Use of educational technologies in the promotion of children’s cardiovascular health: a systematic review

Abstract

Objective:

The aim of this study was to investigate the effectiveness of educational technologies for cardiovascular health promotion in children.

Methods:

A systematic review was carried out through a search in Biblioteca Virtual de Saúde, Comissão de Aperfeiçoamento de Pessoal do Nível Superior, EBSCOHot Information Services, and US National Library of Medicine National Institutes of Health databases, using the descriptors: play and plaything, cardiovascular diseases, child, and health promotion, between 2012 and 2019.

Results:

Eight articles were selected for this review. The identified technologies were based on low-tech interventions, such as play workshops, using tools such as CARDIOKIDS, the SI! program, MOVI-2, and activities with wide-ranging digital tools such as Fooya!, Fit2Play^TM, and the exergame cycling program.

Conclusions:

It is noteworthy that all of the analyzed interventions were effective and those that involved playing were better accepted by the children.

Keywords

children health promotion cardiovascular diseases playthings

Introduction

Cardiovascular diseases (CVDs) constitute the main cause of morbidity and mortality worldwide (1), accounting for 17.9 million deaths in 2016 (2). In Brazil, data show that from January to May of 2019 there were 159,013 deaths from CVDs (3).

The issue becomes even more a matter of concern when considering studies for the evaluation of children and adolescents. This fact is supported by a study carried out in the US that monitored four risk factors for CVD (body mass index (BMI), diet, total cholesterol, and blood pressure), showing that none of the children had all factors within the expected parameters for cardiovascular health (4).

CVDs are highly likely to develop in adults when they are linked to multiple associated risk factors in childhood, such as inadequate eating habits and lifestyle (5,6).

In this scenario, one identifies the need for CVD prevention in childhood, aiming at preventing them or reducing their complications in adult life (6). Therefore, given the opportunity to promote the health of populations and, consequently, decrease the morbidity and mortality rates caused by chronic diseases such as CVD, it becomes necessary to discuss the use of more efficient health promotion strategies (1).

There has been a concern aimed at ensuring equality of opportunity and providing the means for individuals to have a favorable chance to know and control the conditioning factors and determinants to achieve cardiovascular health. Therefore, it is of crucial importance to prevent potential CVD-related risk factors in children using multifaceted strategies that involve primary and secondary prevention, as well as regulatory initiatives such as the strict control of products with high trans-fat content, to be carried out in the school environment (7). Among these strategies, the use of technologies in CVD prevention aimed at encouraging behavioral changes is highlighted (1,8). Scientific evidence shows that traditional interventions have little or no effect on modifiable cardiovascular risk factors (9), and, thus, innovative approaches are necessary. It has been observed that technological innovations have shown to be an excellent opportunity for behavioral interventions to stimulate healthy habits, which has a positive impact on the change in health-related behaviors (10,11).

Based on this context, the aim was to investigate the effectiveness of educational technologies aimed at cardiovascular health promotion in children through a systematic review of the literature.

Methods

A systematic review of the literature was carried out through a search in Biblioteca Virtual em Saúde (BVS), Comissão de Aperfeiçoamento de Pessoal do Nível Superior (CAPES), EBSCOHot Information Services, and US National Library of Medicine National Institutes of Health (PubMed – NBCI), with the results being presented based on the criteria for Systematic Review and Meta-Analyses from the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) tool (12).

A systematic review is understood as the characterization of a review that seeks to obtain the subsidies for evidence-based practice (EBP). It comprises a strict methodology that identifies studies about a certain topic, applies explicit and systematized search methods, and evaluates the quality and validity of these studies, as well as their applicability in the context in which the changes will be implemented. This allows one to select the studies that provide scientific evidence and make their synthesis available, aiming to facilitate its implementation in EBP (13).

However, carrying out a systematic review requires the creation of a protocol. Thus, eight steps are followed: 1) creation of the research question; 2) literature search; 3) article selection; 4) data extraction; 5) methodological quality assessment; 6) data synthesis; 7) evaluation of the quality of evidence; and 8) writing and publication of the results (14).

Initially, to guide the creation of the study question, the ‘population, intervention, comparison, outcomes and study design’ (PICOS) strategy was used, according to Table 1 (12).

Table 1.

Guidelines for the creation of the study question.

Population	Children
Intervention	Educational technology (playing, playthings, and/or games)
Comparison	Children divided into two groups – control and intervention to evaluate the changes in life habits using playing, playthings, and/or games as intervention, being effective for healthy behavioral improvements among the children
Outcomes	Actions to promote cardiovascular health in children that demonstrate the effectiveness of the use of games, playthings, and/or playing to promote the cardiovascular health of the pediatric population
Study design	Intervention studies

Considering this strategy, the study question was created: ‘What is the effectiveness of educational technologies (playing, playthings, and/or games) used in actions aimed to promote the cardiovascular health of children?’

This review uses the terms game, plaything, and/or play, as even though these terms have different concepts, it is necessary to join them for a recreational activity to occur. A game is characterized by the existence of rules for its performance, whereas the plaything is a support for the play, which has rules that allow its flexibility and the inclusion of new participants, without changing the recreational action being performed at that moment (15).

This review was carried out from March to May 2019, aiming to identify scientific articles classified as empirical research on the use of educational technologies, with or without digital tools, to promote cardiovascular health in children. This was done by cross-referencing four English keywords from the Medical Subject Headings (MeSH) and in Portuguese from the Descriptors in Health Sciences (DeCS), using the Boolean operator AND: play and plaything AND cardiovascular diseases AND child and health promotion, at the abovementioned databases, using the combination of four triads between the descriptors.

Articles that reported educational technologies, using or not using digital tools, in English, Portuguese or Spanish, and published from January 2012 to May 2019 were included in the review. Articles such as ‘Annals’, technical papers, editorials, reviews, comments, reflection articles, theses, dissertations, and those that did not match the study question, as well as duplicate articles, were excluded.

After the cross-referencing of the descriptors, the search resulted in 362 articles in the Virtual Health Library, 481 in the CAPES portal, 520 in EBSCOHot Information Services, and 306 in PubMed – NBCI database, comprising a total of 1669 articles.

After this first sample selection, the careful reading of the titles and abstracts of the selected articles was carried out by two independent researchers to identify those that included information that answered the guiding question of the present review. After the selected articles went through this screening, they were continually assessed by the researchers and in the case of any disagreement between them, they were solved by a third author, with the final selection being carried out by reading the full-text articles, as well as the filing of the articles.

Results

After the selection, three publications were obtained from the Biblioteca Virtual de Saúde (BVS), none from the Comissão de Aperfeiçoamenteo de Pessoal do Nível Superior (CAPES), one from EBSCOHot Information Services, and four from PubMed – NBCI databases, as a final result for this review, as shown in Figure 1.

Figure 1.

Description of the selection, evaluation, and inclusion of studies in the systematic review of games and/or playthings using or not using digital tools, developed for the promotion of the cardiovascular health of children.

For the organization and tabulation of data obtained from the selected articles, a tool adapted from Ursi and Gavão (16) was used, which contained the following information: author, year of publication, study site, target population, sample size, level of evidence, objectives of the study, educational technology used, digital tool used, and intervention effectiveness (Tables 2 and 3).

Table 2.

Characterization of the articles on educational technologies for the promotion of children’s cardiovascular health.

Articles	Study site (Country)	Study participants	Study design	LE
Padman et al. (17)	USA	100 schoolchildren	RCT	I
Messiah et al. (18)	USA	1546 children aged 6 to 14 years	Intervention	I
Ceccehetto et al. (19)	Brazil	79 students aged 7 to 11 years	RCT	I
Knights et al. (20)	Canada	8 children aged 9 to 18 years	RCT	I
Peñalvo et al. (21)	Spain	24 schools, including 2062 children (3 to 5 years)	Cluster randomized trial	I
Martínez-Vizcaíno et al. (22)	Spain	712 schoolchildren aged 8 to 10 years	RCT	I
Céspedes et al. (23)	Colombia	1216 children aged 3 to 5 years, 928 parents, and 120 teachers	RCT	I
Knox et al. (24)	UK	115 children aged 11 to 14 years	Quasi-experimental	III

RCT: randomized clinical trial; LE: level of evidence.

Table 3.

Presentation of the studies according to the educational technology used and evidence of its effectiveness.

Articles	Study objectives	Educational technologies (game, playthings, and/or playing)	Digital tool	Intervention effectiveness
Padman et al. (17)	Assess the impact of a mobile game on diet and lifestyle and food choices	Fooya! Game for mobile devices, developed as a ‘digital vaccine’ to reduce the risk of chronic non-communicable diseases in the long term	Fooya!	The game showed a positive effect on healthy food choices, after only 40 minutes of exposure to the intervention
Messiah et al. (18)	To evaluate the change in several modifiable cardiovascular risk factors related to obesity after participating in the Fit2Play™	Fit2Play^TM Post-school program, structured for the urban municipal park system	Fit2Play^TM	The post-school program was effective in preventing and treating childhood obesity and successful in high-risk groups
Ceccehetto et al. (19)	To verify the impact of play workshops on children’s knowledge, self-care, and body weight	Play workshops	No	The workshops provided increased knowledge about healthy habits and risk factors for cardiovascular disease, as measured by CARDIOKIDS, in addition to changes in physical activity levels and body mass index immediately after the intervention
Knights et al. (20)	To evaluate the effects of an Internet-platform exergame cycling program on cardiovascular fitness in children and young individuals with cerebral palsy	Cycling program	Exergame (digital game)	A cycling program using exergame can lead to cardiovascular fitness improvement in children and young individuals with cerebral palsy
Peñalvo et al. (21)	To evaluate the effect of a three-year multidimensional intervention at school to improve lifestyle behaviors	SI!	No	The SI! program was an effective strategy to encourage healthy habits among preschoolers, resulting in benefits and a significant effect when started early and maintained for more than three years
Martínez-Vizcaíno et al. (22)	To evaluate the impact of a physical activity program on adiposity and cardiometabolic risk factors in schoolchildren	(MOVI-2) Recreational and non-competitive activities	No	Non-competitive physical activity during one school year was a safe and effective measure to reduce adiposity in both genders and improve the cardiometabolic risk profile
Céspedes et al. (23)	Evaluate changes in preschoolers’ knowledge, attitudes, and habits regarding healthy eating and an active lifestyle	Educational intervention in preschool facilities	No	The proposed preschool intervention was feasible, effective, and sustainable in very young children
Knox et al. (24)	To investigate the response of risk factors for cardiovascular diseases after the introduction of fast walking in curricular classes	Intercultural physical activity intervention of 18 weeks in a high school	No	This intervention was shown to be sustainable, effective, and inexpensive to engage children in physical activity on a daily basis

According to Table 2, the characterization of the studies shows the different countries where they were carried out, using the approach to promote the cardiovascular health of children, as well as the different participants involved in the studies, in addition to the methodological outline.

Most of the studies were carried out in developed countries, with emphasis on Spain (21 –23) and the US (17–18). From 2012 onward, there was a gradual increase of publications on the subject, showing the interest of the scientific community on the topic.

Regarding the sample size, it ranged from eight (20) to 1546 (18) children, showing the purpose of including other social actors, either directly or indirectly with the promotion of cardiovascular health, such as parents and teachers (23).

As for the methodological aspect of the studies, a high percentage of high-impact studies were obtained, such as randomized clinical trials (17,20), which used effective interventions to promote cardiovascular health in children.

Table 3 shows the studies according to the authors, year of publication, objectives, educational technology used, use of digital tools, and the evidence of intervention effectiveness.

As shown in Table 3, it was possible to identify that the objectives were aimed at promoting cardiovascular health in children, through the performance of activities aimed at addressing risk factors in a specific way, such as concerns about inadequate diet (23), sedentary lifestyle (22,24), being overweight (18 –20), and lack of knowledge (19,23). Moreover, other studies have been carried out to provide an active lifestyle for the children (17,21,23).

Different strategies were used to promote cardiovascular health in children. Services using wide-ranging digital tools such as Fooya (17), Fit2Play^TM (18), and exergame in a cycling program (20), as well as low-tech interventions, such as play workshops using tools such as CARDIOKIDS (19), the SI! Program (21), MOVI-2 (22), and interventions carried out in the school environment (23,24) were the actions used in these scientific productions.

Of the educational technologies described in the intervention, three studies mentioned the use of digital games (17,20), in addition to associating this type of game with real elements (municipal parks) (18). Other studies have used art workshops through drawings, dancing with music, and memory games (19). One of the studies (21) added virtual elements such as emotion cards, healthy tips, and online resources into their real activities. Recreational and non-competitive activities were also present in one of the studies (22) through the use of traditional games and outdoor activities. And, finally, one intervention (24) included a daily brisk walk.

According to the effectiveness of the abovementioned interventions, positive results achieved through physical activity are described in the studies (18,21 –23). However, the other studies (17,19,24) mention the possibility of satisfactory outcomes when using healthy lifestyle strategies (diet and physical activity).

The study developed with children diagnosed with cerebral palsy (20), which stimulated physical activity, suggests in its results that this action can lead to cardiovascular fitness improvement.

Regarding the process of child development, one publication (20) suggests aspects related to constructivism and organic maturation (25). Other studies (18–19,21 –24) were related to the socio-ecological model (22), social cognitive theory (17,23), and transtheoretical model (23).

Discussion

The strategies used showed significant results in promoting cardiovascular health in children, since they are recreational tools that stimulate an environment that arouses the interest of the children. It was observed that the literature is still scarce, specifically regarding this topic related to children. However, even with only eight studies identified in the literature, sufficient potential was observed to trigger a line of reflection within the cardiovascular health approach.

It is possible to infer that all analyzed educational interventions were effective for the promotion of cardiovascular health in children, but the importance of including recreation to ensure effectiveness is emphasized, since the recreational aspect attracts and motivates children to participate in the proposed actions (19,22).

By analyzing the educational strategies used in the studies that constitute this review, the emphasis was on the use of interventionist methodologies, which provided the collectivity’s interaction (18–19,21 –24).

Considering these assumptions, it is understood that this assertion also becomes valid when discussing the question of knowledge about cardiovascular health. One of the main challenges to the promotion of cardiovascular health in children is the issue of childhood obesity, including the availability of prevention and/or treatment in easily accessible programs (17 –19,22).

Thus, focusing on the obesity risk factor, the change in several cardiovascular problems related to obesity was evaluated after participation in an intervention program called Fit2Play™, created for urban municipal parks. As a result of this strategy, it was observed that children aged six to 14 years participating in the intervention over a five-year period (2010–2015) showed that after one year, the groups with excess weight significantly decreased the mean percentile of BMI. It should also be noted that the nutritional knowledge of those submitted to the interventions significantly improved as well, suggesting that structured health/wellness programs created for parks constitute a low-cost and high-value tool for the promotion of cardiovascular health (18).

Studies show that overweight in childhood and adolescence has been a cause of great concern worldwide (25 –27), since little is known about the complications that this phenomenon, which occurs early in life, can cause in the long term (28).

However, at this stage of development, it is expected that actions to prevent excessive weight gain will be effective, because at this stage there is greater energy expenditure in comparison to the other phases of life. Moreover, it is essential to minimize sedentary activities, such as sitting for long periods in front of the television, at the computer, or playing video games (29). In addition to a sedentary lifestyle, they report that dietary interventions related to cardiovascular health should be incorporated into young populations at an early age, as they target interventions and changes in eating habits that are considered inadequate (30).

Considering this context, simple and low-cost interventions can also have a significant impact on the promotion of the cardiovascular health of children, provided they comprise recreational and educational activities, as shown by the study performed with low-income children in a Brazilian school, which improved knowledge about healthy habits and risk factors for CVD, in addition to being useful for the planning of preventive strategies (19,21–22).

Another example was the SI! program, which demonstrated that a multidimensional intervention for preschoolers brought significant improvement to lifestyle-related behaviors and measures of adiposity in those involved along the intervention years (21). This fact was identified in the first year of the program, with a differential increase of 5% (31).

Another study that showed significant results in this systematic review was the evaluation of the effects of an Internet-platform exergame cycling program for cardiovascular fitness of children and young individuals with cerebral palsy. Thus, the study observed that there were significant post-intervention improvements, with the conclusion that an exergame cycling program could lead to improvements in cardiovascular fitness (20).

The impact of an intervention consisting of a physical activity program called MOVI-2 related to cardiometabolic risk factors, carried out for one year, is also highlighted. This program was characterized by presenting recreational and non-competitive activities, based on a sociological model, for schools, parents, and teachers, aiming to increase the practice of physical activity. The intervention also led to lower serum low-density lipoprotein cholesterol levels and reduced insulin levels. Among the boys, there was a decrease in waist circumference, demonstrating that studies such as this one comprise safe and effective measures (22).

Another study that also focused on physical activity investigated the response of risk factors for CVDs after the introduction of walking activities to the school curriculum. The intervention was characterized as a cross-cultural physical activity lasting 18 months, with evaluations both in the pre- and post-intervention phase of physical activity and diet, demonstrating that the intervention was sustainable, effective, and a low-cost strategy to engage children in daily physical activities (24).

Programs carried out in the school environment are effective in changing knowledge, attitudes, and habits that are important for the long-term risk of CVDs associated with sedentary lifestyles. This was evidenced by an educational and recreational intervention study involving children, parents, and teachers (23).

However, it can be observed that the number of specific scientific publications aimed at this particular population is scarce, especially in developing countries (19,23), which becomes a major concern due to the severity of CVD and the increase of its incidence (32).

The limitations of this review include the fact that some studies did not have a detailed description of each developed intervention, which made it difficult to further investigate the association between the use of educational technology and the variables assessed in the studies, as well as their effects on the outcomes.

Conclusion

The study found a significant diversity of educational technologies developed and evaluated for the promotion of the cardiovascular health in children, with the involvement of several strategies that associate playing with health education, making them more attractive and interesting for children.

It was observed that the scientific corpus of the systematic review showed that the interventions were effective, demonstrating the importance of working with this topic even in childhood. However, to attain a significant result, one must recognize that playing is the important characteristic of the actions developed with the children, even if the tool used does not have high technological features.

Moreover, it was demonstrated that interventional studies of this type require a longitudinal design for better long-term observation of the impact of these interventions on the children’s daily routine, as well as on the prevention of future CVDs.

It is noteworthy that the use of digital technologies for the promotion of children’s health is a viable one, through a recreational approach, the use of repetition that makes the contents more easily understood, the interaction that promotes socialization, in addition to the low risk and costs involved.

Footnotes

Declaration of conflicting interests

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Francisca Bertilia Chaves Costa

Ana Maria Fontenelle Catrib

July Grassiely de Oliveira Branco

Rafaela Oliveira de Sales

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