JMIR Publications

ABSTRACT

Background:

Microaggressions in healthcare contribute to disparities in care, reduced patient trust, and negative outcomes for both patients and professionals. Despite their impact, many healthcare providers lack effective training to recognize and respond to these subtle forms of bias. Traditional diversity training often relies on passive methods and shows limited long-term effectiveness. Serious games offer interactive and experiential learning environments that can enhance engagement, empathy, and behavioral awareness. While these tools have been widely used in healthcare education, their role in addressing microaggressions remains underexplored. A clearer understanding of how existing game designs can support bias awareness and inclusive behavior is needed to guide future development.

Objective:

This study aims to systematically review digital educational games that address microaggressions and bias awareness, and to evaluate their effectiveness in supporting learning outcomes such as awareness, engagement, and behavioral intention. It also examines key game design features, including engagement, feedback, immersion, and real world simulation, to identify strengths, limitations, and opportunities for adapting or developing serious games for healthcare training.

Methods:

This study followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines to identify and evaluate relevant digital educational games. A structured literature search was conducted across Google Scholar, PsycINFO, and PubMed for studies published between 2014 and 2024 using combinations of keywords related to serious games, microaggressions, bias awareness, and training. Studies were included if they used a digital game as the primary intervention and focused on microaggressions or implicit bias. After screening and eligibility assessment, five interventions were selected for analysis: Fair Play, Blind Spot, The World of EMPA, Passage Home VR, and Killing Me Softly. Each intervention was evaluated based on learning outcomes such as awareness, engagement, and behavioral intention, as well as key design features including engagement in gameplay, in game feedback, immersion, and real world simulation. Study design and evaluation methods, including experimental and qualitative approaches, were also examined to assess the strength of evidence.

Results:

Five digital educational games met the inclusion criteria. Across studies, interventions consistently showed positive effects on awareness of microaggressions, perspective taking, and intention to intervene. Games that used narrative role play and immersive elements demonstrated stronger engagement and emotional involvement. Two interventions used randomized or controlled designs and reported measurable improvements in empathy, bias awareness, or reduced distress. The remaining studies relied primarily on qualitative feedback and self reported outcomes, limiting generalizability. Across design features, all games incorporated engagement and real world scenarios, while feedback mechanisms and levels of immersion varied. Real time and behavior responsive feedback appeared to support deeper reflection. However, most interventions focused on target or bystander perspectives, with no games addressing the role of the perpetrator. Overall, findings indicate that serious games have potential to support microaggression awareness, but evidence is limited by small samples, short term evaluation, and lack of standardized outcome measures.

Conclusions:

Serious games show strong potential as tools for raising awareness of microaggressions and supporting inclusive behavior in educational and healthcare related contexts. Their interactive and experiential nature enables engagement, perspective taking, and reflection beyond traditional training methods. However, current evidence remains limited by short term evaluations, reliance on self reported outcomes, and lack of standardized assessment tools. Future work should focus on developing healthcare specific interventions, incorporating multiple role perspectives, and applying more rigorous and longitudinal evaluation methods to better understand their impact on real world behavior.