Gamified Interventions for Promoting the Psychosocial Well-Being of School-Aged Children: A Scoping Review

Abstract

Gamified health interventions can offer child-centered and tailored health-promoting strategies. Evidence suggests that its various mechanics foster engagement that can be utilized to promote health and well-being and influence health behavior. At present, psychosocial challenges among school-aged children are becoming a global predicament. We conducted a scoping review to explore the range and nature of evidence on gamified interventions for promoting the psychosocial well-being of school-aged children from the general population. We followed the Arksey and O’Malley framework and extracted sources of evidence from five databases. Our review findings were summarized with basic numerical analysis and provided with narrative accounts based on a gamification taxonomy and the Template for Intervention Description and Replication (TIDieR). We identified 12 gamified interventions and included 23 records that reported their development and evaluation. Theories on emotions, behaviors, social skills, and mental health were commonly applied frameworks. Narrative was found as the most commonly used gamification mechanic (11/12, 91.7%), followed by avatar and tasks (10/12, 83.3%), feedback system and level progression (9/12, 75%), points (7/12, 58.3%), badges (5/12, 41.7%), progress bar (4/12, 33.3%), and virtual goods, reminders, and time pressure (2/12, 16.7%). The included sources of evidence reported significant improvements in some of the measured psychosocial outcomes; however, studies on this domain for this particular target group are still considerably limited. Further research is needed to determine how the applied theories and gamification mechanics brought about the change in psychosocial outcomes, bridging the gap in current evidence.

Introduction

Digital interventions for promoting health and well-being are growing in popularity. The World Health Organization (WHO) recognized how this approach showcased great potential in enhancing various health outcomes¹ and continues to strengthen evidence-based digital health interventions.² In promoting children’s health and well-being, gamification gained recognition as an innovative approach offering child-friendly, health-promoting strategies.³ It is defined as the application of game design and its mechanics in a nongame context other than for entertainment purposes.⁴ Evidence suggests that gamified interventions have positive effects on children’s health and well-being,⁵ their health behaviors,⁶ and their perspectives toward health.⁷ These interventions fill in the shortcomings of their conventional counterparts (nongamified interventions) such as intrinsic motivation, accessibility through technological devices such as tablets and smartphones, appeal to wider population, applicability to various health domains, cost–benefit efficiency—particularly in intervention scalability, ease of fitting the intervention with other daily-life activities, and generating positive and fun experiences.⁵ Gamification can foster intervention engagement and convenience.^3,5

Psychosocial well-being is one of the many dimensions of mental health,⁸ which focuses on the psychological and social levels of human functioning.⁹ There are varying definitions and interpretations to date. Generally, the term psychosocial refers to the correlation of the mind, body, and social environment in the contexts of a person’s experience, behavior, and social dynamics.^10,11 It impacts one’s quality of life¹² extending to personal growth, values, purposeful activity, and self-perceived life satisfaction.^13,14 Challenges in these areas may escalate to various health risks.^12–14

The high prevalence of psychosocial challenges among school-aged children is a growing global predicament.¹⁵ It has become a significant barrier even for children with no underlying health deficiency. Children’s psychosocial well-being is affected by their health behavior, relationships with family, peers, and society in general.¹⁶ Recognizing their psychological resources, for example, their self-esteem and emotional resilience, as well as their social environment, is crucial.^17,18 Studies have shown that the effect of these resources is highly significant to children’s health risks such as obesity, lack of physical activity, early smoking, and alcohol use.¹⁹ Furthermore, the continuous effect of the changes in social norms brought about by the Coronavirus disease 2019 (COVID-19) pandemic aggravated negative psychosocial outcomes, especially in children.²⁰ In light of this escalating predicament, child-centered interventions that address the psychosocial well-being of children are needed. As research and development on gamified health interventions are continuously growing,^5–7 it is of our interest to explore the extent of evidence on its application to promote the psychosocial well-being of children from the general population.

Methods

Given the broad and complex nature of our topic, we conducted a scoping review to explore and provide an overview of the range and nature of evidence on using gamification for promoting the psychosocial well-being of school-aged children. A scoping review is useful to rapidly map evidence across a wide range of sources, identify areas where research warrants further investigation, and assess if a more in-depth type of review is feasible,^21,22 which are in line with our objectives. We adhered to the five-stage Arksey & O’Malley framework for scoping reviews.²³ This framework offers a straightforward process while encouraging flexibility and consideration of key elements of our review questions as our familiarity with literature develops. The review protocol was preregistered under the Open Science Framework (https://osf.io/7df2a).

Stage 1: Identifying the research questions

This review was conducted with the following questions: (1) What are the available gamified interventions for promoting the psychosocial well-being of children from the general population? (2) What theoretical frameworks and gamification mechanics were used to support their psychosocial outcomes? (3) What psychosocial outcomes and changes were observed after playing the gamified interventions?

Stage 2: Identifying relevant studies

We conducted our initial search in April 2022 and performed updated searches in December 2022 and February 2024 to identify additional evidence published until the end of 2023 ensuring our review is up to date. The eligibility criteria were predetermined prior to our review. We included sources of evidence without published date restrictions on gamified digital interventions, health games, serious games, or mobile health apps, for the promotion of psychosocial well-being or its resources and for children aged 6–12 years. We excluded reviews and meta-analyses, focused on children with underlying physical or mental health disorders, and sources not available in English.

We identified the studies from PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Scopus using keywords generated based on synonymity and as identified from preliminary search of literature. The construction of search phrases was based on identified keywords from population, concepts, contexts, as well as Medical Subject Headings (MeSH) terms and subject headings as applicable. Each was tailored accordingly as per database. We also referred to the information retrieval strategies by Salvador-Oliván²⁴ to avoid misappropriation of keywords as search phrases and to ensure that applied search suffixes comply with each database search syntax. For example in PubMed, we used the search string (“Child”[Mesh] OR child*[tw] OR “school aged child*”[tw] OR “school-aged child*”[tw]) AND (“Gamification”[Mesh] OR “Mobile Applications”[Mesh] OR gamif*[tw] OR “health game*”[tw] OR “serious game*”[tw] OR” health app*”[tw] OR “mobile app*”[tw] OR mhealth[tw] OR m-health[tw] OR ehealth[tw] OR e-health[tw] OR “digital intervention*”[tw]) AND (“Mental Health”[Mesh] OR “psychosocial health*”[tw] OR “mental health*”[tw]). At this stage, gray literatures were explored through Google Scholar. Reviewers have agreed that the first 100 hits from the search engine will be extracted for screening prior to search. Sci-Hub was also used to map literature as found necessary. Bibliographic references were inspected for further study inclusion.

Stage 3: Study selection

The criteria were applied at every screening stage (title, abstract, full text) by two independent reviewers (K.K., J.A.). If ambiguity occurred during the screening process, we retained the source of evidence for further examination. Our screening decisions were discussed at every stage and concluded prior to the commencement of the following stage. Study authors and game developers were contacted as necessary, to ensure that relevant study reports were obtained. Primarily, we were looking for gamified interventions intended for children ages from 6- to 12 years. We decided not to exclude sources that also catered to children beyond the age criteria as long as the target users include those from 6 to 12 years old. Else, we will be missing on sources of evidence for this review’s particular population. We used Rayyan screening management tool²⁵ in our screening process.

Stage 4: Charting the data

Data were charted from the selected sources of evidence using an Excel spreadsheet designed for the purpose of this review (K.K.). The charting was cross-checked by two independent reviewers (K.J., A.P.) for consistency. We grouped the sources based on gamified interventions and extracted information on their general characteristics. To have a structured way of describing the identified gamified interventions, we (K.K., F.A.) recorded information based on the Template for Intervention Description and Replication (TIDieR). Its primary use is to enhance the reporting of interventions and address challenges that can hinder the replication, implementation, and synthesis of evidence.²⁶ We used the Schöbel & Janson’s gamification taxonomy²⁷ to have a consistent approach in identifying the reported gamification mechanics applied in the intervention such as collection system (i.e., points, badges, and virtual goods), leaderboard, level, progress bar, feedback, representing avatar, tasks, narratives, reminder, and time pressure. The taxonomy provides explanations, meanings, and characteristics of game design elements that can guide a cohesive gamification process. Therefore, we can avoid the misrepresentation of overlapping terminologies used in different studies.

Stage 5: Collating, summarizing, and reporting the results

We collated the charted information and summarized our results with basic numerical analysis. The gamification taxonomy we used and adapted items from TIDieR guided our thematic construction in presenting narrative accounts of our findings. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)²⁸ guided our reporting procedure.

Results

Our search yielded a total of 2132 potential records. During the first search, there were 1420 records identified with which 504 records were removed after deduplication. After the updated search, we found 311 additional records with 85 duplicates. From our latest updated search, we found 401 additional records with 92 duplicates. Of the 1451 total records, 36 met our eligibility criteria and screened for full text. Six were excluded, as these were neither actual gamified interventions nor serious games; but rather incorporated mini-games. Five were for the wrong target group such as interventions intended for diagnosed children with underlying health conditions. Four records were not for promoting psychosocial well-being, and four were reviews. We depicted our evidence identification process using the PRISMA flow diagram²⁹ as shown in Figure 1.

FIG. 1.

PRISMA 2020 flow diagram of evidence identification process.

We found a total of 23 records^30–52 of different studies of gamified interventions for promoting the psychosocial well-being of school-aged children (Table 1). The earliest was published in 2017 and the latest in 2023. The studies were conducted in 10 different countries. There were seven randomized controlled trials (RCT), with two studies employing waitlist control groups, four business-as-usual groups, and one with educational sessions by a school psychologist. There were 12 evaluation studies that did not use RCT design, three protocols, and one descriptive qualitative study. There were 22 records published in peer-reviewed journals and one conference article.

Table 1.

Characteristics of Total Records Included in the Scoping Review

Characteristics	Number (n = 23)	Percentage (%)
Publication year
2017	1	4.3
2019	5	21.7
2020	3	13.0
2021	8	34.8
2022	3	13.0
2023	3	13.0
Types of studies
Randomized controlled trial (RCT)	7	30.4
Non-RCT evaluation studies	12	52.2
Protocol	3	13.0
Qualitative	1	4.3
Publication type
Peer-reviewed journal article	22	95.7
Conference article	1	4.3
Country
Australia	2	8.7
Cyprus	2	8.7
Finland	1	4.3
Hong Kong	1	4.3
Iran	1	4.3
Netherlands	3	13.0
Romania	5	21.7
Spain	4	17.4
United Kingdom	2	8.7
United States of America	2	8.7

Gamified interventions

We identified 12 gamified interventions aimed to promote the psychosocial well-being of children and presented their descriptions in Table 2. Eleven (91.6%) gamified interventions were designed to target the psychological and social well-being of children, whereas one (8.3%) was aimed to promote the overall psychosocial well-being of children together with increasing their physical activity levels. The age range of the target groups widely differed for each of the identified gamified interventions. In the context of school-aged children (6–12 years old), majority catered to 11-year-olds (10/12, 83.3%), followed by those to 10- and 12-year-olds (9/12, 75%), 8- and 9-year-olds (6/12, 50%), 7-year-olds (3/12, 25%), and 6-year-olds (2/12, 16.7%).

Table 2.

Description of the Gamified Interventions

Author(s), year of publication, country	Gamified intervention	Target group	Description
Cejudo et al., 2020, Spain	Aislados	12–17 years old	A video game for promoting social competence and social–emotional well-being of adolescents and young people. It is accessible via browser and Android devices.³⁰
David et al., 2019a; 2019b; 2021; 2022; Iuga et al., 2023; Romania	REThink	10–16 years old	A theory-based video game for promoting emotional resilience such as functional emotions, effective problem solving, and positive emotions of children and adolescents. It is accessible on iOS (iPad).^31–35
De la Barrera et al., 2021a; 2021b; Spain	EmoTIC	11–15 years old	A serious game for developing socioemotional competencies. It is accessible on any web-based platform on all devices.^36,37
Gijzen et al., 2021; Tuijnman et al., 2019; 2022; Netherlands	Moving Stories	11–15 years old	A 3D video game that targets components of mental health literacy such as recognition of depression development, treatments and help-seeking options, and first aid skills to support those who are having mental health crisis. It is a game-based school program implemented in the entire class. It is accessible on Android and iOS devices.^38–40
Keinonen et. al., 2023; Finland	Magis	10–12 years old	A magical adventure mobile game aimed to promote psychological flexibility and overall well-being of children aged 10–12 years old. The game was based on dialogues and story plots based on acceptance and commitment therapy (ACT). It is accessible for on Android and iOS devices in Finnish, Swedish, and English.⁴¹
Li et al., 2021; Sanchez et al., 2017; United States of America	Adventures aboard the S.S. GRIN	7–11 years old	An online digital game based on Social Skills Group Intervention (S.S. GRIN) that helps children develop social-emotional skills and problem solving. It is accessible on computers.^42,43
Moltrecht et al., 2021; 2022; United Kingdom	EDA	10–12 years old	A web-based app for promoting children’s mental health and well-being by improving their emotion regulation skills. The game is accessible on computers and mobile devices. It was optimized for tablets.^44,45
Nasab et al., 2019, Iran	Man-Man	8–10 years old	A mobile-based game for improving children’s psychological skills, sense of control, self-esteem, and teaches the importance of self-acceptance and self-love.⁴⁶
Nicolaidou et al., 2019; 2022; Cyprus	Kids Stress Relief Interactive Story-telling app	5–12 years old	A gamified story-telling app for promoting emotion regulation of children in stressful situations. It is accessible on Android tablet.^47,48
Saleme et al., 2020; 2021; Australia	R.E.M.I.	8–11 years old	An interactive game with augmented reality (AR) experience to strengthen children’s social-emotional skill and prosocial behavior. Accessible on iOS devices.^49,50
Sotos-Martinez et al., 2023, Spain	Classdojo	8–13 years old	A versatile gamified platform that evaluates specific behaviors based on learning goals of a class or curriculum. It is accessible on Android and iOS devices.⁵¹
Wong et al., 2020, Hong Kong	Family Move	6–15 years old with their parents	A mobile-based game with parent–child exercises to increase physical activity levels and reduce the psychosocial problems of children. It is accessible on Android and iOS devices.⁵²

Theoretical frameworks

Various theoretical frameworks on emotions, behaviors, social skills, and mental health were applied in the game development to support the psychosocial outcomes of the interventions. Two gamified interventions (16.7%) were based on the assumptions of social emotional learning and also two (16.7%) applied the social cognitive theory. There was a substantial heterogeneity in the applied theoretical frameworks as with the characteristics of the gamified interventions, we therefore presented each separately in Table 3.

Table 3.

Characteristics of the Gamified Interventions

Gamified intervention	Theoretical framework	Gamification mechanics	Implementation setting	Dose of intervention	Outcome measures
Aislados³⁰	Social Emotional Learning (SEL)	Avatar, feedback, narrative, points, task	School setting (classroom)	55 minutes/ week, 28 hours total	Health-related quality of life (KIDSCREEN), Satisfaction with Life Scale (SWLS), Positive and Negative Affect Schedule (PANAS), Mental Health (MH-5), Trait Emotional Intelligence Questionnaire Adolescents Short Form (TEIQue-ASF)
REThink^31–35	Rational Emotive Therapy (REBT)	Avatar, badges, feedback, level, narrative, progress bar, tasks	School setting (after classes)	50–60 minutes × 7 modules in 1 month	Strengths and Difficulties Questionnaire—child version (SDQ), Attitudes and Beliefs Scale Short form (ABS), Child and Adolescent Scale of Irrationality (CASI), Children’s Automatic Thoughts Scale-Negative/Positive (CATS N/P), Problem Solving Abilities—Visual Analogue Scale (VAS), Treatment Satisfaction Visual Analogue Scales (TS-VAS)
EmoTIC^36,37	Mayer & Salovey’s Ability Model of Emotional Intelligence	Badges, level, narrative, points, tasks, virtual goods	School setting (4 classroom sessions with 12 home activities)	50 minutes × Y4 sessions in 4 weeks	Trait Meta-Mood Scale-24 (^TMMS-24), Rosenberg Self-esteem Scale (RSE), The Scale of Positive and Negative Experiences (SPANE), Strengths and Difficulties Questionnaire (SDQ), Depression, Anxiety, and Stress Scales (DASS-21)
Moving Stories^38–40	Australian Mental Health First Aid training	Avatar, feedback, narrative, points, reminders, tasks, time pressure	School setting (classroom and non-classroom)	10–15 minutes × 5 days	Mental health literacy on depression, First Aid Confidence, First Aid Intentions and Skills, Beliefs About Help, Help-Seeking Intentions, Dutch Depression Stigma Scale, Social Distance Scale for youths, First Aid Behavior, Help-Seeking Behavior, Children’s Depression Inventory
Magis⁴¹	Acceptance and commitment therapy [transdiagnostic third-wave Cognitive Behavioral Therapy (CBT)]	Avatar, feedback, narrative, tasks, level, feedback, time pressure, reminders, progress bar	School setting (classroom)	30–45 minutes per chapter/ week in 4 weeks	Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), Strengths and Difficulties Questionnaire, (SDQ), Health-Related Quality of Life (KINDL), brief self-rating visual analog scales (VAS) for mood, school satisfaction, loneliness, and friendships
Adventures aboard the S.S. GRIN^42,43	Social Skills Group Intervention training program (S.S. GRIN) based on Social Emotional Learning (SEL)	Avatar, feedback, level, narrative, progress bar, tasks	School setting (classroom and distance learning sessions)	30 to 45 minutes per episode/ week for 9 weeks	Devereux Student Strengths Assessment-Mini (DESSA-Mini), Behavioral and Emotional Rating Scale Second Edition (BERS-2), Social Skills and Behavioral Index (SSBI), SELweb, Zoo U, observations and interviews to assess game engagement
EDA^44,45	Cognitive Behavioral Therapy (CBT)	Avatar, feedback narrative, points	Flexible setting	Users can play freely for 3 months	Short Mood and Feelings Questionnaire, Me & My Feelings Questionnaire, Satisfaction with Life Scale for Children, How I feel—Questionnaire
Man-Man⁴⁶	Principles of story therapy, reality therapy, and cognitive therapy	Avatar, level, narrative, tasks	Psychologist’s clinic	30 to 45 minutes × 6 sessions	Rosenberg self-esteem scale (RSE), Piers-Harris Children Self-Concept scale (CSCS)
Kids Stress Relief Interactive Story-telling app^47,48	Mindfulness, behavioral change and principles of positive psychology	Avatar, feedback, level, narrative, badges, virtual goods	Non-school setting	5 stories, users can play freely	Semi-structured interview questions developed for exploring the understanding of children about anger management techniques offered by the game
R.E.M.I.^49,50	Social Cognitive Theory (SCT)	Avatar, badges, feedback, level, narrative, points, tasks	School setting (classroom)	45 minutes × 1 session per school	Jolliffe and Farrington Empathy Scale, General Normative Beliefs subscale
Classdojo⁵¹	Self-determination Theory	Avatar, feedback, narrative, tasks, points, badges, level, feedback	School setting (classroom)	6 weeks	Basic Psychological Needs in Classroom Scale (BPN-CS) and questionnaire designed to explore children’s cooperation, participation, motivation, respect, and rejection of contempt and harassment
Family Move⁵²	Social Cognitive Theory (SCT)	Level, points, progress bar, tasks	Non-school setting	30-second burst exercises × 3 difficulty levels in 8 weeks	Chinese Child Health Questionnaire—Parent Form — 50 (CHQ-PF50), Chinese Strength and Difficulties Questionnaire (SDQ), International Physical Activity Questionnaire—Short Form—Chinese version (IPAQ-SF)

Gamification mechanics

The narrative or the story of the game was the most applied gamification mechanic (11/12, 91.7%), followed by avatar or virtual characters and tasks (10/12, 83.3%), feedback system and level progression (9/12, 75%), points (7/12, 58.3%), badges (5/12, 41.7%), progress bar (4/12, 33.3%), and virtual goods, reminders, and time pressure (2/12, 16.7%) to support the psychosocial outcomes of the interventions.

Intervention delivery

The delivery of the gamified interventions varied from school settings (8/12, 66.7%), nonschool settings (2/12, 16.7%), psychologist’s clinic (1/12, 8.3%), and flexible setting (1/12, 8.3%) with which users can play the game on their chosen time and place. Although EmoTIC and Moving Stories are school-based programs, both gamified interventions had combinations of game tasks that needed to be completed at school and at home.^36,38–40 Moreover, Li et al. reported that in their recent evaluation study of the Adventures Aboard the S.S. GRIN, they delivered the intervention as part of the school’s distance learning because of COVID-19 restrictions when all elementary schools were closed.⁴²

The doses of interventions differed per gamification approach. Nine (75%) gamified interventions were delivered per session with which the maximum time was <60 minutes, whereas the least was 10 minutes. Two (16.7%) were played freely by target users with no time constraints or level progressions that can indicate the end of the game, whereas one (8.3%) was based on level progressions with short in-game challenges. The length of the overall gameplay ranges from a one-time session, 1 school week, 1 month, 2 months, 3–6 months.

Intervention findings

Various study designs and instruments were used to measure the gamified interventions’ outcomes. Children’s self-reported instruments were used in nine (75%) gamified interventions, one (8.3%) used both self-reported and teacher-reported, whereas one (8.3%) used parent proxy-reported instruments. One (8.3%) gamified intervention explored the study outcomes through interviews of child participants. One (8.3%) also explored the perspectives of teachers to complement the instruments. We presented the intervention findings in the contexts of psychological and social levels.

Psychological level

Eleven (91.7%) gamified interventions showcased improvements in children’s emotions toward self, related to their social functions. Three (25%) gamified interventions reported improvements in children’s self-esteem after playing the game.^36,46,52 De la Barrera et al. further reported that their developed gamified intervention can also prevent the increase of children’s emotional problems, although it was not clear in their findings if children’s emotional intelligence improved.³⁶ One (8.3%) gamified intervention reported that children’s cognitive and affective well-being improved, but there were no statistically significant improvements in children’s trait emotional intelligence.³⁰ There were improvements in children’s emotion regulation in three (25%) gamified interventions.^42,45,47 Although according to Nicolaidou et al., there were only 7 out of 20 child participants who were able to identify or demonstrate the techniques learned from the gamified intervention.⁴⁷ One (8.3%) gamified intervention showcased moderate effects on improving children’s emotional resilience in two separate trials. In the first trial, children improved their emotional awareness (d = 0.64) and ability for emotion control (d = 0.69).³¹ In the second trial, there was a decrease in children’s emotional difficulties (d = 0.42), irrational beliefs (Attitudes and Beliefs Scale Short form d = 0.58; Child and Adolescent Scale of Irrationality d = 0.30), and negative thoughts (d = 0.41).³⁴ Statistically significant effect on children’s emotions and attitudes toward empathy (P < 0.01) was observed in one (8.3%) gamified intervention, but no effect was detected in their knowledge toward empathy.⁵⁰ Sotos-Martinez et al. observed increases in the values of children’s autonomy (Z = −5.306; P < 0.001; ES = 0.336), competence (Z = −7.145; P < 0.001; effect size = 0.452), and relatedness (Z = −5.285; P < 0.001; effect size = 0.334).⁵¹ Keinonen et al. did not observe effects on children’s psychological flexibility or in health-related quality of life. However, the gamified intervention was effective in alleviating self-rated loneliness.⁴¹

Improving mental health literacy and reducing children’s stigma toward negative emotions such as depression were aimed in one (8.3%) gamified intervention.^38,40 However, Tuijnman et al. found no statistically significant differences in symptom recognition, first-aid intentions, knowledge of first aid, first-aid confidence, beliefs about help, and help-seeking intentions aside from short-term improvements in reducing depression stigma at 3-month follow-up (P < 0.001), but not at 6-month follow-up.⁴⁰

Social level

Five (41.7%) gamified interventions addressed the children’s social well-being. One (8.3%) showed statistically significant gains with good effect sizes between treatment and control groups in children’s communication skills (P = 0.005, effect size = 0.39), social skills (P = 0.033, effect size = 0.29), and prosocial behavior (P = 0.004, effect size = 0.37).⁴² One (8.3%) reported that based on the Strengths and Difficulties Questionnaire, the overall psychosocial problems of children declined at 6-month follow-up (P = 0.005), with great improvements in children’s prosocial behavior score (P = 0.003) and hyperactivity/inattention (P = 0.002).⁵² In one (8.3%) gamified intervention, social awareness was addressed by letting the child participants virtually experience behavioral and peer relationship problems as well as hyperactivity through the game.³⁷ One (8.3%) showcased improvements in children’s overall empathic behavior (P < 0.01).⁴⁹ Increased motivation for cooperative attitude and teamwork was emphasized by children during post-intervention interview.⁵¹ In one (8.3%) gamified intervention, there were no significant effects on children’s social normative beliefs or statistically significant differences with children’s help-seeking behavior and intentions between groups on follow-ups.⁴⁰

Discussion

The psychosocial distress of school-aged children increased exponentially at present times.^53,54 In the era of growing popularity of digital health interventions, we conducted the first scoping review providing an overview of the range and nature of evidence on gamified interventions for promoting the psychosocial well-being of school-aged children in the general population. The identified gamified interventions addressed various resources of children’s psychosocial well-being. As psychosocial well-being is a complex construct that represents the psychological and social levels of human functioning,¹⁰ there were varying outcomes. On a psychological level, emotions affecting the children’s social behavior such as self-esteem and emotions toward self and others, as well as mental health literacy toward negative emotions were addressed. On a social level, children’s communication skills, prosocial and empathic behaviors, hyperactivity/inattention, and social awareness were the focus. There were three gamified interventions catered to all school-aged children ages 6–12 years old. The target groups were mostly preadolescents and fewer for younger children from ages 6–9 years old. It is worth noting that preadolescence is a critical stage when children develop long-term health behaviors as well as their inter- and intrapersonal skills.⁵⁵ This is also a stage when health-related interventions can achieve maximum effect.⁵⁶ However, as challenges to children’s psychosocial well-being are becoming a global dilemma,¹⁵ the need for promotive and preventive strategies for all school-aged children is adamant.

The theoretical frameworks applied in the gamified interventions varied widely to support the psychosocial outcomes. Common to these theories is shaping children’s awareness on emotions toward self and others, which in turn help them develop prosocial skills. Narrative was not surprisingly the most commonly applied gamification mechanic (91.7%). As mentioned in earlier studies, it plays an important role in gamified interventions as it can set the context and flow of the intervention.⁵⁷ Narratives can provide more meaning to gamified interventions, and they can help users understand the objectives and challenges of the game as well as instill knowledge.⁵⁸ All identified gamified interventions in this review used combinations of different gamification mechanics to support the psychosocial outcomes. This is consistent with previous studies that when certain gamification mechanics are combined, they can elevate user experience and foster engagement which can lead to maximum effectiveness.⁵⁸ For example, narrative with feedback to inform players of the efficacy of their game actions;⁵⁹ points, rewards system, and level progression to drive desire toward goal achievements, sense of empowerment,⁵ and as performance benchmark.²⁷ Gamification in health interventions primarily enhances motivation and outcomes by engaging individuals actively in learning through practice, problem-solving, and reflection in a safe environment. It promotes retention and application of knowledge. In this article, we did not seek to compare the efficiency of combining different gamification mechanics. Nevertheless, we would like to emphasize that it is crucial to not overlook the variety of game mechanics and their combinations for achieving diverse outcomes.⁶⁰Although the delivery of a gamified intervention relies on its mechanics and objectives, we found that school setting was the most popular choice (66.7%). Based on the target groups we explored, this setting offered opportunities for sample saturation, school’s role in fostering children’s literacy, behavior, and development.^59,61 However, flexibility in implementation settings is essential, especially considering situations like the COVID-19 pandemic, where interventions may need to extend beyond classrooms. As in the case of Li et al., the gamified intervention was able to be delivered to children when school activities were either halted or shifted online.⁴² Despite variations in gameplay frequency and duration, the identified studies showed promising effects in enhancing the psychosocial well-being of school-aged children. Yet, warranting further understanding of how the applied theories and gamification mechanics influence psychosocial outcomes. Gamification, with its playful and immersive nature, can enhance conventional interventions, such as school-based programs.^4,5 It is crucial to note that gamified interventions cannot fully substitute face-to-face interactions; thus, real interaction opportunities are indispensable.⁶²

This scoping review included studies conducted in 10 countries which added cultural diversity and strengthened our undertaking. It is limited to studies published in English up to December 2023. Owing to the heterogeneity of the characteristics of the identified evidence, we could not conduct a meta-analysis. There were no uniform psychosocial theories used in the intervention approaches. Future research and development on gamified interventions for promoting the psychosocial well-being of children still need to strengthen the theoretical framework of the intervention approach and its effectiveness in the general population.

Conclusion

Our findings indicated that gamification can be effective in promoting the nonphysical aspect of health and well-being. However, gamified interventions for promoting the psychosocial well-being of school-aged children from the general population are still understudied. This article provides relevant contribution to health and gamification literature, shedding light on the need to enrich evidence on using gamification for the promotion and risk prevention of children’s psychosocial well-being.

Footnotes

Authors’ Contributions

K.K.: Conceptualization (lead), methodology (lead), validation (equal), formal analysis (lead), investigation (lead), writing original draft (lead), and writing—review and editing (equal). J.A.: Validation (equal), formal analysis (supporting), and writing—review and editing (equal). F.A.: Formal analysis (supporting). K.J.: Methodology (supporting), writing—review and editing (equal), supervision (supporting). A.P.: Conceptualization (supporting), methodology (supporting), writing—review and editing (equal), and supervision (lead).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

K.K. was in a funded doctoral student position during the conduction of this scoping review by the Department of Nursing , University of Turku.

References

World Health Organization. Global strategy on digital health 2020–2025 [Internet]. World Health Organization; 2021. Available from: https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf.

World Health Organization. WHO guideline: Recommendations on digital interventions for health system strengthening [Internet]. Geneva: World Health Organization; 2019. Available from: https://apps.who.int/iris/handle/10665/311941 [Last accessed: May 3, 2023].

Edwards

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