The Use of Games in the Self-Management of Oncological Disease: An Integrative Literature Review

Abstract

Games have been considered important strategies for the promotion and development of skills for self-management of the signs and symptoms of various diseases. This research was designed to identify current scientific knowledge about the use of games in the management of oncological disease. For this integrative review of literature, a search was conducted in the databases Medline® and CINAHL® Psychology and Behavioural Sciences Collection ® and in SCIELO®. The search used specific Boolean phrases and key terms. A total of 390 studies were identified. Inclusion and exclusion criteria were applied and a total of 13 articles were considered for analysis. From the data analysis, three themes were identified: categorization based on the participants, type of games, and purpose of the thematic areas of the game. Games used in healthcare are engaging and amusing and have the potential to change the attitudes and behaviours of users. They can improve health through self-management of signs and symptoms. The knowledge and the development of these games are a strong complementary component of interventions performed by health professionals.

Introduction

The research and development of serious games in health have increased particularly over the past decade (Kharrazi, Lu, Gharghabi & Coleman, 2012; Bedwell, Pavlas, Heyne, Lazzara & Salas, 2012). The concept of gaming has been applied to education and training, rather than merely for entertainment purposes, resulting in what is known as “serious games” (Sipiyaruk, Gallagher, Hatzipanagos & Reynolds, 2018).
Serious games in health have been referenced for more than three decades, since the beginning of the 80’s (Safdari, Ghazisaeidi, Goodini, Mirzaee & Farzi, 2016). These games are used for different purposes, namely for education, health education, and health promotion and management of disease directed at different populations and contexts (Friedman, Cosby, Boyko, Hatton-Bauer & Turnbull, 2011; Charlier et al., 2016; Ghazisaeidi, Safdari, Goodini, Mirzaiee & Farzi, 2017; Fernandes & Ângelo, 2018). In the early stages, these games were mainly directed to education, particularly for the training of health professionals (Fernandes & Ângelo, 2018) and also commonly associated with children (Charlier, et al., 2016). There are numerous studies with the use of health games with childre. (Friedman et al., 2011; Charlier, et al., 2016), namely in oncology (Safdari et al., 2016; Charlier, et al., 2016; Ghazisaeidi et al., 2017). Health games are still rarely explored and are often associated with children (Pon, 2010).

In recent years, the exponential increase of serious games has been mostly linked to the development of internet and electronic games, including the development of applications for mobile phones (Stinson, et al., 2013; Rocha, et al., 2016). New technological advancements, such as the internet and multimedia technologies, have had a strong impact on education and literacy in health, providing privileged access to information. In health games, the way in which activities, information and data are presented to the patient seeks to motivate behaviour change, distinguishing it from a purely informative solution (Charlier, et al., 2016).

However, researchers believe that the information should be specifically targeted and acknowledge that serious games have a stronger impact than exposition methods. Games are capable of enhancing understanding due to their interactive elements, as opposed to other passive approaches (Roubidoux, Hilmes, Abate, Burhansstipanov & Trapp, 2005).

Serious games are designed to achieve goals that are camouflaged by their recreational aspect (Safdari et al., 2016). It should be noted that games comprise and connect a specific set of meanings, recognizable by the user, who acts in accordance with its objectives. This means that the game "speaks," the user interprets the "message," “responds” to this message and, in turn, a new message is defined. This new message expresses the way that individuals assimilate, interpret and perceive meaning (Cruz, 2017). Gaming places individuals in a parallel reality, stimulating consciousness and, ultimately, stimulating responses at psychological, physiological and behavioural levels (Khalil, 2012). Serious games are engaging, enjoyable, challenging and experiential, with the potential to change attitudes and behaviours and very likely to improve the health condition of their users (Safdari et al., 2016).

The educational content of serious games is usually designed to increase the knowledge related to health, in particular, adherence behaviours, expecting that these changes will lead to better health outcomes (Beale, Marin-Bowling, Guthrie & Kato, 2006) (14). The games promote user behaviour changes in adherence and self-management (Rocha, et al., 2016). They have been applied in different areas, including to the management of oncological disease (Wilkinson & Whitehead, 2009; Azadmanjir, Safdari & Ghazisaeidi, 2015; Silva & Pontífice, 2015; Safdari et al., 2016).

Cancer is a chronic disease with increased prevalence worldwide. Self-care and self-management strategies are important to improve the results in the control and management of the disease (Azadmanjir, Safdari & Ghazisaeidi, 2015). Serious games are considered key complementary elements in health interventions to improve self-management of signs and symptoms (Friedman et al., 2011).

The concept of self-care is associated with autonomy, independence and personal accountability, either innate or learned with the purpose to develop health potential (Silva & Pontífice, 2015). Self-care involves the ability to act and make choices and is influenced by knowledge, skills, values, motivation, the locus of control and efficacy (Wilkinson & Whitehead, 2009). Despite the great importance of disseminating information about diseases and treatments, education and information alone do not guarantee adherence to health behaviours.

The importance of self-care as an increased focus of attention in health domains has been influenced by the increase of chronic diseases, a greater focus on health promotion, the increasing relevance of outpatient and home care, and the extended health literacy of citizens, empowering people in health care decision-making (Wilkinson & Whitehead, 2009; Silva & Pontífice, 2015).

In the field of oncology, games can effectively complement the interventions of health professionals by promoting self-care and self-management (Ghazisaeidi et al., 2017). Games help to change attitudes, perspectives and perceptions.

An integrative literature review was conducted with the purpose of mapping the existing evidence on the use of games in the management of the oncological disease.

Methodology

The integrative review was conducted based on the Joanna Briggs Institute guidelines (Joanna Briggs Institute, 2017). A question was formulated using the elements PICO (population, intervention, comparison, outcome) to define the scope of the review and assist in the development of the database search strategy. The inclusion and exclusion criteria presented in Table 1 were applied for the selection of the studies.

Table 1: Criteria for the selection of studies

Based on the guiding question, the search for articles was performed by peers, in May 2018, in the following databases: MEDLINE® (Medical Literature Analysis and Retrieval System Online), CINAHL® (Cumulative Index to Nursing and Allied Health Literature), Psychology and Behavioral Sciences Collection ® and the Scientific Electronic Library Online (SciELO). The search was conducted using the following keywords and terms for the construction of Boolean phrases.

((("Games, Experimental") OR ("Play and playthings") OR ("didactic tool") OR ("game*") OR ("Board game") OR ("play") OR ("Self directed learning") AND (("Self Care") OR ("Self efficacy") OR ("Self-efficacy") OR ("Self-care") OR ( "Self-Control") OR ("Self control") OR ("Self-care behavior") OR ("Self care Behavior") OR ("Self-care Strategies") OR ("Self care Strategies") OR ("Self concept") OR ("Self-concept") OR ("Self-regulation") OR ("Self-regulation") OR ("Self management") OR ("Self-management") OR ("Patient Care Management") OR ("Disease Management") OR ("Self care agency") OR ("Self-care agency") OR ("Self care demand") OR ("Self-care demand") OR ("Self care requirements") OR ("Self-care requirements") OR ("Self") or monitotoring ("Self-monitotoring") OR ("Self Medication") OR ("Self-Medication") OR ("Symptom management") OR ("Patient autonomy*") OR ("Patient Compliance") OR ("Health behavior") OR ("Attitude to health") OR ("Attitude to illness") OR ("Patient attitude*") OR ( "Choice behavior") OR ( "Illness behavior") OR ("Control (Psychology)") OR ("Informal Social Control,")) (("Chemotherapy") OR ("Antineoplastic Protocols") OR ("Antineoplastic Combined Chemotherapy protocols") OR ("Antineoplastic Agents") OR ("Chemotherapy, Adjuvant") OR ("Consolidation Chemotherapy") OR ("Maintenance Chemotherapy") OR ("Oncolog* Patient*") OR ("Cancer Patient*") OR Malignant tumor ("**") OR ("Neoplasm")))

The entire review process was carried out independently by researchers and the final result were obtained after reaching consensus. A specific tool designed by the researchers was used to systematize and categorize data extracted from the articles that were later processed. The process for selection of the studies involved different stages, according to the diagram PRISMA® (Preferred Reporting Items for Systematic Review and Meta-Analyses), displayed in Figure 1.

Figure 1: Process of identification and inclusion of studies - PRISMA® Diagram Flow
To increase the accuracy of this review, the selected articles were sorted hierarchically, based on the levels of evidence for effectiveness suggested by the Joanna Briggs Institute (2014).
At level 1, Experimental Designs:

• Level 1.a – Systematic review of Randomized Controlled Trials (RCTs),
• Level1.b – Systematic review of RCT sand other study designs,
• Level 1.c – RCT and
• Level 1.d – Pseudo-RCTs.

At level 2, Quasi-experimental designs:

• Level 2.a – Systematic review of quasi-experimental studies,
• Level2.b – Systematic review of quasi-experimental and other lower study designs,
• Level 2.c – Quasi-experimental prospectively controlled study, and
• Level 2.d – Pre-test – post-test or historic/retrospective control group study.

At level 3, Observational – Analytic Designs:

• Level 3.a – Systematic review of comparable cohort studies,
• Level3.b – Systematic review of comparable cohort and other lower study designs,
• Level 3.c – Cohort study with control group,
• Level 3.d – Case-controlled study and
• Level 3.e – Observational study without a control group.

At level 4, Observational–Descriptive Studies:

• Level4.a – Systematic review of descriptive studies,
• Level 4.b – Cross-sectional study,
• Level 4.c – Case series Level, and
• Level 4.d – Case study.

And at level 5, Expert Opinion and Bench Research:

• Level 5.a – Systematic review of expert opinion,
• Level 5.b – Expert consensus, and
• Level 5.c – Bench research/ single expert opinion (Joanna Briggs Institute, 2014).

Results and Discussion

A total of 390 articles were initially identified, from which 59 repeated articles were excluded. After applying the different steps displayed in the diagram (Figure 1), a final sample of 13 articles was selected. Table 2 summarizes the articles that comprised the review, considering the authors, year, country, objective, methodology, participants, type of game and the level of evidence.

Table 2: Summary of articles comprising the integrative review

After a brief characterization of the studies under analysis, it is clear that the majority of the studies were conducted in the United States (N=10). This evidence, also corroborated by other authors, can be explained by the fact that this review does not include publications in all languages, which may have contributed to the few publications about health games from Japan and China, despite their significant role in the gaming industry (Kharrazi et al., 2012).

In relation to publication year, the first selected study was published in 2005, meaning that the results concern the last 14 years. This fact is likely connected to rapid technological development in recent years. Although the current technology has been available for 30 years, the boom in its application is associated with advances in internet accessibility and more sophisticated game development software (Charlier, et al., 2016). Although the games do not have to be only related to the development of software and computer applications, the results show that their development is associated with the development of computers and the Internet (Rocha, et al., 2016). The huge spread of the Internet, commonly through mobile devices, has fostered a new area of intervention: mobile health or mHealth (Charlier, et al., 2016). In a review study on serious health games, the authors also found the majority of related studies were published after 2005 (71.8%) (Kharrazi et al., 2012).

This analysis of the selected studies enabled the researchers to identify three relevant thematic areas: categorization based on the participants, type of games, and purpose of the thematic areas of the game.

Categorization Based on the Participants

Serious games have emerged to provide education and improve self-management (Kharrazi et al., 2012; Safdari et al., 2016; Charlier, et al., 2016). Due to the increased processing and storage capacities, smartphones have become part of people’s daily lives and are often indispensable. Smartphones are often used on a daily basis and are easily adapted to a large variety of activities linked to professional, education, communication and entertainment topics. Some games are becoming more appealing to a growing number of users and are even reaching older age groups. Initially, when digital games emerged, they were designed especially for young people, because the characteristics of the games matched the "Digital Age" learning styles of those who grew up around computers, video games and the Internet (Charlier, et al., 2016).

Although serious games in health are becoming a joint intervention involving various age groups, the articles under analysis are essentially focused on their application for adolescents (S1, S6, S12, S13) and young adults (S1, S4, S6, S9, S11) (details in Table 2).

Studies S2, S5 and S7 reported games that targeted adults, but did not specify the ages of participants. Only two studies (S3, S10) related to games specifically applied to elderly participants. The review study conducted by Kharrazi et al. (2012) pointed out that in a total of 149 studies, 65% of participants were younger than 20 years old.

The age of the users seems to be an important aspect in the design of the games. As stated by Charlier et al. (2016), younger people are typically more oriented to the visual aspect of the software compared to older people and can easily manage multiple streams of information simultaneously.

In a study conducted on the design and assessment of a mobile application targeting the elderly, the authors made important recommendations in relation to the navigation system. They proposed that designers be cautious with the use of template panorama and pivot, considering its complexity when applied to older adults, who are more likely to experience difficulties in mentally organizing and structuring these components. They also suggested the use of a back-function key to safely return to the previous menu, the use of semantically adapted words, providing sufficient letter spacing between items, and using icons alongside the text when designing buttons (Barros, Leitão & Ribeiro, 2014).

Type of Games

As the link between health literacy and positive health outcomes gradually increases, researchers also seek to find interactive games as a means to provide health information (Reichlin et al., 2011). Games are a phenomenon that is part of the history of humanity and has reached a new level alongside technological development (Cruz, 2017). A game is a process in which players are involved in a simulated challenge, with specific rules in pursuit of a specific goal or objective (Kharrazi et al., 2012; Bedwell et al., 2012). However, when the goal of a game extends beyond mere entertainment, by stimulating mental exercise, physical education, health, training and the acquisition of knowledge, it is called a serious game (Schmidt & Marchi, 2017). Hence, the main difference between serious games and other types of games is the focus on a specific outcome to achieve changes, using the specificities of interactive games for purposes other than entertainment, such as education or training (Reichlin et al., 2011). Although the serious games for management of oncology disease are currently linked to digital games, they can be presented in a different format (Bedwell et al.,2012; Fernandes & Ângelo, 2018). Different resources were identified in this study, the majority being electronic games for computer or cell phone.

Board Games

In the studies analysed, two board games were identified (S7, S9). A board game of communication, "My Wonderful Life Board Game"®, features appealing and therapeutic elements such as the sharing of answers to the questions presented in the cards and the conduction of specific activities (Pon, 2010). Another board game, "ShopTalk"®, includes a coloured box with 10 houses, each with a set of 15 cards of topic-related questions. The names of the houses reflect concerns of young people living with cancer. The questions in each house are mainly open questions, allowing creative responses (Wiener et al., 2011).

Electronic Games

Electronic games are mostly for computer use; however, they are also presented in mobile game format. Some of the studies refer to the use of electronic games but do not add any description (S6, S10 and S12) (Kato & Beale, 2006; Jones, et al., 2010 ; Loerzel, Clochesy & Geddie, 2018).  In studies under analysis, the Re-Mission® was the most applied game (S1, S4 and S11) (Beale et al., 2006; Khalil, 2012; Khalil, Beale, Chen & Prokhorov, 2016). Re-Mission® is an electronic computer game to promote adherence to self-care during the treatment and teaching strategies of self-care and knowledge related to cancer. Re-Mission® is a third-person action game in which the player manipulates an avatar (a young humanoid robot) in three-dimensional (3-D) missions. The game consists of a set of missions to defeat cancerous cells and other enemies (for example, bacteria, mucositis, etc). The objective of the players is to destroy their enemies by using weapons such as the common treatments (chemotherapy, radiation and antibiotics). To complete the objectives, the player must use elements of the game called "communication taps,” allowing engagement in positive self-care behaviours such as performing mouth care to combat the mucositis, using relaxation techniques to reduce stress, managing medication, among other activities (Beale et al., 2006).

In study S3, an interactive serious computer game “Time After Time®” was used. The game aims specifically at increasing the awareness and understanding of men about the impact and quality of life associated with the main treatment options, as well as to improve communication with health professionals. Throughout the game, the user is faced with side-effect scenarios by using images from the deck of cards. For each treatment option and in a specific period of time (immediately after treatment, two months and 12 months after), the players are presented with card combinations of side-effects. Each time a card is presented, players are asked to score it from one to five. Throughout this process, users can keep any card for further discussion with healthcare professionals at the end of at least one round of the game (Reichlin, et al., 2011).

Study S8 presented three types of interactive electronic games that were designed and made available on the internet for women. In the game ‘'Native Breast Cancer Detective" (with two versions, users and health professionals), players scored by answering questions about case scenarios. The game "Breast Care Bingo"® is a game in which the user responds to certain questions. The game ends when the player hits ''BINGO'' (e.g. five correct answers in vertical, horizontal or diagonal row). In the ''Breast Health Advisor'® game, there is an animated scenario with specific situations in which the characters discuss breast health problems, with multiple choice questions. In this game, the player acts as a health advisor having to deal with the questions asked by the characters in the scenario (Roubidoux et al., 2005).

The mHealth® game was used in the study S2 and consists of a mobile health tool for use on an iPad. The game guides people with lung cancer to assertive communication strategies during visits to virtual clinics. The users are welcomed to a point outside the oncology center where they are assisted by a guide or coach. The trainer is presented as a friend offering explanation and support, whose advice and information can be tapped through the entire experience. The goal of the players is to choose the more assertive responses to help gather the largest amount of information to manage their clinical status (Brown-Johnson, Berrean & Cataldo, 2015).

In study S13, a game called "Pain Squad"® was developed, consisting of a pain assessment tool for smartphones. The application works as an electronic diary for pain and allows data collection on the intensity of pain, duration, site and impact of pain in the activities of daily life (e.g. relationships, work, school, sleep, mood). The game also evaluates the effectiveness of medication and other strategies of physical and psychological pain management. Users are prompted twice a day, at specific times to complete 20 questions about their pain difficulties. Using a web interface, the application sends the results to a database for aggregated reports. Each entry in the logbook represents a case of pain presented by an adolescent with cancer. A reward system encourages the consistent use of the diary (Stinson, et al., 2013).

The types of games under analysis in a similar study are in line with the results of this present study, showing a total of 149 publications, of which 67.8% used computer video games and approximately 5% of health games were designed for mobile devices (Kharrazi et al., 2012). We believe that these results are related to the fact that the development of mobile phone applications is not yet published in studies. These results are associated with the absence of publications and instruments to validate their application (Primack, et al., 2012 ; Schmidt & Marchi, 2017). Although mobile health (mHealth) is a new way of generating evidence, there is still a lack of publication and discussion about its use and effectiveness (Primack, et al., 2012; Rocha, et al., 2016).

Purpose of the Thematic Areas of the Game

Serious games have become increasingly popular to draw the attention of people to the promotion of healthier lifestyles and to help people learn about a variety of health conditions and treatments. Games are oriented to ease health communications and to positively influence attitudes and behaviours of individuals (Safdari et al., 2016). New technological achievements and the dissemination of the Internet have opened new perspectives for health interventions. Among the potential applications of this type of resource, a special highlight is given to interventions on health promotion (Rocha et al., 2016) and support for health-illness transition processes through the promotion of self-care (Charlier et al., 2016).

Health Promotion

Studies S4, S5, S8 and S11 focused on the management of health promotion activities. In study S4, the authors used a game for young people to help them acknowledge the severity of cancer and to promote healthy behaviours (Khalil, 2012). In study S5, the authors evaluated the use of a serious game to provide information about the risk of prostate cancer (Cosma et al., 2016). In study S8, the authors used a game to promote teaching on surveillance and knowledge about breast cancer (Roubidoux et al., 2005). Finally, in study S11, the perceptions of young adults on the risk of cancer and their motivation to protect themselves and seek information from health professionals were assessed (Khalil, 2012).

Health-Illness Transitions

Meleis (2007) defined health-disease transition as a change in health status involving adaptation to the event. This transition implies a redefinition of their selves through the learning of new knowledge and skills, in this case for the self-management of cancer disease.

It is observed that the majority of the studies aimed to promote knowledge of the health-disease process, facilitating the transition and the development of self-care skills. In studies S1, S6 and S12, the main focus of the games was to determine the effects of their use in the self-care of young people with cancer (Beale et al., 2006; Kato & Beale, 2006; Jones, et al., 2010). In study S13, which also targeted young people with cancer, the game aimed to promote the use of strategies for the management of pain (Stinson, et al., 2013).

In study S2, the use of mHealth aimed to guide patients with lung cancer to improve communication with health professionals and self-management (Brown-Johnson, et al., 2015). The game included in study S3 was specifically aimed at increasing the awareness and understanding of the impact of the various treatment options on the quality of life of patients with prostate cancer (Reichlin, et al., 2011). Studies S7 and S9 included games directed at different users but with a single purpose of enhancing communication. Study S7 (Pon, 2010) addressed a game directed at patients with cancer in an advanced stage, and in study S9 (Wiener, et al., 2011), the game was directed at young people encouraging them to discuss their experiences with cancer. Finally, study S12 included a game developed for the management of nausea and vomiting induced by chemotherapy in elderly patients with cancer (Jones, et al., 2010).

Games can adapt content and challenges according to the user’s ability, educational level, personal interest and disease experiences, thus allowing users to adopt a self-management plan using their own resources (Charlier, et al., 2016). Learning for self-management implies an individuals' knowledge of their own health condition, how to monitor signs and symptoms, interpret their meaning, and evaluate available options and implement strategies for effective management (Silva & Pontífice, 2015).

In the Study S1, results indicated a specific effect of the game “Re-Mission” played on cancer knowledge that is not attributable to patients’ expectations (Beale et al., 2006). In study S11, by virtually experiencing the consequences of cancer cell behaviour, players of ‘‘Re-Mission’’ increased their perception of cancer risks, protective motivation, and intentions to seek cancer-related information (Khalil, 2012). However, the same results of the game were not obtained in a healthy population (Khalil et al., 2016). In study S12, teens receiving the CD-ROM were significantly more likely to increase their internal locus of control scores (Jones, et al., 2010).

The correct application of serious games implies proper planning, as well as the requirement of assessment methods to ensure achievement of the desirable outcomes (Schmidt & Marchi, 2017). The studies under analysis used a diversity of strategies to evaluate the effectiveness of games, including questionnaires and personal or group interviews. All studies reported advantages with the use of games, such as credibility, clinical adequacy, health promotion, health communication, and utility for managing signs, symptoms and self-care.

The benefits of using games are diverse, including benefits for health professionals and organizations. The advantages for health institutions are the reduction of treatment costs and visits to centers and increased satisfaction of users and health professionals (Safdari et al., 2016). There are advantages to the health system, such as the opportunity to promote the culture of health through the education of healthy behaviours in the community. There are advantages to society by increasing the level of participation and literacy in health, and there are advantages for patients through continuity of care without the constraints of time and place (Safdari et al., 2016).

A review study on the role of games to improve health outcomes, included a total of 38 studies, emphasized the importance of the implementation of appropriate assessment methodologies, extended follow-up time of users, and best quality measures, as well as the use of standardized measures with specific tools (Primack et al., 2012). In addition to the dimensions of joy, happiness, emotional experience, education and promotion of knowledge, games can also have negative dimensions due to improper use and incorrect design potentially leading to cognitive, mental and physical damages. If the games are not adapted to the user’s age, culture and content, they are likely to cause harmful consequences such as social isolation, decreased performance, increase of aggressive behaviours, impaired attention, and attention problems, among others (Safdari et al., 2016).
Nurses and other health professionals need to be actively involved in the development of games for the management of disease. The information in these games should be validated by health professionals, such as nurses, who are responsible for and qualified to provide patient education. With first-hand knowledge on the existing games, nurses can assist their patients to use health information and encourage them to be more active in their healthcare. 

This review study reveals some limitations, including the fact that the articles under analysis do not always provide all the information about the game. Another limitation of the study concerns the use of games only describing their application. This criterion was adopted to obtain a higher level of evidence on the use of games in the management of the oncological disease.

Conclusion

This systematic literature review permitted the identification of the scientific production related to the use of games in the self-management of oncology disease. The publications which were used to describe the use of games were published in the last 14 years. It should be noted that in relation to the management of the oncological disease, serious games may be an effective means for education and health intervention, especially for self-care, and the management of signs and symptoms, among others.

Despite the benefits of these resources, games should be carefully designed considering specific objectives. The combination of recreational components and the training of self-care skills enhance the empowerment of people to control their health and medical conditions, promoting self-management and increasing their knowledge.

Citation: Fernandes, C, Magalhaes, B., Santos, C., and Martines-Galiano, J. (Fall, 2019). The use of games in the self-management of oncological disease: An integrative literature review. Online Journal of Nursing Informatics (OJNI), 23(3), Available at http://www.himss.org/ojni

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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