Special series on “effects of board games on health education and promotion” board games as a promising tool for health promotion: a review of recent literature

Board games are played by moving game pieces in particular ways on special boards marked with patterns. To clarify the possible roles of board game use in psychosomatic medicine, the present review evaluated studies that investigated the effects of this activity on health education and treatment. A literature search conducted between January 2012 and August 2018 identified 83 relevant articles; 56 (67%) targeted education or training for health-related problems, six (7%) examined basic brain mechanisms, five (6%) evaluated preventative measures for dementia or contributions to healthy aging, and three (4%) assessed social communication or public health policies. The results of several randomized controlled trials indicated that the playing of traditional board games (e.g., chess, Go, and Shogi) helps to improve cognitive impairment and depression, and that the playing of newly developed board games is beneficial for behavioral modifications, such as the promotion of healthy eating, smoking cessation, and safe sex. Although the number of studies that have evaluated board game use in terms of mental health remains limited, many studies have provided interesting findings regarding brain function, cognitive effects, and the modification of health-related lifestyle factors.


Introduction
Board games are played by moving game pieces in particular ways on special boards marked with patterns [1]. For example, one game originated in northern India in the sixth century AD and spread to Eastern as well as Western countries. In the West, it spread to Persia and then to Spain via the Moorish conquest, and then throughout Europe, where it ultimately became "chess." In the East, this game became "Xiangqi" in China, "Shogi" in Japan, and a variety of similar games in other countries. Other popular board games that use two patterns for the game pieces include "Go" and "Othello," also known as "Reversi." In the field of psychosomatic medicine, board game playing is sometimes regarded as a leisure activity, and engagement in this type of activity has been shown to protect against dementia and cognitive decline in elderly individuals [2]. For example, a 20-year prospective population-based study conducted in southwestern France investigated the relationship between the playing of board games and the risk of subsequent dementia [3]. Of the 3675 participants without dementia in that study, 1176 (32%) reported regular board game playing and 840 (23%) developed dementia during the follow-up period. The risk of dementia was 15% lower in board game players than in non-players, and board game players exhibited lesser declines in Mini-Mental State Examination (MMSE) scores and less incident depression than did non-players. Although the mechanisms underlying the reduced risk of dementia in board game players have yet to be elucidated fully, these games require players to be proactive and to anticipate, thinking several steps ahead, during play. These processes may enhance logical thinking and prevent declines in cognitive function. Individuals may also engage in non-verbal communication while playing board games, and players are more likely to have the opportunity to gather and participate in a fun activity with others. These factors could enhance individuals' social networks, which also protects against cognitive decline. Furthermore, in terms of leisure activities, board game playing may also be a form of stress management [4], as the fight-or-flight response is regulated safely within the sophisticated structures of match-type games. Board game playing could also be a form of art therapy, similar to miniature garden therapy [5], facilitating infinite internal manifestations within a narrow space.
In terms of education, the playing of board games may help children learn to follow rules and stay seated for a certain amount of time, and it may increase children's concentration levels [6]. For students and trainees, board game use can enhance health education by stimulating players' interests and motivation. A search of the Cochrane Database of Systematic Reviews [7] identified a total of 2079 unique citations related to educational games, such as board games and games based on television shows. Of these citations, 84 were potentially eligible for review based on methodological quality, number of participants, interventions, and outcomes of interest, and two randomized controlled trials (RCTs) were chosen. The first study [8] was based on the television game show "Family Feud" and focused on infection control; the group that was randomized to play the game had significantly higher scores on a knowledge test. The second study [9] compared game-based learning (using "Snakes and Ladders") with traditional case-based learning of stroke prevention and management information. Although the two study groups did not have significantly different knowledge test scores immediately or 3 months after the intervention, the reported level of enjoyment was higher in the game-based learning group. The findings of an original review of articles published through January 2012 [7] neither confirmed nor refuted the utility of game playing as a teaching strategy for health professionals. Thus, the present study aimed to clarify the possible roles of board game use in psychosomatic medicine through a literature search for articles published after 2012 that focused on the effects of board game playing on health-related issues.

Mind/body changes due to board game use
Using "board game" as a PubMed search term, 83 studies published between January 2012 and August 2018 were identified; 56 (67%) articles targeted education or training for health-related problems, six (7%) examined basic brain mechanisms, five (6%) evaluated preventative measures for dementia or contributions to healthy aging, and three (4%) assessed social communication or public health policies. The major studies that investigated the effects of traditional board game use are shown in Table 1  ; some of the articles listed in the table were identified in the reference sections of the original 56 articles or other databases.
Experimental studies investigating brain magnetic resonance imaging (MRI) or electroencephalographic (EEG) signals in professional board game players [10,22,[26][27][28]31] demonstrated that the basal ganglia play an important role in the ability to rapidly determine, or intuit, the best subsequent move in a game situation [24]. Additionally, variations in heart rate and eye movements were examined as physiological parameters during chess play [10,14,16]. In case studies and case-control studies, board games were shown to effectively improve symptoms in individuals who experience panic attacks [11], as well as those with attention-deficit/hyperactivity disorder (ADHD) [21] and Alzheimer's disease (AD) [29]. On the other hand, one study revealed possible hazardous effects associated with the playing of "Go" in individuals with seizure disorders [23]. The amounts of real and virtual playing of board games have increased recently and, as a result, the number of published studies assessing the effects of board game use has also increased [12,13,17,19]. The increase in game play is likely due to the prevalence of computer systems in the current age of information and communication technology (ICT) and artificial intelligence (AI).

Recent RCTs evaluating board game use
According to a recent meta-analysis of four studies that investigated chess play [14], age and skill have differential effects on two tasks during game play: selecting the best move for chess positions and recalling chess game positions. The authors found that age was associated negatively, whereas skill was associated positively, with performance in both tasks. Another RCT showed that an intervention using Go improved depression and increased serum levels of brain-derived neurotrophic factor (BDNF) in patients with AD [20]. Similarly, players' depression and anxiety levels were shown to decrease significantly during a 6-week stress management intervention that utilized Shogi games [25]. Although these data have been presented only at a scientific conference, they will soon be published in this special series. The authors also reported that several patterns of negative cognitive distortion (e.g., lower levels of activity) significantly improved following completion of the Shogi program compared with those in a wait-list control group. An RCT showed that the playing of "Ska," a traditional board game in Thailand [32], enhanced cognitive function in terms of memory and attention in elderly subjects.  (Table 2). A variety of board games has been developed to aid in the health education of patients, children, and medical trainees; most of these games are focused on behavioral modifications, such as the promotion of healthy eating [34,38], smoking cessation [43], and safe sex [45]. For example, in a Swiss study [43], 240 current smokers were assigned randomly to a group participating in smoking cessation program employing an educational board game ("Pick-Klop") and a wait-list control group. Compared with those in the wait-list group, individuals in the board game group were less likely to remain smokers at the end of the program and at the 3-month follow-up assessment. The authors suggested that use of the board game would be an interesting alternative for the education of smokers in the precontemplation stage.

Clinical applications of board games
Based on the results of studies investigating traditional and non-traditional board games, it was hypothesized that board game use would prevent cognitive impairment in elderly individuals and illness-prone behaviors in children and adults. Board game playing also seems to be an effective, fun means of delivering medical and safety education to students and trainees. Currently, many people spend large portions of their time playing games online and offline on television monitors, personal computers, tablets, and/or smart-phones. For example, more than half of Japanese elementary and junior-high school students play video games for more than 1 h on weekdays [46]. Thus, video game-based training will become more popular in the future.
On the other hand, a series of meta-analyses [47] found only small or null effect sizes in three models examining correlations between video game skills and cognitive ability, differences in cognitive ability between game players and non-players, and the effects of video game-based training on cognitive ability, respectively. Thus, examination of the clinical effects of real or virtual training using board games may provide more appropriate information for discussion of the advantages and disadvantages of each style of board game for future applications in clinical settings. A recent assessment of cognitive science research on board game playing [48] highlighted six suggestions for future studies: 1) do not forget about chess (i.e., a traditional board game for which large amounts of data have been collected), 2) look beyond action games and chess, 3) use optimal play to understand human play and players, 4) investigate social phenomena, 5) raise the standards for studies investigating game play as treatment, and 6) talk to real experts.

Conclusions
Although the number of studies investigating board game use remains limited, interesting findings have recently been obtained in terms of brain function, cognitive effects, and health-related lifestyle modification. Board games may also be applicable as educational tools for health professionals. Although a systematic review [7] neither confirmed nor refuted the utility of game playing as a teaching strategy for health professionals, these findings were published in 2013 and additional high-quality studies have been reported since then. Thus, it is time to re-evaluate the usefulness of games and gamifications following technological advances made in modern society. Clinical medicine is closely linked to a public health approach, and medical practices should be undertaken within the limited human, time, and financial resources available [49]. In this sense, appropriate health education programs with a board game component would be useful for both preventive and therapeutic intervention for cognitive-behavioral functioning (e.g., ADHD and dementia), psychological conditions (e.g., depression and anxiety disorders), and life-style diseases (e.g., metabolic syndromes and smoking-related diseases).