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The Social Effects of Exergames on Older Adults: A Systematic Review and Metric Analysis

Background: Recently, many studies have been conducted to investigate the effects of exergames on the social well-being among older adults. Objective: The aim of this paper is to synthesise existing studies and provide an overall picture on the social effects of exergames on older adults. Methods: A comprehensive literature search with inclusive criteria was conducted in major social science bibliographic databases. The characteristics exergames, participants, methodology, as well as outcome measurements were extracted from the relevant studies included in the review. The bibliometric and altmetric outreach of the included studies were also investigated. Results: A total of 10 studies were included in the review, with 8 studies having applied Nintendo‟s Wii platform. Most of the studies recruited healthy older adults from local communities or senior activity centers. Three groups of social-related outcomes have been identified, including emotion-related, behavior-related, and attitude-related outcomes. A metric analysis has shown that the emotion-related and behavior-related outcomes received high attention from both the academic community and social media platforms. Conclusions: Overall, the majority of exergame studies demonstrated promising results for enhanced social well-being, such as reduction of loneliness, increased social connection and positive attitudes towards others. The paper also provided implications for healthcare researchers and exergame designers.


Introduction
Our world has been experiencing significant ageing. A recent report from the United Nations [1] indicated the number of older adults aged 60 and above was 901 million in 2015, taking up 13% of the entire population. The report predicted that this number would have doubled by 2050, reaching nearly 2.1 billion. Population ageing has become a major global demographic trend, which raises many public concerns on the well-being of older adults [2,3]. Older adults often suffer from several common negative events, such as a lack of close family ties (e.g. living alone), a loss of a loved one, a decline in mobility, or a reduction in active participation in social activities. The accumulation of these negative events could result in inadequate social support, or impaired social interaction [4,5]. Some studies indicated that lack of social interaction led to frequently experienced social problems and disorders, such as social isolation and loneliness [6][7][8]. Given the potential harmful effects of social isolation and loneliness, it is therefore important to develop social interventions in order to reduce emotional damage to older adults and inappropriate health and social service usage.
With the advent of digital technology, exergames, which combine digital gaming and physical exercise, have become common daily exercise programmes [9]. Despite being originally designed for entertainment, exergames have been increasingly used in healthcare promotion. There is a rapid growth in the popularity and use of exergames as health programmes in public settings, such as in communities [10], schools and work environments [11]. Many previous studies [12,13] have assessed the potential benefits of exergames in physical, cognitive and psychological well-being. For example, evidence from a 2-week pilot study demonstrated that exergames were able to significantly improve upper extremity function for post-stroke patients [14]. A pilot study from Chan et al. [15] showed that older adults in virtual reality cognitive training programmes had better improvements in repetition and memory retention than those in usual programmes. Albores et al. [16] reported that older patients with chronic obstructive pulmonary disease had significant improvements in emotional well-being after a 12-week Wii Fit training.
The social effects of exergames have drawn considerable attention from researchers [17][18][19]. Exergaming is a social experience that gives players the opportunity to interact with each other. This can in turn foster social networking and friendships among them. The results from Kooiman & Sheehan [17] showed that exergaming over the Internet increased students" social relatedness in physical education. Social interaction was reported as the most important motivation for adolescents in a 20-week exergaming intervention [20]. Besides the young generation, recent research on exergames has also extended the investigation of the social effects of exergaming to the older population [21,22].
Considering the major concerns regarding older adults with social disorders, it is important to have an overview on whether exergames may serve as an effective intervention for the social well-beings of this group of people. In the literature on exergaming, many systematic reviews only focused on the physical and cognitive benefits on older adults [23][24][25]. Papers that reviewed the psychosocial effects of exergames, mainly www.videleaf.com referred to psychological changes, such as depression, mood, and enjoyment [26][27][28][29]. However, an overall picture is still lacking on the social effects of exergames on older adults. With increasing research efforts in the field, the current systematic review was conducted to synthesise existing studies and provide implications for improving social well-being in older adults via exergaming. Additionally, the review also investigated the bibliometric and altmetric outreach of the included studies in this systematic review, to understand their impacts in both academic and non-academic (social media) platforms.

Method
The current review adopted the definition of exergame from Oh and Yang [9] who defined it as "an experiential activity in which playing exergames or any videogames requires physical exertion or movements that are more than sedentary activities and also include strength, balance, and flexibility activities". The included studies in the systematic review should thus involve exergames, according to the above definition, as the primary intervention of the study.. Other inclusion criteria were: 1) the study should incorporate measures of social outcomes such as social connection, social bonding, or loneliness; 2) the study should target participants aged 55 or above; 3) the study should report original research in English. The term "older adult" commonly refers to a person having a chronological age of 65 years and older [30]. Nevertheless, extensive studies indicate that insights into the needs of future older adults could be provided if preolder adults aged 55 to 64 were included in the investigations [31,32]. Consequently, the current review includes studies with participants aged 55 and above. Meanwhile, the current review has a restriction to English-only articles because non-English publications do not appear in major bibliographic databases. In order to achieve a complete picture of exergaming effects on social outcomes, there were no particular constraining criteria with regards to the study design. The review thus included studies using both qualitative and quantitative methods.
A comprehensive literature search was conducted in major social science bibliographic databases, including PsycINFO, www.videleaf.com PubMed, CINAHL, and ScienceDirect. Potential studies were identified by the combination of exergame terms (exergame OR Wii OR Kinect OR active video game), social terms (socia* OR social support OR social interaction OR social bonding OR communicat*), and ageing terms (aging OR aged OR elderly OR older OR senior). Reference lists of the included studies and relevant reviews were also inspected for additional studies to be included in the current systematic review. We retrieved a total of 319 articles published before 22 January 2017 for reviewing and analyzing. All articles were assessed by either title, abstract, or full text to determine their eligibility in the current systematic review. For the articles without full texts in the databases, they were excluded if the full texts could not be retrieved either by using online search engines or contacting the authors directly. After identifying the final list of included studies, the characteristics of exergames, participants (country, sample size, age, and profile), methodology (study design and duration), as well as outcome measurements were extracted from the studies. Screening and data extraction was performed mainly by one reviewer, while a second reviewer was involved in the checking and editing process of the data extraction.
To investigate the bibliometric (in terms of citation count) and altmetric or social media presence of the articles included in the systematic review, we collected citation counts from Scopus [33], as well as usage and capture data from PlumX [34] before 31 April 2017. We also collected Tweet counts, Mendeley readers, and the Altmetric Attention Score from Altmetric [35]. Altmetrics can be described as new or alternative measures of the impact of research objects, based mainly on social media data sources [36]. The Altmetric Attention Score is a weighted aggregate metric comprising diverse online sources from news outlets, policy documents, blogs, Wikipedia, Twitter, Facebook, YouTube, and other social media sources. Usage data from PlumX is a combined metric incorporating counts from downloads, views, library holdings, video plays, clicks, collaborators, and other usage metrics. Capturing data from PlumX comprises counts from bookmarks, favorites, followers, readers, subscribers, watchers, exports/saves and code forks. The 2015 QS world university rankings [37] were used to determine www.videleaf.com the prestigious universities. We used a logarithmic scale for a better visualization of the data. These metrics gave us an insight into the outreach and impact of the included studies in this systematic review.

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

Characteristics of the Studies Included
Exergame types: Eight out of the 10 studies investigated social effects of exergames on Nintendo"s Wii, while 2 studies investigated social effects of exergames on Microsoft Xbox Kinect. Both platforms are the most popular exergaming platforms in the current market, which offer console-based devices and games that make exergaming possible in home settings. In terms of game topics, it is interesting to find that half of the studies (n=5) applied games from Nintendo"s Wii Sports package [39][40][41][42][43]. The Wii Sports game package allows participants to play virtual sport games (such as tennis, bowling, baseball, golf, or boxing) by performing body motions that they would do in actual sports. Another study from Wu, Li, and Theng [45] also used a virtual bowling game, but from the Microsoft Kinect Sports game package. Two studies were reported to use exercise games from Nintendo"s Wii Fit, or its successor Nintendo"s Wii Fit U [21,38]. Different from Wii Sports games, Wii Fit exergames aim to improve players" physical fitness through exercise activities such as strength training, aerobics, yoga and balance games. Besides those simulating actual exercise, exergames with topics from daily life activities were also found in two studies [39,43], such as cookery simulation-styled Cooking Mama and party simulationstyled Wii Party.
Participants: Most of the studies recruited healthy older adults from local communities or senior activity centers. Two studies [38,44] are the exceptions that investigated the social effects of exergames on older adults with physical or social problems, such as those with impaired balance, with a disability, or those who were socially isolated. Six studies included participants with Western cultural backgrounds, including the United States, Australia, and Canada. Among these Western studies, one was found to be particularly focused on African Americans [21]. Four studies were conducted in the context of Asia, all of which came from Singapore. The majority of the studies involved a small sample size involving less than 50 participants. www.videleaf.com Methodology: Half of the studies applied post-study qualitative methods to assess the social effects of exergames, such as semistructured interview, semi-structured group interview, or focus group discussion. Among those applying quantitative methods, four studies tested the effects between exergames and other control conditions. For example, Wu et al. [45], Jung et al. [39], and Kahlbaugh et al. [40] compared exergames with traditional activities such as playing board games, watching television programmes, or performing normal exercise. Xu et al."s [22] study is an exception which compared the effects among three exergame conditions (playing alone vs. playing with elderly vs. playing with youths). One study [43] applied a within-group experiment method to compare the effects before and after the exergame intervention. The duration of the intervention period ranged from 1 to 12 weeks, while most of the studies involved 8 sessions or more. Two reviewers independently applied the risk of bias tool from Cochrane Collaboration [46] to assess the methodological quality of 4 studies with control conditions. Table 2 shows the results of the quality assessment of the 4 controlled studies. According to the Cochrane recommendations [46], two studies [22,45] were identified to have "High Risk of Bias", while the other two studies [39,40] were identified to have "Moderate or Unclear Risk of Bias".

Social Outcomes
The findings of the included studies have identified several social-related outcomes. Based on the different natures of the outcomes, they were categorized into three groups: emotionrelated; behavior-related; and attitude-related.
Emotion-related: Loneliness was identified to be the main emotion-related social outcome affected by exergames. Jung et al. [39] conducted a study to assess the potential of Nintendo Wii in improving the quality of life among older adults in a longterm care facility. Their results indicated that elderly participating in the Wii condition group had a significantly lower level of loneliness than those participating in the other condition group, who played traditional board games. Similarly, another between-group study in the US also reported that playing Wii rather than watching television programmes led to lower loneliness [40]. Xu et al. [22] also found a significant decrease in loneliness among older adults after exergaming, although little differences were found across different play types or age groups (young-old vs. old-old). In the same study, social anxiousness was also found to have significantly declined, however this was noticed only in the young-old participants who played exergames with youths [22].
Behavior-related: Exergames were found to have several behavior-related outcomes on older adults, such as changes in social connection, bonding, and engagement. After completing an exergaming programme over 14 weeks, some older adults felt that they were more connected with others [21]. Three studies [38,41,44] also indicated that exergames provided an avenue for more intensive socialization and stronger bonding with peers or even with grandchildren. Millington [42] further found that exergames were able to increase social engagement in retirement centres by bringing the seniors together and also by getting them to be more active. In Xu et al."s study [22], sociability was increased significantly among the young-old participants playing exergames with youths, and old-old participants playing with their peers. www.videleaf.com Attitude-related: Wu et al. [45] presented a study which examined the exergame effects on social presence, which was defined as the sense of connecting or being with others in a media-mediated environment. Their results found that older adults in the exergame setting had a significant lower social presence than those in traditional exercise. Another Singapore study from Theng et al. [43] showed that playing exergames with youths led to improvement in older adults" positive attitude towards the younger age group.

Metric Analysis
Currently, the study from Agmon et al. [38] has received the most attention from the scholarly community with a total of 105 citations, 27 of which came from prestigious universities. Wollersheim et al. [44] also received a good amount of attention with a total of 63 citations, of which 8 were from prestigious universities. Most of the citations of these two studies came from articles published between 2014 and 2016, and mainly from the fields of Medicine and Computer Science. Since the studies from Xu et al. [22] and Chao et al. [21] were only recently published in December 2016 and January 2017 respectively, no citations could yet be found for these articles. Figure 2 shows the bibliometric outreach of the exergame studies.   Figure 3 gives an overview of the altmetric outreach of the exergame studies. The study with the highest Altmetric Attention Score was Theng et al. [43] with a score of 29. This high score was attributed to three mentions on news outlets in March 2017, naming this study as an example of how Nintendo"s motion control system has helped to make gaming accessible to new groups of users. Kahlbaugh et al. [40] had a very high PlumX usage count of 5,300, and a high PlumX capture count of 498. These were mainly due to abstract views, clicks on outbound links, and exports/ saves on EBSCO [47]. Agmon et al. [38] had a high count of 180 Mendeley readers, but since Altmetric.com does not include Mendeley readers in its score, this is not reflected as this study had a score of 3. Again, two recent studies [21,22] did not yet have any altmetrics, however one tweet could already be found for the article from Chao et al. [21], giving this article an Altmetric Attention Score of 0.5. Tweet counts were however low across all studies, with Milington [42] and Agmon et al. [38] having the highest count of 5 tweets each.

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

Social Benefits of Exeragmes
Although the social benefits of exergames have been discussed often in literature on exergames, there has been no particular review found on this topic. By summarizing the existing original studies, the findings from the current review showed that exergames could be an effective intervention for social improvements among older adults. It supported that exergames were able to reduce the loneliness level among older adults. The decrease in loneliness was perhaps not due to playing the exergame itself, but rather due to the increased interactions between older participants and other players. In a large sample survey study, Lee and Ishii-Kuntz [49] indicated that doing something together with other people reduced loneliness among older adults. Many included studies also suggested that exergames provide opportunities for social interaction and connectedness with peers and family members [38,41,44]. Older adults often lack the motivation to engage in exercise. Chao et al. [27] indicated that these behavior-related social outcomes of exergames may increase exercise motivation and adherence among older adults. A metric analysis has shown that the emotion-related and behavior-related outcomes of exergames www.videleaf.com received a lot of attention in the academic community as well as on social media.
Attitude-related social outcomes are one new finding that has not been mentioned in previous exergame reviews such as Chao et al. [27] or Matallaoui et al. [29]. Exergames were found to affect a sense of being with others [45] and positive attitudes towards others [43]. The findings were similar to recent research in persuasive video gaming [50,51]. An experiment from Alhabash & Wise [50] found that video game role-play led to a change in students" explicit and implicit attitudes toward Palestinians and Israelis. In another study, students who played the persuasive social impact game had an increased positive attitude towards the homeless [51]. Results from the current review further supported that active video games, such as exergames, have the potential to affect older adults" attitudes towards other groups of people. Although attitude-related social outcomes currently have a low academic impact in the exergaming research area, they have begun to receive a certain amount of discussion on social media.

Implications for Future Study
The findings also suggested that Nintendo"s Wii was the most frequently used exergaming platform in the included studies. It was supported by another review [27], which also reported Nintendo Wii to be one of the most accessible and popular exergames for seniors. Chao et al. [27] further indicated the high attendance rates among older players in Wii exergames programmes. Although the evidences may suggest Wii to be a suitable platform for older adults to perform exergames, there are no previous studies conducted to investigate the different effects between Wii and other platforms, such as Microsoft Kinect consoles. More studies are needed to compare the effects of different exergaming platforms. Sport games were identified to be the favored type of games used in the included studies, while bowling was a particular sport exergame tested in three studies [40,42,45]. According to the American College of Sports Medicine [52], older adults were encouraged to perform physical activities that maintained or increased their balance and www.videleaf.com flexibility through slow movements. The bowling games allow slow movements that match these typical physical activities recommended for older adults. Meanwhile, bowling was a selfpaced exercise in which older adults could take the time they need to perform the moves [27]. However, all the studies applied commercial exergames available on the market; none of the interventions were integrated with social theories. This highlights the need to combine social-related theories with exergame programmes in order to optimize the effectiveness of social improvements.
Although most of studies targeted healthy older adults, two studies examined the social effects on older adults with physical disabilities [38,44]. Physical disability, particularly low mobility, was often identified to be a risk factor for social isolation among older adults [53]. Low mobility prevents seniors from participating in active social engagement and connection, leading to common social disorders such as loneliness. Two included studies have shown that playing exergames was able to improve their social well-being by increasing the social bonding with their peers and grandchildren. However, the physical limitation of this group of older adults may have led to some difficulties in interacting with the exergames. They may have been exposed to frustrating experiences or even accidents if the exergames were performed without proper human or technical assistance. As a result, healthcare providers and exergame designers should take this into consideration when implementing future social exergame programmes for older adults with disabilities. In terms of cultural background, the studies were conducted in both Western and Asian contexts. It appears that exergames might have social effects on older adults with various cultural backgrounds, but knowledge is lacking on whether the social outcomes would be affected by cultural factors. Future studies are recommended to compare the social effects between different cultural contexts.
Study designs varied in rigor, with 6 studies applying withingroup design, and 4 studies applying between-group design comparing exergames with a control condition. Although the majority of studies showed promising results for the use of www.videleaf.com exergames for social enhancement, the conclusions need to be interpreted with caution due to the limited number of randomized controlled trials. The included studies were either predominantly small pilot trials or feasibility studies; they lacked the adequate sample sizes needed for a powered efficacy trial. Meanwhile, half of the studies used qualitative methods for data collection. Without validated quantitative instruments, their findings can not have the capacity to detect significant changes in social outcomes.

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