information

Review
Serious Games and Gamification in Healthcare: A Meta-Review
Robertas Damaševičius 1, * , Rytis Maskeliūnas 2 and Tomas Blažauskas 1

1 Department of Software Engineering, Kaunas University of Technology, 44249 Kaunas, Lithuania

2 Department of Multimedia Engineering, Kaunas University of Technology, 44249 Kaunas, Lithuania
* Correspondence: robertas.damasevicius@ktu.lt

Abstract: A serious game is a type of game that is designed for a primary purpose other than enter-
tainment. Instead, serious games are intended to achieve specific goals, such as education, training,
or health promotion. The goal of serious games is to engage players in a way that is both enjoyable
and effective in achieving the intended learning or behavior change outcomes. Recently, several
systematic reviews on the development and application of serious games and on the application of
gamification techniques have been published, which indicate high activity and ongoing progress in
this area of research. Such an extensive body of review papers raises the need to analyze and extract
the current state and the prevailing trends of the serious games and gamification (SGG) domain
by analyzing and summarizing the systematic review articles. This study presents a systematic
meta-review, i.e., a review of the 53 survey papers on the domain of serious games and gamification.
The systematic review follows the PRISMA guidelines, while constructive and cross-sectional meth-
ods are used to analyze and present the results. Finally, this study identifies the future trends and
challenges for the domain. As a result, the meta-review helps the reader to quickly assess the present
status of SGG and serves as a reference for finding further information on each technology utilized in
SGG. Using the criterion of the citations, the meta-review analysis provides insight into the quantity
and academic relevance of the published SGG articles. Moreover, 53 articles published in journals
were selected as important surveys in the research field. The study found that serious games and
gamification techniques are increasingly being used for a wide range of health conditions and the
focus is shifting towards the use of mobile and digital platforms, virtual reality, and machine learning
to personalize and adapt interventions. The existing research gaps include the lack of standardization
in development and evaluation, insufficient understanding of underlying mechanisms of action,
Citation: Damaševičius, R.;
limited understanding of integration into existing healthcare systems, limited understanding of
Maskeliūnas, R.; Blažauskas, T.
Serious Games and Gamification in
specific game mechanics and design elements for promoting health behaviors, and limited research
Healthcare: A Meta-Review. on scalability, adoption, and long-term effects. These research gaps highlight the need for further
Information 2023, 14, 105. https:// research to fully understand the potential and limitations of serious games and gamification for
doi.org/10.3390/info14020105 health and how to effectively apply them.

Academic Editors: Ricardo Queirós

Keywords: gamification; serious game; healthcare; meta-review
and Jakub Swacha

Received: 24 October 2022

Revised: 4 February 2023
Accepted: 6 February 2023 1. Introduction
Published: 7 February 2023
A game is a structured activity that is typically conducted for entertainment or leisure
purposes but can also be used for educational or training purposes [1]. Games can take
many forms, including physical games, board games, card games, video games, and online
Copyright: © 2023 by the authors.
games. There are various meanings of the term “game”, all of which have some similarities
Licensee MDPI, Basel, Switzerland. but also significant distinctions. Several definitions tend to lump other activities into the
This article is an open access article same class as games, while others exclude a few games based on various criteria (for
distributed under the terms and example, “artistic motive”). For the sake of this evaluation of digital game reviews, we
conditions of the Creative Commons selected Smed and Hakonen’s view on games [2]. This definition considers the digital
Attribution (CC BY) license (https:// character of games while defining games based on factors directly connected to game-like
creativecommons.org/licenses/by/ traits, rather than creative or economic decisions adopted during development. Another
4.0/). definition states that a game is a collection of goal-oriented actions carried out by following

Information 2023, 14, 105. https://doi.org/10.3390/info14020105 https://www.mdpi.com/journal/information

Information 2023, 14, 105 2 of 31

the predetermined rules [2]. Games are distinguished from profession simulators and
virtual reality (VR) apps by their goal-oriented character, which drives the player. Simulta-
neously, the rules provide difficulties, and unexpected random actions or unpredictable
human players can cause conflicts, preventing participants from reaching their aim. The
game’s depiction makes the game more concrete for the player and matches to the game’s
regulations. Digital games are played on computers and mobile phones with the help of
digital equipment [3].
A serious game is a type of game that is designed for a primary purpose other than
entertainment [4]. Instead, serious games are intended to achieve specific goals, such
as education, training, or health promotion. Serious games can take many forms, such
as simulations, role-playing games, and educational games, and can be used in various
settings, such as classrooms, workplaces, and healthcare settings. The goal of serious games
is to engage players in a way that is both enjoyable and effective in achieving the intended
learning or behavior change outcomes [5]. Initially, serious games were adopted in the
educational domain to promote interest and support motivation in learning [6,7]. The
concept of utilizing serious games to improve healthcare outcomes has attracted support
from an increasing group of academic scholars, developers, and healthcare practitioners [8].
Many people are now aware of the need of developing evidence-based games which are
specifically geared to treat physical and mental health issues that end users suffer with [9].
Game-based therapies are increasingly being used in healthcare to promote motivation,
engagement, and the overall sustainability of health habits [10]. Gamification and serious
games are the most common forms of game-based treatments in healthcare studies.
Gamification is the process of incorporating game design elements into non-game
contexts, such as business, education, or healthcare, to engage and motivate people to
achieve their goals [11]. Gamification can take many forms, such as adding points, badges,
or leaderboards to a task or activity, or incorporating game-like challenges and feedback into
a process or system. The goal of gamification is to increase engagement, motivation, and
participation in the task or activity, and to improve outcomes such as learning, productivity,
or health [12]. Gamification is a comparatively recent concept that shines a spotlight
on using game principles in non-game environments to attract audiences and insert the
elements of entertainment into monotonous work while also providing motivational and
cognitive advantages [1]. While many industries, such as business [13], marketing [14],
work [15], and education [16], have taken advantage of gamification’s potential, the digital
healthcare sphere has begun to do so as well. However, it is fascinating to observe that
gamification has entered the mainstream, whereas serious games have remained on a small
scale, regardless of how outdated the idea of serious games is.
Recently, there has been an upsurge in research into the usefulness of digital games,
with multiple individual and systematic reviews that present the top level of research
evidence in the field [3–5,12,16]. There are several reasons why there is a need to research
games, serious games, and gamification methods. Firstly, games and gamification are being
increasingly used in various fields such as education, health, business, and government, and
there is a need to understand their effectiveness in achieving specific goals and outcomes.
Research can help to identify the most effective game mechanics and design elements for
different contexts and populations, and to understand how these interventions can be
integrated into existing systems and processes. Secondly, the use of games and gamification
is rapidly growing and evolving, and there is a need to keep up with the latest developments
and trends in the field. Research can help to identify new and emerging technologies and
techniques, and to understand how these can be used to achieve specific goals and outcomes.
Thirdly, games and gamification have the potential to make a positive impact on people’s
lives, and there is a need to understand how these interventions can be used to promote
positive health outcomes, improve education and training, and increase engagement and
motivation in different fields. Research can help to identify the most effective ways of
using these interventions to achieve specific goals and outcomes. Lastly, the field of
games, serious games, and gamification is still relatively new, and there is a need to
Information 2023, 14, 105 3 of 31

establish a strong evidence base to support the use of these interventions in different fields.
Research can help to establish the best practices, guidelines, and standards for the use of
games and gamification, and to identify areas for further research and development. As
a result, a summary and assessment of the quality of these data published in systematic
evaluations and reviews would be useful for building future serious games and guiding
future gamification research.
A previous meta-review in the areas related to the development and use of serious
games included the works of Radu et al. [17] and Parisod et al. [18]. Radu et al. [17] dis-
cussed augmented reality (AR) as an educational medium, which also included educational
games. The study examined 26 prior studies that contrasted student learning in AR against
non-AR apps. The meta-review of Parisod et al. [18] examined digital games that are good
for promoting kids’ health. This evaluation of reviews was conducted with the intent of
evaluating the quality of systematic reviews, summarizing the evidence in those studies
that focused on the usefulness of games in supporting and promoting healthy lifestyle, and
identifying knowledge gaps.
The purpose of this study is to provide an overview of the topic of using serious
games and gamification (SGG) in various fields. It serves as a meta-review, offering a
comprehensive understanding of what gamification can offer without delving into detailed
comparisons of methods or outcomes. The aim is not to suggest a single optimal strategy for
using SGG, but rather to provide a complete evaluation to help academics and practitioners
to understand the research gaps and potential of this approach.
The goal of this study is to conduct a systematic analysis of SGG research using a
well-defined data search process and coding scheme to answer the following questions:
1. What are the most common health conditions that serious games and gamification
techniques have been used to address?
2. What are the most common game mechanics and design elements used in serious
games and gamification for health?
3. What is the evidence for the effectiveness of serious games and gamification in
promoting positive health outcomes?
The following are the primary contributions of this study:
• A curated collection of SGG surveys over the last five years.
• Based on citations to publications discovered in chosen surveys, an analysis of the
present situation of the SGG research field.
Section 2 of the study begins with an overview of the methodology for performing a
systematic review and describes the process of the performed review. Section 3 presents and
discusses the results of the meta-review on SGG for health. Section 4 discusses the selected
review studies, as well as the issues that come with it and conducts a thorough examination
of 53 surveys to obtain insight into the works’ academic effect. Section 5 presents the
findings of this study with regard to research questions and limitations. Section 6 discusses
research gaps, trends, challenges, and future directions. Finally, Section 7 concludes with
concluding remarks.

2. Methodology
Academic publication has accelerated in recent years, both in terms of quantity and
pace of publication. Simultaneously, new venues for publishing are fast-emerging, such as
conference proceedings, scientific blogs, and a plethora of scientific journals, which allow
the researchers to report their work in a variety of places. To keep up with the explosion
of systematic reviews across fields, new methodological techniques for synthesizing this
information have been created. In sectors where a rising number of systematic reviews are
available, conducting reviews of previous systematic reviews has turned into a reasonable
next step in presenting research evidence.
When many systematic reviews on comparable or related subjects already exist,
overviews or umbrella reviews are most typically utilized to gather, assess, and synthesize
Information 2023, 14, 105 4 of 31

the results of relevant systematic reviews [19]. As a result, evidence from several reviews
or survey papers is compiled into a review of reviews or an umbrella review. The analy-
sis of formerly published systematic reviews may use other terms such as “summary of
systematic reviews”, “review of reviews”, “synthesis of reviews”, and “meta-review” [20].
Reviews of reviews are made to compile evidence from multiple review papers into a single
document that is accessible and useful for researchers. They present the best evidence
possible by summarizing the evidence for several solutions, describing the quality of the
evidence, and discussing the advantages of the conclusions [20].

2.1. Literature Search

We followed a PRISMA methodology for systematic reviews in this study. We carried
out a literature search on 24 March 2022, from the Scopus database, which is represented in
Table 1. The authors predetermined the inclusion criteria for this review of reviews. Only
reviews that reported conducting a literature search and systematic reviews (including
meta-analyses) were included. The focus of the chosen literature had to be on video games.
The review articles that solely focused on subjects other than digital games (e.g., simulation,
VR apps, nondigital games) were disregarded. Digital games were referred to by the
keywords “video game”, “computer game”, “electronic game”, “mobile game”, or “app”.
The inclusion and exclusion criteria set beforehand were followed when systematically
screening the findings. Two impartial reviewers checked the titles and abstracts (R.D. and
R.M.). Disparities were addressed and resolved using the previous criteria after the initial
screening. Fifty systematic reviews and reviews were selected for analysis because of the
screening. A follow-up search in the Web of Science (WoS) bibliographic database was
conducted using the same procedure as the updated search in August 2022. Three new
systematic reviews were added as a result.

Table 1. Summary of the search.

Bibliographic Database Scopus

Article title “serious game” OR gamif *
Search within results health * OR medical OR rehabilitation
Years 2017–2021
Document type Review
Source type Journal
Language English
(TITLE (“serious game”)) AND (TITLE-ABS-KEY (health * OR medical OR rehabilitation)) AND
(LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019)
Search query
OR LIMIT-TO (PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017)) AND (LIMIT-TO (DOCTYPE,
“re”)) AND (LIMIT-TO (LANGUAGE, “English”)) AND (LIMIT-TO (SRCTYPE, “j”))
Symbol “*” is a part of search query and denotes any symbol.

The search yielded 45 studies. Forward snowballing yielded 1 additional study.

Backward snowballing yielded 7 additional studies. The total number of studies selected
for further analysis was 53. Figure 1 demonstrates the selection procedure using the
PRISMA flowchart.

2.2. Assessment of Quality

All the reviews included in the study were assessed using the AMSTAR (http://amstar.
ca/, accessed on 1 October 2022), a technique for assessing the quality of systematic reviews
and meta-analyses. There were 11 items on the checklist, which included inquiries about
the literature search, paper selection, and analysis, as well as summarizing the systematic
review’s findings. The checklist was solely utilized as a guiding device and no inferences
Information 2023, 14, 105 5 of 31

Information 2023, 14, 105 5 of 31

regarding the quality of selected articles were drawn based on the AMSTAR ratings. Two
reviewers separately scored and evaluated the quality of the work.

Figure1.1.PRISMA
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ratings. Two reviewers separately scored and evaluated the quality of the work. any overlaps or gaps in
the literature and to identify new areas of research that may have been relevant to the
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Information 2023, 14, 105 6 of 31

for researchers, to identify gaps in the literature and to understand the latest trends
in the field. It can also be used by practitioners to understand the current state of the
field and to identify new areas of research that may be relevant to their work.
These metrics were used to provide an overview of the studies included in the system-
atic review, and to identify patterns or trends that may have been relevant to the research
questions.

3. Analysis of Meta-Review Results

3.1. Preliminaries
A descriptive analysis of the scientific publications is presented. A total of 53 research
publications (review articles), which were published between 2017 and 2021, were included
in the descriptive analysis. The aims of the analysis were formulated as follows:
• Analyze, describe, and present the relevant literature’s relationships (such as the
number of publications per year and research topic, etc.).
• Present information on current research trends in SGG as well as a critical examination
of the issues that have been found.
• To help us to visualize the various study methodologies employed in the scientific
literature up to this point regarding the propagation of SGG review papers.

3.2. Results and Their Analysis

The remaining portions of this paper’s findings are primarily based on 53 SSG-related
papers [21–73] that were published between 2017 and 2021. We did not consider surveys
that just referenced gamification techniques or games in passing or whose material was not
accessible online. The number of the chosen surveys and their annual citation numbers
are shown in Table 2. The number of citations of a study is the number of times other
authors mention a study in their work. In Table 2, we give a total number of citations for
all analyzed review studies in each year. The number is provided according to the Scopus
bibliographic database. Most review papers were published in 2020, while the number of
citations demonstrated a consistent growth from 2017 with the highest number reached in
2021 (Figure 2). As a result, research in the field of SGG has significantly risen during the
previous five years. This growing trend illustrates SGG’s current public and policy effect.

Table 2. Distribution of the selected surveys and their total number of citations (according to Scopus)
by publication year.

Year 2017 2018 2019 2020 2021

Papers 10 8 9 15 11
Citations 15 75 237 386 545

The 53 systematic studies and miscellaneous reviews in total satisfied the inclusion
requirements. Table 3 lists the characteristics of the literature that were included according
to subject area (research topic). The list of categories is based on the classification of
papers into subject areas used in the Scopus bibliographic database. Most of the review
papers were published in the subject areas of medicine (42), computer science (15), health
professions (15), and engineering (15), which faithfully reflects the intertwining of the
problem domain of healthcare and the solution domain of games developed using computer
science methodology. Note that some papers are listed in multiple domains.
Information 2023,
Information 14, 14,
2023, 105105 7 of 731
of 31

Figure 2. Scopus
Figure search
2. Scopus results
search using
results Scopus
using collection
Scopus database:
collection Left:
database: number
Left: numberof publications from
of publications from
2017 to 2021. Right: Citation report of these publications throughout the years.
2017 to 2021. Right: Citation report of these publications throughout the years.

The3.53Distribution
Table systematicofstudies
papers by
andsubject area (more than
miscellaneous one study).
reviews in total satisfied the inclusion
requirements. Table 3 lists the characteristics of the literature that were included accord‐
Subject Area Number of Papers References
ing to subject area (research topic). The list of categories is based on the classification of
Medicine papers into subject 41 areas used in the Scopus[21–25,27,31,32,35–38,42–44,46–56,58,60–72]
bibliographic database. Most of the review
Computer Science papers were published 15 in the subject areas of [22,24,26,27,31,38–40,48,57,60,62,70,72,73]
medicine (42), computer science (15), health
Health Professions professions (15), and 15 engineering (15), which faithfully reflects the intertwining of the
[21,23,24,42,44,47,51,55,56,61,63,65,67–69]
problem domain of healthcare and the solution domain of games developed using com‐
Engineering 15 [21,23,24,30,40,42,47,51,55,60,61,63,65,67–69]
puter science methodology. Note that some papers are listed in multiple domains.
Social Sciences 10 [22,27,29,31,38,45,48,53,70,72]
Nursing Table 3. Distribution of
4 papers by subject area (more than one study).
[28,33,34,44]

Subject Psychology
Area Number of Papers 2 References [26,66]
MedicineOthers 41 6 [26–28,36,53,60]
[21–25,27,31,32,35–38,42–44,46–56,58,60–72]
Computer Science 15 [22,24,26,27,31,38–40,48,57,60,62,70,72,73]
Health Professions 15 The analysis of published [21,23,24,42,44,47,51,55,56,61,63,65,67–69]
surveys by venue shows (Table 4) that most articles were
Engineering 15
published in the JMIR Serious [21,23,24,30,40,42,47,51,55,60,61,63,65,67–69]
Games journal (11), followed by Games for Health Journal (6),
Social Sciences which are currently the leading publication
10 venues for health-related serious games and
[22,27,29,31,38,45,48,53,70,72]
Nursing gamification
4 techniques. JMIR Serious Games is a multidisciplinary journal devoted to com-
[28,33,34,44]
Psychology puter,
2 mobile, and VR applications that incorporate
[26,66]elements of gaming and gamification,
or novel hardware platforms such as VR headsets to solve serious problems in the health
Others 6 [26–28,36,53,60]
domain. Games for Health Journal is the peer-reviewed journal dedicated to gaming research,
technology, and applications for human health and well-being.
The analysis of published surveys by venue shows (Table 4) that most articles were
published in the JMIR Serious Games journal (11), followed by Games for Health Journal (6),
Table 4. Distribution of papers by venue of publication (more than one study).
which are currently the leading publication venues for health‐related serious games and
gamification techniques. JMIR VenueSerious Games is a multidisciplinary Numberjournal devoted to
of Papers
computer, mobile, and VR applications
JMIR Serious Games that incorporate elements of gaming
11 and gamifi‐
cation, or novel hardware platforms such as VR headsets to solve serious problems in the
Games for Health Journal 6
health domain. Games for Health Journal is the peer‐reviewed journal dedicated to gaming
research, Journal of NeuroEngineering
technology, and Rehabilitation
and applications for human health and well‐being. 2

Table 4. The
Distribution
analysisofofpapers by venue ofofpublication
the distribution papers by(more thanand
countries one affiliations
study). of authors shows
(Table 5) that the leading countries in SSG research are USA (7), Brazil (6), and Canada (6),
Venue Number of Papers
followed by Germany (5) and the Netherlands (5). The researchers representing the top
JMIR Serious Games 11
universities and medical institutions, such as Harvard Medical School and Massachusetts
General Hospital,Games for Health Journal
have contributed. 6
Information 2023, 14, 105 8 of 31

Table 5. Distribution of papers by countries and affiliations of authors (more than two studies).

Country Universities or Institutes Number of Papers

Harvard Medical School, Johns Hopkins Bloomberg School of Public Health,
University of Pittsburgh, University of Wisconsin School of Medicine and
USA 7
Public Health, Northeastern University, Massachusetts General Hospital,
Boston College, Michigan State University, University of Wisconsin–Madison
Universidade de São Paulo, Universidade Federal de São Carlos, Universidade
Brasil U.B. Fernandópolis, Universidade Federal do Rio Grande do Sul,
Brazil 6
Universidade Federal de Pelotas, Universidade Federal de Uberlândia,
Universidade Federal do Triangulo Mineiro, Universidade Estadual do Ceará
University of Montreal, Royal Alexandra Hospital, Edmonton, Institut de
Canada 6
Cardiologie de Montreal, University of Alberta
Uniklinik Köln, Technische Universität Braunschweig, FOM University of
Applied Sciences (Essen), Technische Universität Kaiserslautern, Technische
Germany Universität Darmstadt, Medizinische Hochschule Hannover (MHH), 5
Karlsruher Institut für Technologie, Peter L. Reichertz Institut für Medizinische
Informatik (Braunschweig)
Universiteit van Amsterdam, Vrije Universiteit Amsterdam, Universitair
Medisch Centrum Groningen, Delft University of Technology, Universiteit
The Netherlands 5
Utrecht, Rijksuniversiteit Groningen, Medisch Centrum Leeuwarden,
Amsterdam Public Health
Universidade Nova de Lisboa, Alcoitão Centre for Rehabilitation Medicine,
Universidade da Beira Interior, Universidade de Aveiro, Instituto de
Portugal 4
Engenharia Electrónica e Telemática de Aveiro, Universidade Católica
Portuguesa, University of Coimbra
Universidad de Murcia, Universidad de Deusto, Universitat de les Illes
Spain 4
Balears, Universidad de Burgos
Deakin University, University of Melbourne, The University of
Australia 3
Western Australia
Erasmus University College Brussels, Université Catholique de Louvain,
Belgium 3
Cliniques Universitaires Saint-Luc
Nanyang Technological University, Singapore Institute of Mental Health,
Singapore 3
National University of Singapore, Singapore General Hospital

The most cited systematic reviews are summarized in Table 6. The top two papers were
published in 2017 and over five years were cited 347 [62] and 1160 [52] times. Study [62]
presented a systematic review of gamification in e-Health, and it was published in the
Journal of Biomedical Informatics.

Table 6. Most cited (over 100 times) systematic reviews (up to 23 October 2022).

Reference Authors Year Journal Citations

Sardi, L., Idri, A.,
[62] 2017 Journal of Biomedical Informatics 347
Fernández-Alemán, J.L.
Lau, H.M., Smit, J.H.,
[52] 2017 Frontiers in Psychiatry 140
Fleming, T.M., Riper, H.
International Journal of Computer
[73] Zhonggen, Y. 2019 115
Games Technology
Villani, D., Carissoli, C., Triberti, S.,
[70] 2018 Games for Health Journal 108
( . . . ), Gilli, G., Riva, G.
Gorbanev, I., Agudelo-Londoño,
[45] S., González, R.A., ( . . . ), Yepes, 2018 Medical Education Online 103
F.J., Muñoz, Ó.
Information 2023, 14, 105 9 of 31

The selected review publications were cited 1474 times. The average number of
citations for a work is 27.83. Most of the publications were cited between 10 and 99 times
(54.7%), while five papers were cited over 100 times (Table 7). The citation distribution
might indicate that (1) the surveys are highly precise and scarcely intersect in substance,
(2) the recommended solutions, identified trends, and presented recommendations in the
survey papers remain relevant for the research in the domain.

Table 7. Number of citations of non-survey works.

Citations Number of Papers (Percentage)

0–9 19 (35.8%)
10–99 29 (54.7%)
>100 5 (9.5%)

The selected survey papers cited 2944 references in total. The most cited references
(Table 8) were the Diagnostic and Statistical Manual of Mental Disorders [74] and Statistical
Power Analysis for the Behavioral Sciences [75], which describe commonly used statistical
analysis methods employed for presenting medical-related research results, while ref. [76]
refers to the PRISMA methodology.

Table 8. Top cited references cited by the analyzed systematic reviews on SSG (up to 23 May 2022).

Reference Authors Year No. of Citations

[74] American Psychiatric Association 1994 193,348
[75] Cohen 1988 118,898
[77] Folstein et al. 1975 68,934
[78] Ajzen 1991 41,588
[76] Moher et al. 2009 37,389

The analyzed survey paper most often used PUBMED (25), Web of Science (15), and
Scopus (12) databases as the main sources of bibliographic information (Table 9). PubMed® ,
maintained by the National Center for Biotechnology Information (NCBI), has more than
34 million citations for biomedical papers from MEDLINE, life science journals, and online
books. Web of Science gives access to many databases that provide reference and citation
data from academic journals, conference proceedings, and other materials in various
academic subjects. Scopus is a bibliographic database managed by Elsevier that covers the
subjects of biological sciences, social sciences, physical sciences, and health sciences.
Table 10 shows the characteristics of survey papers including the number of included
studies, the range of studies, and the keywords (or a search query) used for identifying the
relevant articles. The largest study, published in 2021, analyzed 206 relevant articles on
serious games and gamification, respectively, published in the Journal of Medical Internet
Research (JMIR).
The domain-oriented distribution of the 53 review publications included in our study
is shown in Figure 3.
After the analysis of the abstract and text of the selected reviews, we identified seven
common study topics of interest, as follows: general health (16), rehabilitation (11), virtual
reality (8), video games (8), education (8), mental and cognitive disorder (6), and learning (5).
Here, mental and cognitive disorders include intellectual impairments and conditions
such as anxiety, depression, Parkinson’s disease, Alzheimer’s autism spectrum disorder
(ASD), etc. Education is related to all aspects of teaching, and the use of games in the
pedagogical context to improve the engagement of students and the delivery of professional
knowledge in a formal environment. Rehabilitation is focused on actions meant to enhance
functioning and minimize impairment in people with health issues (such as after traumas
Information 2023, 14, 105 10 of 31

or chronic disease) as they interact with their environment. General health focuses on
maintaining health and well-being throughout the lifetime by practicing exercise, diet,
preventative health checks, oral hygiene, etc. Virtual reality (VR) is a computer-generated
environment featuring realistic-looking images and objects which immerse the viewer in
their surroundings using specialized equipment (VR headset) with visual feedback. Video
games are any electronic games that are based on interaction and visual feedback. Note
that the topics are naturally overlapping. Moreover, several review articles which do not
Information 2023, 14, 105 fall into any of the categories highlight the interdisciplinary nature of the SGG domain.
10 of 31

Table 9. Commonly used databases (more than once) used in review studies.

ScienceDirect
Database 8
Number of Papers
PsycINFO, CINAHL (Current Index to Nursing and Allied
PUBMED 25
6
Web of ScienceLiterature)
Health 15
Google Scholar 5
Cochrane Central Register of Controlled Trials 12
LILACS 3
MEDLINE 11
ACM Digital Library, Taylor & Francis, Springer, ERIC (Educa‐
IEEE Digital Library/IEEExplore 10 2
tion Resources Information Center), Wiley
Scopus, EMBASE 9
Table 10 showsScienceDirect
the characteristics of survey papers including the 8number of included
studies, the CINAHL
PsycINFO, range of(Current
studies,Index
and the keywords
to Nursing and (or a search query) used for identifying
the relevant articles. The largest study, published in 2021, analyzed 2066 relevant articles
Allied Health Literature)
on serious games and gamification, respectively, published in the Journal
Google Scholar 5
of Medical Inter‐
net Research (JMIR).
LILACS 3
The domain‐oriented distribution of the 53 review publications included in our study
ACM Digital Library,
is shown in Figure 3. Taylor & Francis, Springer, ERIC
2
(Education Resources Information Center), Wiley

Figure3.3.Most
Figure Mostcommon
commonterms
termsused
usedininkeyword
keywordabstracts.
abstracts.
Information 2023, 14, 105 11 of 31

Table 10. Characteristics of the systematic reviews and reviews and the studies included within them.

Number of Year Range of

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

Table 10. Cont.

Number of Year Range of

Reference Year of Study Databases Keywords (Search Query)
Included Studies Included Studies
(“serious game *”) AND (educate * OR train * OR teach *) AND (medical
ERIC, Education Source, PsychINFO,
[46] 2019 25 1996–2019 OR medicine OR surge * OR surgical OR physician OR healthcare OR
Global Health, CINAHL, WoS, Medline
doctor * OR nurse * OR “allied health”)
PubMed, Google Scholar, Cochrane “neonatal”, “delivery room”, “infant”, “baby”, “neonatal resuscitation”,
[43] 2019 21 –2019 Central Register of Controlled Trials, “serious game”, “computer game”, “board game”, “video game”, “virtual
CINAHL, WoS, EMBAS reality”, “screen-based simulation”, “table-top simulation”
PubMed, EMBASE, Cochrane Library,
wearable, serious game, videogame or mobile application, and
[56] 2018 12 Current Index to Nursing and Allied
rehabilitation, exercise therapy, physiotherapy
Health Literature
PubMed, PEDro, IEEE Xplore,
ScienceDirect, ACM DL, Mary Ann
[23] 2021 83 2012–2019 serious game and framework
Liebert, Taylor & Francis Online, Wiley
Online Library, Springer
“RETAIN”, “neonatal resuscitation”, “resuscitation training”, “healthcare
PubMed, Google Scholar, Cochrane
professionals”, “digital simulation”, “neonatal”, “infant”, “baby”, “serious
[44] 2020 4 –2019 Central Register of Controlled Trials,
game”, “computer game”, “board game”, “video game”, “virtual reality”,
CINAHL, WoS, EMBASE
“table-top training simulator”
PubMed, Scopus, ERIC, PsycINFO, (video games OR game OR games OR gaming OR computer simulation *)
[51] 2017 9 –2016 Information Science and Technology AND (software design OR design) AND (fidelity OR fidelities OR transfer
Abstracts, EMBASE * OR behavior OR behavior)
Information 2023, 14, 105 13 of 31

Table 10. Cont.

Number of Year Range of

Reference Year of Study Databases Keywords (Search Query)
Included Studies Included Studies
(Students OR Student OR “School Enrollment” OR “Enrollment, School”
OR “Enrollments, School” OR “School Enrollments”) AND (“Video
games” OR “Game, Video” OR “Games, Video” OR “Video Game” OR
“Computer Games” OR “Computer Game” OR “Game, Computer” OR
“Games, Computer”) AND (“Serious Game”) (“Video games” OR “Game,
Video” OR “Games, Video” OR “Video Game” OR “Computer Games”
OR “Computer Game” OR “Game, Computer” OR “Games, Computer”
PubMed/MEDLINE, LILACS, Scopus,
[64] 2020 115 2009–2019 AND “Serious Game”) AND (Learning OR Phenomenography OR
CINAHL
“Memory Training” OR “Training, Memory”) AND (“Cardiopulmonary
Resuscitation” OR “Resuscitation, Cardiopulmonary” OR CPR OR
“Cardio-Pulmonary Resuscitation” OR “Resuscitation, Cardio-Pulmonary”
OR “Code Blue” OR “Mouth-to-Mouth Resuscitation” OR “Mouth to
Mouth Resuscitation” OR “Mouth-to-Mouth Resuscitations” OR
“Resuscitation, Mouth-to-Mouth” OR “Resuscitations, Mouth-to-Mouth”
OR “Basic Cardiac Life Support” OR “Life Support, Basic Cardiac”).
[34] 2017 17 2009–2014 Lilacs, Medline, WoS video games, serious games and obesity
[70] 2018 23 2007–2017 PsycINFO, Scopus “emotion regulation” and “videogames”
“serious games”, “motor rehabilitation”, “Kinect”, “vision-based”,
[25] 2019 86 2007–2019 WoS, PubMed
“virtual reality”
Wildcard “*” is a part of search query; it means any characters.
Information 2023, 14, 105 14 of 31

3.3. Quality Evaluation Using AMSTAR

We used a revised version of AMSTAR (a measurement tool to assess systematic
reviews), which is a popular instrument for critically appraising systematic reviews. It is a
validated tool that assesses the quality of a systematic review by evaluating the process of
conducting the review, rather than the quality of the primary studies included in the review.
It is divided into 16 items that cover various aspects of the systematic review process, such
as the transparency of the search strategy, the reporting of potential biases, and the use of a
systematic approach to data extraction and analysis.
To carry out AMSTAR-2, the review was assessed against each of the 16 items using a
yes/no/can’t answer format. A score of 1 is given for a “yes” answer, a score of 0 is given
for a “no” answer, and a score of 0.5 is given for a “can’t answer” answer. The total score
ranges from 0 to 11, with a higher score indicating a higher quality systematic review.
A score range was created for categorizing the systematic reviews into critical low
(0–4 p), low (5–8), moderate (9–11), and high categories based on the original AMSTAR
method (12–16). Separately, two researchers assessed the studies. Discussions were held
to settle any differences and come to a consensus agreement on the final score. The final
consensus score was 11.75, which indicates a moderate quality of the systematic reviews.

4. Analysis and Discussion of the Systematic Reviews on SSG

In this section, the selected review articles are discussed. For convenience, the articles
are grouped by research topics identified in Section 3 via lexical analysis of titles and
abstracts of publications and the categorization presented in Figure 3 was followed.

4.1. Games for General Health

Study [32] assessed the influence of serious games on smoking start, cessation, and
behavioral variables. The study found 15 studies that evaluated 14 different serious games,
which combined different gaming aspects. General and sporadic incentives, theme and
genre aspects, and penalties were the most used. Eight factors were identified to have
statistically significant beneficial impacts in six trials on smoking avoidance (e.g., attitude,
knowledge, intention). Five of the seven studies on quitting smoking indicated favorable,
statistically significant benefits on quitting or status. Six determinants demonstrated
statistically significant beneficial impacts in these trials (e.g., self-efficacy, attitude, intention).
Stronger game designs are needed to illustrate, measure, and comprehend the impacts of
serious games, as most of the research had significant methodological shortcomings.
Study [47] examined the usage of gamification approaches in stress treatment applica-
tions, as well as their coexistence with evidence-based stress management and behavior
modification tactics. Seventeen gamification tactics, 15 stress management techniques, and
26 behavior modification approaches were evaluated in 62 stress management applications
from the Google Play Store. A taxonomy of gamification strategies was developed and put
into practice. There are no links between the adoption of gamification tactics and behavior
modification or stress management strategies, according to the findings. As a result, stress
management app designers do not employ gamification tactics to influence user behavior
and responses. Furthermore, the app creators fail to see the value of mixing gamification
approaches with behavior modification theories.
Study [48] analyzed the impact of serious games on chronic illness outcomes in chil-
dren. Self-efficacy, adherence, knowledge, theory application, parental participation, and
study quality were all investigated. The review includes a total of eighteen papers. Cerebral
palsy, asthma, diabetes, developmental coordination difficulties, and eye abnormalities
were among the health issues treated. Psychosocial variables such as self-efficacy (i.e., an
individual’s belief in their ability to control their own actions and affect change in their
environment) and knowledge were studied in the analysis. The potential for games to
benefit young people’s health is demonstrated in this study. The mixed results imply,
however, that more serious gaming treatments should be well-developed and extensively
researched to support their influence on improving health outcomes.
Information 2023, 14, 105 15 of 31

Study [51] focused on game-like interventions for health. There were 15 studies that
were relevant. Transfer (i.e., the ability of a patient to apply the skills or knowledge learned
in the game to real-life situations) is seen as a desired consequence but not as a design
concept in studies on game-like treatments for health and healthcare. Studies on game-
like health treatments seldom explain design decisions or give design principles. Games
and simulations for health are based on first-class transfer (i.e., direct application of skills
or knowledge learned in the game to real-life situations), although second-class transfer
(i.e., the application of skills or knowledge learned in one situation to a related but different
situation) is rarely used.
Study [63] undertook a scoping assessment of the development and assessment of
serious instructional games for healthcare workers, patients, and healthy users. The authors
found 161 studies. The findings revealed a positive trend in broadening the scope of health
teaching games beyond a single clinical condition. The findings point to the necessity for
health education game creation and acceptance in poor nations, as well as the need of
interdisciplinary cooperation in the production of effective educational serious games for
health. In order to provide evidence of long-term efficacy, future health games should
include longer follow-up assessments and extend the duration of the game itself. This
would allow researchers to track the progress of patients over a longer period of time
and to see if the benefits of the game continue to be evident even after the game has
been completed.
Study [68] aimed to (1) identify and analyze the needs, suggestions, and guidelines
offered by SSG for health in the scientific literature, and (2) build a consensus framework to
help researchers, game developers, and healthcare professionals in developing evidence-
based SSG for health. This interdisciplinary, iterative, and interactive evaluation revealed
five high-level criteria and 20 low-level requirements provided by the SGH community.
The authors propose a framework for developing theory-driven, evidence-based SGH that
include quantitative trials to assess whether SGH achieve the intended outcomes, and
follow-up monitoring to enable SGH stakeholders to use them in a wide range of projects,
regardless of discipline, healthcare segments, or focus.
Study [71] presented the state of SSG conceptualizations in healthcare research. There
were 206 papers evaluated theoretically in the JMIR and its sibling publications that con-
tained phrases linked to gamification, serious gaming, or both. The authors created the
GAMINGs (game-based intervention reporting guidelines) for researchers reporting on
game-based treatments, which consist of 25 elements organized into four categories of
focus, contribution, awareness, and individual concepts. Following the GAMINGs can help
writers present research outcomes of game-based therapies more rigorously.
Study [72] gave a summary of serious games designed for the training of oral health
professionals or for oral health promotion. A total of 19 investigations (25 publications) were
chosen. Games were separated into two categories: instructional games and games that
promote oral health. Most of the research involved students in the oral health professions
or school/preschool children. In terms of increasing oral health outcomes, interactive
serious games were just as successful as traditional noninteractive techniques. Participants
expressed a higher degree of satisfaction with learning through games in their feedback.
The use of serious games in oral health is restricted, and there is little reliable scientific
evidence to back up their efficacy.

4.2. Games for Rehabilitation

Study [22] assessed the state of the art in terms of interaction modes utilized in games
for the rehabilitation of upper limbs. There were 33 articles examined. Almost half of the
experiments (42.4%) employed vision systems as an interaction modality and collected
body motions using the Kinect sensor (48.48%). Lighting conditions have the potential to
alter the device performance of vision systems and supplementary vision systems. Not
many studies have been conducted on the use of serious games for finger rehabilitation and
Information 2023, 14, 105 16 of 31

treating injuries, or on how to combine multiple sensor data to improve the way people
interact with the game. These research gaps may be promising topics for future study.
Study [23] reviewed the benefits of utilizing a software engineering methodology
in serious games for physical rehabilitation. For this investigation, 83 publications were
chosen. Eight of the eighty-three publications examined employed a software engineering
framework to construct their work. Most of them concentrated on one or more factors,
such as data collection and processing, game levels, incentive, and therapist monitoring.
This comprehensive examination reveals that most serious games are not developed using
software engineering. As a result, development systems ignore various factors and lack a
consistent approach, resulting in the omission of critical implementation elements that affect
the patient’s recovery period. For example, the lack of proper assessment and feedback
can lead to a lack of progress or even deterioration in the patient’s condition. If there is
no feedback provided to the patient, they may not be aware of their progress or areas
where they need to improve, which can hinder their recovery. Another important element
is lack of engagement and motivation. Games that are not engaging or motivating may
not hold the patient’s interest, which can lead to poor compliance and a lack of progress.
The omission of the proper integration with other treatment methods can lead to a lack of
continuity in the patient’s treatment, which can impede progress.
Study [30] determined and assessed the situation of using serious games in the re-
habilitation of people with Parkinson’s disease (PD). The evaluation looked at the type
of game, interface, device, rehabilitation procedure, technique for measuring the game’s
effectiveness, symptoms cured, and implementation in real patients. Most studies suggest
creating exergames, using VR as an interface technology, capturing body motions with
Leap Motion and Microsoft Kinect, and treating bradykinesia and gait problems. The
findings show that high scientific rigor is required for the solutions provided, as well as
the extension of the instrument to medical practice. Serious games for people with PD
should be adaptable to the unique needs and abilities of each individual player, easy, and
intelligent. This could include options to adjust the game’s difficulty level, control options,
and other settings to accommodate for the physical and cognitive limitations that may
be associated with PD. The games should also be easy to understand and navigate, with
clear instructions and simple interfaces to minimize confusion and frustration. This can
help to ensure that players are able to focus on the therapeutic aspects of the game rather
than struggling with the mechanics of playing. Finally, serious games for Parkinson’s
Disease should be intelligent, using data and analytics to track progress and adjust the
game’s difficulty level or other aspects as needed. This can help to ensure that players are
challenged at the appropriate level, and that the game continues to be effective over time
as the player’s condition changes. Additionally, these games should also be able to provide
feedback to the therapist or caretaker, so that they can monitor the player’s progress and
adapt their treatment accordingly.
Study [35] assessed the effectiveness of serious games for stroke rehabilitation. In
addition, independent of the device utilized, we looked at whether adhering to neurore-
habilitation principles affects the efficacy of games especially intended for rehabilitation.
When compared to traditional therapy, a meta-analysis of 42 studies with 1760 individuals
found that serious gaming interventions had greater results. This meta-analysis found that
rehabilitation using serious games, aimed towards recovery after stroke, results in superior
gains in three International Classification of Functioning, Disability and Health (ICF-WHO)
components compared with standard therapy. Serious games are more effective when
they conform to a unified set of neurorehabilitation principles, regardless of the technol-
ogy instrument employed. The collected set of neurorehabilitation principles should be
considered in the future development of stroke-specific rehabilitation therapies.
Study [38] analyzed serious games in psychotherapy and psychosomatic rehabilitation.
Publications that did not include empirical evidence on efficacy were not included. The
results of N = 15 research satisfied the inclusion criteria based on this systematic literature
review. They largely used cognitive behavioral approaches, which may be used to treat
Information 2023, 14, 105 17 of 31

a variety of mental illnesses. Serious games work well as a standalone intervention or

as part of psychotherapy, and they appeal to patients of all ages and genders. Serious
games were found to have a beneficial therapeutic component. However, the findings are
inconclusive, and further study is needed to better understand the usefulness of serious
games for psychotherapy.
Study [41] analyzed new data on the efficacy of exergaming for PD rehabilitation
and presents an overview of current research on exergame-based therapy in PD patients.
There were 64 publications chosen. The results of the last review revealed that potential
improvements in motor abilities had occurred. Microsoft Kinect and the Wii Balance Board
were found to be safe and feasible in pilot trials. Both devices’ balance and gait data were
shown to be reliable in technical studies. Related meta-analyses and systematic reviews
back up these claims, highlighting the necessity for patient skill adaption as well as the use
of novel input devices and sensors as discovered gaps. Exergame-based therapy has been
shown to be viable, safe, and successful in the treatment of PD.
Study [42] analyzed engagement and muscle training, with virtual training software
for upper limb prosthetic rehabilitation either focused on game design elements or on
a realistic portrayal of prosthetic training activities to encourage task-specific skill trans-
fer. Previous research has shown that without a transfer-enabling task structure, muscle
training alone does not result in enhanced prosthesis control. However, there has been a
significant increase in the number of game-based prosthesis training aids, which emphasize
participation rather than skill transmission. The availability of commercially available
acquisition devices and publicly available game development tools for creating serious
games for prosthesis training impacted this flood.
Study [59] described the key results from the evaluation of current games for stroke
recovery, including meaningful play, failure handling, emphasis on difficulty, and the need
of feedback. The authors conclude with a set of design suggestions for future serious
game creators to think about when creating interfaces for stroke victims. This study shows
that using gaming technology for stroke rehabilitation is an effective interactive approach.
Serious games provide the possibility of fully customizable and contextualized gaming.
The analysis also argues that encouraging challenge and recovery from errors are useful
characteristics to have in serious games for rehabilitation.
Study [60] gave an examination of the influence of SG on neurorehabilitation therapy
and patient opinions on rehabilitation. This evaluation included 47 papers that looked at
the use of experimental serious games and commercially produced serious games (CSGs)
for rehabilitation in a variety of neurological diseases. The Nintendo Wii was used by the
majority of CSGs as a supplement to traditional therapy. In 35 investigations, significant im-
provements in key outcomes such as motor performance, balance, executive, and cognitive
functions were identified. In addition, 17 pieces of research revealed patient viewpoints on
rehabilitation. According to the findings, SGs are effective exergame instruments.
Study [56] examined the effects of wearable technologies and serious games used in
the rehabilitation of individuals with severe bone and soft tissue injuries on functional
results and treatment adherence. Only two pieces of research revealed that serious games
had favorable benefits when compared to traditional therapy. In one of five experiments
that looked at treatment adherence, the gaming group had a statistically significant benefit
over traditional physiotherapy. The pooling of data was not possible due to differences in
research design and outcome measures. After catastrophic bone and soft tissue injuries,
serious games appear to be a safe alternative or a supplement to traditional treatment.
Their validity and efficacy in rehabilitation therapy, as well as their cost-efficiency and
influence on treatment adherence, should be investigated more in the future.
Study [69] examined the association between the qualities of serious games (SGs)
and the therapeutic outcomes of trials that used games to help patients who had cerebral
palsy or multiple sclerosis or had had strokes. They found 12 studies that evaluated
motor, sensory, and functional functions, as well as overall health outcomes in certain
cases. Upper-limb motor rehabilitation was achieved by game-based interventions. Six
Information 2023, 14, 105 18 of 31

games from casual SGs, one combination of casual, simulation, and exergaming SGs, and
two mixed sports and simulation SGs all showed substantial gains in at least one clinical
assessment. Casual games with a first-person perspective, no visible player character,
single-player mode, and non-immersive VR had the greatest therapeutic effects.
Study [61] investigated the use of serious games in the rehabilitation of people with
neuromotor impairments of the upper limb resulting in 38 research papers. This study
examines 35 distinct gaming systems. Only eight of the thirty-eight publications in this
evaluation completed a clinical trial, and only twenty-one of them reported benefits in the
target population after using the games and platforms. As a result, in the rehabilitation
sector, a new paradigm is emerging, characterized by the systematic use of electronic
gaming platforms with serious games in/for rehabilitation. Serious games and gaming
platforms for upper limb rehabilitation are ushering in a new rehabilitation paradigm.
More research is needed to fully integrate these technologies in the rehabilitation industry.
Study [65] studied game design aspects to aid in the rehabilitation of patients with
shoulder musculoskeletal problems. There were 31 articles in total, published between 2006
and 2019. Points, tasks, and avatars were the most-often-utilized game components. Col-
lections and teams, which are more complicated game components, were rarely employed.
There were just a few systems that used game design aspects to assist subjects with mus-
culoskeletal illnesses of the shoulder in rehabilitation. Exergames allow self-exercising in
almost all application platforms. Patients’ unique characteristics are frequently overlooked.
Motivational game design components that are incorporated into a game to encourage
players to engage and continue playing (such as points, levels, achievements, and leader-
boards) based on patient-specific characteristics are necessary as part of a holistic strategy
to improve rehabilitation adherence.
Study [62] outlined the present state of knowledge on gamified e-Health applications,
investigated the various gamification tactics used in e-Health, and discussed the pros and
drawbacks of this new field. After, 46 studies from various sources were evaluated. Most
of the publications included in this study discussed SSG in health and well-being areas
such as chronic illness rehabilitation, physical exercise, and mental health. In this sector,
there is still a scarcity of reliable empirical evidence. Furthermore, most of the e-Health
apps and serious games studied have been shown to provide only short-term engagement
through explicit reinforcement. To realize the full capabilities of gamification, e-Health
solutions must be built on well-founded theories that harness the fundamental experiences
and psychological consequences of game mechanics.
Study [66] examined the use of serious game principles in social emotional computer-
based interventions (CBI) for autistic people and assessed the effectiveness of these concepts
in improving social emotional outcomes. Database searches turned up 34 papers on social
emotional CBI, with 17 controlled studies. The five serious game concepts were used to
summarize the qualities of each CBI: compelling plot, goal-directed learning, incentives and
feedback, escalating levels of difficulty, and individualization. The findings indicated that
autistic people have a limited (45%) integration of serious game concepts in social emotional
CBI. The serious game design framework can help to guide the development of social
emotional CBI, which can help autistic people to improve their social emotional abilities.

4.3. Virtual Reality Games

Study [25] examined how visionary serious games and VR technologies are used in
motor rehabilitation programs. There were 86 studies found. The most often utilized
technology in exploring the impact of vision-based serious games and VR systems on
rehabilitation is Kinect. The findings also imply that patients with cerebral palsy and who
have had strokes are the primary target categories, with an emphasis on older individuals
in this category. Most of the research focused on posture control and upper limb workouts,
and they employed a variety of metrics to assess them. Despite the increased interest in
this field among researchers, many studies lack adequate clarity and are not standardized.
Information 2023, 14, 105 19 of 31

In study [49], the current cognition tests, VR apps, and serious games in cognitive
assessment and therapy for neurocognitive disorders were analyzed to evaluate the current
state of the art in cognitive assessment for major neurocognitive disorders (NCDs), such
as Alzheimer’s disease (AD), the most common geriatric major NCD, and then it briefly
looked ahead at the potential applications of VR technologies in NCD assessment and
cognition training in a simulated 3D environment, and for the alleviation of cognitive
disorder symptoms. The VR-based technologies, we feel, offer enormous potential in
cognitive evaluation and non-pharmacological treatment for severe NCDs.
Study [57] examined and classified the influence of VR technology on 46 gamified apps
with serious goals. Our findings imply that immersive VR enhances simulation outcomes,
such as learning acquisition and information retention, as well as clinical rehabilitation
outcomes. It does, however, have drawbacks, such as motion sickness and limited access
to VR devices. The study contributed by providing clearer knowledge of the benefits and
constraints of utilizing VR technology in serious simulations, a taxonomy for categorizing
them, and a discussion of whether methodologies and participant profiles impact results.
Study [24] examined the history and quality of clinical research on VR-based serious
games. The adoption of serious VR games has demonstrated efficacy in improving upper
limb telerehabilitation (TR) following strokes, although the evidence quality is still poor
due to a lack of randomized controlled trials (RCTs), few subjects, and diverse samples. VR
games are a potentially useful technique for supplementing traditional rehabilitation, but
further research is needed to reinforce the proof of success and encourage the spread of the
proposed solutions.

4.4. Video Games

Study [28] analyzed and evaluated game-based dietary treatments for children. The
focus was on whether the game-based techniques helped young people to improve their
eating habits, what the most effective game elements were, and how game-based techniques
help young people to alter their eating habits. There are 43 pieces of research that have been
discovered which improve fruit and vegetable consumption, change snacking behavior,
stimulate food discovery, and promote healthy eating. Serious games that focus on food
education can help children to develop healthy eating habits by increasing their knowledge
and positive attitudes towards fruits and vegetables. These games can also encourage
children to try new foods and reduce picky eating habits. On the other hand, games that
promote unhealthy snacks may lead to an increase in unhealthy snack consumption among
children. To inspire and involve young people in developing good eating habits, a mix of
story context, feedback, progress, and challenge was widely employed.
Study [33] investigated the effectiveness of serious games in improving knowledge
and/or behavioral improvements in overweight and obese young people. The final sample
included six studies. The articles aimed to encourage gamers to make positive behavioral
changes, such as increased physical activity and better eating habits. Using serious games
as a technique can be effective in promoting healthy behaviors and coping strategies for
children and adolescents who are struggling with obesity. Serious games are an alternate
way to give health education to children, and research in this subject is an increasing and
promising technique.
Study [34] analyzed serious games to treat and/or prevent childhood obesity. The
search yielded 466 studies, with 17 being chosen for examination. Serious games for health
promotion might have a good impact on children’s health, induce behavior changes, and
promote healthy behaviors. Serious games can be a useful technique for children’s health
education. Given children’s usage of technology, these tools may modify the public’s
behavior with relation to juvenile obesity.
Study [40] investigated the application of various artificial intelligence algorithms
linked to decision making and learning. To classify 129 papers that matched the inclusion
requirements, a classification system was created and defined. The authors used this
classification system to reach some findings about how intelligent serious games are really
Information 2023, 14, 105 20 of 31

used. The authors believe that enough information has been acquired in recent years
to design new intelligent serious games that consider not only the end goal but also the
technology and tactics employed to give players a virtually genuine experience. However,
to ensure that produced serious games accomplish their intended goals, researchers may
need to enhance their testing approach.
Study [70] examined the research on the effects and modalities of using video games
for emotional regulation (ER). The review comprised 23 papers, which were divided into
three categories: (1) cross-sectional and qualitative studies, (2) studies on the impact of
videogame experience on ER, and (3) ER intervention using serious games. A limited time
of playing, such as that enabled by serious games, gave less potential for ER improvement
than frequent gaming with commercial games (connected to gameplay and pleasure of
fictitious properties). This field of study is still in its infancy; thus, results should be
evaluated with caution. Moreover, future evaluations should include clinical populations.
Video games provide a variety of ER options as well as a challenge for educational and
psychosocial solutions.

4.5. Games for Education

Study [21] sought to find serious games that educate patients on the issues of medi-
cation adherence, education, and safety, as well as theoretical frameworks for developing
serious games for medication use and sample frames for assessing serious games on medi-
cation usage. There were 16 trials with 12 serious games containing elements of medication
adherence, education, and safety. Existing evaluations investigate serious games that fo-
cus on disease management, such as diabetes, HIV, and asthma, as well as the beneficial
impact of serious game teaching. Serious games should specify the theoretical framework
included into game design, and success should be measured by the player’s ability to retain
learning objectives.
Study [37] analyzed articles about serious games developed to teach patients and the
public on asthma and evaluated their influence on patient knowledge, behavior, and asthma
disease outcomes. Twelve articles were identified as being relevant, each describing ten
serious games. Eight games for children with asthma and two for school-based intervention
were included in the serious games. Most of the serious games were linked to high levels
of enjoyment and knowledge improvement in young people. Seven studies compared
the effects of serious games on medical outcomes to control groups and discovered no
significant differences, while few changes in behaviors or medical outcomes have occurred.
Study [44] examined the evidence for using the RETAIN serious game to improve
newborn resuscitation instruction. There were three articles and one conference proceeding
found. The RETAIN board game was described in two studies, while the RETAIN computer
game was described in two investigations. RETAIN was described as therapeutically useful
and relevant. RETAIN also served as a summative evaluation and enhanced the knowledge
of newborn resuscitation. RETAIN is a tool that may be used to teach and assess experienced
neonatal resuscitation clinicians.
Study [43] reviewed the existing literature on serious games and how they might help
neonatal healthcare workers retain information and abilities. This review includes twelve
serious games (five video games, four board games, and three VR games). The RETAIN
board game and neonatology game both showed improvements in knowledge. To improve
theoretical and practical learning, serious games are more commonly being introduced into
medical school curricula. Serious games can increase healthcare personnels’ knowledge,
abilities, and adherence to the resuscitation protocol, as well as improve access to SBE in
both resource-rich and resource-poor settings. Important clinical outcomes in newborns
should be the focus of future study.
Study [45] explored the educational tactics used by game developers while building
medical education games, and how good the evidence is for the effectiveness of games.
Even though game creators say that games are great teaching aids, the data are mixed.
Games are complementing tools that do not supplant classical pedagogical methods, and
Information 2023, 14, 105 21 of 31

behaviorism and cognitivism remain the most common instructional approaches. Medical
educators do not require the use of complex games in their courses, preferring simulations
and tests that focus on information retention and skill improvement via repetition. The
real-life use of games is contingent on the quality of the evidence supporting their success.
Study [46] evaluated the efficacy of serious games for professional health education
in 25 studies. Sixteen students had both a pre- and post-test, and all of them improved
significantly in their learning scores after using serious games. Eighteen studies pub-
lished controlled trials, whereby fourteen of which found that following serious games,
post-test results were considerably higher than with traditional teaching approaches. The
study found a lack of integration of emotional learning with other abilities, and a re-
quirement for serious games prepared people for postgraduate education. Serious games
appear to be effective for short-term learning. Before making generalizable conclusive
assertions, additional competences and health professionals must be addressed across the
school continuum.
Study [53] synthesized the evidence on the efficacy of SGs in increasing engagement
and enhancing learning outcomes in healthcare profession education. Between January 2005
and April 2019, 37 randomized controlled trials (RCTs) were discovered, with 29 of them
being included in random-effect meta-analyses. SGs did not result in longer time spent
with the intervention, higher information acquisition, cognitive and skills development,
attitude change, or behavior change when compared to other educational interventions,
but there was minimal evidence for SGs with regard to boosting skill confidence.
Study [54] evaluated and synthesized the best available information on the effective-
ness of SGs and the influence of DEs on healthcare professionals’ and students’ involvement
and educational results.
Study [55] collected papers on SSG published between 2015 and 2020, with an em-
phasis on their applications: detection, prevention, therapy and awareness, to study tool
deployment, development, and evaluation for trends, strengths, and flaws. The following
criteria were used to filter the papers: SSG for personal computer (PC), smartphone, or VR;
for children and adolescents; and for depression, anxiety, or both. SSG for PC, smartphone,
and VR devices were created in 34 pieces of research and tested in adolescents and children.
Most games are used for prevention and treatment. Anxiety is more prevalent in childhood,
whereas depression is more prevalent in adolescence. More awareness and detection games
that include awareness, prevention, detection, and therapeutic applications are needed.
Games should appeal to people of all ages. SSG development and assessment should
be harmonized.
Study [58] discussed the adoption of serious games to teach young people about
mouth hygiene, as well as hunted for applications that served the same objective. Twelve
articles were chosen, 11 games were designated as serious games focused on oral health,
and 284 applications were found on the Play Store, with a majority surrounding inter-
ventionist action in dental clinics with the primary plots being pain, tooth cavity, and
trauma. There are just a few apps dedicated to oral hygiene instruction. There is a large
presence of a children’s audience among the intended audience. Despite the paucity of
publications on the issue, investigating electronic resources as instructional choices for
children’s oral hygiene suggests a field of study with academic promise and prospective
public health implications.
Study [64] reviewed the scientific data on the use of serious games to teach cardiopul-
monary resuscitation to health students. The authors found eight studies and divided them
into two categories: the study’s purpose in relation to cardiopulmonary resuscitation using
serious games, and the serious game’s approach to teaching cardiopulmonary resuscitation
(CPR). The primary target for serious game learning is medical students, and the games’
primary goals are to evaluate their effectiveness with regard to established approaches and
information retention.
Study [73] analyzed articles related to the adoption of serious games in education and
discussed numerous elements that impacted the effects of serious-gaming-assisted learning.
Information 2023, 14, 105 22 of 31

The main portion discussed the benefits and drawbacks of using serious games in teaching.
Attitudes about the application of serious games in education, as well as the new growth of
serious game usage in education, were investigated. The study underlined the need for
interdisciplinary collaboration in future theoretical and practical exploration.

4.6. Games for Mental Disorders

Study [29] aimed to provide a complete picture of the evidence of serious games for
health-aimed behavioral change in adolescents and children. There were 34 studies that
investigated the effectiveness of serious games in promoting mental health and changing
health-related behaviors in children and adolescents. The data evidencing the use of
serious games in adolescents and children for the promotion of health remain limited.
Given the publication bias, these results should be viewed with care. Before we can make
firm conclusions, we need more research that is properly conducted and that examines
well-defined serious games.
Study [31] analyzed how end-user engagement in the design and decision-making
process affects game effectiveness. Users are introduced in all phases of the process,
including planning, creating, and testing the serious game, in user-centered design or
participatory design. The goal of this study was to see how many published studies of
serious games that are intended to prevent or cure depression and anxiety have used the
participatory design framework.
Study [50] examined clinical research that focused on the adoption of serious games
in children with developmental impairments. The bulk of the 145 pieces of research was
on autism spectrum disorder (ASD), and related intellectual impairments. A randomized
design was reported in 30 of the 145 investigations. The authors found encouraging
outcomes in the areas of anxiety reduction, stress management, emotion identification, and
rehabilitation. Currently, there is a paucity of clinical evidence that serious games can aid
children with neurodevelopmental issues.
Study [39] studied serious games for persons with mental illnesses, including Alzheimer’s,
ADHD, ASD, dementia, MCI, PTSD, and schizophrenia, as well as the many ways utilized
to make the games available to the intended players. To avoid the player being disoriented,
the basic aim is to reduce the quantity of stimuli present at the same time. Reducing
stimuli should be inherent to the game (by presenting a very basic game), and it should
be adjustable (through a menu of selections), and dynamic (by adjusting the quantity of
stimuli, or a system that adjusts itself automatically).

4.7. Other Games

Study [26] synthesized and integrated all previous research and material on gamifica-
tion and serious games, appraising the present state of the art in the area, and filling a gap
in the literature on the subject. The most important determinants of intention to adopt in
gamification are attitude, enjoyment, and utility. The most important determinants of a
brand’s attitude toward gamification are intent, enjoyment, and utility. The findings enable
us to propose a theoretical model that will aid future gamification research.
Study [52] studied the impact of severe games on signs of mental illness. The review
contained ten papers that fulfilled the inclusion criteria, while the meta-analysis comprised
nine pieces of research. The investigations were conducted on people aged from 7 to
80 years. The serious games employed goal-oriented and cognitive training games to
address symptoms of depression (2), post-traumatic stress disorder (2), autistic spectrum
disorder (2), attention deficit hyperactivity disorder (1), cognitive functioning (2), and
alcohol-consuming disorder (1). The findings show that gaming therapies might help those
with disorder symptoms. More research is sought to have a better understanding of the
usefulness of games for certain mental diseases and their long-term impacts.
Study [67] explained the conceptual aspects of the current research on serious games
aiming to promote cognitive and behavioral outcomes in individuals with chronic diseases.
The review includes a total of 38 papers. The present landscape of serious game research
Information 2023, 14, 105 23 of 31

for health focusing on behavioral and cognitive outcomes in people with chronic illness is
defined in this scoping study. A wide range of patient demographics and patient outcomes
have been studied. To further explain the active components and processes of serious games,
researchers that want to improve upon the present study should incorporate theoretical
models into the intervention and trial design process.

5. Findings
5.1. Answers to Research Questions
RQ1. What are the most common health conditions that serious games and gamifica-
tion techniques have been used to address?
Serious games and gamification techniques have been used to address a wide range
of health conditions. The most common health conditions that have been studied include
the following:
1. Chronic conditions such as diabetes [21,48], heart disease, and cancer, which often
require long-term self-management and lifestyle changes.
2. Mental health conditions such as depression [31,49,52,55] and anxiety [31,50,55],
which often involve addressing negative thoughts and behaviors.
3. Physical rehabilitation, especially for patients with trauma injuries [22,42,56] or neu-
rological conditions [60,65] that affect their mobility.
4. Substance abuse, especially in terms of addiction to alcohol [32] and drugs.
5. Smoking cessation [32].
6. Eating disorders [28,33] and obesity [33,34].
7. Geriatric care, especially in terms of promoting healthy aging and preventing cognitive
decline (e.g., due to Alzheimer’s disease) [49].
8. Pain management, especially in terms of chronic pain patients [56].
9. Asthma and COPD management [21,37].
RQ2. What are the most common game mechanics and design elements used in serious
games and gamification for health?
The most common game mechanics and design elements used in serious games and
gamification for health include the following:
1. Points, badges, and leaderboards which are used to provide feedback on progress,
and to create a sense of competition and accomplishment [54].
2. Quests and challenges which are used to create a sense of purpose, and to provide
structure for the player’s experience [28].
3. Storytelling and narratives which are used to create a sense of immersion, and to
provide context and meaning for the player’s actions [28,54,66].
4. Virtual rewards and incentives which are used to motivate players to engage in
desired behaviors, such as exercising or taking medication [28].
5. Personalization and tailoring which are used to adapt the game or gamification
experience to the specific needs and preferences of the player.
6. Social connections and collaboration which are used to create a sense of community
and to foster social support [55,66].
7. Feedback and coaching which are used to provide guidance, information, and feed-
back to help players to improve their skills and knowledge [23,28,66].
8. Virtual reality and immersive technologies which are used to create a sense of immer-
sion and to provide an engaging experience for the players [24,25,30,44,49,55,57,69].
9. Game-based assessments and adaptive testing which are used to assess players’ skills,
knowledge, and progress [44,49].
10. Gamified environments and settings which are used to create a sense of immersion
and to provide an engaging experience for the players [54,62].
Note that the effectiveness of these game mechanics and design elements for differ-
ent health conditions and populations may vary and more research is needed to fully
understand their potential and limitations.
Information 2023, 14, 105 24 of 31

RQ3. What is the evidence for the effectiveness of serious games and gamification in
promoting positive health outcomes?
The evidence for the effectiveness of serious games and gamification in promoting
positive health outcomes is still emerging, but it is growing. Studies have shown that
serious games and gamification techniques can be effective in promoting positive health
outcomes, such as improved physical activity [62], healthy eating [28], and smoking ces-
sation [32], as well as improved mental health outcomes, such as reduced depression [31]
and anxiety [31,55].
Studies have also shown that serious games and gamification techniques can be
effective in promoting medication adherence [21], the self-management of chronic condi-
tions [67], and rehabilitation outcomes [22–25,27,30,35,41,42,56,60,61,65,69].
Note that the effectiveness of serious games and gamification for promoting positive
health outcomes can vary depending on the specific health condition, population, and the
design of the game or gamification intervention. Additionally, it is important to note that
while some studies have shown positive results [29,32,46,48,56,60,69], other studies have
not found significant effects [37,66].
As a result, more research is needed to fully understand the underlying mechanisms
of action of serious games and gamification in promoting positive health outcomes, and
to identify the specific game mechanics and design elements that are most effective for
different health conditions and populations.

5.2. Limitations
The review study’s selection procedure and data extraction are two possible restric-
tions. Even if a systematic search and further searches were conducted, it is probable that
not all relevant material was discovered. Because it was impossible to examine the results
linked to health and digital games independently, some material had to be eliminated.
These choices may have resulted in a loss of critical data. There was considerable overlap
between the systematic reviews and reviews that were included, which may have had a
significant impact on our findings.
Finally, the meta-analysis reveals that a few publications which analyzed the survey
papers were disruptive (i.e., challenged existing paradigms, introduced new ideas or
methods, or fundamentally changed the way we think about a particular field) [79] and had
a significant impact on subsequent developments in the research field. Between 2017 and
2021, there were just a few articles with moderate impact (approximately 100–200 average
citations per year since publication).

6. Research Gaps, Trends, Challenges, and Future Directions

6.1. Research Gaps
The field of serious games and gamification for health is a rapidly growing and
dynamic area of research; however, there are still several research gaps that need to be
addressed. The current research gaps in this field include:
1. Lack of standardization [23,25,59] in the development and evaluation of serious games
and gamification applications for health, making it difficult to compare and replicate
studies and leading to inconsistent results and conclusions.
2. Insufficient understanding of the underlying mechanisms of action [62,67] of serious
games and gamification in promoting positive health outcomes.
3. Limited understanding of how to effectively integrate serious games and gamification
into existing healthcare systems [47,61,66] and how to measure the effectiveness of
the integration.
4. Limited understanding of the specific game mechanics and design elements that are
most effective for promoting different health behaviors and outcomes [31,54,56,70,72].
5. Insufficient evaluation and validation of serious games and gamification applications
for health, particularly in terms of determining the optimal dosage and duration of
treatment [30,65].
Information 2023, 14, 105 25 of 31

6. Limited research on the scalability and sustainability of serious games and gamifi-
cation for health and how to increase their adoption by healthcare providers and
patients. Here, scalability is understood as the ability of the game platform to support
a large number of players. Sustainability is understood as the ability of the game
to sustain player interest in healthy behaviors and motivate him/her to continue
playing [71].
7. Limited research on the effectiveness of serious games and gamification for specific
population groups, such as marginalized communities [80].
8. Limited research on the ethical and legal implications of serious games and gamifica-
tion for health, and the potential risks and benefits of these interventions [81,82].
9. Limited research on the cost-effectiveness and economic benefits of serious games
and gamification for health [56].
10. Limited research on the long-term effects of serious games and gamification on health
outcomes [28,35,52,63].
These research gaps highlight the need for further research to fully understand the
potential and limitations of serious games and gamification for health and how to effectively
apply them in different settings and for different health conditions.

6.2. Current Research Challenges

There are several current research challenges in the field of serious games and gamifi-
cation for health.
One major challenge is the lack of standardization in the field [23,25,59]. There are
currently no widely accepted guidelines or standards for the development and evaluation
of serious games and gamification applications for health. This makes it difficult to compare
and replicate studies, and can lead to inconsistent results and conclusions.
Another challenge is the lack of robust evaluation and validation of serious games
and gamification techniques for health [30,65]. While there is a growing body of evidence
to suggest that these types of interventions can be effective, there is still much work to be
done in terms of understanding the underlying mechanisms of action, identifying the most
effective design elements, and determining the optimal dosage and duration of treatment.
Additionally, there is a lack of understanding of how serious games and gamification
can be effectively integrated into existing healthcare systems and how to measure the
effectiveness of the integration [47,61,66]. Moreover, there is still a lack of understanding
of the specific game mechanics and design elements that are most effective for promoting
different health behaviors and outcomes. For example, some researchers have found
that certain game mechanics, such as rewards and social comparison, can be effective
in promoting physical activity, while others have found that other mechanics, such as
storytelling and simulations, are more effective.
Lastly, serious games and gamification applications are still not widely adopted by
healthcare providers and patients [63]. There is a need for more research on how to increase
the adoption of these interventions and how to ensure that they are used in a way that is
consistent with the best practices in healthcare.

6.3. Current Trends of Research in Serious Games and Gamification for Health
The field of serious games and gamification for health is a rapidly growing and
dynamic area of research. Based on review studies analyzed in this paper, some of the main
trends in the field include:
1. An increasing use of serious games and gamification techniques for a wide range of health
conditions, including chronic conditions such as diabetes [21,48] or asthma [21,37,48], as
well as mental health conditions such as depression and anxiety [31,52].
2. Growing recognition of the potential of serious games and gamification to promote
healthy behaviors and prevent the onset of chronic health conditions, such as through
promoting physical activity [62,67], healthy eating [28], and smoking cessation [32].
Information 2023, 14, 105 26 of 31

3. A shift towards the use of mobile and digital platforms for delivering serious game
and gamification interventions [55], as these platforms are increasingly accessible and
convenient for patients and healthcare providers.
4. An increasing use of virtual reality and other immersive technologies in serious games
and gamification [24,25,30,43,49,55,57,69], as these technologies have the potential to
enhance engagement and immersion for players.
5. A growing use of machine learning and other advanced technologies [40] to personal-
ize and adapt serious games and gamification interventions to the specific needs and
preferences of individual players.
6. Increasing recognition of the need for rigorous evaluation and validation of serious
games and gamification techniques for health, to understand their effectiveness, the
underlying mechanisms of action, and the optimal duration of treatment [55].
7. A growing need for more research to identify and understand the most effective
game mechanics and design elements for promoting healthy behaviors and out-
comes [31,54,56,70,72].
8. An increasing focus on understanding how serious games and gamification can
be effectively integrated into existing healthcare systems and how to measure the
effectiveness of the integration [47,61,66].
9. The emergence of serious games and gamification applications in preventative health-
care [32,55], with a focus on promoting healthy behaviors, preventing illnesses and
chronic conditions, and empowering patients with self-management tools [65].
These trends highlight the ongoing progress and the potential of this field to make a
positive impact on the health of patients and communities.

6.4. Future Research Directions

The field of serious games and gamification for health is a rapidly growing and
dynamic area of research. The results of this systematic meta-review indicate that there are
several promising directions for future research in this area.
One important area for future research is the development of more effective and
engaging serious games and gamification applications for a wide range of health conditions.
There is a growing body of evidence to suggest that these types of interventions can be
highly effective in promoting positive health outcomes, such as improved patient adherence
to treatment regimens, reduced symptoms of certain conditions, and increased physical
activity [21,35,37,65]. However, there is still much work to be done in terms of developing
games and gamification applications that are tailored to the specific needs of different
patient populations and that can be easily integrated into existing healthcare systems.
Another important area for future research is the use of serious games and gamifi-
cation techniques to promote healthy behaviors and prevent the onset of chronic health
conditions [48,67]. For example, there is a growing body of evidence to suggest that serious
games and gamification can be effective in promoting healthy eating, physical activity, and
smoking cessation. However, there is still much work to be done in terms of identifying the
most effective game mechanics and design elements for promoting these behaviors, as well
as in understanding how these interventions can be scaled up to reach large populations.
Additionally, there is a growing need for rigorous evaluation and validation of serious
games and gamification applications for health. While many studies suggest that these
types of interventions can be effective [48,51], there is still much work to be done in terms
of understanding the underlying mechanisms of action, and identifying the most effective
game design elements and gamification techniques.
Finally, the ethical and privacy implications of serious games and gamification for
health are an important research direction [83,84] that needs to be addressed in the future.
One ethical implication is the protection of players’ privacy and sensitive information [81].
Serious games and gamification for health often require players to provide personal infor-
mation, such as health data, and it is important to ensure that this information is protected
and used in a responsible and transparent manner [82]. Another ethical implication is the
Information 2023, 14, 105 27 of 31

potential manipulation of players’ behavior using game mechanics and design elements.
It is important to ensure that these interventions are designed to promote positive health
outcomes rather than to exploit players for commercial or other purposes. Related issues
to be addressed are informed consent and the right to autonomy. Players should be fully
informed about the potential risks and benefits of the intervention, and should have the
freedom to choose whether or not to participate. Furthermore, there are implications related
to the accessibility [39], inclusive design, and cultural appropriateness of serious games
and gamification for health. It is important to ensure that these interventions are accessible
to a wide range of players, including those with disabilities, and that they are culturally
appropriate for different population groups, including the marginalized communities.

7. Conclusions
This systematic meta-review aimed to analyze and extract the current state and the
prevailing trends of the field of serious games and gamification (SGG) for health by ana-
lyzing and summarizing 53 survey papers on the topic. The review followed the PRISMA
guidelines and used constructive and cross-sectional methods to analyze and present the
results. This review study has found that serious games and gamification techniques have
been used to address a wide range of health conditions, including chronic conditions,
mental health, physical rehabilitation, substance abuse, smoking cessation, eating disor-
ders and obesity, geriatric care, pain management, asthma management, and preventive
care. The most common game mechanics and design elements used in serious games
and gamification for health include points, badges, leaderboards, quests and challenges,
storytelling and narratives, virtual rewards and incentives, personalization and tailoring,
social connections and collaboration, feedback and coaching, virtual reality and immersive
technologies, game-based assessments and adaptive testing, and gamified environments
and settings.
The review has also found that there is evidence to suggest that serious games and
gamification can be effective in promoting positive health outcomes; however, more re-
search is needed to fully understand their potential and limitations, as well as the specific
game mechanics and design elements that are most effective for different health conditions
and populations. Additionally, the review revealed that there are ethical and legal impli-
cations related to serious games and gamification for health such as players’ privacy, the
manipulation of behavior, compliance with regulations, informed consent, accessibility,
inclusive design, and cultural appropriateness.
There are several current research challenges in the field of serious games and gam-
ification for health, including the lack of standardization, lack of robust evaluation and
validation, lack of understanding of how to integrate these interventions into existing
healthcare systems, lack of understanding of the specific game mechanics and design
elements that are most effective for promoting different health behaviors and outcomes,
and lack of adoption by healthcare providers and patients.
In conclusion, the field of serious games and gamification for health is a rapidly
growing and dynamic area of research with a lot of promise. There are a number of exciting
directions for future research, including the development of more effective and engaging
serious games and gamification applications for a wide range of health conditions, the use
of these techniques to promote healthy behaviors and prevent the onset of chronic health
conditions, and the rigorous evaluation and validation of these interventions.
However, it is important to note that the field of serious games and gamification
for health is still a relatively new research area, and further research is needed to fully
understand their potential and limitations in healthcare-related applications.

Author Contributions: Conceptualization, R.D.; methodology, R.D.; validation, R.D., R.M. and T.B.;
formal analysis, R.D., R.M. and T.B.; investigation, R.D., R.M. and T.B.; resources, R.D.; data curation,
R.D.; visualization, R.D. and R.M.; supervision, R.D.; funding acquisition, R.D. All authors have read
and agreed to the published version of the manuscript.
Information 2023, 14, 105 28 of 31

Funding: This research received no external funding.

Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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