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Developing a digital cardiovascular health education for adolescents in Nepal
University of Skövde, School of Informatics. University of Skövde, Informatics Research Environment. (Interaction Lab (iLab))ORCID iD: 0009-0003-3037-1953
Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden ; Department of Nursing, Kathmandu Medical College, Nepal.
University of Skövde, School of Informatics. University of Skövde, Informatics Research Environment. (GAME)ORCID iD: 0000-0003-0977-1285
University of Skövde, School of Informatics. University of Skövde, Informatics Research Environment. (GAME)ORCID iD: 0000-0001-5617-9984
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2026 (English)In: INTERNATIONAL JOURNAL OF SERIOUS GAMES, E-ISSN 2384-8766, Vol. 13, no 3, p. 25-44Article in journal (Refereed) Published
Abstract [en]

The high prevalence of cardiovascular disease risk factors among adolescents of Nepal necessitates targeted interventions among this age group. Adolescents need a user friendly, acceptable and hands on media for cardiovascular health education. Digital technologies such as serious games have proven pedagogic potential. In this study, we aim to describe the steps followed to develop a serious game tailored to the needs of the adolescents in a sub-urban community in Nepal. We adopted a three-step development process: (1) defining learning goals, (2) developing and testing the game design and (3) incorporating active culturalization throughout the iterative game development process. We describe how culturalization was applied in each step to achieve educational viability. The final game called Happy Heart consisted of seven mini games: Name the food, Food sorter, Sugar rush, Salt seeker, Fat buster, Plan your meal and Activate. The game was augmented by an in-game journal that addressed complex concepts that could not be integrated into the game mechanics. The final game was culturally adapted and addressed the learning gaps of the target population. Learning through games has high potential in a lower middle-income country like Nepal.

Place, publisher, year, edition, pages
Serious Games Society , 2026. Vol. 13, no 3, p. 25-44
Keywords [en]
Serious games, Digital health, Cardiovascular health, Health promotion, Interdisciplinary, Adolescents, Game development, Culturalization
National Category
Public Health, Global Health and Social Medicine Human Computer Interaction
Research subject
Interaction Lab (ILAB); GAME Research Group; Research on Citizen Centered Health, University of Skövde (Reacch US)
Identifiers
URN: urn:nbn:se:his:diva-26813DOI: 10.17083/svahca52ISI: 001806865900003Scopus ID: 2-s2.0-105042306746OAI: oai:DiVA.org:his-26813DiVA, id: diva2:2083278
Funder
Swedish Research Council, 2020-03333
Note

CC BY-NC-ND 4.0

This study was funded by the Swedish Research Council, project 2020-03333, to Alexandra Krettek. We acknowledge the support of the schools during on-site visits and meeting with adolescents. The support of Scribendi Inc. (Chatham, ON, Canada) is acknowledged for their professional language editing and proofreading.

Available from: 2026-07-01 Created: 2026-07-02 Last updated: 2026-08-10Bibliographically approved
In thesis
1. Visuals Make Connections: A Framework for Effective Visual Communication in Cross-Cultural Serious Games
Open this publication in new window or tab >>Visuals Make Connections: A Framework for Effective Visual Communication in Cross-Cultural Serious Games
2026 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Designing serious game visuals for multiple cultural contexts presents significant challenges, as imagery familiar to one audience may be misunderstood or carry different meanings in another. This thesis adopts the perspective that visuals in serious games are not merely decorative but function as connectors between game content and players’ cultural and perceptual contexts. It argues that visual elements must be both clear and appealing across different cultural and domain contexts, and therefore investigates how varying levels of visual fidelity influence players’ visual recognition and visual preferences in cross-cultural serious game contexts.

A mixed-methods research approach was adopted, combining a literature review, fieldwork, and multiple case studies, with qualitative and quantitative data collected in Nepal and Sweden. To support the empirical investigation, a serious game titled Happy Heart was designed and developed as both an educational game and a research instrument, enabling systematic evaluation of visual fidelity across culturally distinct contexts. In both locations, the same Happy Heart game was implemented in localized versions and playtested with local participants.

The findings indicate that higher levels of visual fidelity generally support improved recognition, increased preference, and greater familiarity with serious games in both cultural contexts. However, higher visual fidelity did not consistently result in stronger emotional responses. Participants in both Nepal and Sweden experienced difficulties identifying culturally specific food items, highlighting the role of visual literacy in shaping how visual representations are interpreted. The results further suggest that adolescents’ visual recognition and preferences are shaped more strongly by exposure to global media, such as video games, animation, and social platforms, than by everyday lived experiences. A clear preference for 3D graphics and globally recognizable game aesthetics was observed, reflecting increasing familiarity with shared visual design conventions across cultures.

Based on these findings, this thesis proposes a Visual Alignment Framework to support culturally inclusive serious game design. The framework offers structured guidance for selecting representational objects and determining appropriate levels of visual fidelity when designing for diverse audiences, thereby reducing the risk of visual miscommunication in cross-cultural contexts. This research contributes both empirically and conceptually to the field of serious games by providing cross-cultural evidence and a theoretical foundation for visual alignment in game visuals. By synthesizing insights from the Nepalese and Swedish case studies, the thesis advances understanding of how visual communication can be strategically aligned with players’ cultural and perceptual contexts to support more effective (in terms of visual recognition and visual preference) and inclusive educational game design. Future research is encouraged to further evaluate the framework across additional cultural settings and game genres.

Abstract [sv]

Att designa visuella element i serious games för flera kulturella kontexter innebär betydande utmaningar, eftersom bildspråk som är bekant för en målgrupp kan missförstås eller bära andra betydelser i en annan. Denna avhandling utgår från perspektivet att visuella element i serious games inte enbart är dekorativa, utan fungerar som länkar mellan spelets innehåll och spelarnas kulturella och perceptuella kontexter. Avhandlingen argumenterar för att visuella element måste vara både tydliga och tilltalande i olika kulturella och ämnesspecifika sammanhang, och undersöker därför hur varierande nivåer av visuell fidelitet påverkar spelares visuella igenkänning och visuella preferenser i tvärkulturella serious game-kontexter.

En flermetod (mixed method)-ansats tillämpades, där litteraturstudie, fältarbete och flera fallstudier kombinerades, med både kvalitativa och kvantitativa data insamlade i Nepal och Sverige. För att möjliggöra den empiriska undersökningen designades och utvecklades ett serious game med titeln Happy Heart, som fungerade både som ett utbildningsspel och som ett forskningsinstrument. Detta möjliggjorde en systematisk utvärdering av visuell fidelitet i kulturellt skilda kontexter. På båda platserna implementerades lokaliserade versioner av Happy Heart, vilka speltestades med lokala deltagare.

Resultaten visar att högre nivåer av visuell fidelitet generellt stödjer förbättrad igenkänning, ökad preferens och större förtrogenhet med serious games i båda kulturella kontexterna. Däremot ledde högre visuell fidelitet inte konsekvent till starkare emotionella responser. Deltagare i både Nepal och Sverige hade svårigheter att identifiera kulturellt specifika livsmedel, vilket belyser den visuella läskunnighetens (visual literacy) betydelse för hur visuella representationer tolkas. Vidare indikerar resultaten att ungdomars visuella igenkänning och preferenser i högre grad formas av exponering för globala medier – såsom datorspel, animation och sociala plattformar – än av vardagliga erfarenheter. En tydlig preferens för 3D-grafik och globalt igenkännbara spelestetiker observerades, vilket speglar en ökande förtrogenhet med gemensamma visuella designkonventioner över kulturella gränser.

Baserat på dessa resultat föreslår avhandlingen ett Visual Alignment Framework för att stödja kulturellt inkluderande design av serious games. Ramverket erbjuder strukturerad vägledning för val av representativa objekt och fastställande av lämpliga nivåer av visuell fidelitet vid design för diversifierade målgrupper, med syfte att minska risken för visuell misskommunikation i tvärkulturella sammanhang. Forskningen bidrar både empiriskt och konceptuellt till området serious games genom III att tillhandahålla tvärkulturella belägg samt en teoretisk grund för visuell anpassning av spelgrafik. Genom att syntetisera insikter från fallstudierna i Nepal och Sverige fördjupar avhandlingen förståelsen för hur visuell kommunikation strategiskt kan anpassas till spelares kulturella och perceptuella kontexter för att stödja mer effektiv (vad gäller visuell igenkänning och visuell preferens) och inkluderande design av serious games. För framtida forskning rekommenderas att vidareutvärdera ramverket i ytterligare kulturella miljöer och för andra spelgenrer. 

Place, publisher, year, edition, pages
Skövde: University of Skövde, 2026. p. xvii, 114
Series
Dissertation Series ; 70
Keywords
Visual Communication, Cross-Cultural Serious Games, Visual Development Framework, Visual Fidelity, Health
National Category
Computer and Information Sciences Human Computer Interaction
Research subject
GAME Research Group
Identifiers
urn:nbn:se:his:diva-26889 (URN)978-91-989081-4-5 (ISBN)978-91-989081-3-8 (ISBN)
Public defence
2026-09-18, G110, 13:00 (English)
Opponent
Supervisors
Note

Ett av sex delarbeten (övriga se rubriken Delarbeten/List of papers):

6. Bai, H., Wilhelmsson, U., Zhang, R., Alklind Taylor, A. S., Backlund, P., Krettek, A. Cultural Alignment and Effective Visual Design in Cross-Culture Serious Games. Submitted to International Journal of Computer Games Technology. (In review)

Available from: 2026-07-16 Created: 2026-07-08 Last updated: 2026-07-16Bibliographically approved

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Bankler, VictorBai, HuaWilhelmsson, UlfBacklund, PerOli, NataliaVaidya, AbhinavKrettek, Alexandra

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