Use of recreational activities in health education: Integrative review of literature

Abstracts

OBJETIVO: Identificar as intervenções lúdicas eficazes na educação em saúde com vistas a subsidiar a reflexão e o aprimoramento do ensino nessa área. MÉTODOS: A temática é abordada por meio da revisão integrativa da literatura, um instrumento da Prática Baseada em Evidências. Realizou-se um levantamento bibliográfico em bases de dados digitais, segundo rigor metodológico pré-estabelecido. RESULTADOS: Os dados extraídos das produções selecionadas são discutidos, configurando uma análise descritiva por categorização. Os achados referem-se à educação em saúde como tema de jogos (de computador, de tabuleiro, de cartas) e de dinâmicas. CONCLUSÕES: São ressaltados aspectos como: incorporação do lúdico, mudanças de comportamento em saúde, aprendizagem, prevenção e promoção em saúde.

Jogos e brinquedos; Educação; Saúde

REVISION ARTICLE

Gisele Coscrato^I; Juliana Coelho Pina^I; Débora Falleiros de Mello^II

^INurse graduated from University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil

^IIFull Professor at Maternal-Infant and Public Health Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To identify effective recreational interventions in health education in order to subsidize the reflection and improvement of education in that area.

METHODS: The subject is approached through an integrative review of literature - an instrument of practice based on evidence. A bibliographical survey was conducted in digital databases, according to predetermined methodological rigor.

RESULTS: The data from selected productions were discussed, setting a descriptive analysis by categories. The findings referred to health education as a subject of games (computer, board, cards) and dynamic.

CONCLUSIONS: There are highlighted the following issues: incorporation of recreational activities, changes in health behavior, learning, prevention and health promotion.

Keywords: Play and playthings ; Education; Health

RESUMEN

OBJETIVO: Identificar las intervenciones lúdicas eficaces en la educación en salud con el objetivo de subsidiar la reflexión y el perfeccionamiento de la enseñanza en esa área.

MÉTODOS: La temática es abordada por medio de la revisión integradora de la literatura, un instrumento de la Práctica Basada en Evidencias. Se realizó un levantamiento bibliográfico en bases de datos digitales, según rigor metodológico preestablecido.

RESULTADOS: Los datos extraídos de las producciones seleccionadas son discutidos, configurando un análisis descriptivo por categorización. Los hallazgos se refieren a la educación en salud como tema de juegos (de computador, de tablero, de cartas) y de dinámicas.

CONCLUSIONES: Son destacados aspectos como: incorporación de lo lúdico, cambios de comportamiento en salud, aprendizaje, prevención y promoción en salud.

Descriptores: Juegos implementos de juego; Educación; Salud

INTRODUCTION

Mediated learning is appointed as a form of interaction that develops effective learning attitudes and basic competences, permitting a dynamics of knowledge and information deconstruction and reconstruction. In mediated learning, a mediator comes in between the learner and the world of stimuli, facilitating their interpretation and signification through the subject's participation, involvement and motivation^(1-2).

Three criteria are considered fundamental for mediation: intentionality/ reciprocity, meaning and transcendence. Hence, the mediated person's (or learner's) system of needs is expanded, including the need for understanding, reflexive thinking and relations among things⁽¹⁾.

Play could act as a mediator in the teaching-learning process, as an alternative method to support this process. In this sense, the playful considers the criteria for effective learning, as it calls attention to a given subject (intentionality/ reciprocity), its meaning can be discussed among all participants and the knowledge produced based on the play activity can be transported to reality, characterizing transcendence.

In the context in which the learner is a passive learning agent, "teaching" is mixed up with "transmitting" and the learner's need get lost. The idea that teaching is aroused by the learner's interest generated another understanding about pedagogical material; teaching professionals effectively turned into stimulators. In that context, games become an ideal learning tool as they stimulate the learner⁽³⁾.

The health education concept also goes beyond information transmission, configuring combinations of learning experiences designed to facilitate voluntary actions that lead to health. These combinations involve the exchange of life experiences, behavioral aspects and therapeutic and interactional measures⁽⁴⁾.

In view of the importance of health education, this research aimed to identify effective play interventions in this practice, aimed at supporting reflection and improved teaching in that area.

METHODS

This is an integrative literature review about the use of play activities in health education.

The integrative literature review is an evidence-based practice (EBP) instrument that permits the synthesis and analysis of knowledge produced about the research theme. It is a methodologically sound research technique, increasing the reliability and depth of its conclusions^(5-6).

EBP encourages health professionals to seek scientific knowledge by developing research or applying results found in literature in their practice, in a critical and conscientious way, seeking the best possible evidence⁽⁷⁾.

The quality or strength of evidence can be ranked in five levels: level 1, strong evidence, based on at least one systematic review of multiple, randomized, controlled and well-designed studies; level 2, based on at least one randomized, controlled study with appropriate design and adequate size; level 3, evidence based on well-designed studies without randomization, a single pre and post-cohort group, time series or paired case-control; level 4, evidence based on well-designed, non-experimental studies, carried out at more than one center or by more than one research group; level 5, opinions by respected authorities, based on clinical evidence, descriptive studies or expert committee reports⁽⁸⁾. The following guiding question was adopted for this study: what effective play interventions are used for health education? To select the articles, the keywords games, education and health were used in MEDLINE, LILACS and CINAHL.

The studies included in this integrative review complied with the following inclusion criteria: abstract available in the above databases; language of publication Portuguese, English or Spanish; publication period between 1996 and 2006, systematic reviews of multiple randomized controlled clinical trials (Cochrane standard), research with experimental and quasi-experimental designs, besides themes related to the use of play interventions in health education.

Studies specifically related to undergraduate teaching were excluded, as they also involved professional education aspects, besides the health education scope.

Only systematic reviews (Cochrane standard) and research with experimental and quasi-experimental designs were included, due to the characteristics of the guiding question, related to the efficacy of an intervention, which necessarily involves research with evidence levels 1, 2 and 3. In this study, the term efficacy assesses the result of a process, in which the expectations of the subjects involved in the process are responded or not⁽⁹⁾, that is, if the results of a process/intervention comply with the proposed objectives.

Data were collected by two researchers and later confronted. Information about the studies was summarized in a table, indicating: title, authors, study design, purpose, results and conclusions, for the sake of comparative analysis.

Data were analyzed descriptively. The information extracted from the selected studies was categorized in thematic groups, based on the identification of variables of interest and key concepts, as proposed in specific sources about integrative literature reviews⁽¹⁰⁾.

RESULTS

The digital search resulted in 135 studies, distributed as follows between databases: MEDLINE- 120 and LILACS - 15; no papers were located in CINAHL. In this group, 118 studies were discarded that did not comply with preset inclusion criteria and one that complied with an exclusion criterion (was specifically related to undergraduate teaching).

In this integrative review, 16 studies were analyzed (13 in MEDLINE and 3 in LILACS), all of which were journal articles. With regard to source, each paper was published in one of the following journals: Pediatrics; Journal of School Health; Annals of Allergy, Asthma & Immunology; Academic Radiology; Journal of the American Medical Informatics Association; American Journal of Preventive Medicine; Revista de Nutrição; Revista FOB; Archives of Dermatology; Patient Education and Counseling; Tropical Doctor; Ethnicity and Disease; Texto & Contexto Enfermagem; Revista Latino-Americana de Enfermagem; Revista Panamericana de Salud Publica; and Journal Drug Education.

As to the research design of the assessed studies, the sample comprised nine experimental and seven quasi-experimental studies.

The selected studies are summarized in Chart 1 to 4, about Computer Games (four studies), Dynamias (six studies), Card Games (two studies) and Board Games (four studies).

DISCUSSION

The studies included in this review aimed to assess the efficacy of play interventions as mediators in health education, covering aspects like food habits, hygiene, oral health, growth, mother and baby care, exposure to sun, transmissible diseases, chronic diseases and substance abuse.

An intervention is effective when the expected results are achieved. In this sense, effective play interventions for health education should promote learning (as evidenced by increased knowledge level) and broader aspects, such as behavior changes and improved quality of life⁽⁴⁾. As presented, in this research, the goal was to assess the efficacy of the educative interventions and, hence, we will consider aspects of learning as well as its development in people's lives.

Although that conception is adopted here, an educative intervention by itself does not guarantee behavioral change and improved quality of life, due to the sociocultural and economic issues involved. Moreover, the goal of health education should not only be considered as behavioral change, as the subjects' values may be different from the educator's, making them choose other means to develop their daily practices⁽²⁷⁾.

Among the analyzed studies, five assessed both the improvement in knowledge levels and the occurrence of behavioral changes after the intervention^{(13-14,16-17,20)}, three of which were experimental (evidence level 2) and two quasi-experimental (evidence level 3).

With regard to the three experimental studies, two provided level-2 evidence about the efficacy of computer games in health education. One of them proved the game's efficacy to improve quality of life and knowledge levels about self-care among North-American children with asthma, suffering from moderate to severe symptoms. Although there were no statistically significant differences between the groups with regard to clinical variables, this difference was statistically significant in terms of knowledge retention (up to eight weeks after the intervention) and changes in functional state and improved quality of life in the long term (32 and 52 weeks). The authors appoint the need for further research with larger samples to determine the intervention's impact on morbidity due to asthma⁽¹³⁾. The other study demonstrated improvements in North American children's knowledge and eating habits through increased fruit, juice and vegetable consumption after the game, within two weeks. Possible bias should be considered though as, despite randomization, the control group was slightly older and the experimental group consumed slightly more fruit and vegetables in the pretest⁽¹⁴⁾.

Hence, computer games figure among effective educative alternatives in health education. Computer technology is flexible, can be associated with precise information about individuals and offers continuing educational support and active learning. Disadvantages include access problems, in terms of the variable quality of the places offering computer use, and in terms of "technological alphabetization", or computer knowledge and skills, demanding rigorous investigation to assess the educative interventions and their applicability to the target public^(11-13).

The third of the evidence level-2 studies (experimental studies) about behavioral and learning aspects proved the efficacy of an intervention involving Afro-American girls, which associated dynamics and dance classes to reduce the time spent in front of television and food consumption while watching, including the consequent decrease in BMI, waist circumference and increased physical exercise at the end of the intervention, during three months⁽²⁰⁾.

The two evidence level-3 studies (quasi-experimental) studies that proved efficacy related to improvements in knowledge levels and behavioral changes, mediated by play, used dynamics. One of them proved the efficacy of an educative program in oral health for Brazilian adolescents, including theoretical activities and scavenger hunts, through the reduction in dental plaque ratios and highly satisfactory scores on cognitive assessments two months after the intervention. The need for further research is appointed though, to validate the cognitive knowledge contribution assessment instrument⁽¹⁶⁾. The other study proved the efficacy of an educative campaign in the form of dynamics, with a view to limiting French children's exposure to the sun, achieving improvements in knowledge, attitudes and behaviors related to solar exposure (greater hat, T-shirt and sun screen use, reapplication of the sun screen, recognizing the sun as a risk factor and avoiding peak sun times) three months after the intervention. The efficacy of the campaign is highlighted, but authors recommend its extension for a longer period and long-term assessment of changes⁽¹⁷⁾.

Both learning and behavioral change should be assessed in the long term as well, with a view to determining whether knowledge was retained and whether it provides long-term behavioral changes that will influence the study population's quality of life. This long-term assessment is particularly important to permit that, over time, the new knowledge interacts with daily sociocultural and economic conditions, determining whether behavior will change and how.

Among the five studies mentioned here about learning and behavioral aspects, four assessed results immediately after the intervention and within three months afterwards^{(14,16,17,20)} and only one assessed long-term results (8 to 13 months)⁽¹³⁾.

The other 11 studies focused their assessment of content learning only, verifying whether health knowledge levels improved after the play intervention, without covering the assessment of behavioral changes. Among these studies, six provided evidence level 2 (experimental studies)^{(11-12,15,18,24-25)} and five evidence level 3 (quasi-experimental studies)^{(19,21-23,26)}. These studies used computer^(11-12), card^(21-22), board games^(23-26) and dynamics^(15,18-19) for health education related to basic concepts about child health⁽²⁴⁾, growth⁽¹⁹⁾, nutrition⁽¹⁵⁾, oral health⁽¹⁸⁾, health of mothers and infants^(22-23), child asthma^(11-12), transmissible diseases^(21,26) and alcohol abuse⁽²⁵⁾.

FINAL CONSIDERATIONS

In view of the above, strong evidence (levels 2 and 3) exists to determine the efficacy of computer games and dynamics in health education for children and adolescents, related to health promotion (oral health education and eating habits), disease and problem prevention (prevention of overweight, obesity and skin cancer) and chronic disease management (asthma). This evidence comes from research that assessed learning and behavioral aspects after the intervention. The efficacy of some of these play interventions needs to be assessed in the long term.

Despite strong evidence about other play interventions (card and board games), this evidence comes from research that only assessed content learning, without including the assessment of behavioral aspects and quality of life; therefore, it cannot be affirmed that strong evidence exists about the efficacy of these interventions for health education. The importance of card and board games should be taken into account though, as they favor mediated learning, stimulating understanding about the subject in a pleasant way, reflections about the obtained knowledge and the development of relations between the knowledge provided by play and reality, covering individual and collective behavioral aspects.

The results of this review offer scientific evidence to use play in health education. Its use in higher education was not addressed though, and should be discussed in future studies.

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Use of recreational activities in health education: integrative review of literature

Utilización de actividades lúdicas en la educación en salud: una revisión integradora de la literatura

Publication Dates

• Publication in this collection
  26 May 2010
• Date of issue
  Apr 2010