This systematic review aimed to analyse the psychological impact of AVG (Active Video Games) on overweight and obese adolescents. This review included 10 studies and the analysis was based on the results of PICO (Population, Intervention, Comparison, Outcome).
4.1 Population
i. Nationality of participants The studies in this review were conducted across different countries, including Singapore, Tunisia, Turkey, Spain, and the USA. Notably, a majority of the AVG interventions took place in the USA, accounting for 60% of the selected studies. It is crucial to highlight that only one study took place in Singapore. According to World Obesity (2022), the prevalence of obesity among children and adolescents aged five to 19 years in Southeast Asia will reach more than 21 million by 2030. Furthermore, it is important to acknowledge that in China, which has the highest population, the incidence of obesity in children and adolescents has reached 11.9% (Cai et al., 2017). Hence, it is imperative to develop innovative strategies to address the issue of obesity in these areas.
ii. Gender The results revealed that in seven out of the 10 research, the participants consisted of both males and females. Meanwhile, two studies fully focused on females, while only one study solely focused on males. Between 2000 and 2019, the prevalence of obesity among boys in China had a growth rate that was nearly double that of females (Zhang et al., 2022). Hence, it is imperative to conduct a targeted study on male adolescents who are overweight or obese in the future research.
4.2 Interventions
i. AVG mode The results indicated that the primary intervention approaches employed in the 10 chosen publications were single-player AVG and multi-player AVG. Nevertheless, it is important to acknowledge that in the multi-player AVG, the individuals' partners were solely limited to peers or siblings, with no parental involvement. Grossman et al. (2017) indicated that family participation strategy underscored the parents' capacity to influence the adoption of healthy behaviors and the weight status of their children. The weight-related behaviours of children, which are mostly observed in the family setting and influenced by parental modelling, can be effectively influenced in a positive manner. Therefore, it underscores the need of parental involvement in the therapy procedure (Altman & Wilfley, 2015). Moreover, a review examining interventions aimed at decreasing sedentary time in children through parental involvement was more crucial than the specific intervention itself (Marsh et al., 2014). Another meta-analysis also highlighted that direct parental involvement and role modeling play a crucial role in the physical activity intervention of adolescents (Guo et al., 2023).
ii. Experimental setting Regarding AVG interventions in various environments, the results indicate that there is insufficient evidence to verify the effects of AVG interventions in the family environment on the psychology of overweight and obese adolescents. The World Health Organisation (WHO) has consistently emphasised the significance of family sports, particularly the involvement of parents in fostering physical activity among adolescents (WHO, 2022). Family factors, including the physical environment (such as sports facilities and equipment), family structure, economic income, parental education, and family environment, have been found to be associated with adolescents' physical exercise (Chang & Wu, 2008; Lv et al., 2020; Weaver et al., 2018; Cleland et al., 2011). However, the behaviour and words of parents may have a more direct, influential, and representative impact on children's social cognition and behaviour acquisition (Hu et al., 2017; Gao & Wang, 2015; Liu et al., 2020). During the crucial stage of social development, the behavioural decisions and behaviours of adolescents are frequently influenced by their parents' independent support and physical activity routines (Hu et al., 2017; Dong & Mao, 2018; Fuemmeler et al., 2011; Adamo et al., 2012).
In summary, given the information provided, future studies on AVG intervention should prioritise investigating the family environment and delves into the influence of parental involvement on adolescent obesity and the psychological issues associated with obesity.
iii. The type of AVG console In terms of the type of AVG console, the results indicated that there were a variety of AVG consoles utilised across the 10 studies, ranging from a single console, such as Nintendo Wii and Kinect for Xbox 360, to the use of multiple consoles in a single study. This diversity in intervention methods underscores the flexibility and adaptability of AVGs in research settings.
According to the results, both the Nintendo Wii and Kinect for Xbox360 have a notable positive impact on self-efficacy (Staiano et al., 2013; Flynn et al., 2018; Staiano et al., 2019; Staiano et al., 2017). However, when it comes to social support and peer support, the Nintendo Wii surpasses the Kinect for Xbox360 significantly (Staiano et al., 2013 Staiano et al., 2019 Staiano et al., 2018). Additionally, research has demonstrated that the Wii is more attractive and cost-effective when compared to other home-based technology (Glen et al., 2017).
Therefore, it is imperative for future studies to thoroughly evaluate the economic feasibility and accessibility of AVG, taking into account the distinctive features of various game consoles. Researchers should select different game consoles based on specific research objectives in order to maximise the benefits offered by each console.
4.3 Comparison
A total of 10 studies examined five different types of comparison. Despite the varying study designs, AVG shows promise as a viable intervention to improve the psychological well-being of overweight and obese adolescents.
From the provided results, it can be inferred that AVG has the potential to significantly enhance the psychological well-being of adolescents, especially those who are overweight or obese. Furthermore, cooperating with AVG has a substantial impact on psychosocial factors. However, additional investigation is required to examine other experimental designs in relation to the quality of life in order to improve it. Additionally, there is insufficient evidence to assess the psychological impact of individual AVG and group-based AVG, and it has still to be determined whether AVG can effectively replace conventional sedentary activities like as watching TV, video gaming, and mobile phone usage. How may AVG be integrated into the leisure time activities of overweight and obese adolescents to decrease their sedentary behaviour while maintaining their psychological well-being? This question necessitates cautious consideration by researchers in future research. Hence, it is imperative for future studies to do a comparative analysis among individual AVG and group-based AVG, and traditional sedentary behaviour.
4.4 Outcomes
i. Self-efficacy While Staiano et al. (2013) found no significant differences between cooperative and competitive groups, both groups showed improvements compared to the control group. Flynn et al. (2018) and Staiano et al. (2017) reported a notable improvement in self-efficacy in the AVG group. Staiano et al. (2019) highlighted a significant boost in self-efficacy with group-based AVG. Yet, Martí et al. (2015) reported that when comparing the effects of AVG combined with treadmills, both the overweight and normal weight groups of adolescents did not demonstrate any significant improvement in self-efficacy. Possible explanation for inconsistent self-efficacy evaluations is due to the diverse intervention strategies. Previous research has employed independent AVG as an intervention, whereas Martí et al. (2015) has utilised AVG in conjunction with a treadmill as an intervention. Studies have demonstrated that engaging in treadmill exercise does not yield a substantial impact on enhancing self-efficacy (Hambly et al., 2017; Shaughnessy et al., 2012).
ii. Social support and peer support From the results, it can be found that cooperative AVG, competitive AVG, and individual AVG can effectively improve peer support and social support. However, in group-based AVG, peer support did not show significant improvement. There could be multiple factors contributing to this phenomenon: 1. Controlled setting for conducting experiments. Staiano et al. (2013) conducted their study in a school setting, with participants who were all peers. The participants played the game either through cooperation or competition with their peers, which increased interaction during the game and improved peer support. In contrast, Staiano et al. (2019) conducted their study in a family setting, where the partners of the participants could be peers, family members, or siblings. This led to limited social interaction with peers during the gaming process, resulting in no improvement in peer support. Staiano et al. (2018) conducted their study in a laboratory setting. However, it is important to note that the laboratory environment does not fully replicate real social environments. As a result, participants may not have the same psychological response as they would in a real-life scenario. Previous study has demonstrated that findings from laboratory experiments, where researchers actively manipulate and control variables, may not easily apply to other real-life situations, leading to limited external validity (AQA, 2022);
2. Different game console. Staiano et al. (2013) employed the Nintendo Wii console and specifically selected sports games like basketball, baseball, tennis, and volleyball for their experiment. In contrast, Staiano et al. (2018) utilised Just Dance, a game available on Kinect for Xbox 360, which could potentially result in participants experiencing boredom with the game during the experiment. Empirical studies have shown that AVG fails to maintain player engagement over a longer period (Liang & Lau, 2014). Additionally, the selection of a sole game can also induce feelings of boredom among players (Radhakrishnan et al., 2019).
Based on the above information, self-efficacy, as per social cognitive theory (Bandura, 2004b), is the primary factor that influences healthy behaviour. Moreover, it can also exert an impact on social structural variables and outcome expectations, and these two aspects can also serve as mediators in promoting healthy behaviour. Hence, it is easily comprehensible why self-efficacy and social support, or peer support, comprise the largest share among the articles selected. Nevertheless, the authors of these articles have failed to consider the impact of parental support on influencing adolescent health behaviours within family settings while examining social support components. Research has demonstrated that parental support of physical exercise can impact children's engagement in moderate-to-vigorous physical activities (Hosokawa et al., 2023). Furthermore, a global survey encompassing 74 nations revealed a strong association between parental support and adolescents’ physical activity in the Western Pacific region (Khan et al., 2020).
iii. Motivation The results indicate that AVG has a substantial influence on the exercise motivation of both overweight and obese adolescents. It is noteworthy that Li et al. (2014) revealed a higher level of exercise motivation among individuals in the group with normal avatar body size. According to Peña & Kim (2014), females who controlled avatars with a normal weight engaged in more physical activity compared to those who controlled avatars with obesity. Males who utilise avatars with a normal weight would experience an increase in their physical activity levels during the process of playing AVGs (Peña et al., 2016). Therefore, it is imperative to consider this matter in future research on AVG experiments to enable participants to elicit greater positive psychological responses.
iv. Quality of life Staiano et al. (2018) and Staiano et al. (2019) did not find any substantial influence of AVG on quality of life. This could be attributed to the fact that both researches utilised 10-item version of the KIDSCREEN Index for assessing quality of life, as stated by the author. Although the 10-item version has demonstrated criterion validity and test-retest reliability (Ravens-Sieberer et al., 2010), its limited number of items leads to reduced variability compared to longer scales, potentially resulting in null effects. Therefore, further research should prioritise the examination of alternative evaluation instruments such as the PedsQL, which are widely employed and have the potential to offer more comprehensive evaluations of domains that are susceptible to modifications and hold significance for adolescents with obesity, including physical, emotional, and social functioning (Buttitta et al., 2014).
v. Self-esteem The results revealed that the combination of AVG and health programmes yielded inconclusive outcomes in relation to self-esteem. Duman et al. (2016) incorporated an exercise programme that consisted of a greater amount of aerobic activity. This led to noteworthy enhancements in BMI, waist circumference, and triceps skinfold thickness among the participants. Additionally, there was a considerable boost in self-esteem. In contrast, Christison et al. (2016) incorporated a greater number of nutritious dietary habits into the health programme. While the individuals' BMI and physical fitness demonstrated improvement, there was no statistically significant difference, and self-esteem did not exhibit notable improvement. Additionally, there is an adverse association between greater BMI and self-esteem, as demonstrated by Kiviruusu et al. (2016). Furthermore, self-esteem is inversely related to certain attitudes and behaviours around weight and body shape, including physical dissatisfaction and cognitive impression of being overweight. (van den Berg et al., 2010; Perrin et al., 2010).
According to the above information, for future experiments that combine AVG with health programmes, it is recommended to incorporate more exercise components into the health programme. This will help to enhance the level of exercise, potentially leading to a considerable improvement in the weight status of participants and an improvement in their self-esteem.
vi. Other psychological outcomes The results revealed diverse positive effects on various psychological outcomes, including attitudes (Li et al., 2014), depression (Duman et al., 2016), mood state (Abedelmalek, 2022), self-worth (Christison et al., 2016a), subjective health, enjoyment (Staiano et al., 2018), satisfaction, and expectancies (Flynn et al., 2018). These results suggest that AVG has the potential to improve the psychological well-being of overweight and obese adolescents.