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R E V I E W Open Access
Special series on “effects of board games
on health education and promotion”board
games as a promising tool for health
promotion: a review of recent literature
Mutsuhiro Nakao
Abstract
Board games are played by moving game pieces in particular ways on special boards marked with patterns. To
clarify the possible roles of board game use in psychosomatic medicine, the present review evaluated studies that
investigated the effects of this activity on health education and treatment. A literature search conducted between
January 2012 and August 2018 identified 83 relevant articles; 56 (67%) targeted education or training for health-
related problems, six (7%) examined basic brain mechanisms, five (6%) evaluated preventative measures for
dementia or contributions to healthy aging, and three (4%) assessed social communication or public health policies.
The results of several randomized controlled trials indicated that the playing of traditional board games (e.g., chess,
Go, and Shogi) helps to improve cognitive impairment and depression, and that the playing of newly developed
board games is beneficial for behavioral modifications, such as the promotion of healthy eating, smoking cessation,
and safe sex. Although the number of studies that have evaluated board game use in terms of mental health
remains limited, many studies have provided interesting findings regarding brain function, cognitive effects, and the
modification of health-related lifestyle factors.
Keywords: Board game, Chess, Dementia, Go, Lifestyle modification, Shogi
Introduction
Board games are played by moving game pieces in par-
ticular ways on special boards marked with patterns [1].
For example, one game originated in northern India in
the sixth century AD and spread to Eastern as well as
Western countries. In the West, it spread to Persia and
then to Spain via the Moorish conquest, and then
throughout Europe, where it ultimately became “chess.”
In the East, this game became “Xiangqi”in China,
“Shogi”in Japan, and a variety of similar games in other
countries. Other popular board games that use two pat-
terns for the game pieces include “Go”and “Othello,”
also known as “Reversi.”
In the field of psychosomatic medicine, board game
playing is sometimes regarded as a leisure activity, and
engagement in this type of activity has been shown to
protect against dementia and cognitive decline in elderly
individuals [2]. For example, a 20-year prospective
population-based study conducted in southwestern
France investigated the relationship between the playing
of board games and the risk of subsequent dementia [3].
Of the 3675 participants without dementia in that study,
1176 (32%) reported regular board game playing and
840 (23%) developed dementia during the follow-up
period. The risk of dementia was 15% lower in board
game players than in non-players, and board game
players exhibited lesser declines in Mini-Mental State
Examination (MMSE) scores and less incident depres-
sion than did non-players. Although the mechanisms
underlying the reduced risk of dementia in board game
players have yet to be elucidated fully, these games re-
quire players to be proactive and to anticipate, thinking
several steps ahead, during play. These processes may
enhance logical thinking and prevent declines in
Correspondence: m-nakao@iuhw.ac.jp
Department of Psychosomatic Medicine, School of Medicine, International
University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba-ken
286-8686, Japan
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nakao BioPsychoSocial Medicine (2019) 13:5
https://doi.org/10.1186/s13030-019-0146-3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
cognitive function. Individuals may also engage in
non-verbal communication while playing board games,
and players are more likely to have the opportunity to
gather and participate in a fun activity with others.
These factors could enhance individuals’social networks,
which also protects against cognitive decline. Further-
more, in terms of leisure activities, board game playing
may also be a form of stress management [4], as the
fight-or-flight response is regulated safely within the
sophisticated structures of match-type games. Board
game playing could also be a form of art therapy, similar
to miniature garden therapy [5], facilitating infinite
internal manifestations within a narrow space.
In terms of education, the playing of board games may
help children learn to follow rules and stay seated for a
certain amount of time, and it may increase children’s
concentration levels [6]. For students and trainees, board
game use can enhance health education by stimulating
players’interests and motivation. A search of the
Cochrane Database of Systematic Reviews [7] identified
a total of 2079 unique citations related to educational
games, such as board games and games based on televi-
sion shows. Of these citations, 84 were potentially
eligible for review based on methodological quality,
number of participants, interventions, and outcomes of
interest, and two randomized controlled trials (RCTs)
were chosen. The first study [8] was based on the televi-
sion game show “Family Feud”and focused on infection
control; the group that was randomized to play the game
had significantly higher scores on a knowledge test. The
second study [9] compared game-based learning (using
“Snakes and Ladders”) with traditional case-based learn-
ing of stroke prevention and management information.
Although the two study groups did not have significantly
different knowledge test scores immediately or 3 months
after the intervention, the reported level of enjoyment
was higher in the game-based learning group. The find-
ings of an original review of articles published through
January 2012 [7] neither confirmed nor refuted the
utility of game playing as a teaching strategy for health
professionals. Thus, the present study aimed to clarify
the possible roles of board game use in psychosomatic
medicine through a literature search for articles pub-
lished after 2012 that focused on the effects of board
game playing on health-related issues.
Mind/body changes due to board game use
Using “board game”as a PubMed search term, 83 stud-
ies published between January 2012 and August 2018
were identified; 56 (67%) articles targeted education or
training for health-related problems, six (7%) exam-
ined basic brain mechanisms, five (6%) evaluated
preventative measures for dementia or contributions
to healthy aging, and three (4%) assessed social
communication or public health policies. The major
studies that investigated the effects of traditional
board game use are shown in Table 1[10–33]; some
of the articles listed in the table were identified in
the reference sections of the original 56 articles or
other databases.
Experimental studies investigating brain magnetic
resonance imaging (MRI) or electroencephalographic
(EEG) signals in professional board game players [10,22,
26–28,31] demonstrated that the basal ganglia play an
important role in the ability to rapidly determine, or in-
tuit, the best subsequent move in a game situation [24].
Additionally, variations in heart rate and eye movements
were examined as physiological parameters during chess
play [10,14,16]. In case studies and case-control stud-
ies, board games were shown to effectively improve
symptoms in individuals who experience panic attacks
[11], as well as those with attention-deficit/hyperactivity
disorder (ADHD) [21] and Alzheimer’s disease (AD)
[29]. On the other hand, one study revealed possible
hazardous effects associated with the playing of “Go”in
individuals with seizure disorders [23]. The amounts of
real and virtual playing of board games have increased
recently and, as a result, the number of published studies
assessing the effects of board game use has also in-
creased [12,13,17,19]. The increase in game play is
likely due to the prevalence of computer systems in the
current age of information and communication technol-
ogy (ICT) and artificial intelligence (AI).
Recent RCTs evaluating board game use
According to a recent meta-analysis of four studies that
investigated chess play [14], age and skill have differen-
tial effects on two tasks during game play: selecting the
best move for chess positions and recalling chess game
positions. The authors found that age was associated
negatively, whereas skill was associated positively, with
performance in both tasks. Another RCT showed that an
intervention using Go improved depression and
increased serum levels of brain-derived neurotrophic
factor (BDNF) in patients with AD [20]. Similarly,
players’depression and anxiety levels were shown to de-
crease significantly during a 6-week stress management
intervention that utilized Shogi games [25]. Although
these data have been presented only at a scientific con-
ference, they will soon be published in this special series.
The authors also reported that several patterns of nega-
tive cognitive distortion (e.g., lower levels of activity) sig-
nificantly improved following completion of the Shogi
program compared with those in a wait-list control
group. An RCT showed that the playing of “Ska,”a
traditional board game in Thailand [32], enhanced cog-
nitive function in terms of memory and attention in
elderly subjects.
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Table 1 Examples of recent studies using traditional board games
Authors (years) Countries Study design Subjects or materials Outcomes or variables Impact
Chess:
Fuentes JP et al.
(2018) [10]
Spain Experimental,
single case
Expert chess player,
male, 33 years old
EEG changes, decreased
heart rate variability
Increased cortical arousal by critical flicker
fusion threshold, decreased heart rate
variability during chess play
Barzegar K &
Barzegar S (2017)
[11]
Iran Clinical case Middle-aged man
with panic attack after
post-traumatic stress
Clinical course, including
subjective physical
symptoms
No symptom of nausea, vomiting, or panic
attack after cell-phone chess play
Schaigorodsky AL
et al. (2016) [12]
Argentina Database 1.4 million chess
games played by
humans
Long-range correlations,
inter-event time
distributions
Cattuto’s model well described long-range
memory used in opening chess lines
Chassy P & Gobet F
(2015) [13]
UK Database 667,599 chess games
played by experts
from 11 civilizations
Conflict avoidance, risk-
taking behaviors during
open aggression
Buddhist experts used riskiest strategy
nearly 35% more vs. Jewish experts
Sheridan H &
Reingold EM (2014)
[14]
Canada Experimental 41 chess players (17
experts, 24 novices)
Eye movements in 8
chess problems
Only experts distinguished relevant and
irrelevant information during early trial
Moxley JH &
Charness N (2013)
[15]
USA Meta-analysis 4 studies of age and
skill effects in chess
Age, chess skill, move
selection, chess recall
Best-move, recall tasks associated
negatively with aging, positively with skill
Leone MJ et al.
(2012) [16]
Argentina Experimental 25 chess games
played by 9 subjects
Heart rate variation Heart rate signals relevant cognitive
episodes, e.g., objective choice correctness
events
Go:
Barradas-Bautista D
et al. (2018) [17]
Mexico Computer
simulation
Ising Hamiltonian
model of black, white
Go stones fighting
Two-player scenarios,
cancer vs. immune
system
Go, Ising model provided elements for
characterization of cancer invasion,
reduction, metastasis
Bae J et al.
(2017) [18]
Republic of
Korea
Questionnaire
survey
63 subjects predicting
outcome of AlpaGo
vs. Sedol Lee match
Network density, game
predictions
Game predictions more accurate in low-
density vs. high-density group
Silver D et al.
(2016) [19]
UK AI Go program Search algorithm of
Monte Carlo
simulation and
networks
Go win rate AlphaGo had 99.8% win rate against other
Go programs, defeated human Go
champion
Lin Q et al.
(2015) [20]
China RCT 147 patients with
Alzheimer’s disease
Cognitive impairment,
depression, anxiety,
serum BDNF level
Go ameliorated Alzheimer’s disease
symptoms, with BDNF up-regulation
Kim SH et al.
(2014) [21]
Republic of
Korea
Case-control
study
17 children with
ADHD, 17 age-, sex-
matched controls
Cognitive function, brain
EEG changes during Go
play–based education
Right theta/beta change in prefrontal
cortex during study period greater in
ADHD group
Jung WH et al.
(2013) [22]
Republic of
Korea
Experimental 17 Go experts Structural, functional MRI
during working memory
tasks
Experts had increased gray-matter volume,
functional connectivity around amygdala
Lee MK et al.
(2012) [23]
Republic of
Korea
Clinical case 11 patients with reflex
epilepsy, including 6
male Go players
MRI, EEG with clinical
course
Individualized strategies like game
avoidance most effectively prevented
seizures
Shogi:
Tanaka K
(2018) [24]
Japan Review Summary of data from
[26,27,30]
fMRI changes in game
situations
Cingulate cortex essential for intuitive,
strategic decision making for any given
Shogi board position
Nakao M et al.
(2017) [25]
Japan Protocol, RCT 65 men aged ≥65
years
Cognitive-behavioral
attitudes, depression,
anxiety, well-being
Depression, anxiety levels lower during 6-
week Shogi stress management program
Wan X et al.
(2016) [26]
China Experimental 17 professional, 17
amateur Shogi players,
19 novices
fMRI signals during
problem-solving tasks
In professional group, rostral frontal cortex
activated only in post-decision period
Wan X et al.
(2015) [27]
China Experimental 17 amateur Shogi
players
fMRI signals during quick
offense-vs.-defense
Rostral anterior, posterior cingulate
cortices encoded defense, attack strategy
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Of the 83 articles identified in the present PubMed lit-
erature search, 12 articles [34–45] report on RCTs that
assessed non-traditional board games (Table 2). A variety
of board games has been developed to aid in the health
education of patients, children, and medical trainees;
most of these games are focused on behavioral modifica-
tions, such as the promotion of healthy eating [34,38],
smoking cessation [43], and safe sex [45]. For example,
in a Swiss study [43], 240 current smokers were assigned
randomly to a group participating in smoking cessa-
tion program employing an educational board game
(“Pick-Klop”) and a wait-list control group. Compared
with those in the wait-list group, individuals in the
board game group were less likely to remain smokers
at the end of the program and at the 3-month
follow-up assessment. The authors suggested that use
oftheboardgamewouldbeaninteresting alternative
for the education of smokers in the precontemplation
stage.
Clinical applications of board games
Based on the results of studies investigating traditional
and non-traditional board games, it was hypothesized
that board game use would prevent cognitive impair-
ment in elderly individuals and illness-prone behaviors
in children and adults. Board game playing also seems to
be an effective, fun means of delivering medical and
safety education to students and trainees. Currently,
many people spend large portions of their time playing
games online and offline on television monitors, per-
sonal computers, tablets, and/or smart-phones. For
example, more than half of Japanese elementary and
junior-high school students play video games for more
than 1 h on weekdays [46]. Thus, video game–based
training will become more popular in the future.
On the other hand, a series of meta-analyses [47]
found only small or null effect sizes in three models
examining correlations between video game skills and
cognitive ability, differences in cognitive ability between
game players and non-players, and the effects of video
game–based training on cognitive ability, respectively.
Thus, examination of the clinical effects of real or virtual
training using board games may provide more appropri-
ate information for discussion of the advantages and
disadvantages of each style of board game for future
applications in clinical settings. A recent assessment of
cognitive science research on board game playing [48]
highlighted six suggestions for future studies: 1) do not
forget about chess (i.e., a traditional board game for
which large amounts of data have been collected), 2)
look beyond action games and chess, 3) use optimal play
to understand human play and players, 4) investigate
social phenomena, 5) raise the standards for studies
investigating game play as treatment, and 6) talk to real
experts.
Conclusions
Although the number of studies investigating board
game use remains limited, interesting findings have
recently been obtained in terms of brain function, cogni-
tive effects, and health-related lifestyle modification.
Board games may also be applicable as educational tools
Table 1 Examples of recent studies using traditional board games (Continued)
Authors (years) Countries Study design Subjects or materials Outcomes or variables Impact
strategy decisions values
Nakanishi H &
Yamaguchi Y
(2014) [28]
Japan Experimental 12 professional, 12
amateur Shogi players,
12 novices
EEG responses in quick
understanding of Shogi
game patterns
Frontal area responded only to
meaningful game positions, in contrast to
temporal area
Aoyagi M & Ogawa
T (2013) [29]
Japan Clinical case Man with Alzheimer’s
disease aged 75–79
years
Frequent chewing for
aspiration pneumonia
prevention
Shogi play encouragement useful for
education about frequent, smooth
chewing during eating
Wan X et al.
(2012) [30]
Japan Experimental 20 men aged 20–22
years with little Shogi
knowledge
fMRI changes during
Shogi training period
Activation in caudate nucleus head
developed over training course
Others:
Duan X et al.
(2014) [31]
China Experimental 20 expert Chinese-
chess players, 20
novices
Functional connectivity
networks assessed by
fMRI
Increased connectivity between basal
ganglia, thalamus, hippocampus and
parietal, temporal areas in experts
Panphunpho S et
al. (2013) [32]
Thailand RCT 20 elderly Ska players,
20 elderly controls
Cognitive function
(memory, attention,
executive function)
16-week Ska group joiners had
significantly better cognitive function
scores
van den Dries S &
Wiering MA (2012)
[33]
The
Netherlands
Computer
algorithms of
learning to play
Othello
Combination of three
structured neural
network techniques
Evaluation functions
(simple linear networks,
multilayered perceptions)
Method outperforms linear networks, fully
connected neural networks or evaluation
functions evolved with algorithms
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for health professionals. Although a systematic review
[7] neither confirmed nor refuted the utility of game
playing as a teaching strategy for health professionals,
these findings were published in 2013 and additional
high-quality studies have been reported since then.
Thus, it is time to re-evaluate the usefulness of games
and gamifications following technological advances
made in modern society. Clinical medicine is closely
linked to a public health approach, and medical practices
should be undertaken within the limited human, time,
and financial resources available [49]. In this sense, ap-
propriate health education programs with a board game
component would be useful for both preventive and
therapeutic intervention for cognitive-behavioral
Table 2 Examples of recent RCTs using board games
Authors (years) Countries Subjects Board games Control setting Outcomes or
variables
Impact
Nederkoorn C et
al. (2018) [34]
The
Netherlands
66 children
aged 3–10
years
Age-appropriate
memory-related board
game
Play with large bowl
filled with colorless,
odorless jelly (Jelly
group)
Acceptance of a
food with a specific
texture
Jelly group ate significantly
more jelly dessert
Fancourt D et al.
(2016) [35]
UK 352 subjects
aged > 16
years without
surgical
training
Board game requiring
removal of 3 organs
from Cavity Sam
(experimental tool)
Operating theater
sound, classical
music, or rock as
background music
Surgical speed,
accuracy, and
perceived
distraction
Rock music impaired men’s
performance of complex
surgical procedures in
board game
Karbownik MS et
al. (2016) [36]
Poland 124 medical
students
AntimicroGAME to
learn bacteriology,
antimicrobial drug
actions
Lecture-based
seminar
Short-term
knowledge
retention about
pharmacology of
antimicrobial drugs
Long-term knowledge
retention greater in board
game participants vs.
controls
Sharps M &
Robinson E
(2016) [37]
UK 143 children
aged 6–11
years
Board game with
descriptive social
norm–based or health
message
Board game with
animal images
Children’s fruit and
vegetable intake
Health and social norm–
based messages increased
fruit and vegetable intake
vs. controls
Viggiano A et al.
(2015) [38]
Italy 3110 subjects
aged 9–19
years
Kaledo board game to
promote nutrition
education, improve
dietary behavior
No board game
during study period
Adolescent food
habits and body
mass index
Treatment group showed
improved nutrition
knowledge, healthy diet,
food habits, physical activity
Fernandes SC et
al. (2014) [39]
Sweden 125 children
aged 8–12
years
Educational board
game, video, or
booklet with surgery
and hospitalization
information
Entertaining tools
with same formats
(comparison group),
no tool (control
group)
Children’s
preoperative worries
and parental anxiety
Educational group less
worried about surgery,
hospital procedures vs.
other two groups
Laski EV & Siegler
RS (2014) [40]
USA 42
kindergartners,
mean age 5.8
years
Numerical board
game, counting on
from current number
on board
Same game, standard
count-from-1
procedure
Children’s
knowledge of
numbers in the 0–
100 range
Number line estimates,
numeral identification,
count-on skill improved
more in count-on group
Charlier N & De
Fraine B (2013)
[41]
Belgium 120 students Board game to obtain
first-aid knowledge
Traditional lecture Students’
Knowledge of first
aids
Game condition was
preferred, but lecture more
effectively increased
knowledge
Swiderska N et al.
(2013) [42]
UK 67 medical
students
Educational board
game in neonatology
Normally provided
teaching
Students’test scores
in neonatology
Neonatology test scores
higher in game vs. control
group (p= 0.09)
Khazaal Y et al.
(2013) [43]
Switzerland 240 current
smokers aged
18–65 years
Pick-Klop game, cards
with smoking-related
questions, response
options
Psychoeducation to
stop smoking, wait-
list control
Smoking-related
attitudes and
behaviors
Game group less likely to
remain smokers vs. wait-list
group
Cho KH et al.
(2012) [44]
Republic of
Korea
24 stroke
patients
Virtual reality training
with balance-board
game system
Standard
rehabilitation
program only
Statics balance of
chronic stroke
patients
Significant improvement in
dynamic balance in chronic
stroke patients with virtual-
reality balance training
Wanyama JN et
al. (2012) [45]
Uganda 180 HIV-
positive
participants
Educational board
game to impart health
knowledge
Standardized health
talk
Uptake of
knowledge to HIV
and sexually
transmitted
infections
Educational game improved
uptake of HIV, sexually
transmitted infection
knowledge
Nakao BioPsychoSocial Medicine (2019) 13:5 Page 5 of 7
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functioning (e.g., ADHD and dementia), psychological
conditions (e.g., depression and anxiety disorders), and
life-style diseases (e.g., metabolic syndromes and
smoking-related diseases).
Abbreviations
(f)MRI: (functional) Magnetic resonance imaging; AD: Anno Domini;
ADHD: Attention-deficit/hyperactivity disorder; AI: Artificial intelligence;
BDNF: Brain-derived neurotrophic factor; EEG: Electroencephalographic;
HIV: Human immunodeficiency virus; ICT: Information and communication
technology; RCT: Randomized controlled trial
Acknowledgements
The author (M.N.) appreciates the support of the members of the Japan
Shogi Association and officials in Kakogawa City for conceptualizing health
promotion models using board games, such as Shogi and other traditional
games.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Authors’contributions
The author (MN) wrote the entire manuscript and holds final responsibility
for the decision to submit the manuscript for publication. The author read
and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The author (M.N.) declares no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 10 January 2019 Accepted: 7 February 2019
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