GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 4, Number 3, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2014.0124
The Effects of Nursing Interventions Utilizing Serious Games That Promote Health Activities on the Health Behaviors of Seniors Hyeoi-yun Lee, RN, MSN,1 Jeongeun Kim, PhD, RN,2 and Kyung Sik Kim, PhD 3
Abstract
Objectives: Seniors, during their senescence, experience difficulties when engaging in physical, social, and leisure activities. Meanwhile, increased access to information technology in recent years among seniors has led to the increased applicability of games aiding senior activities that incorporate information technology. In this study, we constructed and assessed a nursing intervention incorporating an actual walking exercise game developed for the use of seniors in order to identify the cognitive, social, and physical impact it has on their health behaviors. Subjects and Method: This quasi-experimental study used a one-group pre-/post-test design in which 15 people 65 years of age or older were selected to participate through a serious health game conducted at the senior welfare center twice a week, for 12 weeks. Besides having their basic physical measurements taken, seniors participated in physical exercise sessions that included educational content. The measured variables were health beliefs and concerns, subjective knowledge, subjective norms, perceived reliability, perceived ease of use and usefulness, perceived behavioral control, attitudes about health behaviors, intentions to perform health behaviors, health behaviors, blood pressure, pulse rate, endurance, agility and balance, and flexibility. Results: Significant increases in health beliefs and concerns, perceived reliability, perceived behavioral control, perceived ease of use, attitudes about health behaviors, and intentions to perform health behaviors were observed at post-test, compared with pre-test data points. These increases were also recorded for physical domains. Significant increases in systolic blood pressure and pulse rates were noted immediately after the intervention, along with increased endurance levels, indicating that the exercise had an effect on participants’ health. Conclusions: Ongoing research is required regarding the development and impact of distinctive nursing interventions, conducted through various forms of serious health games relatively easy to use, by integrating various motivating factors for engaging in health behaviors and the entertainment value of such games.
Introduction
T
here has been an increased interest in serious games within South Korea in recent years, in line with the growing interest in the topic around the world. The development of serious games focusing on health represents efforts to utilize such games for the promotion of health, by integrating the entertaining elements of gameplay with health care, which has been shown to have an impact on the treatment of certain diseases. Although the development and application of serious health games have been continuous in South Korea, research on this area has centered on its therapeutic effects. Studies, as well as evaluations, have mainly been conducted in a medical environment. 2 3
The utilization of a nursing intervention that combines gaming with health care can result in cognitive transformation as well as better motor learning, as the subject actively engages in the program because of the curiosity that the game generates.1 In particular, virtual reality programs create situations very similar to actual ones, which increases interest through immersion and allows the subject to learn appropriate reactions and gain similar experiences in a safer environment.2 These programs can also strengthen motivation within the subject through the immediate visual feedback they provide, the interest they create, and the degree of task performance they require. Additionally, because the medium of computers and the Internet can be used as the optimal tool for providing visual information and an experience of virtual reality, it opens the possibility of providing
Research Institute of Nursing Science, College of Nursing, 1Seoul National University, Seoul, South Korea. Department of Game Development, Hoseo University, Cheonan, South Korea.
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the appropriate stimulation that the subject requires along with the opportunity to conduct experiments in this matter. There is a need for more leisure activities suited to the current generation of seniors, due to factors such as the increasing senior population and physical deterioration, which is an external characteristic of older adults. For this reason, a range of leisure activities and programs is increasingly being sought, and the act of freely expressing one’s emotions as well as self-realization through active interactions with others can provide actual psychological stability for seniors. Of these, regular physical activities have a positive effect on seniors—physically, psychologically, and socially—and improve their quality of life.3 The necessity for regular physical, social, and leisure activities during senescence has been emphasized in numerous studies. Despite various positive effects, seniors have experienced difficulties in implementing the actual process of engaging in these activities, due to financial and temporal reasons as well as limited accessibility. In order to better ensure that older adults engage in ongoing exercise, a cognitive separation strategy that encourages interest in the environment or enjoyable recreational activities as an alternative to exercise-related sensory training may be used.4 Games involving physical exercise that can easily be accessed in a relatively short period of time and generate interest, as well as entertain, may be used as nursing intervention tools for promoting health behaviors in older adults. Research questions
In this study, a serious health game was developed and used as a nursing intervention for seniors to encourage physical exercise and to create an educational opportunity on content such as the need for leisure activities during senescence, chronic diseases among seniors, and basic nutritional information. The effects of the intervention on physical symptoms and cognitive transformation related to health behaviors were identified.
FIG. 1.
The research hypotheses were as follows: 1. There will be a difference in the seniors’ health beliefs and concerns, subjective knowledge, subjective norms, perceived reliability, perceived behavioral control, perceived ease of use and usefulness, attitudes about health behaviors, intentions to perform health behaviors, and health behaviors before and after the implementation of the serious health game as a nursing intervention. 2. There will be a difference in the seniors’ blood pressure, pulse rate, endurance, agility and balance, and flexibility before and after the implementation of the serious health game as a nursing intervention. Subjects and Methods Intervention development
A method of intervention that could be performed together with other subjects, and one that was relatively simple and could be used generally, regardless of individuals’ health problems, was sought, based on the results of survey data. A serious health game serving as a nursing intervention has yet to be developed in South Korea. Therefore, a nursing intervention using a serious health game entitled ‘‘Paldokangsan’’ was researched and developed for seniors in the present study. ‘‘Paldokangsan’’ is a serious health game that promotes walking as a leisure activity for seniors. Research on this game has demonstrated the effects of therapeutic play it holds for seniors. Among these are the vitality and intellectual capability they gain and maintain through playing the game, as well as the vicarious satisfaction they experience from exercise involving mutual cooperation and competition.5 In ‘‘Paldokangsan,’’ avatars on the screen walk in accordance with the movement of subjects when two participants hold handles with buttons in each hand and step onto a pad with sensors and start walking. As they walk,
A scene from playing ‘‘Paldokangsan.’’ Color images available online at www.liebertonline.com/g4h
NURSING INTERVENTIONS USING SERIOUS GAMES
sheep will appear every predetermined distance, and the aim of the game is for participants to frequently press the button on the handle to avoid losing any sheep as they attempt to walk to the finish line with these sheep. This study added ‘‘method of knowledge transfer regarding food and diseases’’ to the merits of ‘‘Paldokangsan’’ (Fig. 1) and planned the approach of the intervention to focus more on the health, diet, and habits of seniors. The Game Engineering Department of Hoseo University developed the scenario of the researchers for the game ‘‘Paldokangsan 2,’’ which was based on the traditional market and had new features, such as avoiding obstacles with the button on the handle and selecting food ingredients from shops that popped up as the subject passed by walking on the sensor pad (Fig. 2). The participants selected a disease at the start of the game, and they were given 10 seconds to remember foods connected to the disease. Participants moved in the game by walking on the pad and had to avoid obstacles while they selected foods shown as they passed the shops. It took approximately 10–15 minutes for participants to complete the walking exercise, depending on their speed, and the foods they had selected were eventually scored. This score was shown at the end of the game, together with general information on the disease. The mini-games (Fig. 3) were played using a keyboard or joystick. Two categories of mini-games were created: ‘‘platform arcade action’’ and ‘‘setting the table.’’ In ‘‘platform arcade action,’’ the participant selected a disease at the
FIG. 2.
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start of the game and was given 10 seconds to remember foods associated with the disease, after which the goal of the game was for the game character to avoid bad foods and select good foods that the participant encountered while walking through the market. The game for ‘‘setting the table’’ involved preparing a meal by selecting foods that help fight the disease. These games were used to create a nursing intervention (Table 1), and the contents were supplied through the pilot test. The study was approved by the senior citizens’ center in Gayang Welfare Hall of Seoul and received approval from the Institutional Review Board of the Nursing College of Seoul National University on July 7, 2011. Participants
The study began with the informed consent of 30 subjects who were over the age of 65 years. It was conducted from August 14 to November 1, 2012. Of the seniors who could walk, not many were able to participate in the study twice a week for 12 weeks. The final number of participants who took part in the post-intervention survey at the end of the study was narrowed down to 15, because of factors such as subjects dropping out during the study because of personal issues, health reasons, or a change of mind. This was also due in part to technical issues associated with the limited number of pieces of equipment, which did not allow multiple groups
A scene from playing ‘‘Paldokangsan 2.’’ Color images available online at www.liebertonline.com/g4h
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FIG. 3.
A scene from playing the mini-games. Color images available online at www.liebertonline.com/g4h
to participate in the game simultaneously, and the characteristic of the serious health game nursing intervention (i.e., requiring 10–15 minutes to complete a single game). Study design
A one-group pre-test/post-test design was used in this study to determine the impact of nursing interventions using serious health games for physical exercise on the health behaviors of seniors. Outcome measures Health behavior impact parameters. Previous research was considered when selecting the appropriate measuring tools for variables and the Health Information Technology Acceptance Model measuring tool6 assessing health beliefs
and concerns, perceived sensitivity and severity, perceived ease of use and usefulness, and subjective knowledge. These variables are those in the framework of the Health Information Technology Acceptance Model, which applies the Technology Acceptance Model7 to health. The tool was referenced with the approval of the developer. Its Cronbach’s a for reliability was 0.85. The tool was modified and supplemented for the purpose of this study. The resulting survey consisted of 35 items: five items on health beliefs and concerns, three items on subjective knowledge, four on subjective norms (objects’ subjective perceptions of and responses to the expectations or responses of those around them regarding the former’s particular behavior), three on perceived reliability (professionalism and reliability of the information applied to research), four on perceived behavioral control, four on perceived usefulness (degree of economic gain,
Table 1. Serious Health Game Nursing Intervention Intervention period Weeks 1–4 Weeks 5–8 Weeks 9–12
Intervention content Applying ‘‘Paldokangsan’’ twice a week Applying ‘‘Paldokangsan2’’ and ‘‘mini-game’’ twice a week Applying a game selected by the subject twice a week
Blood pressure and pulse rate were measured before and after participants completed the game. Education providing general information regarding chronic diseases and diet was performed. O, X quizzes were conducted on chronic diseases. The results were scored; the first place was selected every month and awarded a prize.
NURSING INTERVENTIONS USING SERIOUS GAMES
improvements in physical abilities, and positive effect on life habits as perceived by gameplayers), five on perceived ease of use (how little physical, mental, and material effort a game requires [i.e., how easy it is easy to play]), five on attitudes about health behaviors through the serious health game nursing intervention, and two on intentions to perform health behaviors. Each item further consisted of a 5-point Likert scale. A Cronbach’s a of 0.65 for reliability was obtained for the tool in this study. Health behaviors. The health behavior measuring tool for Korean seniors8 was used in this study to measure health behaviors. This tool was developed to measure the health behaviors of seniors performed within the lifestyle of the Korean culture, as well as the conceptual understanding of health behaviors among Korean seniors. It contained 33 items addressing four areas or domains: 13 items on the physical, 10 items on the emotional, 7 items on the social, and 3 items on the spiritual. Assessments with the tool were made on a 5-point scale, with 1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neither agree nor disagree,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree.’’ The tool has previously demonstrated a reliability of 0.91 (Cronbach’s a), and in this study a Cronbach’s a of 0.86 was obtained.
An A&D (San Jose, CA) digital blood pressure monitor (model UA-767 BT-C) was used to measure blood pressure and pulse. These were measured, in the same posture, when participants were at rest and after they had completed the serious health game nursing intervention in every session for 12 weeks. Blood pressure and pulse.
Endurance. The Chair Stand Test, which is a senior fitness test (SFT) designed to evaluate lower body strength, was used to measure endurance. Participants each sat on a chair—backs straight, feet on the ground—and the number of complete stand ups they could perform in 30 seconds while crossing their arms was counted. The test was conducted both before and after each session.
The Timed Up and Go test, an SFT in which participants stand up from the chair, walk 3 m, and come back, was used to measure agility and balance in this study. The time (in seconds) it took each participant sitting on a chair—back straight, feet on the ground—to go to a point 3 m away and return was recorded. The test was conducted both before and after each session. Agility and balance.
Flexibility. Flexibility was measured using another SFT: The Sit and Reach Test. The distance from participants’ fingers to the start point was measured in centimeters when their arms were stretched straight while they were seated and they reached down without bending their elbows. These measurements were made before and after the activity.
As for pre- and post-tests on the participants, those on vital signs were conducted before and after each intervention in the same locations and in the same manner. Surveys on the other variables and SFTs were conducted before and after the entire study by the same researcher and in the same manner. As for statistical analysis, paired t tests were conducted. Analyses.
179 Results
The seniors who participated in this study were all female, the majority of whom (73.3 percent) were in their seventies. Participants had less than an elementary school education, and 66.7 percent were living alone without family members. When asked whether they exercised, 46.6 percent responded that they exercised less than twice a week, and 46.7 percent said three or four times a week; one participant (6.7 percent) responded that she exercised daily. Regarding underlying diseases, the most prevalent was hypertension, at 42.1 percent, whereas the most common types of general health management procedures were exercising and going for regular health check-ups (47.4 percent and 36.8 percent, respectively). The analysis of changes in variables that influence health behavior (Table 2) indicated significant differences in both seniors’ health beliefs and concerns (t = - 2.248, P = 0.033) and the intervention’s perceived reliability (t = - 2.106, P = 0.044). The results also showed highly significant differences in perceived behavioral control (t = - 3.483, P = 0.002) and perceived ease of use (t = - 4.134, P < 0.001). However, no significant differences were found with regard
Table 2. Changes in Variables Influencing Participants’ Health Behaviors, Measured Before and After the Intervention (n = 15) Variable
Mean – SD
t
Health beliefs and concerns Pre-test 3.89 – 0.64 - 2.248 Post-test 4.33 – 0.41 Subjective knowledge Pre-test 2.49 – 0.73 - 0.971 Post-test 2.76 – 0.77 Subjective norms Pre-test 3.58 – 0.46 - 1.446 Post-test 3.87 – 0.60 Perceived reliability Pre-test 3.76 – 0.48 - 2.106 Post-test 4.24 – 0.76 Perceived behavioral control Pre-test 3.43 – 0.37 - 3.483 Post-test 4.05 – 0.58 Perceived usefulness Pre-test 3.52 – 0.57 - 1.206 Post-test 3.80 – 0.71 Perceived ease of use Pre-test 3.56 – 0.42 - 4.134 Post-test 4.33 – 0.59 Attitudes about health behaviors Pre-test 3.72 – 0.51 - 6.191 Post-test 4.71 – 0.35 Intentions to perform health behaviors Pre-test 3.87 – 0.61 - 3.576 Post-test 4.60 – 0.51 Health behaviors Pre-test 3.75 – 0.40 - 2.007 Post-test 4.16 – 0.67
P 0.033a 0.340 0.159 0.044a 0.002b 0.238 < 0.001b < 0.001b
Significant differences are indicated: aP < 0.05, bP < 0.01. SD, standard deviation.
0.001b 0.055
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to the intervention’s perceived usefulness (t = - 1.206, P = 0.238). Significant differences were also observed in seniors’ attitudes about health behaviors and intentions to perform health behaviors, influenced by parameters. There seemed to be a major change in attitudes after the nursing intervention through the implementation of serious health games (t = - 6.191, P < 0.001). There was also a significant increase in their intentions to perform health behaviors (t = - 3.576, P = 0.001). Analysis of the changes in health behaviors showed an increase in participants’ total health behavior scores, from a mean of 3.75 to 4.16 (t = - 2.007, P = 0.055). When we examined changes in scores for the physical domain (13 items) of the senior health behavior measurement tool, we also found a statistically significant increase (t = - 2.76, P = 0.01). Table 3 separately shows the points for the physical domain out of the four domains of health behavior because only they changed significantly. Analysis of the physical symptoms of participants showed a significant increase in systolic blood pressure, indicating exercise effects (t = 3.375, P = 0.001). The average diastolic blood pressure increased from 77.97 mm Hg before the game to 78.46 mm Hg after the game. However, the difference was not statistically significant. The difference in pulse rate was statistically significant (t = 8.512, P < 0.001). Changes were also observed in several SFT measurement variables (Table 4). There was an increase in endurance, but it was not statistically significant. Discussion
Previous health-related interventions targeting the senior population were mostly studies that applied existing games or mediated different types of exercise programs in different forms. In this study, we developed a new serious health game nursing intervention, in which attributes of the existing walking game were kept while new nursing intervention features were added, such as information support and knowledge transfer. Furthermore, because concepts such as knowledge, attitude, and self-efficacy are factors that can predict exercise behaviors,9 they were taken into account during the development of the intervention. In order to increase its effectiveness, we added selective features to enable the application of different interventions according to personal circumstances, such as age and health status, the degree of difficulty of the game, and the level of interest. We tried to collect a variety of data and incorporate different intervention methods. In order to prevent the loss of interest and boost motivation, we made an effort to add rewarding compensations for quizzes and attendance. Participants
Table 3. Changes in the Physical Domain of Participants’ Health Behaviors, Assessed Before and After the Intervention (n = 15) Physical domain
Mean – SD
t
P
Pre-test Post-test
3.58 – 0.36 4.09 – 0.62
- 2.76
0.01a
a P < 0.05 indicates a significant difference. SD, standard deviation.
Table 4. Changes in Physical Symptoms of Participants, Measured Before and After the Intervention (n = 15) Variable
Mean – SD
Systolic BP (mm Hg) Pre-test 135.33 – 23.13 Post-test 139.95 – 21.99 Diastolic BP (mm Hg) Pre-test 77.97 – 10.26 Post-test 78.46 – 10.84 Pulse rate (beats) Pre-test 74.49 – 11.04 Post-test 79.56 – 13.40 Endurance (number of stands) Pre-test 12.13 – 1.60 Post-test 13.80 – 3.69 Agility and balance (seconds) Pre-test 9.60 – 2.16 Post-test 7.83 – 2.05 Flexibility (cm) Pre-test 64.93 – 6.26 Post-test 63.60 – 4.42
t
P
3.375
0.001b
0.764
0.446
8.512
< 0.001b
- 1.606
0.119
2.295
0.029a
0.674
0.506
Significant differences are indicated: aP < 0.05, bP < 0.01. BP, blood pressure; SD, standard deviation.
showed curiosity and interest in the intervention conducted during the study period, and the responses of those around the participants who observed them had a positive impact on the intervention. The participants were immersed in the easyto-play, realistic game environment and seemed to enjoy the competitive scoring system of the game. The significant changes observed in health beliefs and concerns seemed to be the result of providing ongoing information about diseases and eating habits in a new form of intervention incorporating a game, which increased the effects. Significant increases in perceived reliability also indicated recognition of the serious health game as an effective and professional form of intervention for facilitating improvement in health behaviors, despite its being different from existing interventions. There was a significant difference in perceived behavioral control, which seemed to have been affected by the immediate feedback regarding the process of self-operating the device and making one’s own decisions on food selection. The results were consistent with those of previous studies demonstrating increases in self-efficacy, a concept similar to perceived behavioral control, through exercise intervention programs,10–13 and studies based on virtual reality and games.14,15 There was also a significant difference in perceived ease of use, which may be attributed to the use of avatars in the serious health game, and the visualization of shapes of diseases and food, which excluded additional explanation and made the game seem simple and easy to play. On the other hand, no significant difference was observed in the intervention’s perceived usefulness, which was likely due to the highly visualized nature of the intervention in the form of the game that may have led to diminished feelings of usefulness. A significant increase found in this study in seniors’ health attitudes and intentions to perform health behaviors agreed
NURSING INTERVENTIONS USING SERIOUS GAMES
with the results of a previous study, which indicated that interest affects attitude.16 It could also be said that the nursing intervention, through the use of a serious health game, increased the intention to maintain and improve one’s health among seniors. In the case of vital signs, the results were similar to that of a previous study in which significant increases in systolic blood pressure and pulse rate were observed from pre- to post-intervention that resulted in higher systolic blood pressure and lower or equal diastolic blood pressure during heavy exercise.17 The present findings also echoed those obtained in a study conducted by Ahn,18 in which changes in the blood pressure of female older adults were compared according to their walking distances, revealing significant increases in systolic blood pressure up to 800 m, and those of the study conducted by Baek,19 where increased systolic blood pressure was observed in males in their twenties immediately after light exercise. Among SFT measurement items, scores for endurance increased from an average of 12.13 before the intervention to 13.80 after; however, this increase was not statistically significant. These results were similar to those of a study performed by Janssen et al.,20 which examined the use of the ‘‘Wii Fit Plus’’ (Nintendo, Kyoto, Japan) among seniors in nursing homes and found significant differences in overall physical activity but no such differences in the detailed balance test. This shows that the intensity of game enough increase the blood pressure as physical activity. The general results of the serious health game nursing intervention for physical exercise developed and applied in this study indicated significant improvements in seniors’ exercise behaviors and vital signs. In particular, highly positive effects in perceived health beliefs and concerns, reliability, ease of use, and perceived behavioral control were detected. Although it was not statistically significant, an increase in subjective knowledge was also found; thus, the intervention’s role in providing information and knowledge through memory training could be seen. Among physical signs, changes in participants’ vital signs indicated that there were some effects as exercise. The serious health game nursing intervention’s effectiveness was also demonstrated in this study with regard to seniors’ attitudes about health behaviors and intentions to perform health behaviors. Furthermore, the game was easily self-operated, proving to be effective in terms of perceived behavioral control and perceived ease of use, due to its visual and auditory effects. Conclusions
We believe that the intervention implemented during this study was significant in that, during the not-so-short duration of the study, the physical abilities of the seniors participating had not deteriorated, but had been retained or had shown partial improvements through the intervention. In addition, during development, we predicted walking time to be appropriate for examining the effects of exercise on seniors. However, we realized that it was not sufficient to elicit direct physical changes other than changes in vital signs. Therefore, we believe that further adjustments to the time spent exercising and the intensity of the exercise are required. We propose the following suggestions as to the above findings:
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It will be necessary to develop various forms of serious health games that combine fun and motivating factors of games with medical, therapeutic interventions. It will be necessary to develop nursing interventions that provide personalized training exercises combined with education and knowledge transfer. Further research must be conducted to study the effectiveness of various interventions using serious health games that can be applied in public spaces such as community and senior centers and that can easily be used and enjoyed by seniors. Acknowledgments
This work was supported by National Research Foundation of Korea grant NRF-2013S1A5B6043614 funded by the Korean government. Author Disclosure Statement
No competing financial interests exist. References
1. Lee SW. Effects of a virtual reality exercise program on physical function and falls efficacy in elderly persons with type 2 diabetes [PhD thesis]. Seoul: Ewha Womans University; 2011. 2. Bricken M. Virtual reality learning environments: Potentials and challenges. ACM SIGGRAPH Comput Graphics 1991; 25:178–184. 3. Park CH. Physical activity programming for older adults: A way to improve quality of life. J Sport Leisure Stud 2009; 38:653–662. 4. Pender NJ. Health Promotion in Nursing Practice [Transl. Choi MA, Lee IS]. Seoul: Hyunmoon; 1997;232. 5. Kim KS, Oh SS, Ahn JH, et al. Development and analysis of a walking game using controllers of armrests and footboards (title: Paldokangsan). J Korea Game Soc 2011; 11(6):43–52. 6. Kim JE, Park HA. Development of a health information technology acceptance model using consumers’ health behavior intention. J Med Internet Res 2012; 14:e133. 7. Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Q 1989; 13:318–339. 8. Choi YH, Kim SY. Development of health behavior assessment tool of the Korean elders. J Korean Acad Nurs 1997; 27:601–613. 9. Conn VS. Older adults and exercise: Path analysis of selfefficacy related constructs. Nurs Res 1998; 47:180–189. 10. Kim HJ, Hong YS. An effect of muscle strength training program on muscle strength, muscle endurance, instrumental activities of daily living and quality of life in the institutionalized elderly. J Korean Community Nurs 1995; 6:55–73. 11. Kim JH, Park YS. The effect of aerobic rhythmical exercise program on physical fitness, self-efficacy and quality of life in elderly. J Korean Public Health Nurs 2000; 14:12–25. 12. Shin KR, Kim JS. The effects of exercise program on knowledge and attitude of exercise and depression in lowincome elderly women. J Korean Acad Nurs 2005; 35: 1144–1152.
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13. Kim SJ, Jeong GH, Yang SO. The effect of a physical exercise program using elastic bands in the attitude of physical exercise and the degree of joint pain. J Korean Acad Community Health Nurs 2007; 18:79–89. 14. Lange BS, Requejo P, Flynn SM, et al. The potential of virtual reality and gaming to assist successful aging with disability. Phys Med Rehabil Clin N Am 2010; 21:339–356. 15. Lewis GN, Woods C, Rosie JA, et al. Virtual reality games for rehabilitation of people with stroke: Perspectives from the users. Disabil Rehabil Assist Technol 2011; 6:453–463. 16. Kim SJ. The effect of Tai Chi exercise applied to the elderly at the hall for the aged [MA thesis]. Seoul: Hanyang University; 2007. 17. Johansen LP. Hemodynamics in early essential hypertension. Acta Med 1967; 181:59–66. 18. Ahn YS. The effect on blood pressure by taking a walk through a forest focused on elder women who are living in senior citizen communities with slight hypertension [MA thesis]. Seoul: Kyung Hee University; 2004.
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19. Baek KY. Effect of different exercise intensity on the blood pressure and inflammatory markers change in pre-hypertension leveled male [PhD thesis]. Gwangju, Korea: Chonnam National University; 2008. 20. Janssen S, Tange H, Arends R. A preliminary study on the effectiveness of exergame Nintendo ‘‘Wii Fit Plus’’ on the balance of nursing home residents. Games Health J 2012; 2:64–69.
Address correspondence to: Jeongeun Kim, PhD, RN Research Institute of Nursing Science College of Nursing Seoul National University 103 Deahak-ro, Jongno-gu Seoul, 110-799, South Korea E-mail: [email protected]
The Effects of Nursing Interventions Utilizing Serious Games That Promote Health Activities on the Health Behaviors of Seniors Hyeoi-yun Lee, RN, MSN,1 Jeongeun Kim, PhD, RN,2 and Kyung Sik Kim, PhD 3
Abstract
Objectives: Seniors, during their senescence, experience difficulties when engaging in physical, social, and leisure activities. Meanwhile, increased access to information technology in recent years among seniors has led to the increased applicability of games aiding senior activities that incorporate information technology. In this study, we constructed and assessed a nursing intervention incorporating an actual walking exercise game developed for the use of seniors in order to identify the cognitive, social, and physical impact it has on their health behaviors. Subjects and Method: This quasi-experimental study used a one-group pre-/post-test design in which 15 people 65 years of age or older were selected to participate through a serious health game conducted at the senior welfare center twice a week, for 12 weeks. Besides having their basic physical measurements taken, seniors participated in physical exercise sessions that included educational content. The measured variables were health beliefs and concerns, subjective knowledge, subjective norms, perceived reliability, perceived ease of use and usefulness, perceived behavioral control, attitudes about health behaviors, intentions to perform health behaviors, health behaviors, blood pressure, pulse rate, endurance, agility and balance, and flexibility. Results: Significant increases in health beliefs and concerns, perceived reliability, perceived behavioral control, perceived ease of use, attitudes about health behaviors, and intentions to perform health behaviors were observed at post-test, compared with pre-test data points. These increases were also recorded for physical domains. Significant increases in systolic blood pressure and pulse rates were noted immediately after the intervention, along with increased endurance levels, indicating that the exercise had an effect on participants’ health. Conclusions: Ongoing research is required regarding the development and impact of distinctive nursing interventions, conducted through various forms of serious health games relatively easy to use, by integrating various motivating factors for engaging in health behaviors and the entertainment value of such games.
Introduction
T
here has been an increased interest in serious games within South Korea in recent years, in line with the growing interest in the topic around the world. The development of serious games focusing on health represents efforts to utilize such games for the promotion of health, by integrating the entertaining elements of gameplay with health care, which has been shown to have an impact on the treatment of certain diseases. Although the development and application of serious health games have been continuous in South Korea, research on this area has centered on its therapeutic effects. Studies, as well as evaluations, have mainly been conducted in a medical environment. 2 3
The utilization of a nursing intervention that combines gaming with health care can result in cognitive transformation as well as better motor learning, as the subject actively engages in the program because of the curiosity that the game generates.1 In particular, virtual reality programs create situations very similar to actual ones, which increases interest through immersion and allows the subject to learn appropriate reactions and gain similar experiences in a safer environment.2 These programs can also strengthen motivation within the subject through the immediate visual feedback they provide, the interest they create, and the degree of task performance they require. Additionally, because the medium of computers and the Internet can be used as the optimal tool for providing visual information and an experience of virtual reality, it opens the possibility of providing
Research Institute of Nursing Science, College of Nursing, 1Seoul National University, Seoul, South Korea. Department of Game Development, Hoseo University, Cheonan, South Korea.
175
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LEE ET AL.
the appropriate stimulation that the subject requires along with the opportunity to conduct experiments in this matter. There is a need for more leisure activities suited to the current generation of seniors, due to factors such as the increasing senior population and physical deterioration, which is an external characteristic of older adults. For this reason, a range of leisure activities and programs is increasingly being sought, and the act of freely expressing one’s emotions as well as self-realization through active interactions with others can provide actual psychological stability for seniors. Of these, regular physical activities have a positive effect on seniors—physically, psychologically, and socially—and improve their quality of life.3 The necessity for regular physical, social, and leisure activities during senescence has been emphasized in numerous studies. Despite various positive effects, seniors have experienced difficulties in implementing the actual process of engaging in these activities, due to financial and temporal reasons as well as limited accessibility. In order to better ensure that older adults engage in ongoing exercise, a cognitive separation strategy that encourages interest in the environment or enjoyable recreational activities as an alternative to exercise-related sensory training may be used.4 Games involving physical exercise that can easily be accessed in a relatively short period of time and generate interest, as well as entertain, may be used as nursing intervention tools for promoting health behaviors in older adults. Research questions
In this study, a serious health game was developed and used as a nursing intervention for seniors to encourage physical exercise and to create an educational opportunity on content such as the need for leisure activities during senescence, chronic diseases among seniors, and basic nutritional information. The effects of the intervention on physical symptoms and cognitive transformation related to health behaviors were identified.
FIG. 1.
The research hypotheses were as follows: 1. There will be a difference in the seniors’ health beliefs and concerns, subjective knowledge, subjective norms, perceived reliability, perceived behavioral control, perceived ease of use and usefulness, attitudes about health behaviors, intentions to perform health behaviors, and health behaviors before and after the implementation of the serious health game as a nursing intervention. 2. There will be a difference in the seniors’ blood pressure, pulse rate, endurance, agility and balance, and flexibility before and after the implementation of the serious health game as a nursing intervention. Subjects and Methods Intervention development
A method of intervention that could be performed together with other subjects, and one that was relatively simple and could be used generally, regardless of individuals’ health problems, was sought, based on the results of survey data. A serious health game serving as a nursing intervention has yet to be developed in South Korea. Therefore, a nursing intervention using a serious health game entitled ‘‘Paldokangsan’’ was researched and developed for seniors in the present study. ‘‘Paldokangsan’’ is a serious health game that promotes walking as a leisure activity for seniors. Research on this game has demonstrated the effects of therapeutic play it holds for seniors. Among these are the vitality and intellectual capability they gain and maintain through playing the game, as well as the vicarious satisfaction they experience from exercise involving mutual cooperation and competition.5 In ‘‘Paldokangsan,’’ avatars on the screen walk in accordance with the movement of subjects when two participants hold handles with buttons in each hand and step onto a pad with sensors and start walking. As they walk,
A scene from playing ‘‘Paldokangsan.’’ Color images available online at www.liebertonline.com/g4h
NURSING INTERVENTIONS USING SERIOUS GAMES
sheep will appear every predetermined distance, and the aim of the game is for participants to frequently press the button on the handle to avoid losing any sheep as they attempt to walk to the finish line with these sheep. This study added ‘‘method of knowledge transfer regarding food and diseases’’ to the merits of ‘‘Paldokangsan’’ (Fig. 1) and planned the approach of the intervention to focus more on the health, diet, and habits of seniors. The Game Engineering Department of Hoseo University developed the scenario of the researchers for the game ‘‘Paldokangsan 2,’’ which was based on the traditional market and had new features, such as avoiding obstacles with the button on the handle and selecting food ingredients from shops that popped up as the subject passed by walking on the sensor pad (Fig. 2). The participants selected a disease at the start of the game, and they were given 10 seconds to remember foods connected to the disease. Participants moved in the game by walking on the pad and had to avoid obstacles while they selected foods shown as they passed the shops. It took approximately 10–15 minutes for participants to complete the walking exercise, depending on their speed, and the foods they had selected were eventually scored. This score was shown at the end of the game, together with general information on the disease. The mini-games (Fig. 3) were played using a keyboard or joystick. Two categories of mini-games were created: ‘‘platform arcade action’’ and ‘‘setting the table.’’ In ‘‘platform arcade action,’’ the participant selected a disease at the
FIG. 2.
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start of the game and was given 10 seconds to remember foods associated with the disease, after which the goal of the game was for the game character to avoid bad foods and select good foods that the participant encountered while walking through the market. The game for ‘‘setting the table’’ involved preparing a meal by selecting foods that help fight the disease. These games were used to create a nursing intervention (Table 1), and the contents were supplied through the pilot test. The study was approved by the senior citizens’ center in Gayang Welfare Hall of Seoul and received approval from the Institutional Review Board of the Nursing College of Seoul National University on July 7, 2011. Participants
The study began with the informed consent of 30 subjects who were over the age of 65 years. It was conducted from August 14 to November 1, 2012. Of the seniors who could walk, not many were able to participate in the study twice a week for 12 weeks. The final number of participants who took part in the post-intervention survey at the end of the study was narrowed down to 15, because of factors such as subjects dropping out during the study because of personal issues, health reasons, or a change of mind. This was also due in part to technical issues associated with the limited number of pieces of equipment, which did not allow multiple groups
A scene from playing ‘‘Paldokangsan 2.’’ Color images available online at www.liebertonline.com/g4h
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FIG. 3.
A scene from playing the mini-games. Color images available online at www.liebertonline.com/g4h
to participate in the game simultaneously, and the characteristic of the serious health game nursing intervention (i.e., requiring 10–15 minutes to complete a single game). Study design
A one-group pre-test/post-test design was used in this study to determine the impact of nursing interventions using serious health games for physical exercise on the health behaviors of seniors. Outcome measures Health behavior impact parameters. Previous research was considered when selecting the appropriate measuring tools for variables and the Health Information Technology Acceptance Model measuring tool6 assessing health beliefs
and concerns, perceived sensitivity and severity, perceived ease of use and usefulness, and subjective knowledge. These variables are those in the framework of the Health Information Technology Acceptance Model, which applies the Technology Acceptance Model7 to health. The tool was referenced with the approval of the developer. Its Cronbach’s a for reliability was 0.85. The tool was modified and supplemented for the purpose of this study. The resulting survey consisted of 35 items: five items on health beliefs and concerns, three items on subjective knowledge, four on subjective norms (objects’ subjective perceptions of and responses to the expectations or responses of those around them regarding the former’s particular behavior), three on perceived reliability (professionalism and reliability of the information applied to research), four on perceived behavioral control, four on perceived usefulness (degree of economic gain,
Table 1. Serious Health Game Nursing Intervention Intervention period Weeks 1–4 Weeks 5–8 Weeks 9–12
Intervention content Applying ‘‘Paldokangsan’’ twice a week Applying ‘‘Paldokangsan2’’ and ‘‘mini-game’’ twice a week Applying a game selected by the subject twice a week
Blood pressure and pulse rate were measured before and after participants completed the game. Education providing general information regarding chronic diseases and diet was performed. O, X quizzes were conducted on chronic diseases. The results were scored; the first place was selected every month and awarded a prize.
NURSING INTERVENTIONS USING SERIOUS GAMES
improvements in physical abilities, and positive effect on life habits as perceived by gameplayers), five on perceived ease of use (how little physical, mental, and material effort a game requires [i.e., how easy it is easy to play]), five on attitudes about health behaviors through the serious health game nursing intervention, and two on intentions to perform health behaviors. Each item further consisted of a 5-point Likert scale. A Cronbach’s a of 0.65 for reliability was obtained for the tool in this study. Health behaviors. The health behavior measuring tool for Korean seniors8 was used in this study to measure health behaviors. This tool was developed to measure the health behaviors of seniors performed within the lifestyle of the Korean culture, as well as the conceptual understanding of health behaviors among Korean seniors. It contained 33 items addressing four areas or domains: 13 items on the physical, 10 items on the emotional, 7 items on the social, and 3 items on the spiritual. Assessments with the tool were made on a 5-point scale, with 1 = ‘‘strongly disagree,’’ 2 = ‘‘disagree,’’ 3 = ‘‘neither agree nor disagree,’’ 4 = ‘‘agree,’’ and 5 = ‘‘strongly agree.’’ The tool has previously demonstrated a reliability of 0.91 (Cronbach’s a), and in this study a Cronbach’s a of 0.86 was obtained.
An A&D (San Jose, CA) digital blood pressure monitor (model UA-767 BT-C) was used to measure blood pressure and pulse. These were measured, in the same posture, when participants were at rest and after they had completed the serious health game nursing intervention in every session for 12 weeks. Blood pressure and pulse.
Endurance. The Chair Stand Test, which is a senior fitness test (SFT) designed to evaluate lower body strength, was used to measure endurance. Participants each sat on a chair—backs straight, feet on the ground—and the number of complete stand ups they could perform in 30 seconds while crossing their arms was counted. The test was conducted both before and after each session.
The Timed Up and Go test, an SFT in which participants stand up from the chair, walk 3 m, and come back, was used to measure agility and balance in this study. The time (in seconds) it took each participant sitting on a chair—back straight, feet on the ground—to go to a point 3 m away and return was recorded. The test was conducted both before and after each session. Agility and balance.
Flexibility. Flexibility was measured using another SFT: The Sit and Reach Test. The distance from participants’ fingers to the start point was measured in centimeters when their arms were stretched straight while they were seated and they reached down without bending their elbows. These measurements were made before and after the activity.
As for pre- and post-tests on the participants, those on vital signs were conducted before and after each intervention in the same locations and in the same manner. Surveys on the other variables and SFTs were conducted before and after the entire study by the same researcher and in the same manner. As for statistical analysis, paired t tests were conducted. Analyses.
179 Results
The seniors who participated in this study were all female, the majority of whom (73.3 percent) were in their seventies. Participants had less than an elementary school education, and 66.7 percent were living alone without family members. When asked whether they exercised, 46.6 percent responded that they exercised less than twice a week, and 46.7 percent said three or four times a week; one participant (6.7 percent) responded that she exercised daily. Regarding underlying diseases, the most prevalent was hypertension, at 42.1 percent, whereas the most common types of general health management procedures were exercising and going for regular health check-ups (47.4 percent and 36.8 percent, respectively). The analysis of changes in variables that influence health behavior (Table 2) indicated significant differences in both seniors’ health beliefs and concerns (t = - 2.248, P = 0.033) and the intervention’s perceived reliability (t = - 2.106, P = 0.044). The results also showed highly significant differences in perceived behavioral control (t = - 3.483, P = 0.002) and perceived ease of use (t = - 4.134, P < 0.001). However, no significant differences were found with regard
Table 2. Changes in Variables Influencing Participants’ Health Behaviors, Measured Before and After the Intervention (n = 15) Variable
Mean – SD
t
Health beliefs and concerns Pre-test 3.89 – 0.64 - 2.248 Post-test 4.33 – 0.41 Subjective knowledge Pre-test 2.49 – 0.73 - 0.971 Post-test 2.76 – 0.77 Subjective norms Pre-test 3.58 – 0.46 - 1.446 Post-test 3.87 – 0.60 Perceived reliability Pre-test 3.76 – 0.48 - 2.106 Post-test 4.24 – 0.76 Perceived behavioral control Pre-test 3.43 – 0.37 - 3.483 Post-test 4.05 – 0.58 Perceived usefulness Pre-test 3.52 – 0.57 - 1.206 Post-test 3.80 – 0.71 Perceived ease of use Pre-test 3.56 – 0.42 - 4.134 Post-test 4.33 – 0.59 Attitudes about health behaviors Pre-test 3.72 – 0.51 - 6.191 Post-test 4.71 – 0.35 Intentions to perform health behaviors Pre-test 3.87 – 0.61 - 3.576 Post-test 4.60 – 0.51 Health behaviors Pre-test 3.75 – 0.40 - 2.007 Post-test 4.16 – 0.67
P 0.033a 0.340 0.159 0.044a 0.002b 0.238 < 0.001b < 0.001b
Significant differences are indicated: aP < 0.05, bP < 0.01. SD, standard deviation.
0.001b 0.055
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to the intervention’s perceived usefulness (t = - 1.206, P = 0.238). Significant differences were also observed in seniors’ attitudes about health behaviors and intentions to perform health behaviors, influenced by parameters. There seemed to be a major change in attitudes after the nursing intervention through the implementation of serious health games (t = - 6.191, P < 0.001). There was also a significant increase in their intentions to perform health behaviors (t = - 3.576, P = 0.001). Analysis of the changes in health behaviors showed an increase in participants’ total health behavior scores, from a mean of 3.75 to 4.16 (t = - 2.007, P = 0.055). When we examined changes in scores for the physical domain (13 items) of the senior health behavior measurement tool, we also found a statistically significant increase (t = - 2.76, P = 0.01). Table 3 separately shows the points for the physical domain out of the four domains of health behavior because only they changed significantly. Analysis of the physical symptoms of participants showed a significant increase in systolic blood pressure, indicating exercise effects (t = 3.375, P = 0.001). The average diastolic blood pressure increased from 77.97 mm Hg before the game to 78.46 mm Hg after the game. However, the difference was not statistically significant. The difference in pulse rate was statistically significant (t = 8.512, P < 0.001). Changes were also observed in several SFT measurement variables (Table 4). There was an increase in endurance, but it was not statistically significant. Discussion
Previous health-related interventions targeting the senior population were mostly studies that applied existing games or mediated different types of exercise programs in different forms. In this study, we developed a new serious health game nursing intervention, in which attributes of the existing walking game were kept while new nursing intervention features were added, such as information support and knowledge transfer. Furthermore, because concepts such as knowledge, attitude, and self-efficacy are factors that can predict exercise behaviors,9 they were taken into account during the development of the intervention. In order to increase its effectiveness, we added selective features to enable the application of different interventions according to personal circumstances, such as age and health status, the degree of difficulty of the game, and the level of interest. We tried to collect a variety of data and incorporate different intervention methods. In order to prevent the loss of interest and boost motivation, we made an effort to add rewarding compensations for quizzes and attendance. Participants
Table 3. Changes in the Physical Domain of Participants’ Health Behaviors, Assessed Before and After the Intervention (n = 15) Physical domain
Mean – SD
t
P
Pre-test Post-test
3.58 – 0.36 4.09 – 0.62
- 2.76
0.01a
a P < 0.05 indicates a significant difference. SD, standard deviation.
Table 4. Changes in Physical Symptoms of Participants, Measured Before and After the Intervention (n = 15) Variable
Mean – SD
Systolic BP (mm Hg) Pre-test 135.33 – 23.13 Post-test 139.95 – 21.99 Diastolic BP (mm Hg) Pre-test 77.97 – 10.26 Post-test 78.46 – 10.84 Pulse rate (beats) Pre-test 74.49 – 11.04 Post-test 79.56 – 13.40 Endurance (number of stands) Pre-test 12.13 – 1.60 Post-test 13.80 – 3.69 Agility and balance (seconds) Pre-test 9.60 – 2.16 Post-test 7.83 – 2.05 Flexibility (cm) Pre-test 64.93 – 6.26 Post-test 63.60 – 4.42
t
P
3.375
0.001b
0.764
0.446
8.512
< 0.001b
- 1.606
0.119
2.295
0.029a
0.674
0.506
Significant differences are indicated: aP < 0.05, bP < 0.01. BP, blood pressure; SD, standard deviation.
showed curiosity and interest in the intervention conducted during the study period, and the responses of those around the participants who observed them had a positive impact on the intervention. The participants were immersed in the easyto-play, realistic game environment and seemed to enjoy the competitive scoring system of the game. The significant changes observed in health beliefs and concerns seemed to be the result of providing ongoing information about diseases and eating habits in a new form of intervention incorporating a game, which increased the effects. Significant increases in perceived reliability also indicated recognition of the serious health game as an effective and professional form of intervention for facilitating improvement in health behaviors, despite its being different from existing interventions. There was a significant difference in perceived behavioral control, which seemed to have been affected by the immediate feedback regarding the process of self-operating the device and making one’s own decisions on food selection. The results were consistent with those of previous studies demonstrating increases in self-efficacy, a concept similar to perceived behavioral control, through exercise intervention programs,10–13 and studies based on virtual reality and games.14,15 There was also a significant difference in perceived ease of use, which may be attributed to the use of avatars in the serious health game, and the visualization of shapes of diseases and food, which excluded additional explanation and made the game seem simple and easy to play. On the other hand, no significant difference was observed in the intervention’s perceived usefulness, which was likely due to the highly visualized nature of the intervention in the form of the game that may have led to diminished feelings of usefulness. A significant increase found in this study in seniors’ health attitudes and intentions to perform health behaviors agreed
NURSING INTERVENTIONS USING SERIOUS GAMES
with the results of a previous study, which indicated that interest affects attitude.16 It could also be said that the nursing intervention, through the use of a serious health game, increased the intention to maintain and improve one’s health among seniors. In the case of vital signs, the results were similar to that of a previous study in which significant increases in systolic blood pressure and pulse rate were observed from pre- to post-intervention that resulted in higher systolic blood pressure and lower or equal diastolic blood pressure during heavy exercise.17 The present findings also echoed those obtained in a study conducted by Ahn,18 in which changes in the blood pressure of female older adults were compared according to their walking distances, revealing significant increases in systolic blood pressure up to 800 m, and those of the study conducted by Baek,19 where increased systolic blood pressure was observed in males in their twenties immediately after light exercise. Among SFT measurement items, scores for endurance increased from an average of 12.13 before the intervention to 13.80 after; however, this increase was not statistically significant. These results were similar to those of a study performed by Janssen et al.,20 which examined the use of the ‘‘Wii Fit Plus’’ (Nintendo, Kyoto, Japan) among seniors in nursing homes and found significant differences in overall physical activity but no such differences in the detailed balance test. This shows that the intensity of game enough increase the blood pressure as physical activity. The general results of the serious health game nursing intervention for physical exercise developed and applied in this study indicated significant improvements in seniors’ exercise behaviors and vital signs. In particular, highly positive effects in perceived health beliefs and concerns, reliability, ease of use, and perceived behavioral control were detected. Although it was not statistically significant, an increase in subjective knowledge was also found; thus, the intervention’s role in providing information and knowledge through memory training could be seen. Among physical signs, changes in participants’ vital signs indicated that there were some effects as exercise. The serious health game nursing intervention’s effectiveness was also demonstrated in this study with regard to seniors’ attitudes about health behaviors and intentions to perform health behaviors. Furthermore, the game was easily self-operated, proving to be effective in terms of perceived behavioral control and perceived ease of use, due to its visual and auditory effects. Conclusions
We believe that the intervention implemented during this study was significant in that, during the not-so-short duration of the study, the physical abilities of the seniors participating had not deteriorated, but had been retained or had shown partial improvements through the intervention. In addition, during development, we predicted walking time to be appropriate for examining the effects of exercise on seniors. However, we realized that it was not sufficient to elicit direct physical changes other than changes in vital signs. Therefore, we believe that further adjustments to the time spent exercising and the intensity of the exercise are required. We propose the following suggestions as to the above findings:
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It will be necessary to develop various forms of serious health games that combine fun and motivating factors of games with medical, therapeutic interventions. It will be necessary to develop nursing interventions that provide personalized training exercises combined with education and knowledge transfer. Further research must be conducted to study the effectiveness of various interventions using serious health games that can be applied in public spaces such as community and senior centers and that can easily be used and enjoyed by seniors. Acknowledgments
This work was supported by National Research Foundation of Korea grant NRF-2013S1A5B6043614 funded by the Korean government. Author Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Jeongeun Kim, PhD, RN Research Institute of Nursing Science College of Nursing Seoul National University 103 Deahak-ro, Jongno-gu Seoul, 110-799, South Korea E-mail: [email protected]
