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AECT Design & Development Outstanding Book Award for 2008!

Design and Development Research  thoroughly discusses methods and strategies appropriate for conducting design and development research. Rich with examples and explanations, the book describes actual strategies that researchers have used to conduct two major types of design and development research: 1) product and tool research and 2) model research. Common challenges confronted by researchers in the field when planning and conducting a study are explored and procedural explanations are supported by a wide variety of examples taken from current literature. Samples of actual research tools are also presented. Important features in this volume include:

• concise checklists at the end of each chapter to give a clear summary of the steps involved in the various phases of a project;
• an examination of the critical types of information and data often gathered in studies, and unique procedures for collecting these data;
• examples of data collection instruments, as well as the use of technology in data collection; and
• a discussion of the process of extracting meaning from data and interpreting product and tool and model research findings.

Design and Development Research is appropriate for both experienced researchers and those preparing to become researchers. It is intended for scholars interested in planning and conducting design and development research, and is intended to stimulate future thinking about methods, strategies, and issues related to the field.

TABLE OF CONTENTS

Chapter | 14  pages, an overview of design and development research, chapter | 19  pages, identifying design and development research problems, chapter | 12  pages, design and development research methodology, chapter | 18  pages, product and tool research: methods and strategies, model research: methods and strategies, chapter | 15  pages, selecting participants and settings, chapter | 28  pages, collecting data in design and development research, chapter | 17  pages, interpreting design and development findings, chapter | 10  pages, the status and future of design and development research.

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Design and Development Research: Methods, Strategies, and Issues

• Rita C. Richey , James D. Klein
• Published 5 March 2007
• Education, Environmental Science

376 Citations

Design and development research, development research of a teachers’ educational performance support system: the practices of design, development, and evaluation, building research capacity through an academic community of practice: a design case study, design science method and theory in a construction and engineering context: “a phronetic tale of research”, employing ddr to design and develop a flipped classroom and project based learning module to applying design thinking in design and technology, socio-technical system as factors and influences in form design development, design and development research: a model validation case, the implications of the differences between design research and instructional systems design for educational technology researchers and practitioners, developing a method for the design of sharable pedagogical scenarios, using instructional design to support community engagement in clinical and translational research: a design and development case.

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Design and Development Research

• First Online: 01 January 2013

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• Rita C. Richey 5 &
• James D. Klein 6  

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This chapter focuses on design and development research, a type of inquiry unique to the instructional design and technology field dedicated to the creation of new knowledge and the validation of existing practice. We first define this kind of research and provide an overview of its two main categories—research on products and tools and research on design and development models. Then, we concentrate on recent design and development research (DDR) by describing 11 studies published in the literature. The five product and tool studies reviewed include research on comprehensive development projects, studies of particular design and development phases, and research on tool development and use. The six model studies reviewed include research leading to new or enhanced ID models, model validation and model use research. Finally, we summarize this new work in terms of the problems it addresses, the settings and participants examined, the research methodologies employed used, and the role evaluation plays in these studies.

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Design and Development Research 1st Edition Methods, Strategies, and Issues

• Author(s) Rita C. Richey; James D. Klein
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AECT Design & Development Outstanding Book Award for 2008!Design and Development Research thoroughly discusses methods and strategies appropriate for conducting design and development research. Rich with examples and explanations, the book describes actual strategies that researchers have used to conduct two major types of design and development research: 1) product and tool research and 2) model research. Common challenges confronted by researchers in the field when planning and conducting a study are explored and procedural explanations are supported by a wide variety of examples taken from current literature. Samples of actual research tools are also presented. Important features in this volume include:concise checklists at the end of each chapter to give a clear summary of the steps involved in the various phases of a project;an examination of the critical types of information and data often gathered in studies, and unique procedures for collecting these data;examples of data collection instruments, as well as the use of technology in data collection; anda discussion of the process of extracting meaning from data and interpreting product and tool and model research findings.Design and Development Research is appropriate for both experienced researchers and those preparing to become researchers. It is intended for scholars interested in planning and conducting design and development research, and is intended to stimulate future thinking about methods, strategies, and issues related to the field.

Table of Contents

Contents: Preface. An Overview of Design and Development Research. Identifying Design and Development Research Problems. Design and Development Research Methodology. Product and Tool Research--Methods and Strategies. Model Research--Methods and Strategies. Selecting Participants and Settings. Collecting Design and Development Research Data. Interpreting Design and Development Findings. The Status and Future of Design and Development Research.

Overview of Design and Development Research (DDR) For Applied Doctorate Students in the Instructional Design Program

Types of design and development research, 3 stages in design and development research, data collection methods and sources of data in ddr.

• Qualitative Narrative Inquiry Research
• Action Research Resource
• Case Study Design in an Applied Doctorate
• SAGE Research Methods
• Research Examples (SAGE) This link opens in a new window
• Dataset Examples (SAGE) This link opens in a new window
• IRB Resource Center This link opens in a new window

The purpose of this quick guide is to assist Applied Doctorate students in the Instructional Design Program in determining the best methodology and design for their Applied Doctorate Experience (ADE) dissertation. The guide covers intended target audience, an overview of Design and Development Research (DDR), types of DDR research including product, program, tool research, and model research, 3 stages providing alignment of DDR with NUs Applied Doctoral Record (DDR) deliverables, examples of problem, purpose, and research questions for DDR research, and suggested references. 

Target Audience: Doctoral Students in Instructional Design in the ADE program

This quick reference guide will aid doctoral students in instructional design challenged with deciding on what type of applied research study they want to do for their dissertation.

Overview of Design and Development Research (DDR) Methods

At the core of the instructional design and instructional technology and media field, is the design, development, implementation and evaluation of instructional products, tools, programs, models, and frameworks.  In many ways DDR is like Action Research (Goldkuhl, 2012), however, there are many differences. DDR research allows instructional designers a pathway to test theory, models, and frameworks and to authenticate practice. The focus of DDR is on the use, design, development, implementation, and evaluation of products, tools, programs, and models using instructional design models and frameworks. Richey and Klein (2007) defined DDR as “the systematic study of design, development, and evaluation processes with the aim of establishing an empirical basis for the creation of instructional and non-instructional products and tools and new or enhanced models that govern their development” (p. xv). Often the models and frameworks are validated and/or further developed and enhanced through the DDR. DDR is applied research. An area of DDR research that is particularly applicable to ADE students is the creation, implementation, and evaluation of one or more artifacts, such as products, tools, models, new technologies, and learning objects that will aid in solving a complex problem in practice that can be addressed through human imagination, creativity, engagement, and interaction (Ellis & Levy, 2010). These types of problems are found in K-12 education, higher education, corporations, not-for-profits, healthcare, and the military. 

• Example Design and Development Research

The field of DDR is constantly evolving and expanding as technology and media are changing at exponential rates.  Richey and Klein (2007) in their seminal work divided DDR into two major categories:

• Product and Tool Research and
• Model Research.

Table 1 provides a summary of common designs used in DDR. Most DDR work falls under the qualitative research category of qualitative case study, however, methodologies such as quantitative and mixed method have been used as well as other qualitative designs, including Delphi.

Product, Program, and Tool Research

Ellis and Levy (2010) asserted that DDR must go beyond commercial product development by determining a research problem, based on existing research literature and gaps in the literature that researchers assert must be studied to add to the instructional design knowledgebase.

Product and Tool Research can be further divided into:

• Comprehensive Design and Development Projects covering all phases of the instructional design process,
• Specific Project Phases (such as those in the ADDIE model: Analysis, Design, Development, Implementation, and Evaluation), and
• Design, Development, and Use of tools (Richey & Klein, 2007).

Model Research

Instructional designers and instructional technologists have focused on model research since the emergence of the field.

Model research can be broken into three types:

• Model Development,
• Model Validation and

Model development can focus on a comprehensive model design or on part of a process. Model validation research uses empirical processes to prove the effectiveness of a model in practice. Finally, model use research addresses usability typically from the perspective of instructional designers and stakeholder experts.

3 Stages in Design and Development Research for the ADE Doctoral Student’s Dissertation

NU doctoral students in the Instructional Design Program can use one of the various types of DDR research to complete their doctoral dissertation using the NU ADE template. There will be three stages in this process and in each stage the student will have one or more deliverables using the NU template and posting in the ADR on NU One.

Stage 1: Design and Development Research aligned with the NU ADE Template Process

• Identify a research worthy problem which is expressed by researchers in peer reviewed research literature. Ask yourself, what is going wrong? What do researchers say is known about the problem? And what is needed to be known to address the problem?
• Describe the purpose of your research ensuring that it aligns with your problem statement. In the description state your methodology and design and which DDR type of research you will do. Be sure to include a description of your target population (audience), the size of your sample and the sampling strategy you will use to access your sample. What permissions do you need? Site permission? Other IRB permission?
• Write your research questions to align with your problem and purpose statements.
• Complete Section 1 of your Applied Doctoral Experience (ADE) template securing all necessary approvals in the Applied Doctoral Record (ADR).
• Needs Assessment
• Measurable Goals and Objectives
• Sample size and Access to the sample
• Sampling strategy
• Content analysis (course, program, product, or tool descriptions)
• Technology and media analysis/selection
• Learning management system(s)
• Asynchronous
• Synchronous
• Evaluation Plan
• Complete Section 2, Proposal Draft, Proposal for AR, and Final Proposal of the ADE securing all necessary approvals in the ADR.
• Submit Proposal and IRB Application to secure IRB approval.

Stage 2: Design and Development Research aligned with the NU ADE Template Process

After receiving IRB approval of your ADE Proposal, it is time to design, develop, test, validate, and/or evaluate your artifacts. Below are example steps:

• Review and Finalize Design Document
• Recruit Expert Participants, if required
• Recruit Artifact User/Participants, if required
• Lesson plan or syllabus
• Instructional strategies and activities
• Participant materials
• Trainer materials
• Storyboards and scripts
• Other media
• Create model, tool, product, or program.
• Validate model, if required
• Evaluation plan (Kirkpatrick Levels 1, 2, 3, 4)
• Alpha test, Beta test, Pilots.
• Rapid Prototyping
• Participant reaction
• Trainer/facilitator reaction
• Were Design Goals met?
• Were Design Objectives met?
• Revise artifact(s), Retest, if necessary.

Stage 3: Design and Development Research aligned the NU ADE Template Process

Complete Section 3 of the ADE template presenting the study findings, conclusions, and implications. Next pull all three sections into a dissertation manuscript for approval in the ADR.

While DDR covers a wide variety of approaches, most doctoral students in the ADE program will find case study to be the preferred design. To strengthen trustworthiness of the data, multiple sources of data will typically be used.  Using multiple sources of data is called triangulation in research. Figure 1 shows examples of sources of data for DDR.

The goal is to create, use, and/or validate New Artifacts by collecting and analyzing various sources of data including:

• Existing artifacts,
• Expert individual and focus group interviews,
• Participant/user individual interviews, talk aloud-think aloud interviews, focus group interviews,
• Research observation and participant observation,
• Evaluation, Kirkpatrick Levels 1-4, and
• Needs assessment and design documents.

The new artifacts may be lesson plans, student guides, facilitator/teacher guides, learning objects, tools, models, programs, and/or products.

Figure:  Sources of Data in DDR

Ellis, T.J. & Levy, Y. (2010). A guide for novice researchers: Design and development research methods. Proceedings of Informing Science & IT Education Conference (InSITE) 2010, pp. 108-118. http://proceedings.informingscience.org/InSITE2010/InSITE10p107-118Ellis725.pdf

Goldkuhl, G. (2012). From Action Research to Practice Research. Australasian Journal of Information Systems, 17 (2). https://doi.org/10.3127/ajis.v17i2.688

Richey, R. C. & Klein, J. D. (2007). Design and Development Research. Routledge

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Research progress and intellectual structure of design for digital equity (DDE): A bibliometric analysis based on citespace

• Baoyi Zhang   ORCID: orcid.org/0000-0003-4479-7587 1  

Humanities and Social Sciences Communications volume  11 , Article number:  1019 ( 2024 ) Cite this article

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• Cultural and media studies
• Science, technology and society

Digital equity is imperative for realizing the Sustainable Development Goals, particularly SDG9 and SDG10. Recent empirical studies indicate that Design for Digital Equity (DDE) is an effective strategy for achieving digital equity. However, before this review, the overall academic landscape of DDE remained obscure, marked by substantial knowledge gaps. This review employs a rigorous bibliometric methodology to analyze 1705 DDE-related publications, aiming to delineate DDE’s research progress and intellectual structure and identify research opportunities. The retrieval strategy was formulated based on the PICo framework, with the process adhering to the PRISMA systematic review framework to ensure transparency and replicability of the research method. CiteSpace was utilized to visually present the analysis results, including co-occurrences of countries, institutions, authors, keywords, emerging trends, clustering, timeline analyses, and dual-map overlays of publications. The results reveal eight significant DDE clusters closely related to user-centered design, assistive technology, digital health, mobile devices, evidence-based practices, and independent living. A comprehensive intellectual structure of DDE was constructed based on the literature and research findings. The current research interest in DDE lies in evidence-based co-design practices, design issues in digital mental health, acceptance and humanization of digital technologies, digital design for visually impaired students, and intergenerational relationships. Future research opportunities are identified in DDE’s emotional, cultural, and fashion aspects; acceptance of multimodal, tangible, and natural interaction technologies; needs and preferences of marginalized groups in developing countries and among minority populations; and broader interdisciplinary research. This study unveils the multi-dimensional and inclusive nature of methodological, technological, and user issues in DDE research. These insights offer valuable guidance for policy-making, educational strategies, and the development of inclusive digital technologies, charting a clear direction for future research.

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Introduction.

Digital equity has emerged as a critical factor in achieving the Sustainable Development Goals (SDGs), especially SDG9 (Industry, Innovation, and Infrastructure) and SDG10 (Reduced Inequalities) (United Nations, 2021 ; UNSD 2023 ), amidst the rapid evolution of digital technologies. In our increasingly digitalized society, these technologies amplify and transform existing social inequalities while offering numerous benefits, leading to more significant disparities in access and utilization (Grybauskas et al., 2022 ). This situation highlights the critical need for strategies that promote equitable digital participation, ensuring alignment with the overarching objectives of the SDGs. Digital equity, a multi-faceted issue, involves aspects such as the influence of cultural values on digital access (Yuen et al., 2017 ), the challenges and opportunities of technology in higher education (Willems et al., 2019 ), and the vital role of government policies in shaping digital divides (King & Gonzales, 2023 ), and the impact on healthcare access and delivery (Lawson et al., 2023 ). Equally important are the socioeconomic factors that intersect with digital equity (Singh, 2017 ) and the pressing need for accessible digital technologies for disabled individuals (Park et al., 2019 ). These issues are observed globally, necessitating diverse and inclusive strategies.

Design thinking, in addressing issues of social equality and accessibility, plays an essential role in accessibility (Persson et al., 2015 ; Dragicevic et al., 2023a ); in other words, it serves as a crucial strategy for reducing social inequality. Indeed, design strategies focused on social equality, also known as Equity-Centered Design (Oliveri et al., 2020 ; Bazzano et al., 2023 ), are diverse, including universal design (Mace ( 1985 )), Barrier-free design (Cooper et al., 1991 ), inclusive design (John Clarkson, Coleman ( 2015 )), and Design for All (Bendixen & Benktzon, 2015 ). Stanford d.school has further developed the Equity-Centered Design Framework based on its design thinking model (Stanford d.school, 2016 ) to foster empathy and self-awareness among designers in promoting equality. Equity-centered approaches are also a hot topic in academia, especially in areas like education (Firestone et al., 2023 ) and healthcare (Rodriguez et al., 2023 ). While these design approaches may have distinct features and positions due to their developmental stages, national and cultural contexts, and the issues they address, Equity-Centered Design consistently plays a vital role in achieving the goal of creating accessible environments and products, making them accessible and usable by individuals with various abilities or backgrounds (Persson et al., 2015 ).

Equity-centered design initially encompassed various non-digital products, but with the rapid advancement of digitalization, it has become increasingly critical to ensure that digital technologies are accessible and equitable for all users. This can be referred to as Design for Digital Equity (DDE). However, the current landscape reveals a significant gap in comprehensive research focused on Design for Digital Equity (DDE). This gap highlights the need for more focused research and development in this area, where bibliometrics can play a significant role. Through systematic reviews and visualizations, bibliometric analysis can provide insights into this field’s intellectual structure, informing and guiding future research directions in digital equity and design.

Bibliometrics, a term first coined by Pritchard in 1969 (Broadus, 1987 ), has evolved into an indispensable quantitative tool for analyzing scholarly publications across many research fields. This method, rooted in the statistical analysis of written communication, has significantly enhanced our understanding of academic trends and patterns. Its application spans environmental studies (Wang et al., 2021 ), economics (Qin et al., 2021 ), big data (Ahmad et al., 2020 ), energy (Xiao et al., 2021 ), medical research (Ismail & Saqr, 2022 ) and technology acceptance (Wang et al., 2022 ). By distilling complex publication data into comprehensible trends and patterns, bibliometrics has become a key instrument in shaping our understanding of the academic landscape and guiding future research directions.

In bibliometrics, commonly used tools such as CiteSpace (Chen, 2006 ), VOSviewer (Van Eck, Waltman ( 2010 )), and HistCite (Garfield, 2009 ) are integral for advancing co-citation analysis and data visualization. Among these, CiteSpace, developed by Professor Chen (Chen, 2006 ), is a Java-based tool pivotal in advancing co-citation analysis for data visualization and analysis. Renowned for its integration of burst detection, betweenness centrality, and heterogeneous network analysis, it is essential in identifying research frontiers and tracking trends across various domains. Chen demonstrates the versatility of CiteSpace in various fields, ranging from regenerative medicine to scientific literature, showcasing its proficiency in extracting complex insights from data sets (Chen, 2006 ). Its structured methodology, encompassing time slicing, thresholding, and more, facilitates comprehensive analysis of co-citations and keywords. This enhances not only the analytical capabilities of CiteSpace but also helps researchers comprehend trends within specific domains. (Chen et al. 2012 ; Ping et al. 2017 ). Therefore, CiteSpace is a precious tool in academic research, particularly for disciplines that require in-depth analysis of evolving trends and patterns.

After acknowledging the significance of DDE in the rapidly evolving digital environment, it becomes imperative to explore the academic contours of this field to bridge knowledge gaps, a critical prerequisite for addressing social inequalities within digital technology development. We aim to scrutinize DDE’s research progress and intellectual structure, analyzing a broad spectrum of literature with the aid of bibliometric and CiteSpace methodologies. Accordingly, four research questions (RQs) have been identified to guide this investigation. The detailed research questions are as follows:

RQ1: What are the trends in publications in the DDE field from 1995 to 2023?

RQ2: Who are the main contributors, and what are the collaboration patterns in DDE research?

RQ3: What are the current research hotspots in DDE?

RQ4: What is the intellectual structure and future trajectory of DDE?

The remainder of this paper is structured as follows: The Methods section explains our bibliometric approach and data collection for DDE research. The Results section details our findings on publication trends and collaborative networks, addressing RQ1 and RQ2. The Discussion section delves into RQ3 and RQ4, exploring research hotspots and the intellectual structure of DDE. The Conclusion section summarizes our study’s key insights.

In this article, the systematic review of DDE follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (PRISMA 2023 ), which are evidence-based reporting guidelines for systematic review reports (Moher et al., 2010 ). PRISMA was developed to enhance the quality of systematic reviews and enhance the clarity and transparency of research findings (Liberati et al., 2009 ). To achieve this goal, the research workflow in this study incorporates an online tool based on the R package from PRISMA 2020. This tool enables researchers to rapidly generate flowcharts that adhere to the latest updates in the PRISMA statement, ensuring transparency and reproducibility in the research process. This workflow comprises three major stages: Identification, Screening, and Inclusion, as illustrated in Fig. 1 .

PRISMA flowchart for the DDE systematic review.

Additionally, to obtain high-quality data sources, the Web of Science (referred to as WOS), provided by Clarivate Analytics, was chosen. WOS is typically considered the optimal data source for bibliometric research (van Leeuwen, 2006 ). The WOS Core Collection comprises over 21,000 peer-reviewed publications spanning 254 subject categories and 1.9 billion cited references, with the earliest records traceable back to 1900 (Clarivate, 2023 ). To thoroughly explore the research on DDE, this review utilized all databases within the WOS Core Collection as the source for data retrieval.

Search strategy

Developing a rational and effective search strategy is crucial for systematic reviews (Cooper et al., 2018 ), typically necessitating a structured framework to guide the process (Sayers, 2008 ). This approach ensures comprehensive and relevant literature coverage. To comprehensively and accurately assess the current state and development of “Design for Digital Equity,” this paper employs the PICo (participants, phenomena of interest, and context) model as its search strategy, a framework typically used for identifying research questions in systematic reviews (Stern et al., 2014 ). While the PICo framework is predominantly utilized within clinical settings for systematic reviews, its structured approach to formulating research questions and search strategies is equally applicable across many disciplines beyond the clinical environment. This adaptability makes it a suitable choice for exploring the multi-faceted aspects of digital equity in a non-clinical context (Nishikawa-Pacher, 2022 ).

This review, structured around the PICo framework, sets three key concepts (search term groups): Participants (P): any potential digital users; Phenomena of Interest (I): equity-centered design; Context (Co): digital equity. To explore the development and trends of DDE comprehensively, various forms of search terms are included in each PICo element. The determination of search terms is a two-stage process. In the first stage, core terms of critical concepts like equity-centered design, digital equity, and Design for Digital Equity, along with their synonyms, different spellings, and acronyms, are included in the list of candidate search terms. Wildcards (*) are used to expand the search range to ensure the inclusion of all variants and derivatives of critical terms, thus enhancing the thoroughness and depth of the search. However, studies have indicated the challenge of identifying semantically unrelated terms relevant to the research (Chen, 2018 ). To address this issue, the second phase of developing the search strategy involves reading domain-specific literature reviews using these core terms. This literature-based discovery (LBD) approach can identify hidden, previously unknown relationships, finding significant connections between different kinds of literature (Kastrin & Hristovski, 2021 ). The candidate word list is then reviewed, refined, or expanded by domain experts. Finally, a search string (Table 1 ) is constructed with all search terms under each search term group linked by the Boolean OR (this term or that term), and the Boolean links each group AND (this group of terms and that group of terms).

Inclusion criteria

Following the PRISMA process (Fig. 1 ), literature in the identification phase was filtered using automated tools based on publication data attributes such as titles, subjects, and full texts or specific criteria like publication names, publication time ranges, and types of publication sources. Given the necessity for a systematic and extensive exploration of DDE research, this review employed an advanced search using “ALL” instead of “topic” or “Title” in the search string to ensure a broader inclusion of results. No limitations were set on other attributes of the literature. The literature search was conducted on December 5, 2023, resulting in 1747 publications exported in Excel for further screening.

During the literature screening phase, the authors reviewed titles and abstracts, excluding 11 publications unrelated to DDE research. Three papers were inaccessible in the full-text acquisition phase. The remaining 1729 publications were then subjected to full-text review based on the following inclusion and exclusion criteria. Eventually, 1705 papers meeting the criteria were imported into CiteSpace for analysis.

Papers were included in this review if they met the following criteria:

They encompassed all three elements of PICo: stakeholders or target users of DDE, design relevance, and digitalization aspects.

They had transparent research methodologies, whether empirical or review studies employing qualitative, quantitative, or mixed methods.

They were written in English.

Papers were excluded if they:

Focused solely on digital technology, unrelated to design, human, and social factors.

Contained terms with identical acronyms but different meanings, e.g., ICT stands for Inflammation of connective tissue in medicine.

Were unrelated to topics of social equality.

Were in languages other than English.

Data analysis

To comprehensively address Research Question 1: “What are the publication trends in the DDE field from 1995 to 2023?” this study utilized CiteSpace to generate annual trend line graphs for descriptive analysis. This analysis revealed the annual development trends within the DDE research field and identified vital research nodes and significant breakthroughs by analyzing the citation frequency of literature across different years. Utilizing the burst detection feature in CiteSpace, key research papers and themes were further identified, marking periods of significant increases in research activity. For Research Question 2: “Who are the main contributors to DDE research, and what are their collaboration patterns?” nodes for countries, institutions, cited authors, cited publications, and keywords were set up in CiteSpace for network analysis. Our complex network diagrams illustrate the collaboration relationships between different researchers and institutions, where the size of the nodes indicates the number of publications by each entity, and the thickness and color of the lines represent the strength and frequency of collaborations.

Additionally, critical scholars and publications that act as bridges within the DDE research network were identified through centrality analysis. In the keyword analysis, the focus was on co-occurrence, trend development, and clustering. Current research hotspots were revealed using the LSI algorithm in CiteSpace for cluster analysis, demonstrating how these hotspots have evolved over time through timeline techniques. A dual-map overlay analysis was used to reveal citation relationships between different disciplines, showcasing the interdisciplinary nature of DDE research. In the visual displays of CiteSpace, the visual attributes of nodes and links were meticulously designed to express the complex logical relationships within the data intuitively. The size of nodes typically reflects the publication volume or citation frequency of entities such as authors, institutions, countries, or keywords, with larger nodes indicating highly active or influential research focal points. The change in node color often represents the progress of research over time, with gradients from dark to light colors indicating the evolution from historical to current research. Whether solid or dashed, the outline of nodes differentiates mainstream research areas from marginal or emerging fields. The thickness and color of the lines reflect the strength of collaborations or frequency of citations, aiding in the identification of close collaborations or frequent citations. These design elements not only enhance the information hierarchy of the diagrams but also improve the usability and accuracy for users exploring and analyzing the data, effectively supporting researchers in understanding the structure and dynamics of the academic field. The subsequent research results section provides detailed descriptions for each visual element.

The first section of the Results primarily addresses RQ1: “What are the trends in publications in the DDE field from 1995 to 2023?” The subsequent sections collectively address RQ2: “Who are the main contributors, and what are the collaboration patterns in DDE research?”

Analysis of Publication Trends

Figure 2 , extracted from the WOS citation analysis report, delineates the progression of annual scholarly publications within the Design for Digital Equity field. This trend analysis resonates with de Solla Price’s model of scientific growth (Price 1963 ), beginning with a slow and steady phase before transitioning into a period of more rapid expansion. Notably, a pronounced spike in publications was observed following 2020, characterized by the global COVID-19 pandemic. This uptick indicates an acute scholarly response to the pandemic, likely propelled by the heightened need for digital equity solutions as the world adapted to unprecedented reliance on digital technologies for communication, work, and education amidst widespread lockdowns and social distancing measures. The graph presents a clear visualization of this scholarly reaction, with the peak in 2021 marking the zenith of research output, followed by a slight retraction, which may suggest a period of consolidation or a pivot towards new research frontiers in the post-pandemic era.

Trends in Scholarly Publications on Design for Digital Equity (1997–2023).

Visual analysis by countries or regions

Table 2 presents an illustrative overview of the diverse global contributions to research on “Design for Digital Equity,” including a breakdown of the number of publications, centrality, and the initial year of engagement for each participating country. The United States stands preeminent with 366 publications, affirming its central role in the domain since the mid-1990s. Despite fewer publications, the United Kingdom boasts the highest centrality, signaling its research as notably influential within the academic network since the late 1990s. Since China entered the DDE research arena in 2011, its publications have had explosive growth, reflecting rapid ascension and integration into the field. Furthermore, the extensive volume of publications from Canada and the notable centrality of Spain underscores their substantial and influential research endeavors. The table also recognizes the contributions from countries such as Germany, Italy, and Australia, each infusing unique strengths and perspectives into the evolution of DDE research.

Figure 3 , crafted within CiteSpace, delineates the collaborative contours of global research in Design for Digital Equity (DDE). Literature data are input with ‘country’ as the node type and annual segmentation for time slicing, employing the ‘Cosine’ algorithm to gauge the strength of links and the ‘g-index’ ( K  = 25) for selection criteria. The visualization employs a color gradient to denote the years of publication, with the proximity of nodes and the thickness of the interconnecting links articulating the intensity and frequency of collaborative efforts among nations. For instance, the close-knit ties between the United States, Germany, and France underscore a robust tripartite research collaboration within the DDE domain. The size of the nodes corresponds directly to the proportion of DDE publications contributed by each country. Larger nodes, such as those representing the USA and Germany, suggest more publications, indicating significant research activity and influence within the field. Purple nodes, such as those representing England and Canada, signal a strong centrality within the network, suggesting these countries contribute significantly and play a pivotal role in disseminating research findings throughout the network. The intertwining links of varying thickness reveal the nuanced interplay of collaboration: dense webs around European countries, for instance, underscore a rich tradition of continental cooperation, while transatlantic links point to ongoing exchanges between North American and European researchers. Moreover, the appearance of vibrant links extending toward Asian countries such as China and South Korea reflects the expanding scope of DDE research to encompass a truly global perspective, integrating diverse methodologies and insights as the research community tackles the universal challenges of digital equity.

Collaborative networks between countries and regions in DDE research.

Visual analysis by institutions

Table 3 presents a quantified synopsis of institutional research productivity and centrality within the Design for Digital Equity field. The University of Toronto emerges as the most prolific contributor, with 64 publications and a centrality score of 0.06, indicating a significant impact on the field since 2008. The University System of Georgia and the Georgia Institute of Technology, each with 27 and 25 publications, respectively, registering a centrality of 0.01 since 2006, denoting their sustained scholarly activity over time. The Oslo Metropolitan University, with 23 publications and a centrality of 0.02 since 2016, and the Consiglio Nazionale delle Ricerche, with 17 publications since 2009, highlight the diverse international engagement in DDE research. The table also notes the early contributions of the Pennsylvania Commonwealth System of Higher Education, with 17 publications since 2004, although its centrality remains at 0.01. Institutions such as Laval University, Monash University, and the Polytechnic University of Milan show emergent centrality in the field, with recent increases in scholarly output, as indicated by their respective publication counts of 13, 12, and 12 since 2019, 2020, and 2018. This data evidences a dynamic and growing research domain characterized by historical depth and contemporary expansion.

Figure 4 displays a network map highlighting the collaborative landscape among institutions in the field of DDE. The University of Toronto commands a central node with a substantial size, indicating its leading volume of research output. The University of Alberta and CNR exhibit nodes colored to represent earlier works in the field, establishing their roles as foundational contributors. Inter-institutional links, albeit pleasing, are observable, suggesting research collaborations. Nodes such as the University of London and the Polytechnic University of Milan, while smaller, are nonetheless integral, denoting their active engagement in DDE research. The color coding of nodes corresponds to publication years, with warmer colors indicating more recent research, providing a temporal dimension to the map. This network visualization is an empirical tool to assess the scope and scale of institutional contributions and collaborations in DDE research.

Network Map of Institutional Collaboration in DDE.

Analysis by publications

Table 4 delineates the pivotal academic publications contributing to the field, as evidenced by citation count, centrality, and publication year, offering a longitudinal perspective of influence and relevance. ‘Lecture Notes in Computer Science’ leads the discourse with 354 citations and the highest centrality of 0.10 since 2004, indicating its foundational and central role over nearly two decades. This is followed by the ‘Journal of Medical Internet Research,’ with 216 citations since 2013 and centrality of 0.05, evidencing a robust impact in a shorter timeframe. The relationship between citation count and centrality reveals a pattern of influential cores within the field. Publications with higher citation counts generally exhibit greater centrality, suggesting that they are reference points within the academic network and instrumental in shaping the digital equity narrative. The thematic diversity of the publications—from technology-focused to health-oriented publications like ‘Computers in Human Behavior’ and ‘Disability and Rehabilitation’—reflects the interdisciplinary nature of research in digital equity, encompassing a range of issues from technological access to health disparities. ‘CoDesign,’ despite its lower position with 101 citations since 2016 and centrality of 0.01, represents the burgeoning interest in participatory design practices within the field. Its presence underscores the evolving recognition of collaborative design processes as essential to achieving digital equity, particularly in the later years where user-centered design principles are increasingly deemed critical for inclusivity in digital environments.

Visual analysis by authors

Table 5 enumerates the most influential authors in the domain of DDE research, ranked by citation count and centrality within the academic network from the year of their first cited work. The table is led by Braun V., with a citation count of 103 and a centrality of 0.13 since 2015, indicating a strong influence in the recent scholarly conversation on DDE. Close behind, the World Health Organization (WHO), with 97 citations and a centrality of 0.10 since 2012, and Nielsen J., with an impressive centrality of 0.32 and 89 citations since 1999, denote long-standing and significant contributions to the field. The high centrality scores, remarkably Nielsen’s, suggest these authors’ works are central nodes in the network of citations, acting as crucial reference points for subsequent research. Further down the list, authors such as Davis F.D. and Venkatesh V. are notable for their scholarly impact, with citation counts of 74 and 59, respectively, and corresponding centrality measures that reflect their substantial roles in shaping DDE discourse. The table also recognizes the contributions of authoritative entities like the United Nations and the World Health Organization, reflecting digital equity research’s global and policy-oriented dimensions. The presence of ISO in the table, with a citation count of 25 since 2015, underscores the importance of standardization in the digital equity landscape. The diversity in authors and entities—from individual researchers to global organizations—highlights the multi-faceted nature of research in DDE, encompassing technical, social, and policy-related studies.

Figure 5 illustrates the collaborative network between cited authors in the DDE study. The left side of the network map is characterized by authors with cooler-colored nodes, indicating earlier contributions to digital equity research. Among these, Wright Ronald stands out with a significantly large node and a purple outline, highlighting his seminal role and the exceptional citation burst in his work. Cool colors suggest these authors laid the groundwork for subsequent research, with their foundational ideas and theories continuing to be pivotal in the field. Transitioning across the network to the right, a gradual shift to warmer node colors is observed, representing more recent contributions to the field. Here, the nodes increase in size, notably for authors such as Braun V. and the WHO, indicating a high volume of publications and a more contemporary impact on the field. The links between these recent large nodes and the earlier contributors, such as Wright Ronald, illustrate a scholarly lineage and intellectual progression within the research community. The authors with purple outlines on the right side of the map indicate recent citation bursts, signifying that their work has quickly become influential in the academic discourse of digital equity research. These bursts are likely a response to the evolution of digital technologies and the emerging challenges of equality within the digital space.

Collaborative networks of globally cited authors in DDE research.

Visual analysis by keywords

The concurrent keywords reflect the research hotspots in the field of DDE. Table 6 presents the top 30 keywords with the highest frequency and centrality, while Fig. 6 shows the co-occurrence network of these keywords. Within the purview of Fig. 6 , the visualization elucidates the developmental trajectory of pivotal terms in the digital equity research domain. The nodes corresponding to ‘universal design,’ ‘assistive technology,’ and ‘user-centered design’ are characterized by lighter centers within their larger structures, signifying an established presence and a maturation over time within scholarly research. The robust, blue-hued link connecting ‘universal design’ and ‘assistive technology’ underscores these foundational concepts’ strong and historical interrelation. The nodes encircled by purple outlines, such as ‘universal design,’ ‘inclusive design,’ and ‘participatory design,’ denote a high degree of centrality. This indicates their role as critical junctions within the research network, reflecting a widespread citation across diverse studies and underscoring their integral position within the thematic constellation of the field. Of particular note are the nodes with red cores, such as ‘design for all,’ ‘digital health,’ ‘visual impairment,’ ‘mobile phone,’ and ‘digital divide.’ These nodes signal emergent focal points of research, indicating recent academic interest and citation frequency surges. Such bursts are emblematic of the field’s dynamic nature, pointing to evolving hotspots of scholarly investigation. For instance, the red core of ‘digital health’ suggests an intensifying dialogue around integrating digital technology in health-related contexts, a pertinent issue in modern discourse.

Keyword co-occurrence networks in the DDE domain.

Building upon the highlighted red-core nodes denoting keyword bursts in Figs. 6 , 7 , “Top 17 Keywords with the Strongest Citation Bursts in DDE,” offers a quantified analysis of such emergent trends. This figure tabulates the keywords that have experienced the most significant surges in academic citations within the field of DDE from 1997 to 2023. Keywords such as ‘design for all’ and ‘universal design’ anchor the list, showcasing their foundational bursts starting from 1997, with ‘design for all’ maintaining a high citation strength of 20.66 until 2015 and ‘universal design’ demonstrating enduring relevance through 2016. This signifies the long-standing and evolving discourse surrounding these concepts. In contrast, terms like ‘mobile phone,’ ‘digital health,’ and ‘participation’ represent the newest fronts in DDE research, with citation bursts emerging as late as 2020 and 2021, reflecting the rapid ascent of these topics in the recent scholarly landscape. The strength of these bursts, particularly the 7.07 for ‘mobile phone,’ suggests a burgeoning field of study responsive to technological advancements and societal shifts. The bar graph component of the figure visually represents the duration of each burst, with red bars marking the start and end years. The length and position of these bars corroborate the temporal analysis, mapping the lifecycle of each keyword’s impact.

Top 17 Keywords with the Strongest Citation Bursts in DDE.

The authors have conducted a keyword clustering analysis on the data presented in Fig. 6 , aiming to discern the interrelationships between keywords and delineate structured knowledge domains within the field of DDE. Utilizing the Latent Semantic Indexing (LSI) algorithm to derive the labeling of clusters, they have effectively crystallized seven distinct clusters in DDE research, as depicted in Fig. 8 . The cluster represented in red, labeled ‘#0 universal design,’ signifies a group of closely related concepts that have been pivotal in discussions on making design accessible to all users. This cluster’s central placement within the figure suggests its foundational role in DDE. Adjacent to this, in a lighter shade of orange, is the ‘#1 user-centered design’ cluster, indicating a slightly different but related set of terms emphasizing the importance of designing with the end-user’s needs and experiences in mind. The ‘#2 assistive technology’ cluster, shown in yellow, groups terms around technologies designed to aid individuals with disabilities, signifying its specialized yet crucial role in promoting digital equity. Notably, the #3 digital health cluster in green and the #4 mobile phone cluster in turquoise highlight the intersection of digital technology with health and mobile communication, illustrating the field’s expansion into these dynamic research areas. The ‘#6 participatory design’ cluster in purple and ‘#7 independent living’ cluster in pink emphasize collaboration in design processes and the empowerment of individuals to live independently, respectively.

Keyword clustering analysis map for DDE research.

In addition, the timeline function in CiteSpace was used to present the seven clusters in Fig. 8 and the core keywords they contain (the threshold for Label was set to 6) annually, as shown in Fig. 9 . The timeline graph delves deeper into the clusters’ developmental stages and interconnections of keywords. In the #0 universal design cluster, the term ‘universal design’ dates back to 1997, alongside ‘assistive technology,’ ‘user participation,’ and ‘PWDs,’ which together marked the inception phase of DDE research within the universal design cluster, where the focus was on creating accessible environments and products for the broadest possible audience. With the advancement of digital technologies, terms like ‘artificial intelligence’ in 2015, ‘digital accessibility’ in 2018, and the more recent ‘students with disabilities’ have emerged as new topics within this cluster. Along with #0 universal design, the #6 participatory design cluster has a similarly lengthy history, with terms like ‘computer access’ and ‘design process’ highlighting the significance of digital design within this cluster. Moreover, within this timeline network, many terms are attributed to specific populations, such as ‘PWDs,’ ‘children,’ ‘aging users,’ ‘adults,’ ‘students,’ ‘blind people,’ ‘stroke patients,’ ‘family caregivers,’ ‘persons with mild cognitive impairments,’ ‘active aging,’ and ‘students with disabilities,’ revealing the user groups that DDE research needs to pay special attention to, mainly the recent focus on ‘mild cognitive impairments’ and ‘students with disabilities,’ which reflect emerging issues. Then, the particularly dense links in the graph hint at the correlations between keywords; for instance, ‘children’ and ‘affective computing’ within the #6 participatory design cluster are strongly related, and the latest terms ‘education’ and ‘autism spectrum disorder occupational therapy’ are strongly related, revealing specific issues within the important topic of education in DDE research. Other nodes with dense links include ‘digital divide,’ ‘user acceptance,’ ‘social participation,’ ‘interventions,’ ‘social inclusion,’ and ‘design for independence,’ reflecting the issues that have received scholarly attention in social sciences. Finally, on the digital technology front, ‘smart home’ emerged in 2006, followed by the terms ‘digital divide’ and ‘user interface’ in the same year. The emergence of ‘VR’ in 2014, ‘AR’ in 2016, and ‘wearable computing’ in 2017 also explain the digital technology focal points worth attention in DDE research.

Timeline plot of 8 clusters of DDE keywords.

Dual-map overlays analysis of publications clusters

The double map overlay functionality of CiteSpace has been utilized to present a panoramic visualization of the knowledge base in DDE research (Fig. 10 ). This technique maps the citation dynamics between clusters of cited and cited publications, revealing the field’s interdisciplinary nature and scholarly communication. The left side of the figure depicts clusters of citing publications, showcasing newer disciplinary domains within DDE research. In contrast, the right side represents clusters of cited publications, reflecting the research foundations of DDE studies. Different colored dots within each cluster indicate the distribution of publications in that cluster. Notably, the arcs spanning the visualization illustrate the citation relationships between publications, with the thickness of the arcs corresponding to the citation volume. These citation trajectories from citing to cited clusters demonstrate the knowledge transfer and intellectual lineage of current DDE research within and across disciplinary boundaries. Notably, the Z-score algorithm converged on those arcs with stronger associations, yielding thicker arcs in green and blue. This indicates that the foundation of DDE research stems from two main disciplinary areas, namely ‘5.

The left side represents citing publication clusters and the right side represents cited publication clusters.

Health, nursing, medicine’ and ‘7. psychology, education, and social on the right side of the figure. Publications from ‘2. MEDICINE, MEDICAL, CLINICAL’ and ‘10. ECONOMICS, ECONOMIC POLITICAL,’ and ‘6. On the left side, PSYCHOLOGY, EDUCATION, and health cite these two disciplinary areas extensively. In other words, the knowledge frontier of DDE research is concentrated in medicine and psychology, and their knowledge bases are also in the domains of health and psychology. However, there is a bidirectional cross-disciplinary citation relationship between the two areas—additionally, the red arcs from the ‘1. MATHEMATICS, SYSTEMS, MATHEMATICAL’ publications cluster showcase another facet of the knowledge frontier in DDE research, as they cite multiple clusters on the right side, forming a divergent structure, which confirms that some of the frontiers of MATHEMATICS in DDE research are based on a broader range of disciplines. The different network structures macroscopically reveal the overall developmental pattern of DDE research.

Hotspots and emerging trends

To answer RQ3, based on the research findings, the literature was re-engaged to reveal the research hotspots and emerging trends of DDE. These hotspots and trends are primarily concentrated in the following areas:

Embracing co-design and practical implementation in inclusive and universal design research

Research in inclusive and universal design increasingly emphasizes co-design with stakeholders, reflecting significant growth in publication (Table 4 on Co-design). In the digital context, transitioning from theory to practice in equity-centered design calls for enhanced adaptability and feasibility of traditional design theories. This shift requires a pragmatic and progressive approach, aligning with recent research (Zhang et al., 2023 ). Furthermore, the evidence-based practices in DDE (Cluster #6) are integral to this dimension, guiding the pragmatic application of design theories.

Focusing on digital mental health and urban-rural inequalities

In DDE, critical issues like the digital divide and mental health are central concerns. The focus on digital and mobile health, highlighted in Fig. 9 , shows a shift towards using technology to improve user engagement and address health challenges. As highlighted by Cosco (Cosco et al., 2021 ), mental health has emerged as a crucial focus in DDE, underscoring the need for designs that support psychological well-being. Additionally, ageism (Mannheim et al., 2023 ) and stereotypes (Nicosia et al., 2022 ) influence technology design in DDE, pointing to societal challenges that need addressing for more inclusive digital solutions. Patten’s (Patten et al., 2022 ) focus on smoking cessation in rural communities indicates a growing emphasis on reducing health disparities, ensuring that digital health advancements are inclusive and far-reaching. These trends in DDE highlight the importance of a holistic approach that considers technological, societal, and health-related factors.

Integration of empathetic, contextualized, and non-visual digital technologies

In the realm of DDE, the technology dimension showcases a range of emerging trends and research hotspots characterized by advancements in immersive technologies, assistive devices, and interactive systems. Technologies like VR (Bortkiewicz et al., 2023 ) and AR (Creed et al., 2023 ) are revolutionizing user experiences, offering enhanced empathy and engagement while raising new challenges. The growth in mobile phone usage (Cluster #4) and the development of 3D-printed individualized assistive devices (IADs) (Lamontagne et al., 2023 ) reflect an increasing emphasis on personalization and catering to diverse user needs. Tangible interfaces (Aguiar et al., 2023 ) and haptic recognition systems (Lu et al., 2023 ) make digital interactions more intuitive. The integration of cognitive assistive technology (Roberts et al., 2023 ) and brain-computer interfaces (BCI) (Padfield et al., 2023 ) is opening new avenues for user interaction, particularly for those with cognitive or physical limitations. The exploration of Social Assistive Robots (SAR) (Kaplan et al., 2024 ) and the application of IoT (Almukadi, 2023 ) illustrate a move towards socially aware and interconnected digital ecosystems, while voice recognition technologies (Berner & Alves, 2023 ) are enhancing accessibility. Edge computing (Walczak et al., 2023 ) represents a shift towards decentralized and user-oriented solutions.

For intergenerational relationships, students with disabilities and the visually impaired

The concurrent digitization trends and rapid global aging closely resemble the growth curve of DDE publications, as shown in Fig. 2 . The concept of active aging, championed by WHO (World Health Organization 2002 ), exerts a substantial impact. This effect is evident across multiple indicators, including a significant number of DDE papers published in the journal GERONTOLOGIST (109 articles), the prominent node of “elderly people” in keyword co-occurrence, and the notable mention of “elderly people” in keyword analysis (strength=3.62). Moreover, in 2011, China, the country with the largest elderly population globally, contributed 73 articles related to DDE (Table 2 ), further emphasizing the growing demand for future DDE research focusing on the elderly. Within DDE studies on the elderly, intergenerational relationships (Li & Cao, 2023 ) represent an emerging area of research. Additionally, two other emerging trends are centered on the educational and visually impaired populations. The term ‘students with disabilities’ in Fig. 9 illustrates this trend. This is reflected in the focus on inclusive digital education (Lazou & Tsinakos, 2023 ) and the digital health needs of the visually impaired (Yeong et al., 2021 ), highlighting the expanding scope of user-centric DDE research.

The intellectual structure of DDE

Previous studies have dissected DDE through various disciplinary lenses, often yielding isolated empirical findings. However, a comprehensive synthesis that contemplates the intricate interplay among DDE constructs has yet to be conspicuously absent. To fill this gap and answer RQ4, an intellectual structure that encapsulates the entirety of DDE was developed, amalgamating user demographics, design strategies, interdisciplinary approaches, and the overarching societal implications. This holistic structure, depicted in Fig. 11 , The DDE structure elucidates the multi-faceted approach required to achieve digital equity, integrating diverse user needs with tailored design strategies and bridging technological innovation with interdisciplinary methodologies. Its core function is to guide the creation of inclusive digital environments that are accessible, engaging, and responsive to the varied demands of a broad user spectrum.

Design for Digital Equity (DDE) intellectual structure.

At the core of discussions surrounding digital equity lies the extensively examined and articulated issue of the digital divide, a well-documented challenge that scholars have explored (Gallegos-Rejas et al., 2023 ). This is illustrated in the concentric circles of the red core within the keyword contribution analysis, as depicted in Fig. 6 . It reflects the persistent digital access and literacy gaps that disproportionately affect marginalized groups. This divide extends beyond mere connectivity to encompass the nuances of social engagement (Almukadi, 2023 ), where the ability to participate meaningfully in digital spaces becomes a marker of societal inclusion. As noted by (Bochicchio et al., 2023 ; Jetha et al., 2023 ), employment is a domain where digital inequities manifest, creating barriers to employment inclusion. Similarly, feelings of loneliness, social isolation (Chung et al., 2023 ), and deficits in social skills (Estival et al., 2023 ) are exacerbated in the digital realm, where interactions often require different competencies. These social dimensions of DDE underscore the need for a more empathetic and user-informed approach to technology design, one that can cater to the nuanced needs of diverse populations, including medication reminders and telehealth solutions (Gallegos-Rejas et al., 2023 ) while minimizing cognitive load (Gomez-Hernandez et al., 2023 ) and advancing digital health equity (Ha et al., 2023 ).

The critical element of the DDE intellectual structure is the design strategy, as evidenced by the two categories #0 generic design and #6 participatory design, which contain the most prominent nodes in the keyword clustering in Part IV of this paper. Digital transformation through design thinking (Oliveira et al., 2024 ), user-centered design (Stawarz et al., 2023 ), and the co-design of 3D printed assistive technologies (Aflatoony et al., 2023 ; Benz et al., 2023 ; Ghorayeb et al., 2023 ) reflect the trend towards personalized and participatory design processes. Empathy emerges as a recurrent theme, both in contextualizing user experiences (Bortkiewicz et al., 2023 ) and in visualizing personal narratives (Gui et al., 2023 ), reinforcing the need for emotional durability (Huang et al., 2023 ) and accessible design (Jonsson et al., 2023 ). These approaches are not merely theoretical but are grounded in the pragmatics of participatory design (Kinnula et al., 2023 ), the living labs approach (Layton et al., 2023 ), and virtual collaborative design workshops (Peters et al., 2023 ), all of which facilitate the co-creation of solutions that resonate with the lived experiences of users.

One of the significant distinctions between DDE and traditional fairness-centered design lies in technical specifications. Supporting these strategies are fundamental theories and standards such as the Web Content Accessibility Guidelines (WCAG) (Jonsson et al., 2023 ), the Technology Acceptance Model (TAM) (Alvarez-Melgarejo et al., 2023 ), and socio-technical systems (STS) (Govers & van Amelsvoort, 2023 ), which provide the ethical and methodological framework for DDE initiatives. Additionally, digital ethnography (Joshi et al., 2023 ) and the Person-Environment-Tool (PET) framework (Jarl, Lundqvist 2020 ) offer valuable perspectives to analyze and design for the intricate interplay of human, technological, and environmental interactions.

Another noteworthy discovery highlighted by the previously mentioned findings is the rich interdisciplinary approach within the field of DDE. This interdisciplinary nature, exemplified by the integration of diverse knowledge domains, is evident in publications analysis of DDE (Table 4 ) and is visually demonstrated through the overlay of disciplinary citation networks (Fig. 10 ). Strategies such as gamification (Aguiar et al., 2023 ), music therapy (Chen & Norgaard, 2023 ), and multimodal communication strategies (Given et al., 2023 ) underline the synergistic potential of integrating diverse knowledge domains to foster more inclusive digital environments. Cognitive Behavioral Therapy (Kayser et al., 2023 ), multimedia advocacy (Watts et al., 2023 ), arts-based methods (Miller & Zelenko, 2022 ), storytelling (Ostrowski et al., 2021 ), and reminiscence therapy (Unbehaun et al., 2021 ) are not merely adjuncts but integral components that enhance the relevance and efficacy of DDE interventions.

Equally important, the relationship between the target users of DDE and digital technologies needs to be focused on as a design strategy. This includes attitudes, needs, challenges, risks, and capacity indicators. Positive outlooks envision digital transformation as a new norm post-pandemic for individuals with disabilities (Aydemir-Döke et al., 2023 ), while others display varied sentiments (Bally et al., 2023 ) or even hostile attitudes, as seen in the challenges of visually impaired with online shopping (Cohen et al., 2023 ). These attitudes interplay with ‘Needs’ that span essential areas, from service to recreational, highlighting the importance of ‘Capacity Indicators’ like digital literacy and digital thinking (Govers & van Amelsvoort, 2023 ) to bridge these gaps. The ‘Challenges and Risks’ associated with DDE, such as the adverse impacts of apps in medical contexts (Babbage et al., 2023 ) and ergonomic issues due to immersive technologies (Creed et al., 2023 ), present barriers that need to be mitigated to foster a conducive environment for digital engagement. Despite a generally positive attitude toward digital transformation, the low usage rates (Dale et al., 2023 ), usability concerns (Davoody et al., 2023 ), cultural differences in thinking, and the need for a humanizing digital transformation (Dragicevic et al., 2023b ) underscore the complexity of achieving digital equity. The widespread resistance and abandonment of rehabilitative technologies (Mitchell et al., 2023 ) further emphasize the need for DDE strategies that are culturally sensitive and user-friendly.

Going deeper, the arrows signify dynamic interrelationships among various components within the DDE intellectual structure. “Needs” drive the design and application of “Digital Technologies,” which in turn inspire “Innovative” solutions and approaches. Feedback from these innovations influences “Attitudes,” which, along with “Needs,” can pose “Challenges and Risks,” thereby shaping the “Capacity Indicators” that gauge proficiency in navigating the digital landscape. This cyclical interplay ensures that the DDE framework is not static but an evolving guide responsive to the changing landscape of digital equity.

future research direction

In the process of identifying research gaps and future directions, innovative research opportunities were determined from the results of temporal attributes in the visual, intellectual graph:

Emotional, cultural, and aesthetic factors in human-centered design: Universal Design (UD) and Design for All (DFA) will remain central themes in DDE. However, affective computing and user preferences must be explored (Alves et al., 2020 ). Beyond functional needs, experiential demands such as aesthetics, self-expression, and creativity, often overlooked in accessibility guidelines, are gaining recognition (Recupero et al., 2021 ). The concept of inclusive fashion (Oliveira & Okimoto, 2022 ) underscores the need to address multi-faceted user requirements, including fashion needs, cultural sensitivity, and diversity.

Digital technology adoption and improving digital literacy: The adoption of multimodal and multisensory interactions is gaining increased attention, with a growing focus on voice, tangible, and natural interaction technologies, alongside research into technology acceptance, aligning with the findings (Li et al., 2023 ). Exploring these interactive methods is crucial for enhancing user engagement and experience. However, there is a notable gap in research on the acceptance of many cutting-edge digital technologies. Additionally, investigating how design strategies can enhance digital literacy represents a valuable study area.

Expanding the Geographic and Cultural Scope: Literature indicates that the situation of DDE in developing countries (Abbas et al., 2014 ; Nahar et al., 2015 ) warrants in-depth exploration. Current literature and the distribution of research institutions show a significant gap in DDE research in these regions, especially in rural areas (as seen in Tables 2 and 3 and Figs. 3 and 4 ). Most research and literature is concentrated in developed countries, with insufficient focus on developing nations. Conversely, within developed countries, research on DDE concerning minority groups (Pham et al., 2022 ) and affluent Indigenous populations (Henson et al., 2023 ) is almost nonexistent. This situation reveals a critical research gap: even in economically advanced nations, the needs and preferences of marginalized groups are often overlooked. These groups may face unique challenges and needs, which should be explored or understood in mainstream research.

Multi-disciplinary Research in Digital Equity Design: While publication analysis (Table 4 ) and knowledge domain flow (Fig. 10 ) reveal the interdisciplinary nature of DDE, the current body of research predominantly focuses on computer science, medical and health sciences, sociology, and design. This review underscores the necessity of expanding research efforts across a broader spectrum of disciplines to address the diverse needs inherent in DDE adequately. For instance, the fusion of art, psychology, and computer technology could lead to research topics such as “Digital Equity Design Guidelines for Remote Art Therapy.” Similarly, the amalgamation of education, computer science, design, and management studies might explore subjects like “Integrating XR in Inclusive Educational Service Design: Technological Acceptance among Special Needs Students.” These potential research areas not only extend the scope of DDE but also emphasize the importance of a holistic and multi-faceted approach to developing inclusive and accessible digital solutions.

Practical implication

This study conducted an in-depth bibliometric and visualization analysis of the Digital Equity Design (DDE) field, revealing key findings on publication trends, significant contributors and collaboration patterns, key clusters, research hotspots, and intellectual structures. These insights directly affect policy-making, interdisciplinary collaboration, design optimization, and educational resource allocation. Analysis of publication trends provides policymakers with data to support digital inclusivity policies, particularly in education and health services, ensuring fair access to new technologies for all social groups, especially marginalized ones. The analysis of significant contributors and collaboration patterns highlights the role of interdisciplinary cooperation in developing innovative solutions, which is crucial for organizations and businesses designing products for specific groups, such as the disabled and elderly, in promoting active aging policies. Identifying key clusters and research hotspots guides the focus of future technological developments, enhancing the social adaptability and market competitiveness of designs. The construction of intellectual structures showcases the critical dimensions of user experience within DDE and the internal logic between various elements, providing a foundation for promoting deeper user involvement and more precise responses to needs in design research and practice, particularly in developing solutions and assessing their effectiveness to ensure that design outcomes truly reflect and meet end-user expectations and actual use scenarios.

Limitations

Nevertheless, this systematic review is subject to certain limitations. Firstly, the data sourced exclusively from the WOS is a constraint, as specific functionalities like dual-map overlays are uniquely tailored for WOS bibliometric data. Future studies could expand the scope by exploring DDE research in databases such as Scopus, Google Scholar, and grey literature. Additionally, while a comprehensive search string for DDE was employed, the results were influenced by the search timing and the subscription range of different research institutions to the database. Moreover, the possibility of relevant terms existing beyond the search string cannot be discounted. Secondly, despite adhering to the PRISMA guidelines for literature acquisition and screening, subjectivity may have influenced the authors during the inclusion and exclusion process, particularly while reviewing abstracts and full texts to select publications. Furthermore, the reliance solely on CiteSpace as the bibliometric tool introduces another limitation. The research findings are contingent on the features and algorithms of the current version of CiteSpace (6.2.r6 advanced). Future research could incorporate additional or newer versions of bibliometric tools to provide a more comprehensive analysis.

This systematic review aims to delineate the academic landscape of DDE by exploring its known and unknown aspects, including research progress, intellectual structure, research hotspots and trends, and future research recommendations. Before this review, these facets could have been clearer. To address these questions, a structured retrieval strategy set by PICo and a PRISMA process yielded 1705 publications, which were analyzed using CiteSpace for publication trends, geographic distribution of research collaborations, core publications, keyword co-occurrence, emergence, clustering, timelines, and dual-map overlays of publication disciplines. These visual presentations propose a DDE intellectual structure, although the literature data is focused on the WOS database. This framework could serve as a guide for future research to address these crucial issues. The DDE intellectual structure integrates research literature, particularly eight thematic clusters. It not only displays the overall intellectual structure of DDE on a macro level but also reveals the intrinsic logic between various elements. Most notably, as pointed out at the beginning of this review, digital equity, as a critical factor in achieving sustainable development goals, requires human-centered design thinking. An in-depth discussion of the research findings reveals that the development of DDE is characterized by a multi-dimensional approach, encompassing a wide range of societal, technological, and user-specific issues. Furthermore, emerging trends indicate that the future trajectory of DDE will be more diverse and inclusive, targeting a broad spectrum of user needs and societal challenges. Another significant aspect of this review is the proposition of four specific directions for future research, guiding researchers dedicated to related disciplines.

Data availability

The datasets generated or analyzed during the current study are available in the Dataverse repository: https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/S5XXFB .

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Diagnostic evaluation of the contribution of complementary training subjects in the self-perception of competencies in ethics, social responsibility, and sustainability in engineering students.

1. Introduction

2. theoretical framework, 3. review of related research, 4. materials and methods, 4.1. study population, 4.2. instrument, 4.3. data analysis technique, 5.1. descriptive statistics, 5.2. analysis of competencies in ers vs. courses taken, 5.3. relationship of ers competencies with sociodemographic variables, 6. discussion, 7. conclusions, 8. future work, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Yepes, S.M.; Montes, W.F.; Herrera, A. Diagnostic Evaluation of the Contribution of Complementary Training Subjects in the Self-Perception of Competencies in Ethics, Social Responsibility, and Sustainability in Engineering Students. Sustainability 2024 , 16 , 7069. https://doi.org/10.3390/su16167069

Yepes SM, Montes WF, Herrera A. Diagnostic Evaluation of the Contribution of Complementary Training Subjects in the Self-Perception of Competencies in Ethics, Social Responsibility, and Sustainability in Engineering Students. Sustainability . 2024; 16(16):7069. https://doi.org/10.3390/su16167069

Yepes, Sara María, Willer Ferney Montes, and Andres Herrera. 2024. "Diagnostic Evaluation of the Contribution of Complementary Training Subjects in the Self-Perception of Competencies in Ethics, Social Responsibility, and Sustainability in Engineering Students" Sustainability 16, no. 16: 7069. https://doi.org/10.3390/su16167069

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This paper is in the following e-collection/theme issue:

Published on 19.8.2024 in Vol 26 (2024)

Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework

Authors of this article:

• Made Ary Sarasmita 1, 2 * , MClinPharm, PhD   ; 
• Ya-Han Lee 1, 3 , MSc   ; 
• Fan-Ying Chan 1 , MSc   ; 
• Hsiang-Yin Chen 1, 3 * , PharmD  

1 Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan

2 Program Study of Pharmacy, Faculty of Mathematics and Science, Udayana University, Badung, Indonesia

3 Department of Pharmacy, Wan Fang Hospital, Taipei, Taiwan

*these authors contributed equally

Corresponding Author:

Hsiang-Yin Chen, PharmD

Department of Clinical Pharmacy

School of Pharmacy

Taipei Medical University

Health and Science Building, 7th Fl.

250 Wuxing Street

Taipei, 110

Phone: 886 02 2736 1661 ext 6175

Fax:886 02 2736 1661

Email: [email protected]

Background: Digital serious games (SGs) have rapidly become a promising strategy for entertainment-based health education; however, developing SGs for children with chronic diseases remains a challenge.

Objective: In this study, we attempted to provide an updated scope of understanding of the development and evaluation of SG educational tools and develop a framework for SG education development to promote self-management activities and behavior change in children with chronic diseases.

Methods: This study consists of a knowledge base and an analytical base. This study followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. To build the knowledge base, 5 stages of research were developed, including refining the review question (stage 1), searching for studies (stage 2), selecting relevant studies (stage 3), charting the information (stage 4), and collating the results (stage 5). Eligible studies that developed SG prototypes and evaluated SG education for children with chronic diseases were searched for in PubMed, Embase, Google Scholar, and peer-reviewed journals. In the analytical base, the context-mechanism-output approach and game taxonomy were used to analyze relevant behavioral theories and essential game elements. Game taxonomy included social features, presentation, narrative and identity, rewards and punishment, and manipulation and control. A total of 2 researchers selected the domains for the included behavioral theories and game elements. The intended SG framework was finalized by assembling SG fragments. Those SG fragments were appropriately reintegrated to visualize a new SG framework.

Results: This scoping review summarized data from 16 randomized controlled trials that evaluated SG education for children with chronic diseases and 14 studies on SG frameworks. It showed that self-determination theory was the most commonly used behavioral theory (9/30, 30%). Game elements included feedback, visual and audio designs, characters, narratives, rewards, challenges, competitions, goals, levels, rules, and tasks. In total, 3 phases of a digital SG framework are proposed in this review: requirements (phase 1), design and development (phase 2), and evaluation (phase 3). A total of 6 steps are described: exploring SG requirements (step 1), identifying target users (step 2), designing an SG prototype (step 3), building the SG prototype (step 4), evaluating the SG prototype (step 5), and marketing and monitoring the use of the SG prototype (step 6). Safety recommendations to use digital SG-based education for children in the post–COVID-19 era were also made.

Conclusions: This review summarizes the fundamental behavioral theories and game elements of the available literature to establish a new theory-driven step-by-step framework. It can support game designers, clinicians, and educators in designing, developing, and evaluating digital, SG-based educational tools to increase self-management activities and promote behavior change in children with chronic diseases.

Introduction

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.

Study Design

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.

Knowledge Base

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 ].

Refining the Review Question (Stage 1)

SGs are digital games that blend concepts of learning and performing attitudes and are enjoyable to play, with challenging goals [ 28 ]. On the basis of the literature, we began exploring the idea of how to develop an SG framework to improve self-management and promote behavior changes in children with chronic diseases. To develop an SG framework, a scientific foundation should be built supported by documented relevant evidence.

Identifying Relevant Studies (Stage 2)

Databases and search strategy.

Relevant studies that had developed and published established SG frameworks and SG prototypes for children with chronic diseases were searched for using electronic databases, including PubMed, Embase, and Google Scholar. A hand searching method was also used to obtain additional relevant articles in peer-reviewed journals that focused on game research and were indexed in Web of Science, such as Games for Health Journal and JMIR Serious Games . We searched for articles using keywords obtained from Medical Subject Heading terms, such as “computer game,” “video game,” and “children,” with no restriction on publication year (1980-2024). The panel in Multimedia Appendix 1 shows keyword term variations, and detailed search strategies are described in Table S1 in Multimedia Appendix 1 . Reference lists of articles found through the electronic database searching were hand searched to obtain additional relevant information.

Inclusion Criteria

The inclusion criteria were (1) studies involving children aged 5 to 14 years, (2) studies that developed an SG framework for children with chronic diseases, and (3) studies that applied and evaluated the use of SG education for children with chronic diseases. Relevant articles were classified into two groups: (1) studies that focused on developing an SG framework and (2) studies that focused on evaluating SG educational tools for children with chronic diseases. Review or original articles explaining learning theories, behavioral theories, game theories, and game elements or presenting a general or specific SG model or framework that focused on behavior changes in children were included in the “SG framework studies” group. Randomized controlled trials (RCTs) that implemented and evaluated SG-based educational tools for children with chronic diseases were included in the “SG education studies/RCTs” group.

SG-based education is described as the use of SG prototypes or interventions, which are also known as computer games, for educational health and promotion of treatments, health education, patient adherence, therapeutic and side effect monitoring, and patient engagement. In this study, any changes in health-related outcomes in an RCT were descriptively reported. Clinical outcomes referred to any reduction in symptoms of chronic diseases and risks of complications, emergency visits, and hospitalizations. Humanistic outcomes were considered to be any condition that affected physical and social functions [ 29 ], including changes in attitudes and behaviors, adherence to treatment and medication, knowledge, quality of life, and patient satisfaction.

Selecting Relevant Studies (Stage 3)

The collected articles were initially imported into reference manager software (EndNote version 20; Clarivate Analysis). After removing duplicates, 2 researchers (MAS and YHL) independently assessed the articles using the inclusion criteria by examining titles and abstracts. Abstracts that met the inclusion criteria were retained for full-text review.

Charting the Information (Stage 4)

Characteristics of SG education for children with chronic diseases that were evaluated in RCTs were charted into a table, including authors’ information, conditions, target ages, interventions, comparators, sample sizes, study duration, length of the study, and health-related outcomes. Data were summarized by 2 authors (MAS and YHL). Disagreements were resolved through discussion involving a third reviewer (HYC).

Collating the Results (Stage 5)

The components of SGs were collated from the included studies using the CMO approach [ 23 ]. According to the CMO approach, “context” consists of any fundamental principles that enhance the efficacy of SG education to induce behavior changes, including behavioral theories, learning theories, and game theories. “Mechanism” refers to rules of how a game works, the dynamics through which children interact in response to the game, and the game’s appearance. It includes game elements to actively engage and motivate target users to perform self-management activities and positive behaviors. “Output” is related to any outcomes, study output, or study prototype.

Analytical Base

Identifying sg components.

Components of SG educational tools comprise behavioral theories, learning theories, game theories (context), and game taxonomy (mechanism). Behavioral theories and game elements were identified after collating all the included studies. Details of the identified SG components based on the CMO approach are presented in Tables S2 and S3 in Multimedia Appendix 1 . The most often used behavioral theories were selected for inclusion in the analysis (n=9), as shown in Table S4 in Multimedia Appendix 1 . Detailed categories of the game taxonomy are shown in Table S5 in Multimedia Appendix 1 . Table S4 in Multimedia Appendix 1 presents SDT domains, consisting of the psychological needs of autonomy, competence, and relatedness to boost motivation. The autonomy domain refers to how users make decisions and boost the sense of control, such as adjusting choices, levels, and difficulties [ 11 ]. The sense of control evokes autonomy and fuels users’ willingness to continue playing. Competence refers to achieving targeted goals of successful actions, such as challenges, learning tasks, competitions, and rewards [ 11 ]. Relatedness expresses how children interact and how their interactions affect others within the game, such as avatars, feedback, and emotions [ 11 ]. Game taxonomy was applied to identify game elements in all studies, including social features, presentation, narrative, identity, rewards and punishments, and manipulation and control [ 30 ]. A total of 3 domains of SDT and 5 categories of game taxonomy intersected based on similar characteristics. Those elements were reintegrated to build new, appropriate game elements for children with chronic diseases. These SG components are reviewed and discussed throughout the analysis.

Assembling SG Fragments and Visualizing an SG Framework

SG fragments describe the strategies or systematic procedures for designing, developing, and evaluating SG educational tools for children with chronic diseases. After identifying SG components through SDT and game taxonomy, 2 researchers (MAS and YHL) individually analyzed SG framework studies (n=14) based on their step-by-step procedural techniques (fragments). The collected fragments were appropriately assembled into 5 steps following the method by Khaleghi et al [ 24 ]: objective definitions (step 1); users’ needs and game element identification (step 2); game concept generation, game mechanics selection, and prototyping (step 3); implementation (step 4); and monitoring (step 5). Fragments of SG development were appropriately reintegrated to build a new SG framework.

Fragments for building up a new SG framework were established and consisted of 3 main phases (requirements, design and development, and evaluation). Each main phase was redesigned to formulate 2 procedural steps and generate output materials. A proposed SG framework was visualized by one researcher (MAS) and then carefully reviewed by 2 other authors (YHL and HYC). Following the method by Carvalho et al [ 25 ], a game structure was designed to supplement the SG framework to explain the actions, tools, and achieved goals of learning and gaming (Figure S1 in Multimedia Appendix 1 ). The process of assembling the SG fragments and then visualizing the SG framework and game structure were discussed among the 3 researchers throughout the study.

We retrieved 1947 articles from PubMed (n=451, 23.16%), Embase (n=131, 6.73%), Google Search (n=512, 26.3%), Google Scholar (n=130, 6.68%), JMIR Serious Games (n=272, 13.97%), and Games for Health Journal (n=451, 23.16%). After removing duplicates, 738 full-text articles were reviewed. In total, 30 articles were included in the scoping review, consisting of 16 (53%) RCTs that evaluated SG educational tools for children with chronic diseases and 14 (47%) studies on SG frameworks ( Figure 2 ).

Charting the Information

Table 1 describes the included 16 RCTs that evaluated the use of SG educational tools for children with chronic diseases. SG educational tools that blended the concepts of learning and gaming were developed for children with asthma (7/16, 44%) [ 31 - 37 ], obesity and risk of diabetes or only diabetes (4/16, 25%) [ 38 - 41 ], cancer (2/16, 13%) [ 42 , 43 ], cystic fibrosis (1/16, 6%) [ 44 ], cerebral palsy (1/15, 6%) [ 45 ], and HIV or AIDS (1/15, 6%) [ 46 ]. The number of study participants ranged from 10 to 375; however, 60% (9/15) of the studies had <100 participants, as shown in Table 1 . SG educational tools were delivered to children whose ages ranged from 3 to 17 years, with an average duration of play of approximately 40 minutes.

A total of 47% (7/15) of the studies reported improvements in clinical outcomes, including improved energy expenditure, heart rate, and blood pressure [ 31 ], or reduced symptoms, such as dyspnea and fatigue [ 31 - 33 , 44 ], as well as fewer hospitalizations [ 32 ] and unscheduled physician visits [ 38 ]. Regarding humanistic outcomes, 87% (13/15) of the RCTs evaluated behavioral outcomes. In total, 47% (7/15) of the studies presented improvements in knowledge, and 40% (6/15) reported improvements in behaviors, including asthma self-management [ 32 , 33 ], healthy dietary habits [ 39 ], communication with parents [ 38 ], disease-related risk communication [ 46 ], and lower medication use [ 34 ]. A total of 100% (15/15) of the studies evaluated users’ acceptance and satisfaction, resulting in 100% (15/15) of the RCTs showing positive acceptance toward SG educational tools and consideration of SG educational tools as enjoyable strategies for learning and practicing self-management tasks. None of the 15 RCTs evaluated economic outcomes.

a FeNO: fractional exhaled nitric oxide.

Collating SG Components

Table 2 describes essential components of the SG-based education for developing the proposed SG framework based on the CMO approach (N=30). For context, several studies applied behavioral theories (23/30, 77%) and game theories (22/30, 73%). Regarding mechanisms , several aspects were concerned with embedding social features or feedback (28/30, 93%); presentation or esthetics (30/30, 100%); personalization, including narratives (24/30, 80%), characters (23/30, 77%), and rewards and punishments (26/30, 87%); and manipulation and control, including game genre or rules (23/30, 77%), game goals (28/30, 93%), and challenges (27/30, 90%). Regarding output, 27% (8/30) of the studies generated specific SG frameworks for children with chronic illnesses, including children with diabetes [ 39 , 40 , 47 , 48 ], children with cystic fibrosis [ 49 ], and children who needed physical rehabilitation [ 24 , 50 , 51 ]. The most commonly used behavioral theory in the studies was SDT (9/30, 30%). Relevant studies that used SDT as the behavioral theory foundation are identified in Table S6 in Multimedia Appendix 1 . Game elements from all the included studies (N=30) are described in Table S7 in Multimedia Appendix 1 .

a Not applicable.

Table 3 summarizes the intersection of the 3 domains of SDT and 5 categories of game taxonomy (n=9). On the basis of our findings, game elements that should be inserted in a proposed SG framework for children with chronic diseases include feedback, such as tailored messages and links to social media (social); visual designs, such as images, videos, animations, and cartoons, and audio designs, such as music and sounds (presentation); avatars, characters, and emotions (identity); storyline (narrative); rewards and progress bar (rewards and punishments); and challenges, choices, competitions, goals, rules, levels, and tasks (manipulation and control). Details of the intersection of SDT and game taxonomy (n=9) are described in Table S8 in Multimedia Appendix 1 .

b NR: not reported.

Assembling SG Fragments and Visualizing the Framework

Table 4 presents the determination of SG fragments from the included studies (14/30, 47%) and then assembles those SG fragments into a proposed SG framework. Each existing study offered different procedural steps for developing an SG prototype, yet the game elements and behavioral theories complemented each other. Only 50% (7/14) of the studies created SG prototypes [ 24 , 25 , 40 , 47 , 49 , 52 , 53 ]. Of the 14 SG framework studies, 3 (21%) specifically targeted self-management activities [ 21 , 41 , 47 ]. On the basis of these findings, we reintegrated those fragments into 3 main phases with 6 step-by-step procedural techniques.

In phase 1 (requirements), there are 2 important steps, including exploring the idea and SG requirements (step 1) using literature reviews and identifying target users’ needs (step 2) using iterative discussions or interviews. The outputs of phase 1 are relevant theories, game taxonomy, and children’s needs and preferences. In phase 2 (design and development), 2 steps should be considered by designers, including designing the game elements and educative materials (step 3) and building an SG prototype (step 4) using appropriate software programs and hardware equipment. The output of phase 2 is the SG prototype with a game structure. The final phase is phase 3 (evaluation), which is concerned with evaluating the SG prototype using a clinical trial design (step 5) and marketing the SG and monitoring its use (step 6) throughout clinic-based practice. Outputs of phase 3 are health outcome results and the final SG prototype with recommendations for its use.

a Present or reported.

The Proposed SG Framework

On the basis of our knowledge base and analytical base, we propose a new SG-based framework that integrates the principles of SDT and game elements into self-management practices, titled Self-Management Interactive Learning and Entertainment for children with chronic diseases, as presented in Figure 3 . It consists of 3 main phases, starting from the requirements of SG educational tools (phase 1), design and development (phase 2), and evaluation of the SG educational tools (phase 3). In total, 2 procedural steps are included in each phase, resulting in 6 procedural steps. Each step has input materials as the foundation to support the actions and process and to produce output materials. Output materials in the first phase (phase 1) can be used as the input for the next phase (phase 2), and so forth. Each phase has critical points, revisions, and adjustments that should be considered by any game designer, researcher, or health care provider who would like to create an SG educational tool. Each game should be suitable for target users and their conditions; for example, an SG educational tool for children with asthma should have specific learning materials (asthma action plans and asthma medications), target goals (improved quality of life), and tasks and challenges (asthma self-management activities, breathing technique, and proper asthma medication use) that might differ from those of other diseases. Figure S1 in Multimedia Appendix 1 shows the gaming and learning structure of an SG prototype that blends SDT domains and game elements. The mechanism of how players achieve the target goal by accomplishing challenges should be set in clear game rules. Children will make their first choice by selecting an avatar or character, directly engaging with the game. Learning materials will help children understand their disease management, yet the game instructions will help them simultaneously observe challenges and tasks. After completing the tasks, their performance should be rewarded through points or a performance meter.

Exploring SG Requirements (Step 1)

A robust theoretical SG-based foundation should be established using literature reviews that gather principles of learning theories, behavioral theories, and game theories. This step is aimed at exploring SG requirements by searching for evidence related to game-based behavior change programs for children using electronic databases, for example, behavioral and game theories. If such evidence is not available, it is recommended to consult established game developers and collect perspectives from target audiences regarding obstacles in their daily lives [ 21 ]. According to Bramer et al [ 56 ], critical points include how to determine a clear and focused research question, how to choose databases and interfaces to begin, how to use an appropriate search technique, and how to document and translate collected documents. After determining relevant SG literature, game elements and behavioral theories should be translated and adopted for use by children with chronic diseases. Relevant articles can be used as inputs to conduct iterative discussions to identify users’ needs.

Identifying Target Users (Step 2)

Step 2 began through iterative discussions with a multidisciplinary, collaborative team. The iterative approach refers to the iterative process of refining, creating, and revising a project until agreement is achieved, and it is commonly used for agile software development [ 57 ]. The aim of this step is to collect perspectives on identifying users’ profiles and needs, their daily difficulties and barriers related to their chronic conditions, and target outcomes [ 7 ]. In this step, critical points emphasize what the players’ backgrounds are, what age groups are considered, to which chronic conditions would the SG educational tool be applied, how many users would be involved in the game, and what outcomes need to be achieved [ 53 ]. A multidisciplinary team consisting of pediatricians, child psychologists, child educators, game prototype designers, and multimedia experts [ 54 ] needs to identify resilient attitudes and consistent stimuli that suit children’s characteristics. Designers should carefully identify users’ cultures, beliefs, mindset, and literacy to concisely adopt those preferences into the game’s elements [ 24 ]. Directly involving children through focus group discussions or in-depth interviews will help the team gamify self-management tasks based on their needs and level of understanding, including medication adherence, physical exercise, and maintenance of healthy dietary habits.

Designing the SG Prototype (Step 3)

A key driver for successful SG education is consolidating a balance between self-management tasks (serious) and game elements (entertainment) [ 6 , 58 ]. This step aims to design the mechanism and user interface of the game itself by consolidating the most appropriate behavioral theories, learning materials, and game elements. Designers begin to create a prototype after establishing selected relevant theories, game elements, and users’ needs and outcomes (input). First, designers should elucidate selected, well-established behavioral and learning theories into educational materials and game taxonomy into appropriate game elements for children. Game designers should consider several critical points, including what topics are inserted into the learning materials, which game elements are best suited to achieve the desired outcomes, and how interacting with the game can lead to targeted behaviors [ 49 ]. The educational materials should contain disease information, including its pathophysiology, signs and symptoms, treatments and medications, self-management, side effects, the importance of adherence, and daily practices.

It is recommended to insert game elements that offer enjoyment to stimulate children to play, at the same time directly motivating them to learn [ 51 ]. Cartoon characters, genres, and stories represent personalization for children [ 52 ]. To grow children’s mindset, challenges should be designed with competitive levels and rewards provided when a mission is accomplished [ 12 ]. A role model with a positive attitude should be inserted into the SG design to encourage children to become masters of practicing self-management activities. Adding these elements facilitates children responding when confronted with conflicts [ 50 ] and enhances their sense of resilience. It is important to design an SG prototype that mimics real-world circumstances by setting precise goals and instructing players to perform targeted skills over time [ 25 ]. It is also suggested to embed the features of feedback, a progress bar, or trend alerts to evaluate their performance after completing the challenges.

Building the SG Prototype (Step 4)

Step 4 aims to develop an actual prototype based on the selected behavioral theories and game elements. It requires extensive discussions with researchers, multimedia experts, and the game industry to integrate the technology into a game console. A graphic user interface should be built to present the set of game rules. Designers may consider facilitating level adjustments if children fail to win to maintain the developed mindset. Critical points are how the prototype can be built for efficient learning and playing, how to perform such tasks, and how to rapidly respond regarding those performances. Esthetics is an essential aspect to be considered. Game visuals can be appropriately created using 2D or 3D formats [ 55 ]. Music and animation can be added to enhance excitement and enjoyment. To effectively promote self-management tasks, virtual reality SGs should be equipped with body movement tools that specifically target childhood chronic diseases that involve physical disabilities [ 50 ]. Moreover, privacy should be protected because SG prototypes can be used in multiplayer settings, and the accessibility to enter measured data should be restricted [ 13 ].

Evaluating the SG Prototype (Step 5)

Step 5 focuses on evaluating the efficacy of the SG educational tools and unexpected effects after implementation. This step allows researchers to gather feedback from experts and children for further improvements [ 20 , 59 ]. A pilot test, followed by a clinical trial, is recommended, which quantitatively analyzes how the prototype achieves the intended outcomes and qualitatively explores users’ experiences. An RCT study design is preferred due to its high quality. The ability to perform a task at an expected level and with minimal adverse events may be set as the intended outcome. It should be carefully determined how long participants will be engaged in the game, how many sessions a child needs to reach the goals, and how long it takes to complete a session. A short duration is associated with unfamiliarity with the tasks, whereas a long duration leads to boredom [ 60 ].

Moreover, health outcomes, including clinical, humanistic, and economic outcomes, should be periodically evaluated [ 61 ]. Clinical outcomes may include symptom improvement and reduction of morbidity, whereas humanistic outcomes may include knowledge and attitudes, behavior changes, and an improved mindset. As no economic outcomes were available in the studies in this review, researchers are encouraged to evaluate economic outcomes when using the prototype. Possible unexpected impacts of SG interventions on aggressive behaviors should also be evaluated, especially for SG interventions that encompass violent elements [ 62 , 63 ]. Continued discussions with clinicians are still relevant to ensure that the game world setting can be applied to the real world.

Marketing and Monitoring Use of the Prototype (Step 6)

Disseminating and promoting a well-evaluated SG educational tool can enhance access to a broader population that may benefit the most and promptly inform the game industry to invest in such interventions. Commercialization of an SG educational tool for children remains a challenge due to the need for high-end technologies, animated multimedia design, artists, illustrators, and other consoles. Gameplay is rapidly changing due to advances in technology, and it should be developed in line with current modalities to minimize the obsolescence of software and hardware [ 39 ]. To ensure market readiness, business experts should be consulted and involved throughout the process. It is recommended for researchers to accelerate partnerships with the gaming industry for sustainable SG maintenance.

Specific practice skills can be designed in a modest simulation. For example, children with type 1 diabetes should be able to use insulin regularly, exercise, maintain a healthy diet, and be aware of the signs of hypoglycemia. Modest instruction will help clinicians in applying SG education for children with chronic diseases in the real world. It is important to underline that an excellent performance in the game world is not directly associated with mastery in the real world. Practicing self-management skills, such as physical activities and medication use, should regularly be guided by health care professionals. It may be relevant to consult with policy makers and health care associations regarding the establishment of policies and recommendations for appropriate uses of SG educational tools in clinical practice. Postmarketing feedback should continually be collected to improve the SG’s quality.

Principal Findings

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.

Comparison With Prior Work and Considerations for Using the Proposed Framework

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.

Challenges and Pitfalls of SG Design and Development

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 Concerns for Children in the Post–COVID-19 Era

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 ].

Limitations

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.

Implications of the Study and Further Research

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.

Conclusions

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.

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' Contributions

MAS contributed to the conceptualization, methodology, software, validation, formal analysis, writing—original draft, and visualization. YHL contributed to formal analysis and writing—review and editing. FYC contributed to visualization and writing—review and editing. HYC contributed to conceptualization, methodology, formal analysis, resources, writing—review and editing, supervision, project administration, and funding acquisition. All authors contributed to data interpretation and manuscript preparation. All authors read and approved the final manuscript.

Conflicts of Interest

None declared.

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Abbreviations

Edited by S Ma; submitted 06.06.23; peer-reviewed by R Gorantla, K Spruyt, T Baranowski; comments to author 20.12.23; revised version received 13.04.24; accepted 25.06.24; published 19.08.24.

©Made Ary Sarasmita, Ya-Han Lee, Fan-Ying Chan, Hsiang-Yin Chen. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.08.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.