Developing and evaluating MindMax: promoting mental wellbeing through an Australian Football League-themed app incorporating applied games (including gamification), psychoeducation, and social connectedness

Gamification is increasingly being used as a behavioural change strategy to increase engagement with apps and technologies for mental health and wellbeing. While there is promising evidence supporting the effectiveness of individual gamification elements, there remains little evidence for its overall effectiveness. Furthermore, a lack of consistency in how ‘gamification’ and related terms (such as ‘applied games’, an umbrella term of which gamification is one type) are used has been observed within and across multiple academic fields. This contributes to the difficulty of studying gamification and decreases its accessibility to people unfamiliar with applied games. Finally, gamification has also been critiqued by both game developers and by academics for its reliance on extrinsic motivators and for the messages that gamified systems may unintentionally convey. In this context, the aims of this thesis were fourfold: 1) to iteratively co-design and develop a gamified app for mental health and wellbeing, 2) to evaluate the eventuating app, 3) to consolidate literature on gamification for mental health and wellbeing, and 4) to synthesise findings into practical guidelines for implementing gamification for mental health and wellbeing. Chapter 2 reports the first study which addresses the first aim of this thesis. Six participatory design workshops were conducted to support the development of MindMax, an Australian Football League (AFL)-themed mobile phone app aimed at AFL fans (particularly male ones) that incorporates applied games, psychoeducation, and social connectedness. Findings from these workshops were independently knowledge translated and fed back to the software development team, resulting in a MindMax prototype. This prototype was further tested with 15 one-on-one user experience testing interviews at three separate time points to iteratively refine MindMax’s design and delivery of its content. The findings of this study suggest that broadly, participants endorsed a customisable user experience with activities requiring active user participation. These specifications were reflected in the continual software updates made to MindMax. Chapters 3 and 4 report the second and third studies which address the second aim of this thesis. As regular content, performance, and aesthetic updates were applied to MindMax (following the model of the wider tech industry), a naturalistic longitudinal trial, described in Chapter 3, was deemed to be the most appropriate systematic evaluation method. In this study, participants (n=313) were given access to MindMax and asked to use it at their leisure, and surveys were sent out at multiple time points to assess their wellbeing, resilience, and help-seeking intentions. Increases in flourishing (60-day only), sense of connection to MindMax, and impersonal help-seeking intentions were observed over 30 and 60 days, suggesting that Internet-based interventions like MindMax can contribute to their users’ social connectedness and encourage their help-seeking. The third study, described in Chapter 4, reports a secondary analysis of data collected for Chapter 3, and further explores participants’ help-seeking intentions and their links to wellbeing, resilience, gender, and age. An explanatory factor analysis was conducted on Day 1 General Help-Seeking Questionnaire (GHSQ) data (n=530), with the best fitting solution resulting in three factors: personal sources, health professionals, and distal sources. In addition to providing more evidence that younger people aged 16–35 categorise apps and technologies for mental health and wellbeing like MindMax alongside other distal social sources such as phone helplines and work or school, our findings also suggest that the best way to target individuals who are least likely to seek help, particularly men, may be through these distal sources as well. Chapter 5 reports the fourth study, which addresses the third aim. In order to consolidate literature on gamification for mental health and wellbeing, this systematic review identified 70 papers that collectively reported on 50 apps and technologies for improving mental health and wellbeing. These papers were coded for gamification element, mental health and wellbeing domain, and researchers’ justification for applying gamification to improving mental health and wellbeing. This study resulted in two major findings: first, that the current application of gamification for mental health and wellbeing does not resemble the heavily critiqued mainstream application that relies on extrinsic motivators; and second, that many authors of the reviewed papers provided little or no justification for why they applied gamification to their mental health and wellbeing interventions. While the former finding is encouraging, the latter suggests that the gamification of mental health and wellbeing is not theory-driven, and is a cause for concern. Finally, to address the final aim of this thesis, all study learnings were synthesised into practical guidelines for implementing gamification for mental health and wellbeing. First, it is important to assess the suitability of implementing gamification into the intervention. Second, this implementation should ideally be integrated at a deeper, systemic level, with the explicitly qualified intention to support users, evidence-based processes, and user engagement with these processes. Third, it is important to assess the acceptability of this gamified intervention throughout its development, involving all relevant stakeholders (particularly representative end user populations). Fourth, it is important to evaluate the impact of this gamified intervention. Fifth, and finally, comprehensive and detailed documentation of this process should be provided at all stages of this process. This thesis contributes to a growing literature on the increasing importance and relevance of Internet-based resources and apps and technologies for mental health and wellbeing, particularly for young people. Given the dominance of games in society and culture across history, and the increasing contemporary prominence of digital games (also known as video games) in particular, gamification is uniquely positioned to have the potential to make large contributions to mental health and wellbeing research. In this context, this thesis contributes a systematically derived operationalisation of gamification, an evaluation of a gamified app for mental health and wellbeing, and best practice guidelines for implementing gamification for mental health and wellbeing, thereby providing frameworks that future implementations of gamified mental health and wellbeing interventions and initiatives may find useful

Eye quietness and quiet eye in expert and novice golf performance: an electrooculographic analysis

Quiet eye (QE) is the final ocular fixation on the target of an action (e.g., the ball in golf putting). Camerabased eye-tracking studies have consistently found longer QE durations in experts than novices; however, mechanisms underlying QE are not known. To offer a new perspective we examined the feasibility of measuring the QE using electrooculography (EOG) and developed an index to assess ocular activity across time: eye quietness (EQ). Ten expert and ten novice golfers putted 60 balls to a 2.4 m distant hole. Horizontal EOG (2ms resolution) was recorded from two electrodes placed on the outer sides of the eyes. QE duration was measured using a EOG voltage threshold and comprised the sum of the pre-movement and post-movement initiation components. EQ was computed as the standard deviation of the EOG in 0.5 s bins from –4 to +2 s, relative to backswing initiation: lower values indicate less movement of the eyes, hence greater quietness. Finally, we measured club-ball address and swing durations. T-tests showed that total QE did not differ between groups (p = .31); however, experts had marginally shorter pre-movement QE (p = .08) and longer post-movement QE (p < .001) than novices. A group × time ANOVA revealed that experts had less EQ before backswing initiation and greater EQ after backswing initiation (p = .002). QE durations were inversely correlated with EQ from –1.5 to 1 s (rs = –.48 - –.90, ps = .03 - .001). Experts had longer swing durations than novices (p = .01) and, importantly, swing durations correlated positively with post-movement QE (r = .52, p = .02) and negatively with EQ from 0.5 to 1s (r = –.63, p = .003). This study demonstrates the feasibility of measuring ocular activity using EOG and validates EQ as an index of ocular activity. Its findings challenge the dominant perspective on QE and provide new evidence that expert-novice differences in ocular activity may reflect differences in the kinematics of how experts and novices execute skills

SUPPORTING THERAPY-CENTERED GAME DESIGN FOR BRAIN INJURY REHABILITATION

Brain injuries (BI) are a major public health issue. Many therapists who work with patients who have had a BI include games to ameliorate boredom associated with repetitive rehabilitation. However, designing effective, appropriate, and engaging games for BI therapy is challenging. The challenge is especially manifested when considering how to consolidate the different mindsets and motivations among key stakeholders; i.e., game designers and therapists. In this dissertation, I investigated the ideation, creation, and evaluation of game design patterns and a design tool, GaPBIT (Game Design Patterns for BI Therapy) that leveraged patterns to support ideation of BI therapy game concepts and facilitate communication among designers and therapists. Design patterns, originated from the work of Christopher Alexander, provide a common design language in a specific field by documenting reusable design concepts that have successfully solved recurring problems. This investigation involved four overlapping phases. In Phase One, I interviewed 11 professional game designers focused on games for health (serious games embedded with health-related goals) to explore how they perceived and approached their work. In Phase Two, I identified 25 therapy-centered game design patterns through analyzing data about game use in BI therapy. Based on those patterns, in Phase Three I created and iterated the GaPBIT prototype through user studies. In Phase Four, I conducted quasi-experimental case studies to establish the efficacy and user experience of GaPBIT in game design workshops that involved both game designers and therapists. During the design workshops, the design patterns and GaPBIT supported exploration of game design ideas and effectively facilitated discussion among designers and therapists. The results also indicated that these tools were especially beneficial for novice game designers. This work significantly promotes game design for BI rehabilitation by providing designers and therapists with easier access to the information about requirements in rehabilitation games. Additionally, this work modeled a novel research methodology for investigating domains where balancing the role of designers and other stakeholders is particularly important. Through a “practitioner-centered” process, this work also provides an exemplar of investigating technologies that directly address the information needs of professional practitioners

A Comparison of Registered Nurses’ Motivation and Knowledge Levels Between Gamified And Traditional Courses

Registered nurses (RNs) working in today’s healthcare environment must consistently learn new knowledge and skills, keep abreast of practice changes, and implement strategies to improve patient outcomes. However, healthcare organizations face significant challenges as they attempt to facilitate efficient training. Nursing professional development practitioners miss opportunities to leverage learner motivation, which drives investment, knowledge retention, and practice application. Gamification, which strategically embeds game elements and mechanics into an educational design to boost motivation, offers a potential solution. It aims to increase learner engagement by presenting learners with challenges, tracking their progress, and offering feedback, ultimately leading to knowledge retention and application. The purpose of this quantitative study was to examine whether gamification leads to increases in motivation to learn and knowledge levels for RNs. Specifically, the study focused on RNs who did not have previous cardiac monitoring experience. The study used flow theory and self-determination theory to optimally incorporate gamification. A quasi-experimental posttest-only design with a comparison group allowed for comparisons among RNs who completed a traditional ECG course with those who completed a gamified ECG course. The comparison group contained 66 eligible participants who completed the survey and the experimental group contained 64 participants. Post-course surveys were electronically distributed to registered nurses who completed either the traditional or the gamified version of the ECG course. Research instruments included a demographic survey, the Flow Perceptions Questionnaire (a self-reporting motivational survey), and an ECG knowledge test. Additionally, RNs who completed the gamified version were administered a short survey measuring the motivational effects of included game elements and mechanics. Two hierarchical multiple regressions were conducted to identify differences between the comparison and experimental groups when controlling for age and current patient care environment. The first indicated the addition of the variable class type to the prediction of ECG test scores was statistically significant (ΔR2 = .116, p \u3c.001). Therefore, the experimental group scored statistically significantly higher than the comparison group. The second hierarchical multiple regression suggested the addition of the variable class type to the prediction of Flow Perceptions Questionnaire scores was not statistically significant (ΔR2 = .006, p = .397). Thus, no significant differences were discovered between the two groups specific to learner motivation. In fact, the comparison group reported higher motivation levels than the experimental group. The proposed theoretical framework effectively guided the ECG course’s gamification design; however, since anticipated learner motivation scores were not achieved, minor adjustments might be warranted. Game mechanics and game elements, specifically selected for the gamified ECG course based on learner personas, were mostly rated as promoting higher motivation levels. Future research must be conducted to improve sample diversity, control, and motivation measurement, in addition to exploring qualitative data, longitudinal outcomes, and gamification’s various technological sophistication levels

Level up learning: a national survey on teaching with digital games

Digital games have the potential to transform K-12 education as we know it. But what has been the real experience among teachers who use games in the classroom? In 2013, the Games and Learning Publishing Council conducted a national survey among nearly 700 K-8 teachers. The report reveals key findings from the survey, and looks at how often and why teachers use games in the classroom, as well as issues they encounter in their efforts to implement digital games into their practice

Technology-enhanced Personalised Learning: Untangling the Evidence

Technology-enhanced personalised learning is not yet common in Germany, which is why we have tasked scientists with summarising the current status of international research on the matter. This study demonstrates the great potential of technology in implementing effective personalised learning. Nevertheless, it has not been assessed yet whether the practical implementation actually works: Even in countries such as the U.S., which lead the way in using techology in classroom settings, hardly any evaluation studies have been done to prove the effectiveness of technology-enhanced personalised learning. In the light of the above, the authors make recommendations for actions to be taken in Germany to make best use of the potential of technology in providing individual support and guidance to students

Why so serious?:game-based learning in health profession education: state of the art and future directions

If you look around carefully, you see a lot of use of game elements that aim to motivate people towards a certain behaviour. From smileys on posts that aim to lower your driving speed, to earning stars in language learning apps. Game-based learning is the use of game elements to make learning more attractive and to encourage people to continue their learning. This is logical right? The longer you learn, the better the outcome. Or not? This doctoral thesis examines the effects of using game-based learning in medical education. Why and when should it be applied? We have investigated whether it is advisable to develop a game suitable for everyone. We discovered that there are 5 different game personas (player types): competitors, socializers, social achievers, explorers and trolls. Everyone has their own preferences when it comes to social interactions and achieving goals within a game. From this we were able to develop a taxonomy, which has been tested at almost all medical universities in the Netherlands. It shows that medical students are mainly socially oriented players. While most game based learnings are not at all. This doctoral research can offer perspective in current developments, gives direction where it could go, but also has a critical note on the use of game-based learning that is should not be applied too much

Efeitos negativos e limitações da gamificação no período entre 2005 e 2020: uma revisão sistemática da literatura

A gamificação tem sido definida como a aplicação de elementos de jogo a contextos que não são de jogo (Deterding et al, 2011), de forma a promover comportamentos nos indivíduos (Hamari & Koivisto, 2015). A investigação acerca da gamificação tem sido desenvolvida numa perspetiva de procura de benefícios em áreas como o marketing, a gestão e a educação (Rodrigues, Oliveira & Rodrigues, 2019). Porém, constata-se uma lacuna na literatura relativamente a uma investigação que contemple o lado negativo da gamificação e as suas potenciais limitações. O objetivo geral deste estudo consistiu em compreender os efeitos negativos e limitações da implementação da gamificação ou de elementos de jogo mencionados na literatura científica de diversas áreas. Para tal, elaborou-se uma revisão sistemática da literatura cobrindo 86 textos científicos publicados entre 2005 e 2020 em revistas científicas de ranking maior ou igual a Q2. Utilizou-se o Leximancer para extrair os principais temas e conceitos abordados. Constatou-se que os temas “gamification”, “aprendizagem”, “desempenho”, “comportamento” e “marca” foram os mais explorados pelos investigadores no período analisado. Os conceitos “marca”, “efeitos”, “contexto” e “comportamento” são aqueles que mais se relacionam com o conceito “negativo”, que se associa também com os conceitos “controlo” e “desempenho”. Detetou-se que a gamificação tem, sim, um lado negativo, que está dependente do contexto e que se manifesta principalmente no âmbito de situações de aprendizagem. A base teórica construída neste estudo permitirá a investigação sobre os fatores contextuais que limitam a eficácia da aplicação da gamificação em situação de aprendizagem.Gamification has been defined as the usage of game elements in non-game contexts (Deterding et al, 2011), to promote certain behaviours in individuals (Hamari & Koivisto, 2015). Since it is a recent, gamification has been research from a benefit search point of view in areas like marketing, management and education concept (Rodrigues, Oliveira & Rodrigues, 2019). However, there is a lack of transversal studies about the negative side of gamification and its potential limitations. The main purpose of this study was to understand the negative effects and limitations of the implementation of gamification or gamified elements, mentioned throughout scientific literature of several areas. We have thus performed a systematic review of literature covering 84 scientific texts published between 2005 and 2020 in scientific journals of Q2 or higher. We then used Leximancer to extract the main themes and concepts considered. We concluded that “gamification”, “learning”, “performance”, “behaviour” and “brand were the main themes underlying the investigation conducted in the analysed period. Moreover, “brand”, “effects”, “context” and “behaviour” are the closest concepts to “negative”, which is also associated with “control” and “performance”. We confirmed gamification does have a negative side, which depends on the context and is mainly present in learning situations. The theoretical basis brought by our study allows for future investigation on the context factors that hinder the efficacy of gamification in learning situations