Serious game (SG) educational tools that provide constructive learning with imperative goals for behavior change [1] are increasingly being applied with children with chronic diseases. Training children to self-care for their chronic diseases is highly challenging due to insufficient cognition [2], low attendance [3], complicated treatments [4], and nonadherence to treatments [5]. A properly designed SG educational tool can allow children with chronic diseases to enjoy learning how to overcome real-life challenges [6]. A fully fledged game design provides a safe and controlled environment to experience and practice self-management skills [7]. Holtz et al [8] reported that SG education had positive impacts on self-efficacy, adherence, and knowledge, which drove improvements in behavior and health outcomes over time. Directing the design and application of SGs as an educational intervention to positively support children with chronic diseases could help improve therapeutic outcomes [9].

Behavioral sciences offer insights into how to design effective SG educational tools for children with chronic diseases to achieve the dual goals of internal enjoyment and confidence while promoting their self-care abilities. To understand changes in children’s behaviors, basic principles and theories of learning, behavior, and mindset should be identified. The most commonly used theories explaining behavior change include social cognitive theory [10], self-determination theory (SDT) [11], and the mindset theory [12]. Social cognitive theory defines how behavior change can be achieved depending on personal factors, including cognition, capability, self-control, experiences, and expectations, and environmental factors, including emulation, reinforcement, and observation [10]. SDT addresses motivation and influences children to put themselves in situations in which they are exposed to SG education [13]. A growth mindset enhances greater resilience and positivity than a fixed mindset when dealing with challenges and failures [12]. Children with chronic diseases require continuous, specific self-management tasks to achieve levels of their mindset and cognitive development [12]. Incorporating behavioral theories and instructional learning into game mechanics, including practice tasks and challenges, can facilitate the changing process of a growth mindset and enhance motivation [14].

SG educational tools require a sophisticated design to avoid several potential negative consequences for children. The World Health Organization has articulated increased screen media use as a major concern due to the risk of addictive behaviors [15]. Higher gaming behavior is associated with higher levels of social, health, and behavioral problems in children and adolescents [16,17]. Playing SG interventions can promote behavior changes; however, uncontrolled excessive gaming may lead to gaming disorders [18] when games are used above the level of a child’s age and mindset [19]. It has also been reported that a large proportion of electronic games may have violent content such as fighting, hitting, destroying, and killing [19], which increases the risk of aggressive behaviors in children. Inappropriate visual designs and game elements may distract from the educational purposes [18].

An SG framework that promotes positive behavior change in children is specifically needed because children’s capabilities to respond to emotions and act when encountering difficulties differ from those of adults. Frameworks have been established for developing SG prototypes for adults [20,21]; however, only limited attention has been paid to creating a well-established theoretical SG framework for children. Children are more vulnerable to influences of digital games during their cognitive, social, and emotional development stages [2]. A stepwise SG framework is warranted to guide researchers in designing and evaluating SG educational tools for children with chronic diseases to maximize advantages and avoid unintended effects. This requires pivotal attention by researchers to creatively develop and design appropriate SG educational tools for children that balance the cornerstones of learning and playing.

The study purpose was to offer an updated scoping review of SG education focused on delivering self-management activities and promoting behavior change for children with chronic diseases. It provided a scope of understanding of the development and evaluation of SG educational tools and developed a systematic methodological SG-based framework for children with chronic diseases. The intended SG framework was designed according to the methodology of scoping reviews Levac et al [22] and the context-mechanism-output (CMO) approach [23]. The specific aims were to create two bases: (1) to build a knowledge base that covers all the resources required to design and develop an SG framework and (2) to construct an analytical base by integrating behavioral theories and game elements from the knowledge base to design and visualize the intended SG framework through the CMO approach. The findings of this review can benefit researchers developing and evaluating SG-based learning educational tools for children with chronic diseases.

Figure 1 [24-26] describes the process of developing an SG framework for children with chronic diseases using knowledge and analytical bases. This study followed the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) [27]. For the knowledge base, relevant studies on developing an SG framework and evaluation of SG educational tools for children with chronic diseases were searched and collated throughout 5 stages to cover all the SG resources required. The analytical base used the CMO approach and game taxonomy to build a theory-based foundation for the proposed SG framework. Relevant behavioral theories and essential game elements from relevant studies were appropriately divided into fragments, compared, and assembled to create a visualization of the proposed SG framework. Discussions were conducted throughout the study to resolve any discrepancies among researchers.

There were five stages for building the knowledge base: (1) refining the initial question, (2) identifying relevant studies, (3) selecting relevant studies, (4) charting the information, and (5) collating the results [22].

This scoping review proposed a digital framework to design SG educational tools for children with chronic diseases. The SG framework consists of 3 main strategies to guide the planning, design and development, and implementation of SG educational tools to allow children to practice self-management skills for their chronic condition. Major considerations of how each step is conceptualized, including a theory-driven foundation, contents of health education, joyful reinforcement, and use of technology, were discussed. The game elements and game structure should engage children’s attention and support them in performing gamified self-management tasks, changing their mindset, and increasing their self-care abilities.

Implementation of SG educational tools for children with chronic diseases has been demonstrated in several previous works [8,9,58], specifically concerning health education [55,64], physical activities [65,66], and self-management [9,67,68]; however, none of them offer a theory-driven framework for behavior change. It has been suggested that researchers articulate a scientific framework for the design of SG educational tools [65]. Although behavioral and self-management interventions can be delivered to children from 5 to 18 years of age [67,68], the health educational content is not applicable to the entire age range. Educational materials for children should be supplemented with communication skills, whereas activities for adolescents should focus on self-monitoring and problem-solving [69]. Multidisciplinary teamwork from conception to marketing is strongly emphasized [64], which was accommodated in this framework throughout the proposed phases.

As game-based interventions are continually growing, researchers are considering developing SG educational tools for children, but questions about how to get started have been raised. Developing an SG educational tool is expensive; therefore, several aspects should be carefully considered before initiating development of SG educational tools, including securing funding and building a collaborative team [69]. Developing SG educational tools for children with chronic diseases differs from entertainment-only video games due to their unique components of behavioral theories and learning materials to boost self-management practices and promote positive behavior changes. For example, children with asthma may need knowledge about preventing asthma triggers and adhering to medication, whereas children with cystic fibrosis may need more physical rehabilitation activities than children with other chronic respiratory diseases. Some of them may need specific, scheduled physical activities, whereas others may need the efforts of encouragement or psychological support and companionship. That is why the game design should be able to address those needs.

Establishing a solid team, which involves experienced game developers or game companies, should be noted. Once members are chosen, clear ground responsibilities and expectations regarding the prototype design should be established. The health care professional team can develop appropriate health learning contents and discuss those materials with the game developer team to analyze and resolve potential problems before programming and prototyping. As there is no reimbursement for SG use as a medical treatment [69], acquiring available funding and resources should be prioritized.

Developing appropriate SG educational tools for the specific needs of children with chronic diseases remains a challenge due to the huge investment from ideas to implementation. As the market for SG-based interventions expands across health conditions, there is a trend for SG education to be included as a supportive intervention rather than merely as pure entertainment [23].

On the basis of our heterogeneous results, the procedure through which SG educational tools deliver content might not be the only key contributor to achieve the targeted goals because the intervention should be focused not only on the learning materials but also on the intertwined mechanism of game elements and the elements of behavioral theory. In the context of game-based learning, self-management practices will be correctly performed if users are enjoying themselves, which means having the propensity to engage, blend, and learn. From this perspective, we raised several considerations on the potential of game elements to enhance intrinsic motivation, including how much autonomy (videos, animations or cartoons, choices, and difficulty adjustments of the challenges) must be given to children during play, how can relatedness (narrative or storyline, avatars, characters, and tailored messages) between children and the game be built into SG educational tools, and how can a child’s level of competence be defined to challenge them.

Several critical points in each step were pointed out for game designers to avoid failure. First, there can be failure to define suitable educative materials and targeted behaviors for children with specific difficulties. Second, one can fail to generate a dynamic between players and the game while, at the same time, players have to obtain new learning from the SG educational tools. Game levels were revealed to engage players with a positive learning effect; however, this should be in line with the player’s skills and cognitive development. A high-challenge game with low-skill, fixed-mindset users may induce frustration; meanwhile, a low-challenge game for users with high skills and a growth mindset may generate feelings of triviality [6]. Given rapid trends in digital technology, SG prototypes should be continually adjusted to prevent them from becoming hackneyed by the time the evaluation trial is finished.

Safety aspects of SG educational tools should be of general concern because these tools are considered a persuasive technology for changing human behaviors. Game-based interventions appear to be most effective in users aged <18 years [23]; nevertheless, children and adolescents vary in their ability to master a mission. Children may feel engaged with customizable avatars, but some of these may contain violent characters [19]. Game designers should ensure that the SG intervention is not dangerous or does not increase risks to children, such as by promoting sedentary or aggressive behaviors [47] or increasing the risk of physical injuries due to practicing skills. Several harmful risks are associated with sleep disorders and internet gaming disorders, such as anxiety, unsuccessful attempts at control, and jeopardizing environments [19,70].

The American Academy of Pediatrics has stated concerns about the influence of digital media on the health and cognitive development of children at the ages of 0 to 5 years, and it has proposed limiting screen use to 1 hour per day for children aged 2 to 5 years [71]. It is also recommended to avoid screen time 1 to 2 hours before bedtime for children and adolescents. In 2020, the American Academy of Ophthalmology recommended the 20-20-20 rule, described as a 20-second break every 20 minutes by looking 20 feet away to prevent and relieve digital eyestrain [72].

The COVID-19 pandemic intensified gaming behaviors among children, especially during school closures, and this garnered the concern of policy makers and health care professionals [15]. Sedentary time in children with chronic diseases might have increased [73] as parents were not well prepared for it due to their attention being focused on social and economic burdens caused by the pandemic. Several SG educational tools were developed during the pandemic to stimulate in-home physical rehabilitation [74,75] and improve anxiety and mood disorders in adolescents [76], and those positive behavioral outcomes should be maintained. Even though the pandemic situation has improved, some parents are continuing to work remotely while simultaneously caring for children, leading to obstacles to maintaining children’s learning, especially in households of a low socioeconomic status [77].

Educational, game-based interventions for the post–COVID-19 era should be integrated with appropriate recommendations for their use. Individualized family media use plans are strongly recommended; hence, parental control is central when exposing children to digital media [70]. It is considered important for parents to accompany their children during screen use to foster an effective learning process by understanding the game structure, supporting children in controlling playing times, and monitoring their activities. Instead of giving punishment as a disciplinary matter, by playing together, parents can understand more about SG educational tools and how they can facilitate parent-child interactions. As parents become familiar with their children’s games, they will be able to encourage their children to achieve the intended outcomes and avoid addictive behaviors [78].

This scoping review has a few limitations. This framework was developed based on a review of the most relevant SG educational tools in several RCTs and SG framework studies instead of a direct participatory approach involving health care professionals and children. When comparing the effects of SG educational tools, most RCTs (9/16, 56%) only captured improvements in humanistic outcomes, such as knowledge [57] and enjoyment. Studies on improving clinical outcomes were limited, and none provided economic outcome evaluations. This is in line with the findings of a previous review that presented a lack of clinical evidence of the implementation of SG educational tools in children with neurodevelopmental disorders [79]. Several studies (5/16, 31%) evaluated changes in knowledge over a relatively short duration on beneficial effects on behaviors. Exploration is still needed as to which game elements can have higher effects on self-management and behavior changes. Moreover, issues of maintenance of intended behaviors after exposure to SG interventions should be carefully addressed. With the limitations of the available literature, this framework should be tested in further studies.

This framework provides a theory-driven step-by-step approach to help health educators, clinicians, game developers, and policy makers more efficiently develop SG educational tools for children with chronic diseases. Understanding how to integrate the power of SG educational tools offers significant promise for promoting health behavior changes. Only 4% of the top-rated health apps apply the concepts of gamification [80], indicating that the opportunity to develop high-quality SG educational tools for children with chronic diseases is still wide open. Further research should explore the needs for culture-specific SG educational tools and investigate the mediators of behavior change.

A framework of SG-based educational tools promoting self-management activities and behavior changes in children with chronic diseases was developed by incorporating behavioral principles and mechanisms of SGs. It expedites the translation of fundamental behavioral theories and game elements into a scaled-up industrial level in which digital-based game interventions are being created to enhance children’s participation and motivation. The effectiveness of SG educational tools in achieving targeted behaviors depends on key designs and elements of how they address problems and mindsets of children with difficulties. Underpinning appropriate behavioral theories, learning materials, game elements, esthetics, and technology should be considered in all phases of research. The design, development, and evaluation of SG educational tools for children with chronic diseases need to be broadly explored with the support of a well-validated game-based framework and the deployment of advanced technologies.