in the U.S. have changed over the years. Per a 2014 CDC study:

In 2003, 7.8 percent of children were ever diagnosed with ADHD

In 2007: 9.5 percent

In 2011: 11 percent

[Click to Read: How ADHD is Diagnosed in Children]
ADHD Treatment in Children
About 75 percent of children with ADHD in the U.S. undergo some type of ADHD treatment. ADHD Medication Behavioral Health Most children with ADHD in the U.S. receive some type of intervention - including medication and school supports - to treat ADHD symptoms, according to 2014 data.10

80 percent of children with ADHD received school-based supports

40 percent underwent social-skills training

31 percent participated in parent training

20 percent received cognitive behavioral therapy (CBT)

Related Conditions

Nearly two thirds of children with ADHD have at least one other condition.

51.5 percent of children with ADHD have behavioral or conduct problems

32.7 percent have anxiety problems

16.8 percent have depression

13.7 percent have been diagnosed with autism spectrum disorder (ASD)

1.2 percent have Tourette syndrome

About 45 percent have a learning disorder

Children with ADHD are 12 times more likely to have Loss of Control Eating Syndrome (LOC-ES), a type of eating disorder similar to binge eating disorder in adults.

ADHD Statistics: Adults with ADHD

Adult ADHD diagnosis rates are rising.
ADHD diagnoses among adults are growing four times faster than are ADHD diagnoses among children in the United States (26.4% increase among children compared to 123.3 percent among adults).

Still, ADHD is thought to be underdiagnosed in adults compared to children.
Most scientists believe adult ADHD remains underdiagnosed because diagnostic criteria for ADHD in the DSM-V were developed for children, and because adults with ADHD often have comorbid psychiatric disorders that may mask the symptoms of ADHD.

Adult ADHD frequently co-occurs with other, comorbid conditions.

According to a 2017 meta analysis:

Rates of comorbid bipolar disorder in adults with ADHD are estimated between 5.1 and 47.1 percent.

Roughly one-fifth to one-half of adults with ADHD have major depressive disorder/dysthymia.

About half of individuals with ADHD have some type of anxiety disorder.

Personality disorders are present in more than 50 percent of adults with ADHD

Substance Abuse Disorder

The link between ADHD and substance abuse disorder (SUD) is well-documented. Studies suggest that 25 to 40 percent of adults with SUD also have ADHD.

People with ADHD are at least 1.5 times more likely to develop substance abuse disorders to substances like nicotine, alcohol, marijuana, and cocaine.

ADHD Statistics: Demographics, Race & Ethnicity

According to a 2020 data brief from the National Center for Health Statistics:

Black children aged 3 to 17 years are more likely to have ever been diagnosed with ADHD or a learning disability (16.9 percent) compared to white (14.7 percent) and Hispanic children (11.9 percent).

Children in the lowest income brackets are more likely to be diagnosed with ADHD or a learning disability compared to children in families with income above the federal poverty level (18.7 percent vs 12.7 percent).

Black and white children, regardless of family income, are more likely to be diagnosed with ADHD or a learning disability compared to Hispanic children.

Children with parents who have a high school education or less are more likely to be diagnosed with ADHD (15.4 percent) compared to children with parents with more than a high school education (12.8 percent).

Children living in the U.S. South are more likely to have ever received an ADHD diagnosis compared to peers in other regions.

South: 11 percent

Midwest: 8.4 percent

Northeast: 8.4 percent

West: 6.8 percent

Children living in rural areas are more likely to have ever been diagnosed with ADHD compared to their urban/suburban peers.

Rural: 11.8 percent

Urban/suburban: 9 percent

ADHD diagnosis rates among adults of all race/ethnic groups are rising, but disparities remain (prevalence figures from 2006 to 2017):

White: 0.67 to 1.42 percent

Asian: 0.11 to 0.35 percent

Native Hawaiian/Pacific Islander: 0.11 to 0.39 percent

Black: 0.22 to 0.69 percent

Hispanic: 0.25 to 0.65 percent

American Indian and Alaskan Native: 0.56 to 1.14 percent

ADHD Statistics: More Facts

Children with ADHD

Approximately 41 percent to 55 percent of families with at least one child diagnosed with ADHD have at least one parent with the disorder.

Teen boys with ADHD are more likely to experience problems with attendance, GPA, homework, and more in high school.

Male teens with ADHD miss school 3 to 10 percent of the time;

are between 2.7 and 8.1 times more likely to drop out of high school;

fail 7.5 percent of their courses;

have GPAs five to nine points lower than those of male teens without ADHD.

Adults with ADHD

ADHD, especially if untreated, is associated with impaired quality of life for adults.

Individuals with ADHD are more likely to face difficulty obtaining and maintaining employment compared to adults without ADHD, more so if they did not receive treatment in childhood.

Individuals with ADHD are more likely to experience difficulties with all types of relationships (friendships, romantic, familial, etc.).
Other outcomes associated with adult ADHD include vulnerability to anxiety, mood disorders, negative habits, impaired driving safety, and even premature death from accidents.

ADHD in Women
ADHD Statistics: Next Steps

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Sources
1 Melissa L. Danielson, Rebecca H. Bitsko, Reem M. Ghandour, Joseph R. Holbrook, Michael D. Kogan & Stephen J. Blumberg. (Jan. 24, 2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47:2, 199-212, DOI: 10.1080/15374416.2017.1417860. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834391/pdf/nihms937906.pdf
Updated on March 22, 2021

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ADHD Statistics: New ADD Facts and Research

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How common is ADHD? More than 6 million (9.4 percent) of children in the U.S. have an ADD diagnosis, according to the latest data. Read on for more ADHD statistics, facts, and information regarding attention deficit in kids and adults.

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Neurodiversity: Discovering the Extraordinary Gifts of Autism, ADHD, Dyslexia, and Other Brain Differences

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Neurodiversity: Discovering the Extraordinary Gifts of Autism, ADHD, Dyslexia, and Other Brain Differences

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A new term has emerged from the disability movement in the past decade to help change the way we think about neurological disorders; Neurodiversity. ADHD. DysleYesia. Autism. The number of categories of illnesses listed by the American Psychiatric Association has tripled in the past fifty years.

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Neurodiversity in higher education: a narrative synthesis

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Neurodiversity in higher education: a narrative synthesis

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Abstract

Neurodiversity is an umbrella term, including dyspraxia, dyslexia, attention deficit hyperactivity disorder, dyscalculia, autistic spectrum and Tourette syndrome. The increasing number of students with learning difficulties associated with neurodiversity entering higher education (HE) poses a shared and growing challenge internationally for teachers and institutional leaders. This narrative synthesis draws together a corpus of international literature on how neurodiverse students experience higher education and the ways in which higher education institutions respond to the cluster of neurodiverse conditions. A systematic review was carried out to search, retrieve, appraise and synthesize the available evidence to provide an original contribution to the literature and significant insights of worth to higher education internationally. An inclusive approach to data extraction was used to ensure that all the relevant studies were included. All stages of the review process, including the initial search, screening, sample selection and analysis, are described. Three main themes and 11 subthemes were identified. Although the majority of publications focus on either dyslexia, autistic spectrum disorder, or ADHD, some common themes are evident in student experience across learning difficulties associated with neurodiversity. Although support services and technologies are available to meet students' specific needs, there is an apparent dislocation between the two. Fear of stigmatization and labelling worsens the divide between what is needed and what is available to ensure neurodiverse students' success in higher education, where good intentions are evidently not enough.

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Notes

Common acronyms:

DCDDevelopmental coordination disorder

AD(H)DAttention deficit (hyperactivity) disorder

ASDAutism spectrum disorder

ASAsperger's syndrome

SpLDsSpecific learning difficulties

LDLearning disabilities

References

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Konza, D. (2008). Inclusion of students with disabilities in new times: responding to the challenge. In, P. Kell, W. Vialle, D. Konza, G. Vogl (Eds.), Learning and the learner: exploring learning for new times (pp. 39-63). University of Wollongong.

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WHO (2019) Autistic spectrum disorders https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders

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Acknowledgements

No funding was received for this project.

Author information

Authors and Affiliations

Coventry University, Priory Street, Coventry, UK

Lynn Clouder

University of Milan-Bicocca, Milan, Italy

Alessia Cinotti

Universidad Nacional de Rosario, Rosario, Argentina

María Virginia Ferreyra & Patricia Rojo

University of Colima, Colima, Mexico

Genoveva Amador Fierros

Nazarbayev University, Nur-Sultan City, Kazakhstan

Mehmet Karakus

Corresponding author

Correspondence to Lynn Clouder.

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Clouder, L., Karakus, M., Cinotti, A. et al. Neurodiversity in higher education: a narrative synthesis. High Educ 80, 757-778 (2020). https://doi.org/10.1007/s10734-020-00513-6
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Keywords

Neurodiversity

Disclosure

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Narrative synthesis

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Neurodiversity in higher education: a narrative synthesis - Higher Education

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Neurodiversity is an umbrella term, including dyspraxia, dyslexia, attention deficit hyperactivity disorder, dyscalculia, autistic spectrum and Tourette syndrome. The increasing number of students with learning difficulties associated with neurodiversity entering higher education (HE) poses a shared and growing challenge internationally for teachers and institutional leaders.

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The effect of competition on learning in games

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The effect of competition on learning in games

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Abstract

Today serious games are having an important impact on areas other than entertainment. Studies show that serious games have a potential of creating learning environments to better reach the educational and training goals. The game design characteristics and game elements are need to be explored in detail for increasing the expected benefits of the gaming environments. In this study, the effect of competition, one of the design elements of game environments, on learning is analyzed experimentally. The study is conducted with 142 students. The results of this study show that when a competition environment is created in a serious game, motivation and post-test scores of learners improve significantly. The results of this study are expected to guide the serious game designers for improving the potential benefits of serious games.

Introduction

Today serious games, games having purposes other than entertainment, are being used in several areas such as training, education, and health. However, nowadays these games are blamed to be more like drill and practice software than entertaining and engaging game play (van Eck, 2006). In order to improve the benefits of serious games, one needs to understand their design characteristics and control these characteristics according to educational or training purposes as well as the behaviors and expectations of the learner groups. In that sense, serious game design characteristics need to be analyzed carefully and systematically.

Several game characteristics such as uncertainty, challenge, feedback, fantasy, cooperation, and competition have been studied by several researchers (e.g., Malone & Lepper, 1987). Many other characteristics can be added to this list. Understanding each of these elements and their effect on the game-based learning environments may improve the benefits of these games. On the other hand, there has been little empirical research examining the individual game characteristics on learning (Vandercruysse, Vandewaetere, Cornillie, & Clarebout, 2013) and how the games should be designed for facilitating learning (Dondlinger, 2007). In this study, competition, which is classified as a characteristic of a serious game, is explored. An empirical study is conducted to understand the effect of competition on players' learning performance in serious games.

Section snippets

Serious game design elements

Based on different design perspectives and characteristics, the level of involvement, concentration, flow, learning, engagement and/or skill improvements through the game play may vary. In the scope of game-play, several design elements such as uncertainty, goals, challenge, feedback, learner control, competition, cooperation, fantasy, interactivity, flexibility, and fairness to have been explored in the literature to improve the benefits of games (Hong et al., 2009, Malone and Lepper, 1987).

Participants

The participants of this study were 142 undergraduate students (62 female and 80 male) from computer engineering, software engineering, and information systems engineering departments in Atilim University. The range of their age was between 20 and 28 years ( M = 22.58, SD = 1.64).

Materials

In this study several materials such as prior knowledge test, the game itself and a Turkish version (Acar, 2009) of the instructional materials motivation survey (IMMS) (Keller, 1993) were used. These materials are

Results

An independent samples t-test was performed to compare prior knowledge of participants in the competition and control groups. The results suggested that there was no difference in prior knowledge between the groups, t(140) = 0.36, p = .72 (competition group: M = 7.86, SD = 3.80; control group: M = 8.11, SD = 4.50). In order to compare post-test scores of the competition and the control group, a separate independent samples t-test was conducted. The results indicated that the competition group ( M

Discussions

Consistent with the literature (e.g., Burguillo, 2010, Julian and Perry, 1967, Malone and Lepper, 1987, Nemerow, 1996, Yu, 2000), the results of this study showed that competition in games enhanced learning and motivation of the participants. Participants in the competition group devoted more of their time to responding to the questions in the game than the ones in the control group. However, there was no significant difference between the groups in total reading time of the explanations and

Conclusions

There is a gap of common understanding of the constituting elements of serious games for their effectiveness (Vandercruysse et al., 2013). The results of the current study suggest that adding the gaming element of competition to a game-based learning environment improves learning outcomes and motivation of participants. As a result, game designers should incorporate the element 'competition' to the games they created to facilitate learning.

Providing all challenging dimensions in a single game

Using response times to model student disengagement

Comparative fit indexes in structural models

Instructional applications of computer games

Using heuristics to evaluate the playability of games

M.J. Dondlinger
Educational video game design: a review of the literature

Experimental evaluation of an educational game for improved learning in introductory computing

Digital game-based learning: it's not just the digital natives who are restless

Story and simulations for serious games: Tales from the trenches

View full text

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The effect of competition on learning in games

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Today serious games are having an important impact on areas other than entertainment. Studies show that serious games have a potential of creating learning environments to better reach the educational and training goals. The game design characteristics and game elements are need to be explored in detail for increasing the expected benefits of the gaming environments.

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Tabletop Board Game Elements and Gamification 

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Tabletop Board Game Elements and Gamification 

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Review

1 Department of General Practice, Monash University, Notting Hill, Australia

2 Department of Mathematics, Moreton Bay College, Brisbane, Australia

3 Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia

*these authors contributed equally

Corresponding Author:

Daniel S Epstein, BMedSc, MBBS, FRACGP

Department of General Practice

Monash University

Ferntree Gully Road

Notting Hill

Australia

Phone: 61 408578964

Email: dan.epstein@monash.edu

Background: Games, when used as interventional tools, can influence behavior change by incentivizing, reinforcing, educating, providing feedback loops, prompting, persuading, or providing meaning, fun, and community. However, not all game elements will appeal to all consumers equally, and different elements might work for different people and in different contexts.

Objective: The aim of this study was to conduct a realist review of tabletop games targeting behavior change and to propose a framework for designing effective behavior change games.

Methods: A realist review was conducted to inform program theory in the development of tabletop games for health behavior change. The context, mechanisms used to change behavior, and outcomes of included studies were reviewed through a realist lens.

Results: Thirty-one papers met the eligibility criteria and were included in the review. Several design methods were identified that enhanced the efficacy of the games to change behavior. These included design by local teams, pilot testing, clearly defined targets of behavior change, conscious attention to all aspects of game design, including game mechanics, dynamics, aesthetics, and the elicitation of emotions. Delivery with other mediums, leveraging behavioral insights, prior training for delivery, and repeated play were also important. Some design elements that were found to reduce efficacy included limited replayability or lack of fun for immersive engagement.

Conclusions: Game designers need to consider all aspects of the context and the mechanisms to achieve the desired behavior change outcomes. Careful design thinking should include consideration of the game mechanics, dynamics, aesthetics, emotions, and contexts of the game and the players. People who know the players and the contexts well should design the games or have significant input. Testing in real-world settings is likely to lead to better outcomes. Careful selection and purposeful design of the behavior change mechanisms at play is essential. Fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect.

JMIR Serious Games 2021;9(1):e23302

doi:10.2196/23302

Keywords

Games as a Tool

Tabletop, Card, and Physical Games

In modern times, physical, card, and tabletop games may be considered unsophisticated or outdated and are often overlooked when gamification interventions are considered in favor of contemporary alternatives such as digital or video-based products. However, given that tabletop games are cheaper to produce, arguably easier to design, while promoting an inclusive and social aspect to the gaming experience, they remain a viable alternative for gamification for health behavior change interventions []. The universe of game design is vast. The abovementioned reasons are examples of how each aspect of game design can be considered in function toward achieving a desired behavior or goal. Despite the wide scope for application of gamification as a tool, there is minimal literature available to guide its use in the development of behavior change interventions. Overall, there is a lack of contextual understanding of game mechanics and program theories underlying gamification as a tool for behavior change contexts [].

A Realist Perspective

Games as a tool in health care is an example of a complex intervention. This is because games are multi-faceted and dynamic, where individual agency and context can change behavior outcomes significantly. Given this, it is reasonable to presume that the same intervention would not work uniformly in different contexts []. Realist reviews operate within the lens of realist philosophy and allow a deeper, more nuanced understanding of intervention outcomes than standard systematic reviews. Employing the realist philosophy in the review process, we can unpack an intervention, thereby identifying what underlying mechanisms cause what outcomes, under what conditions, and in what contexts [] providing explanation, rather than judgement, about how an intervention works [,]. This context-mechanism-outcome (CMO) configuration creates an explanatory model for causation. It relies on the theory of complex interventions [], which theorizes that complex interventions have the properties of complex systems []. This is an innovative use of a realist review, as a game design in a behavior change setting has not been formally reviewed with a realist lens. The aim of this study was to review games and game elements designed to affect health behavior change and to propose a framework and program theory to underpin the game design for health behavior change interventions. This review focuses on the use of tabletop games as a behavior change tool in the context of health.

Framework

This realist review uses the framework for realist synthesis described by Pawson et al []. After a preliminary reading of the literature, the emerging central review questions generated were as follows:

What are effective game mechanics design elements in behavior change interventions?

What are the dynamic and context elements that explain outcomes of games and their use as an intervention?

Theory integrity and adjudication: do game element theories work as predicted and fit best?

Reality testing: how does the intent of gamification translate into practice?

Reviewing the current theory and frameworks of game design, can we propose a framework specific for game design in the behavior change context?

Formulating the Initial Intervention Theory

Mechanics: The rules of how the game system works.

Dynamics: The ways in which the participants interact in response to the mechanics.

Aesthetics: The flavor of how the game looks, the storyline, backstory, artwork, physical appearance, or medium.

Emotional aspects: How it makes players feel and relate with themselves, the game, and each other.

Mechanics

Mechanics determine the rules of the universe that a game creates and will form the foundations of how participants interact. A game can be designed for cooperation or competition and the mechanics dictate how the participants interact with the game and with each other. Clearly stated objectives and the progression toward goals determine how outcomes are pursued and how feedback through gameplay can occur. Success, failure, rewards, or punishments can be used to reinforce behaviors positively or negatively through operant conditioning and intrinsic or extrinsic motivation [,,].

Dynamics

Creativity and repeated play within the rules lead to outcomes between the game, players, observers, and spectators that form the game dynamics. All dynamic player behaviors can be designed purposefully to achieve behavior such as cooperation, competition, behavior loops [], and habit formation. Even negative behaviors can provide a fun dynamics for entertaining and engaging game play [] such as cheating, bluffing, conspiring, or even quitting []. Roles other than players may also form influential dynamics. Passive observers contribute to social relatedness and spectators influence the atmosphere, community, and popularity, and they impact player behavior within the game []. Within dynamics, one also needs to consider whether game elements will result in unwanted second-order behaviors [], undesired or unethical outcomes, and whether there will be lasting or novelty effects on desired outcomes.

Aesthetics

The artwork, setting, physical game components, storyline, and immersive objective form an environment that can induce more engaged players and motivate continued play [].

Emotions

Games that trigger emotional responses can be powerful behavior and learning tools but are challenging to design and more difficult to have heterogeneous control over [,]. Some emotions have predictable patterns and can be designed to elicit a sense of achievement, mastery, disappointment, or failure. More subtle emotional outcomes can funnel particular behaviors and can be leveraged through research in psychology and behavioral economics tools such as establishing social norms, endowment effects, scarcity, simplification, chance and probability, framing effects, reducing friction costs, network effects, salience, default states, and cognitive loads [,].

Final Systematic Searching for Primary Studies

A final systematic search was performed in December 2019 (). We searched 10 databases relevant to health and behavior interventions, including PubMed, Web of Science, and PsycInfo, without date restrictions. The search strategy was developed with the guidance of a medical subject librarian. The search terms included "board game," "game," "serious game," "tabletop game," "card game," or "gamification" and "health" but excluding the terms "virtual," "screen," or "video," and all publications were included in the review. We reviewed titles and abstracts to identify relevant studies. The full text of these papers was then accessed to determine if they met the inclusion or exclusion criteria and assessed for relevance and rigor to test against the initial theory [].

Inclusion and Exclusion Criteria

Studies were included if they used a tabletop game as an intervention and measured a health or behavior change outcome. Studies were excluded if they were digital interventions, did not measure health outcomes, were not English texts, were reviews, opinion pieces, or case studies, or the full text was unavailable upon author request. Papers were initially reviewed by title, keywords, and abstracts for relevance and imported into EndNote reference manager by the first author. Full papers of articles that described behavior change interventions in the context of health were accessed and read in full to determine if they met the inclusion criteria. Papers were excluded if the full text was not available ().

‎
Figure 1. Flow diagram for paper selection.
View this figure

Selecting Evidence

The process of quality appraisal in a realist review is different from that of quality appraisal in a systematic review. Studies are selected based on their relevance toward building and testing theory and their rigor in terms of methodological reliability and description power. A formal methodological quality appraisal tool was not used in this study, but research was individually assessed for rigor.

Testing Relevance

Studies were expected to have adequate relevance to build the program theory. The quality of the paper was assessed to see if the study addressed the program theory under testing by contributing enough knowledge to comment on the aspects of tabletop games on health outcomes. Any paper that was not directly assessing a tabletop game intervention or not measuring a behavior change outcome was excluded at this point.

Testing Rigor

The papers were assessed by the reviewers to screen if they were free of bias and were methodologically credible enough to contribute toward the building of the overall program theories. Articles of opinion, review papers, and case studies were excluded, as were non-English texts.

Extracting Data

A theoretically derived CMO framework was populated to evaluate evidence. Data were extracted and recorded in NVivo software (QSR International) during this process. Information extracted included name of the game, country and setting, method of delivery of intervention, demographics of participants, study design, sample size, comparison group exposure, mechanism of intervention effect, behavior change outcome, and any context-dependent outcomes.

Analyzing and Synthesizing Findings

To refine the preliminary program theory, we interrogated the literature asking:

1. For whom did this basic program theory work and not work, and why?

2. In what contexts (C) will this program theory work and not work, and why?

3. What are the main mechanisms (M) by which we expect this program theory to work?

4. If this program theory works, what outcomes (O) will we see?

This formed the codes used for tabulation, indexing, and linking to the program theory in a CMO configuration for each of the effects and their relevance to strengthen the initial program theory.

The resulting CMO configurations were reviewed by 2 authors (DE and CB) for quality assurance during synthesis. This was achieved by identifying recurring patterns and outcomes in the data, confirming and modifying the reviewers' understanding of the data, and assessing if the CMO configurations helped inform the hypothesized theory, thereby seeking to both confirm or contradict the findings [].

Literature Review Findings

Table 1. Contextual and mechanism factors that enhance efficacy of games in behavior change.

Evidence type/factors

Game design elements described in studies

Strong evidence across many trials

‎
Games reiteratively developed through pilot testing with target users and context [,,,-]

Games that leverage behavioral insights such as social norms, emotive engagement, operant conditioning, or intrinsic motivations [-,,,,]

‎

Limited evidence from one or few trials

Table 2. Context and mechanisms leading to positive behavior change outcomes in a realistic game design theory.

Mechanisms

Descriptions in the studies

Clear objective/goals leverage internal motivators

Rewards, success, and failures leverage external motivators

Challenging repeated play leads to competence, mastery, and expertise

Incremental improvement provides feedback on mastery and expertise leading to repeated desired behavior [-,,,].

Effective Game Mechanic Design Elements in Behavior Change Interventions

Dynamic and Context Elements That Explain Outcomes of Games

Reality Testing: Translation of the Intent of Gamification Into Practice

Factors that reduce the efficacy of games targeted for behavior change.
Contextual or mechanism factors

Laborious or unattractive game designs for immersive play [,,]

One-off play or limited replayability [,,,,,-]

Simple question-and-answer games sometimes that are not engaging or immersive [,,,,,]

Textbox 1. Factors that reduce the efficacy of games targeted for behavior change.

Table 3. Theories for games targeting behavior leading to poor behavior change outcomes.

Theories

Behavior change outcome

Not fun or enjoyable leads to low engagement

Unpleasant experiences are unlikely to be engaging or repeated and result in no behavior change

Limited replayability reveals novelty effects

One-off play and wearing off of the game novelty results in lack of repetition and lack of lasting behavior change

Poor contextual design leads to misinterpretation

Missing context dues can lead to poor knowledge translation/misinterpretation and unwanted effects

We refined the preliminary program theory based on the CMO analysis. We propose the following modification of the preliminary program theory in order to help future design of games to achieve health behavior change to include more structure and guidance around these results.

Proposed Framework for Designing Effective Behavior Change Games

Define Goal: Diagnosing the Behavior to Change

Like designing any tool for a task, one should start by considering the desired outcome. Define the behavior to change first. List the barriers to behavior change to target.

Create Order With Game Mechanics: Building Rules to Deliver the Desired Outcome

There are several mechanisms that can be considered processes to achieving this, such as leveraging behavioral insights, reward and punishment, or information delivery. The mechanism chosen is the skeleton from which the core rules and game mechanics can be built.

Expect Chaos Dynamics: Consider How the Individual, Group, and Context Will React to the Rules

Context of the target players, environment, and other constraints at this stage should be reflected upon to consider the dynamics of the player and game interactions.

Make it Fun (Aesthetics): Make it Enjoyable for Higher Engagement

To maximize engagement, the aesthetics of the story, visual values, and physical values of the game are important for the player experience. Games that are not fun will not engage players and lead to minimal behavior change.

Pilot: Test and Reiterate the Product

A reiterative piloting and feedback loop should be the final stages of the game design.

Measure the Desired (and Undesired) Outcomes

Measure with appropriate scientific methods the behavior change defined. Measure the desired outcome, second-order effects, and undesired outcomes. Consider measuring the short and long game of possible behavior change extinction and novelty effects.

Use Other Resources: Use as a Tool in a Toolkit

Delivery alongside other mediums will likely increase the desired changes. Including stakeholders as another resource in this toolkit will likely lead to more effective outcomes.

Principal Findings

Game designers need to consider all aspects of the game experience to achieve the desired behavioral outcomes. First, consideration should begin by defining the target behavior and identifying ways to promote this target behavior through the game. Second, a decision should be made on how the game rules will work to reinforce the desired change (game mechanics). This may include examples such as rewards, punishments, goals, collections, information retention, or physical challenge. Next, reflect on the context of how the players interact with the game and with each other (game dynamics) and if this can be leveraged for the behavior change target. This could include cooperation, negotiation, persuasion, competition, subversion, bargaining, spectatorship, charity, and the pursuit of mastery. Finally, fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect. The aesthetics and emotions of the game should not be forgotten as the experience of play should be pleasant and engaging for the maximum effect. This also includes the role of the spectators, observers, and nonparticipants in the process.

Games appeared to be effective in all age groups, but most of the literature is on participants younger than 18 years. It could be hypothesized that games are only effective for children and adolescents. However, games should be considered a legitimate engaging behavior change intervention for all ages, if the game design process considers the target audience. There is a trend for serious games to be considered a legitimate intervention for a purpose other than pure entertainment. The literature is expanding across all age groups and multiple industries, including applications in military, government, education, corporate business, and health care []. There are a range of potential effects that can be seen with interventional games, including perceptual, cognitive, behavioral, affective, and motivational impacts, knowledge acquisition, content understanding, and learning [,].

Pitfalls in Game Design

Several pitfalls were identified for game designers to avoid in each key area. First, the failure to diagnose a specific behavior to target with the game was a common error in the studies reviewed. Games developers need to define the behavior change first, list the barriers to behavior change to target, and follow a structured design process to decide which elements of game mechanics can be leveraged to target this behavior. This process was best done using local teams who have knowledge of the players and context. Second, the dynamics between how the players will interact with the game and with each other should be considered in the context of play to avoid unwanted effects. Thinking about second-order behaviors and possible unwanted effects could be considered here in the design process. Once the rules and predicted play behavior have been established, the user experience and user interface (or aesthetics) should be considered to enhance fun and engagement. Games in which aesthetics was not given due attention were undesirable or not engaging. Finally, the design process should include pilot testing, wherein behavior change will be assessed carefully and a multi-intervention approach will be considered to maximize the impact of the desired outcome, assuming through realism that no 1 intervention will work for everyone.

Metagaming

The concept of metagaming can also be considered for advanced game design strategy. Designers can abstract outside of the rules of the game to consider how the player will use the game outside of its intended rules or environment []. The concept of metagaming is defined as a player taking action outside the rules or design of a game such as developing higher strategy, cheating, applying outside information, or strategy not intended by the mechanics [,]. Designing for metagaming behavior is not usually part of the core mechanics but can be intentionally thought of in the design process to add another engaging layer to the game experience. For example, the game itself could be used as a collectable item for a desired outcome, having the physical world around the game change the way it is played or reward cheating in the core mechanics to improve the likelihood of desired behavior outcomes. Considering the target behavior at the metagaming level can advance the engagement and is an interesting opportunity for behavior change game designers.

Limitations

First, this review was limited by the small number of published studies using games as an intervention. This limits the potential analysis of the topic. Second, the included studies were of varying degrees of methodological quality. One concern is that only a limited number of papers used in this review showed evidence of behavior change in their interventions. Most studies focused on education and knowledge changes owing to the short intervention period and lack of follow-up. As is common in a realist review, we did not exclude papers based on methodological quality. Finally, working definitions of games and the wording of interventions that could be considered games is likely not consistent. It is possible that this review did not contain all evidences on game-like interventions owing to the varying definition of what "is" a game, for example, setting blood pressure target goals could be considered a game element. However, we performed further hand searching of the reference lists from the included studies to mitigate this limitation. This review is also limited in the framework being applicable only to tabletop game contexts.

Conclusion

Games can be used as a successful intervention tool for effective behavior change. The ability of games to achieve behavior change is a product of their design-to address a clearly defined problem. Using a realist review methodology, we synthesized evidence from published papers and proposed a framework for game design. This framework outlines the considerations for making a game for a behavior change intervention. Game designers should consider elements of this framework specifically early in the design process to map the context and flow of participants through play, help create the mechanics that govern the rules, consider the dynamics and experiential aspects of playing, and maximize the aesthetics of the play experience. This framework is designed to achieve the best possible interventional results without unintentional outcomes in a realist context, acknowledging that not all interventions will work for all participants in all contexts. Game designers can use this framework to improve the quality of the design process for behavior change interventions. Future work in this field is to apply further realist lens to serious game design in fields outside the context of behavior change or tabletop games or to test this thesis framework in the context of digital game design.

Conflicts of Interest

None declared.
‎ ‎

Multimedia Appendix 2

Realist review papers included in the full review.
DOCX File , 31 KB
‎
‎

CMO: context-mechanism-outcome

Edited by N Zary; submitted 06.08.20; peer-reviewed by K Rodrigues, C Brown; comments to author 06.10.20; revised version received 21.10.20; accepted 13.02.21; published 31.03.21

©Daniel S Epstein, Adam Zemski, Joanne Enticott, Christopher Barton. Originally published in JMIR Serious Games (http://games.jmir.org), 31.03.2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included.

Background: Games, when used as interventional tools, can influence behavior change by incentivizing, reinforcing, educating, providing feedback loops, prompting, persuading, or providing meaning, fun, and community. However, not all game elements will appeal to all consumers equally, and different elements might work for different people and in different contexts.

Objective: The aim of this study was to conduct a realist review of tabletop games targeting behavior change and to propose a framework for designing effective behavior change games.

Methods: A realist review was conducted to inform program theory in the development of tabletop games for health behavior change. The context, mechanisms used to change behavior, and outcomes of included studies were reviewed through a realist lens.

Results: Thirty-one papers met the eligibility criteria and were included in the review. Several design methods were identified that enhanced the efficacy of the games to change behavior. These included design by local teams, pilot testing, clearly defined targets of behavior change, conscious attention to all aspects of game design, including game mechanics, dynamics, aesthetics, and the elicitation of emotions. Delivery with other mediums, leveraging behavioral insights, prior training for delivery, and repeated play were also important. Some design elements that were found to reduce efficacy included limited replayability or lack of fun for immersive engagement.

Conclusions: Game designers need to consider all aspects of the context and the mechanisms to achieve the desired behavior change outcomes. Careful design thinking should include consideration of the game mechanics, dynamics, aesthetics, emotions, and contexts of the game and the players. People who know the players and the contexts well should design the games or have significant input. Testing in real-world settings is likely to lead to better outcomes. Careful selection and purposeful design of the behavior change mechanisms at play is essential. Fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect.

JMIR Serious Games 2021;9(1):e23302

doi:10.2196/23302

Keywords

Games as a Tool

Tabletop, Card, and Physical Games

In modern times, physical, card, and tabletop games may be considered unsophisticated or outdated and are often overlooked when gamification interventions are considered in favor of contemporary alternatives such as digital or video-based products. However, given that tabletop games are cheaper to produce, arguably easier to design, while promoting an inclusive and social aspect to the gaming experience, they remain a viable alternative for gamification for health behavior change interventions []. The universe of game design is vast. The abovementioned reasons are examples of how each aspect of game design can be considered in function toward achieving a desired behavior or goal. Despite the wide scope for application of gamification as a tool, there is minimal literature available to guide its use in the development of behavior change interventions. Overall, there is a lack of contextual understanding of game mechanics and program theories underlying gamification as a tool for behavior change contexts [].

A Realist Perspective

Games as a tool in health care is an example of a complex intervention. This is because games are multi-faceted and dynamic, where individual agency and context can change behavior outcomes significantly. Given this, it is reasonable to presume that the same intervention would not work uniformly in different contexts []. Realist reviews operate within the lens of realist philosophy and allow a deeper, more nuanced understanding of intervention outcomes than standard systematic reviews. Employing the realist philosophy in the review process, we can unpack an intervention, thereby identifying what underlying mechanisms cause what outcomes, under what conditions, and in what contexts [] providing explanation, rather than judgement, about how an intervention works [,]. This context-mechanism-outcome (CMO) configuration creates an explanatory model for causation. It relies on the theory of complex interventions [], which theorizes that complex interventions have the properties of complex systems []. This is an innovative use of a realist review, as a game design in a behavior change setting has not been formally reviewed with a realist lens. The aim of this study was to review games and game elements designed to affect health behavior change and to propose a framework and program theory to underpin the game design for health behavior change interventions. This review focuses on the use of tabletop games as a behavior change tool in the context of health.

Framework

This realist review uses the framework for realist synthesis described by Pawson et al []. After a preliminary reading of the literature, the emerging central review questions generated were as follows:

What are effective game mechanics design elements in behavior change interventions?

What are the dynamic and context elements that explain outcomes of games and their use as an intervention?

Theory integrity and adjudication: do game element theories work as predicted and fit best?

Reality testing: how does the intent of gamification translate into practice?

Reviewing the current theory and frameworks of game design, can we propose a framework specific for game design in the behavior change context?

Formulating the Initial Intervention Theory

Mechanics: The rules of how the game system works.

Dynamics: The ways in which the participants interact in response to the mechanics.

Aesthetics: The flavor of how the game looks, the storyline, backstory, artwork, physical appearance, or medium.

Emotional aspects: How it makes players feel and relate with themselves, the game, and each other.

Mechanics

Mechanics determine the rules of the universe that a game creates and will form the foundations of how participants interact. A game can be designed for cooperation or competition and the mechanics dictate how the participants interact with the game and with each other. Clearly stated objectives and the progression toward goals determine how outcomes are pursued and how feedback through gameplay can occur. Success, failure, rewards, or punishments can be used to reinforce behaviors positively or negatively through operant conditioning and intrinsic or extrinsic motivation [,,].

Dynamics

Creativity and repeated play within the rules lead to outcomes between the game, players, observers, and spectators that form the game dynamics. All dynamic player behaviors can be designed purposefully to achieve behavior such as cooperation, competition, behavior loops [], and habit formation. Even negative behaviors can provide a fun dynamics for entertaining and engaging game play [] such as cheating, bluffing, conspiring, or even quitting []. Roles other than players may also form influential dynamics. Passive observers contribute to social relatedness and spectators influence the atmosphere, community, and popularity, and they impact player behavior within the game []. Within dynamics, one also needs to consider whether game elements will result in unwanted second-order behaviors [], undesired or unethical outcomes, and whether there will be lasting or novelty effects on desired outcomes.

Aesthetics

The artwork, setting, physical game components, storyline, and immersive objective form an environment that can induce more engaged players and motivate continued play [].

Emotions

Games that trigger emotional responses can be powerful behavior and learning tools but are challenging to design and more difficult to have heterogeneous control over [,]. Some emotions have predictable patterns and can be designed to elicit a sense of achievement, mastery, disappointment, or failure. More subtle emotional outcomes can funnel particular behaviors and can be leveraged through research in psychology and behavioral economics tools such as establishing social norms, endowment effects, scarcity, simplification, chance and probability, framing effects, reducing friction costs, network effects, salience, default states, and cognitive loads [,].

Final Systematic Searching for Primary Studies

A final systematic search was performed in December 2019 (). We searched 10 databases relevant to health and behavior interventions, including PubMed, Web of Science, and PsycInfo, without date restrictions. The search strategy was developed with the guidance of a medical subject librarian. The search terms included "board game," "game," "serious game," "tabletop game," "card game," or "gamification" and "health" but excluding the terms "virtual," "screen," or "video," and all publications were included in the review. We reviewed titles and abstracts to identify relevant studies. The full text of these papers was then accessed to determine if they met the inclusion or exclusion criteria and assessed for relevance and rigor to test against the initial theory [].

Inclusion and Exclusion Criteria

Studies were included if they used a tabletop game as an intervention and measured a health or behavior change outcome. Studies were excluded if they were digital interventions, did not measure health outcomes, were not English texts, were reviews, opinion pieces, or case studies, or the full text was unavailable upon author request. Papers were initially reviewed by title, keywords, and abstracts for relevance and imported into EndNote reference manager by the first author. Full papers of articles that described behavior change interventions in the context of health were accessed and read in full to determine if they met the inclusion criteria. Papers were excluded if the full text was not available ().

‎
Figure 1. Flow diagram for paper selection.
View this figure

Selecting Evidence

The process of quality appraisal in a realist review is different from that of quality appraisal in a systematic review. Studies are selected based on their relevance toward building and testing theory and their rigor in terms of methodological reliability and description power. A formal methodological quality appraisal tool was not used in this study, but research was individually assessed for rigor.

Testing Relevance

Studies were expected to have adequate relevance to build the program theory. The quality of the paper was assessed to see if the study addressed the program theory under testing by contributing enough knowledge to comment on the aspects of tabletop games on health outcomes. Any paper that was not directly assessing a tabletop game intervention or not measuring a behavior change outcome was excluded at this point.

Testing Rigor

The papers were assessed by the reviewers to screen if they were free of bias and were methodologically credible enough to contribute toward the building of the overall program theories. Articles of opinion, review papers, and case studies were excluded, as were non-English texts.

Extracting Data

A theoretically derived CMO framework was populated to evaluate evidence. Data were extracted and recorded in NVivo software (QSR International) during this process. Information extracted included name of the game, country and setting, method of delivery of intervention, demographics of participants, study design, sample size, comparison group exposure, mechanism of intervention effect, behavior change outcome, and any context-dependent outcomes.

Analyzing and Synthesizing Findings

To refine the preliminary program theory, we interrogated the literature asking:

1. For whom did this basic program theory work and not work, and why?

2. In what contexts (C) will this program theory work and not work, and why?

3. What are the main mechanisms (M) by which we expect this program theory to work?

4. If this program theory works, what outcomes (O) will we see?

This formed the codes used for tabulation, indexing, and linking to the program theory in a CMO configuration for each of the effects and their relevance to strengthen the initial program theory.

The resulting CMO configurations were reviewed by 2 authors (DE and CB) for quality assurance during synthesis. This was achieved by identifying recurring patterns and outcomes in the data, confirming and modifying the reviewers' understanding of the data, and assessing if the CMO configurations helped inform the hypothesized theory, thereby seeking to both confirm or contradict the findings [].

Literature Review Findings

Table 1. Contextual and mechanism factors that enhance efficacy of games in behavior change.

Evidence type/factors

Game design elements described in studies

Strong evidence across many trials

‎
Games reiteratively developed through pilot testing with target users and context [,,,-]

Games that leverage behavioral insights such as social norms, emotive engagement, operant conditioning, or intrinsic motivations [-,,,,]

‎

Limited evidence from one or few trials

Table 2. Context and mechanisms leading to positive behavior change outcomes in a realistic game design theory.

Mechanisms

Descriptions in the studies

Clear objective/goals leverage internal motivators

Rewards, success, and failures leverage external motivators

Challenging repeated play leads to competence, mastery, and expertise

Incremental improvement provides feedback on mastery and expertise leading to repeated desired behavior [-,,,].

Effective Game Mechanic Design Elements in Behavior Change Interventions

Dynamic and Context Elements That Explain Outcomes of Games

Reality Testing: Translation of the Intent of Gamification Into Practice

Factors that reduce the efficacy of games targeted for behavior change.
Contextual or mechanism factors

Laborious or unattractive game designs for immersive play [,,]

One-off play or limited replayability [,,,,,-]

Simple question-and-answer games sometimes that are not engaging or immersive [,,,,,]

Textbox 1. Factors that reduce the efficacy of games targeted for behavior change.

Table 3. Theories for games targeting behavior leading to poor behavior change outcomes.

Theories

Behavior change outcome

Not fun or enjoyable leads to low engagement

Unpleasant experiences are unlikely to be engaging or repeated and result in no behavior change

Limited replayability reveals novelty effects

One-off play and wearing off of the game novelty results in lack of repetition and lack of lasting behavior change

Poor contextual design leads to misinterpretation

Missing context dues can lead to poor knowledge translation/misinterpretation and unwanted effects

We refined the preliminary program theory based on the CMO analysis. We propose the following modification of the preliminary program theory in order to help future design of games to achieve health behavior change to include more structure and guidance around these results.

Proposed Framework for Designing Effective Behavior Change Games

Define Goal: Diagnosing the Behavior to Change

Like designing any tool for a task, one should start by considering the desired outcome. Define the behavior to change first. List the barriers to behavior change to target.

Create Order With Game Mechanics: Building Rules to Deliver the Desired Outcome

There are several mechanisms that can be considered processes to achieving this, such as leveraging behavioral insights, reward and punishment, or information delivery. The mechanism chosen is the skeleton from which the core rules and game mechanics can be built.

Expect Chaos Dynamics: Consider How the Individual, Group, and Context Will React to the Rules

Context of the target players, environment, and other constraints at this stage should be reflected upon to consider the dynamics of the player and game interactions.

Make it Fun (Aesthetics): Make it Enjoyable for Higher Engagement

To maximize engagement, the aesthetics of the story, visual values, and physical values of the game are important for the player experience. Games that are not fun will not engage players and lead to minimal behavior change.

Pilot: Test and Reiterate the Product

A reiterative piloting and feedback loop should be the final stages of the game design.

Measure the Desired (and Undesired) Outcomes

Measure with appropriate scientific methods the behavior change defined. Measure the desired outcome, second-order effects, and undesired outcomes. Consider measuring the short and long game of possible behavior change extinction and novelty effects.

Use Other Resources: Use as a Tool in a Toolkit

Delivery alongside other mediums will likely increase the desired changes. Including stakeholders as another resource in this toolkit will likely lead to more effective outcomes.

Principal Findings

Game designers need to consider all aspects of the game experience to achieve the desired behavioral outcomes. First, consideration should begin by defining the target behavior and identifying ways to promote this target behavior through the game. Second, a decision should be made on how the game rules will work to reinforce the desired change (game mechanics). This may include examples such as rewards, punishments, goals, collections, information retention, or physical challenge. Next, reflect on the context of how the players interact with the game and with each other (game dynamics) and if this can be leveraged for the behavior change target. This could include cooperation, negotiation, persuasion, competition, subversion, bargaining, spectatorship, charity, and the pursuit of mastery. Finally, fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect. The aesthetics and emotions of the game should not be forgotten as the experience of play should be pleasant and engaging for the maximum effect. This also includes the role of the spectators, observers, and nonparticipants in the process.

Games appeared to be effective in all age groups, but most of the literature is on participants younger than 18 years. It could be hypothesized that games are only effective for children and adolescents. However, games should be considered a legitimate engaging behavior change intervention for all ages, if the game design process considers the target audience. There is a trend for serious games to be considered a legitimate intervention for a purpose other than pure entertainment. The literature is expanding across all age groups and multiple industries, including applications in military, government, education, corporate business, and health care []. There are a range of potential effects that can be seen with interventional games, including perceptual, cognitive, behavioral, affective, and motivational impacts, knowledge acquisition, content understanding, and learning [,].

Pitfalls in Game Design

Several pitfalls were identified for game designers to avoid in each key area. First, the failure to diagnose a specific behavior to target with the game was a common error in the studies reviewed. Games developers need to define the behavior change first, list the barriers to behavior change to target, and follow a structured design process to decide which elements of game mechanics can be leveraged to target this behavior. This process was best done using local teams who have knowledge of the players and context. Second, the dynamics between how the players will interact with the game and with each other should be considered in the context of play to avoid unwanted effects. Thinking about second-order behaviors and possible unwanted effects could be considered here in the design process. Once the rules and predicted play behavior have been established, the user experience and user interface (or aesthetics) should be considered to enhance fun and engagement. Games in which aesthetics was not given due attention were undesirable or not engaging. Finally, the design process should include pilot testing, wherein behavior change will be assessed carefully and a multi-intervention approach will be considered to maximize the impact of the desired outcome, assuming through realism that no 1 intervention will work for everyone.

Metagaming

The concept of metagaming can also be considered for advanced game design strategy. Designers can abstract outside of the rules of the game to consider how the player will use the game outside of its intended rules or environment []. The concept of metagaming is defined as a player taking action outside the rules or design of a game such as developing higher strategy, cheating, applying outside information, or strategy not intended by the mechanics [,]. Designing for metagaming behavior is not usually part of the core mechanics but can be intentionally thought of in the design process to add another engaging layer to the game experience. For example, the game itself could be used as a collectable item for a desired outcome, having the physical world around the game change the way it is played or reward cheating in the core mechanics to improve the likelihood of desired behavior outcomes. Considering the target behavior at the metagaming level can advance the engagement and is an interesting opportunity for behavior change game designers.

Limitations

First, this review was limited by the small number of published studies using games as an intervention. This limits the potential analysis of the topic. Second, the included studies were of varying degrees of methodological quality. One concern is that only a limited number of papers used in this review showed evidence of behavior change in their interventions. Most studies focused on education and knowledge changes owing to the short intervention period and lack of follow-up. As is common in a realist review, we did not exclude papers based on methodological quality. Finally, working definitions of games and the wording of interventions that could be considered games is likely not consistent. It is possible that this review did not contain all evidences on game-like interventions owing to the varying definition of what "is" a game, for example, setting blood pressure target goals could be considered a game element. However, we performed further hand searching of the reference lists from the included studies to mitigate this limitation. This review is also limited in the framework being applicable only to tabletop game contexts.

Conclusion

Games can be used as a successful intervention tool for effective behavior change. The ability of games to achieve behavior change is a product of their design-to address a clearly defined problem. Using a realist review methodology, we synthesized evidence from published papers and proposed a framework for game design. This framework outlines the considerations for making a game for a behavior change intervention. Game designers should consider elements of this framework specifically early in the design process to map the context and flow of participants through play, help create the mechanics that govern the rules, consider the dynamics and experiential aspects of playing, and maximize the aesthetics of the play experience. This framework is designed to achieve the best possible interventional results without unintentional outcomes in a realist context, acknowledging that not all interventions will work for all participants in all contexts. Game designers can use this framework to improve the quality of the design process for behavior change interventions. Future work in this field is to apply further realist lens to serious game design in fields outside the context of behavior change or tabletop games or to test this thesis framework in the context of digital game design.

# data[].attributes.attachment_link.title
Tabletop Board Game Elements and Gamification Interventions for Health Behavior Change: Realist Review and Proposal of a Game Design Framework

# data[].attributes.attachment_link.description
Background: Games, when used as interventional tools, can influence behavior change by incentivizing, reinforcing, educating, providing feedback loops, prompting, persuading, or providing meaning, fun, and community. However, not all game elements will appeal to all consumers equally, and different elements might work for different people and in different contexts.

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The challenge of audience reception: a developmental model for educational game engagement

# data[].attributes.subject
The challenge of audience reception: a developmental model for educational game engagement

# data[].attributes.attachment_link.readable_text
Abstract

According to educational gaming advocates, the engaging nature of games encourages sustained game play and enhanced attention to learning outcomes among players. Because children's and adolescents' play time varies by game genre, engagement with a game likely reflects the match between the genre and the player's preferences and needs. Youth learn which games are likely to promote satisfying psychological needs and yield positive experiences, which then informs their engagement with the games. A model is presented for research and development of educational games based on uses and gratifications theory from communication science, as well as developmental science and cognitive science findings.

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national center for biotechnology information

# data[].attributes.attachment_link.title
The challenge of audience reception: a developmental model for educational game engagement - PubMed

# data[].attributes.attachment_link.description
According to educational gaming advocates, the engaging nature of games encourages sustained game play and enhanced attention to learning outcomes among players. Because children's and adolescents' play time varies by game genre, engagement with a game likely reflects the match between the genre and ...

# data[].attributes.headline
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# data[].attributes.subject
Table-top role-playing games as a therapeutic intervention with adults to increase social connectedness

# data[].attributes.attachment_link.readable_text
ABSTRACT
Research shows that social connectedness is decreasing and loneliness increasing in the United States, subsequently resulting in a health crisis due to the anxiety and depression these attributes can cause. There is evidence that clinicians have difficulty treating individuals experiencing social anxiety and there is need for intervention strategies that lower treatment barriers. There has been scant research recognizing the use of table-top role-playing games to incorporate when treating social anxiety. The current manuscript describes a year-long group using Dungeons and Dragons in a therapeutic setting and explores perceptions from participants who experienced this group. Core concepts of the model and lessons learned from the developers are described for clinicians who hope to incorporate such a model. Participants described increased confidence in social situations, particularly with boundaries or making mistakes. Secondly, the skills practiced in the game were transferred into real-world experiences. Implications for future research and limitations were described.

Disclosure statement

No potential conflict of interest was reported by the author(s).

# data[].attributes.attachment_link.title
Table-top role-playing games as a therapeutic intervention with adults to increase social connectedness

# data[].attributes.attachment_link.description
ABSTRACT Research shows that social connectedness is decreasing and loneliness increasing in the United States, subsequently resulting in a health crisis due to the anxiety and depression these attributes can cause. There is evidence that clinicians have difficulty treating individuals experiencing social anxiety and there is need for intervention strategies that lower treatment barriers.

# data[].attributes.headline
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# data[].attributes.subject
Engagement states and learning from educational games

# data[].attributes.attachment_link.readable_text
Abstract

Children's and adolescents' cognitive, affective, and behavioral states of engagement enhance or impede enjoyment of, and performance with, educational games. We propose a comprehensive model of engagement states and apply it to research on educational game development and research on the role of various aspects of engagement on game play and learning. Emphasis is placed on individual differences in attention, memory, motor speed and control, persistence, and positive and negative affect (approach/avoidance), and how these pertain to social cognitions regarding mathematics achievement. Our challenge is to develop educational games that are effective for a wide variety of student engagement states.

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Introduction

The application of game design approaches and technologies has gained popularity in healthcare as a means of creating more engaging interventions, which can improve knowledge, change real-world behaviors, and subsequently impact therapeutic outcomes. Successful examples exist in the areas of treatment adherence, pain management, physical rehabilitation, depression, schizophrenia, and phobias.1–6 Games can support engagement in play and fantasy, which are described as important mechanisms facilitating greater attentional control, enhanced learning and providing patient insight toward impacting long-term behaviors.7 From a theoretical perspective, it has been suggested that games stimulate or facilitate learning through immersion flow, and meeting individual's needs concerning mastery, fantasy, challenge, and connectedness.8–11

Although digital games are popular, nondigital formats have also been addressed in the research literature.12 Board games have a history of use in therapeutic contexts.13–15 Aside from its engaging and entertaining characteristics, one of the great advantages of using a board game is its ability to facilitate face-to-face interactions with peers, tutors, family members, or even a therapist. These social interactions are assumed to enhance learning opportunities.16 However, only a very small proportion of board games described in the literature have been evaluated to determine their impact.16 Reviews focusing on evaluating the use of board games in medical education, conclude that it would be premature to claim that board games have an impact on knowledge or other educational outcomes in medicine given the strength of the existing evidence reviewed.17,18 More recently, evaluations of board games for health with patients and community members have demonstrated promising impacts on knowledge (e.g., knowledge of HIV and sexually transmitted diseases; STIs),19 health behaviors (e.g., improved food habits),20 and objective indicators of health (e.g., HbA1c improvements among patients with Type II Diabetes).21 Results of these evaluations have not been synthesized or systematically assessed in the literature to date. Thus, there is a need to update previous reviews of board games in medical education and to expand the review, including evaluations of board games in other healthcare contexts.

The aim of this systematic review and meta-analysis is to answer the following two questions: (1) What kinds of board games targeting medical and health-related outcomes have been evaluated in the literature? and (2) What is the overall impact of these board games on health-related outcomes?

Method

This review follows the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).22,23 In conformity with these guidelines, the Supplementary Data (available online at https://www.liebertpub.com/suppl/doi/g4h.2018.0017) provide readers with additional detail regarding our method and results, while keeping the body of this article a manageable length. The Supplementary Data include detailed database search terms and strategies, elaborated descriptions of data collection and analysis methods, details of within-studies risk of bias (RoB) analyses (e.g., bias matrices and interrater reliability results), effect sizes (ES) for each outcome comparison included in this study, and expanded results of publication bias analyses.

Inclusion and exclusion criteria

In this article, board games are defined as “a game of strategy […] played by moving pieces on a board,”24 which does not include games played exclusively with cards (“card games”) or dice. Inclusion criteria were evaluations (1) of a health or medical-related nondigital board game intervention; (2) either as a standalone intervention or as part of a larger intervention program; (3) using random or other method of assignment to no treatment or active control group; (4) with participants from any sociodemographic background; (5) assessing medical and health-related outcomes; (6) of scholarly publications in a journal, thesis, research report, or conference proceeding; (7) published in English. Exclusion criteria were evaluations (1) of digital board games (i.e., played on computers or smart phones); (2) of board games not implemented as an intervention (e.g., used as an assessment tool); and (3) of a board game's impact on processes rather than outcomes (e.g., usability, acceptability, credibility). Notably, digital board games were not included because they breach into the category of digital game-based learning and often involve more complex gaming and learning mechanics, which would increase the heterogeneity of the included studies, rendering conclusions about overall efficacy more difficult to summarize.16

Search method

An electronic search was performed on five databases: ProQuest (encompassing ERIC, IBSS, PsycINFO), Scopus, PubMed, JSTOR, and OVID (encompassing Medline, Embase). The search targeted board games specifically (term: “board game”) in the area of health (terms: “health,” “medical,” “patient,” “illness,” “disease”) (Supplementary Data for full search details). The searches were performed on February 8, 2017 and include studies available up until this date. Hand searching of the reference lists of articles that met final eligibility was also performed using the “snowball sampling” method.25

Study selection

Database search results were imported into RefWorks, where duplicates and non-scholarly publications were removed. The remaining abstracts were screened to exclude articles if a nondigital medical or health-related board game was not mentioned. The full texts of the remaining articles were reviewed in detail to see if they met the inclusion/exclusion criteria. Reasons for excluding articles were documented. Three researchers independently evaluated the articles for eligibility for inclusion. A fourth rater performed a reliability check of a random selection of 33% of the articles for eligibility. Interrater reliability was calculated using Cohen's kappa (κ) coefficient, where a value greater than 0.7 would be deemed acceptable. The raters met to discuss and resolve any discrepancies until 100% agreement was achieved.

Data collection and data items

For each included article, information such as the study design, participant characteristics, sample size, and means and standard deviations of measured outcomes at each recorded time point (preintervention, postintervention, delayed follow-up) were extracted (all data items are listed in the Supplementary Data).

To identify what aspects of health and medicine have been impacted by board games in the literature, we performed a preliminary inductive coding of the measures and outcomes in each article. Only outcomes that were measured for the board game group and one or more comparison groups were coded. Following the preliminary coding, the primary coder and another investigator held a meeting to refine the coding scheme until 100% agreement on codes was reached.

Data analyses

Summary measures

Based on the extracted detailed data, the ES and 95% confidence intervals (CIs) were calculated using Cohen's d, based on a between-group mean difference for each continuous data outcome at each time point (preintervention, postintervention, delayed follow-up).26 For dichotomous data, ES and standard errors were first calculated with a log odds ratio (using natural logarithm) then converted to Cohen's d by the method described in Borenstein et al. (p. 47),27 to establish comparability. Special considerations in the ES calculation were made for studies with a cluster randomized design, for studies with multiple comparison groups, and for studies with multiple outcome measures within the same outcome category (Supplementary Data).28

Since most outcome measurements extracted from the included studies did not report variance metrics for pre-to-postintervention change/improvement (only 7.4% of outcomes included these data), our analysis focused on ES comparing postintervention scores between experimental groups and, when reported, delayed follow-up scores. The ES of preintervention scores were taken into account when evaluating the RoB for each comparison. Where negative ES represented a preferred outcome (e.g., age- and sex-adjusted body mass index (zBMI) as related to obesity, or reduction in positive attitudes toward cigarette smoking), these results were multiplied by −1 to reflect a positive result in the meta-analysis.

Synthesis of data

It has been argued that combining heterogeneous studies may be appropriate if the purpose of the analysis is to come to higher-order generalizations about the topic in question.29,30 As such, this review combines heterogeneous studies investigating an array of board games and populations to answer our research questions. A summary of inconsistency across studies for each outcome is given by the value I 2 under each table summarizing the meta-analysis.28 For each outcome measure category (e.g., knowledge, behavior, self-efficacy, etc.)—and separately for both postintervention and delayed follow-up time points—the following random-effects meta-analyses are produced when two or more data points were available:

1.

An overall analysis that synthesizes all comparisons, where an ES could be calculated (Summary Measures section).

2.

A sensitivity analysis using only outcome comparisons at a low RoB.

Risk of bias

RoB in individual studies

For each extracted outcome measure, its RoB was assessed using the Cochrane Collaboration tool for assessing RoB,28 where six categories of bias (selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias) were evaluated. These categories were judged as either “low risk,” if the bias was unlikely to affect the study's results; “unclear risk,” if the information was not included or was insufficient; or “high risk,” if the bias would seriously affect confidence in the results. Two raters assessed risk in each study and interrater reliability for each category of bias was calculated using Cohen's kappa coefficient, where a value greater than 0.7 was deemed acceptable. Discrepancies between the two assessors were identified, discussed, and resolved with 100% agreement.

RoB across studies

The inverse standard error and the weighted variance for each study's combined d statistic were calculated to investigate the risk of publication bias across studies visually with a funnel plot. Egger's regression test was used to assess the (1) overall publication bias in the literature (i.e., across outcomes) at postintervention and delayed follow-up separately, and (2) for each outcome category individually, at the postintervention time point. For the analysis across all outcomes, to avoid a unit-of-analysis error, all results from each study were combined into a single ES (Supplementary Data: Summary Measures section).

Results

Study selection

Our electronic database search resulted in a total of n = 1043 articles from ProQuest (n = 578), Scopus (n = 185), PubMed (n = 55), JSTOR (n = 18), and OVID (n = 207), whereas another three (n = 3) other references were identified as potential candidates based on a “snowball” search of the reference lists of eligible articles. Figure 1 documents the study selection process. A total of 22 articles met our inclusion/exclusion criteria; however, n = 2 articles reported the same outcomes and intervention.31,32 Data from these two articles were extracted, summarized, and considered as one article, resulting in 21 total selected studies. Additionally, two of the articles evaluated the same board game reported on different outcomes in two distinctly different studies.20,33 They are thus considered separate studies of one board game in this report. Interrater reliability on the study selection process was high, with κ = 0.86 and a 97.92% agreement rate.

FIG. 1.  Flow diagram of study selection process.

Study characteristics

Table 1 summarizes study characteristics across the 21 research studies, including study designs, sample/cluster sizes, populations/locations, and play duration, whereas the details of each board game intervention (i.e., purpose, general intervention structure, and mechanics employed) are presented in Table 2.

Table 1. Study Design Characteristics, Including Sample Size, Age Range, Location of Study, Description of Participants, Types of Comparison Group(s), and the Duration of the Intervention (i.e., How Long Did the Participants Play The Game)

Source | Study design | Sample size (clusters) | Location | Age range | Description of participants | Comparison group(s) | Duration of intervention
Amaro et al.33 | cRCT | 241 (13) | Italy | 11–14 | Middle-school children | No intervention | 15–30 min/week for 24 weeks (6–12 hours total)
Anyanwu44 | RCT | 79 | Nigeria | Undefined (young adults) | Second-year medical and dental students | No intervention (traditional learning) | Variable, over 11 days
Bartfay and Bartfay47 | RCT | 23 | Canada | Undefined (∼10–12-year- olds) | Sixth-grade school children | No intervention | Two 1-hour sessions, 2 weeks apart (2 hours total)
Burghardt et al.42 | NRS | 193 | USA | 18 to >65 | Low-literacy adults within a community pharmacy | No intervention | One session of variable length
Charlier and De Fraine31,32 | cRCT | 120 (4) | Belgium | 13–14 | Belgian secondary school children | Lecture | 1 hour
Crawford and Wiltz21 | NRS | 411 | USA | 59 ± 8.3 | Adults with type 2 diabetes | No intervention | 2 h/week for 4 weeks (8 hours total)
Czuchry et al.34 | RCT | 183 | USA | 18–24 | College students | Educational videos; No intervention (unrelated questionnaires) | 1 hour 5 minutes
Fernandes et al.35 | RCT | 80 | Portugal | 8–12 | Preoperative children | Educational video; Educational booklet | Undefined (time between admission and operation)
Fissler et al.40 | RCT | 17 | Germany | Mean 70.4 and 69.8 | Community-dwelling older adults | No intervention | 2 hours, 3 times/week, for 5 weeks (30 hours total)
Khazaal et al.43 | RCT | 240 | Switzerland | 18–65 | Adult daily smokers | Lecture; No intervention | Two 1.5-hour sessions over 2 weeks (3 hours total)
Lennon and Coombs36 | RCT | 168 | Philippines | 11–14 | School-aged children and high-school-enrolled adolescents | Lecture | 35 minutes
Maclachlan et al.45 | NRS | 828 | Malawi | 14–20 | High-school-enrolled adolescents | No intervention | 1 h/week for 4 weeks (4 hours total)
McKay et al.46 | NRS | 78 | USA | Undefined (sixth-grade children) | Sixth-grade students | No intervention | Undefined (6 sessions over 1 month)
Moyer and Nelson38 | RCT | 28 | USA | 23–98 | Patients in rehabilitation facility with lower extremity dysfunction | Rehab alone; Rehab with another | 5 minutes
Ogunsile and Ogundele48 | NRS | 143 | Nigeria | 10–14 | High-school-enrolled adolescents | No intervention | 1 hour 20 min/week for 8 weeks (10 hours 40 minutes total)
Okitika et al.41 | NRS | 274 | USA | 6 to >30 | General public attending a free Global Health Exhibit | No intervention | 10–15 minutes
Swiderska et al.49 | cRCT | 67 (8) | United Kingdom | Undefined (young adults) | Undergraduate medical students | No intervention | 1 hour
Torres et al.39 | RCT | 49 | Spain | 18–50 | Patients with schizophrenia | Social/psychomotor skills training; No intervention | 1 h/week for 6 weeks (6 hours)
Udin and Kuster37 | RCT | 42 | USA | Undefined (young adults) | Dental students | Lecture; No intervention | 1 hour
Viggiano et al.20 | cRCT | 3110 (20) | Italy | 9–19 | School-aged children and high-school-enrolled adolescents | No intervention | 15–30 min/week for 20 weeks (5–10 hours total)
Wanyama et al.19 | RCT | 180 | Uganda | 24–40 | HIV-positive patients | Lecture | 20–30 minutes (plus 15 minutes for questions)

Table 2. Board Game Intervention Titles, Content Description, and Identifiable Learning Mechanics for Each Study

Source | Board game or program | Content | Identifiable learning mechanics
Amaro et al.33 | Kalèdo | Healthy lifestyle through diet and activity; emphasis on healthy food items and food variety | Action and consequence; Competition
Viggiano et al.20
Anyanwu44 | Anatomy Adventure | Human anatomy of the upper limb | Question and answer; Competition
Bartfay and Bartfay47 | The Lifestyles Board Game | Anatomy and physiology, diet and nutrition, and lifestyle risk factors associated with the development of heart disease and cancer | Question and answer; Competition
Burghardt et al.42 | Six custom-made board games in a “health party” | Pharmacy-related information: med interactions, cost-saving | Question and answer; Discussion/game facilitator; Competition
Charlier and De Fraine31,32 | Game for learning first aid content | First Aid-related content (derived from the European First Aid Manual) | Question and answer; Competition
Crawford and Wiltz21 | The Conversation Map | Diabetes and diabetes management | Discussion/game facilitator; Collaboration
Czuchry et al.34 | Downward Spiral | Consequences of alcohol and drug use | Action and consequence; Competition
Fernandes et al.35 | Custom-made board game | Hospital procedures, medical equipment, operation, and recovery procedures for children | [Not enough detail]
Fissler et al.40 | Fifteen off-the-shelf and self-developed board games | Games with simple rules tapping components of executive control | [Not enough detail]
Khazaal et al.43 | Pick-Klop | Smoking-related information, regarding smoking history, health effects, costs, cessation strategies, etc. | Question and answer; Action and consequence; Competition
Lennon and Coombs36 | Goodbye-to-Dengue | Mosquito characteristics, dengue control and treatment, dengue signs and symptoms | Question and answer; Competition
Maclachlan et al.45 | Custom-made board game | HIV and AIDS facts and prevention | Question and answer; Competition
McKay et al.46 | Hold the Salt! program | Relationship between sodium and health, high/low-sodium foods, strategies to reduce sodium intake | [Not enough detail]
Moyer and Nelson38 | Bulb-squeeze hockey for rehabilitation | Involves squeezing a bulb (a rehabilitation technique) to blow a ball into a net | Competition
Okitika et al.41 | Polio Eradication Game | Polio eradication strategies, interdisciplinary teamwork, and complex issues in Global Health | Action and consequence; Collaboration
Ogunsile and Ogundele48 | Game-enhanced nutrition program | Facts and strategies for healthy nutrition | [Not enough detail]
Swiderska et al.49 | Neonatology | Curriculum-derived neonatology knowledge (medical care of newborn infants) | Question and answer; Competition
Torres et al.39 | El Tren + social skills training | Problem solving, communication, illness-self-management, positive/negative situations | Discussion/game facilitator; Collaboration
Udin and Kuster37 | Smile | Behavior-management strategies and modifications to dental treatment of handicapped patients | [Not enough detail]
Wanyama et al.19 | Make a positive start today! | Facts about HIV, STIs, antiretroviral treatment, prevention behavior, myths regarding the disease | Question and answer; Competition

Study design

Studies consisted of n = 11 randomized controlled trials; n = 4 cluster randomized controlled trials; and n = 6 quasi-experimental or nonrandomized trials, one of which was a case–control trial. Most of the studies (n = 16) included a “no intervention” or a standard of care/learning comparison group. Two studies compared the board game with other educational media,34,35 and four compared the board game with an educational lecture.19,31,32,36,37 Finally, two studies included a specialized training intervention as control that mirrored the content/experiences targeted in the board game.38,39

Sample sizes

Studies varied in sample size, from small (n = 17)40 to large (n = 3110 across 20 clusters),20 with n = 6554 total participants across all 21 studies. Of these, n = 3055 received a board game-based intervention and n = 3499 were in a comparison/control group.

Populations

The samples used to evaluate the board games included a wide range of age groups, from children as young as 8 years old35 to older adults.40 Most (57%, n = 12) of the studies' participants were students enrolled in school. Participants in the remaining n = 9/21 studies (who were not students enrolled in schools) were patients in n = 6 studies and people recruited from specific communities in the remaining n = 3 studies.

Duration of play

Interventions varied in total play-time reported ranging from 5 minutes38 to 30 hours,40 and in overall duration of intervention, from a single session to 24 weeks.33

Description of the board game interventions

Purpose/aims of the board game interventions

Most of the board game interventions focused on education to increase knowledge and/or skills (n = 17/21 studies representing 16 board games). The remaining board games evaluated in n = 4/21 studies aimed to directly impact a neurological skill (i.e., cognitive functioning for community seniors),40 physical rehabilitation skills (i.e., hand pinch strength),38 increase interest in Global Health issues,41 or change in motivations among community members to increase their intentions to seek local pharmacy advice.42

General intervention structure

Most of the included studies (n = 15 studies, representing n = 14 board games) evaluated a board game in itself as an intervention, whereas n = 6 studies investigated the effect of a board game as part of a multicomponent intervention program.

Game design and mechanics

The mechanics for only n = 15/20 board games could be interpreted (Table 2). Notably, most games (n = 12) were competitive in nature. The most popular learning mechanic implemented in the board game was a question-and-answer (self-testing) strategy, with n = 9 interventions employing this mechanic as their primary method of learning. In all cases, progressing in the game required questions to be answered correctly. In contrast, n = 4 board games implemented an action-and-consequence style of learning mechanic that involved a more reflective learning. For example, to affect diet and lifestyle behavior in children, Kalèdo employs nutrition and activity cards that the children must balance to optimize calorie-intake and energy expenditure; furthermore, the player faces consequences (e.g., loss or gain of points) throughout the game for real-life dietary/exercise decisions made during the day, thereby enhancing their understanding of healthy and unhealthy behavior and encouraging real-world transfer.20,33

Outcomes assessed

Coding of the outcome measures resulted in eight categories of health-related outcomes across the studies: (1) health-related behavior (including self-reported behavior, self-reported behavioral intentions, and measured behaviors), (2) knowledge (of a health concept or skill), (3) self-efficacy (perceived confidence in one's abilities to carry out a health-related behavior), (4) attitudes and beliefs about a health concept, (5) biological health indicators, (6) social functioning, (7) anxiety, and (8) executive functioning. The distribution of studies, measures, and between-group comparisons across outcome categories are presented in Table 3. Hereafter, we use the term “outcome” to refer to the construct that was measured; the “measure” to refer to the method or means used to quantify the outcome; and “comparison” to refer to a between-group analysis of two or more comparisons between groups for a single measure (e.g., game vs. no intervention, game vs. lecture).

Table 3. The Number of Studies, Measures, and Game-Control Comparisons Extracted from the Literature in Each Outcome Category

Outcome | Studies | Measures | Postintervention comparisons a | Delayed follow-up comparisons a
Overall | MA—all RoB | MA—low RoB | Overall | MA—all RoB | MA—low RoB
Behavior b | 10 | 19 | 28 | 8 | 2 | 7 | 2 | 2
Self-reported behavior | 5 | 10 | 12 | 4 | 2 | 7 | 2 | 2
Behavioral intentions | 4 | 7 | 12 | 3 | 0 | 0 | 0 | 0
Measured behavior | 1 | 2 | 4 | 1 | 0 | 0 | 0 | 0
Knowledge | 11 | 13 | 13 | 8 | 2 | 2 | 2 | 1
Self-efficacy | 4 | 5 | 7 | 3 | 2 | 4 | 2 | 2
Attitudes and beliefs | 6 | 10 | 15 | 4 | 2 | 11 | 2 | 2
Biological health indicators | 3 | 5 | 6 | 3 | 1 | 1 | 1 | 1
Social functioning | 1 | 7 | 14 | 1 | 0 | 0 | 0 | 0
Anxiety | 1 | 2 | 4 | 0 | 0 | 0 | 0 | 0
Executive functioning | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0
Total | (21) | 62 | 88 | 28 | 9 | 25 | 9 | 8

RoB within studies

Overall, n = 3 studies were considered to have an overall low RoB19,20,43; n = 7 were considered to have an overall high RoB31,32,35,41,42,44–46; and n = 11 were considered to have an unclear RoB.21,33,34,36–40,47–49 RoB matrices for each outcome category and interrater reliability statistics are reported in the Supplementary Data. Table 3 also presents the number of low RoB and other comparisons suitable for inclusion in the data synthesis.

Results by type of outcome

Below, we present the syntheses of between-group mean difference ES (Cohen's d) for each study categorized by the type of outcome measurement at both the postintervention and delayed follow-up (if applicable) time points (visualized in Fig. 2). Overall synthetic analyses (using comparisons at all levels of RoB) and sensitivity analyses (using only comparisons at a low RoB) are presented. An ES given as “d*” denotes a synthesized effect across two or more studies, whereas “d” denotes an effect within a single study. A summary of the RoB across studies in each category is included in each subsection.

FIG. 2.  Forest plots of effect sizes at the postintervention and delayed postintervention time points, displaying results at all levels of risk of bias (diamonds). Refer to Table 4 through Table 9 for details.

Health-related behavior

Health-related behaviors are made up of the subcategories of self-reported behavior, behavioral intentions, and measured behaviors. Taken together, health behaviors showed a small-to-moderate effect in favor of board games compared with control group(s) at immediate postintervention assessment (d* = 0.33, 95% CI [0.16–0.51], Q = 18.90, df = 7, C = 373.59, Tau = 0.03, I 2 = 62.97%, Z = 3.83, P < 0.001) and a small effect in favor of board games at delayed follow-up (d* = 0.24, 95% CI [0.02–0.45], Q = 1.86, df = 1, C = 70.45, Tau = 0.01, I 2 = 46.24%, Z = 2.18, P = 0.029). Each subcategory of health-related behavior is discussed individually in more detail below.

Self-reported behavior

In the subcategory of self-reported health behaviors (Table 4), we observe a significant small-to-moderate effect in favor of board games (d* = 0.38, 95% CI [0.07–0.69]) over other control conditions immediately after the intervention takes place. Additionally, we see a small effect at delayed follow-up (d* = 0.24, 95% CI [0.02–0.45]). Overall, the RoB associated with self-reported behavior outcomes was deemed to be “unclear,” with ∼56% of the weight at a low RoB, ∼31% at an unclear RoB, and 13.3% at a high RoB. However, sensitivity analyses—that include only comparisons at a low RoB—show similar effects at both the postintervention (d* = 0.38, 95% CI [0.08–0.83]) and delayed follow-up (d* = 0.24, 95% CI [0.01–0.46]).

Table 4. Effect Size Details for Studies Measuring Self-Reported Health-Related Behavior

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
A. Synthesis of data at all RoB
Amaro et al.33 | 2 | Unclear | 0.18 (−0.19 to 0.55) | 25.5 | — | —
Khazaal et al.43 | 4 | Low/unclear | 0.05 (−0.38 to 0.48) | 22.8 | 0.39 (0.10–0.68) | 34.7
McKay et al.46 | 2 | High | 0.80 (0.11–1.49) | 13.3 | — | —
Viggiano et al.20 | 3 | Low | 0.56 (0.44–0.69) | 38.5 | 0.16 (0.01–0.31) | 65.3
Synthesized effect | | | 0.38 (0.07–0.69)a | | 0.24 (0.02–0.45)b |
B. Synthesis of data at low RoB
Khazaal et al.43 | 3 | Low | 0.09 (−0.36 to 0.54) | 39.2 | 0.40 (0.08–0.73) | 32.7
Viggiano et al.20 | 3 | Low | 0.56 (0.44–0.69) | 60.8 | 0.16 (0.01–0.31) | 67.3
Synthesized effect | | | 0.38 (0.08–0.83)c | | 0.24 (0.01–0.46)d |

Behavioral intentions

Behavioral intentions as a subcategory are considered distinct from self-reported behaviors because they measure intent to engage in behaviors in the future, as opposed to self-reported behaviors that occurred in the past. A small effect of board games over control groups is observed for behavioral intentions postintervention (d* = 0.28, 95% CI [0.06–0.50]; Table 5). No study measured behavioral intentions at delayed follow-up. The RoB associated with comparisons measuring behavioral intentions is high overall, with 44.3% weighted as “unclear” RoB, and 55.6% as high RoB. No study provided low RoB comparisons, so sensitivity analyses were not performed.

Table 5. Effect Sizes for Studies Measuring Health-Related Behavioral Intentions

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
Burghardt et al.42 | 1 | Unclear | 0.48 (0.19–0.78) | 29.1 | — | —
Czuchry et al.34 | 8 | Unclear | 0.30 (0.12–0.47) | 44.3 | — | —
Okitika et al.41 | 1 | Unclear | 0.03 (−0.29 to 0.34) | 26.5 | — | —
Synthesized effect | | | 0.28 (0.06–0.50)a | | — |

Measured behavior

Finally, Moyer and Nelson assessed the subcategory of health-related behavior directly, with hand pinch strength (pressure) and pinch repetitions in individuals attending rehabilitation sessions.38 Combining multiple comparisons in this study, no effect of board game over the control group was observed (d = 0.33, 95% CI [−0.22 to 0.88], Z = 1.18, P = 0.239). This comparison has an overall unclear RoB.

Knowledge

A large and significant postintervention effect of health/disease-related knowledge in favor of board games was observed at immediate follow-up (d* = 0.82, 95% CI [0.15–1.48]). The effect was small and not significant at the delayed follow-up (d* = 0.25, 95% CI [−0.53 to 1.03]). Heterogeneity of the postintervention ES was very high (I 2 = 94.50%) and included studies measuring very different types of knowledge. The synthesis of ES for health-related knowledge outcomes have only 28.7% of the weight associated with low RoB, 27.6% with high RoB, and 43.8% with an unclear RoB. Using only low RoB ES, the large postintervention ES remains (d* = 1.05, 95% CI [0.82–1.28]), and the one study20 that did a delayed follow-up assessment of knowledge shows a marginally significant small-to-moderate effect (d = 0.34, 95% CI [−0.03 to 0.72], p = .063). Refer to Table 6 for details.

Table 6. Effect Sizes for Studies Measuring Health-Related Knowledge

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
A. Synthesis of data at all RoB
Anyanwu44 | 1 | Unclear | 0.45 (0.00–0.91) | 13.9 | — | —
Charlier and De Fraine31,32 | 1 | Unclear | −2.15 (−6.22 to 1.92) | 2.3 | −1.51 (−4.99 to 1.96) | 4.9
Lennon and Coombs36 | 1 | Unclear | −0.55 (−0.86 to 0.24) | 14.4 | — | —
Maclachlan et al.45 | 1 | High | 1.89 (1.52–2.26) | 14.2 | — | —
McKay et al.46 | 1 | High | 1.76 (1.19–2.32) | 13.4 | — | —
Swiderska et al.49 | 1 | Unclear | 0.57 (−0.02 to 1.16) | 13.3 | — | —
Viggiano et al.20 | 1 | Low | 1.13 (0.80–1.46) | 14.3 | 0.34 (−0.03 to 0.72) | 95.1
Wanyama et al.19 | 1 | Low | 0.97 (0.66–1.29) | 14.4 | — | —
Synthesized effect | | | 0.82 (0.15–1.48)a | | 0.25 (−0.53 to 1.03)b |
B. Synthesis of data at low RoB
Viggiano et al.20 | 1 | Low | 1.13 (0.80–1.46) | 46.9 | 0.34 (−0.03 to 0.72) | 100
Wanyama et al.19 | 1 | Low | 0.97 (0.66–1.29) | 53.1 | — | —
Synthesized effect | | | 1.05 (0.82–1.28)c | | |

Self-efficacy

Self-efficacy refers to an individual's self-perceived abilities to engage in behaviors despite challenges.50 The mean ES for self-efficacy showed no evidence of an effect at immediate (d* = 0.09, 95% CI [−0.03 to 0.22]) or at delayed follow-up (d* = 0.18, 95% CI [−0.36 to 0.71]), Table 7. The comparisons for self-efficacy are at an overall low RoB, with ∼69% of weighted data at low risk and ∼31% at an unclear risk. Results are consistent with the overall synthesis (above) when analyzing only comparisons with a low RoB at the posttest (d* = 0.12, 95% CI [−0.02 to 0.25]) and delayed follow-up (d* = 0.18, 95% CI [−0.39 to 0.75]).

Table 7. Effect Sizes for Studies Measuring Health-Related Self-Efficacy

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
A. Synthesis of data at all RoB
Khazaal et al.43 | 2 | Low/unclear | 0.18 (−0.04 to 0.40) | 28.7 | 0.45 (0.23–0.68) | 49.2
Lennon and Coombs36 | 1 | Unclear | −0.11 (−0.41 to 0.20) | 16.2 | — | —
Viggiano et al.20 | 2 | Low | 0.11 (0.04 to 0.25) | 55.1 | −0.09 (−0.27 to 0.08) | 50.8
Synthesized effect | | | 0.09 (−0.03 to 0.22)a | | 0.18 (−0.36 to 0.71)b |
B. Synthesis of data at low RoB
Khazaal et al.43 | 1 | Low | 0.16 (−0.16 to 0.47) | 18.2 | 0.5 (0.17–0.80) | 47.3
Viggiano et al.20 | 2 | Low | 0.11 (−0.04 to 0.25) | 81.8 | −0.1 (−0.27 to 0.08) | 52.7
Synthesized effect | | | 0.12 (−0.02 to 0.25)c | | 0.18 (−0.39 to 0.75)d |

Attitudes and beliefs

Participants' attitudes and beliefs about a health topic showed a small but significant effect in favor of board games postintervention (d* = 0.15, 95% CI [0.05–0.25]), but not at delayed follow-up (d* = 0.06, 95% CI [−0.05 to 0.18]), Table 8. The comparisons associated with health-related attitudes and beliefs are largely at a low RoB, with ∼72% weighted at low RoB, ∼17% at an unclear RoB, and ∼11% at a high RoB. Sensitivity analyses using only low-RoB comparisons confirm a small effect of board games over other control comparators at the posttest (d* = 0.23, 95% CI [0.11–0.36]) and a very small and trending effect upon delayed follow-up (d* = 0.12, 95% CI [−0.01 to 0.24]).

Table 8. Effect Size Details for Studies Measuring Attitudes and/or Beliefs

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
A. Synthesis of data at all RoB
Khazaal et al.43 | 10 | Low/unclear | 0.13 (−0.01 to 0.27) | 54.0 | 0.05 (−0.08 to 0.19) | 79.7
Lennon and Coombs36 | 1 | Unclear | 0.03 (−0.28 to 0.33) | 11.5 | — | —
Okitika et al.41 | 1 | High | 0.09 (−0.22 to 0.40) | 11.1 | — | —
Viggiano et al.20 | 1 | Low | 0.27 (0.06–0.48) | 23.4 | 0.09 (0.18–0.35) | 20.3
Synthesized effect | | | 0.15 (0.05–0.25)a | | 0.06 (−0.05 to 0.18)b |
B. Synthesis of data at low RoB | | |
Khazaal et al.43 | 9 | Low | 0.22 (0.06–0.37) | 65.8 | 0.12 (−0.02 to 0.27) | 76.6
Viggiano et al.20 | 1 | Low | 0.27 (0.06–0.48) | 34.2 | 0.09 (0.18–0.35) | 23.4
Synthesized effect | | | 0.23 (0.11–0.36)c | | 0.12 (−0.01 to 0.24)d |

Biological health indicators

There was a small-to-moderate effect of board games on biological health indicators (e.g., zBMI, diabetes indicators) measured immediately after the intervention (d* = 0.37, 95% CI [0.21–0.52], Table 9). Only Viggiano et al.20 performed a delayed follow-up measurement, which showed a moderate effect of lower zBMI scores in favor of the game group over a no-intervention group. The comparisons in this category's synthesis showed 45.5% weight at low risk and the remaining 54.6% at an unclear risk. Only the comparisons by Viggiano et al.20 are at a low RoB, so sensitivity analyses were not performed.

Table 9. Effect Size Details for Studies Measuring Health-Related Biological Health Indicators

Source | Comps | RoB | Postintervention | Delayed follow-up
ES (95% CI low to high) | Weight (%) | ES (95% CI low to high) | Weight (%)
Amaro et al.33 | 1 | Unclear | 0.21 (−0.20 to 0.62) | 11.5 | — | —
Crawford and Wiltz21 | 4 | Unclear | 0.29 (0.17–0.41) | 43.1 | — | —
Viggiano et al.20 | 1 | Low | 0.47 (0.37–0.58) | 45.5 | 0.51 (0.36–0.67) | 100
Synthesized effect | | | 0.37 (0.21–0.52)a | | |

Social functioning

A single study targeted social functioning in patients with schizophrenia with seven subscales.39 Although the authors report significant outcomes on a few subscales (e.g., recreational activities), there was no significant effect of the board game on social functioning (d = 0.19, 95% CI [−0.11 to 0.48], Z = 1.22, P = 0.221). The RoB associated with the comparisons in this combined ES was unclear.

Anxiety

The effect of a board game intervention on anxiety was assessed in one study by Fernandes et al. in preoperative children and their parents.35 The authors did not provide information about variance for the data, which prevented us from calculating ES for anxiety. These comparisons were at an overall high RoB.

Executive functioning

Finally, executive functioning was assessed by Fissler et al. among elderly retirement home patients at risk of dementia.40 An overall large but nonsignificant effect of the game intervention program was observed at immediate follow-up (d = 0.88, 95% CI [−0.19 to 1.95], Z = 1.82, P = 0.068). This comparison was associated with an unclear RoB.

RoB across studies

The risk of publication bias across studies was assessed visually with a funnel plot (Fig. 3). Although there is a noticeable lack of studies to support other interventions over board games (dots left of zero), Egger's test was not significant for postintervention comparisons (β0 = −0.09, 90% CI [−3.84 to 3.64], dftotal = 16, t = −0.05, P = 0.964). Publication bias was also not observed in the majority of the individual outcome categories (Supplementary Data). Lastly, Egger's test was not significant for delayed follow-up comparisons (β0 = −0.91, 90% CI [−6.05 to 4.24], dftotal = 2, t = −1.11, P = 0.466).

FIG. 3.  Funnel plot of effect sizes from postintervention and delayed follow-up comparisons against the inverse of the standard error of the effect, across all outcome categories.

Discussion

This systematic review and meta-analysis is the first to provide a synthesis on and analysis of nondigital board games for health impacts for users in academic, patient/hospital, and community settings together. It extends Bochennek et al. review of board games for medical education by also including games for patients and laypeople from a community context.16 The findings further contribute to theories about how games can facilitate learning and behavior change.8–11 The overall quality of the studies investigated was not high; RoB assessments revealed that 85.7% of the studies had a high or unclear RoB associated with their methodological designs. Keeping these biases in mind, we have been able to draw some general insights about the impact of board games on health-related outcomes and about potential future directions for research.

Main findings

The designs of board games evaluated, and the types of measures used to evaluate outcomes across studies were heterogeneous; a finding that is consistent with previous reviews of board games for medical education that also found the topics addressed and game approaches difficult to place in broad categories due to the diversity of examples in the literature.16,18 The diversity of approaches and topics addressed in board games was also found in reviews of digital game-based learning and serious games.2,51

While the majority of games in this review are applied to behavioral challenges consistent with major healthcare priorities (e.g., reduction in rates of obesity), they typically aim to affect change by conveying knowledge. For instance, Viggiano et al.20 targeted lifestyle changes in children by conveying knowledge about healthy diet and exercise. Our meta-analysis showed that board games resulted in significantly more knowledge attainment than other nongame conditions, consistent with findings of meta-analyses in the realm of digital game-based learning.52–55 This—along with the null or very small effects measured in self-efficacy and attitudes/beliefs—suggests that the primary value of board games thus far is shown when applied to behavioral problems arising through lack of knowledge or difficulty in communicating health-related concepts, rather than those characterized by the persistence of negative behavior in the presence of knowledge. Even Khazaal et al.,43 who did not measure knowledge directly, aimed to change smoking behavior through the conveyance of facts about smoking (e.g., costs associated with addiction, biological effects of smoking). However, it should be noted that the lack of analyses of board games applied to situations, wherein negative behavior persists in the face of knowledge precludes conclusions regarding their suitability in these contexts.

Overall, and in many cases as a result of increased knowledge through gameplay,20,33,34,41–43,46 health-related behavioral outcomes (e.g., smoking cessation, diet, and lifestyle changes) showed a small-to-moderate postintervention effect in favor of board games, particularly in the self-reported behavior category. This is consistent with studies of videogames targeting health behavior change that generally show positive effects.2,56 However, self-reported measures of behavior are particularly vulnerable for bias because they can be associated with social stigmas (e.g., around diet and exercise).57,58 Unfortunately, only a single study in our review included an objective measure of behavior.38 Ultimately, downstream biological health/patient outcomes, such as reduced zBMI scores, are the desired objectives of behavior-targeting games and indicate real-world behavior change; our synthesis of biological health outcomes demonstrated small-to-moderate effects in this category, highlighting the potential of board games to facilitate real-world change, although only three studies included such outcomes. A meta-analysis investigating the synthesized effects of active videogames on health outcomes also showed small to large effects.59

While our analyses suggest that board games can be effective at increasing knowledge, changing behavior and, in turn, affecting biological outcomes, the evidence for improvement of self-efficacy was not significant; this is inconsistent with a meta-analysis of active videogames that showed moderate effects on self-efficacy,59 perhaps because players of active videogames experience the behavior first-hand, instead of receiving knowledge about the behavior to apply at a later time, like in the reviewed board games. Furthermore, we can fairly confidently conclude (due to the low RoB and significant synthesized effects) that board games affect attitudes and/or beliefs very little, which contrasts stronger findings in the digital game-based learning literature.60 Lastly, there is insufficient evidence to conclude whether board games may impact other outcomes in health and medicine, such as anxiety, social functioning, and executive functioning, with only single studies covering these themes. However, game-based studies of other “nonboard” games not included in this review (e.g., Mahjong) have shown some promise in the realm of executive functioning.61–63

Limitations

This meta-analysis is limited by heterogeneity of outcomes used to evaluate the board games, poor methodological design of many of the studies, and the small sample size/inadequate power of most of the included studies. Synthesizing highly heterogeneous studies (note the high I 2 values for our various syntheses), is a clear weakness in this meta-analysis. However, heterogeneous outcomes are often examined to come to higher-order generalizations about a topic in question.29,30 In this case, we were interested in examining whether board games could be used as a tool to impact outcomes in the domain of health. Therefore, the results should be used as a general summary of the effect across the educational board game literature in different outcomes. Furthermore, because of the limited number of comparisons within each outcome category, we were unable to perform moderator analyses to investigate possible confounding effects of, for example, total play time, primary game mechanic (e.g., question-and-answer vs. action-and-consequence), or target audience (e.g., adults or children). It should finally be noted that, since studies with larger samples (and therefore less variance) tended to contribute more toward synthesized effects (e.g., Viggiano et al.20 accounted for ∼40% of the weight in self-reported behavior; Khazaal et al. accounted for 54% of the weight in attitudes and beliefs), our reported effects may be more representative of the types of board games or play contexts found in these more robust studies.

Another limitation of the data synthesis is that, while we examined outcomes from studies with control/comparison groups, some of these included research designs that did not randomize participants to treatment and control groups. The randomized trial is considered the Gold Standard for determining causality in evaluating the impact of interventions on outcomes.4 Until results from larger and higher quality, randomized, controlled trials of board game interventions in healthcare are available, the research results presented in this review represent the best strategy for appraising the evidence, while considering the inherent bias in the studies evaluated.

A further limitation is that the findings reported do not consider preintervention results because (1) some studies did not include baseline measurements and (2) most studies did not report variance for pre to postintervention change, thus excluding pre–post improvement information from ES calculations; this precluded our ability to evaluate whether or not differences between treatment and control groups observed at the postintervention may have been related to preexisting differences at baseline. However, it should be noted that effects with baseline imbalances (or no reported baseline measurements at all) were excluded from sensitivity analyses as they fell into the high or unclear RoB categories. Finally, the findings from this study are also limited due to missing data from studies; there was missing data from 11/88 postintervention comparisons where the authors did not include enough information for ES to be calculated (all these studies are at an unclear to high RoB).

Despite these limitations, it should be noted that an overall strength of this review is that it synthesizes data across diverse populations to estimate the impact that board games have had on various health-related outcomes, which has not previously been done in the literature.

Future directions

Our suggestions based on our critical review of the studies are consistent with previous games for health guidelines that call for the use of randomized controlled trials with adequate sample sizes to clarify the causal role of the intervention's impact on outcomes.56,64 Studies should also aim to measure behavior through direct means or consecutively logged activity to prevent biases associated with self-reports and, when possible, include more objective biological outcomes (e.g., zBMI) to corroborate behavior findings in a standard way across studies.

Furthermore, as discussed above, a main finding of this review was that the majority of board games targeting health-related behaviors did so through conveying new knowledge. Future research might investigate whether a board game might be effective in changing persistent, negative behaviors in the presence of knowledge.

Finally, a qualitative interpretation of the included studies would suggest that board games integrating a question-and-answer mechanic (i.e., trivia genre; a popular gaming pattern implemented by most of the included studies)19,31,32,36,42–45,47,49 have potential to lead to significant gains in knowledge; this is consistent with other research regarding the impact of self-testing strategies on knowledge consolidation in nongaming contexts.65,66 However, there appears to be a lack of board games that incorporate learning and gaming mechanics in more complex ways (e.g., through action-and-consequence),20,33,34,43 which limits our understanding of the different ways board games can be designed to support learning. Future games as educational tools should attempt to integrate more complex design strategies and explore whether or not existing digital game design frameworks (e.g., Learning Mechanics-Game Mechanics model, or the Activity Theory Model of Serious Games)67,68 can be applied to justify design decisions and advance our understanding in this area. Moreover, game efficacy should be examined through studies designed to clarify whether mechanisms of the board game itself (e.g., cooperative or competitive) or the context of its delivery (e.g., in a clinic, in a school setting) is responsible for the impacts observed in carefully designed studies; while such investigations are inherently more difficult to perform, the importance of asking more design-oriented questions is well recognized.53,69

Conclusion

In sum, this systematic review updates and extends previous reviews of board games for health. Although the findings of this meta-analysis are limited, given the current state of evaluations of board games for health in the literature, they do show preliminary evidence for the use of board games to improve knowledge in health outcomes. Future efforts to develop board games should focus on directly targeting behaviors related to downstream biological health outcomes, exploring alternative game design strategies to the trivia-genre, and evaluating board game interventions using rigorous scientific methods. Once knowledge about the overall efficacy of board games is better established, healthcare professionals, patients, students and community members can benefit from this engaging approach to promote health and medical outcomes.

Acknowledgments

The authors wish to thank Ouarda Yvray for helpful comments on the review. This work was supported by Pfizer and the Social Sciences and Humanities Research Council of Canada through a Michael Smith Foreign Study Supplement.

Author Disclosure Statement

No competing financial interests exist.

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Last Updated on September 10, 2020 by Editorial Team
Please Note : This post may contains affiliate links. Please read my disclosure (link) for more info.
Board games offer a participative way of developing language and numeric literacy in dyslexic children. These are fun manipulatives that teach the dyslexic children the skills of strategic thinking, planning, and coordinating mind and body to achieve the learning objectives. By the actions of sorting, analyzing, challenging, and helping each other, the dyslexic children try to learn and adopt fluency in reading and writing while building social intelligence in the process.
Advantages of using board games for dyslexic children
Board games offer playful methods of developing basic reading, writing, and math skills in dyslexic children. These games help in the following ways:

These help remove the negative reaction of dyslexic children who have difficulty reading and writing through conventional means.

These help in providing instructions in a way that students can enjoy and comprehend easily

These encourage students to involve themselves better and learn by better participation

Listed here are the 10 most popular board games for dyslexics that have changed the learning curve to better for such children.

1. Think fun Zingo Bingo

Zingo - Bingo with a Zing is a mind-stimulating game beneficial for pre-readers. This game helps develop language and matching skills in early learners of language and reading. By the way of gamification, the students learn to grasp the word-picture recognition concept.

The speedier expelling of the cards from the box helps students enhance memory retention and recall. This game is available for 7 players to play at a time, thus, helping the children to develop the virtue of sociability. The game is certainly quite an effective teaching tool; it also offers the parents an opportunity to bond with the children at home.

2. Disney matching game

All children love cartoon characters like Mickey Mouse, Minnie, and several others. Using the matching cards dedicated to the cartoon characters, the parents can help dyslexic children build memory and enhance focus.

Teachers can enhance the associative memory of children and develop their minds to establish relation which can further be utilized in the identification of numbers, words, etc. By flashing cards at a pace, the mind can be stimulated for faster learning and quicker association with images. It is easy to learn and one can start playing within minutes of opening it.

3. Articulate

Articulate is a game where a child describes the word without uttering it. It is a time-pressed game compelling the child to think faster, developing fluency in thinking and speaking words in the process. Teacher can familiarize the student by telling instructions in an easy way.

The whole game can be played in a group. With ample material for 20 to 30 people to play, it makes a very good classroom activity with the help of which children can develop associative memory and word recognition ability.

4. Balderdash

Balderdash offers fun-filled and stress-free way of learning commonly used words. It comes with lots of interesting categories like people, movies, words, initials. The player makes phony definitions to hide the real identity of the word.

This game allows learning words by the way of expressions and also helps improve reading abilities. Since no actual reading is involved, it helps the teacher befriend the child with words in a playful manner. The virtues of association, word-picture match improve the mental abilities of the child, and so, it is quite popularly used in games session in the school.

5. Scrabble Junior

Scrabble Junior is the popular board game for dyslexic played worldwide. It is a favorite among kids who are early learners of reading. The game primarily involves word-picture matching. It offers ample practice of identifying words and associating them with picture to the kids.

In the advanced stage of playing this game, the players try making their own words with the help of arranging letter cards on the board. This game helps develop word-building skills by the way of gamification, strategic thinking, and practice. Scrabble Junior is helpful in building spelling skills. To gain fluency, it can be played in a timed manner too.

6. Labyrinth

Labyrinth game is a team effort. Teachers or parents can play with the kids, or friends can play with each other. The shortest route to finding all the treasures and targets is to be found to win the game.

This game is quite helpful in teaching the concepts of cause and effect on the child. It also helps build the abilities of association and recognition. Since the game is played in a team, it helps the child learn sequencing by the way of taking turns. This board game for dyslexia is suitable for children above 7 years of age.

7. Spelligator board game

Spelligator board game for dyslexia is an effective tool for teaching the concepts of phonics, letter recognition, and spellings to the child. The game contains some letter tiles and a few alligator shaped slots. The child arranges the letter tiles on the alligator-shaped slots to form the word.

The concept of starting, ending and middle sound of the word, spellings of the words, and pronunciation can be taught to the child in a playful manner in this game. Tiles are easily adjustable and fit only when the correct letters in the correct sequence are arranged.

8. Junior Learning 6 Speaking Board Games

Junior Learning 6 Speaking Board Games for Dyslexia offers an interesting way of learning spellings and words' sounds. It is used as a teaching tool for developing the concepts of linguistic thinking, questioning, and general language skills.

By the way of using scenario cards, picture puzzles, and board games, the memory retention of spellings is improved. It helps build vocabulary comprising of generally used words. The children can enhance their association skills to get the concept right.

9. Learning resources sum swamp game

Learning Resources Sum Swamp Board game for dyslexia is an effective tool for developing math and number skills in the child. The players are made to perform various mathematical operations on the route from start to endpoint of the game.

Children learn counting and operations and by racing with one another get to develop fluency in calculations too. Teachers can encourage kids to befriend math drills with the help of enhancing participation and real involvement in the activity.

10. Phonics board game

Phonics board games for dyslexia offer ample material and playful pretext for engaging children in word construction practice. The spinner is provided to pick the vowel and kids try to make words using the selected vowel.

Children learn the correct way of constructing words using this board game. The availability of four board game options offer adequate practice. Teachers engage them using the colorful illustrations provided in the game and help them build phonics and word making skills.
How to employ board games for dyslexia in teaching
The challenge is to enable the student understand that it is just not a game, but a tool for learning. Also, the controlling of children while playing is also a feat to conquer. To make the best use of board games for dyslexia, one can consider using these strategies:

To make it work, the games are chosen according to the intellectual abilities and not the reading abilities of a child.

Teachers need to avoid judging or gloating mistakes in order to keep the child's interest alive, which means it has to be played in a helper mode.

Encourage the child to suggest strategies to play to make it easier for him to grasp the concept

First, show how to do the activity and let the child track along and then simply ask to re-do to find if the concept has rightly been understood.

So, use board games for dyslexia to create a collaborative atmosphere for learning for the child. These help building confidence in language and math skills without involving the actual process of reading and evaluating.
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10 cool board games for kids with dyslexia - Number Dyslexia

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Last Updated on September 10, 2020 by Editorial Team Please Note : This post may contains affiliate links. Please read my disclosure (link) for more info. Board games offer a participative way of developing language and numeric literacy in dyslexic children.

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The Clinical Teacher - 2018 - Bharamgoudar - Gamification

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The board games turning science into playtime | Science | The Guardian

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Science-themed board games are an increasingly popular way to learn about everything from atom building to colonising space

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Students with learning idsablities drop out rates

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Gameplay in secondary biology classrooms

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Gameplay in secondary biology classrooms

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Low income childrens imrpovements with number boardgames

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Low income childrens imrpovements with number boardgames

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Child Development - 2008 - Ramani - Promoting Broad and Stable Improvements in Low‐Income Children s Numerical Knowledge

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Gamification: Student feedback and creation of bespoke board games

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Gamification: Student feedback and creation of bespoke board games

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https://www-proquest-com.gold.idm.oclc.org/docview/1902043735/abstract/1612177A702F4920PQ/1?accountid=11149

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Effects of a Collaborative Board Game on Bullying Intervention: A Group-Randomized Controlled Trial

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Effects of a Collaborative Board Game on Bullying Intervention: A Group-Randomized Controlled Trial

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- Dynamic, evidence based decision-making experience of games, integrating theory to practice

- The facilitation of an enjoyable, competitive atmosphere in

which the realities of change and uncertainty are explored

in a low risk setting

- Safe experiential learning of the leadership, team working

and time management attributes valued when games are played by students

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Using a Board Game to Reinforce Learning

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Using a Board Game to Reinforce Learning

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The Journal of Continuing Education in Nursing; Thorofare Vol. 45, Iss. 3, (Mar 2014)

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How games fit into all catergories of STEM

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How games fit into all catergories of STEM

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Science: Games Content based on Science studies, topics and lessons.

Technology: Epistemic logic (Knowlegde of Logic)

Engineering: Game Theory and Critical Thinking

Maths: Probabilities and Scores

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Game theory came to the fore as a sub-discipline of economics in the mid-twentieth century.

Even though games as such appear rather innocent, there are many other human activities

that can be analysed as games, that is to say, as proceduralised interaction between often fairly

small groups of individuals, where game moves correspond to choice between well-described

alternative actions. For example, opposing generals on a battlefield have to choose between

attack and defence; traders playing the stock market have to choose between buying and

selling; voters in the election have to choose between different parties; and so on. In all these

cases, one models the strategic choices of different players that can act either simultaneously

or sequentially, where each individual player’s choice depends on the choices of all other

players.

Game theory analyses the general case where a finite number of players can each choose

from a set of actions, and typically they are assumed to be able to act simultaneously. This

analysis can be complex because, as demonstrated, each player’s best choice depends on the

choice of the other players.
This comes into play in Reaction! Where players have to make choices about what cards to trade and strategise how to get rid of cards they don't need, whilst simultaneously making sure they aren't allowing the other players to get ahead

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Of  somewhat  later  date  than  game  theory  is  the  logical  discipline  known  as

epistemic logic, or the logic of knowledge. The  basic  idea  is  that  you  know  that  a

proposition is true if, and only if, that proposition is true in all states of the world that you

cannot distinguish from the state you are in.

Techonology and games: That such analyses are no mere trivialities but ‘serious business’ comes to the fore when

we  think  of  designing  computer  systems  that  understand  or  generate  (written)  language.

When we speak (as when we write) we often leave out details that can be taken for granted

in a ‘normal’ context of communication. If Anne says to Bill ‘You do not know that P ...’ this is

only informative for Bill if Anne actually means to say ‘P

is true and I am informing you of P

and this is helpful because you do not know P.’

So all this extra information has to be taken

into account by Bill, even though it is not strictly being said by Anne. Now imagine replacing Bill by a computer. If one intends to have Anne talk to the computer as if it were human, the

computer had better understand Anne as that human. So the computer has to make a similar

expansion of the information as above. Otherwise, Anne would have to use many more words

for interaction with that computer than with a human, which makes the computer inhuman...

‘Do you know what time it is?’ ‘Yes!’ ‘???? Tell me what time it is, you idiot!’ ‘5:30 PM.’ She

had only asked for knowledge, not for time itself. Such modelling assumptions also lie behind

things like automated travel assistants, but at the present state of the art, for other semantic

reasons than epistemic logical reasons.

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Summary of Research on game learning theories: 1 Probability Theory 

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Summary of Research on game learning theories: 1 Probability Theory 

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Probabilities  have  been  applied  to  the  analysis  of  games  since  times  immemorial  and

in particular since the sixteenth century. Ascal  laid  the  foundation  for  the  theory  of  probability  in

correspondence with Pierre de Fermat, another well-known mathematician from that era.

Both Cardano

and Fermat investigated what is known as the dice problem.
The dice problem asks how many

times one must throw a pair of dice before expecting a double six. Of course the answer to

this question is not a number! The probability of double six after one throw (with a pair of two

dice) is 1/36 (about 3%); the probability of double six after two throws is (1 - (the probability of

not having double 6 after two throws)) = (1 - (35/36)

2

) = (1 - 1225/1296) = 71/1296 which

is, roughly, 5.5%. This is of course higher than 1/36, as there is still another chance to throw.

Also note that this probability is a lot more than (1/36)

2

, which amounts to less than 0.1%,

this is namely the probability of throwing double six

twice

. And so on, for throwing thrice, four

times...Double sixes were, as we saw, already an issue in the Risk game, as a double six beats

the opponent’s armies.
This probability Maths equation is applied to my games.