JMIR Serious Games

Virtual Reality–Delivered Exposure for Contamination Concerns in Adults With Obsessive-Compulsive Symptoms: Single-Arm Pilot Study

2026-06-23T17:15:15-04:00

Background: Exposure and response prevention is a first-line intervention for obsessive-compulsive disorder (OCD), yet many individuals with contamination concerns do not access care. Virtual reality exposure–based therapy (VRET) may improve scalability and acceptability. Objective: This pilot study evaluated the feasibility and acceptability of a standardized single-session VRET protocol targeting contamination concerns and whether it elicited within-session anxiety and exploratory contamination symptom change at 1-month follow-up. Methods: We conducted a single-arm pilot study in adults with elevated contamination concerns and no formal OCD diagnosis, recruited via convenience sampling. Participants completed a baseline survey, an in-laboratory VRET session using a standardized virtual public toilet environment, and a follow-up survey. Outcomes included momentary anxiety (Subjective Units of Distress Scale) during exposure, affect (positive and negative affect schedule) across time points, and contamination symptoms (Obsessive-Compulsive Inventory–Revised contamination subscale) at baseline and follow-up. Usability (System Usability Scale) and VR sickness were also assessed. Within-session outcomes used repeated-measures ANOVA or Friedman tests; symptom change used paired tests (α=.05); point estimates include 95% CIs. Missing data were addressed using multiple imputation (random forest; m=5); 37.5% of participants did not complete the follow-up survey (overall missingness: 5.47%). Results: Sixteen participants were included (aged 18‐32 years). Anxiety increased during exposure tasks and decreased after virtual hand washing in both trials (Exposure 1 Friedman Test: ²=28.56; <.001; W=0.6); Exposure 2 repeated measures ANOVA: =5.35; =.01; Greenhouse-Geisser corrected=0.058. Negative and positive affect both changed significantly across time points (negative affect: Friedman Test: ²=13.76; =.003; W=0.29 and positive affect: repeated measure ANOVA: =4.60‐4.71; =.006-.007; Greenhouse-Geisser corrected=0.07‐0.073). Contamination symptoms did not significantly change from baseline to follow-up (mean change 1.30, SD 3.39; 95% CI –0.36 to 2.96; =.12). Usability was adequate (System Usability Scale mean 69.5, 95% CI 62.79-76.21). Conclusions: This study is among the first to systematically evaluate a standardized single-session contamination-focused VRET protocol in adults with elevated contamination concerns who did not meet diagnostic criteria for OCD, a subthreshold population underrepresented in prior VRET research, which has focused on clinically diagnosed samples and multisession protocols. The protocol proved feasible and acceptable, eliciting within-session anxiety and providing benchmarks in existing clinical literature. Contamination symptom change at 1-month follow-up was not statistically significant, and the effect size estimate was sensitive to the missingness assumption, underscoring the need for adequately powered multisession designs in future trials. The usability profile and VR sickness levels that did not prevent session completion suggest self-administered or minimally supervised delivery warrants evaluation, with implications for scalable early intervention in individuals with elevated contamination concerns who have not accessed formal treatment.

Tonal Auditory Discrimination Training in Youths: Design, Implementation, and Evaluation of Game-Based Versus Non–Game-Based Systems in a Cross-Sectional Study

2026-06-22T18:00:25-04:00

Background: Auditory discrimination training is widely used to supplement aural habilitation and rehabilitation in individuals with hearing or auditory challenges. Recently, gamification has been introduced as a strategy to enhance attention, motivation, and engagement during training. However, the relationship between user experience (UX) and auditory discrimination performance remains unclear. In addition, maintaining long-term interest in auditory training is still a challenge, particularly in younger populations, highlighting the need for more engaging and user-centered approaches. Objective: The objective of our study was to develop and compare 2 pure-tone auditory discrimination training systems: a game-based system with dual-task gamified activities and a non–game-based control system with identical auditory tasks but without gamified elements. We further aimed to evaluate differences in UX, engagement, usability, and behavioral auditory discrimination performance between the two systems. Methods: A 3-stage process (design, implementation, and evaluation) yielded beta versions of both systems. Both platforms were developed using identical auditory stimuli, task logic, and performance metrics to isolate the effect of gamification, differing only in the interface and game elements. In the evaluation stage, a cross-sectional study with 11 young adults (aged 18-30 y) was conducted, where participants completed usability, UX, and engagement questionnaires after using each system. Behavioral performance was assessed through mean response time, proportion of correct responses, the Balanced Integration Score, and a novel Auditory Discrimination Performance Index integrating the Weber fraction and response time. UX was measured using the User Experience Questionnaire, the Post-Study System Usability Questionnaire, and the User Engagement Scale-Short Form. Statistical analyses included Shapiro-Wilk tests, paired tests, and Wilcoxon signed rank tests. Results: The game-based system produced significantly higher scores in 6 of 11 evaluated questionnaire dimensions, including focused attention, aesthetic appeal, reward, attractiveness, stimulation, and novelty, while no significant differences were found in most auditory discrimination performance metrics. Specifically, measures such as response time, accuracy, and Balanced Integration Score showed comparable results between systems. Usability-related outcomes showed a slight advantage for the non–game-based system, whereas all engagement-related domains consistently favored the game-based system, indicating improved user involvement and overall engagement without compromising performance. Conclusions: These findings suggest that gamification can substantially improve UX and engagement without degrading short-term discrimination performance. This indicates that gamified auditory training systems may enhance user adherence without compromising task effectiveness. This study is innovative in that it directly compares game-based and non–game-based auditory training systems under controlled conditions, isolating the effect of gamification. Unlike other studies that primarily evaluate gamified systems without a control condition, this work clarifies the specific contribution of game elements to UX and performance. These findings contribute to the development of more effective, user-centered auditory training technologies and highlight the need for future longitudinal studies to determine whether these advantages translate into sustained auditory benefits across tasks. Trial Registration: ISRCTN ISRCTN443661994; https://www.isrctn.com/ISRCTN43661994 International Registered Report Identifier (IRRID): RR2-10.1371/journal.pone.0313478

Game Customization and Pace Effects on Movement Performance and the User Experience During Serious Games for Balance Among People After a Stroke: Cross-Sectional Repeated Measures Study

2026-06-17T16:30:17-04:00

Background: Serious games can be custom or noncustom, each offering advantages for rehabilitation. Custom serious games developed specifically for rehabilitation allow control over feedback and adjustment of game speed and difficulty. Alternatively, noncustom games do not offer these controls but provide attractive graphics, sounds, and engaging game mechanics. The differences between these systems may affect users’ exercise intensity, quality of movement, and experience during gameplay, which have implications for system and game selection in rehabilitation. Objective: This study compared movement performance and user experience of patients after a stroke while playing custom and noncustom virtual reality balance games that were either game-paced or self-paced. Methods: A group of community-dwelling patients in the chronic phase post stroke participated in a cross-sectional repeated measures study. They were familiarized with 12 games; half were played using the custom system (Equio, Kinestica) and half with the noncustom system (Nintendo Wii Balance Board, Wii Fit games). Over 2 gameplay sessions with randomized blocks of game type (self-paced and game-paced) and the order of the system (custom and noncustom), participants played games requiring comparable movement of the center of pressure for each system. Movement performance (weight-shift repetitions and movement amplitude) was extracted from video recordings using the Kinovea software. User enjoyment (Modified Physical Activity Enjoyment Scale), flow (Flow State Scale for Occupational Tasks), and likability were assessed twice in each study block. Comparisons between the systems were conducted using paired tests or Wilcoxon tests. Effect sizes (ES) were calculated using Cohen . Results: Twenty-six participants (aged 27‐70 years) were included in the analysis. Repetitions and movement amplitude were significantly greater (repetitions: ˂.001–.003; amplitude: =.002–.03) with large ES for all noncustom game–paced games and for half of the noncustom self-paced games (repetitions: ES 0.8‐2.5; amplitude: ES 0.6‐0.9). Perception of exertion was greater for noncustom game-paced games (ES 0.6; =.005). In contrast, users’ flow state (total and subdomains of sense of control and emotional experience; ES 0.6‐0.8; ≤.03) and user preference were significantly greater for custom game-paced games. There was no significant difference between custom and noncustom games for enjoyment. Conclusions: Serious gameplay was influenced by customization and type of game pacing, both of which should be considered when selecting serious games for balance training. Repetitions, movement amplitude, and perception of effort were greatest for the noncustom game-paced games, indicating greater intensity, while also addressing the difficulty patients after a stroke have with weight-shifting to the affected side. In contrast, custom games provided a sense of control and increased flow state, which may promote better adherence. Findings from this study have implications for clinicians and game designers. Both custom and noncustom games offer training features that support stroke rehabilitation. Trial Registration: ClinicalTrials.gov NCT06463730; https://clinicaltrials.gov/study/NCT06463730

The Effects of Open-World and Fun, Accessible Games on Perceived Loneliness and Stoicism in Adults: Cross-Sectional Survey Study

2026-06-17T16:30:17-04:00

Background: Loneliness has been linked to reduced mental and physical health. The “loneliness epidemic” is recognized as a public health crisis. However, questions remain about the potential of video games, which people play by themselves, to help reduce perceived loneliness. Objective: This study explored the extent to which open-world games (eg, ) and fun, accessible games (eg, ) can help reduce loneliness in adults. We examined how such gameplay can foster a stoic approach to life and how stoicism mediates the reduction of perceived loneliness. Methods: A cross-sectional survey was conducted using convenience sampling near a video game store. The sample comprised 2252 adults aged 21 years and older (women: n=966, 42.90%; men: n=1281, 56.90%; prefer not to disclose: n=5, 0.20%). Participants completed a questionnaire to measure perceived loneliness and stoicism, as well as their gameplay habits. Data were analyzed using ANOVA and moderated mediation with the PROCESS macro (bootstrapped samples=5000; 95% CI) to examine the effects of video gameplay on stoicism and loneliness, with the α level set at .05. Results: Zelda players indicated higher stoicism (mean 4.87, SD 0.11; 95% CI 4.66-5.08) than nonplayers (mean 3.23, SD 0.07; 95% CI 3.09-3.37; =164.95; <.001). Yoshi players also noted significantly higher stoicism (mean 4.49, SD 0.12; 95% CI 4.27-4.72) than nonplayers (mean 3.61, SD 0.05; 95% CI 3.50-3.71; =48.33; <.001), with a significant interaction effect (=7.89; =.005) on stoicism. Furthermore, Zelda players indicated lower loneliness (mean 3.02, SD 0.11; 95% CI 2.81-3.22) than nonplayers (mean 4.28, SD 0.07; 95% CI 4.14-4.42; =98.32; <.001). Yoshi players also noted significantly lower loneliness (mean 3.09, SD 0.12; 95% CI 2.86-3.32) than nonplayers (mean 4.21, SD 0.05; 95% CI 4.10-4.32; =76.32; <.001). Moderated mediation analysis demonstrated that Zelda gameplay was positively associated with stoicism (β=1.28, 95% CI 1.07-1.50; <.001), and stoicism was negatively associated with perceived loneliness (β=−0.49, 95% CI −0.52 to −0.45; <.001). Conclusions: This study is innovative in identifying stoicism as a potential emotional pathway through which video games may reduce loneliness. Moving beyond views of gaming as passive escapism, our findings suggest that specific gameplay experiences may serve as active spaces for cultivating resilience. We introduce a “digital diet” framework, indicating that balancing open-world challenges (eg, Zelda) with low-stakes restoration (Yoshi) produces synergistic psychological support. Practically, thoughtfully curated gaming experiences may serve as scalable and cost-effective digital adjuncts for public mental health interventions addressing the loneliness epidemic.

Association Between Task Difficulty Regulation in Game-Based Digital Therapeutics and Attention-Deficit/Hyperactivity Disorder Symptoms in Children: Secondary Analysis of a Randomized Controlled Trial

2026-06-11T16:15:14-04:00

Background: Recent advances in digital therapeutics (DTx) have led to the development of game-based, home-delivered interventions for children with attention-deficit/hyperactivity disorder (ADHD). Prior studies have demonstrated the feasibility and clinical potential of DTx for reducing ADHD symptoms but have primarily evaluated usage metrics, including training frequency and duration, which do not capture in-game performance or learning processes during training. In addition, the association between task difficulty regulation during DTx training and ADHD symptom improvement in children has not been well studied. Objective: This study aimed to examine whether task difficulty regulation during DTx training is associated with ADHD symptom improvement in children and to evaluate the clinical relevance of difficulty-related behavioral measures as indicators of treatment response. Methods: In this study, a secondary post hoc analysis of data from 35 children aged 6 to 13 years with ADHD who participated in a randomized controlled trial was performed. The participants had completed a 4-week training program comprising 5 digital cognitive tasks from the DTx Neuro-World. During training, task difficulty was automatically adjusted in real time according to participants’ response accuracy to maintain an appropriate challenge level. Training difficulty was quantified by 3 indices: average task difficulty, task difficulty variability, and task difficulty slope. Associations between difficulty indicators and ADHD symptom changes were examined using regression analyses and group comparisons. Results: We found that lower average task difficulty during tasks 1, 2, and 4 of Neuro-World was associated with improvements in ADHD symptoms, as assessed by the total Korean-ADHD Rating Scale (K-ARS) score. In addition, the average task difficulty of tasks 1 to 4 was related to improvements in hyperactivity/impulsivity symptoms of ADHD, as assessed by the K-ARS hyperactivity or impulsivity subscore, but not to improvements in inattention symptoms. Moreover, lower variability of task difficulty in task 5 improved ADHD hyperactivity/impulsivity symptoms, as assessed by K-ARS, but did not affect Korean-Child Behavior Checklist scores. Finally, we found that a negative task difficulty slope was associated with the alleviation of ADHD hyperactivity or impulsivity. These findings should be interpreted with caution, given the exploratory nature of the study and the absence of formal correction for multiple comparisons. Conclusions: As an exploratory investigation, our study provides a novel perspective by demonstrating that individualized and stable regulation of task difficulty, rather than the mere attainment of higher difficulty levels, is associated with ADHD symptom improvement. These findings indicate that dynamic difficulty trajectories derived from in-game behavioral data are clinically relevant, going beyond the conventional focus in the literature on usage metrics or overall training intensity. Our results support the role of individualized difficulty trajectories as potential digital biomarkers of clinical response. This approach has important implications for the design of DTx that incorporate personalized and adaptive difficulty regulation to enhance clinical effectiveness and scalability. Trial Registration: The Korea Clinical Research Information Service KCT0009326; https://tinyurl.com/yr8yv9j4

Serious Games in Nursing Education: Scoping Review of Applications, Effectiveness, and Future Directions

2026-06-11T16:00:21-04:00

Background: Serious games (SGs) have emerged as a promising tool in nursing education, providing interactive learning environments for clinical simulation, skill development, and feedback. These games enhance knowledge, clinical reasoning, and psychomotor skills. However, evidence on their effectiveness is dispersed across various platforms and outcome measures, making it difficult to derive clear guidelines for their integration into nursing curricula. Objective: This scoping review aimed to systematically identify and map existing evidence on the use of SGs in nursing education, analyze game characteristics, and identify critical gaps to inform future research and practice development. Methods: This scoping review followed the JBI framework and the PRISMA-ScR checklist. Nine databases (PubMed, Web of Science, Embase, CINAHL, the Cochrane Library, CBM, Wanfang Data, CNKI, and VIP) were searched from inception to January 15, 2026. Eligible studies were those reporting on original research on SGs in nursing education. Two reviewers screened titles, abstracts, and full texts. Risk of bias was assessed using a standardized checklist. The extracted data encompassed study characteristics, study design, participant information, sample sizes, application context, teaching content, and SG characteristics. Data were extracted and synthesized with descriptive statistics and content analysis. An evidence gap map was created to show the study distribution across course categories and outcome domains. Results: We screened 6078 records and included 24 studies. Publications were from 2021 to 2025 (n=13, 54%), with the majority conducted in Europe (n=13, 54%). Quasi-experimental designs (n=10, 42%) and randomized controlled trials (n=8, 33%) were predominant. SGs were mainly used in fundamental or skills training and adult nursing courses. Scenario-based decision points (n=20, 83%) and points, badges, or leaderboards (n=20, 83%) were the most common game mechanics, while progression or unlocking and collaborative elements were less frequent. Outcomes most often assessed were knowledge (n=16, 67%), skills (n=10, 42%), and engagement or usability (n=13, 54%). Objective use metrics were rarely reported (n=1, 4%), indicating limited data on in-platform learning behaviors. Most SGs were delivered as digital non–virtual reality applications or computer-based simulation games. Follow-up assessment beyond immediate postintervention outcomes was infrequent. An evidence gap map showed studies concentrated in skills-based training and adult nursing, with fewer studies in maternity or neonatal nursing, critical care, and foundational sciences. Conclusions: This review extends earlier work on SGs in nursing education by mapping evidence across curricular areas, intervention reporting, and outcome assessment, rather than focusing mainly on effectiveness or specific formats. It shows where evidence is concentrated and where important gaps remain, particularly in underrepresented course areas, intervention descriptions, follow-up assessments, and objective use data. These findings provide a clearer picture of the evidence base and can inform curriculum planning; the use of SGs in skills-based and clinical training; and future decisions about their design, implementation, and evaluation.

Multimodal Psychophysiological Assessment of Craving in Patients With Alcohol Dependence During Virtual Reality Cue Exposure: Exploratory Single-Arm Clinical Study

2026-06-10T15:00:22-04:00

Background: Craving is a diagnostic criterion and predictor of relapse in patients with alcohol dependence (AD) and is induced in cue exposure therapy (CET) to prepare patients for real-life risk situations. The benefits of virtual reality (VR) as an innovative tool within treatment for this highly prevalent disorder include increased practicability, standardization, and personalization of CET. Accurate measurement of craving is essential to develop effective virtual reality cue exposure (VR-CE) scenarios. Despite being relevant for diagnostics and therapy, the psychophysiological reaction to alcohol cues and its relationship to subjective craving has not been sufficiently examined. Objective: This study aimed to investigate the induction of subjective craving, its physiological correlates, and their relationship in patients with AD during an innovative VR-CE paradigm, including 2 alcohol-associated risk scenarios (bar and living room) and a neutral baseline scenario. Methods: Craving was analyzed by measuring physiological reactions (electrodermal activity, including nonspecific skin conductance responses [NS-SCR] and skin conductance level [SCL]; heart rate [variability] [HR(V)]; brightness-corrected pupil diameter [BCPD]; and respiration rate [RR]) and subjective craving (visual analog scale) in 61 patients with AD. Linear mixed-effects models were conducted to estimate the effects of VR-CE. Correlations between subjective and physiological craving parameters were analyzed using Spearman correlations. Results: Results showed that alcohol-associated VR scenarios had significant effects on subjective craving ( values between 9.48, 95% CI 6.02‐12.95 and 15.93, 95% CI 12.47‐19.40, with moderate effect sizes between =0.56 and =0.72) and on NS-SCR frequency ( values between 0.97, 95% CI 0.14‐1.80 and 3.06, 95% CI 2.23‐3.89, with small-to-large effect sizes between =0.31 and =0.91), BCPD ( values between 0.03, 95% CI 0.01‐0.06 and 0.05, 95% CI 0.02‐0.07, with small effect sizes between =0.21 and =0.29), and RR ( values between 0.67, 95% CI 0.06‐1.28 and 1.66, 95% CI 1.05‐2.26, with small effect sizes between =0.22 and =0.45), but not on SCL and HR(V). Correlation analyses showed significant but weak correlations between subjective craving and electrodermal activity (SCL: =0.20, =.04; NS-SCR frequency: =0.21, =.03). Conclusions: This study showed that subjective and physiological craving (NS-SCR, BCPD, and RR but not SCL and HR[V]) can be successfully induced by VR-CE in patients with AD. These outcomes add to research on the induction of craving using a wide range of psychophysiological and subjective parameters. Furthermore, this study expands the still-limited research on the relationship between subjective and psychophysiological craving in patients with AD. In the long term, this study informs the development of effective VR-CET, which could, by further building on psychophysiological parameters, lead to biofeedback VR-CET as an innovative treatment option for patients with AD. Trial Registration: ClinicalTrials.gov NCT05861843; https://clinicaltrials.gov/study/NCT05861843 International Registered Report Identifier (IRRID): RR2-https://doi.org/10.1186/s12888-023-05346-y

The Impact of Gamified Teaching on Undergraduate Nursing Students’ Disaster Nursing Competence, Self-Efficacy, and Self-Directed Learning Ability: Quasi-Experimental Study

2026-06-10T14:45:13-04:00

Background: Gamified teaching is considered an effective strategy for enhancing learning motivation. However, there is insufficient research on systematically designing theory-based gamified approaches for disaster nursing, particularly in resource-limited conventional classroom settings. Objective: This study aimed to compare the impact of gamified teaching versus conventional teaching on disaster nursing competence, self-efficacy, and self-directed learning ability among undergraduate nursing students. Methods: A quasi-experimental, nonequivalent control group pretest-posttest design was used. Participants were third-year nursing students who had completed foundational and medical-surgical nursing courses with no prior gamified learning (GL) experience. They were nonrandomly allocated to experimental (GL group, n=66) and conventional learning (CL group, n=66) groups based on scheduling feasibility. The GL group received 180 minutes (4 class hours) of gamification, incorporating points, group competitions, and collaboration. The CL group received traditional instruction. Outcomes were measured at 3 time points (preintervention, immediate posttest, and 1-week follow-up) using the Disaster Nursing Competence Scale, General Self-Efficacy Scale, and Self-Directed Learning Ability Scale of Nursing Undergraduates. Data were analyzed using linear mixed models with group, time, group × time interaction, and baseline differences (disaster experience) as covariates. Results: The GL group scored significantly higher than the CL group on the total posttest score for disaster nursing competence (mean difference [MD]=0.205, 95% CI 0.032‐0.378; =.02), although the difference was not statistically significant at follow-up. The knowledge dimension (MD=0.274; =.01) and practical skills dimension (MD=0.201; =.03) showed the same pattern of immediate improvement, whereas the physical and mental qualities dimension demonstrated a delayed effect at follow-up (MD=0.537; =.003). The total score for self-directed learning ability was higher in the gamified teaching group than in the control group at follow-up (MD=0.116, 95% CI 0.012‐0.220; =.03), with significant improvements in collaborative learning ability (group × time interaction effect =5.17, =.01; follow-up between-group difference=0.243, =.001) and information competence (follow-up between-group difference=0.140; =.04), but no significant change in self-management ability. There were no significant differences between the 2 groups in general self-efficacy at any time point (interaction effect =.33). Conclusions: Unlike most studies focusing on digital gaming platforms, this study shows that a low-technology, highly interactive classroom gamification approach is feasible under conventional teaching conditions. The uniqueness of this gamified teaching lies in its ability to simultaneously improve multidimensional competencies (knowledge, skills, psychological qualities, self-directed learning, and learning collaboration ability) and reveal a delayed effect on physical and mental qualities—a pattern rarely reported before. This suggests potential utility in resource-limited nursing education and provides a practical, resource-sensitive solution for disaster nursing training. However, the absence of significant effects on general self-efficacy indicates that gamified teaching may not influence all psychological constructs equally. Furthermore, the 1-week follow-up may be insufficient to capture longer-term changes in psychological outcomes, and caution is warranted when generalizing these findings to other educational contexts without adaptation.

Serious Game Aimed at Assessing Executive Planning Skills in Children With Autism: Cross-Sectional Design and Formative Evaluation of ShopAutiPlan

2026-06-08T14:45:12-04:00

Background: Planning deficits are a common and functionally significant executive function difficulty in children with autism, affecting everyday activities such as organizing tasks, prioritizing goals, and monitoring progress. Traditional neuropsychological assessments often lack ecological validity and may not capture these skills in real-world contexts. Serious games offer promising alternatives by simulating everyday scenarios and enabling observation of planning behaviors during interactive tasks. However, most existing systems focus on training rather than theory-driven assessment, and are rarely evaluated for usability before deployment with children with autism. Objective: This study aimed to design and evaluate ShopAutiPlan, a supermarket-based serious game intended to assess executive planning skills in children with ASD by conducting a formative expert evaluation before its use in clinical or research settings. The evaluation sought to identify usability strengths and limitations, ensuring that the system aligns with planning theory and accommodates the unique needs of autistic users. Methods: A theory-driven design approach grounded in the Hayes-Roth cognitive model of planning was used to map planning subcomponents—including goal formulation, strategy generation, sequencing, execution, and monitoring—to in-game tasks and logged behavioral metrics. A cross-sectional, formative expert-based usability evaluation was conducted using inspection and think-aloud protocols. Six domain experts (2 psychologists, 2 human-computer interaction researchers, and 2 game developers) participated in individual evaluation sessions. Usability assessment was guided by ASD-specific usability heuristics, and experts completed the System Usability Scale (SUS). SUS scores were summarized using descriptive statistics, and qualitative feedback was analyzed through deductive coding mapped to heuristic categories. Results: Across experts, 45 usability issues were identified, spanning cognitive accessibility, feedback clarity, realism, and technical performance. Severity ratings varied according to disciplinary perspectives: psychologists highlighted cognitive load, sensory accessibility, and task clarity, whereas developers focused on system responsiveness, interaction consistency, and technical reliability. The overall SUS score (mean 70.4, 95% CI 45.2‐95.7) exceeded the standard benchmark of 68, supporting the acceptability of the system and complementing the qualitative findings from the heuristic evaluation. Recommendations from the evaluation informed iterative refinements to interface design, interaction flow, and task representation to enhance alignment between planning constructs and user experience. Conclusions: To the best of our knowledge, this study introduces the first shopping-based serious game specifically designed to assess executive planning skills in children with autism. Unlike many existing autism-related serious games that primarily focus on intervention or training, ShopAutiPlan adopts a theory-driven assessment-oriented design grounded in a cognitive model of planning and supported by gameplay-based behavioral measures. By integrating cognitive theory, serious game design, and interdisciplinary usability evaluation, the study proposes a structured framework for developing ecologically valid digital assessment tools that may complement conventional neuropsychological approaches in autism research and clinical practice.

Nintendo Switch–Based Exergaming for Subthreshold Depression: Mixed Methods Randomized Controlled Trial

2026-06-05T13:30:16-04:00

Background: Subthreshold depression (StD) increases the risk of progression to major depressive disorder. Although exercise can reduce depressive symptoms, adherence remains challenging. Exergames on platforms such as Nintendo Switch may improve motivation and participation in physical activity; however, evidence for efficacy in StD is limited. Objective: This study aims to evaluate the effects of a Nintendo Switch–based exergaming intervention on depressive symptoms, anxiety, and sleep quality, and to explore participant experiences among adults with StD. Methods: This sequential explanatory mixed methods study comprised a randomized controlled trial followed by semistructured interviews. Eighty-four adults with StD were randomized using computer-generated permuted blocks with concealed allocation to an intervention group (IG; n=42), which received an 8-week Nintendo Switch–based exergame program (2‐3 sessions/week, 50‐60 minutes/session), or a control group (CG; n=42), which continued usual activities. Outcome assessors and data analysts were blinded. Depressive symptoms, anxiety, and sleep quality were assessed at baseline (T0), postintervention (T1, Week 8), one-month follow-up (T2, Week 12), and 2-month follow-up (T3, Week 16). Generalized estimating equations (GEE) were used to analyze longitudinal changes and time×group interactions under the intention-to-treat principle. Semistructured interviews were conducted with a purposive subsample of IG participants (n=17) at T1 and analyzed using thematic analysis. Results: Eighty-four participants were randomized; 81 completed the postintervention assessment, with 3 out of 42 (7.1%) CG participants lost to follow-up at T1. Baseline characteristics were similar across groups (mean age 23.07, SD 1.45 years; 70/84, 83.3% female). Compared with CG, the IG showed significantly greater reductions in depressive symptoms at all time points (T1: =−4.07, 95% CI −5.84 to −2.30; <.001; T2: =−4.29, 95% CI −6.14 to −2.43; <.001; T3: =−3.81, 95% CI −5.54 to −2.08; <.001), along with significant improvements in sleep quality (T1: =−2.98, 95% CI −4.55 to −1.40; <.001; T2: =−2.19, 95% CI −3.58 to −0.80; =.002; T3: =−2.45, 95% CI −3.81 to −1.09; <.001). Anxiety also improved significantly at T1 (=−2.60, 95% CI −4.70 to −0.50; =.02) and T3 (=−2.38, 95% CI −4.62 to −0.14; =.04). Group×time interactions were significant for depressive symptoms (Wald =28.18; =.001) and sleep quality (Wald =23.21; <.001), confirming sustained intervention effects. Qualitative findings supported these results, highlighting immersive engagement, perceived psychophysiological benefits, and adherence facilitators. No adverse events were reported. Conclusions: A Nintendo Switch–based exergaming intervention was associated with improvements in depressive symptoms, anxiety, and sleep quality in adults with StD. Using mixed methods design, this study provides evidence integrating effectiveness and participant experience, extending prior research focused on other populations or quantitative outcomes. These findings suggest that commercially available exergaming platforms may serve as accessible, engaging tools for early mental health support in real-world settings. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300068970; https://www.chictr.org.cn/showproj.html?proj=180172