Ethical and pedagogical reflections around serious games in patients education (PE):

Introduction

In 2019, the French Ministry of Solidarity and Health presented its roadmap for digital health policy, which aims to make digital technology a major opportunity for the development and improvement of healthcare. ¹ E-health covers diverse applications such as telehealth, telemedicine, telecare, mobile health, connected objects and sensors, digital health records, serious health games, gamification strategies… A wide range of solutions is mobilising new technologies with the primary aim of improving health. The scope of e-health thus affects many areas of healthcare practice including monitoring chronic diseases, therapeutic patient education (PE), home care, etc.

In the wake of the COVID-19 pandemic, digital health has sometimes been seen as a solution to address needs related to the accessibility, continuity and efficiency of healthcare, particularly in the field of PE.^2,3 The development and use of serious games in health care have never been more relevant as they are now, as digital health has been brought to the forefront while raising questions about healthcare ethics. ⁴

By exploring the existing scientific literature and by drawing on the expertise of key individuals, collected and compiled as part of a series of webinars we organised, we were able to define a set of themes covering the concepts of e-health, e-PE and e-patient.

Since 2019, France has been experiencing an acceleration and a digital revolution in health, that is e-health, supported by the Ministry and the Haute Autorité de Santé. ¹ Throughout the COVID-19 period, healthcare providers digitised practices in therapeutic PE, generating this new approach called e-PE. ² Lastly, we were able to take a close look at an approach by Ferguson, who, in the 1980s, addressed the paradigm of the ‘e-patient’, i.e. a user who is not only ‘connected’ because of the digital environment, but who is above all empowered, educated, committed, equipped and an expert. ⁵

On this basis, we felt it was important to look at the ethical issues surrounding e-health and the introduction of digital tools in healthcare. The main ethical principles of digital health care are beneficence in bringing benefits to individuals, non-maleficence in avoiding harm to patients, fairness and equity in ensuring equitable access to digital health technologies, and autonomy in making decisions about their health. The ‘Ethics by design’ principle developed by Fisher also encouraged us to start thinking about ethics right from the design phase of a tool.^6,7

Generally speaking, the integration of serious games and digital entertainment into PE programmes presents a significant opportunity to improve patient engagement, knowledge acquisition and general well-being.

However, the rapid advancement of digital technologies in healthcare has outpaced the development of a comprehensive ethical framework for their application.

While existing research has explored the issues of data security and the e-health digital divide in a variety of healthcare contexts, there is a notable dearth of studies specifically examining the impact on psychosocial skills and the ethical implications of these digital interventions within therapeutic education programmes for adult patients. Furthermore, the ethical implications of using digital technologies like serious games warrant careful consideration.

Healthcare professionals can define serious games as interactive and playful devices that create a gaming experience with the expected therapeutic effect of treating, relieving, or improving the patient's state of health. DRAGO^© is one of these serious games designed for allergic patients, half of whom are adults, who must undergo desensitisation treatment for 3 years while facing the risk of non-compliance with treatment continuity.^8,9 The game aims to improve patients’ management of their immunotherapy treatment.

The purpose of this study is to question the impact that serious games can have in therapeutic education programmes for adult patients, or more simply to ask: ‘Can we play with our health?'. By investigating the perception of e-health and serious games as well as the ethical impact on PE programmes, this research aims to contribute to the development of ethical guidelines and good practices for the responsible use of these technologies.

Methods

Results

Quantitative study

We sent the questionnaire to 120 PE programme coordinators in the Centre Val de Loire region, all of whom are healthcare professionals. We received 56 responses from them. Games are rarely used in the PE programmes (19.7%). In these PE programmes, several games can be used (e.g. cards, quizzes) and their use can enhance playfulness in various ways (Table 1).

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Table 1.

Place of games in PE programmes, types of media and expected playfulness expressed by PE programme coordinators.

The place of games in the PE offer		PE programme coordinators
		n	%
Total expressed of which		56	100
	Not present at all	11	19.6
	Not very important	34	60.7
	Relatively important	8	14.3
	Very important	3	5.4
Types of edutainment media used		Several answers possible
		n	%
Total expressed of which		115	100
	Card games	35	30.4
	Quizzes, puzzles, riddles	27	23.5
	Board games	16	13.9
	Role-playing games	15	13.0
	Digital games, video games, serious games	4	3.5
	Escape game	4	3.5
	Toy	2	1.7
	Other	4	3.5
	None	8	7.0
Expected playfulness		Several answers possible
		n	%
Total expressed of which		146	100
	Interact with other player-patients	45	30.8
	Progress through game levels	29	19.9
	Fulfilling missions and challenges	26	17.8
	To escape, provide for decontextualisation	24	16.4
	Earn rewards and badges	6	4.1
	Earning points, establishing a score	6	4.1
	Use an avatar	4	2.7
	Integrate a player ranking	1	0.7
	Other	5	3.4

The majority of respondents (60.7%) report that games still play a minor role in their educational system. If we add to this the respondents (19.6%) who said that games were ‘not at all present’, we come to a total of 4/5 of those questioned who said that games were not or only slightly a part of their programme. This reflects a significant lack of acculturation, which may be linked to mistrust, resistance or a basic ignorance of the benefits that play can generate in terms of learning, as described below.

Among the play media used, card games are the most popular (30.4%). Next, come quizzes, riddles and riddle games (23.5%), followed by board games which are used in nearly identical proportions to role-playing games (13.0–14.0%). Only four people (3.5%) use serious video games (referred to as Serious Games in this work), a point that will likely be discussed later. Finally, eight professionals (7.0%) do not use any of these fun resources in their PE sessions.

Professionals expect games to enable interaction between player-patients (30.8%). Practitioners want games to enable progression through levels (19.9%), to complete challenges (17.8%), or to provide an escape and decontextualisation (16.4%) from the care environment. These aspects are noteworthy as they highlight some of the key elements as to what a Serious Game should be, among other things. On the other hand, respondents showed little or no interest in ‘patient-players’ being able to obtain rewards, earn points, have an avatar, or be ranked (these values ranged from 0.5% to 4.1%), even though these elements are inherent components of a digital serious game.

Qualitative study

We conducted 12 interviews with users of the DRAGO game, 6 of whom were healthcare professionals, 4 men and 2 women aged 26 to 64, and 6 patients, 3 men and 3 women aged 19 to 52.

The interviews produced a total of 188 verbatims (Table 2) including 130 from healthcare professionals (69.0%) and 58 from patients after transcription (31.0%).

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Table 2.

Categorisation and percentage of verbatims expressed by health professionals and patients on e-ETP topics.

‘e-ETP’	Healthcare professionals		Patients
	n	%	n	%
e-health	39	30	17	29
(e-)patient	35	27	30	52
Digital ethics	56	43	11	19
Total	130	100	58	100

The three themes were identified using the grounded theory method, and following lexicometric analysis, the 188 verbatims were categorised according to the 3 emerging themes of e-health, e-patient and digital ethics.

e-health

Professionals: For healthcare professionals, e-health comes second place (30.0%). One of these professionals acknowledges that ‘we’re in a different phase today’, with a more welcoming view of the deployment of digital health. The emergence and impact that e-health will have on the healthcare landscape is, for this other practitioner, ‘something that is inevitable in any case, that we’re going to have to learn to work with, and that we have to embrace and know how to do. Which is not always the case. So we need to be supported in this too’.

Patients: In second place was the mention of e-health by patients (29.0%). One patient describes the strong, even excessive anchoring that he feels digital technology can have in our society, saying that ‘(young people) are more addicted to the telephone than I am, even though, well, I have two of them’.

The (e-)patient

To evoke this theme, which leads us to consider the patient in his or her capacity as a capable, involved, committed being within a holistic approach that acknowledges his or her full and complete singularity, our interview populations expressed themselves in equal parts; 27.0% for professionals and 52.0% for patients.

Professionals: The majority of professionals expressed a negative opinion about patients’ ability to engage with a digital environment, primarily due to their age, with some very clear-cut statements such as: ‘An elderly person doesn’t (know) how to use technology’. However, this negativity was often nuanced when discussing the introduction of digital technology to adult audiences: ‘No, which is probably a mistake, it's true that I didn’t think about it. (…) I didn’t see it that way at first. (…) Since then, we’ve talked about it, and I’ve said to myself that I might have to extend it (to populations other than children)’. One practitioner concludes that ‘you could say it's (for) young people, but not necessarily, in fact’. Another added that ‘we have 50-year-old men who will love it, and we have (…) children who won’t like it at all’.

Patients: The majority of patients interviewed expressed first-intention verbatims about the (e-)patient.

The youngest DRAGO^© patient interviewed, aged 19, also expressed a negative view of the profile of eligible patients, noting that the video game solution is not suitable ‘for senior citizens, because I see my grandparents, and they don’t know how to use a tablet or anything’.

Finally, not without humour and affection, one professional describes another reality that leaves room for the prospect of digitalisation in the face of these new e-patient profiles: ‘We have little geeks, even geeky grannies (…). We call them that because they contact us (on) social networks’.

Digital ethics

Professionals: First of all, we note that elements relating to digital ethics (43.0%) were the most prominent among healthcare professionals.

Practitioners mention limiting factors for the use of serious games, such as ‘the association of games and care (is) not necessarily natural for me’. This last point is added to another of the reservations often expressed about video games: ‘My big fear with games is an addiction (to screens)’. This same caregiver had a third opinion of mistrust in content carried by digital media: ‘We’re always a little afraid (that the digital medium) won’t give the same message as we do’. This may echo the fear of discrediting already mentioned in the quantitative study, as expressed by one practitioner's remark: ‘(beware of) trivialising things too much, the person still has to understand that it's still an illness, that they’re still sick. (…) You also don’t want everything to be a bit too light-hearted’.

However, among the proportion of elements in favour of the digital and the use of play, one professional says: ‘Just because we’re going to popularise things doesn’t mean that it's going to discredit the care or treatment or the healthcare professional we’re dealing with’.

Another professional also highlights a limiting factor, related to the design and objectives of digital health aids: “(other applications) might have brought something to us as doctors, in that people could come in with their curves, but it didn’t bring anything to the patients.

The resistance, mistrust and questioning surrounding these new innovations are rooted in the history of healthcare practices, as this professional reminds us: ‘I come from a generation where there was the doctor and the patient, that's all’. He goes on to add what is for him, and no doubt for others, an intrinsic component of the practitioner's position: ‘I think that for the doctor, it's not always easy to let go, to delegate’.

One professional points out that it's interesting to be able to move on: ‘finally to something a bit fun that will help them take their treatment; they’re really happy’. During consultations with their patients, they noted that they ‘very often see patients’ or mothers’ faces light up when we say ‘finally something fun’, reinforcing this notion of acceptability perceived by patients around videogame practices in healthcare.

Patients: Among patients, the dimension of digital ethics was barely mentioned, recurring only eleven times in the six verbatims. One of the patients would like to see a paradigm shift and a change in attitude on the part of caregivers regarding the place given to playful intentions in the care relationship.

Both populations expressed a favourable stance on the ethical issues raised by the use of digital technology and gaming in healthcare, considering these practices to be perfectly acceptable.

From an overall analysis of the results, we can conclude that:

- Professionals put forward elements of discourse around the ethics of care.

- Patients, on the other hand, were more interested in expressing themselves as e-patients, and less in questioning digital ethics.

Discussion

The quantitative study showed that games were poorly integrated into PE practices (19.7%), and that serious games were very much in the minority in terms of usage (3.5%). However, high expectations were expressed, raising questions about the perception of e-health, the e-patient model and digital ethics.

In the qualitative study, sampled DRAGO users help us to understand the implications and challenges of introducing serious games into PE programmes.

When we look at the results of our various surveys, we can see that both professionals and patients questioned by semi-directive interviews were in favour of the advent of e-health. Conversely, in the questionnaire survey, only 12.0% of respondents saw the advent of e-health as an opportunity. Practitioners and patients mobilising new healthcare technologies such as DRAGO^© seem less reticent about using digital media in care.

One of the practitioners interviewed, moreover, argues that to dismiss the e-health dimension (and even the playful one) would amount to ‘not being in step with the evolution of society on the one hand, and to deprive ourselves of the digital side on the other hand, and the playful side, which in fact, we don’t realise, but lots of people play’.

According to Gillet and Brun, ‘the lack of knowledge of digital worlds in the healthcare environment does not facilitate the work of converging the various isolated approaches of the few therapists who develop such a practice.^{11, p. 177}

As part of this societal impetus, we've also noted the omnipresence of cell phones in the hands of patients during consultations and educational activities.

Like other therapies, such as medication, digital tools (of which Serious Games are a part) can be seen by some as remedies with their own effects, indications and contraindications. In one of the interviews conducted with a professional, he surprised himself by considering the video-educational game as a medicine, evoking the principle of ‘prescribing them DRAGO^©, if we can say that we prescribe DRAGO^©’.

Gillet and Leroux define these digital devices intending to treat by the terminologies ‘video game therapy’, ‘video game group’, ‘virtual mediations’, ‘digital mediations’ and ‘virtual reality therapies.^,12 However, the authors warn us to beware of the proliferation of unevaluated video-educational concepts, which can lead to questionable practices in the absence of evidence-based data and a lack of legal framework.

Vlachopoulou mentions that ‘the virtual, omnipresent in our lives, is still struggling to find legitimacy in the eyes of some care professionals. ^{13 , p. 33} As we have seen from the questionnaire results, caregivers are not currently inclined to use edutainment media (card games, board games…) as therapeutic mediation tools, for reasons ranging from a lack of resources to unfamiliarity with existing digital media. As a result, reservations about the use of new technologies become quite entrenched when the means to demonstrate their relevance are not in place.

However, e-health is gradually finding its place in care practices, as shown in this example, which could pass for harmless when this practitioner benefits from ‘QR codes that I stick on the prescription’ so that patients can directly download DRAGO^© by scanning it.

Faced with the rise of these technological innovations, one of his colleagues argues that ‘we’re going to have to develop everything we can to support the doctor-patient relationship with other digital players’.

For one of the patients interviewed, the use of his e-health mobile application ‘is becoming a bit of a habit, (…) an appointment’, in the spirit of an educational activity scheduled with the patient by the healthcare team.

Gillet et al. encourage us to recognise that ‘the practice of virtual-digital mediation presupposes a work of reflection and questioning of the caregiver's practice in the course of video game therapy, to be able to adapt the device to the patient's needs. ^{14 , p. 129}

Our research work invites us to reflect on the roles of stakeholders, particularly chronically ill patients identified as e-patients, concerning the prospects offered by PE and even more so by e-PE. Indeed, Stora supports this point by stating that the theoretical-clinical stakes of ICT affect various social and generational categories in society, both at the level of caregivers and patients. ¹⁵

Throughout our study, the most pressing issues did not revolve so much around e-health questions, but rather around fears inherent to the profile of the patients involved in PE programmes. This seems to be a legitimate concern for caregivers who, in principle, adopt a benevolent and empathetic stance towards the patients they care for, and who are always striving for a more holistic approach.

Although coordinators in the quantitative study do see an interest in using games as part of PE programmes, first and foremost the interaction that could take place between player-patients (30.8%), professionals expressed strong reservations in the qualitative study about their patients’ eligibility for these new digital media, particularly concerning the generation to which they belong, as mentioned above. In parallel to this, we should also note that patients consider themselves capable of adapting to the digital environment.

Frété reminds us that we now face one or even two generations who, since the 1980s, have grown up with technology and interactivity, where video-educational games could take their rightful place. ¹⁶

Video games are now used by users of all ages and genders, whereas up until now they were often only identified as being used by a male and juvenile audience. Surveys show that adults are as involved as children, the difference being that the former organise this leisure activity around their time constraints, and that women enjoy them as much as their male counterparts. ¹⁷

However, one element of our quantitative study calls to mind that games are predominantly ‘Not at all present’ in educational activities, at least in the PE programmes represented in the survey. Furthermore, Bundy et al. consider that the use of games as a therapeutic modality should not be limited to the paediatric sector, but should also be extended to the adult patient population, as do Guitard et al.^18,19 To add to this point of view, one of the healthcare professionals interviewed said that ‘We’ve been surprised about the people who use it. So that encourages me even more to discuss it, to talk about it’.

During the qualitative research, the verbatims relating to digital ethics (43.0%) were the most strongly evoked by the healthcare professionals interviewed, which seems to demonstrate that they are particularly aware of these aspects when new therapeutic paradigms arise.

In the two populations surveyed in the interviews, both expressed a favourable stance concerning the ethical issues that may be raised by the role of digital technology and gaming in healthcare, considering these practices to be perfectly acceptable.

On the other hand, as with many other aspects of this research, questioning about the role of e-health is more reserved or even distrustful among professionals surveyed by questionnaire (who make little or no use of Serious Games), with only 12.0% expressing a favourable opinion as to its development.

For Goupil, as expressed by some of the professionals interviewed, the growing societal popularity of video games raises concerns about possible negative effects: possible infantilisation, a break with the real environment, or excessive use tending toward addiction. ²⁰

Another obstacle to the deployment of Serious Games in healthcare, and one already well identified in public health beyond the problem of addiction mentioned above, is that the practice of screens comes into contradiction with prevention and health education messages aimed at combating sedentariness and promoting physical activity.

In fact, Gillet and Brun call for vigilance, as a video game will fit poorly into a care programme if it has no particular purpose. ²¹

With this in mind, Serious Game designers are gradually becoming aware that some players may be spending too much time in front of their screens. In DRAGO^©, for example, the game activity is limited to the time it takes to absorb the treatment, i.e. 2 min. The system will not allow the player to return to the game until the following day, thus protecting patients from excessive screen time.

So, despite these various controversies, more and more professionals, psychotherapists first, are recognising the potential of using video games in treatment, as indicated by Gillet and Leroux. ¹⁴

One of the professionals interviewed who uses DRAGO^© with his patients recognises that ‘it's a complementary tool for patients. And that's it, the objective is the patient and their compliance, it's about their health’.

As Golay et al. generally emphasise, the practitioner's involvement in the changes in practice expected from the patient depends on ‘the degree of conviction they have in the usefulness of the treatment or behavioral intervention’. ²² Thus, in the field of Serious Games studied in our research, a professional with whom we spoke insisted on this point, asserting that ‘you sell things better if you believe in them’.

To assess the acceptability of video-educational games among caregivers, we must also consider the ethical implications for the beneficiaries, namely the patients, albeit from a different perspective. Gillet and Brun take this direction, proposing ‘to establish partnerships with video game software designers with whom it would be possible to create such a project. ^{21 , p. 179}

For example, we could take the opportunity to draw on the community of patient experts and partners by utilising the work of the ‘Montreal model’, or even, dare we say it, by involving patient co-researchers who could conduct research in the field of Serious Games alongside us. ²³ In this way, to meet the expectations of ethics by design, they would have a legitimate place in problematising the issues surrounding video-educational practices in healthcare, in their capacity as ‘co-design’ researchers in the context of action research, for example.

Finally, the ethical approach specific to the introduction of digital media in health also rekindles, as some patients confided to us during interviews, interest in involving them in the design phase of these techno-pedagogical tools that are serious games. We can then draw inspiration from the Montreal Model, which introduces the notion of patient partners and resources that can influence the research and development of new media, especially as co-designers.

Implications

The intention to set up a multi-disciplinary team, coupled with the experiential knowledge of beneficiaries, would have the ambition of highlighting the most relevant expertise and needs for the design and adaptation of the programme according to the desired goal, particularly in the healthcare context where very often, only the opinion of one of the parties is taken into account.

A new generation of caregivers and nurses needs greater acculturation and training in the digital elements of healthcare to use them ethically and responsibly with the patients they care for.

Limitations

The COVID-19 crisis during the 3rd and 4th waves of 2021 in France complicated our efforts to collect responses to the questionnaires for our quantitative study, which we began sending them out in June 2021. Programme coordinators said that they had little or no time to devote to our quantitative study. Partial data collection (only 56 respondents out of a targeted panel of 120 coordinators) leads to several biases. A selection bias, as the people who responded were undoubtedly those who had an interest in this research theme around play in PE programmes. A sampling bias, as the sample of 56 out of 120 does not allow us to apply our conclusions to the entire population of coordinators.

In the qualitative study, apart from the difficulty of applying conclusions on the use of serious games in PE programmes given the small sample, we can also point to a possible analysis bias in that the classification of certain verbatims may be open to discussion regarding the interpretation that the researcher may have made from the remarks collected from the interviewees.

Conclusion

To conclude this work, we propose operational perspectives on our results while also identifying new lines of thought on the use of serious games ‘in society’, for example. Furthermore, we must consider that the e-patient can’t evolve in the field of e-health, of which serious games are an integral part, without being accompanied by a new generation of e-caregivers who embody the characteristics described by Fergusson and highlighted in our two studies.

In this quest to develop ever more advanced and effective edutainment videos, we need to encourage co-conception and co-design, for example, using ‘living labs’ where users and professionals work together to ensure the relevance of tools that meet real needs.

The intention would be to bring out digital expert patients as co-designers who could encourage the use of this therapeutic mediation among peers. In this perspective of user communities made up of resource patients, there are many avenues of research in the era of ‘patient-centred care’ and the recognition of a user who can be involved in the redesign of healthcare practices as a co-author rather than a simple actor playing a role assigned to them.

In the future, we will have to ethically question the advent of artificial intelligence and its impact on the patient experience, as well as the deployment of the metaverse in training, where the serious game will, without a doubt, find its place.