JMIR Publications

ABSTRACT

Background:

Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens.

Objective:

To realize this potential, insight is needed into how it works, why, for whom, and when in actual treatment circumstances.

Methods:

Following a realist approach, process evaluations were performed before, during, and after a two-armed natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. Before (2 sessions) and after (1 session) the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers and experts. Patients participated in a survey (n=114) and in semi-structured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing (with regression models) routinely collected clinical outcome data. An updated ‘program theory’ was formulated after mixing the qualitative and quantitative results.

Results:

Qualitative data showed that part of the patients perceived improvement of their self-awareness in moments of daily social interaction. This learning results was explained by patients by triggers in the serious game ‘LAKA’ for a “confrontation with yourself”. These reflected ‘self-discrepancies’. Important characteristics of serious gaming in the context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, the (limited) flexibility to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role taking and the planning and facilitating (local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed ‘very small’ average differences between the study groups in self-reported depression, pain and fatigue changes (-.07<β<-.17, all 95% confidence interval upper bounds <0), which were mediated by ‘small’ group differences in mindfulness (β=.26, 95% CI=.02-.51). Mindfulness changes were positively associated with patient involvement in serious gaming (n=114, β=.36, P=001). Acceptance of serious gaming was lower in older patients. Average health outcome changes went up to a ‘medium’ size in patients that reported lower active coping with stress and pain coping before serious gaming. Mindfulness change and gaming acceptance perceptions co-varied with group structure and ‘immediate’ feedback sessions after serious gaming.

Conclusions:

This study developed transferable insight into how and why serious gaming can facilitate additional learning about coping for reducing burdens of chronic pain or fatigue symptoms in certain patients and actual treatment circumstances. Future studies are needed to continue the development of this fallible theory. Such research will further support decisions about using, designing, allocating and tailoring serious gaming for optimal chances of important patient health benefit. Clinical Trial: This study was registered in the Netherlands Trial Registry NTR6020 on June 10th, 2016.