Serious Games and Gamification in Healthcare: A Meta-Review

Abstract

A serious game is a type of game that is designed for a primary purpose other than entertainment. Instead, serious games are intended to achieve specific goals, such as education, training, or health promotion. The goal of serious games is to engage players in a way that is both enjoyable and effective in achieving the intended learning or behavior change outcomes. Recently, several systematic reviews on the development and application of serious games and on the application of gamification techniques have been published, which indicate high activity and ongoing progress in this area of research. Such an extensive body of review papers raises the need to analyze and extract the current state and the prevailing trends of the serious games and gamification (SGG) domain by analyzing and summarizing the systematic review articles. This study presents a systematic meta-review, i.e., a review of the 53 survey papers on the domain of serious games and gamification. The systematic review follows the PRISMA guidelines, while constructive and cross-sectional methods are used to analyze and present the results. Finally, this study identifies the future trends and challenges for the domain. As a result, the meta-review helps the reader to quickly assess the present status of SGG and serves as a reference for finding further information on each technology utilized in SGG. Using the criterion of the citations, the meta-review analysis provides insight into the quantity and academic relevance of the published SGG articles. Moreover, 53 articles published in journals were selected as important surveys in the research field. The study found that serious games and gamification techniques are increasingly being used for a wide range of health conditions and the focus is shifting towards the use of mobile and digital platforms, virtual reality, and machine learning to personalize and adapt interventions. The existing research gaps include the lack of standardization in development and evaluation, insufficient understanding of underlying mechanisms of action, limited understanding of integration into existing healthcare systems, limited understanding of specific game mechanics and design elements for promoting health behaviors, and limited research on scalability, adoption, and long-term effects. These research gaps highlight the need for further research to fully understand the potential and limitations of serious games and gamification for health and how to effectively apply them.

Full text

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Information2023,14,105.https://doi.org/10.3390/info14020105www.mdpi.com/journal/information
Review
SeriousGamesandGamificationinHealthcare:
AMeta‐Review
RobertasDamaševičius
1,
*,RytisMaskeliūnas
2
andTomasBlažauskas
1

1
DepartmentofSoftwareEngineering,KaunasUniversityofTechnology,44249Kaunas,Lithuania
2
DepartmentofMultimediaEngineering,KaunasUniversityofTechnology,44249Kaunas,Lithuania
*Correspondence:robertas.damasevicius@ktu.lt
Abstract:Aseriousgameisatypeofgamethatisdesignedforaprimarypurposeotherthanenter‐
tainment.Instead,seriousgamesareintendedtoachievespecificgoals,suchaseducation,training,
orhealthpromotion.Thegoalofseriousgamesistoengageplayersinawaythatisbothenjoyable
andeffectiveinachievingtheintendedlearningorbehaviorchangeoutcomes.Recently,several
systematicreviewsonthedevelopmentandapplicationofseriousgamesandontheapplicationof
gamificationtechniqueshavebeenpublished,whichindicatehighactivityandongoingprogressin
thisareaofresearch.Suchanextensivebodyofreviewpapersraisestheneedtoanalyzeandextract
thecurrentstateandtheprevailingtrendsoftheseriousgamesandgamification(SGG)domainby
analyzingandsummarizingthesystematicreviewarticles.Thisstudypresentsasystematicmeta‐
review,i.e.,areviewofthe53surveypapersonthedomainofseriousgamesandgamification.The
systematicreviewfollowsthePRISMAguidelines,whileconstructiveandcross‐sectionalmethods
areusedtoanalyzeandpresenttheresults.Finally,thisstudyidentifiesthefuturetrendsandchal‐
lengesforthedomain.Asaresult,themeta‐reviewhelpsthereadertoquicklyassessthepresent
statusofSGGandservesasareferenceforfindingfurtherinformationoneachtechnologyutilized
inSGG.Usingthecriterionofthecitations,themeta‐reviewanalysisprovidesinsightintothequan‐
tityandacademicrelevanceofthepublishedSGGarticles.Moreover,53articlespublishedinjour‐
nalswereselectedasimportantsurveysintheresearchfield.Thestudyfoundthatseriousgames
andgamificationtechniquesareincreasinglybeingusedforawiderangeofhealthconditionsand
thefocusisshiftingtowardstheuseofmobileanddigitalplatforms,virtualreality,andmachine
learningtopersonalizeandadaptinterventions.Theexistingresearchgapsincludethelackof
standardizationindevelopmentandevaluation,insufficientunderstandingofunderlyingmecha‐
nismsofaction,limitedunderstandingofintegrationintoexistinghealthcaresystems,limitedun‐
derstandingofspecificgamemechanicsanddesignelementsforpromotinghealthbehaviors,and
limitedresearchonscalability,adoption,andlong‐termeffects.Theseresearchgapshighlightthe
needforfurtherresearchtofullyunderstandthepotentialandlimitationsofseriousgamesand
gamificationforhealthandhowtoeffectivelyapplythem.
Keywords:gamification;seriousgame;healthcare;meta‐review

1.Introduction
Agameisastructuredactivitythatistypicallyconductedforentertainmentorlei‐
surepurposesbutcanalsobeusedforeducationalortrainingpurposes[1].Gamescan
takemanyforms,includingphysicalgames,boardgames,cardgames,videogames,and
onlinegames.Therearevariousmeaningsoftheterm“game”,allofwhichhavesome
similaritiesbutalsosignificantdistinctions.Severaldefinitionstendtolumpotheractivi‐
tiesintothesameclassasgames,whileothersexcludeafewgamesbasedonvarious
criteria(forexample,“artisticmotive”).Forthesakeofthisevaluationofdigitalgame
reviews,weselectedSmedandHakonen’sviewongames[2].Thisdefinitionconsiders
Citation:Damaševičius,R.;
Maskeliūnas,R.;Blažauskas,T.
SeriousGamesandGamificationin
Healthcare:AMeta‐Review.
Information2023,14,105.
https://doi.org/10.3390/info14020105
AcademicEditor:RicardoQueirós
andJakubSwacha
Received:24October2022
Revised:4February2023
Accepted:6February2023
Published:7February2023

Copyright:©2023bytheauthors.Li‐
censeeMDPI,Basel,Switzerland.
Thisarticleisanopenaccessarticle
distributedunderthetermsandcon‐
ditionsoftheCreativeCommonsAt‐
tribution(CCBY)license(https://cre‐
ativecommons.org/licenses/by/4.0/).

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thedigitalcharacterofgameswhiledefininggamesbasedonfactorsdirectlyconnected
togame‐liketraits,ratherthancreativeoreconomicdecisionsadoptedduringdevelop‐
ment.Anotherdefinitionstatesthatagameisacollectionofgoal‐orientedactionscarried
outbyfollowingthepredeterminedrules[2].Gamesaredistinguishedfromprofession
simulatorsandvirtualreality(VR)appsbytheirgoal‐orientedcharacter,whichdrivesthe
player.Simultaneously,therulesprovidedifficulties,andunexpectedrandomactionsor
unpredictablehumanplayerscancauseconflicts,preventingparticipantsfromreaching
theiraim.Thegame’sdepictionmakesthegamemoreconcretefortheplayerandmatches
tothegame’sregulations.Digitalgamesareplayedoncomputersandmobilephoneswith
thehelpofdigitalequipment[3].
Aseriousgameisatypeofgamethatisdesignedforaprimarypurposeotherthan
entertainment[4].Instead,seriousgamesareintendedtoachievespecificgoals,suchas
education,training,orhealthpromotion.Seriousgamescantakemanyforms,suchas
simulations,role‐playinggames,andeducationalgames,andcanbeusedinvariousset‐
tings,suchasclassrooms,workplaces,andhealthcaresettings.Thegoalofseriousgames
istoengageplayersinawaythatisbothenjoyableandeffectiveinachievingtheintended
learningorbehaviorchangeoutcomes[5].Initially,seriousgameswereadoptedinthe
educationaldomaintopromoteinterestandsupportmotivationinlearning[6,7].Thecon‐
ceptofutilizingseriousgamestoimprovehealthcareoutcomeshasattractedsupportfrom
anincreasinggroupofacademicscholars,developers,andhealthcarepractitioners[8].
Manypeoplearenowawareoftheneedofdevelopingevidence‐basedgameswhichare
specificallygearedtotreatphysicalandmentalhealthissuesthatenduserssufferwith
[9].Game‐basedtherapiesareincreasinglybeingusedinhealthcaretopromotemotiva‐
tion,engagement,andtheoverallsustainabilityofhealthhabits[10].Gamificationand
seriousgamesarethemostcommonformsofgame‐basedtreatmentsinhealthcarestud‐
ies.
Gamificationistheprocessofincorporatinggamedesignelementsintonon‐game
contexts,suchasbusiness,education,orhealthcare,toengageandmotivatepeopleto
achievetheirgoals[11].Gamificationcantakemanyforms,suchasaddingpoints,badges,
orleaderboardstoataskoractivity,orincorporatinggame‐likechallengesandfeedback
intoaprocessorsystem.Thegoalofgamificationistoincreaseengagement,motivation,
andparticipationinthetaskoractivity,andtoimproveoutcomessuchaslearning,
productivity,orhealth[12].Gamificationisacomparativelyrecentconceptthatshinesa
spotlightonusinggameprinciplesinnon‐gameenvironmentstoattractaudiencesand
inserttheelementsofentertainmentintomonotonousworkwhilealsoprovidingmotiva‐
tionalandcognitiveadvantages[1].Whilemanyindustries,suchasbusiness[13],mar‐
keting[14],work[15],andeducation[16],havetakenadvantageofgamification’spoten‐
tial,thedigitalhealthcarespherehasbeguntodosoaswell.However,itisfascinatingto
observethatgamificationhasenteredthemainstream,whereasseriousgameshavere‐
mainedonasmallscale,regardlessofhowoutdatedtheideaofseriousgamesis.
Recently,therehasbeenanupsurgeinresearchintotheusefulnessofdigitalgames,
withmultipleindividualandsystematicreviewsthatpresentthetoplevelofresearchev‐
idenceinthefield[3–5,12,16].Thereareseveralreasonswhythereisaneedtoresearch
games,seriousgames,andgamificationmethods.Firstly,gamesandgamificationarebe‐
ingincreasinglyusedinvariousfieldssuchaseducation,health,business,andgovern‐
ment,andthereisaneedtounderstandtheireffectivenessinachievingspecificgoalsand
outcomes.Researchcanhelptoidentifythemosteffectivegamemechanicsanddesign
elementsfordifferentcontextsandpopulations,andtounderstandhowtheseinterven‐
tionscanbeintegratedintoexistingsystemsandprocesses.Secondly,theuseofgames
andgamificationisrapidlygrowingandevolving,andthereisaneedtokeepupwiththe
latestdevelopmentsandtrendsinthefield.Researchcanhelptoidentifynewandemerg‐
ingtechnologiesandtechniques,andtounderstandhowthesecanbeusedtoachieve
specificgoalsandoutcomes.Thirdly,gamesandgamificationhavethepotentialtomake
apositiveimpactonpeople’slives,andthereisaneedtounderstandhowthese

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interventionscanbeusedtopromotepositivehealthoutcomes,improveeducationand
training,andincreaseengagementandmotivationindifferentfields.Researchcanhelp
toidentifythemosteffectivewaysofusingtheseinterventionstoachievespecificgoals
andoutcomes.Lastly,thefieldofgames,seriousgames,andgamificationisstillrelatively
new,andthereisaneedtoestablishastrongevidencebasetosupporttheuseofthese
interventionsindifferentfields.Researchcanhelptoestablishthebestpractices,guide‐
lines,andstandardsfortheuseofgamesandgamification,andtoidentifyareasforfur‐
therresearchanddevelopment.Asaresult,asummaryandassessmentofthequalityof
thesedatapublishedinsystematicevaluationsandreviewswouldbeusefulforbuilding
futureseriousgamesandguidingfuturegamificationresearch.
Apreviousmeta‐reviewintheareasrelatedtothedevelopmentanduseofserious
gamesincludedtheworksofRaduetal.[17]andParisodetal.[18].Raduetal.[17]dis‐
cussedaugmentedreality(AR)asaneducationalmedium,whichalsoincludededuca‐
tionalgames.Thestudyexamined26priorstudiesthatcontrastedstudentlearninginAR
againstnon‐ARapps.Themeta‐reviewofParisodetal.[18]examineddigitalgamesthat
aregoodforpromotingkids’health.Thisevaluationofreviewswasconductedwiththe
intentofevaluatingthequalityofsystematicreviews,summarizingtheevidenceinthose
studiesthatfocusedontheusefulnessofgamesinsupportingandpromotinghealthylife‐
style,andidentifyingknowledgegaps.
Thepurposeofthisstudyistoprovideanoverviewofthetopicofusingserious
gamesandgamification(SGG)invariousfields.Itservesasameta‐review,offeringa
comprehensiveunderstandingofwhatgamificationcanofferwithoutdelvingintode‐
tailedcomparisonsofmethodsoroutcomes.Theaimisnottosuggestasingleoptimal
strategyforusingSGG,butrathertoprovideacompleteevaluationtohelpacademicsand
practitionerstounderstandtheresearchgapsandpotentialofthisapproach.
ThegoalofthisstudyistoconductasystematicanalysisofSGGresearchusinga
well‐defineddatasearchprocessandcodingschemetoanswerthefollowingquestions:
1. Whatarethemostcommonhealthconditionsthatseriousgamesandgamification
techniqueshavebeenusedtoaddress?
2. Whatarethemostcommongamemechanicsanddesignelementsusedinserious
gamesandgamificationforhealth?
3. Whatistheevidencefortheeffectivenessofseriousgamesandgamificationinpro‐
motingpositivehealthoutcomes?
Thefollowingaretheprimarycontributionsofthisstudy:
 AcuratedcollectionofSGGsurveysoverthelastfiveyears.
 Basedoncitationstopublicationsdiscoveredinchosensurveys,ananalysisofthe
presentsituationoftheSGGresearchfield.
Section2ofthestudybeginswithanoverviewofthemethodologyforperforminga
systematicreviewanddescribestheprocessoftheperformedreview.Section3presents
anddiscussestheresultsofthemeta‐reviewonSGGforhealth.Section4discussesthe
selectedreviewstudies,aswellastheissuesthatcomewithitandconductsathorough
examinationof53surveystoobtaininsightintotheworks’academiceffect.Section5pre‐
sentsthefindingsofthisstudywithregardtoresearchquestionsandlimitations.Section
6discussesresearchgaps,trends,challenges,andfuturedirections.Finally,Section7con‐
cludeswithconcludingremarks.
2.Methodology
Academicpublicationhasacceleratedinrecentyears,bothintermsofquantityand
paceofpublication.Simultaneously,newvenuesforpublishingarefast‐emerging,such
asconferenceproceedings,scientificblogs,andaplethoraofscientificjournals,whichal‐
lowtheresearcherstoreporttheirworkinavarietyofplaces.Tokeepupwiththeexplo‐
sionofsystematicreviewsacrossfields,newmethodologicaltechniquesforsynthesizing
thisinformationhavebeencreated.Insectorswherearisingnumberofsystematic

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reviewsareavailable,conductingreviewsofprevioussystematicreviewshasturnedinto
areasonablenextstepinpresentingresearchevidence.
Whenmanysystematicreviewsoncomparableorrelatedsubjectsalreadyexist,over‐
viewsorumbrellareviewsaremosttypicallyutilizedtogather,assess,andsynthesizethe
resultsofrelevantsystematicreviews[19].Asaresult,evidencefromseveralreviewsor
surveypapersiscompiledintoareviewofreviewsoranumbrellareview.Theanalysis
offormerlypublishedsystematicreviewsmayuseothertermssuchas“summaryofsys‐
tematicreviews”,“reviewofreviews”,“synthesisofreviews”,and“meta‐review”[20].
Reviewsofreviewsaremadetocompileevidencefrommultiplereviewpapersintoa
singledocumentthatisaccessibleandusefulforresearchers.Theypresentthebestevi‐
dencepossiblebysummarizingtheevidenceforseveralsolutions,describingthequality
oftheevidence,anddiscussingtheadvantagesoftheconclusions[20].
2.1.LiteratureSearch
WefollowedaPRISMAmethodologyforsystematicreviewsinthisstudy.Wecar‐
riedoutaliteraturesearchon24March2022,fromtheScopusdatabase,whichisrepre‐
sentedinTable1.Theauthorspredeterminedtheinclusioncriteriaforthisreviewofre‐
views.Onlyreviewsthatreportedconductingaliteraturesearchandsystematicreviews
(includingmeta‐analyses)wereincluded.Thefocusofthechosenliteraturehadtobeon
videogames.Thereviewarticlesthatsolelyfocusedonsubjectsotherthandigitalgames
(e.g.,simulation,VRapps,nondigitalgames)weredisregarded.Digitalgameswerere‐
ferredtobythekeywords“videogame”,“computergame”,“electronicgame”,“mobile
game”,or“app”.Theinclusionandexclusioncriteriasetbeforehandwerefollowedwhen
systematicallyscreeningthefindings.Twoimpartialreviewerscheckedthetitlesandab‐
stracts(R.D.andR.M.).Disparitieswereaddressedandresolvedusingthepreviouscrite‐
riaaftertheinitialscreening.Fiftysystematicreviewsandreviewswereselectedforanal‐
ysisbecauseofthescreening.Afollow‐upsearchintheWebofScience(WoS)biblio‐
graphicdatabasewasconductedusingthesameprocedureastheupdatedsearchinAu‐
gust2022.Threenewsystematicreviewswereaddedasaresult.
Table1.Summaryofthesearch.
BibliographicDatabaseScopus
Articletitle“seriousgame”ORgamif*
Searchwithinresultshealth*ORmedicalORrehabilitation
Years2017–2021
DocumenttypeReview
Sourcetype
J
ournal
LanguageEnglish
Searchquery
(TITLE(“seriousgame”))AND(TITLE‐ABS‐KEY(health*ORmedicalORrehabilita‐
tion))AND(LIMIT‐TO(PUBYEAR,2021)ORLIMIT‐TO(PUBYEAR,2020)ORLIMIT‐TO
(PUBYEAR,2019)ORLIMIT‐TO(PUBYEAR,2018)ORLIMIT‐TO(PUBYEAR,2017))
AND(LIMIT‐TO(DOCTYPE,“re”))AND(LIMIT‐TO(LANGUAGE,“English”))AND
(LIMIT‐TO(SRCTYPE,“j”))
Symbol‘*”isapartofsearchqueryanddenotesanysymbol.
Thesearchyielded45studies.Forwardsnowballingyielded1additionalstudy.Back‐
wardsnowballingyielded7additionalstudies.Thetotalnumberofstudiesselectedfor
furtheranalysiswas53.Figure1demonstratestheselectionprocedureusingthePRISMA
flowchart.


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Figure1.PRISMAflowchartofthereviewselectionprocess.
2.2.AssessmentofQuality
AllthereviewsincludedinthestudywereassessedusingtheAMSTAR(http://am‐
star.ca/,accessedon1October2022),atechniqueforassessingthequalityofsystematic
reviewsandmeta‐analyses.Therewere11itemsonthechecklist,whichincludedinquiries
abouttheliteraturesearch,paperselection,andanalysis,aswellassummarizingthesys‐
tematicreview’sfindings.Thechecklistwassolelyutilizedasaguidingdeviceandno
inferencesregardingthequalityofselectedarticlesweredrawnbasedontheAMSTAR
ratings.Tworeviewersseparatelyscoredandevaluatedthequalityofthework.
2.3.QuantitativeEvaluation
Weusedseveralmetricsthatcouldbeusedtoanalyzethebibliographiccharacteris‐
ticsofstudiesincludedinasystematicreview:
 Publicationyearhelpedtoidentifypublicationtrendsovertimeandtounderstand
howtheresearchfieldhasevolved.
 Subjectareahelpedtoidentifythespecificfieldordisciplineinwhichthestudies
wereconductedandwasusefulinhelpingtounderstandthebroadercontextofthe
research.Theanalysisofsubjectareaalsohelpedtoidentifyanyoverlapsorgapsin
theliteratureandtoidentifynewareasofresearchthatmayhavebeenrelevantto
thespecificfieldordiscipline.
 Journalprovidedinformationonthequalityofthejournal,theimpactfactor,andthe
reachofthejournal.
 Authorprovidedinformationonthenumberofauthors,theauthors’affiliations,and
theauthors’publicationhistory,whichwereusefulwhenidentifyingthemostinflu‐
entialauthorsinacertainareaofresearch.

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 Numberofcitationsincludedinformationonthenumberoftimesthestudywascited
byotherpapers,whichwasusedasanindicatoroftheimpactandinfluenceofa
studywithinitsfield.Studieswithahighnumberofcitationsareoftenconsideredto
behighlyinfluentialandimportantinthefield.Inthisstudy,allcitationcountswere
retrievedfromtheScopusbibliographicdatabase.
 Distributionofkeywordshelpedtoidentifythemostcommontermsusedinthestud‐
iesandtounderstandthelanguageusedtodescribetheresearch,whichwasoffur‐
therhelptoidentifykeyareasintheresearchfield.Thisinformationcanbeusefulfor
researchers,toidentifygapsintheliteratureandtounderstandthelatesttrendsin
thefield.Itcanalsobeusedbypractitionerstounderstandthecurrentstateofthe
fieldandtoidentifynewareasofresearchthatmayberelevanttotheirwork.
Thesemetricswereusedtoprovideanoverviewofthestudiesincludedinthesys‐
tematicreview,andtoidentifypatternsortrendsthatmayhavebeenrelevanttothere‐
searchquestions.
3.AnalysisofMeta‐ReviewResults
3.1.Preliminaries
Adescriptiveanalysisofthescientificpublicationsispresented.Atotalof53research
publications(reviewarticles),whichwerepublishedbetween2017and2021,werein‐
cludedinthedescriptiveanalysis.Theaimsoftheanalysiswereformulatedasfollows:
 Analyze,describe,andpresenttherelevantliterature’srelationships(suchasthe
numberofpublicationsperyearandresearchtopic,etc.).
 PresentinformationoncurrentresearchtrendsinSGGaswellasacriticalexamina‐
tionoftheissuesthathavebeenfound.
 Tohelpustovisualizethevariousstudymethodologiesemployedinthescientific
literatureuptothispointregardingthepropagationofSGGreviewpapers.
3.2.ResultsandTheirAnalysis
Theremainingportionsofthispaper’sfindingsareprimarilybasedon53SSG‐related
papers[21–73]thatwerepublishedbetween2017and2021.Wedidnotconsidersurveys
thatjustreferencedgamificationtechniquesorgamesinpassingorwhosematerialwas
notaccessibleonline.Thenumberofthechosensurveysandtheirannualcitationnumbers
areshowninTable2.Thenumberofcitationsofastudyisthenumberoftimesother
authorsmentionastudyintheirwork.InTable2,wegiveatotalnumberofcitationsfor
allanalyzedreviewstudiesineachyear.ThenumberisprovidedaccordingtotheScopus
bibliographicdatabase.Mostreviewpaperswerepublishedin2020,whilethenumberof
citationsdemonstratedaconsistentgrowthfrom2017withthehighestnumberreached
in2021(Figure2).Asaresult,researchinthefieldofSGGhassignificantlyrisenduring
thepreviousfiveyears.ThisgrowingtrendillustratesSGG’scurrentpublicandpolicy
effect.
Table2.Distributionoftheselectedsurveysandtheirtotalnumberofcitations(accordingtoSco‐
pus)bypublicationyear.
Year20172018201920202021
Papers10891511
Citations15 75237386545

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Figure2.ScopussearchresultsusingScopuscollectiondatabase:Left:numberofpublicationsfrom
2017to2021.Right:Citationreportofthesepublicationsthroughouttheyears.
The53systematicstudiesandmiscellaneousreviewsintotalsatisfiedtheinclusion
requirements.Table3liststhecharacteristicsoftheliteraturethatwereincludedaccord‐
ingtosubjectarea(researchtopic).Thelistofcategoriesisbasedontheclassificationof
papersintosubjectareasusedintheScopusbibliographicdatabase.Mostofthereview
paperswerepublishedinthesubjectareasofmedicine(42),computerscience(15),health
professions(15),andengineering(15),whichfaithfullyreflectstheintertwiningofthe
problemdomainofhealthcareandthesolutiondomainofgamesdevelopedusingcom‐
putersciencemethodology.Notethatsomepapersarelistedinmultipledomains.
Table3.Distributionofpapersbysubjectarea(morethanonestudy).
SubjectAreaNumberofPapersReferences
Medicine41[21–25,27,31,32,35–38,42–44,46–56,58,60–72]
ComputerScience15[22,24,26,27,31,38–40,48,57,60,62,70,72,73]
HealthProfessions15[21,23,24,42,44,47,51,55,56,61,63,65,67–69]
Engineering15[21,23,24,30,40,42,47,51,55,60,61,63,65,67–69]
SocialSciences10[22,27,29,31,38,45,48,53,70,72]
Nursing4[28,33,34,44]
Psychology 2[26
,
66]
Others6[26–28
,
36,53,60]
Theanalysisofpublishedsurveysbyvenueshows(Table4)thatmostarticleswere
publishedintheJMIRSeriousGamesjournal(11),followedbyGamesforHealthJournal(6),
whicharecurrentlytheleadingpublicationvenuesforhealth‐relatedseriousgamesand
gamificationtechniques.JMIRSeriousGamesisamultidisciplinaryjournaldevotedto
computer,mobile,andVRapplicationsthatincorporateelementsofgamingandgamifi‐
cation,ornovelhardwareplatformssuchasVRheadsetstosolveseriousproblemsinthe
healthdomain.GamesforHealthJournalisthepeer‐reviewedjournaldedicatedtogaming
research,technology,andapplicationsforhumanhealthandwell‐being.
Table4.Distributionofpapersbyvenueofpublication(morethanonestudy).
VenueNumberofPapers
JMIRSeriousGames11
GamesforHealthJournal6

Information2023,14,1058of31
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
JournalofNeuroEngineeringandRehabilitation2
Theanalysisofthedistributionofpapersbycountriesandaffiliationsofauthors
shows(Table5)thattheleadingcountriesinSSGresearchareUSA(7),Brazil(6),and
Canada(6),followedbyGermany(5)andtheNetherlands(5).Theresearchersrepresent‐
ingthetopuniversitiesandmedicalinstitutions,suchasHarvardMedicalSchooland
MassachusettsGeneralHospital,havecontributed.
Table5.Distributionofpapersbycountriesandaffiliationsofauthors(morethantwostudies).
CountryUniversitiesorInstitutesNumberofPapers
USA
HarvardMedicalSchool,JohnsHopkinsBloombergSchoolofPublicHealth,Univer‐
sityofPittsburgh,UniversityofWisconsinSchoolofMedicineandPublicHealth,
NortheasternUniversity,MassachusettsGeneralHospital,BostonCollege,Michigan
StateUniversity,UniversityofWisconsin–Madison
7
Brazil
UniversidadedeSãoPaulo,UniversidadeFederaldeSãoCarlos,UniversidadeBra‐
silU.B.Fernandópolis,UniversidadeFederaldoRioGrandedoSul,Universidade
FederaldePelotas,UniversidadeFederaldeUberlândia,UniversidadeFederaldo
TrianguloMineiro,UniversidadeEstadualdoCeará
6
CanadaUniversityofMontreal,RoyalAlexandraHospital,Edmonton,InstitutdeCardiolo‐
giedeMontreal,UniversityofAlberta6
Germany
UniklinikKöln,TechnischeUniversitätBraunschweig,FOMUniversityofApplied
Sciences(Essen),TechnischeUniversitätKaiserslautern,TechnischeUniversität
Darmstadt,MedizinischeHochschuleHannover(MHH),KarlsruherInstitutfür
Technologie,PeterL.ReichertzInstitutfürMedizinischeInformatik(Braunschweig)
5
TheNether‐
lands
UniversiteitvanAmsterdam,VrijeUniversiteitAmsterdam,UniversitairMedisch
CentrumGroningen,DelftUniversityofTechnology,UniversiteitUtrecht,Rijksuni‐
versiteitGroningen,MedischCentrumLeeuwarden,AmsterdamPublicHealth
5
Portugal
UniversidadeNovadeLisboa,AlcoitãoCentreforRehabilitationMedicine,Univer‐
sidadedaBeiraInterior,UniversidadedeAveiro,InstitutodeEngenhariaElec‐
trónicaeTelemáticadeAveiro,UniversidadeCatólicaPortuguesa,Universityof
Coimbra
4
SpainUniversidaddeMurcia,UniversidaddeDeusto,UniversitatdelesIllesBalears,Uni‐
versidaddeBurgos4
AustraliaDeakinUniversity,UniversityofMelbourne,TheUniversityofWesternAustralia3
BelgiumErasmusUniversityCollegeBrussels,UniversitéCatholiquedeLouvain,Cliniques
UniversitairesSaint‐Luc3
SingaporeNanyangTechnologicalUniversity,SingaporeInstituteofMentalHealth,National
UniversityofSingapore,SingaporeGeneralHospital3
ThemostcitedsystematicreviewsaresummarizedinTable6.Thetoptwopapers
werepublishedin2017andoverfiveyearswerecited347[62]and1160[52]times.Study
[62]presentedasystematicreviewofgamificationine‐Health,anditwaspublishedin
theJournalofBiomedicalInformatics.
Table6.Mostcited(over100times)systematicreviews(upto23October2022).
ReferenceAuthorsYearJournalCitations
[62]Sardi,L.,Idri,A.,Fernández‐Alemán,J.L. 2017 JournalofBiomedicalInformatics347
[52]Lau,H.M.,Smit,J.H.,Fleming,T.M.,Riper,H. 2017 FrontiersinPsychiatry140
[73]Zhonggen,Y.2019 InternationalJournalofComputer
GamesTechnology115

Information2023,14,1059of31


[70]Villani,D.,Carissoli,C.,Triberti
,
S.,(...),Gilli,G.,
Riva,G. 2018 GamesforHealthJournal108
[45]Gorbanev,I.,Agudelo‐Londoño,S.,González,
R.A.,(...),Yepes,F.J.,Muñoz,Ó. 2018 MedicalEducationOnline103
Theselectedreviewpublicationswerecited1474times.Theaveragenumberofcita‐
tionsforaworkis27.83.Mostofthepublicationswerecitedbetween10and99times
(54.7%),whilefivepaperswerecitedover100times(Table7).Thecitationdistribution
mightindicatethat(1)thesurveysarehighlypreciseandscarcelyintersectinsubstance,
(2)therecommendedsolutions,identifiedtrends,andpresentedrecommendationsinthe
surveypapersremainrelevantfortheresearchinthedomain.
Table7.Numberofcitationsofnon‐surveyworks.
CitationsNumberofPapers(Percentage)
0–919(35.8%)
10–9929(54.7%)
>1005(9.5%)
Theselectedsurveypaperscited2944referencesintotal.Themostcitedreferences
(Table8)weretheDiagnosticandStatisticalManualofMentalDisorders[74]andStatistical
PowerAnalysisfortheBehavioralSciences[75],whichdescribecommonlyusedstatistical
analysismethodsemployedforpresentingmedical‐relatedresearchresults,whileref.[76]
referstothePRISMAmethodology.
Table8.TopcitedreferencescitedbytheanalyzedsystematicreviewsonSSG(upto23May
2022).
ReferenceAuthorsYearNo.ofCitations
[74]AmericanPsychiatricAssociation1994193,348
[75]Cohen1988118,898
[77]Folsteinetal.197568,934
[78]Ajzen199141,588
[76]Moheretal.200937,389
TheanalyzedsurveypapermostoftenusedPUBMED(25),WebofScience(15),and
Scopus(12)databasesasthemainsourcesofbibliographicinformation(Table9).Pub‐
Med®,maintainedbytheNationalCenterforBiotechnologyInformation(NCBI),has
morethan34millioncitationsforbiomedicalpapersfromMEDLINE,lifesciencejournals,
andonlinebooks.WebofSciencegivesaccesstomanydatabasesthatprovidereference
andcitationdatafromacademicjournals,conferenceproceedings,andothermaterialsin
variousacademicsubjects.ScopusisabibliographicdatabasemanagedbyElsevierthat
coversthesubjectsofbiologicalsciences,socialsciences,physicalsciences,andhealthsci‐
ences.
Table9.Commonlyuseddatabases(morethanonce)usedinreviewstudies.
DatabaseNumberofPapers
PUBMED25
WebofScience 15
CochraneCentralRegisterofControlledTrials12
MEDLINE11
IEEEDigitalLibrary/IEEExplore10
Scopus,EMBASE9

Information2023,14,10510of31


ScienceDirect8
PsycINFO,CINAHL(CurrentIndextoNursingandAllied
HealthLiterature)6
GoogleScholar5
LILACS3
ACMDigitalLibrary,Taylor&Francis,Springer,ERIC(Educa‐
tionResourcesInformationCenter),Wiley2
Table10showsthecharacteristicsofsurveypapersincludingthenumberofincluded
studies,therangeofstudies,andthekeywords(orasearchquery)usedforidentifying
therelevantarticles.Thelargeststudy,publishedin2021,analyzed206relevantarticles
onseriousgamesandgamification,respectively,publishedintheJournalofMedicalInter‐
netResearch(JMIR).
Thedomain‐orienteddistributionofthe53reviewpublicationsincludedinourstudy
isshowninFigure3.

Figure3.Mostcommontermsusedinkeywordabstracts.


Information2023,14,10511of31
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
Table10.Characteristicsofthesystematicreviewsandreviewsandthestudiesincludedwithinthem.
ReferenceYearof
Study
Numberof
IncludedStudies
YearRangeof
IncludedStudiesDatabasesKeywords(SearchQuery)
[73]2019462009–2018WebofScience(WoS)“seriousgame”,“seriousgaming”,“education”,“learning”
[66]2019341990–2018CINAHLPlus(EBSCOhost),Embase,ERIC
(Proquest),Medline,PsychInfo“autism”,“social”,“emotion”,“computer”
[62]2017462010–2015ACM,IEEE‐Xplore,Springer,WileyInterscience,
ScienceDirect,PubMed,GoogleScholar
software(app,framework,system,electronic)ANDhealth(PHR,HER,medic,
clinic,patient)ANDgamification(gameelements,game,gamemechanics)
[37]2017121980–2015PubMed,EMBASE,CochraneLibrary,PsychInfo,
WoSseriousgames,videogame,gamingANDasthma
[45]2017212011–2015WoS,Scopus,ProQuest,EbscoHost,
OvidMedline
computer‐based,medicaleducation,technology‐enhanced,medicalstudents,
learning,physicians,e‐learning,education,m‐learning,mobilephone,
smartphone,mobileapp,app,game*,seriousgames,gamification
[30]2021382011–2021WoS,Scopus,PubMed,Bireme,ScienceDirect,
IEEEDigitalLibrary,ACMDL,GoogleScholar“seriousgame”,“Parkinson”
[55]2021342015–2020
PubMed,Scopus,Wiley,Taylor&Francis,
Springer,PsycINFO,PsycArticles,WoS,Science
Direct
(seriousgameORvideogameORappliedgameORcomputergameORmobile
gameORonlinegameORgaming)AND(childrenORadolescentORchildhood
ORadolescence)AND(cognitivebehavioraltherapyORcognitivetrainingOR
anxietytreatmentORanxietydisorderORmentalhealthORdepressionOR
stigmaORhelpingbehaviorORmeditation)
[28]2019432019Medline(Ovid),Scopus,PSYCINFO
(gamificationORseriousgameORgame*ORgaming)AND(child*ORkid)
AND(eatingbehaviorORfoodpreference*ORintakeORfoodacceptanceOR
foodattitudeORlikingORconsumption)
[71]2021206–2020JournalofMedicalInternetResearch(JMIR)website
gamification(searchterms:gamification,gamified,gamifying,orgamify)orseri‐
ousgames(searchterms:seriousANDgames,seriousANDgaming,orserious
ANDgame)
[33]20186
PublicMedline,WoS,ScienceDirect,LatinAmeri‐
canandCaribbeanHealthSciencesLiterature,
HealthGameResearch,CumulativeIndexto
NursingandAlliedHealthLiterature
videogamesandobesity
[46]2019251996–2019ERIC,EducationSource,PsychINFO,Global
Health,CINAHL,WoS,Medline
(“seriousgame*”)AND(educate*ORtrain*ORteach*)AND(medicalOR
medicineORsurge*ORsurgicalORphysicianORhealthcareORdoctor*OR
nurse*OR“alliedhealth”)

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
[43]201921–2019PubMed,GoogleScholar,CochraneCentralReg‐
isterofControlledTrials,CINAHL,WoS,EMBAS
“neonatal”,“deliveryroom”,“infant”,“baby”,“neonatalresuscitation”,“serious
game”,“computergame”,“boardgame”,“videogame”,“virtualreality”,
“screen‐basedsimulation”,“table‐topsimulation”
[56]201812
PubMed,EMBASE,CochraneLibrary,CurrentIn‐
dextoNursingandAlliedHealthLiterature
wearable,seriousgame,videogameormobileapplication,andrehabilitation,ex‐
ercisetherapy,physiotherapy
[23]2021832012–2019
PubMed,PEDro,IEEEXplore,ScienceDirect,
ACMDL,MaryAnnLiebert,Taylor&Francis
Online,WileyOnlineLibrary,Springer
seriousgameandframework
[44]20204–2019
PubMed,GoogleScholar,CochraneCentralReg‐
isterofControlledTrials,CINAHL,WoS,EM‐
BASE
“RETAIN”,“neonatalresuscitation”,“resuscitationtraining”,“healthcareprofes‐
sionals”,“digitalsimulation”,“neonatal”,“infant”,“baby”,“seriousgame”,
“computergame”,“boardgame”,“videogame”,“virtualreality”,“table‐top
trainingsimulator”
[51]20179–2016PubMed,Scopus,ERIC,PsycINFO,Information
ScienceandTechnologyAbstracts,EMBASE
(videogamesORgameORgamesORgamingORcomputersimulation*)AND
(softwaredesignORdesign)AND(fidelityORfidelitiesORtransfer*ORbehav‐
iorORbehavior)
[64]20201152009–2019PubMed/MEDLINE,LILACS,Scopus,CINAHL
(StudentsORStudentOR“SchoolEnrollment”OR“Enrollment,School”OR“En‐
rollments,School”OR“SchoolEnrollments”)AND(“Videogames”OR“Game,
Video”OR“Games,Video”OR“VideoGame”OR“ComputerGames”OR
“ComputerGame”OR“Game,Computer”OR“Games,Computer”)AND(“Seri‐
ousGame”)(“Videogames”OR“Game,Video”OR“Games,Video”OR“Video
Game”OR“ComputerGames”OR“ComputerGame”OR“Game,Computer”
OR“Games,Computer”AND“SeriousGame”)AND(LearningORPhenome‐
nographyOR“MemoryTraining”OR“Training,Memory”)AND(“Cardiopul‐
monaryResuscitation”OR“Resuscitation,Cardiopulmonary”ORCPROR“Car‐
dio‐PulmonaryResuscitation”OR“Resuscitation,Cardio‐Pulmonary”OR“Code
Blue”OR“Mouth‐to‐MouthResuscitation”OR“MouthtoMouthResuscitation”
OR“Mouth‐to‐MouthResuscitations”OR“Resuscitation,Mouth‐to‐Mouth”OR
“Resuscitations,Mouth‐to‐Mouth”OR“BasicCardiacLifeSupport”OR“Life
Support,BasicCardiac”).
[34]2017172009–2014Lilacs,Medline,WoSvideogames,seriousgamesandobesity
[70]2018232007–2017PsycINFO,Scopus‘‘emotionregulation’’and‘‘videogames’’
[25]2019862007–2019WoS,PubMed“seriousgames”,“motorrehabilitation”,“Kinect”,“vision‐based”,“virtualreal‐
ity”
Wildcard‘*”isapartofsearchquery;itmeansanycharacters.

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Aftertheanalysisoftheabstractandtextoftheselectedreviews,weidentifiedseven
commonstudytopicsofinterest,asfollows:generalhealth(16),rehabilitation(11),virtual
reality(8),videogames(8),education(8),mentalandcognitivedisorder(6),andlearning
(5).Here,mentalandcognitivedisordersincludeintellectualimpairmentsandconditions
suchasanxiety,depression,Parkinson’sdisease,Alzheimer’sautismspectrumdisorder
(ASD),etc.Educationisrelatedtoallaspectsofteaching,andtheuseofgamesinthe
pedagogicalcontexttoimprovetheengagementofstudentsandthedeliveryofprofes‐
sionalknowledgeinaformalenvironment.Rehabilitationisfocusedonactionsmeantto
enhancefunctioningandminimizeimpairmentinpeoplewithhealthissues(suchasafter
traumasorchronicdisease)astheyinteractwiththeirenvironment.Generalhealthfo‐
cusesonmaintaininghealthandwell‐beingthroughoutthelifetimebypracticingexercise,
diet,preventativehealthchecks,oralhygiene,etc.Virtualreality(VR)isacomputer‐gen‐
eratedenvironmentfeaturingrealistic‐lookingimagesandobjectswhichimmersethe
viewerintheirsurroundingsusingspecializedequipment(VRheadset)withvisualfeed‐
back.Videogamesareanyelectronicgamesthatarebasedoninteractionandvisualfeed‐
back.Notethatthetopicsarenaturallyoverlapping.Moreover,severalreviewarticles
whichdonotfallintoanyofthecategorieshighlighttheinterdisciplinarynatureofthe
SGGdomain.
3.3.QualityEvaluationUsingAMSTAR
WeusedarevisedversionofAMSTAR(ameasurementtooltoassesssystematicre‐
views),whichisapopularinstrumentforcriticallyappraisingsystematicreviews.Itisa
validatedtoolthatassessesthequalityofasystematicreviewbyevaluatingtheprocessof
conductingthereview,ratherthanthequalityoftheprimarystudiesincludedinthere‐
view.Itisdividedinto16itemsthatcovervariousaspectsofthesystematicreviewpro‐
cess,suchasthetransparencyofthesearchstrategy,thereportingofpotentialbiases,and
theuseofasystematicapproachtodataextractionandanalysis.
TocarryoutAMSTAR‐2,thereviewwasassessedagainsteachofthe16itemsusing
ayes/no/can’tanswerformat.Ascoreof1isgivenfora“yes”answer,ascoreof0isgiven
fora“no”answer,andascoreof0.5isgivenfora“can’tanswer”answer.Thetotalscore
rangesfrom0to11,withahigherscoreindicatingahigherqualitysystematicreview.
Ascorerangewascreatedforcategorizingthesystematicreviewsintocriticallow
(0–4p),low(5–8),moderate(9–11),andhighcategoriesbasedontheoriginalAMSTAR
method(12–16).Separately,tworesearchersassessedthestudies.Discussionswereheld
tosettleanydifferencesandcometoaconsensusagreementonthefinalscore.Thefinal
consensusscorewas11.75,whichindicatesamoderatequalityofthesystematicreviews.
4.AnalysisandDiscussionoftheSystematicReviewsonSSG
Inthissection,theselectedreviewarticlesarediscussed.Forconvenience,thearticles
aregroupedbyresearchtopicsidentifiedinSection3vialexicalanalysisoftitlesandab‐
stractsofpublicationsandthecategorizationpresentedinFigure3wasfollowed.
4.1.GamesforGeneralHealth
Study[32]assessedtheinfluenceofseriousgamesonsmokingstart,cessation,and
behavioralvariables.Thestudyfound15studiesthatevaluated14differentserious
games,whichcombineddifferentgamingaspects.Generalandsporadicincentives,theme
andgenreaspects,andpenaltieswerethemostused.Eightfactorswereidentifiedtohave
statisticallysignificantbeneficialimpactsinsixtrialsonsmokingavoidance(e.g.,attitude,
knowledge,intention).Fiveofthesevenstudiesonquittingsmokingindicatedfavorable,
statisticallysignificantbenefitsonquittingorstatus.Sixdeterminantsdemonstratedsta‐
tisticallysignificantbeneficialimpactsinthesetrials(e.g.,self‐efficacy,attitude,intention).
Strongergamedesignsareneededtoillustrate,measure,andcomprehendtheimpactsof
seriousgames,asmostoftheresearchhadsignificantmethodologicalshortcomings.

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Study[47]examinedtheusageofgamificationapproachesinstresstreatmentappli‐
cations,aswellastheircoexistencewithevidence‐basedstressmanagementandbehavior
modificationtactics.Seventeengamificationtactics,15stressmanagementtechniques,
and26behaviormodificationapproacheswereevaluatedin62stressmanagementappli‐
cationsfromtheGooglePlayStore.Ataxonomyofgamificationstrategieswasdeveloped
andputintopractice.Therearenolinksbetweentheadoptionofgamificationtacticsand
behaviormodificationorstressmanagementstrategies,accordingtothefindings.Asa
result,stressmanagementappdesignersdonotemploygamificationtacticstoinfluence
userbehaviorandresponses.Furthermore,theappcreatorsfailtoseethevalueofmixing
gamificationapproacheswithbehaviormodificationtheories.
Study[48]analyzedtheimpactofseriousgamesonchronicillnessoutcomesinchil‐
dren.Self‐efficacy,adherence,knowledge,theoryapplication,parentalparticipation,and
studyqualitywereallinvestigated.Thereviewincludesatotalofeighteenpapers.Cere‐
bralpalsy,asthma,diabetes,developmentalcoordinationdifficulties,andeyeabnormali‐
tieswereamongthehealthissuestreated.Psychosocialvariablessuchasself‐efficacy(i.e.,
anindividual’sbeliefintheirabilitytocontroltheirownactionsandaffectchangeintheir
environment)andknowledgewerestudiedintheanalysis.Thepotentialforgamesto
benefityoungpeople’shealthisdemonstratedinthisstudy.Themixedresultsimply,
however,thatmoreseriousgamingtreatmentsshouldbewell‐developedandextensively
researchedtosupporttheirinfluenceonimprovinghealthoutcomes.
Study[51]focusedongame‐likeinterventionsforhealth.Therewere15studiesthat
wererelevant.Transfer(i.e.,theabilityofapatienttoapplytheskillsorknowledge
learnedinthegametoreal‐lifesituations)isseenasadesiredconsequencebutnotasa
designconceptinstudiesongame‐liketreatmentsforhealthandhealthcare.Studieson
game‐likehealthtreatmentsseldomexplaindesigndecisionsorgivedesignprinciples.
Gamesandsimulationsforhealtharebasedonfirst‐classtransfer(i.e.,directapplication
ofskillsorknowledgelearnedinthegametoreal‐lifesituations),althoughsecond‐class
transfer(i.e.,theapplicationofskillsorknowledgelearnedinonesituationtoarelated
butdifferentsituation)israrelyused.
Study[63]undertookascopingassessmentofthedevelopmentandassessmentof
seriousinstructionalgamesforhealthcareworkers,patients,andhealthyusers.Theau‐
thorsfound161studies.Thefindingsrevealedapositivetrendinbroadeningthescopeof
healthteachinggamesbeyondasingleclinicalcondition.Thefindingspointtotheneces‐
sityforhealtheducationgamecreationandacceptanceinpoornations,aswellastheneed
ofinterdisciplinarycooperationintheproductionofeffectiveeducationalseriousgames
forhealth.Inordertoprovideevidenceoflong‐termefficacy,futurehealthgamesshould
includelongerfollow‐upassessmentsandextendthedurationofthegameitself.This
wouldallowresearcherstotracktheprogressofpatientsoveralongerperiodoftimeand
toseeifthebenefitsofthegamecontinuetobeevidentevenafterthegamehasbeen
completed.
Study[68]aimedto(1)identifyandanalyzetheneeds,suggestions,andguidelines
offeredbySSGforhealthinthescientificliterature,and(2)buildaconsensusframework
tohelpresearchers,gamedevelopers,andhealthcareprofessionalsindevelopingevi‐
dence‐basedSSGforhealth.Thisinterdisciplinary,iterative,andinteractiveevaluation
revealedfivehigh‐levelcriteriaand20low‐levelrequirementsprovidedbytheSGHcom‐
munity.Theauthorsproposeaframeworkfordevelopingtheory‐driven,evidence‐based
SGHthatincludequantitativetrialstoassesswhetherSGHachievetheintendedout‐
comes,andfollow‐upmonitoringtoenableSGHstakeholderstousetheminawiderange
ofprojects,regardlessofdiscipline,healthcaresegments,orfocus.
Study[71]presentedthestateofSSGconceptualizationsinhealthcareresearch.There
were206papersevaluatedtheoreticallyintheJMIRanditssiblingpublicationsthatcon‐
tainedphraseslinkedtogamification,seriousgaming,orboth.Theauthorscreatedthe
GAMINGs(game‐basedinterventionreportingguidelines)forresearchersreportingon
game‐basedtreatments,whichconsistof25elementsorganizedintofourcategoriesof

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focus,contribution,awareness,andindividualconcepts.FollowingtheGAMINGscan
helpwriterspresentresearchoutcomesofgame‐basedtherapiesmorerigorously.
Study[72]gaveasummaryofseriousgamesdesignedforthetrainingoforalhealth
professionalsorfororalhealthpromotion.Atotalof19investigations(25publications)
werechosen.Gameswereseparatedintotwocategories:instructionalgamesandgames
thatpromoteoralhealth.Mostoftheresearchinvolvedstudentsintheoralhealthprofes‐
sionsorschool/preschoolchildren.Intermsofincreasingoralhealthoutcomes,interactive
seriousgameswerejustassuccessfulastraditionalnoninteractivetechniques.Partici‐
pantsexpressedahigherdegreeofsatisfactionwithlearningthroughgamesintheirfeed‐
back.Theuseofseriousgamesinoralhealthisrestricted,andthereislittlereliablescien‐
tificevidencetobackuptheirefficacy.
4.2.GamesforRehabilitation
Study[22]assessedthestateoftheartintermsofinteractionmodesutilizedingames
fortherehabilitationofupperlimbs.Therewere33articlesexamined.Almosthalfofthe
experiments(42.4%)employedvisionsystemsasaninteractionmodalityandcollected
bodymotionsusingtheKinectsensor(48.48%).Lightingconditionshavethepotentialto
alterthedeviceperformanceofvisionsystemsandsupplementaryvisionsystems.Not
manystudieshavebeenconductedontheuseofseriousgamesforfingerrehabilitation
andtreatinginjuries,oronhowtocombinemultiplesensordatatoimprovethewaypeo‐
pleinteractwiththegame.Theseresearchgapsmaybepromisingtopicsforfuturestudy.
Study[23]reviewedthebenefitsofutilizingasoftwareengineeringmethodologyin
seriousgamesforphysicalrehabilitation.Forthisinvestigation,83publicationswerecho‐
sen.Eightoftheeighty‐threepublicationsexaminedemployedasoftwareengineering
frameworktoconstructtheirwork.Mostofthemconcentratedononeormorefactors,
suchasdatacollectionandprocessing,gamelevels,incentive,andtherapistmonitoring.
Thiscomprehensiveexaminationrevealsthatmostseriousgamesarenotdevelopedusing
softwareengineering.Asaresult,developmentsystemsignorevariousfactorsandlacka
consistentapproach,resultingintheomissionofcriticalimplementationelementsthat
affectthepatient’srecoveryperiod.Forexample,thelackofproperassessmentandfeed‐
backcanleadtoalackofprogressorevendeteriorationinthepatient’scondition.Ifthere
isnofeedbackprovidedtothepatient,theymaynotbeawareoftheirprogressorareas
wheretheyneedtoimprove,whichcanhindertheirrecovery.Anotherimportantelement
islackofengagementandmotivation.Gamesthatarenotengagingormotivatingmay
notholdthepatient’sinterest,whichcanleadtopoorcomplianceandalackofprogress.
Theomissionoftheproperintegrationwithothertreatmentmethodscanleadtoalackof
continuityinthepatient’streatment,whichcanimpedeprogress.
Study[30]determinedandassessedthesituationofusingseriousgamesinthereha‐
bilitationofpeoplewithParkinson’sdisease(PD).Theevaluationlookedatthetypeof
game,interface,device,rehabilitationprocedure,techniqueformeasuringthegame’sef‐
fectiveness,symptomscured,andimplementationinrealpatients.Moststudiessuggest
creatingexergames,usingVRasaninterfacetechnology,capturingbodymotionswith
LeapMotionandMicrosoftKinect,andtreatingbradykinesiaandgaitproblems.Thefind‐
ingsshowthathighscientificrigorisrequiredforthesolutionsprovided,aswellasthe
extensionoftheinstrumenttomedicalpractice.SeriousgamesforpeoplewithPDshould
beadaptabletotheuniqueneedsandabilitiesofeachindividualplayer,easy,andintelli‐
gent.Thiscouldincludeoptionstoadjustthegame’sdifficultylevel,controloptions,and
othersettingstoaccommodateforthephysicalandcognitivelimitationsthatmaybeas‐
sociatedwithPD.Thegamesshouldalsobeeasytounderstandandnavigate,withclear
instructionsandsimpleinterfacestominimizeconfusionandfrustration.Thiscanhelpto
ensurethatplayersareabletofocusonthetherapeuticaspectsofthegameratherthan
strugglingwiththemechanicsofplaying.Finally,seriousgamesforParkinson’sDisease
shouldbeintelligent,usingdataandanalyticstotrackprogressandadjustthegame’s
difficultylevelorotheraspectsasneeded.Thiscanhelptoensurethatplayersare

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challengedattheappropriatelevel,andthatthegamecontinuestobeeffectiveovertime
astheplayer’sconditionchanges.Additionally,thesegamesshouldalsobeabletopro‐
videfeedbacktothetherapistorcaretaker,sothattheycanmonitortheplayer’sprogress
andadapttheirtreatmentaccordingly.
Study[35]assessedtheeffectivenessofseriousgamesforstrokerehabilitation.In
addition,independentofthedeviceutilized,welookedatwhetheradheringtoneuroreha‐
bilitationprinciplesaffectstheefficacyofgamesespeciallyintendedforrehabilitation.
Whencomparedtotraditionaltherapy,ameta‐analysisof42studieswith1760individu‐
alsfoundthatseriousgaminginterventionshadgreaterresults.Thismeta‐analysisfound
thatrehabilitationusingseriousgames,aimedtowardsrecoveryafterstroke,resultsin
superiorgainsinthreeInternationalClassificationofFunctioning,DisabilityandHealth
(ICF‐WHO)componentscomparedwithstandardtherapy.Seriousgamesaremoreeffec‐
tivewhentheyconformtoaunifiedsetofneurorehabilitationprinciples,regardlessofthe
technologyinstrumentemployed.Thecollectedsetofneurorehabilitationprinciples
shouldbeconsideredinthefuturedevelopmentofstroke‐specificrehabilitationtherapies.
Study[38]analyzedseriousgamesinpsychotherapyandpsychosomaticrehabilita‐
tion.Publicationsthatdidnotincludeempiricalevidenceonefficacywerenotincluded.
TheresultsofN=15researchsatisfiedtheinclusioncriteriabasedonthissystematiclit‐
eraturereview.Theylargelyusedcognitivebehavioralapproaches,whichmaybeusedto
treatavarietyofmentalillnesses.Seriousgamesworkwellasastandaloneintervention
oraspartofpsychotherapy,andtheyappealtopatientsofallagesandgenders.Serious
gameswerefoundtohaveabeneficialtherapeuticcomponent.However,thefindingsare
inconclusive,andfurtherstudyisneededtobetterunderstandtheusefulnessofserious
gamesforpsychotherapy.
Study[41]analyzednewdataontheefficacyofexergamingforPDrehabilitationand
presentsanoverviewofcurrentresearchonexergame‐basedtherapyinPDpatients.
Therewere64publicationschosen.Theresultsofthelastreviewrevealedthatpotential
improvementsinmotorabilitieshadoccurred.MicrosoftKinectandtheWiiBalance
Boardwerefoundtobesafeandfeasibleinpilottrials.Bothdevices’balanceandgaitdata
wereshowntobereliableintechnicalstudies.Relatedmeta‐analysesandsystematicre‐
viewsbackuptheseclaims,highlightingthenecessityforpatientskilladaptionaswellas
theuseofnovelinputdevicesandsensorsasdiscoveredgaps.Exergame‐basedtherapy
hasbeenshowntobeviable,safe,andsuccessfulinthetreatmentofPD.
Study[42]analyzedengagementandmuscletraining,withvirtualtrainingsoftware
forupperlimbprostheticrehabilitationeitherfocusedongamedesignelementsorona
realisticportrayalofprosthetictrainingactivitiestoencouragetask‐specificskilltransfer.
Previousresearchhasshownthatwithoutatransfer‐enablingtaskstructure,muscletrain‐
ingalonedoesnotresultinenhancedprosthesiscontrol.However,therehasbeenasig‐
nificantincreaseinthenumberofgame‐basedprosthesistrainingaids,whichemphasize
participationratherthanskilltransmission.Theavailabilityofcommerciallyavailableac‐
quisitiondevicesandpubliclyavailablegamedevelopmenttoolsforcreatingserious
gamesforprosthesistrainingimpactedthisflood.
Study[59]describedthekeyresultsfromtheevaluationofcurrentgamesforstroke
recovery,includingmeaningfulplay,failurehandling,emphasisondifficulty,andthe
needoffeedback.Theauthorsconcludewithasetofdesignsuggestionsforfutureserious
gamecreatorstothinkaboutwhencreatinginterfacesforstrokevictims.Thisstudyshows
thatusinggamingtechnologyforstrokerehabilitationisaneffectiveinteractiveapproach.
Seriousgamesprovidethepossibilityoffullycustomizableandcontextualizedgaming.
Theanalysisalsoarguesthatencouragingchallengeandrecoveryfromerrorsareuseful
characteristicstohaveinseriousgamesforrehabilitation.
Study[60]gaveanexaminationoftheinfluenceofSGonneurorehabilitationtherapy
andpatientopinionsonrehabilitation.Thisevaluationincluded47papersthatlookedat
theuseofexperimentalseriousgamesandcommerciallyproducedseriousgames(CSGs)
forrehabilitationinavarietyofneurologicaldiseases.TheNintendoWiiwasusedbythe

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majorityofCSGsasasupplementtotraditionaltherapy.In35investigations,significant
improvementsinkeyoutcomessuchasmotorperformance,balance,executive,andcog‐
nitivefunctionswereidentified.Inaddition,17piecesofresearchrevealedpatientview‐
pointsonrehabilitation.Accordingtothefindings,SGsareeffectiveexergameinstru‐
ments.
Study[56]examinedtheeffectsofwearabletechnologiesandseriousgamesusedin
therehabilitationofindividualswithsevereboneandsofttissueinjuriesonfunctional
resultsandtreatmentadherence.Onlytwopiecesofresearchrevealedthatseriousgames
hadfavorablebenefitswhencomparedtotraditionaltherapy.Inoneoffiveexperiments
thatlookedattreatmentadherence,thegaminggrouphadastatisticallysignificantbenefit
overtraditionalphysiotherapy.Thepoolingofdatawasnotpossibleduetodifferencesin
researchdesignandoutcomemeasures.Aftercatastrophicboneandsofttissueinjuries,
seriousgamesappeartobeasafealternativeorasupplementtotraditionaltreatment.
Theirvalidityandefficacyinrehabilitationtherapy,aswellastheircost‐efficiencyand
influenceontreatmentadherence,shouldbeinvestigatedmoreinthefuture.
Study[69]examinedtheassociationbetweenthequalitiesofseriousgames(SGs)and
thetherapeuticoutcomesoftrialsthatusedgamestohelppatientswhohadcerebralpalsy
ormultiplesclerosisorhadhadstrokes.Theyfound12studiesthatevaluatedmotor,sen‐
sory,andfunctionalfunctions,aswellasoverallhealthoutcomesincertaincases.Upper‐
limbmotorrehabilitationwasachievedbygame‐basedinterventions.Sixgamesfromcas‐
ualSGs,onecombinationofcasual,simulation,andexergamingSGs,andtwomixed
sportsandsimulationSGsallshowedsubstantialgainsinatleastoneclinicalassessment.
Casualgameswithafirst‐personperspective,novisibleplayercharacter,single‐player
mode,andnon‐immersiveVRhadthegreatesttherapeuticeffects.
Study[61]investigatedtheuseofseriousgamesintherehabilitationofpeoplewith
neuromotorimpairmentsoftheupperlimbresultingin38researchpapers.Thisstudy
examines35distinctgamingsystems.Onlyeightofthethirty‐eightpublicationsinthis
evaluationcompletedaclinicaltrial,andonlytwenty‐oneofthemreportedbenefitsinthe
targetpopulationafterusingthegamesandplatforms.Asaresult,intherehabilitation
sector,anewparadigmisemerging,characterizedbythesystematicuseofelectronicgam‐
ingplatformswithseriousgamesin/forrehabilitation.Seriousgamesandgamingplat‐
formsforupperlimbrehabilitationareusheringinanewrehabilitationparadigm.More
researchisneededtofullyintegratethesetechnologiesintherehabilitationindustry.
Study[65]studiedgamedesignaspectstoaidintherehabilitationofpatientswith
shouldermusculoskeletalproblems.Therewere31articlesintotal,publishedbetween
2006and2019.Points,tasks,andavatarswerethemost‐often‐utilizedgamecomponents.
Collectionsandteams,whicharemorecomplicatedgamecomponents,wererarelyem‐
ployed.Therewerejustafewsystemsthatusedgamedesignaspectstoassistsubjects
withmusculoskeletalillnessesoftheshoulderinrehabilitation.Exergamesallowself‐ex‐
ercisinginalmostallapplicationplatforms.Patients’uniquecharacteristicsarefrequently
overlooked.Motivationalgamedesigncomponentsthatareincorporatedintoagameto
encourageplayerstoengageandcontinueplaying(suchaspoints,levels,achievements,
andleaderboards)basedonpatient‐specificcharacteristicsarenecessaryaspartofaho‐
listicstrategytoimproverehabilitationadherence.
Study[62]outlinedthepresentstateofknowledgeongamifiede‐Healthapplications,
investigatedthevariousgamificationtacticsusedine‐Health,anddiscussedtheprosand
drawbacksofthisnewfield.After,46studiesfromvarioussourceswereevaluated.Most
ofthepublicationsincludedinthisstudydiscussedSSGinhealthandwell‐beingareas
suchaschronicillnessrehabilitation,physicalexercise,andmentalhealth.Inthissector,
thereisstillascarcityofreliableempiricalevidence.Furthermore,mostofthee‐Health
appsandseriousgamesstudiedhavebeenshowntoprovideonlyshort‐termengagement
throughexplicitreinforcement.Torealizethefullcapabilitiesofgamification,e‐Health
solutionsmustbebuiltonwell‐foundedtheoriesthatharnessthefundamentalexperi‐
encesandpsychologicalconsequencesofgamemechanics.

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Study[66]examinedtheuseofseriousgameprinciplesinsocialemotionalcomputer‐
basedinterventions(CBI)forautisticpeopleandassessedtheeffectivenessofthesecon‐
ceptsinimprovingsocialemotionaloutcomes.Databasesearchesturnedup34paperson
socialemotionalCBI,with17controlledstudies.Thefiveseriousgameconceptswere
usedtosummarizethequalitiesofeachCBI:compellingplot,goal‐directedlearning,in‐
centivesandfeedback,escalatinglevelsofdifficulty,andindividualization.Thefindings
indicatedthatautisticpeoplehavealimited(45%)integrationofseriousgameconceptsin
socialemotionalCBI.Theseriousgamedesignframeworkcanhelptoguidethedevelop‐
mentofsocialemotionalCBI,whichcanhelpautisticpeopletoimprovetheirsocialemo‐
tionalabilities.
4.3.VirtualRealityGames
Study[25]examinedhowvisionaryseriousgamesandVRtechnologiesareusedin
motorrehabilitationprograms.Therewere86studiesfound.Themostoftenutilizedtech‐
nologyinexploringtheimpactofvision‐basedseriousgamesandVRsystemsonrehabil‐
itationisKinect.Thefindingsalsoimplythatpatientswithcerebralpalsyandwhohave
hadstrokesaretheprimarytargetcategories,withanemphasisonolderindividualsin
thiscategory.Mostoftheresearchfocusedonposturecontrolandupperlimbworkouts,
andtheyemployedavarietyofmetricstoassessthem.Despitetheincreasedinterestin
thisfieldamongresearchers,manystudieslackadequateclarityandarenotstandardized.
Instudy[49],thecurrentcognitiontests,VRapps,andseriousgamesincognitive
assessmentandtherapyforneurocognitivedisorderswereanalyzedtoevaluatethecur‐
rentstateoftheartincognitiveassessmentformajorneurocognitivedisorders(NCDs),
suchasAlzheimer’sdisease(AD),themostcommongeriatricmajorNCD,andthenit
brieflylookedaheadatthepotentialapplicationsofVRtechnologiesinNCDassessment
andcognitiontraininginasimulated3Denvironment,andforthealleviationofcognitive
disordersymptoms.TheVR‐basedtechnologies,wefeel,offerenormouspotentialincog‐
nitiveevaluationandnon‐pharmacologicaltreatmentforsevereNCDs.
Study[57]examinedandclassifiedtheinfluenceofVRtechnologyon46gamified
appswithseriousgoals.OurfindingsimplythatimmersiveVRenhancessimulationout‐
comes,suchaslearningacquisitionandinformationretention,aswellasclinicalrehabili‐
tationoutcomes.Itdoes,however,havedrawbacks,suchasmotionsicknessandlimited
accesstoVRdevices.Thestudycontributedbyprovidingclearerknowledgeofthebene‐
fitsandconstraintsofutilizingVRtechnologyinserioussimulations,ataxonomyforcat‐
egorizingthem,andadiscussionofwhethermethodologiesandparticipantprofilesim‐
pactresults.
Study[24]examinedthehistoryandqualityofclinicalresearchonVR‐basedserious
games.TheadoptionofseriousVRgameshasdemonstratedefficacyinimprovingupper
limbtelerehabilitation(TR)followingstrokes,althoughtheevidencequalityisstillpoor
duetoalackofrandomizedcontrolledtrials(RCTs),fewsubjects,anddiversesamples.
VRgamesareapotentiallyusefultechniqueforsupplementingtraditionalrehabilitation,
butfurtherresearchisneededtoreinforcetheproofofsuccessandencouragethespread
oftheproposedsolutions.
4.4.VideoGames
Study[28]analyzedandevaluatedgame‐baseddietarytreatmentsforchildren.The
focuswasonwhetherthegame‐basedtechniqueshelpedyoungpeopletoimprovetheir
eatinghabits,whatthemosteffectivegameelementswere,andhowgame‐basedtech‐
niqueshelpyoungpeopletoaltertheireatinghabits.Thereare43piecesofresearchthat
havebeendiscoveredwhichimprovefruitandvegetableconsumption,changesnacking
behavior,stimulatefooddiscovery,andpromotehealthyeating.Seriousgamesthatfocus
onfoodeducationcanhelpchildrentodevelophealthyeatinghabitsbyincreasingtheir
knowledgeandpositiveattitudestowardsfruitsandvegetables.Thesegamescanalso
encouragechildrentotrynewfoodsandreducepickyeatinghabits.Ontheotherhand,

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gamesthatpromoteunhealthysnacksmayleadtoanincreaseinunhealthysnackcon‐
sumptionamongchildren.Toinspireandinvolveyoungpeopleindevelopinggoodeat‐
inghabits,amixofstorycontext,feedback,progress,andchallengewaswidelyemployed.
Study[33]investigatedtheeffectivenessofseriousgamesinimprovingknowledge
and/orbehavioralimprovementsinoverweightandobeseyoungpeople.Thefinalsample
includedsixstudies.Thearticlesaimedtoencouragegamerstomakepositivebehavioral
changes,suchasincreasedphysicalactivityandbettereatinghabits.Usingseriousgames
asatechniquecanbeeffectiveinpromotinghealthybehaviorsandcopingstrategiesfor
childrenandadolescentswhoarestrugglingwithobesity.Seriousgamesareanalternate
waytogivehealtheducationtochildren,andresearchinthissubjectisanincreasingand
promisingtechnique.
Study[34]analyzedseriousgamestotreatand/orpreventchildhoodobesity.The
searchyielded466studies,with17beingchosenforexamination.Seriousgamesforhealth
promotionmighthaveagoodimpactonchildren’shealth,inducebehaviorchanges,and
promotehealthybehaviors.Seriousgamescanbeausefultechniqueforchildren’shealth
education.Givenchildren’susageoftechnology,thesetoolsmaymodifythepublic’sbe‐
haviorwithrelationtojuvenileobesity.
Study[40]investigatedtheapplicationofvariousartificialintelligencealgorithms
linkedtodecisionmakingandlearning.Toclassify129papersthatmatchedtheinclusion
requirements,aclassificationsystemwascreatedanddefined.Theauthorsusedthisclas‐
sificationsystemtoreachsomefindingsabouthowintelligentseriousgamesarereally
used.Theauthorsbelievethatenoughinformationhasbeenacquiredinrecentyearsto
designnewintelligentseriousgamesthatconsidernotonlytheendgoalbutalsothetech‐
nologyandtacticsemployedtogiveplayersavirtuallygenuineexperience.However,to
ensurethatproducedseriousgamesaccomplishtheirintendedgoals,researchersmay
needtoenhancetheirtestingapproach.
Study[70]examinedtheresearchontheeffectsandmodalitiesofusingvideogames
foremotionalregulation(ER).Thereviewcomprised23papers,whichweredividedinto
threecategories:(1)cross‐sectionalandqualitativestudies,(2)studiesontheimpactof
videogameexperienceonER,and(3)ERinterventionusingseriousgames.Alimitedtime
ofplaying,suchasthatenabledbyseriousgames,gavelesspotentialforERimprovement
thanfrequentgamingwithcommercialgames(connectedtogameplayandpleasureof
fictitiousproperties).Thisfieldofstudyisstillinitsinfancy;thus,resultsshouldbeeval‐
uatedwithcaution.Moreover,futureevaluationsshouldincludeclinicalpopulations.
VideogamesprovideavarietyofERoptionsaswellasachallengeforeducationaland
psychosocialsolutions.
4.5.GamesforEducation
Study[21]soughttofindseriousgamesthateducatepatientsontheissuesofmedi‐
cationadherence,education,andsafety,aswellastheoreticalframeworksfordeveloping
seriousgamesformedicationuseandsampleframesforassessingseriousgamesonmed‐
icationusage.Therewere16trialswith12seriousgamescontainingelementsofmedica‐
tionadherence,education,andsafety.Existingevaluationsinvestigateseriousgamesthat
focusondiseasemanagement,suchasdiabetes,HIV,andasthma,aswellasthebeneficial
impactofseriousgameteaching.Seriousgamesshouldspecifythetheoreticalframework
includedintogamedesign,andsuccessshouldbemeasuredbytheplayer’sabilitytore‐
tainlearningobjectives.
Study[37]analyzedarticlesaboutseriousgamesdevelopedtoteachpatientsandthe
publiconasthmaandevaluatedtheirinfluenceonpatientknowledge,behavior,and
asthmadiseaseoutcomes.Twelvearticleswereidentifiedasbeingrelevant,eachdescrib‐
ingtenseriousgames.Eightgamesforchildrenwithasthmaandtwoforschool‐based
interventionwereincludedintheseriousgames.Mostoftheseriousgameswerelinked
tohighlevelsofenjoymentandknowledgeimprovementinyoungpeople.Sevenstudies
comparedtheeffectsofseriousgamesonmedicaloutcomestocontrolgroupsand

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discoverednosignificantdifferences,whilefewchangesinbehaviorsormedicalout‐
comeshaveoccurred.
Study[44]examinedtheevidenceforusingtheRETAINseriousgametoimprove
newbornresuscitationinstruction.Therewerethreearticlesandoneconferenceproceed‐
ingfound.TheRETAINboardgamewasdescribedintwostudies,whiletheRETAIN
computergamewasdescribedintwoinvestigations.RETAINwasdescribedastherapeu‐
ticallyusefulandrelevant.RETAINalsoservedasasummativeevaluationandenhanced
theknowledgeofnewbornresuscitation.RETAINisatoolthatmaybeusedtoteachand
assessexperiencedneonatalresuscitationclinicians.
Study[43]reviewedtheexistingliteratureonseriousgamesandhowtheymighthelp
neonatalhealthcareworkersretaininformationandabilities.Thisreviewincludestwelve
seriousgames(fivevideogames,fourboardgames,andthreeVRgames).TheRETAIN
boardgameandneonatologygamebothshowedimprovementsinknowledge.Toim‐
provetheoreticalandpracticallearning,seriousgamesaremorecommonlybeingintro‐
ducedintomedicalschoolcurricula.Seriousgamescanincreasehealthcarepersonnels’
knowledge,abilities,andadherencetotheresuscitationprotocol,aswellasimproveac‐
cesstoSBEinbothresource‐richandresource‐poorsettings.Importantclinicaloutcomes
innewbornsshouldbethefocusoffuturestudy.
Study[45]exploredtheeducationaltacticsusedbygamedeveloperswhilebuilding
medicaleducationgames,andhowgoodtheevidenceisfortheeffectivenessofgames.
Eventhoughgamecreatorssaythatgamesaregreatteachingaids,thedataaremixed.
Gamesarecomplementingtoolsthatdonotsupplantclassicalpedagogicalmethods,and
behaviorismandcognitivismremainthemostcommoninstructionalapproaches.Medical
educatorsdonotrequiretheuseofcomplexgamesintheircourses,preferringsimulations
andteststhatfocusoninformationretentionandskillimprovementviarepetition.The
real‐lifeuseofgamesiscontingentonthequalityoftheevidencesupportingtheirsuccess.
Study[46]evaluatedtheefficacyofseriousgamesforprofessionalhealtheducation
in25studies.Sixteenstudentshadbothapre‐andpost‐test,andallofthemimproved
significantlyintheirlearningscoresafterusingseriousgames.Eighteenstudiespublished
controlledtrials,wherebyfourteenofwhichfoundthatfollowingseriousgames,post‐test
resultswereconsiderablyhigherthanwithtraditionalteachingapproaches.Thestudy
foundalackofintegrationofemotionallearningwithotherabilities,andarequirement
forseriousgamespreparedpeopleforpostgraduateeducation.Seriousgamesappearto
beeffectiveforshort‐termlearning.Beforemakinggeneralizableconclusiveassertions,
additionalcompetencesandhealthprofessionalsmustbeaddressedacrosstheschoolcon‐
tinuum.
Study[53]synthesizedtheevidenceontheefficacyofSGsinincreasingengagement
andenhancinglearningoutcomesinhealthcareprofessioneducation.BetweenJanuary
2005andApril2019,37randomizedcontrolledtrials(RCTs)werediscovered,with29of
thembeingincludedinrandom‐effectmeta‐analyses.SGsdidnotresultinlongertime
spentwiththeintervention,higherinformationacquisition,cognitiveandskillsdevelop‐
ment,attitudechange,orbehaviorchangewhencomparedtoothereducationalinterven‐
tions,buttherewasminimalevidenceforSGswithregardtoboostingskillconfidence.
Study[54]evaluatedandsynthesizedthebestavailableinformationontheeffective‐
nessofSGsandtheinfluenceofDEsonhealthcareprofessionals’andstudents’involve‐
mentandeducationalresults.
Study[55]collectedpapersonSSGpublishedbetween2015and2020,withanem‐
phasisontheirapplications:detection,prevention,therapyandawareness,tostudytool
deployment,development,andevaluationfortrends,strengths,andflaws.Thefollowing
criteriawereusedtofilterthepapers:SSGforpersonalcomputer(PC),smartphone,or
VR;forchildrenandadolescents;andfordepression,anxiety,orboth.SSGforPC,
smartphone,andVRdeviceswerecreatedin34piecesofresearchandtestedinadoles‐
centsandchildren.Mostgamesareusedforpreventionandtreatment.Anxietyismore
prevalentinchildhood,whereasdepressionismoreprevalentinadolescence.More

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awarenessanddetectiongamesthatincludeawareness,prevention,detection,andthera‐
peuticapplicationsareneeded.Gamesshouldappealtopeopleofallages.SSGdevelop‐
mentandassessmentshouldbeharmonized.
Study[58]discussedtheadoptionofseriousgamestoteachyoungpeopleabout
mouthhygiene,aswellashuntedforapplicationsthatservedthesameobjective.Twelve
articleswerechosen,11gamesweredesignatedasseriousgamesfocusedonoralhealth,
and284applicationswerefoundonthePlayStore,withamajoritysurroundinginterven‐
tionistactionindentalclinicswiththeprimaryplotsbeingpain,toothcavity,andtrauma.
Therearejustafewappsdedicatedtooralhygieneinstruction.Thereisalargepresence
ofachildren’saudienceamongtheintendedaudience.Despitethepaucityofpublications
ontheissue,investigatingelectronicresourcesasinstructionalchoicesforchildren’soral
hygienesuggestsafieldofstudywithacademicpromiseandprospectivepublichealth
implications.
Study[64]reviewedthescientificdataontheuseofseriousgamestoteachcardio‐
pulmonaryresuscitationtohealthstudents.Theauthorsfoundeightstudiesanddivided
themintotwocategories:thestudy’spurposeinrelationtocardiopulmonaryresuscitation
usingseriousgames,andtheseriousgame’sapproachtoteachingcardiopulmonaryre‐
suscitation(CPR).Theprimarytargetforseriousgamelearningismedicalstudents,and
thegames’primarygoalsaretoevaluatetheireffectivenesswithregardtoestablished
approachesandinformationretention.
Study[73]analyzedarticlesrelatedtotheadoptionofseriousgamesineducation
anddiscussednumerouselementsthatimpactedtheeffectsofserious‐gaming‐assisted
learning.Themainportiondiscussedthebenefitsanddrawbacksofusingseriousgames
inteaching.Attitudesabouttheapplicationofseriousgamesineducation,aswellasthe
newgrowthofseriousgameusageineducation,wereinvestigated.Thestudyunderlined
theneedforinterdisciplinarycollaborationinfuturetheoreticalandpracticalexploration.
4.6.GamesforMentalDisorders
Study[29]aimedtoprovideacompletepictureoftheevidenceofseriousgamesfor
health‐aimedbehavioralchangeinadolescentsandchildren.Therewere34studiesthat
investigatedtheeffectivenessofseriousgamesinpromotingmentalhealthandchanging
health‐relatedbehaviorsinchildrenandadolescents.Thedataevidencingtheuseofseri‐
ousgamesinadolescentsandchildrenforthepromotionofhealthremainlimited.Given
thepublicationbias,theseresultsshouldbeviewedwithcare.Beforewecanmakefirm
conclusions,weneedmoreresearchthatisproperlyconductedandthatexamineswell‐
definedseriousgames.
Study[31]analyzedhowend‐userengagementinthedesignanddecision‐making
processaffectsgameeffectiveness.Usersareintroducedinallphasesoftheprocess,in‐
cludingplanning,creating,andtestingtheseriousgame,inuser‐centereddesignorpar‐
ticipatorydesign.Thegoalofthisstudywastoseehowmanypublishedstudiesofserious
gamesthatareintendedtopreventorcuredepressionandanxietyhaveusedthepartici‐
patorydesignframework.
Study[50]examinedclinicalresearchthatfocusedontheadoptionofseriousgames
inchildrenwithdevelopmentalimpairments.Thebulkofthe145piecesofresearchwas
onautismspectrumdisorder(ASD),andrelatedintellectualimpairments.Arandomized
designwasreportedin30ofthe145investigations.Theauthorsfoundencouragingout‐
comesintheareasofanxietyreduction,stressmanagement,emotionidentification,and
rehabilitation.Currently,thereisapaucityofclinicalevidencethatseriousgamescanaid
childrenwithneurodevelopmentalissues.
Study[39]studiedseriousgamesforpersonswithmentalillnesses,includingAlz‐
heimer’s,ADHD,ASD,dementia,MCI,PTSD,andschizophrenia,aswellasthemany
waysutilizedtomakethegamesavailabletotheintendedplayers.Toavoidtheplayer
beingdisoriented,thebasicaimistoreducethequantityofstimulipresentatthesame
time.Reducingstimulishouldbeinherenttothegame(bypresentingaverybasicgame),

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anditshouldbeadjustable(throughamenuofselections),anddynamic(byadjustingthe
quantityofstimuli,orasystemthatadjustsitselfautomatically).
4.7.OtherGames
Study[26]synthesizedandintegratedallpreviousresearchandmaterialongamifi‐
cationandseriousgames,appraisingthepresentstateoftheartinthearea,andfillinga
gapintheliteratureonthesubject.Themostimportantdeterminantsofintentiontoadopt
ingamificationareattitude,enjoyment,andutility.Themostimportantdeterminantsof
abrand’sattitudetowardgamificationareintent,enjoyment,andutility.Thefindingsen‐
ableustoproposeatheoreticalmodelthatwillaidfuturegamificationresearch.
Study[52]studiedtheimpactofseveregamesonsignsofmentalillness.Thereview
containedtenpapersthatfulfilledtheinclusioncriteria,whilethemeta‐analysiscom‐
prisedninepiecesofresearch.Theinvestigationswereconductedonpeopleagedfrom7
to80years.Theseriousgamesemployedgoal‐orientedandcognitivetraininggamesto
addresssymptomsofdepression(2),post‐traumaticstressdisorder(2),autisticspectrum
disorder(2),attentiondeficithyperactivitydisorder(1),cognitivefunctioning(2),andal‐
cohol‐consumingdisorder(1).Thefindingsshowthatgamingtherapiesmighthelpthose
withdisordersymptoms.Moreresearchissoughttohaveabetterunderstandingofthe
usefulnessofgamesforcertainmentaldiseasesandtheirlong‐termimpacts.
Study[67]explainedtheconceptualaspectsofthecurrentresearchonseriousgames
aimingtopromotecognitiveandbehavioraloutcomesinindividualswithchronicdis‐
eases.Thereviewincludesatotalof38papers.Thepresentlandscapeofseriousgame
researchforhealthfocusingonbehavioralandcognitiveoutcomesinpeoplewithchronic
illnessisdefinedinthisscopingstudy.Awiderangeofpatientdemographicsandpatient
outcomeshavebeenstudied.Tofurtherexplaintheactivecomponentsandprocessesof
seriousgames,researchersthatwanttoimproveuponthepresentstudyshouldincorpo‐
ratetheoreticalmodelsintotheinterventionandtrialdesignprocess.
5.Findings
5.1.AnswerstoResearchQuestions
RQ1.Whatarethemostcommonhealthconditionsthatseriousgamesandgamifica‐
tiontechniqueshavebeenusedtoaddress?
Seriousgamesandgamificationtechniqueshavebeenusedtoaddressawiderange
ofhealthconditions.Themostcommonhealthconditionsthathavebeenstudiedinclude
thefollowing:
1. Chronicconditionssuchasdiabetes[21,48],heartdisease,andcancer,whichoften
requirelong‐termself‐managementandlifestylechanges.
2. Mentalhealthconditionssuchasdepression[31,49,52,55]andanxiety[31,50,55],
whichofteninvolveaddressingnegativethoughtsandbehaviors.
3. Physicalrehabilitation,especiallyforpatientswithtraumainjuries[22,42,56]orneu‐
rologicalconditions[60,65]thataffecttheirmobility.
4. Substanceabuse,especiallyintermsofaddictiontoalcohol[32]anddrugs.
5. Smokingcessation[32].
6. Eatingdisorders[28,33]andobesity[33,34].
7. Geriatriccare,especiallyintermsofpromotinghealthyagingandpreventingcogni‐
tivedecline(e.g.,duetoAlzheimer’sdisease)[49].
8. Painmanagement,especiallyintermsofchronicpainpatients[56].
9. AsthmaandCOPDmanagement[21,37].
RQ2.Whatarethemostcommongamemechanicsanddesignelementsusedinseri‐
ousgamesandgamificationforhealth?
Themostcommongamemechanicsanddesignelementsusedinseriousgamesand
gamificationforhealthincludethefollowing:

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1. Points,badges,andleaderboardswhichareusedtoprovidefeedbackonprogress,
andtocreateasenseofcompetitionandaccomplishment[54].
2. Questsandchallengeswhichareusedtocreateasenseofpurpose,andtoprovide
structurefortheplayer’sexperience[28].
3. Storytellingandnarrativeswhichareusedtocreateasenseofimmersion,andto
providecontextandmeaningfortheplayer’sactions[28,54,66].
4. Virtualrewardsandincentiveswhichareusedtomotivateplayerstoengageinde‐
siredbehaviors,suchasexercisingortakingmedication[28].
5. Personalizationandtailoringwhichareusedtoadaptthegameorgamificationex‐
periencetothespecificneedsandpreferencesoftheplayer.
6. Socialconnectionsandcollaborationwhichareusedtocreateasenseofcommunity
andtofostersocialsupport[55,66].
7. Feedbackandcoachingwhichareusedtoprovideguidance,information,andfeed‐
backtohelpplayerstoimprovetheirskillsandknowledge[23,28,66].
8. Virtualrealityandimmersivetechnologieswhichareusedtocreateasenseofim‐
mersionandtoprovideanengagingexperiencefortheplayers
[24,25,30,44,49,55,57,69].
9. Game‐basedassessmentsandadaptivetestingwhichareusedtoassessplayers’
skills,knowledge,andprogress[44,49].
10. Gamifiedenvironmentsandsettingswhichareusedtocreateasenseofimmersion
andtoprovideanengagingexperiencefortheplayers[54,62].
Notethattheeffectivenessofthesegamemechanicsanddesignelementsfordifferent
healthconditionsandpopulationsmayvaryandmoreresearchisneededtofullyunder‐
standtheirpotentialandlimitations.
RQ3.Whatistheevidencefortheeffectivenessofseriousgamesandgamificationin
promotingpositivehealthoutcomes?
Theevidencefortheeffectivenessofseriousgamesandgamificationinpromoting
positivehealthoutcomesisstillemerging,butitisgrowing.Studieshaveshownthatse‐
riousgamesandgamificationtechniquescanbeeffectiveinpromotingpositivehealth
outcomes,suchasimprovedphysicalactivity[62],healthyeating[28],andsmokingces‐
sation[32],aswellasimprovedmentalhealthoutcomes,suchasreduceddepression[31]
andanxiety[31,55].
Studieshavealsoshownthatseriousgamesandgamificationtechniquescanbeef‐
fectiveinpromotingmedicationadherence[21],theself‐managementofchroniccondi‐
tions[67],andrehabilitationoutcomes[22–25,27,30,35,41,42,56,60,61,65,69].
Notethattheeffectivenessofseriousgamesandgamificationforpromotingpositive
healthoutcomescanvarydependingonthespecifichealthcondition,population,andthe
designofthegameorgamificationintervention.Additionally,itisimportanttonotethat
whilesomestudieshaveshownpositiveresults[29,32,46,48,56,60,69],otherstudieshave
notfoundsignificanteffects[37,66].
Asaresult,moreresearchisneededtofullyunderstandtheunderlyingmechanisms
ofactionofseriousgamesandgamificationinpromotingpositivehealthoutcomes,and
toidentifythespecificgamemechanicsanddesignelementsthataremosteffectivefor
differenthealthconditionsandpopulations.
5.2.Limitations
Thereviewstudy’sselectionprocedureanddataextractionaretwopossiblere‐
strictions.Evenifasystematicsearchandfurthersearcheswereconducted,itisprobable
thatnotallrelevantmaterialwasdiscovered.Becauseitwasimpossibletoexaminethe
resultslinkedtohealthanddigitalgamesindependently,somematerialhadtobeelimi‐
nated.Thesechoicesmayhaveresultedinalossofcriticaldata.Therewasconsiderable
overlapbetweenthesystematicreviewsandreviewsthatwereincluded,whichmayhave
hadasignificantimpactonourfindings.

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Finally,themeta‐analysisrevealsthatafewpublicationswhichanalyzedthesurvey
papersweredisruptive(i.e.,challengedexistingparadigms,introducednewideasor
methods,orfundamentallychangedthewaywethinkaboutaparticularfield)[79]and
hadasignificantimpactonsubsequentdevelopmentsintheresearchfield.Between2017
and2021,therewerejustafewarticleswithmoderateimpact(approximately100–200
averagecitationsperyearsincepublication).
6.ResearchGaps,Trends,Challenges,andFutureDirections
6.1.ResearchGaps
Thefieldofseriousgamesandgamificationforhealthisarapidlygrowinganddy‐
namicareaofresearch;however,therearestillseveralresearchgapsthatneedtobead‐
dressed.Thecurrentresearchgapsinthisfieldinclude:
1. Lackofstandardization[23,25,59]inthedevelopmentandevaluationofserious
gamesandgamificationapplicationsforhealth,makingitdifficulttocompareand
replicatestudiesandleadingtoinconsistentresultsandconclusions.
2. Insufficientunderstandingoftheunderlyingmechanismsofaction[62,67]ofserious
gamesandgamificationinpromotingpositivehealthoutcomes.
3. Limitedunderstandingofhowtoeffectivelyintegrateseriousgamesandgamifica‐
tionintoexistinghealthcaresystems[47,61,66]andhowtomeasuretheeffectiveness
oftheintegration.
4. Limitedunderstandingofthespecificgamemechanicsanddesignelementsthatare
mosteffectiveforpromotingdifferenthealthbehaviorsandoutcomes
[31,54,56,70,72].
5. Insufficientevaluationandvalidationofseriousgamesandgamificationapplications
forhealth,particularlyintermsofdeterminingtheoptimaldosageanddurationof
treatment[30,65].
6. Limitedresearchonthescalabilityandsustainabilityofseriousgamesandgamifica‐
tionforhealthandhowtoincreasetheiradoptionbyhealthcareprovidersandpa‐
tients.Here,scalabilityisunderstoodastheabilityofthegameplatformtosupport
alargenumberofplayers.Sustainabilityisunderstoodastheabilityofthegameto
sustainplayerinterestinhealthybehaviorsandmotivatehim/hertocontinueplaying
[71].
7. Limitedresearchontheeffectivenessofseriousgamesandgamificationforspecific
populationgroups,suchasmarginalizedcommunities[80].
8. Limitedresearchontheethicalandlegalimplicationsofseriousgamesandgamifi‐
cationforhealth,andthepotentialrisksandbenefitsoftheseinterventions[81,82].
9. Limitedresearchonthecost‐effectivenessandeconomicbenefitsofseriousgames
andgamificationforhealth[56].
10. Limitedresearchonthelong‐termeffectsofseriousgamesandgamificationon
healthoutcomes[28,35,52,63].
Theseresearchgapshighlighttheneedforfurtherresearchtofullyunderstandthe
potentialandlimitationsofseriousgamesandgamificationforhealthandhowtoeffec‐
tivelyapplythemindifferentsettingsandfordifferenthealthconditions.
6.2.CurrentResearchChallenges
Thereareseveralcurrentresearchchallengesinthefieldofseriousgamesandgami‐
ficationforhealth.
Onemajorchallengeisthelackofstandardizationinthefield[23,25,59].Thereare
currentlynowidelyacceptedguidelinesorstandardsforthedevelopmentandevaluation
ofseriousgamesandgamificationapplicationsforhealth.Thismakesitdifficulttocom‐
pareandreplicatestudies,andcanleadtoinconsistentresultsandconclusions.
Anotherchallengeisthelackofrobustevaluationandvalidationofseriousgames
andgamificationtechniquesforhealth[30,65].Whilethereisagrowingbodyofevidence

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tosuggestthatthesetypesofinterventionscanbeeffective,thereisstillmuchworktobe
doneintermsofunderstandingtheunderlyingmechanismsofaction,identifyingthe
mosteffectivedesignelements,anddeterminingtheoptimaldosageanddurationoftreat‐
ment.
Additionally,thereisalackofunderstandingofhowseriousgamesandgamification
canbeeffectivelyintegratedintoexistinghealthcaresystemsandhowtomeasuretheef‐
fectivenessoftheintegration[47,61,66].Moreover,thereisstillalackofunderstandingof
thespecificgamemechanicsanddesignelementsthataremosteffectiveforpromoting
differenthealthbehaviorsandoutcomes.Forexample,someresearchershavefoundthat
certaingamemechanics,suchasrewardsandsocialcomparison,canbeeffectiveinpro‐
motingphysicalactivity,whileothershavefoundthatothermechanics,suchasstorytell‐
ingandsimulations,aremoreeffective.
Lastly,seriousgamesandgamificationapplicationsarestillnotwidelyadoptedby
healthcareprovidersandpatients[63].Thereisaneedformoreresearchonhowtoin‐
creasetheadoptionoftheseinterventionsandhowtoensurethattheyareusedinaway
thatisconsistentwiththebestpracticesinhealthcare.
6.3.CurrentTrendsofResearchinSeriousGamesandGamificationforHealth
Thefieldofseriousgamesandgamificationforhealthisarapidlygrowinganddy‐
namicareaofresearch.Basedonreviewstudiesanalyzedinthispaper,someofthemain
trendsinthefieldinclude:
1. Anincreasinguseofseriousgamesandgamificationtechniquesforawiderangeof
healthconditions,includingchronicconditionssuchasdiabetes[21,48]orasthma
[21,37,48],aswellasmentalhealthconditionssuchasdepressionandanxiety[31,52].
2. Growingrecognitionofthepotentialofseriousgamesandgamificationtopromote
healthybehaviorsandpreventtheonsetofchronichealthconditions,suchasthrough
promotingphysicalactivity[62,67],healthyeating[28],andsmokingcessation[32].
3. Ashifttowardstheuseofmobileanddigitalplatformsfordeliveringseriousgame
andgamificationinterventions[55],astheseplatformsareincreasinglyaccessible
andconvenientforpatientsandhealthcareproviders.
4. Anincreasinguseofvirtualrealityandotherimmersivetechnologiesinserious
gamesandgamification[24,25,30,43,49,55,57,69],asthesetechnologieshavethepo‐
tentialtoenhanceengagementandimmersionforplayers.
5. Agrowinguseofmachinelearningandotheradvancedtechnologies[40]toperson‐
alizeandadaptseriousgamesandgamificationinterventionstothespecificneeds
andpreferencesofindividualplayers.
6. Increasingrecognitionoftheneedforrigorousevaluationandvalidationofserious
gamesandgamificationtechniquesforhealth,tounderstandtheireffectiveness,the
underlyingmechanismsofaction,andtheoptimaldurationoftreatment[55].
7. Agrowingneedformoreresearchtoidentifyandunderstandthemosteffective
gamemechanicsanddesignelementsforpromotinghealthybehaviorsandoutcomes
[31,54,56,70,72].
8. Anincreasingfocusonunderstandinghowseriousgamesandgamificationcanbe
effectivelyintegratedintoexistinghealthcaresystemsandhowtomeasuretheeffec‐
tivenessoftheintegration[47,61,66].
9. Theemergenceofseriousgamesandgamificationapplicationsinpreventative
healthcare[32,55],withafocusonpromotinghealthybehaviors,preventingillnesses
andchronicconditions,andempoweringpatientswithself‐managementtools[65].
Thesetrendshighlighttheongoingprogressandthepotentialofthisfieldtomakea
positiveimpactonthehealthofpatientsandcommunities.


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6.4.FutureResearchDirections
Thefieldofseriousgamesandgamificationforhealthisarapidlygrowinganddy‐
namicareaofresearch.Theresultsofthissystematicmeta‐reviewindicatethatthereare
severalpromisingdirectionsforfutureresearchinthisarea.
Oneimportantareaforfutureresearchisthedevelopmentofmoreeffectiveanden‐
gagingseriousgamesandgamificationapplicationsforawiderangeofhealthconditions.
Thereisagrowingbodyofevidencetosuggestthatthesetypesofinterventionscanbe
highlyeffectiveinpromotingpositivehealthoutcomes,suchasimprovedpatientadher‐
encetotreatmentregimens,reducedsymptomsofcertainconditions,andincreasedphys‐
icalactivity[21,35,37,65].However,thereisstillmuchworktobedoneintermsofdevel‐
opinggamesandgamificationapplicationsthataretailoredtothespecificneedsofdiffer‐
entpatientpopulationsandthatcanbeeasilyintegratedintoexistinghealthcaresystems.
Anotherimportantareaforfutureresearchistheuseofseriousgamesandgamifica‐
tiontechniquestopromotehealthybehaviorsandpreventtheonsetofchronichealthcon‐
ditions[48,67].Forexample,thereisagrowingbodyofevidencetosuggestthatserious
gamesandgamificationcanbeeffectiveinpromotinghealthyeating,physicalactivity,
andsmokingcessation.However,thereisstillmuchworktobedoneintermsofidentify‐
ingthemosteffectivegamemechanicsanddesignelementsforpromotingthesebehav‐
iors,aswellasinunderstandinghowtheseinterventionscanbescaleduptoreachlarge
populations.
Additionally,thereisagrowingneedforrigorousevaluationandvalidationofseri‐
ousgamesandgamificationapplicationsforhealth.Whilemanystudiessuggestthat
thesetypesofinterventionscanbeeffective[48,51],thereisstillmuchworktobedonein
termsofunderstandingtheunderlyingmechanismsofaction,andidentifyingthemost
effectivegamedesignelementsandgamificationtechniques.
Finally,theethicalandprivacyimplicationsofseriousgamesandgamificationfor
healthareanimportantresearchdirection[83,84]thatneedstobeaddressedinthefuture.
Oneethicalimplicationistheprotectionofplayers’privacyandsensitiveinformation[81].
Seriousgamesandgamificationforhealthoftenrequireplayerstoprovidepersonalin‐
formation,suchashealthdata,anditisimportanttoensurethatthisinformationispro‐
tectedandusedinaresponsibleandtransparentmanner[82].Anotherethicalimplication
isthepotentialmanipulationofplayers’behaviorusinggamemechanicsanddesignele‐
ments.Itisimportanttoensurethattheseinterventionsaredesignedtopromotepositive
healthoutcomesratherthantoexploitplayersforcommercialorotherpurposes.Related
issuestobeaddressedareinformedconsentandtherighttoautonomy.Playersshouldbe
fullyinformedaboutthepotentialrisksandbenefitsoftheintervention,andshouldhave
thefreedomtochoosewhetherornottoparticipate.Furthermore,thereareimplications
relatedtotheaccessibility[39],inclusivedesign,andculturalappropriatenessofserious
gamesandgamificationforhealth.Itisimportanttoensurethattheseinterventionsare
accessibletoawiderangeofplayers,includingthosewithdisabilities,andthattheyare
culturallyappropriatefordifferentpopulationgroups,includingthemarginalizedcom‐
munities.
7.Conclusions
Thissystematicmeta‐reviewaimedtoanalyzeandextractthecurrentstateandthe
prevailingtrendsofthefieldofseriousgamesandgamification(SGG)forhealthbyana‐
lyzingandsummarizing53surveypapersonthetopic.ThereviewfollowedthePRISMA
guidelinesandusedconstructiveandcross‐sectionalmethodstoanalyzeandpresentthe
results.Thisreviewstudyhasfoundthatseriousgamesandgamificationtechniqueshave
beenusedtoaddressawiderangeofhealthconditions,includingchronicconditions,
mentalhealth,physicalrehabilitation,substanceabuse,smokingcessation,eatingdisor‐
dersandobesity,geriatriccare,painmanagement,asthmamanagement,andpreventive
care.Themostcommongamemechanicsanddesignelementsusedinseriousgamesand

Information2023,14,10527of31
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gamificationforhealthincludepoints,badges,leaderboards,questsandchallenges,sto‐
rytellingandnarratives,virtualrewardsandincentives,personalizationandtailoring,so‐
cialconnectionsandcollaboration,feedbackandcoaching,virtualrealityandimmersive
technologies,game‐basedassessmentsandadaptivetesting,andgamifiedenvironments
andsettings.
Thereviewhasalsofoundthatthereisevidencetosuggestthatseriousgamesand
gamificationcanbeeffectiveinpromotingpositivehealthoutcomes;however,morere‐
searchisneededtofullyunderstandtheirpotentialandlimitations,aswellasthespecific
gamemechanicsanddesignelementsthataremosteffectivefordifferenthealthcondi‐
tionsandpopulations.Additionally,thereviewrevealedthatthereareethicalandlegal
implicationsrelatedtoseriousgamesandgamificationforhealthsuchasplayers’privacy,
themanipulationofbehavior,compliancewithregulations,informedconsent,accessibil‐
ity,inclusivedesign,andculturalappropriateness.
Thereareseveralcurrentresearchchallengesinthefieldofseriousgamesandgami‐
ficationforhealth,includingthelackofstandardization,lackofrobustevaluationand
validation,lackofunderstandingofhowtointegratetheseinterventionsintoexisting
healthcaresystems,lackofunderstandingofthespecificgamemechanicsanddesignele‐
mentsthataremosteffectiveforpromotingdifferenthealthbehaviorsandoutcomes,and
lackofadoptionbyhealthcareprovidersandpatients.
Inconclusion,thefieldofseriousgamesandgamificationforhealthisarapidly
growinganddynamicareaofresearchwithalotofpromise.Thereareanumberofexcit‐
ingdirectionsforfutureresearch,includingthedevelopmentofmoreeffectiveanden‐
gagingseriousgamesandgamificationapplicationsforawiderangeofhealthconditions,
theuseofthesetechniquestopromotehealthybehaviorsandpreventtheonsetofchronic
healthconditions,andtherigorousevaluationandvalidationoftheseinterventions.
However,itisimportanttonotethatthefieldofseriousgamesandgamificationfor
healthisstillarelativelynewresearcharea,andfurtherresearchisneededtofullyunder‐
standtheirpotentialandlimitationsinhealthcare‐relatedapplications.
AuthorContributions:Conceptualization,R.D.;methodology,R.D.;validation,R.D.,R.M.,and
T.B.;formalanalysis,R.D.,R.M.,andT.B.;investigation,R.D.,R.M.,andT.B.;resources,R.D.;data
curation,R.D.;visualization,R.D.andR.M.;supervision,R.D.;fundingacquisition,R.D.Allauthors
havereadandagreedtothepublishedversionofthemanuscript.
Funding:Thisresearchreceivednoexternalfunding.
DataAvailabilityStatement:Notapplicable.
ConflictsofInterest:Theauthorsdeclarenoconflictsofinterest.
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