Gamification in Radiology: A Systematic Review

ORIGINAL ARTICLE Gamification in Radiology: A Systematic Review Mohammad Kiani Feizabadi1, Amir Mahdi Mafakherian2, Ahmadreza Goudarzi3, Shadi Asadzandi4,5, Mahshad Ahmadi1, Shoaleh Bigdeli6,7 1 2 3 4 Department of Medical Education, Tehran University of Medical Sciences, Tehran, Iran Department of Nano Chemistry, Tehran University of Science and Technology, Tehran, Iran Department of Radiology Sciences, Isfahan University of Medical Sciences, Isfahan, Iran Department of Medical Library and Information Sciences, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran 5 Virtual School, Center for Excellence in ELearning in Medical Education, Tehran University of Medical Sciences, Tehran, Iran 6 Center for Educational Research in Medical Sciences (CERMS), Iran University of Medical Sciences, Tehran, Iran 7 Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran Received: 20 Apr. 2019; Accepted: 28 Oct. 2019 Abstract- Radiology gamification articles were examined to determine the purpose and effect of games on the target audience and to provide a basis for researchers who aim to develop a new gamification. The articles related to radiology gamification, games, and simulations were retrieved from databases, including ProQuest, Springer, Cochrane Library, Ovid, PubMed, Scopus, and Web of Science via electronic search. To assess the quality of the articles Prisma and CASP checklists were used. Finally, according to the inclusion criteria, the appropriate articles were selected. Among 6917 retrieved articles, only 13 articles were related to radiology gamification, two of which were related to the analysis of the effects of radiology gamification in different areas such as differential diagnosis, education, dental radiology, and the number of drugs taken for imaging. These studies show that radiology gamification is few, and there are different forms of gamification, including but not limited to board games, physical games, and video games. Furthermore, in designing an educational game, learner’s characteristics, educational goals, and developing educational content are major steps. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(10):605-613. Keywords: Game; Gamification; Radiology; Systematic review Introduction During recent decades, education is reformed, and its new form and concept have emerged. In this regard, the traditional teacher-centered approach in which the teacher was conveyer of teaching materials within educational settings, and students were receivers and reservoirs of teaching materials has been changed. With magnificent changes in educational paradigms, today, there are various methods and instruments to facilitate teaching and learning, among which gamification is a newly emphasized one. The term ‘gamification,’ first used by Nick Pelling in 2002 (1), is an umbrella for a broader concept of games. Generally, a game is a system in which players challenge abstract concepts (2); and, its environment has certain rules that are monitored by counting achievements of the players. Moreover, gamification is the application of game elements in non-game contexts. (1,3-5) Gamification adds features of games such as target, rules, and regulations, entertainment, excitement, feedback, reward, and progress to the real commercial or educational environments (6). The proper game design facilitates active learning (7), fulfills educational or commercial needs (8), creates an interactive educational environment (9), increases motivation, critical thinking and problem-solving skills (10), permits repetition and facilitates test-taking (11), and improves learners’ skills (12). Since games have specific mechanics that result in excitement, encouragement, and punishment, they are appropriate tools for education, and their use are highly advised (13). Tracking brain functions by FMRI2 indicates that after playing games, the brain becomes more active, and its Corresponding Author: Sh. Bigdeli Center for Educational Research in Medical Sciences (CERMS), Iran University of Medical Sciences, Tehran, Iran Tel: +98 21 88622601, Fax: +98 21 88622607, E-mail addresses: [email protected]; [email protected] Gamification in radiology prefrontal, and parietal lobes are more productive as the result of game reward (14). In addition, gamification has been used in many areas of medical sciences, and its effectiveness has also been studied widely (15-18). Similar to nursing, dentistry, and medicine (19), radiology, as a medical discipline, has employed gamification for its purposes. Radiology is a new dynamic medical specialty that uses rays (e.g., X-ray) to diagnose and treat patients and abnormal conditions (20) by advanced imaging methods, and seeks effective educational aids for utmost learning (21,22). In this context, radiology management is crucial and addresses for its better understanding of radiology students and teachers and increases radiology workers efficiency. On the other hand, the realization of radiology history is attractive and informative for the field researchers. Designing and developing radiology gamification requires an extensive literature review; therefore, this study is an attempt to review all radiology gamification systematically. In this study, all types of radiology gamification are examined to determine their purpose and features, their underpinning learning theories, and their impact on the target audience. Finally, the results of this study provide a clear view of history and clinical management in radiology gamification. Gamification tools are used as an intervention to compare this tool with other learning tools and finally study its effectiveness. The inclusion criteria included access to the full text of articles, English language, and articles classification under radiology gamification. The exclusion criteria included lack of access to the full text of articles and non-English articles. The retrieved articles are summarized in pre-designed forms, including name of author, title of article, time and location of publication, sample of research, design of article, purpose of study, type of game, and study results. To assess the quality of the articles, the Critical Appraisal Skills Program (CASP) checklists were used. Finally, according to the performed study and considering the inclusion and exclusion criteria, 13 articles compatible with the purposes of the study were extracted. Materials and Methods To retrieve articles related to radiology gamification and educational games, databases including ProQuest, Springer, Cochrane Library, Ovid, PubMed, Scopus, and Web of Science were searched electronically. The time limitation for searches was from the establishment of each database to 2017. In order to do advance searching, the following search strategy was used by applying Boolean operators, brackets, and truncation: (("Radiology"[ti, ab] OR "CT"[ti, ab] OR "MRI"[ ti, ab] OR "Sonography"[ti, ab] OR "Medical imaging"[ti, ab]) AND ("gamification"[ ti, ab] OR "Game Based Learning"[ ti, ab] OR "Digital game"[ti, ab] OR "Video game"[ti, ab] OR "Game(s)"[ti, ab] OR "Simulation"[ ti, ab] OR "Gaming"[ti, ab] OR "Computer-assisted gaming"[ti, ab]) OR "Serious Game(s)"[ ti, ab]) OR "Educational game(s)"[ti, ab] OR "Role-playing game(s)"[ti, ab] OR "Real-world game(s)"[ti, ab]) OR "massively multi player online"[ti, ab] OR "role play simulation"[ti, ab] OR "story telling game"[ti, ab]) OR "edutainment"[ti, ab])). PICO is also considered; the population of this study was all people who associated with radiology gamification (doctor, radiologists, student, etc.). 606 Acta Medica Iranica, Vol. 57, No. 10 (2019) Figure 1. Flow Diagram for the selection of the Retrieved Articles Results The bibliographic features of articles are identified in table 1. M. Kiani Feizabadi, et al. Table 1. Bibliographic information of articles Row 1. 2. 3. Title of papers Novel card games for learning radiographic image quality and urologic imaging in veterinary medicine Use of a novel board game in a clinical rotation for learning thoracic differential diagnoses in veterinary medical imaging Assessing the learning potential of an interactive digital game versus an interactive-style didactic lecture: the continued importance of didactic teaching in medical student education 4. An interactive videogame designed to improve respiratory navigator efficiency in children undergoing cardiovascular magnetic resonance 5. App Review Series: Radiology Pocket Game Affiliation of authors Publication year Type of research DOI Christopher P. Ober, DVM, Ph.D., Dipl. ACVR is Associate Professor of Medical Imaging, Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine 2017 Original research 10.3138/jvme.0715-108R American College of Veterinary Radiology Christopher P. Ober, DVM, Ph.D., Dipl. ACVR is Associate Professor of Medical Imaging, Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine 2016 Original research 10.1111/vru.12452 Pediatric Radiology Jesse Courtier, Department of Radiology and Biomedical Imaging, University of California, San, Francisco UCSF Benioff Children’s Hospital--- Emily M. Webb, Department of Radiology and Biomedical Imaging, University of California, San Francisco-- Andrew S. Phelps, Department of Radiology and Biomedical Imaging, University of California, San, Francisco UCSF Benioff Children’s Hospital--- David M. Naeger, Department of Radiology and Biomedical Imaging, University of California, San Francisco 2016 Original research DOI 10.1007/s00247-0163692- Journal of Cardiovascular Magnetic Resonance Sean M. Hamlet, Department of Electrical Engineering, University of Kentucky, Lexington, KY, USA, Department of Pediatrics, University of Kentucky, Lexington, KY, USA--Christopher M. Haggerty, Department of Pediatrics, University of Kentucky, Lexington, KY, USA, Institute for Advanced Application, Geisinger Health System, Danville, PA, USA--Jonathan D. Suever, Department of Pediatrics, University of Kentucky, Lexington, KY, USA, Institute for Advanced Application, Geisinger Health System, Danville, PA, USA--Gregory J. Wehner, Department of Pediatrics, University of Kentucky, Lexington, KY, USA, Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA--- 2016 Original research DOI 10.1186/s12968-0160272- Journal of Digital Imaging V. B. Surya Prasath, Computational Imaging and VisAnalysis (CIVA) Lab, Department of Computer Science, University of Missouri, Columbia, MO, 65211, USA 2016 Review DOI 10.1007/s10278-0169924-7 Journal Journal of Veterinary Medical Education Acta Medica Iranica, Vol. 57, No. 10 (2019) 607 Gamification in radiology Table 1. (Cont.) From analog to apps – developing an app to prepare children for medical imaging procedures Gigi Williams, The Royal Children's Hospital Melbourne--- Siobhan Greene, The Royal Children’s Hospital, Melbourne, Australia 2015 Original research DOI: 10.3109/17453054.2015.11 08285 2015 Original research DOI 10.1186/s12976-0150003-4 2014 Original research 10.7863/ultra.33.10.1843 American College of Radiology Bruce Reiner, MD, Baltimore VA Medical Center, Diagnostic Imaging, Baltimore, Maryland 21201, USA--Eliot Siegel, MD from the University of Maryland 2008 Review DOI: 10.1016/j.jacr.2007.09.002 10. Development of software for dental radiology education using VB.NET International Congress Series H. Tanimoto, Department of Hard Tissue Research, Graduate School of Oral Medicine Oral Science, Matsumoto Dental University, Japan--Y. Arai, Department of Hard Tissue Research, Graduate School of Oral Medicine Oral Science, Matsumoto Dental University, Japan--K. Gro¨ndahl, Department of Oral and Maxillofacial Radiology, The Sahlgrenska Academy, University of Go¨teborg, Sweden---H.-G. Gro¨ndahl, Department of Oral and Maxillofacial Radiology, The Sahlgrenska Academy, University of Go¨teborg, Sweden 2005 Original research https://doi.org/10.1016/j.ics .2005.03.119 11. The slice is right (an exercise in ct windowing) Canadian Journal of Medical Radiation Technology BruceWhalenRTR,Diagnostic Imaging Department, Janeway Child Health Centre/Children's Rehabilitation Centre, Health Care Corporation of St. John's, NL 2003 Original research https://doi.org/10.1016/S08 20-5930(09)60033-5 6. Journal of Visual Communication in Medicine 7. CT brush and CancerZap!: two video games for computed tomography dose minimization Theoretical Biology and Medical Modeling 8. Sonogames An innovative approach to emergency medicine resident ultrasound education American Institute of Ultrasound in Medicine 9. The potential for gaming techniques in radiology education and practice Graham Alvare , BioInformation Technology Laboratory, Department of Plant Science, University of Manitoba, Current address: Faculty of Medicine, University of Manitoba, Box 107, Winnipeg, Canada --- Richard Gordon, Embryogenesis Center, Gulf Specimen Aquarium and Marine Laboratory, C.S. Mott Center for Human Growth and Development, Department of Obstetrics and Gynecology, Wayne State University, Stellarray, 9210 Cameron Road Suite #300, Austin Andrew S. Liteplo, M.D., RDMS, attending physician at Massachusetts General Hospital's Department of Emergency Medicine. Assistant Professor of Surgery at Harvard Medical School--- Nova Panebianco, MD, MPH ,Assistant Professor of Emergency Medicine at the Hospital of the University of Pennsylvania--Teresa Liu, M.D., RDMS ,Associate Director, Ultrasound ,Health Sciences Assistant Clinical Professor--- Alice Fiona Murray, MBChB Instructor, Pediatrics--- Geoffrey Hayden, MD Jefferson University Physician--- Resa E. Lewiss, MD, Director of Point-ofCare Ultrasound, Department of Emergency Medicine, Department of Radiology, University of Colorado School of Medicine 608 Acta Medica Iranica, Vol. 57, No. 10 (2019) M. Kiani Feizabadi, et al. Table 1. (Cont.) Development and evaluation of an interactive webbased breast Imaging Game for Medical Students An interactive multimedia program for imaging the spleen: Concept, design, and development 12. 13. Academic Radiology Marilyn A. Roubidoux, MD, Department of Radiology, University of Michigan Health System, Ann Arbor--Chris M. Chapman, BS--- Mary E. Piontek, MA, PhD 2002 Original research PMID: 12385511 Radiographics Paul S. Calhoun, BFA Eliot K Fishman, MD 1994 Original research DOI:10.1148/radiographics. 14.6.7855349 Table 2. Game features of radiology gamification Type of Game Purpose of Game Method of Game Production Features of Game Card Game Assessing the utility of card games for learning the fundamentals of radiographic image quality and differential list generation in a veterinary classroom First, the data were collected, and cards were designed. Then, card game regulations were set This card game was designed to transfer different concepts of veterinary imaging within classrooms. Cards focus on the quality of radiographic images or differential diagnosis. Board Game Helping students to generate appropriate lists of differential diagnoses when faced with various radiographic findings First, the data were collected, after that, the winning conditions, card, and game regulations were set, and cards were designed The game designs involve a little chance, and the possibility of winning or losing is completely related to players’ skills. Physical Game Assessing all aspects of emergency medicine (the clinician performs an ultrasound examination at the bedside, interprets the images, and immediately implements this into clinical decision making) The game data were collected; then, regulations and conditions of the game were designed. The game is somewhat similar to simulators. It is done within three stages, each of which lasts four hours. The game is running as an event; different teams take part in this game and achieve scores. Video Game Capturing and using human intuition for reducing CT dose The data is collected, and the game is implemented on Java as a videogame The game production and design are very simple. The player should shoot the X-ray photons to tumors and should avoid shooting to the normal tissues. Online Game To develop an interactive computer teaching tool for breast imaging targeted toward the general, 4th-year medical student and to make it available on the World Wide Web The data is collected, and the game is designed as an online game. The game is competitive and is completely designed with Visual Elements1 An interactive videogame designed to improve respiratory navigator efficiency in children undergoing cardiovascular magnetic resonance Video Game Navigator-controlled videogame helps to control breathing patterns and to improve navigator efficiency and maintain image quality The game was produced by custom software called MATLAB This game uses avatars as visual feedback and process the respiratory navigator image in real-time during CMR. The game encourages children to breathe so that the avatar is positioned within the navigator acceptance window throughout image acquisition App review series: radiology pocket game Video Game Teaching the user’s anatomy using radiological images The data is collected, and each game is implemented as a videogame. This game is based on asking question and answer process, and the educational aspect of the game is emphasized. Title Novel card games for learning Radiographic image quality and urologic imaging in veterinary medicine Use of a novel board game in a clinical rotation for learning thoracic differential diagnoses In veterinary medical imaging Sonogames an innovative approach to emergency medicine resident ultrasound education Ct brush and cancerzap! two video games for computed tomography dose minimization Development and evaluation of an interactive web-based breast imaging game for medical students All these games were designed to improve a process or to teach a concept that is an exact match of the Acta Medica Iranica, Vol. 57, No. 10 (2019) 609 Gamification in radiology gamification goals. In all the above-mentioned studies to design the gamification, at the very beginning, data was collected to select the best platform and type of gamification in accordance with the teaching-learning content. The research findings of the effects or end results of games, game audiences, and learning theories applied to develop games are shown in table 3. Table 3. Features of radiology gamification Row Game name Study participants Bloom domain of educational objectives Underpinning learning theory 1 Card games 99 veterinary students Application Artifact recognition/ Cognitive processes 2 Ain’t Doin’ Right: Thorax (ADR: Thorax) 100 fourth-year veterinary students Comprehension Not mentioned 3 Simple interactive digital Tic-tac-toe quiz module 50 students Evaluation Self-directed learning 4 Bubble Gulp (navigator feedback videogame) Fifty children with no significant past medical history Application Not mentioned Radiology Pocket Game (RPG) Not Mentioned Application Not mentioned 5 6 Okee in Medical Imaging children 4–8 years Application Not mentioned 7 CT Brush Not mentioned Application Not mentioned 8 SonoGames Allopathic emergency medicine residencies Knowledge Cognitive Game result/Effectiveness Card game has positive impact on students’ classroom perception Beneficial in improving student understanding of veterinary medical imaging with respect to developing differential lists for thoracic radiographic findings. Students’ fewer tendencies in learning via digital Games compared to traditional speech. Using the designed game was successful, and researchers found that games can play effective roles in education, which leads to increasing interactions among individuals. Not mentioned Significantly reduce procedural anxiety and bolster the support patients and families receive from one of the the department’s dedicated Play Therapists The effects of games on general education are noted, and this is known as one of the methods of teaching public. Not Mentioned 9 Gaming Techniques in Radiology Not Mentioned Knowledge Not Mentioned 10 VB.NET Not mentioned Application Not mentioned 11 The slice is right Interactive Web-based breast imaging game Interactive multimedia program Not mentioned 4th-year medical students Application Not mentioned Problem-based learning (PBL) Games could be a new attractive method for all the staff in the medical imaging area. This approach also provides objective duplicable data that are sharply demanded by the regulators, refunding units, and those who hope to supply imaging services to the market. Students can learn how to position sets of radiographs in a logical order to facilitate their viewing and interpretation. Enables the production of versatile and platformindependent programs the Contents of which are easy to change for the teachers using them in their education. Not mentioned It is both interactive and competitive, which may increase student motivation and interest Not mentioned Application Not mentioned Not mentioned 12 13 Evaluation In some of the reviewed articles, the results of the research are not completely clarified. Among the reviewed articles, two of them were specifically focused on the effects of radiology games. The article entitled "Assessing the learning potential of an interactive digital game versus an interactive-style didactic lecture: the 610 Acta Medica Iranica, Vol. 57, No. 10 (2019) continued importance of didactic teaching in medical student education" aimed to compare traditional education with gamified education. In this article, researchers found that education by applying lectures 1 and educational games could be very effective compared to traditional methods, and games can be used along with M. Kiani Feizabadi, et al. other methods. The article entitled "The Potential Gaming Techniques in Radiology Education and Practice reviewed the effects and potentials of games. The researcher also found that video games are effective educational tools in teaching radiology. In addition, the game could be amusing and transfer educational content in environments similar to the real world. Finally, it could increase individuals’ clinical skills. All the mentioned games applied Bloom’s taxonomy of educational objectives; however, most of them lack explicit underpinning educational theories. In table 4, the articles are reviewed from their relations to radiology areas via using gamifications. Table 4. Radiology gamification and education of health professions Row Title Active radiology areas 1 Novel card games for learning radiographic image quality and urologic imaging in veterinary medicine Quality of images and differential diagnosis of radiographic findings in veterinary medicine 2 Use of a novel board game in a clinical rotation for learning thoracic differential diagnoses in veterinary medical imaging Thoracic differential diagnoses in the veterinary clinical setting 3 Sonogames an innovative approach to emergency medicine resident ultrasound education Education and assessment of ultrasound skills of emergency medical residents 4 5 6 7 8 9 10 11 Assessing the learning potential of an interactive digital game versus an interactive-style didactic lecture: the continued importance of didactic teaching in medical student education From analogue to apps – developing an app to prepare children for medical imaging procedures An interactive videogame designed to improve respiratory navigator efficiency in children undergoing cardiovascular magnetic resonance Subspecialty Veterinary Medicine Emergency Medicine Pediatric radiology Pediatrics Medical imaging procedures in children Cardiovascular magnetic resonance Cardiovascular App review series: radiology pocket game Radiological imaging in anatomy Anatomy Ct Brush And Cancerzap! two video games for computed tomography dose minimization The slice is right (an exercise in CT windowing) The potential for gaming techniques in radiology education and practice Development and evaluation of an interactive webbased Breast imaging game for medical students X-ray dose from computed tomography (CT) scanner CT windowing Medicine (computed tomography (CT)) Medical imaging Medicine (Imaging) Breast imaging 12 Development of software for dental radiology education using VB.NET Dental radiology Dentistry 13 An interactive multimedia program for imaging the spleen: concept, design, and development Radiologic imaging from spleen Gastrointestinal radiology Discussion Game production aims to increase cooperation and collaboration among individuals to perform an activity and to increase or develop certain traits in users (23). This new trend can lead to changing behavior or occurring certain activities among individuals, e.g., respecting nature, paying attention to personal health, and increasing the level of cooperation in an organization (24). Gamification could be used in diverse scientific fields and disciplines. For instance, in medicine, the game 'Pain Squad' can be easily used to detect the amount of pain in cancerous children. The game 'Speed Camera' will provoke drivers to obey certain speed limits for security and protection purposes. In addition, in education, gamification tools have been used for teaching educational processes to learners. In fact, this instrument increases the motivation of learners to gain knowledge and encourages them to cooperate in educational activities (10,25,26). In the present study, among 6917 extracted articles from different databases, only 13 articles related to educational radiology gamification were retrieved and, only two of them dealt specifically with analysis of the effects of gamification in this area. These studies focused on the positive impact of the games on students' learning Acta Medica Iranica, Vol. 57, No. 10 (2019) 611 Gamification in radiology processes. In fact, other articles emphasized the positive impact of educational games on education (27-30). It is worth mentioning that in one of the articles (Table 1. Number 5) the applied game was not effective as an educational tool, and live interaction among learners, the realization of content and enjoyment from learning scored much higher than gamification. The authors considered the importance of gamification completely and mentioned that as a complementary educational tool, it could be used and suggested conducting future studies with a broader statistical population and other educational methods in comparison to gamification (31). In teaching and learning environments, lack of cooperation, and lack of ability to create motivation among learners are usually observed. Therefore, educators should apply new educational techniques such as gamification to enhance teaching and learning processes. One of the probable methods is giving rewards to positive trials or activities that increases the level of motivation among learners. In fact, gamification by making use of game components enhances these processes (32). In several studies, it has been proved that using game mechanics could increase the ability of learners to learn new skills or gain knowledge (33). Also, in the 13 reviewed articles, in diverse areas of radiology such as differential diagnosis, education, and dental radiology, different games have been designed, and their effectiveness was approved. Moreover, there are similarities between games and education; for instance, they both have specified goals and try to create a pleasing environment to remove teaching and learning barriers. In addition, a certain skill or concept is taught via them, or they increase cooperation among the involved parties and convey the intended content. Either in education or educational games assessing individual players is crucially important to understand whether they have reached the intended goals or not (32). However, it is worth saying that games not only increase learners’ behavior, commitment, and motivation but consequently improve their knowledge or skill acquisition (23). Game studies show that game production is not limited to a specific type (30), and different types of games (e.g., board game, physical game, video game, etc.) could be produced and applied in diverse educational settings. In designing an educational game, recognizing learner’s character, educational goals, and developing educational content as well as activities for producing games are crucially important (23,32). The key point for game producers, in designing an appropriate game, is to consider roles, tasks, and responsibilities that learners should undertake. Successful 612 Acta Medica Iranica, Vol. 57, No. 10 (2019) gameplay results in achieving more scores, rewards, passing to the next step, winning the game, and finally achieving educational goals (31). Therefore, it was concluded that, although radiology is a new discipline, using gamification for conveying the contents is highly noted. Acknowledgments The authors are grateful to the National Agency for Strategic Research in Medical Education (NASR) for its financial support. References 1. Lee JJ, Hammer J. Gamification in education: What, how, why bother. Academic exchange quarterly 2011;15:14651. 2. Koster R. A Theory of Fun in Game Design. pdf. Scottsdale: Paraglyph press, 2005. 3. Muntasir M, Franka M, Atalla B, Siddiqui S, Mughal U, Hossain IT. The gamification of medical education: a broader perspective. Med Educ Online 2015;20:30566. 4. Deterding S, Dixon D, Khaled R, Nacke L, editors. From game design elements to gamefulness: defining gamification. Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments; 2011: ACM. 5. Bigdeli S, Kaufman D. Digital games in medical education: Key terms, concepts, and definitions. Med J Islam Repub Iran 2017;31:300-6. 6. Maan J. Social business transformation through gamification. arXiv preprint arXiv:13097063. International Journal of Managing Information Technology (IJMIT) 2013;5:9-16. 7. Royse MA, Newton SE. How gaming is used as an innovative strategy for nursing education. Nurs Educ Perspect 2007;28:263-7. 8. Bartfay WJ, Bartfay E. Promoting health in schools through a board game. West J Nurs Res 1994;16:438-46. 9. Blakely G, Skirton H, Cooper S, Allum P, Nelmes P. Educational gaming in the health sciences: systematic review. J Adv Nurs 2009;65:259-69. 10. Kapp KM. The gamification of learning and instruction: game-based methods and strategies for training and education. United States: John Wiley & Sons, 2012. 11. Pannese L, Carlesi M. Games and learning come together to maximise effectiveness: The challenge of bridging the gap. Br J Educ Technol 2007;38:438-54. 12. Griffiths MD. The educational benefits of videogames. Educ health 2002;20:47-51. M. Kiani Feizabadi, et al. 13. Ahmed M, Sherwani Y, Al-Jibury O, Najim M, Rabee R, Ashraf M. Gamification in medical education. Med Educ Online 2015;20:29536. 14. Howard-Jones PA, Jay T, Mason A, Jones H. Gamification of learning deactivates the default mode network. Front Psychol 2016;6:1891. 15. Andrade LH, Alonso J, Mneimneh Z, Wells J, AlHamzawi A, Borges G, et al. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol Med 2014;44:1303-17. 16. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg 2012;99:1322-30. 17. Dithmer M, Rasmussen JO, Grönvall E, Spindler H, Hansen J, Nielsen G, et al. “The Heart Game”: Using gamification as part of a telerehabilitation program for heart patients. Games Health J 2016;5:27-33. 18. Kerfoot BP, Kissane N. The use of gamification to boost residents’ engagement in simulation training. JAMA surg 2014;149:1208-9. 19. Bigdeli S, Kaufman D. Digital games in health professions education: Advantages, disadvantages, and game engagement factors. Med J Islam Repub Iran 2017;31:7805. 20. dictionary Dim. Dorlands illustrated medical dictionary 32 ed. United States of America: Elsevier, 2012. 21. Lau HM, Smit JH, Fleming TM, Riper H. Serious games for mental health: are they accessible, feasible, and effective? A systematic review and meta-analysis. Frontiers in psychiatry. 2017;7:209. 22. Sardi L, Idri A, Fernández-Alemán JL. A systematic review of gamification in e-health. J Biomed Inform 2017;71:31-48. 23. Simões J, Redondo RD, Vilas AF. A social gamification framework for a K-6 learning platform. Comput Human Behav 2013;29:345-53. 24. Perinot C. Gamification in the field of human resource 25. 26. 27. 28. 29. 30. 31. 32. management. Gamified solutions for recruitment: Università Ca'Foscari Venezia, 2016. Morschheuser BS, Rivera-Pelayo V, Mazarakis A, Zacharias V. Interaction and reflection with quantified self and gamification: an experimental study. J Lit Technol 2014;15:136-56. DomíNguez A, Saenz-De-Navarrete J, De-Marcos L, FernáNdez-Sanz L, PagéS C, MartíNez-HerráIz J-J. Gamifying learning experiences: Practical implications and outcomes. Comput Educ 2013;63:380-92. Michie S, Ashford S, Sniehotta FF, Dombrowski SU, Bishop A, French DP. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health 2011;26:1479-98. Dombrowski SU, Sniehotta FF, Avenell A, Johnston M, MacLennan G, Araújo-Soares V. Identifying active ingredients in complex behavioural interventions for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities: a systematic review. Health Psychol Rev 2012;6:7-32. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol 2009;28:690-701. Greaves CJ, Sheppard KE, Abraham C, Hardeman W, Roden M, Evans PH, et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC public health. 2011;11:119. Kiryakova G, Angelova N, Yordanova L, eds. Gamification in education 2014: Proceedings of 9th International Balkan Education and Science Conference. Giang V. Gamification techniques increase your employees’ ability to learn by 40%. Business Insider. 2013;18. Acta Medica Iranica, Vol. 57, No. 10 (2019) 613