Högskolan i Skövde

The burden of cardiovascular diseases (CVDs) and the risk factors in adolescents are rising in Nepal, a low-income setting. Therefore, focusing on health education related to diet and physical activity for adolescents in their formative years is urgent. A digital medium may be an efficient way to reach this technologically oriented group. We developed a digital educational game through a collaboration between researchers in health and informatics from Nepal and Sweden and piloted the game as part of the ‘Heart-Related Intervention with Digitalization Among Young Adolescents (HRIDAYA)’ study.

We found that 99% of adolescents had access to smartphones and 92% had access to the internet. The digital game was developed for android devices due to their predominance in Nepal. First, a survey was conducted among 649 adolescents to identify their digital prerequisites as well as their gaps in CVD-related knowledge, attitude, and practice. Second, the identified gaps defined the learning goals of the game, forming the foundation for an initial draft of the game concept. Third, we created a game paper prototype and tested it among 10 adolescents to explore their visual recognition and preferences. Based on the findings, we chose two levels of fidelity and tested them with 44 adolescents. We found that a higher-fidelity abstract style resulted in more positive feelings. This style was subsequently used for the final game. Fourth, the game was developed through an iterative process, which included both culturalization efforts and ensuring educational viability. Finally, the completed digital educational game ‘Happy Heart’ was played by 176 adolescents. It consisted of seven mini-games related to sugar, salt, and fat in different food items, physical activities, balanced diet, and nutrition groups. Immediate audio and video feedback kept the players motivated. Written texts in the game journal addressed knowledge gaps that could not be converted to game mechanics.

In conclusion, a digital education like Happy Heart may be helpful in increasing knowledge, attitude and practice regarding CVDs among Nepalese adolescents. The development process indicated that the digital game has the potential to reach many adolescents and that they were receptive to the game. As the game is a low-cost educational effort that can easily be scaled up, it provides a promising avenue for cardiovascular health promotion in similar low-income settings.

Understanding players’ diverse visual recognition and visual preferences, especially in cross-cultural contexts, is critical for the creation of effective serious games. This study aimed to examine how varying levels of fidelity affect players' visual recognition, visual preference, and overall experience in serious gaming, using a mixed-method case study in the Bhaktapur district, Kathmandu, Nepal. Forty-four participants, aged 13 to 16 years, were enrolled in an A/B gameplay test. Fourteen students participated in in-depth interviews, thirty-six completed a questionnaire, and twenty-two provided valid telemetry data. We found that higher fidelity led to more positive affect, better recognition, stronger preference, higher familiarity, and positive emotional response from players. However, challenges were encountered regarding the identification of local food items. This highlights the key role of visual literacy, as adolescents are more influenced by familiar media than by real-life experiences in terms of visual recognition and preference. Effective visual communication in serious games should consider individual differences and the playing environment. This study contributes to serious game research by providing insights into an underrepresented demographic and demonstrating the importance of cultural context in visual communication. Findings offer practical guidance for game developers to design more inclusive and effective serious games.

In serious game development, graphic design needs to be eye-catching, while also depicting subject matter content in a responsible, accurate, and clear way. Previous research has shown that abstract and symbolic game visuals seem to be preferable for learning and providing an engaging experience. Our research focuses on describing the challenges involved in creating effective visual communication through game graphics in cross cultures. In particular, we’re interested in examining if certain styles of visual communication are more or less effective between different cultural demographics. To examine this, we have created a serious game which aims to promote healthy food and nutrition habits to teenagers in both Nepalese and Swedish schools and by doing so also motivate behavioral changes toward healthier eating habits. We are currently conducting studies to see whether preferences and image recognition differ between the two demographical spheres. This paper will only discuss the exploratory study done in Nepal. Ultimately, this paper aims to contribute development guidelines that can aid developers in creating more effective visual communication in their serious games, and we primarily focus on exploring what we call the compromise of ‘clarity’ and ‘appeal’ in the creation of game graphics. We present an initial model for choosing at what level in terms of realism/abstraction and taxonomic hierarchy the graphical components of serious games optimally should be produced in order to solve the dilemma of precise, unmistakable, yet appealing visuals in serious games. It all comes down to two primary decisions: defining the taxonomic hierarchy of the items to depict, and choosing the style in which to depict them. With a better understanding of when different game visuals are more or less appropriate, both in terms of style and in which objects are represented, game developers will be able to balance production costs better while also creating something that strikes the compromise between clarity and appeal.

Background: Digital interventions are promising tools to reach adolescents for cardiovascular health promotion.

Purpose: We assessed adolescents’ knowledge, attitude and practice (KAP) regarding cardiovascular disease (CVD), explored opportunities for a digital intervention, and developed a serious game prototype.

Methods: In total, 649 adolescents grades 8-10 were surveyed in a semi-urban community of Nepal regarding KAP of CVD and digital pre-requisites. Eight focus group discussions (FGDs) separately among boys and girls (n=76) provided deeper understanding of CVD perceptions.

Findings: Median (IQR) percent scores for KAP were 70.6 (10.59), 78.5 (8.46) and 69.5 (11.59), respectively. Good KAP (median percent scores >75%) was found in 27.7%, 69% and 27.8% adolescents, respectively. Knowledge (p<0.001), attitude (p=0.025) and practice (p<0.001) was higher among adolescents in private than government schools. Girls had better attitude than boys (<0.001). Furthermore, 98% adolescents had smartphone access and 91.6% had internet access.

In preliminary FGD analyses adolescents mentioned physical, nutritional, mental, environmental and hereditary causes for CVD. Financial and work-related burdens, plus psychological and family-related issues were perceived to influence CVD severity. Junk food and physical inactivity were health barriers. Adolescents perceived serious games as beneficial and easy to use. Challenging game and attractive visuals were thought to stimulate game use.

Conclusion: With good attitude and excellent digital prerequisites, we conclude that serious games can help fill the existing gaps in knowledge and practice in Nepal. A prototype of “Happy Heart” is being pilot-tested among adolescents as a promising way for digital cardiovascular health promotion.

Today non-communicable diseases (NCD) are the main drivers of morbidity, disability, and mortality in low- and middle-income countries, and are expected to increase due to unhealthy lifestyles in the wake of ongoing societal changes. In Nepal, heart disease is the most common NCD, causing a majority of the country’s hospitalizations.

Previous research found that this issue stems from a lack of information regarding nutrition and healthy activities. Our project initially mapped out the details of this knowledge gap by producing a Knowledge, Attitude, and Practice report based on field studies conducted in Nepal. Based on this report, we have created a mobile serious game - Happy Heart - that aims to fill the identified gaps by providing information, but also by presenting it in a way that we hope changes peoples’ attitudes towards healthy lifestyles. The game presents four main challenges: identifying and categorizing food items based on nutrition, preparing healthy meals, and planning a healthy weekly calendar.

The project is a collaboration between the University of Skövde (Sweden), Kathmandu Medical College, and Patan Academy of Health Sciences (Nepal).

In serious game development, effective communication through both languages, sounds, and icons can be crucial for a game to have its intended impact. While this is also true for entertainment games, serious games have added layers of challenges as they are a) often played by audiences outside of the “typical” game ecosystem, and b) miscommunication can lead to players missing important lessons or even learning incorrect information. When a serious game is intended to be used in different parts of the world, however, clear visual communication gets an added layer of complexity: culturally informed symbol interpretation and visual preference. In order to examine how these might affect players’ experiences when playing serious games, this paper presents the results of a mixed-method study conducted in two schools in Nepal. The study included 10 participants, between 13-16 years old, who played a prototype of a mobile game currently in development, which has the purpose of teaching young players about food nutrition and healthy habits. After playing the prototype, they took a short survey where they were asked to identify different food types, and they were also interviewed to discuss their opinions of the game’s visual style. The results of the study indicate that, while higher fidelity images were much easier to correctly identify by the participants, the participants’ preference for visual fidelity varied to a large degree.

The visuals of a game is a crucial element when it comes to providing good player experiences. Visuals are also an incredibly complex subject in a game context since different modes of visual representation can be more or less “appropriate” for different settings. For example, while one can look at photo-realism as an impressive feature of a game due to its technical complexity and functionally accurate representation of real-world objects, it might still not be a fitting choice for different audiences, or for different pedagogical strategies. Serious game research seldom focuses on understanding the design of these components or their applicability to different types of learning, and it more often focuses on games’ mechanics and how well they manage to capture subject matter content while still being engaging. The aim of this paper is to explore the gap in visual communication research, describing what studies tend to focus on providing some valuable context. This review was conducted on papers that dealt with visual aspects of serious games. The results show that visual communication is rarely addressed in serious game development research. Future research would benefit from taking visual communication in detail to facilitate the effectiveness of serious games.

Games for health is one of the most prominent areas for serious games, i.e. games with a purpose beyond only entertainment. The purpose of a health game may be to inform about health related issues; promote healthy lifestyles and even to drive behavioral change. This paper outlines the initial game design considerations and some future research directions for a game focusing on cardiovascular health. As the overall aim of the project is to promote a healthy lifestyle through diet and physical activity to prevent future cardiovascular disease, we focused on “taking care of your heart” as the basis for the game. Hence we call the game Happy Heart and use a heart symbol as a non-playable character (NPC) that the player needs to take care of. To some extent we are inspired by the electronic Tamagochi toys (Bandai) where players need to take care of a digital pet. The heart symbol is universal and is also an ideograph that expresses the concept of love and as such it transcends language barriers.

The burden of non-communicable diseases (NCD) is rapidly increasing across the world. Today they are the main drivers of morbidity, disability, and mortality in low- and middle income countries (LMICs), and are expected to increase due to unhealthy lifestyles in the wake of ongoing societal changes [1]. Among the major risk factors in many LMICs are poor diet, insufficient physical activity, tobacco and alcohol consumption, and exposure to hazardous substances, e.g. from air pollution. LMICs currently contribute three quarters of the deaths from NCD.

Among the NCD, cardiovascular diseases are the most common cause of hospitalization in Nepal [1]. Digitalization and collaboration with the education sector (e.g. community schools) in health promotion interventions could further improve children’s behavior by targeting factors that affect their lifestyle outside the family environment [4]. Hence, the Digital Game Based Learning approach.