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Introduction

Reports indicate that 30.3 million people are diabetic worldwide as of 2017 and it is estimated that 23.1 million are in early stages of diagnosis. According to the Center for Disease Control and Prevention(CDC) report, about 28.8% of the world population suffer hidden diabetes (1). The prevalence of diabetes is estimated as 6% in the Iranian population, and it is estimated that about 4 million individuals are affected(2).

Diabetes is associated with serious complications and injuries, and several studies suggest that the rate of diabetic complications will increase in the near future and it will occur at younger ages of life (3, 4). Therefore, it is necessary for diabetic patients to control their blood glucose level to have a normal life and avoid unnecessary treatment costs. To achieve this goal, educating diabetics and healthy individuals to lower the risk of developing diabetes (5) and mainly increasing knowledge, awareness and attitude, acquiring necessary skills, enhancing coping with the disease, performing the required care, accelerating improvement and recovery, and minimizing the complications is absolutely necessary. (6-9).Today, educating people with emerging technological advances and multimedia, encourages them to learn and develop an understanding of the disease, and adapt to the new information (10). Therefore, considering the high prevalence of diabetes in the world and its grave unwanted consequences, it is necessary to benefit from new educational technologies and instruments.

One of these technologies is gamification, which as an effective educational tool that enhances the quality of education, creates motivation and enthusiasm, and develops a feeling of competition in the target population. (11). It has the potential to transform knowledge and educational content into personal knowledge to enable users to solve problems in an active or interactive manner (12). It should be mentioned that in addition to gamification, there are other tools such as a serious game (to combine aspects of both serious concept such as teaching, learning, communication, or further information with less entertainment.)(13), an educational game (For teaching the basic and certain subjects with enjoyment and pleasure)(14) game-based learning (to encourage learners to participate in learning while playing, and make the leaning process more interesting by adding fun)(15), that are used as tools to improve the learning process. These tools have their own specific features, but all of them have one purpose of Increasing the level of learning along with increasing motivation and entertainment. In this systematized review, papers regarding diabetes using one of these three tools of gamification, serious game, and educational game were appraised.

Materials and Methods

The databases of PubMed, Ovid, Cochrane, Scopus, Web of Science, ProQuest, Springer, Embase, and Science Direct were searched from the very beginning to February 2018 to retrieve publications related to diabetes and games, using an advanced search query. The search operators included Boolean operators (AND, OR and NOT), parenthesis, and truncation. The keywords to retrieve the papers, were selected from Medical Subject Headings (MeSH) and National Library of Medicine (NLM) thesaurus, and were as follows: ‘diabetes mellitus, diabetes mellitus-type1, diabetes mellitus-type2, gamification, Digital game, Video game, Game(s), Simulation, Computer-assisted gaming, Serious Game(s), Educational game(s), Role-playing game(s), Real-world game(s), massively multi player online game, role play simulation, storytelling game’

An example of the search strategy is as follows: ((‘diabetes mellitus, type1’ OR ‘diabetes mellitus, type2’) AND ( ‘gamifications’ OR ‘serious games’ OR ‘educational games’ OR ‘video games’ OR ‘digital games’ OR ‘Simulation’ OR ‘Computer-assisted gaming’ OR ‘Serious Game(s)’ OR ‘Educational game(s)’ OR ‘Role-playing game(s)’ OR ‘Real-world game(s)’ OR ‘massively multi player online’ OR ‘role play simulation’ OR ‘storytelling game’ ))

The inclusion criteria were: full texts of original research articles, English language, with no time limit that was related to diabetes gamifications (serious games, educational games). Moreover, researchers excluded duplicates while assessing the retrieved studies. Papers were reviewed and appraised by at least two independent researchers and inconsistencies were assessed and resolved, if there were any. The data retrieved from the papers included: title, name(s) of author(s), publication place and year, research sample or population, type of study, objectives and research questions, and type of game. In addition, findings and results of each study were summarized and recorded in predesigned forms. The Critical Appraisal Skills Program checklist (CASP) was applied to assess quality of the papers. The entire process of retrieving and reviewing studies are specified in the flowchart below

It could be concluded from this table that all games were designed to educate, teach skills and make behavior improvement for diabetics and they are less attended to train healthcare providers or healthy people. According to the title or game features, some games are considered as educational game such as the diabetes escape room, Escape from DIAB, Nanoswarm and Packy & Marlon or some of them are serious games such as Mobigame, LAffaire Birman, InsuOnline and Balance which means that all types of games were retrieved based on the purpose of the research. Most of these games are mobile-based; however, some of them were designed for game consoles or game boards. Assessment of learning theories used in these gamifications showed that self-determination theory was frequently applied in games such as Virtual coach, robot, Escape from DIAB and Diab. Classification of games according to Blooms Taxonomy of Behavioral Objectives showed that most gamifications could be classified under cognitive domain (application and knowledge levels); in this regard exergames consider psychomotor activity and could be classified under this domain. Considering effectiveness of games, the retrieved data indicated that gamification in each platform and genre could meet the participants needs and encourage their participation.

The target population of the gamifications was from different age groups including children, diabetic patients, and healthy people and the games were designed for medical students and residents, or students of other related medical majors. There was a marked variation in the type of diabetes and many gamifications encompassed both types. Physical activity and nutrition (14 papers) were the most frequent diabetic subthemes in diabetes gamifications.

Discussion

Gamification is one of the learning methods that has been much considered in the recent years(16, 17). According to Gee, the purpose of gamification is to create a problem-solving environment that can be integrated with continuous education and enjoyment for improving learning process(18). So in this review, the features, educational aspects and effectiveness of gamification (serious, educational games) in diabetes (both types) were investigated.

In this systematized review, 1795 papers were retrieved from eight databases from April to May 2017. After discarding unrelated papers that did not match purposes of this study, 35 papers remained that met the study criteria. At first, all bibliographic information of these papers were retrieved.

Assessment of characteristics and commonalities among diabetes gamifications showed that they were designed as digital games, exergames requiring sensors and motion detectors, and board games. They are all problem-solving games that use the task and goal method in gamification, to deliver teaching and learning indirectly, so that learners learn through missions, tasks, victories and failures. (19, 20). Considering game design, all the related games, except the games for teaching physical skills (exergames), use multiple-choice questions to convey game concepts. (21-23).

Considering underpinning learning theories to develop a gamification is crucial (24). These theories promote learning and improve skills such as problem solving and critical thinking (25-27). In this research, all diabetes gamifications aimed at teaching a skill or concept, changing a behavior or habit positively, or enhancing disease management in the target population and most of them benefited from one or more implicit underpinning learning theories.

Gamification targets knowledge and skills and transfers them to the learner through elements such as repetition, feedback, and entertainment. When the learner becomes skillful, knowledge and skills related to that concept become persistent in the memory so that the learner can focus on perception and implementation of the information. On the other hand, gamification has positive effects on motivation and decision-making capabilities, because the player faces challenges that untimely enhance learning through decision-making, discovery, and trial and error (16, 28, 29). This scientific background is the backbone of the effectiveness of gamifications (30-32). It is also consistent with the results of this study since the target populations of diabetes gamifications could successfully receive and implement the required knowledge and skills. However, it should be noted that retention of information learned through gamification was not assessed in these studies.

Considering diabetes gamification developing team, it is revealed that in addition to the field professionals, an expert technical team, including game design experts, programmers, concept designers, art designers, graphic designer, character designer, and sound designers must be among the game production team members, because identification of the technical, artistic and aesthetic aspects of the game is of paramount importance besides mastery over the gamification topic and field, which is also associated with heavy financial costs. On the other hand, use of several advanced technologies, software, and hardware increases the costs of gamification production and are highly challenging. (33-35).

The research findings indicate that all studies confirm the effectiveness of gamification in the user’s training, and of course encourage other researchers in other clinical fields to develop gamifications or serious games, especially in the disciplines where understanding and learning are tedious and challenging. Since health is a matter of life and death and treatment is a costly process, gamification can improve public health and decrease treatment costs through training healthy individuals to manage and enhance their health literacy or providing disease management training for high-risk groups and patients by creating fun and entertainment. Finally, it is suggested that in the future studies on gamifications, application of learning theories in gamifications and serious games be focus of attention.

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