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The Role of Transfer in Designing Games and Simulations for Health: Systematic Review

The Role of Transfer in Designing Games and Simulations for Health: Systematic Review Background: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. Objective: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. Methods: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. Results: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. Conclusions: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health. http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al (JMIR Serious Games 2017;5(4):e23) doi: 10.2196/games.7880 KEYWORDS transfer; computer simulation; video games; serious games; games for health; fidelity; abstract learning; immersion; metaphor ideas, concepts, and knowledge is juxtaposed against some new Introduction problem or situation. Figural transfer uses existing world knowledge to think or learn about a particular issue. Clear Games and simulations hold the promise of being learning examples of the usage of figural transfer can be found in figural machines [1] because of the ability to build in learning language such as metaphor or simile. Transfer occurs because principles. They can harvest unique features to motivate, trigger, of a successful memory search triggered by a figural learning and facilitate learning processes, opening up new possibilities context, assisting in understanding the transfer context. In some for designing learning for health care professionals and patients. situations, the second class of transfer requires a debrief to With the positive effects on learner motivation and learning explicate experiences and connections made. This class outcomes in mind [2-4], educators must think of new ways to encompasses high-road transfer [8]. make serious subject matter suitable for game play. A transformation of current forms and beliefs on learning may be Optimizing Transfer Conditions needed to make a more natural connection between the serious Games and simulations for health abundantly build on the and the game. principles of first-class literal transfer, but the adoption of second-class transfer types has proven to be scarce. In contrast Transfer to commercial off-the-shelf games, in serious game design, the A possible way to make such a connection can be found in usage of mindful abstractions and metaphorical representations thinking in terms of transfer. Although there are a wide variety is not common practice, despite the fact that it forms a natural of viewpoints and theoretical frameworks regarding transfer in fit with the second class of transfer theories. Earlier research the literature, transfer is seldom a starting point in developing has shown [9] that transfer is hard to establish and that the serious games. Studies on serious games [5,6] have identified design of education should be key to optimize the conditions design principles for flow and immersion as major contributors under which transfer can occur. Although transfer of learning to the gaming experience and presumably beneficial for learning. is a well-established concept in the educational domain, the However, the way games facilitate learning is often regarded extent to which transfer may guide the development of game-like as a black box. interventions in health has rarely been explored. This may be From an educational and technological perspective, transfer is especially true for second-class transfer types: optimizing a a key concept in learning theory and education [7]. The purpose game-like intervention design to accommodate the principles of (medical) education is transfer: the application of skills, of figural transfer. knowledge, or attitudes that were or learned in one situation to Fidelity Types another context. The concept of transfer is widely recognized, but ample evidence shows that transfer from learning The most visible examples of the designers’ uptake of transfer experiences often does not occur. The prospects and conditions in game-like interventions are apparent in the application of of transfer are crucial educational issues. fidelity types: the way fidelity is used in a game-like intervention or simulation demonstrates the expected road to transfer. A If we regard games and simulations as learning contexts that dominant perspective on fidelity in serious game design is that can be designed and specifically tailored for (at least a type of) high fidelity is conditional for learning and transfer, transfer, it seems legitimate to focus attention on how transfer corresponding with the first class of transfer. has been taken into account in designing game-like health interventions. According to Alexander [10], fidelity has dimensions beyond the visual design—physical, functional, and psychological Two Classes of Transfer fidelity [10]. A game or simulation therefore can be low in Transfer theory determines two classes of transfer, both physical and functional fidelity but can be high in psychological encompassing a variety of transfer types [8]. The first class fidelity. It is also possible that a simulation by design is high takes the position that the more the learning context resembles in functional and physical fidelity but lacks psychological the target context, the more likely transfer is to occur. The fidelity. In the literature, the degree of fidelity often refers to conditions for transfer are met when the learning experience physical fidelity alone. Therefore, in this study, cases of shares common stimulus properties with the target context. This cognizant design decisions toward lower fidelity types may means that when game or simulation environments try to prove interesting, as they might include second class of transfer represent the real world as literal as possible, they aim for types. first-class transfer. The first class of transfer encompasses Aim instances of literal, specific, nonspecific, vertical, lateral and low-road transfer. Focusing on the design of game-like interventions for health and health care, this study aimed to (1) find out whether the The second class of transfer theories may be harder to grasp. second class of transfer is recognized or present as a road for According to Royer [7], figural transfer (belonging to the second transfer in game-like interventions, (2) review the application transfer class) involves situations where a known complex of http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al of the second class of transfer type in designing game-like (DK and GT) independently reviewed the title and abstract for interventions, and (3) assess studies that include second-class relevance against the formulated inclusion/exclusion criteria. transfer types reporting transfer outcomes. Papers were only included on the agreement of both DK and GT; a third reviewer (BW) resolved any disagreements. The Methods degree of agreement was calculated by a kappa statistic. Full-text papers were retrieved after this step. Both reviewers (DK and Databases and Search Strategy GT) reviewed each included full-text article. Disagreements in this stage about inclusion were discussed until an agreement In total, 6 databases were searched for potentially relevant was reached. Finally, to check whether any eligible paper had abstracts: PubMed, Scopus, ERIC, PsycINFO, Information been overlooked during the review process, our check included Science & Technology Abstracts, and EMBASE. These studies’ references for additional papers. databases covered a wide range of published research from the field of health and social care. A combination of search terms Results were used to identify relevant papers under the following categories: (video games OR game OR games OR gaming OR Search Results computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior), Our initial search yielded 19,564 records. After removing all where * represents a wildcard to allow for alternative suffixes. duplicates (5226), 14,338 records remained for title and abstract Search strategies were customized for each database. Searches screening, leaving 26 potential suitable papers for full-text included papers published between database inception and assessment. We used Cohen kappa to assess the interrater October 2016. The search was conducted between October 3, reliability of paper inclusion. We found good agreement between 2016 and October 21, 2016. the 2 reviewers ( =.78, 95% CI 0.655-0.883). A total of 11 papers were excluded at full-text screening for various reasons. Study Selection and Inclusion and Exclusion Criteria The total number of included papers is therefore 15. See Figure We included studies that discussed either digital simulations or 1 for a flowchart of the results of the initial searches, screening, games designed for health providers or on health topics. We and selection processes. Table 1 shows an overview of included included only original reports or papers that (1) addressed the studies. design of a serious game or digital simulation; (2) involved an Second-Class Transfer in Game-like Interventions for empirical study, either piloting a game-like intervention or Health and Health Care validating the aspired effects; or (3) otherwise focused on a newly developed game or simulation, created specifically for We studied the full-text papers on how transfer was regarded the study in question. Papers were included when title and and described in serious games or simulations. All 15 studies abstract were considered to be at least indicative of the presence mentioned transfer in the initial concept of the design and of second class of transfer. Papers meeting any of the above described forthcoming consequences, mostly expressed in terms criteria were selected for full-text screening. of fidelity. Although we assumed that the second class of transfer would be identified in varying ways, we found several The following exclusion criteria were used for full-text other reasons to use abstract concepts and low fidelity. In the screening: (1) non–peer-reviewed papers such as abstracts, following section, we have categorized the papers, based on conference posters, or trade journals; (2) full text not available; similarities in conjoining characteristics. (3) language other than English and Dutch; (4) papers that referred to transfer as transfer of data or disease; (5) not Reducing Cognitive Load sufficient information; (6) repurposed commercial off-the-shelf Out of the selected studies, 3 [12,17,24] questioned the necessity games; (7) low fidelity as a means to reduce production costs; of high fidelity to achieve transfer. The basic theory is that (8) nondigital games and simulations; and (9) papers using high high-immersive gaming environments decrease learning fidelity solely as a description of the artifact rather than as a outcomes. The studies argue that reducing complexity prevents founded design decision. Also, in our screening, we considered extraneous cognitive load. In these situations, low fidelity and the transfer class in relation to the fidelity type: high fidelity as deliberate abstractions are aiming—by design—for managing a means for achieving literal transfer led to exclusion. the trainees’ working memory capacity. This is grounded in the cognitive load theory [27]. Screening Process After removing the duplicates, the papers were screened based on title and abstract using Rayyan [11]. In total, 2 reviewers http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al Figure 1. Flowchart of the results of the initial searches, screening, and selection processes. the physical fidelity is low or even nonexistent. The same goes Motor and Spatial Skills Training in Metaphorical for iLift, where the lifting and transfer techniques maintain a Contexts mimetic correspondence to real-world tasks, although the game In our initial selection process, papers that presented literal metaphor encompasses physical and psychological fidelity: transfer axiomatically were excluded. Out of the included catching sheep or helping little robots escape from a mine shows studies, 3 [13-15] were regarded more closely because they use no medical content. These games use metaphorical contexts to metaphorical game environments, possibly indicating the host meaningful play for training skills. presence of second-class transfer types. These game-like Situational Games interventions were designed for skills training (ie, laparoscopic Pervasive game design provides a different approach toward surgery, spatial cognition skills, lifting and transfer techniques). transfer. Of the papers, 2 [19,25] advocate pervasive games, In these scenarios, emphasis is placed on a high degree of where fusing the virtual world with the real-world positions validated functional fidelity, aimed at faithfully mimicking the them in between the first and second class of transfer. One could desired skills. These games facilitate first-class low-road transfer argue that situational games seek to provide what we like to by automating motor and spatial skills, hosted by low physical call blended transfer by emphasizing context awareness in a fidelity metaphors. true-to-life experience on the one hand and on the other hand For example, the game Underground carefully mimics basic adding virtual game elements. Both studies conclude by laparoscopic skills, including custom-made laparoscopic tool accentuating the promise of pervasive game play for transfer shells. The movements in the game are carefully calibrated to of knowledge [25] and transfer of behavior [19] but provide no faithfully represent actual laparoscopic skills. These skills are implications for the design of virtual elements for future acquired in a literal way. It is noteworthy that the tools and pervasive games. movements share high functional fidelity properties, whereas http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al Table 1. Details of included papers. Author Title Transfer Fidelity and transfer Year class rationale Dankbaar, Alsma, Jansen, Van Merrienboer, An experimental study on the effects of a simulation game First Low fidelity, reduc- 2016 Van Saase, and Schuit [12] on students’ clinical cognitive skills and motivation ing cognitive load Kuipers, Wartena, Dijkstra, Terlouw, van T iLift: A health behavior change support system for lifting First Low-road transfer, 2016 Veer, Van Dijk, Prins, and Pierie [13] and transfer techniques to prevent lower-back injuries in skill automatization, healthcare metaphorical Jalink, Gores, Heineman, Pierie, and Ten Face validity of a Wii U video game for training basic la- First Low-road transfer, 2015 Cate Hoedemaker [14] paroscopic skills skill automatization, metaphorical Connors, Chrastil, Sanchez, and Merabet [15] Action video game play and transfer of navigation and First Low-road transfer, 2014 spatial cognition skills in adolescents who are blind spatial recognition Rosenberg, Baughman, and Bailenson [16] Virtual superheroes: using superpowers in virtual reality Second Figural, metaphori- 2013 to encourage prosocial behavior cal Schrader and Bastiaens [17] The influence of virtual presence: effects on experienced First Low fidelity, reduc- 2012 cognitive load and learning outcomes in educational com- ing cognitive load puter games De Freitas and Dunwell [18] Understanding the representational dimension of learning: Second Figural, metaphori- 2012 the implications of interactivity, immersion and fidelity on cal the development of serious games Knoll and Moar [19] The space of digital health games Blended Locative, situational 2012 Rooney [20] A theoretical framework for serious game design: exploring Blended, Abstraction, situa- 2012 pedagogy, play, and fidelity and their implications for the both tional design process Toups, Kerne, and Hamilton [21] The team coordination game: zero-fidelity simulation ab- Second Nonmimetic, abstrac- 2011 stracted from fire emergency response practice tion Hochmitz and Yuviler-Gavish [22] Physical fidelity versus cognitive fidelity training in proce- First Cognitive fidelity, 2011 dural skills acquisition skill acquisition Stone [23] The (human) science of medical virtual learning environ- First Cost reduction 2011 ments Wood, Beckmann, and Birney [24] Simulations, learning, and real world capabilities First Low fidelity, execu- 2009 tion skills, reducing cognitive load Markovic, Petrovic, Kittl, and Edegger [25] Pervasive learning games: a comparative study First Situational 2007 Alessi [26] Fidelity in the design of instructional simulations Both Varying fidelity un- 1988 der conditions Refers to the aspired transfer type described or sought after with the game-like intervention. this illness are metaphorical rather than literal [18]. The game The Application of the Second Class of Transfer play shows little physical or functional fidelity to real-world Of the studies, 3 describe game designs applying the second processes, and measured effects can only be explained in terms class of transfer, and one study [16] describes a video game to of changed mental conceptions, referring to an instance of stimulate prosocial behavior. It examines how playing an avatar second-class (figural) transfer. However, the design with superhero abilities increases prosocial behavior in the real considerations were not elucidated either in this study. world . The study indicates that the in-game superhero metaphor The third study [21] describes the Team Coordination Game, leads to greater helping behavior outside the game. The game a simulation to practice team coordination during fire emergency therefore builds on the second class of transfer, although the response situations. The Team Coordination Game is a study does not explicate design considerations regarding simulation that offers a game environment that requires the use transfer. of effective team communication skills, without concrete De Freitas et al [18] describe Re-Mission, a video game designed elements of the mimicked environment. This nonmimetic game for young people with cancer to encourage them to take their offers a two-dimensional environment that shows low-fidelity medication. The game metaphor, where the player has to combat to real-life fire emergency environments. In the game, 3 avatars cancer cells, seeks to reinforce behavioral change toward in the role of seeker are searching for specific goals, while medication use. Re-Mission fits the figural transfer class as the avoiding threats. A player in the role of coordinator directs the in-game representation of the illness and the power to conquer http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al seekers based on observing the environment from a different able to restore learned behaviors in communication and stress angle. Limited game time creates a certain amount of stress and management in an alternative environment but also capable of pushes the players to work effectively. The study suggests that remixing and repurposing them. The article—in several players were able to restore learned behaviors in communication substudies—describes a variety of positive effects on and stress management in an alternative environment, remixing communication and organizational skills, carried over from the and repurposing them, suggesting a transfer effect. game environment to live training. Although the game offers a so-called zero-fidelity physical Discussion environment, it uses communication instruments that have the same characteristics as real-world radios. This implies at least To our knowledge, this is the first review to explore the aspired a modicum of functional fidelity. Furthermore, the game is transfer in designing game-like interventions in health. We tried based on communication strategies and stress levels from to find and describe examples of the application of second-class real-world fire emergency situations, which suggests some level transfer types by answering 3 research questions, discussed of psychological fidelity. The Team Coordination Game below. simulation study offers clear design implications, labeling and Design for Transfer in Health elaborating on abstraction from reality as a guiding principle, which differs from the other studies included. We tried to determine whether the second class of transfer types is recognized or present as a road for transfer in game-like Psychological Fidelity interventions for health. In our initial search, we expected to In total, 7 studies [12,18,20-23,26] mention psychological find studies in which thinking about a desired transfer outcome fidelity as, if not the most, an important design parameter in would form a guiding principle in the design of game-like serious games and simulations. In addition, these studies claim interventions. Moreover, clearer distinctions in suitable transfer that representing the real world as literal as possible is less types and established examples of figural transfer (or forms important for learning. The definition of psychological fidelity thereof) were anticipated. Both assumptions were proven wrong, in these studies varies slightly [22], but all studies mention the and we had to broaden our inclusion criteria to capture studies abstraction of certain real-world concepts and a process of regarding design considerations, including transfer. recontextualization. Of the studies considered, one [21] added Our results show that transfer is mainly mentioned as a desired suspension of disbelief as an important characteristic of outcome, not as a guide in the design process. The appearance psychological fidelity: one’s temporary allowance to believe of most included game-like artifacts can be explained by the something that is not true. Despite the fact that the second class designer’s fidelity approach. As obvious as this seems, this of transfer is not explicitly stated in those studies, they implicitly fidelity approach also expresses assumptions about the way the confirm the second class of transfer as a promising concept in transfer is expected to take place. As described before, we found serious game design for learning. several reasons for choosing low fidelity over high fidelity and Effects of Design for Figural Transfer vice versa. As none of the studies were designed for achieving The virtual superhero study [16] only reported a transfer effect transfer via a specific type or class of transfer, the question just after playing the game. The study did not cover long-term arises why the design for transfer perspective has received no effects but showed in an experimental 2×2 design that attention. participants (n=60) in the flying superhero condition displayed By nature, design-centered research focuses more on the design significantly increased prosocial behavior compared with itself and puts less emphasis on the eventual aspired outcome. participants who were in the helicopter condition. The study Although it is too strong to state that the design itself of mentions several possibilities for the differences found between game-like interventions in health is not taken into account in the testing conditions: different experiences of immersiveness, thinking about desirable transfer outcomes, our search results involvement versus observation discrepancy, and primed show that describing the game-like interventions in terms of concepts and stereotypes related to superheroes in general. transfer variables is uncommon. One might argue that the design The study reporting on Re-Mission [18] did not elaborate on of a drug is essential to its workings and that the same principle the efficacy of the intervention. Another study [28] focused in applies for game-like interventions. The design of the artifacts greater detail on the transfer effects of Re-Mission and found as exercised in the virtual superhero game [16], Re-Mission that playing the game increased young cancer patients’ feelings [18], and the Team Coordination Game simulation [21] is of self-efficacy or beliefs in their own ability to control and intentional and differs strongly from game-like interventions cope with the disease. A randomized trial with 197 intervention as Underground [14] or Digital Economy [25]. These differences group participants showed a significant increase in arise from a broad and ill-defined range of variables but cancer-related knowledge and self-efficacy scores and offers inevitably reveal the designer’s intent with regard to how the empirical support for the efficacy of a game-like intervention intervention should carry over the effect. Herein lies the in improving behavioral outcomes in adolescents and young rationale for design for transfer. adults with cancer. The Presence of the Second Class of Transfer Using a mixed-method approach, the Team Coordination Game As described, we searched for particular examples of aspired [21] also reported some transfer effect, in addition to an in-game transfer in the second class of transfer types, and found none. effect (n=64). The study suggested that players were not only In 3 studies, the reported effects can only be explained via the http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al road of a second-class transfer type but are described in other of this, we anticipated more conscious and elucidated design terminology. Most studies report about psychological fidelity examples. [12,18,20-23,26], virtual presence [17], and immersion [16,18] Limitations as important conditions for desired outcome. Although this review is based on an extensive search of a large An interesting observation is that the included papers show that number of health and computer science databases, we hardly functional and physical fidelity can be high or low for varying, found any studies of second-class transfer types in game-like well-founded reasons and that psychological fidelity is regarded interventions for health. Studies tend to focus on the as a variable that preferably should be high. The Team effectiveness of game-like interventions and the research Coordination Game simulation [21] adopts a different position methods used, not on design factors that lead or contribute to in stating that the gaming artifact has zero psychological fidelity. measured effects. Due to the very few direct hits, we focused However, the way deliberate abstractions are described and how on the subconscious application of the second class of transfer these resulted in the design of the game itself strongly suggests types by thoroughly screening titles and abstracts. The papers second-class transfer. that were included were subject to interpretation, discussion, and consensus of the reviewers (DK, GT, and BW). To The 3 studies we identified exemplifying an instance of figural counteract subjectivity, papers were independently reviewed transfer introduced a metaphorical approach with by 2 reviewers (DK and GT) and were only included on recontextualized fidelity types. These game metaphors seem to consensus from both reviewers. Remaining conflicts between address and replace both high functional and physical needs as the reviewers were resolved by the third reviewer (BW). well as promote immersion. At this point, we hypothesize that figural transfer builds upon immersion or virtual presence and Conclusions subsequent suspension of disbelief [21]. In more abstract Studies about serious games and game-like interventions for game-like interventions, metaphors provide a storyline, a health do not provide a conscious rationale for designing the context, and a reason for engaging in play. In this way, artifacts for optimizing transfer conditions. We did not find any psychological fidelity is reappointed by the concept of example of a game-like intervention that was the result of a suspension of disbelief, instigated by the metaphor itself. cognizant design process focusing on transfer outcomes. In Second-Class Transfer Outcomes general, we found that definitions of low and high fidelity form the strongest influencers on the design of artifacts, mostly As the literature on transfer has consistently confirmed, exemplified in visual quality or a true-to-life approach. High long-term transfer effects are hard to measure. This might be fidelity was aspired to for its first class, literal transfer aspects particularly the case for the second class of transfer. All 3 without exception. None of the studies explained second class examples report transfer effects, albeit short term and only of transfer or instances thereof, although in 3 instances, implicit vaguely proven. As second-class transfer is the result of the design choices suggested otherwise. It is notable that studies effects interventions trigger in one’s head, the transfer outcomes on game-like interventions for health do not elucidate the design are individual, often nonlinear, and even unpredictable if the choices made, as they bridge the designer’s intent and the second class is not implemented with due care. Precisely because aspired transfer outcome. 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The team coordination game: zero-fidelity simulation abstracted from fire emergency response practice. ACM Trans Comput Hum Interact 2011 Dec 01;18(4):1-37. [doi: 10.1145/2063231.2063237] 22. Hochmitz I, Yuviler-Gavish N. Physical fidelity versus cognitive fidelity training in procedural skills acquisition. Hum Factors 2011 Oct;53(5):489-501. [doi: 10.1177/0018720811412777] [Medline: 22046722] 23. Stone RJ. The (human) science of medical virtual learning environments. Philos Trans R Soc Lond B Biol Sci 2011 Jan 27;366(1562):276-285 [FREE Full text] [doi: 10.1098/rstb.2010.0209] [Medline: 21149363] 24. Wood RE, Beckmann JF, Birney DP. Simulations, learning and real world capabilities. Educ Train 2009 Jun 26;51(5/6):491-510. [doi: 10.1108/00400910910987273] 25. Marković F, Petrovic O, Kittl C, Edegger B. Pervasive learning games: a comparative study. New Rev Hypermedia Multimed 2007 Dec;13(2):93-116. [doi: 10.1080/13614560701712873] 26. Alessi SM. 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[Medline: 18676516] Edited by A McDougall; submitted 18.04.17; peer-reviewed by M Rethlefsen, L Sheets, N Allen; comments to author 29.05.17; revised version received 19.07.17; accepted 06.09.17; published 24.11.17 Please cite as: Kuipers DA, Terlouw G, Wartena BO, van 't Veer JTB, Prins JT, Pierie JPEN JMIR Serious Games 2017;5(4):e23 URL: http://games.jmir.org/2017/4/e23/ doi: 10.2196/games.7880 PMID: 29175812 http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al ©Derek A Kuipers, Gijs Terlouw, Bard O Wartena, Job TB van 't Veer, Jelle T Prins, Jean Pierre EN Pierie. Originally published in JMIR Serious Games (http://games.jmir.org), 24.11.2017. 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The Role of Transfer in Designing Games and Simulations for Health: Systematic Review

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Background: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. Objective: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. Methods: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. Results: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. Conclusions: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health. http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al (JMIR Serious Games 2017;5(4):e23) doi: 10.2196/games.7880 KEYWORDS transfer; computer simulation; video games; serious games; games for health; fidelity; abstract learning; immersion; metaphor ideas, concepts, and knowledge is juxtaposed against some new Introduction problem or situation. Figural transfer uses existing world knowledge to think or learn about a particular issue. Clear Games and simulations hold the promise of being learning examples of the usage of figural transfer can be found in figural machines [1] because of the ability to build in learning language such as metaphor or simile. Transfer occurs because principles. They can harvest unique features to motivate, trigger, of a successful memory search triggered by a figural learning and facilitate learning processes, opening up new possibilities context, assisting in understanding the transfer context. In some for designing learning for health care professionals and patients. situations, the second class of transfer requires a debrief to With the positive effects on learner motivation and learning explicate experiences and connections made. This class outcomes in mind [2-4], educators must think of new ways to encompasses high-road transfer [8]. make serious subject matter suitable for game play. A transformation of current forms and beliefs on learning may be Optimizing Transfer Conditions needed to make a more natural connection between the serious Games and simulations for health abundantly build on the and the game. principles of first-class literal transfer, but the adoption of second-class transfer types has proven to be scarce. In contrast Transfer to commercial off-the-shelf games, in serious game design, the A possible way to make such a connection can be found in usage of mindful abstractions and metaphorical representations thinking in terms of transfer. Although there are a wide variety is not common practice, despite the fact that it forms a natural of viewpoints and theoretical frameworks regarding transfer in fit with the second class of transfer theories. Earlier research the literature, transfer is seldom a starting point in developing has shown [9] that transfer is hard to establish and that the serious games. Studies on serious games [5,6] have identified design of education should be key to optimize the conditions design principles for flow and immersion as major contributors under which transfer can occur. Although transfer of learning to the gaming experience and presumably beneficial for learning. is a well-established concept in the educational domain, the However, the way games facilitate learning is often regarded extent to which transfer may guide the development of game-like as a black box. interventions in health has rarely been explored. This may be From an educational and technological perspective, transfer is especially true for second-class transfer types: optimizing a a key concept in learning theory and education [7]. The purpose game-like intervention design to accommodate the principles of (medical) education is transfer: the application of skills, of figural transfer. knowledge, or attitudes that were or learned in one situation to Fidelity Types another context. The concept of transfer is widely recognized, but ample evidence shows that transfer from learning The most visible examples of the designers’ uptake of transfer experiences often does not occur. The prospects and conditions in game-like interventions are apparent in the application of of transfer are crucial educational issues. fidelity types: the way fidelity is used in a game-like intervention or simulation demonstrates the expected road to transfer. A If we regard games and simulations as learning contexts that dominant perspective on fidelity in serious game design is that can be designed and specifically tailored for (at least a type of) high fidelity is conditional for learning and transfer, transfer, it seems legitimate to focus attention on how transfer corresponding with the first class of transfer. has been taken into account in designing game-like health interventions. According to Alexander [10], fidelity has dimensions beyond the visual design—physical, functional, and psychological Two Classes of Transfer fidelity [10]. A game or simulation therefore can be low in Transfer theory determines two classes of transfer, both physical and functional fidelity but can be high in psychological encompassing a variety of transfer types [8]. The first class fidelity. It is also possible that a simulation by design is high takes the position that the more the learning context resembles in functional and physical fidelity but lacks psychological the target context, the more likely transfer is to occur. The fidelity. In the literature, the degree of fidelity often refers to conditions for transfer are met when the learning experience physical fidelity alone. Therefore, in this study, cases of shares common stimulus properties with the target context. This cognizant design decisions toward lower fidelity types may means that when game or simulation environments try to prove interesting, as they might include second class of transfer represent the real world as literal as possible, they aim for types. first-class transfer. The first class of transfer encompasses Aim instances of literal, specific, nonspecific, vertical, lateral and low-road transfer. Focusing on the design of game-like interventions for health and health care, this study aimed to (1) find out whether the The second class of transfer theories may be harder to grasp. second class of transfer is recognized or present as a road for According to Royer [7], figural transfer (belonging to the second transfer in game-like interventions, (2) review the application transfer class) involves situations where a known complex of http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al of the second class of transfer type in designing game-like (DK and GT) independently reviewed the title and abstract for interventions, and (3) assess studies that include second-class relevance against the formulated inclusion/exclusion criteria. transfer types reporting transfer outcomes. Papers were only included on the agreement of both DK and GT; a third reviewer (BW) resolved any disagreements. The Methods degree of agreement was calculated by a kappa statistic. Full-text papers were retrieved after this step. Both reviewers (DK and Databases and Search Strategy GT) reviewed each included full-text article. Disagreements in this stage about inclusion were discussed until an agreement In total, 6 databases were searched for potentially relevant was reached. Finally, to check whether any eligible paper had abstracts: PubMed, Scopus, ERIC, PsycINFO, Information been overlooked during the review process, our check included Science & Technology Abstracts, and EMBASE. These studies’ references for additional papers. databases covered a wide range of published research from the field of health and social care. A combination of search terms Results were used to identify relevant papers under the following categories: (video games OR game OR games OR gaming OR Search Results computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior), Our initial search yielded 19,564 records. After removing all where * represents a wildcard to allow for alternative suffixes. duplicates (5226), 14,338 records remained for title and abstract Search strategies were customized for each database. Searches screening, leaving 26 potential suitable papers for full-text included papers published between database inception and assessment. We used Cohen kappa to assess the interrater October 2016. The search was conducted between October 3, reliability of paper inclusion. We found good agreement between 2016 and October 21, 2016. the 2 reviewers ( =.78, 95% CI 0.655-0.883). A total of 11 papers were excluded at full-text screening for various reasons. Study Selection and Inclusion and Exclusion Criteria The total number of included papers is therefore 15. See Figure We included studies that discussed either digital simulations or 1 for a flowchart of the results of the initial searches, screening, games designed for health providers or on health topics. We and selection processes. Table 1 shows an overview of included included only original reports or papers that (1) addressed the studies. design of a serious game or digital simulation; (2) involved an Second-Class Transfer in Game-like Interventions for empirical study, either piloting a game-like intervention or Health and Health Care validating the aspired effects; or (3) otherwise focused on a newly developed game or simulation, created specifically for We studied the full-text papers on how transfer was regarded the study in question. Papers were included when title and and described in serious games or simulations. All 15 studies abstract were considered to be at least indicative of the presence mentioned transfer in the initial concept of the design and of second class of transfer. Papers meeting any of the above described forthcoming consequences, mostly expressed in terms criteria were selected for full-text screening. of fidelity. Although we assumed that the second class of transfer would be identified in varying ways, we found several The following exclusion criteria were used for full-text other reasons to use abstract concepts and low fidelity. In the screening: (1) non–peer-reviewed papers such as abstracts, following section, we have categorized the papers, based on conference posters, or trade journals; (2) full text not available; similarities in conjoining characteristics. (3) language other than English and Dutch; (4) papers that referred to transfer as transfer of data or disease; (5) not Reducing Cognitive Load sufficient information; (6) repurposed commercial off-the-shelf Out of the selected studies, 3 [12,17,24] questioned the necessity games; (7) low fidelity as a means to reduce production costs; of high fidelity to achieve transfer. The basic theory is that (8) nondigital games and simulations; and (9) papers using high high-immersive gaming environments decrease learning fidelity solely as a description of the artifact rather than as a outcomes. The studies argue that reducing complexity prevents founded design decision. Also, in our screening, we considered extraneous cognitive load. In these situations, low fidelity and the transfer class in relation to the fidelity type: high fidelity as deliberate abstractions are aiming—by design—for managing a means for achieving literal transfer led to exclusion. the trainees’ working memory capacity. This is grounded in the cognitive load theory [27]. Screening Process After removing the duplicates, the papers were screened based on title and abstract using Rayyan [11]. In total, 2 reviewers http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al Figure 1. Flowchart of the results of the initial searches, screening, and selection processes. the physical fidelity is low or even nonexistent. The same goes Motor and Spatial Skills Training in Metaphorical for iLift, where the lifting and transfer techniques maintain a Contexts mimetic correspondence to real-world tasks, although the game In our initial selection process, papers that presented literal metaphor encompasses physical and psychological fidelity: transfer axiomatically were excluded. Out of the included catching sheep or helping little robots escape from a mine shows studies, 3 [13-15] were regarded more closely because they use no medical content. These games use metaphorical contexts to metaphorical game environments, possibly indicating the host meaningful play for training skills. presence of second-class transfer types. These game-like Situational Games interventions were designed for skills training (ie, laparoscopic Pervasive game design provides a different approach toward surgery, spatial cognition skills, lifting and transfer techniques). transfer. Of the papers, 2 [19,25] advocate pervasive games, In these scenarios, emphasis is placed on a high degree of where fusing the virtual world with the real-world positions validated functional fidelity, aimed at faithfully mimicking the them in between the first and second class of transfer. One could desired skills. These games facilitate first-class low-road transfer argue that situational games seek to provide what we like to by automating motor and spatial skills, hosted by low physical call blended transfer by emphasizing context awareness in a fidelity metaphors. true-to-life experience on the one hand and on the other hand For example, the game Underground carefully mimics basic adding virtual game elements. Both studies conclude by laparoscopic skills, including custom-made laparoscopic tool accentuating the promise of pervasive game play for transfer shells. The movements in the game are carefully calibrated to of knowledge [25] and transfer of behavior [19] but provide no faithfully represent actual laparoscopic skills. These skills are implications for the design of virtual elements for future acquired in a literal way. It is noteworthy that the tools and pervasive games. movements share high functional fidelity properties, whereas http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al Table 1. Details of included papers. Author Title Transfer Fidelity and transfer Year class rationale Dankbaar, Alsma, Jansen, Van Merrienboer, An experimental study on the effects of a simulation game First Low fidelity, reduc- 2016 Van Saase, and Schuit [12] on students’ clinical cognitive skills and motivation ing cognitive load Kuipers, Wartena, Dijkstra, Terlouw, van T iLift: A health behavior change support system for lifting First Low-road transfer, 2016 Veer, Van Dijk, Prins, and Pierie [13] and transfer techniques to prevent lower-back injuries in skill automatization, healthcare metaphorical Jalink, Gores, Heineman, Pierie, and Ten Face validity of a Wii U video game for training basic la- First Low-road transfer, 2015 Cate Hoedemaker [14] paroscopic skills skill automatization, metaphorical Connors, Chrastil, Sanchez, and Merabet [15] Action video game play and transfer of navigation and First Low-road transfer, 2014 spatial cognition skills in adolescents who are blind spatial recognition Rosenberg, Baughman, and Bailenson [16] Virtual superheroes: using superpowers in virtual reality Second Figural, metaphori- 2013 to encourage prosocial behavior cal Schrader and Bastiaens [17] The influence of virtual presence: effects on experienced First Low fidelity, reduc- 2012 cognitive load and learning outcomes in educational com- ing cognitive load puter games De Freitas and Dunwell [18] Understanding the representational dimension of learning: Second Figural, metaphori- 2012 the implications of interactivity, immersion and fidelity on cal the development of serious games Knoll and Moar [19] The space of digital health games Blended Locative, situational 2012 Rooney [20] A theoretical framework for serious game design: exploring Blended, Abstraction, situa- 2012 pedagogy, play, and fidelity and their implications for the both tional design process Toups, Kerne, and Hamilton [21] The team coordination game: zero-fidelity simulation ab- Second Nonmimetic, abstrac- 2011 stracted from fire emergency response practice tion Hochmitz and Yuviler-Gavish [22] Physical fidelity versus cognitive fidelity training in proce- First Cognitive fidelity, 2011 dural skills acquisition skill acquisition Stone [23] The (human) science of medical virtual learning environ- First Cost reduction 2011 ments Wood, Beckmann, and Birney [24] Simulations, learning, and real world capabilities First Low fidelity, execu- 2009 tion skills, reducing cognitive load Markovic, Petrovic, Kittl, and Edegger [25] Pervasive learning games: a comparative study First Situational 2007 Alessi [26] Fidelity in the design of instructional simulations Both Varying fidelity un- 1988 der conditions Refers to the aspired transfer type described or sought after with the game-like intervention. this illness are metaphorical rather than literal [18]. The game The Application of the Second Class of Transfer play shows little physical or functional fidelity to real-world Of the studies, 3 describe game designs applying the second processes, and measured effects can only be explained in terms class of transfer, and one study [16] describes a video game to of changed mental conceptions, referring to an instance of stimulate prosocial behavior. It examines how playing an avatar second-class (figural) transfer. However, the design with superhero abilities increases prosocial behavior in the real considerations were not elucidated either in this study. world . The study indicates that the in-game superhero metaphor The third study [21] describes the Team Coordination Game, leads to greater helping behavior outside the game. The game a simulation to practice team coordination during fire emergency therefore builds on the second class of transfer, although the response situations. The Team Coordination Game is a study does not explicate design considerations regarding simulation that offers a game environment that requires the use transfer. of effective team communication skills, without concrete De Freitas et al [18] describe Re-Mission, a video game designed elements of the mimicked environment. This nonmimetic game for young people with cancer to encourage them to take their offers a two-dimensional environment that shows low-fidelity medication. The game metaphor, where the player has to combat to real-life fire emergency environments. In the game, 3 avatars cancer cells, seeks to reinforce behavioral change toward in the role of seeker are searching for specific goals, while medication use. Re-Mission fits the figural transfer class as the avoiding threats. A player in the role of coordinator directs the in-game representation of the illness and the power to conquer http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al seekers based on observing the environment from a different able to restore learned behaviors in communication and stress angle. Limited game time creates a certain amount of stress and management in an alternative environment but also capable of pushes the players to work effectively. The study suggests that remixing and repurposing them. The article—in several players were able to restore learned behaviors in communication substudies—describes a variety of positive effects on and stress management in an alternative environment, remixing communication and organizational skills, carried over from the and repurposing them, suggesting a transfer effect. game environment to live training. Although the game offers a so-called zero-fidelity physical Discussion environment, it uses communication instruments that have the same characteristics as real-world radios. This implies at least To our knowledge, this is the first review to explore the aspired a modicum of functional fidelity. Furthermore, the game is transfer in designing game-like interventions in health. We tried based on communication strategies and stress levels from to find and describe examples of the application of second-class real-world fire emergency situations, which suggests some level transfer types by answering 3 research questions, discussed of psychological fidelity. The Team Coordination Game below. simulation study offers clear design implications, labeling and Design for Transfer in Health elaborating on abstraction from reality as a guiding principle, which differs from the other studies included. We tried to determine whether the second class of transfer types is recognized or present as a road for transfer in game-like Psychological Fidelity interventions for health. In our initial search, we expected to In total, 7 studies [12,18,20-23,26] mention psychological find studies in which thinking about a desired transfer outcome fidelity as, if not the most, an important design parameter in would form a guiding principle in the design of game-like serious games and simulations. In addition, these studies claim interventions. Moreover, clearer distinctions in suitable transfer that representing the real world as literal as possible is less types and established examples of figural transfer (or forms important for learning. The definition of psychological fidelity thereof) were anticipated. Both assumptions were proven wrong, in these studies varies slightly [22], but all studies mention the and we had to broaden our inclusion criteria to capture studies abstraction of certain real-world concepts and a process of regarding design considerations, including transfer. recontextualization. Of the studies considered, one [21] added Our results show that transfer is mainly mentioned as a desired suspension of disbelief as an important characteristic of outcome, not as a guide in the design process. The appearance psychological fidelity: one’s temporary allowance to believe of most included game-like artifacts can be explained by the something that is not true. Despite the fact that the second class designer’s fidelity approach. As obvious as this seems, this of transfer is not explicitly stated in those studies, they implicitly fidelity approach also expresses assumptions about the way the confirm the second class of transfer as a promising concept in transfer is expected to take place. As described before, we found serious game design for learning. several reasons for choosing low fidelity over high fidelity and Effects of Design for Figural Transfer vice versa. As none of the studies were designed for achieving The virtual superhero study [16] only reported a transfer effect transfer via a specific type or class of transfer, the question just after playing the game. The study did not cover long-term arises why the design for transfer perspective has received no effects but showed in an experimental 2×2 design that attention. participants (n=60) in the flying superhero condition displayed By nature, design-centered research focuses more on the design significantly increased prosocial behavior compared with itself and puts less emphasis on the eventual aspired outcome. participants who were in the helicopter condition. The study Although it is too strong to state that the design itself of mentions several possibilities for the differences found between game-like interventions in health is not taken into account in the testing conditions: different experiences of immersiveness, thinking about desirable transfer outcomes, our search results involvement versus observation discrepancy, and primed show that describing the game-like interventions in terms of concepts and stereotypes related to superheroes in general. transfer variables is uncommon. One might argue that the design The study reporting on Re-Mission [18] did not elaborate on of a drug is essential to its workings and that the same principle the efficacy of the intervention. Another study [28] focused in applies for game-like interventions. The design of the artifacts greater detail on the transfer effects of Re-Mission and found as exercised in the virtual superhero game [16], Re-Mission that playing the game increased young cancer patients’ feelings [18], and the Team Coordination Game simulation [21] is of self-efficacy or beliefs in their own ability to control and intentional and differs strongly from game-like interventions cope with the disease. A randomized trial with 197 intervention as Underground [14] or Digital Economy [25]. These differences group participants showed a significant increase in arise from a broad and ill-defined range of variables but cancer-related knowledge and self-efficacy scores and offers inevitably reveal the designer’s intent with regard to how the empirical support for the efficacy of a game-like intervention intervention should carry over the effect. Herein lies the in improving behavioral outcomes in adolescents and young rationale for design for transfer. adults with cancer. The Presence of the Second Class of Transfer Using a mixed-method approach, the Team Coordination Game As described, we searched for particular examples of aspired [21] also reported some transfer effect, in addition to an in-game transfer in the second class of transfer types, and found none. effect (n=64). The study suggested that players were not only In 3 studies, the reported effects can only be explained via the http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al road of a second-class transfer type but are described in other of this, we anticipated more conscious and elucidated design terminology. Most studies report about psychological fidelity examples. [12,18,20-23,26], virtual presence [17], and immersion [16,18] Limitations as important conditions for desired outcome. Although this review is based on an extensive search of a large An interesting observation is that the included papers show that number of health and computer science databases, we hardly functional and physical fidelity can be high or low for varying, found any studies of second-class transfer types in game-like well-founded reasons and that psychological fidelity is regarded interventions for health. Studies tend to focus on the as a variable that preferably should be high. The Team effectiveness of game-like interventions and the research Coordination Game simulation [21] adopts a different position methods used, not on design factors that lead or contribute to in stating that the gaming artifact has zero psychological fidelity. measured effects. Due to the very few direct hits, we focused However, the way deliberate abstractions are described and how on the subconscious application of the second class of transfer these resulted in the design of the game itself strongly suggests types by thoroughly screening titles and abstracts. The papers second-class transfer. that were included were subject to interpretation, discussion, and consensus of the reviewers (DK, GT, and BW). To The 3 studies we identified exemplifying an instance of figural counteract subjectivity, papers were independently reviewed transfer introduced a metaphorical approach with by 2 reviewers (DK and GT) and were only included on recontextualized fidelity types. These game metaphors seem to consensus from both reviewers. Remaining conflicts between address and replace both high functional and physical needs as the reviewers were resolved by the third reviewer (BW). well as promote immersion. At this point, we hypothesize that figural transfer builds upon immersion or virtual presence and Conclusions subsequent suspension of disbelief [21]. In more abstract Studies about serious games and game-like interventions for game-like interventions, metaphors provide a storyline, a health do not provide a conscious rationale for designing the context, and a reason for engaging in play. In this way, artifacts for optimizing transfer conditions. We did not find any psychological fidelity is reappointed by the concept of example of a game-like intervention that was the result of a suspension of disbelief, instigated by the metaphor itself. cognizant design process focusing on transfer outcomes. In Second-Class Transfer Outcomes general, we found that definitions of low and high fidelity form the strongest influencers on the design of artifacts, mostly As the literature on transfer has consistently confirmed, exemplified in visual quality or a true-to-life approach. High long-term transfer effects are hard to measure. This might be fidelity was aspired to for its first class, literal transfer aspects particularly the case for the second class of transfer. All 3 without exception. None of the studies explained second class examples report transfer effects, albeit short term and only of transfer or instances thereof, although in 3 instances, implicit vaguely proven. As second-class transfer is the result of the design choices suggested otherwise. It is notable that studies effects interventions trigger in one’s head, the transfer outcomes on game-like interventions for health do not elucidate the design are individual, often nonlinear, and even unpredictable if the choices made, as they bridge the designer’s intent and the second class is not implemented with due care. Precisely because aspired transfer outcome. 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[Medline: 18676516] Edited by A McDougall; submitted 18.04.17; peer-reviewed by M Rethlefsen, L Sheets, N Allen; comments to author 29.05.17; revised version received 19.07.17; accepted 06.09.17; published 24.11.17 Please cite as: Kuipers DA, Terlouw G, Wartena BO, van 't Veer JTB, Prins JT, Pierie JPEN JMIR Serious Games 2017;5(4):e23 URL: http://games.jmir.org/2017/4/e23/ doi: 10.2196/games.7880 PMID: 29175812 http://games.jmir.org/2017/4/e23/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e23 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Kuipers et al ©Derek A Kuipers, Gijs Terlouw, Bard O Wartena, Job TB van 't Veer, Jelle T Prins, Jean Pierre EN Pierie. Originally published in JMIR Serious Games (http://games.jmir.org), 24.11.2017. 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JMIR Serious Games – JMIR Publications

Published: Nov 24, 2017

Keywords: transfer; computer simulation; video games; serious games; games for health; fidelity; abstract learning; immersion; metaphor

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