According to the inclusive criteria, a total of 10 studies were eligible to be included in the final review process. Figure 1 illustrates the flowchart of the systematic review process for the selection of the included studies. Tables 1 and 2 outline the key characteristics of these 10 studies.

The findings of the included studies have identified several social-related outcomes. Based on the different natures of the outcomes, they were categorized into three groups: emotion-related, behavior-related, and attitude-related.

Currently, the study from Agmon et al [38] has received the most attention from the scholarly community to date, with a total of 105 citations, 27 of which came from prestigious universities. The study published by Wollersheim et al [44] has also received a good amount of attention with a total of 63 citations, of which 8 were from prestigious universities. Most of the citations of these two studies came from articles published between 2014 and 2016, and mainly from papers published in the fields of Medicine and Computer Science. Since the studies from Xu et al [22] and Chao et al [21] were only recently published (they were published in December 2016 and January 2017 respectively), no citations could yet be found for these articles. Figure 2 shows the bibliometric outreach of the exergame studies.

Figure 3 gives an overview of the altmetric outreach of the exergame studies. The study with the highest Altmetric Attention Score was Theng et al with a score of 29 [43]. This high score was attributed to 3 mentions on news outlets in March 2017, naming this study as an example of how Nintendo’s motion control system has helped to make gaming accessible to new groups of users. Kahlbaugh et al had a very high PlumX usage count of 5300, and a high PlumX capture count of 498 [40]. These were mainly due to abstract views, clicks on outbound links, and exports or saves on EBSCO [47].

Agmon et al had a high count of 180 Mendeley readers, but since Altmetric.com does not include Mendeley readers in its score, this is not reflected as this study had a score of 3 [38]. Again, two recent studies [21,22] did not yet have any altmetrics, however, one tweet could already be found for the article from Chao et al [21], giving this article an Altmetric Attention Score of 0.5. Tweet counts were however low across all studies, with Milington [42] and Agmon et al [38] having the highest count of 5 tweets each.

While previous reviews have synthesized the psychosocial effects of exergames [26,28,29], the current review focused specifically on social benefits and extended to the ageing population. The systematic review shows an increasing interest in using exergames to improve the social well-being among older adults, with 9 out of 10 included studies published after the year 2010. Nevertheless, the small number of identified studies also calls for more investigation in this new research area. Several systematic reviews had similar findings in the area of exergames for mental health, with 12 and 9 studies found in the reviews published by Spek et al [48] and Li et al [28] respectively. Overall, the majority of exergame studies demonstrated promising results for enhanced social well-being in older adults, such as a reduction of loneliness, an increase in social connection, and positive attitudes towards others.

Although the social benefits of exergames are often discussed in the literature on exergames, there has been no particular review found on this topic. By summarizing the existing original studies, the findings from the current review showed that exergames could be an effective intervention for social improvements among older adults. The review supported the finding that exergames were able to reduce the loneliness level among older adults. The decrease in loneliness was perhaps not due to playing the exergame itself, but rather due to the increased interactions between the participants and other players. In a large sample survey study, Lee and Ishii-Kuntz [49] indicated that doing an activity with other people reduced loneliness among older adults. Furthermore, many of the included studies suggested that exergames provide opportunities for social interaction and connectedness with peers and family members [38,41,44]. In addition to loneliness, older adults often lack the motivation to engage in exercise. Chao et al indicated that these behavior-related social outcomes of exergames may increase exercise motivation and adherence among older adults [27]. A metric analysis has shown that the emotion-related and behavior-related outcomes of exergames received a lot of attention in the academic community as well as on social media.

Attitude-related social outcomes are a new finding which have not been reported in previously published exergame reviews (eg, those published by Chao et al [27] or Matallaoui et al [29]). Exergames were found to affect a sense of being with others [45] and positive attitudes towards others [43], similar to findings in recent research on persuasive video gaming [50,51]. An experiment from a study published by Alhabash and Wise [50] found that video game role-play led to a change in students’ explicit and implicit attitudes toward Palestinians and Israelis. In another study, students who played the persuasive social impact game had an increased positive attitude towards the homeless [51]. Results from this review further supports that active video games, such as exergames, have the potential to affect older adults’ attitudes towards other groups of people. Although attitude-related social outcomes currently have a low academic impact in the exergaming research area, they have begun to receive a certain amount of discussion on social media.

This review showed that that Nintendo Wii was the most frequently used exergaming platform in the included studies. This finding is supported by another review [27], which reported that the Nintendo Wii is one of the most accessible and popular exergames for seniors. Chao et al [27] further indicated the high attendance rates among older players in Wii exergames programs. Although the evidence may suggest Wii to be a suitable platform for older adults to perform exergames, there have been no studies conducted which investigate the difference in effect between exergaming using a Wii and other platforms, such as the Microsoft Kinect consoles. More studies are needed to compare the effects of different exergaming platforms. Sport games were identified to be the favored type of games used in the included studies, and bowling was tested in 3 studies [40,42,45]. According to the American College of Sports Medicine [52], older adults are encouraged to perform physical activities that maintain or increase their balance and flexibility through slow movements. The bowling games exergames allow for slow movements which match the typical physical activities recommended for older adults. Additionally, bowling is a self-paced exercise in which older adults could take the time they needed to perform the moves [27]. Crucially, all the studies applied commercial exergames available on the market and none of the interventions were integrated with social theories. This highlights the need to combine social-related theories with exergame programs in order to optimize the effectiveness of social improvements.

Although most of studies targeted healthy older adults, two studies examined the social effects on older adults with physical disabilities [38,44]. Physical disability, particularly low mobility, has often been identified as a risk factor for social isolation among older adults [53]. Low mobility prevents seniors from participating in active social engagement and connection, leading to common social disorders such as loneliness. The two included studies with older adult participants with physical disabilities showed that playing exergames improved their social well-being by increasing social bonding with their peers and grandchildren. However, the physical limitations of this group of older adults may have led to some difficulties in interacting with the exergames. They may have been exposed to frustrating experiences or even accidents if the exergames were performed without proper human or technical assistance. As a result, health care providers and exergame designers should take this into consideration when implementing future social exergame programs for older adults with disabilities. In terms of cultural background, the studies were conducted in both Western and Asian contexts. It appears that exergames might have social effects on older adults with various cultural backgrounds, but knowledge is lacking on whether the social outcomes would be affected by cultural factors. Future studies are recommended to compare the social effects between different cultural contexts.

The study designs included in this study varied in rigor, with 6 studies applying a within-group design, and 4 studies applying between-group design by comparing exergames with a control condition. Although the majority of studies showed promising results for the use of exergames for social enhancement, the conclusions need to be interpreted with caution due to the limited number of randomized controlled trials. The included studies were either predominantly small pilot trials or feasibility studies; they lacked the adequate sample sizes needed for a powered efficacy trial. Meanwhile, half of the studies used qualitative methods for data collection. Without validated quantitative instruments, their findings do not have the capacity to detect significant changes in social outcomes.

There are some limitations in the review. Due to the limited number of identified studies, the systematic review included articles with both qualitative and quantitative analyses. The quality assessment of the included studies was difficult to conduct, and it was not possible to produce mean effect sizes via a meta-analysis. However, the review was broad in scope and included a diversity of study conditions and social outcome measures. Another limitation is that the key conclusions should be interpreted with caution due to the small number of included studies. Furthermore, relevant studies may have been unintentionally excluded because of the specific keywords used and the databases selected. Lastly, a publication bias, particularly language bias, might have occurred because we restricted the search to English language publications.