Exergaming-based Esports Intervention for Older Adults in Hong Kong: A Non-Randomized Controlled Trail Study

Exergaming-based Esports Intervention for Older Adults in Hong Kong: A Non-Randomized Controlled Trail Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exergaming-based Esports Intervention for Older Adults in Hong Kong: A Non-Randomized Controlled Trail Study Leung Ka Man, SHI YUCHEN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5261729/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Exergaming, refers to the video gaming with/without virtual reality which required the use of physical activity during gameplay, has been utilized as an emerging type of physical activity in improving older adults’ physical and mental health. Exergaming can also be considered as esports when the competitive and interactive element is embedded in the gameplay. To date, the impact of exergaming-based esports on older adults’ health and well-being conditions has been less investigated. This study aims to examine the effectiveness of exergaming-based esports intervention program in promoting older adults’ physical, psychological, and cognitive health outcomes in Hong Kong. A total of 54 older adults were recruited and 48 (male = 12; female = 36) were finally retained for data analysis due to six of them did not attend the post-test. All participants were allocated into either an esports group (EG = 24) and a control group (CG = 24). EG participants were invited to participate in an eight-week exergaming-based esports intervention program consisting of 16 training sessions to learn and play the Nintendo Switch™ Fitness Boxing game. A fitness boxing competition was embedded in the final three sessions. Besides, CG participants were instructed with their normal daily activity. Measures including Senior Fitness Test, the University of California, Los Angeles (UCLA) Loneliness Scale (ULS-8), the Chinese version of the Physical Activity Enjoyment Scale (PACES), the number comparison test and trail making test (TMT), and the Short Form-36 (SF-36) Health Survey were used to examine older adults’ physical, psychological, and cognitive conditions. Analysis of covariance (ANCOVA) was used for data analysis. The results showed that EG participants had better lower body strength, better agility, higher aerobic endurance, higher enjoyment level and higher cognitive functioning. This study provides theoretical contribution by filling in the research gap of the investigation of the beneficial effects of exergaming-based esports in enhancing older adults’ health conditions in Hong Kong. Besides, game designers are encouraged to design specific game types with competitive and interactive elements embedded for older adults to play and thus promote their emotional and cognitive well-being. Older adults esports participation exergaming-based intervention study health promotion 1 Introduction Hong Kong’s aging population poses a considerable public health challenge. The overwhelming majority of older adults in Hong Kong do not meet the minimum standards for physical activity (PA) levels recommended by the World Health Organization (Hong Kong Special Administrative Region (HKSAR) Centre for Health Protection, 2023). According to the Census and Statistics Department of the HK SAR (2018), the number of individuals aged 65 or older is expected to increase to 2.16 million by 2031 and 2.56 million by 2041. Being physically inactive and having a sedentary lifestyle contribute to physiological, psychological, and cognitive health problems. The financial burden of cognitive health problems poses social challenges, including increased pressure on health-care and social welfare systems ( 1 ). Due to the effects of net medical inflation, population growth, and aging (assuming service enhancement continues at historical levels), Hong Kong’s recurrent social welfare and health expenditure as a percentage of nominal GDP is projected to increase from $ 56.9 billion and $ 52.4 billion in 2014 and 2015 to $ 523.3 billion in 2041 and $ 563.6 billion in 2042 ( 2 ). A structural financial deficit may then occur within a decade. In examining the aging population and its social implications, studies have suggested various types of PA to promote active aging. In this context, esports, a competitive form of video gaming, has been promoted for its ability to improve physical, psychological, and social well-being ( 3 ). Theoretically, exergaming which is comprised with two terms of “exercise” and “gaming”, is defined as one type of physical exercise integrating multiple video gaming attributes into physical activities and requiring players to move while they play ( 4 ). It reinforces the need of physical exertion such as strength, balance, and flexibility activities ( 4 ). Esports, which normally refers to organized competitive digital gaming that exists on a spectrum of professionalism with multiple organized and competitive aspects, is conceptualized with four core characteristics including the competitiveness, the application of physical and mental skills, the use of communication and information technology, and the interaction between individuals ( 5 , 6 ). In this study, when competitive mode of play and interactive elements are integrated with physical and cognitive efforts in an exercise gaming environment, we propose exergaming as one form of esports. The acceptance and recognition of esports are reflected in the International Olympic Committee’s Olympic esports initiatives, which include organizing an esports forum in 2018 and creating the Olympic Esports Series in 2023. Esports is a fast-growing global industry that is particularly prominent in China and Hong Kong ( 7 ). Since 2000, esports has exploded in popularity in China. Chinese esports revenue accounted for more than 18% of global esports revenue (USD $ 13.63 million) in 2018 ( 8 ). Capitalizing on this trend, the HKSAR government proposed esports as a new sector for economic development in 2017 and engaged in several initiatives to promote the development of the esports industry ( 9 ). For example, the HKSAR government provided more than HK $ 100 million to Cyberport, a digital technology community in Hong Kong, to promote esports by organizing esports events, empowering the esports industry, developing esports talents, making esports mainstream, and promoting a positive public image ( 10 ). Unlike traditional video gaming, which is often associated with negative consequences, such as excessive screen time, addiction, and sedentary behaviors ( 11 ), esports offer substantial benefits, including improved physical fitness and range of motion ( 12 ), increased stress relief and motivation ( 13 ), and enhanced social connectedness and interaction ( 14 ). In this context, exergaming—esports that combines exercise and video games—has been studied for its contributions to health and wellness goals among older adults ( 15 ). Monteiro Pereira et al. ( 16 ) indicated that esports engagement encouraged active lifestyle habits and did not contribute to health problems, contradicting the conclusions of other studies regarding esports participation, although an association between esports practice and mental health problems was observed. Overall, esports participants exhibited improvements in PA levels and were generally physically active ( 16 ). Therefore, although esports participation can have contradictory and occasionally deleterious effects on physical and emotional well-being, esports represents a promising alternative to traditional community-based activities promoting increased levels of PA. To date, the literature examining the effects of esports on health and well-being has put more focus on young populations, especially young students ( 17 , 18 ) and young esports athletes ( 19 – 21 ). Moreover, a scoping review conducted by Monteiro Pereira et al. ( 16 ) investigating the associations between esports participation and health conditions revealed that all participants of the 33 included articles were young adults aged between 16 and 27 years. While the effects of esports on older adults have been studied in recent years, to participate exergaming-based esports represents a novel form of PA for older adults which are less investigated. A recent meta-analysis conducted by Hai et al. (2021) included 47 studies and revealed that exergame training could benefit older adults in multiple physical functioning aspects, such as balance, upper body strength, lower body strength, aerobic endurance, and gait ( 22 ). However, the competitive and interactive features of esports were missed in these studies. In Hong Kong, Leung and Chu ( 2 ) conducted a qualitative study on the perception of esports (e.g., e-swimming and e-car-racing games) among middle-aged and older adults and demonstrated that the physical benefits (attentiveness, strategic thinking, and memory function), psychological benefits (cognitive improvements and sense of achievement), and social benefits (social interactions and a sense of belonging) of esports participation could be explained using the theory of planned behavior, in which the intentions and attitudes underlying actions influence achievement-driven behavior. Their following qualitative study ( 3 ) further examined the esports perceptions and experiences of middle-aged and older adult participants in Hong Kong using a social marketing approach. Their study hypothesized that a community-based esports intervention that met the “five Ps” criteria (product, price, promotion, place, and people) encourage older adults to participate in esports, increase their PA levels, and improve their health. Although the video game used in these two studies were equipped with competitive and interactive elements, the seated and sedentary state of play mode could not be considered as exergaming-based esports. Based on the aforementioned studies, a clear research gap exists in examining the benefits of exergaming-based esports participation, including its effects on physical and psychological health, among older adults. Moreover, previous studies also suggested that older adults could gain a greater sense of enjoyment by experiencing competitive PA ( 23 ). Therefore, to encourage active aging, the present study implemented an exergaming-based esports intervention embedded with competition elements for older adults. This study investigated the effects of exergaming-based esports participation on the physical fitness, cognitive function, and various psychological attributes (loneliness, PA enjoyment, and quality of life) of older adults. We hypothesized that exergaming-based esports significantly improves physical function, cognitive attributes, and psychological health. 2 Methods 2.1 Participants A convenience sampling strategy was employed to recruit participants. Older adults from two branches (Kwun Tong and Hing Tin) of the Neighborhood Elderly Centre in Hong Kong were targeted. All recruited participants were assigned to groups stratified by sex and experience with exergaming-based esports activities. The inclusion criteria were a) being aged 60 years or older, b) living independently in the community, c) not having a cognitive impairment, d) not participating in a structured PA program six months preceding the study, and e) earning passing scores on the Timed-Up-and-Go Test (24) and the Abbreviated Mental Test (25). Participants were required to complete the Timed-Up-and-Go Test within 20 seconds. A minimum score of six points on the Abbreviated Mental Test was required to qualify for this study. The evaluations of participants were carried out by research assistants of the Education University of Hong Kong, who received a one-day training in the university one month prior to the recruitment and evaluation procedures. Besides, all research assistants were instructed to fully understand the meaning of each question under measures that employed in this study. They were responsible to answer potential questions raised by participants when completing the questionnaire in both pretest and posttest. All participants provided written informed consent and were assured that their personal information would remain confidential. 2.2 Measures 2.2.1 Functional Fitness Functional fitness was evaluated using the Senior Fitness Test developed and validated by Rikli and Jones (26). The Senior Fitness Test assesses older adults’ ability to perform normal daily activities independently. The test comprises six parts. First, the back scratch test measures the distance between the two middle fingers when extended. Each participant was required to complete two trials, and the best distance was recorded. Second, a 30-second chair and reach test requires participants to sit on the edge of a chair with one leg bent and the other leg extended straight in front. The test measures the distance between the extended middle finger and the tip of the toe of the extended straight leg. Each participant was required to complete two trials for each leg, and the best distances were recorded. Third, an eight-foot up-and-go test involved participants standing from a seated position, walking as quickly as possible around a cone placed eight feet ahead and returning to their seats. Each participant completed two trials, and the shortest time to finish the test was recorded. Fourth, a 30-second chair stand-up test requires participants to stand from a fully seated position within 30 seconds repeatedly. Each participant was required to complete two trials, and the number of times they did so within the timeframe was recorded. Fifth, a 30-second arm curl test requires participants to lift a dumbbell with their dominant hand as often as possible within 30 seconds. Each participant was required to complete a practice trial followed by a test trial, and the number of repetitions completed was recorded. Sixth, a 2-minute step test involved participants raising each knee to the level of a marked point on the wall representing half the distance between their iliac crest and patella and completing full steps for 2 minutes. Each participant was allowed to do a practice trial followed by a test trial, and the number of full steps completed in 2 minutes was recorded. These tests were reliable (interclass correlation coefficient: .80–.98) and valid, as demonstrated in content, construct, and criterion analyses (26). 2.2.2 Cognitive Function The examination of participants’ cognitive function included two cognitive tests, the number comparison test (NCT; 27) and the trail-making test (TMT; 28). Both NCT and TMT have been widely used as a cognitive tool in examining older adults’ attention and executive functions (29,30). The number comparison test requires participants to identify inconsistent digital pairs by marking an “X” on them within a period of 90 seconds. Scores are calculated by subtracting the number of incorrect markings from the total number of correct markings. The TMT consists of two parts. For Part A, participants are asked to draw a line as quickly as possible that connects the numbers 1 through 25 written on a piece of paper in varying positions. Part B requires participants to draw a continuous line connecting dots in ascending order, alternating between dots associated with numbers (1 to 13) and letters (A to L). The time taken to complete both tasks was recorded. 2.2.3 Loneliness Loneliness was measured using a short version of the University of California, Los Angeles Loneliness Scale (ULS-8; 31), which has been psychometrically developed and evaluated for older adults in diverse language versions (32). This scale consists of eight items evaluating whether participants feel devoid of social contact and assessing their level of loneliness (e.g., “I feel isolated from others”). Items are scored on a 4-point scale with endpoints ranging from 1 ( never ) to 4 ( always ), with total scores ranging from 8 to 32. Higher scores indicate greater levels of loneliness. This scale demonstrated satisfactory internal consistency in this study, with a Cronbach’s alpha value of .81. 2.2.4 Enjoyment of PA Level of enjoyment of PA was measured using the Chinese version of the Physical Activity Enjoyment Scale (PACES), which was developed by Chung and Leung (33). This measurement has been validated as a well-fitting assessment tool to evaluate older adults’ satisfaction with PA (34). This scale comprises eight items scored on a 7-point scale with endpoints ranging from 1 ( I enjoy it ) to 7 ( I dislike it ). Four of the eight items (items 1, 4, 5, and 7) were reverse coded. Higher scores indicate greater levels of PA enjoyment. The scale demonstrated acceptable reliability and internal consistency (Cronbach α = .92; 23). The mean scores for the eight items were calculated to yield a PA enjoyment score. 2.2.5 Quality of Life The Short Form-36 (SF-36) Health Survey is widely employed to assess health-related quality of life among older adults (35). In this study, two subscales, social functioning (2 items) and emotional well-being (5 items), were used. These subscales assess motivation to participate in social activities, physical and emotional problems, and feelings of nervousness, depression, peacefulness, happiness, and calm over the preceding 4 weeks. Items are rated on a 5-point Likert scale, with higher scores indicating a superior state of health. The reliability and validity of the SF-36 questionnaire have been verified in Chinese participants (36). 2.3 Intervention The intervention programs were delivered over a period from July to September 2021 by registered instructors and a research assistant from the Education University of Hong Kong. All the training sessions were carried out in two branches (Kwun Tong and Hing Tin) of the Neighborhood Elderly Centre in Hong Kong. The intervention program comprised 16 training sessions, with 2 sessions per week each lasting 90 minutes. Participants were required to complete a 10-minute warm-up activity prior to starting and a 5-minute stretching and cool-down activity at the end of each session. The fitness video game Fitness Boxing , developed by Imagineer (Tokyo, Japan) for the Nintendo Switch TM console, was selected for participants to play. The reason of selecting Fitness Boxing was its integration of multiple physical and cognitive skills required to play. This game combined elements of physical exercise and music which required players to perform moves by following not only the on-screen cues of physical moves but also the rhythm of the music. Besides, its unique two-player mode could create competitiveness between players by comparing the points they got during the pairwise competition. Participants were required to use the Joy-Con motion controllers of the console to perform basic boxing skills, including punching, ducking, weaving, and stepping. All participants were asked to take part in the training at the same time. The play intensity was designed to range from low to moderate. A Fitness Boxing competition was arranged during the final three sessions. After the intervention, participants were expected to have gained a basic understanding of exergaming-based esports and a knowledge of basic boxing skills. 2.4 Procedures We applied a non-randomized controlled trail design in this study. The reason we selected non-RCT was because we expected that prospective participants were likely to have strong preferences of participating in the EG over CG, thus preventing the randomization. Prior to the intervention, an instruction session was provided to all participants to explain the details of the intervention program. Participants were required to sign consent forms before the commencement of the intervention. After all participants provided written informed consent, they were divided into two groups: an exergaming-based esports group (EG) and a control group (CG). All participants were instructed to measure their height, weight, and body fat percentage using a Tanita machine (Model: BC-418) and to take the aforementioned fitness tests. Participants in the EG participated in the 8-week intervention, which began after the administration of the pretest. A qualified boxercise instructor was recruited to teach and train participants to learn necessary skills (i.e., straight punch, hook, uppercut, mixed punch, weave, and step) in playing this game. Meanwhile, a research assistant from the Education University of Hong Kong was arranged as an assistant of the boxercise instructor to help supervising these participants. Finally, a Fitness Boxing competition was held in the final three sessions using a double-elimination bracket. After the 8-week intervention, participants completed measures using the same procedures as for the pretest. All the tests were conducted at the partnered centers. The participants in the CG were instructed to maintain their normal daily activities. Data collection was approved by the Human Research Ethics Committee of the Education University of Hong Kong (Ref: 2019-2020-0468). 2.5 Statistical Analysis Data were analyzed using SPSS version 27.0. An analysis of covariance was employed to examine group effects on measures of physical and psychological attributes. In the analysis of covariance, the independent variable was the group (EG and CG), and the dependent variable was the posttest score of measures of physical fitness, cognitive functions, and psychological attributes. Pretest scores for each outcome were used as covariates; these scores were used to assess the aforementioned attributes. Subsequently, differences between groups were analyzed using pairwise comparisons with a Bonferroni correction. All effect sizes are reported as partial η². Alpha was set at p < 0.05 for all statistical tests. 3 Results Participant sociodemographic data are presented in Table 1 . Questions of sociodemographic information were put as the last section of the questionnaire. Participant were asked to complete this questionnaire after completing the intervention program. All sociodemographic questions were self-generated. A total of 54 older adults participated in our study (EG = 24; CG = 30). However, six participants did not complete the posttest; data from the remaining 48 participants (EG = 24; CG = 24) were included in our analysis. The mean age of the participants was 70.77 years (standard deviation [SD] = 5.92). In total, 12 men (25%) and 36 women (75%) participated. Ages ranged from 60 to 88 years, with 19 (39.56%) and 16 (33.33%) participants falling within the age ranges of 65 to 69 and 70 to 74 years, respectively. Participant education levels were distributed as follows: four participants (8.33%) had only primary education, 27 (56.25%) had only secondary education, and 15 (31.25%) had tertiary education or above. Two participants did not disclose their education level. Regarding marital status, 60.41% ( n = 29) were married, and 25% ( n = 12) were single; the remaining participants did not disclose their marital status. A total of 31 participants (64.58%) reported their financial status as “moderate,” and only 2 participants (4.17%) considered their income level “slightly high.” A private residence was the most common housing type ( n = 40). Table 1 Socio-demographic characteristics of participants Measures Participants Age (mean ± SD) 70.77 ± 5.92 Gender Female 36 Male 12 Education Primary 5 Secondary 30 Tertiary or above 13 Marriage Married 30 Single 11 Cohabitation 1 Others 6 Employment Retired 41 Part-time 1 Housewife 6 Financial status Low 2 Slightly low 10 Medium 33 Slightly high 3 High 0 Housing types Private housing 33 Home ownership scheme housing 10 Public housing 5 The mean and SD values for the physical fitness, cognitive function, and psychological measures pretest and posttest are presented in Table 2 . In the analysis of pretest scores, no significant differences were observed between the EG and CG groups for any of the outcome measures. ANCOVA was performed to examine the differences in posttest scores between the EG and CG. For physical fitness, significant differences in posttest scores were identified, specifically on the chair stand-up test [F(1, 47) = 11.44, p < .001, partial η 2 = .20], the eight-foot up-and-go test [F(1, 47) = 5.03, p < .05, partial η 2 = .10], and the 2-minute step test [F(1, 47) = 4.65, p < .05, partial η 2 = .09]. Table 2 Means and standard deviations for measures between groups at pre- and post-test Measures CG (N = 24) EG (N = 24) F p Pre-test Post-test Pre-test Post-test Chair stand-up (frequency) 15.46 (4.69) 16.37 (5.07) 14.08 (3.91) 19.79 (5.37) 11.44*** .00*** Arm curl (frequency) 16.71 (5.35) 19.71 (6.24) 15.35 (5.76) 21.00 (7.16) 0.88 .35 Chair sit and reach – left (cm) 2.44 (10.05) 6.99 (9.33) 4.70 (11.47) 5.40 (12.35) 1.71 .20 Chair sit and reach – right (cm) 2.85 (10.24) 7.23 (9.89) 4.89 (10.95) 6.52 (10.91) 0.86 .36 Eight-foot up and go (s) 6.65 (1.61) 5.94 (1.34) 6.38 (1.32) 5.32 (1.05) 5.03* .03* Two-minute step (frequency) 87.00 (22.99) 88.71 (17.38) 82.38 (22.80) 96.79 (20.69) 4.65* .04* Back scratch – left (cm) -2.02 (10.53) -1.76 (10.53) -1.33 (10.69) -1.48 (9.42) 0.01 .92 Back scratch – right (cm) 3.26 (8.30) 2.80 (7.27) 4.32 (7.64) 3.25 (7.55) 0.12 .73 Body mass index (kg/m 2 ) 22.85 (3.40) 23.05 (3.33) 22.18 (3.21) 22.58 (3.16) 0.75 .39 Number comparison (s) 32.25 (9.31) 38.21 (8.09) 31.13 (9.44) 33.00 (10.62) 4.63* .04* TMT part A (s) 75.76 (30.03) 71.56 (30.15) 74.46 (33.64) 61.18 (15.36) 4.30* .04* TMT part B (s) 49.36 (21.85) 45.76 (17.36) 44.58 (19.42) 45.24 (18.35) 0.11 .74 ULS-8 (score) 16.21 (4.70) 15.63 (4.05) 17.38 (4.61) 16.83 (3.91) 0.38 .54 PACES (score) 5.59 (1.09) 5.44 (1.10) 5.26 (0.85) 5.74 (0.85) 5.93* .02* SF-36 (score) Note. * p < .05; ** p < .01; *** p < .001; CG, control group; EG, esports group; TMT, trail making test; ULS-8, University of California, Los Angeles (UCLA) Loneliness Scale; PACES, Physical Activity Enjoyment Scale. The post-test scores were adjusted via ANCOVA for difference in the pre-test scores. The Bonferroni pairwise comparisons revealed that participants in the EG had better lower body strength [M = 19.79 (5.37)] and agility [M = 5.32 (1.05)] and higher aerobic endurance [M = 96.79 (20.69)] than did those in the CG. No significant between-group differences were observed in the arm curl test [F(1, 47) = 0.88, p = .35, partial η 2 = .02], the chair sit and reach test for the left [F(1, 47) = 1.71, p = .20, partial η 2 = .04] or right foot [F(1, 47) = 0.86, p = .36, partial η 2 = .20], the back scratch test for the left [F(1, 47) = 0.01, p = .92, partial η 2 = .00] or right hand [F(1, 47) = 0.12, p = .73, partial η 2 = .00], or body mass index [F(1, 47) = 0.99, p = .33, partial η 2 = .02]. Significant differences in posttest scores were also observed regarding the level of enjoyment of PA [F(1, 47) = 5.93, p < .05, partial η 2 = .12], number comparison test [F(1, 47) = 4.63, p < .05, partial η 2 = .09], and TMT Part A [F(1, 47) = 4.30, p < .05, partial η 2 = .09]. The Bonferroni pairsie comparisons indicated a higher level of enjoyment [M = 5.74 (0.85)] and higher cognitive ability [number comparison test, M = 33.00 (10.62); TMT Part A, M = 61.18 (15.36)] for participants in the EG than participants in the CG. However, no significant group differences were observed in the results of the ULS-8 test [F(1, 47) = 0.38, p = .54, partial η 2 = .01] and the TMT Part B [F(1, 47) = .11, p = .74, partial η 2 = .00]. The full statistical results can be found in Table 2 . 4 Discussion The present study investigated the effects of an 8-week exergaming-based esports intervention (exergaming) on physical fitness, cognitive functions, and psychological attributes among community-based older adults. Our findings revealed that the EG scored higher than did the CG on six outcome measures, specifically a) the lower body strength (chair stand-up test), b) agility and dynamic balance (the eight-foot up-and-go test), c) aerobic ability (2-minute step test), d) cognitive functioning (the number comparison test and the TMT), and e) the PA enjoyment (PACES). However, no differences were observed between groups regarding flexibility, upper body strength and endurance, body mass index, or level of loneliness. These results partially support the hypothesis that greater lower body strength, agility and dynamic balance, aerobic ability, cognitive functioning, and PA enjoyment would be observed in exergaming-based esports participants than in their peers who did not play exergaming-based esports. 4.1 Improvements in Physical Health Significant improvements in lower body strength, agility, dynamic balance, and aerobic endurance were observed in the EG. These improvements were attributed to the physical intensity required to play Fitness Boxing during the 8-week intervention. Instructors taught various skills, including different punches (hook, uppercut, and mixed), ducking, weaving, and stepping. Participants were required to practice these skills during the intervention period. Additionally, specific training sessions and advanced skills sessions (teaching combinations of skills) were organized to increase the intensity of the practice sessions gradually. The duration of these sessions in the exergaming-based esports intervention program exceeded the World Health Organization PA guidelines (37) of engaging in a minimum of 150 minutes of moderate-intensity PA per week. This activity level likely accounts for the observed improvements in physical attributes in older adults in the EG. Moreover, our results align with those of a systematic review focusing on the associations between exergames and older adults’ PA that revealed that older adults who played exercise-based or motion-sensing games exhibited improvements in physical functions such as balance, mobility, and agility (14). Another study on the effects of exergames and video game training on older adults’ physical functioning also demonstrated significant enhancements in lower limb strength and balance among participants in the exergame training group (38). Our findings are consistent with those of a study that employed exergames involving motor functioning and balance in rehabilitation, suggesting the positive effects of exergaming-based esports participation in promoting physical health in older adults (39). 4.2 Improvements in Cognitive Functions The results of the present study reveal that EG participants’ scores on the number comparison test and the TMT Part A significantly improved after receiving the exergaming-based esports intervention, indicating that the intervention provided cognitive benefits for these older adults. These findings are consistent with those of other studies indicating that exergame training positively affects older adults’ cognitive functioning (38, 40). For instance, older adults trained using Nintendo Wii exergames demonstrated substantial improvements on the number comparison test and TMT Parts A and B (40). Moreover, Hou and Li (38) revealed that exergame training interventions enhanced cognitive functioning, specifically verbal memory, top-down attention, and learning efficiency, in older adults. One plausible explanation for these significant observed improvements in cognitive functions may be the complexity of exergames. By providing dynamic game content combining both cognitive and physical exercises during participation (41), the Nintendo Switch TM Fitness Boxing game used in this study typified a dynamic exergame with its requirement to continually monitor the screen and adjust the player character’s position to make appropriate responses using various motor skills. This complicated play style requires significant cognitive effort and is likely responsible for the cognitive benefits observed in the older adults in the present study. 4.3 Improvements in PA Enjoyment Participants in the EG scored higher on the PACES than did those in the CG, indicating greater PA enjoyment in the older adults who participated in the intervention. These results are consistent with those of studies using other exercise-based video games on different exergaming technology platforms, such as Nintendo Wii (40) and Microsoft Kinect (42), in addition to a study using interactive video dance games (43). Lee et al. (44) reported that enjoyment is the primary reason individuals play exergames. Unlike traditional video games, where participants only sit and manipulate a game controller, Fitness Boxing is an exercise-based game where participants must be active by engaging in a boxing match against human or computer opponents, an enjoyable type of PA. Additionally, the Fitness Boxing competition for EG participants at the end of the intervention program may explain the increase in participants’ enjoyment. This suggestion is consistent with the findings of Vorderer et al. (45) on the factors affecting enjoyment experienced by video game players that indicated competition as a key element responsible for players’ enjoyment. Therefore, the Fitness Boxing competition in the final three sessions likely enhanced the experience and contributed to the players’ enjoyment. 4.4 Limitations and Future Research This study is the first to conduct an exergaming-based esports intervention program to assess physical fitness, cognitive functions, and psychological attributes among community-based older adults. Nevertheless, this study is not without limitations. First, participants were recruited through convenience sampling from two community centers for older adults only, and most participants resided near these centers and preferred to participate with friends from the same center. This situation may have introduced bias in participant recruitment. Second, the predominance of female participants (75%) limits the generalizability of the results. Future research should use a random sampling strategy from diverse locations to enhance the generalizability of the findings. Expanding the sample size and including multiple centers may also improve generalizability. Third, no follow-up measures were conducted to monitor older adults’ exergaming-based esports participation and changes in physical and psychological measures. Because exergaming-based esports remains a novel form of PA for older adults in Hong Kong, researchers should conduct longitudinal studies with follow-up assessments to examine retention in exergaming-based esports participation and the effects of such participation on the maintenance of physical and psychological health. Fourth, future studies should use more objective measures of cognitive health, such as neuroimaging. Fifth, this study only examined the influence of exergaming-based esports on older adults’ health, leaving the mechanism behind these health benefits unexamined. Future studies should examine the influence of the competitive nature of esports on these health benefits. 5 Conclusion The results of this study revealed that better lower body strength, better agility, higher aerobic endurance, higher enjoyment level and higher cognitive functioning were founded among participants in the EG, which partially supports that exergaming-based esports is effective in promoting older adults’ physical, psychological, and cognitive health outcomes. This study’s examination of the benefits of exergaming-based esports participation on physical, cognitive, and psychological health outcomes in older adults has several practical implications. First, using the empirical evidence from this study, more centers for older adults can introduce exergaming-based esports activities to their members and gradually organize regular play sessions and competitions to enhance older adults’ health. The need of physical movements, the complexity of the game, and the embedded competitive and interactive elements in this exergaming-based esports intervention are all unique attributes in contributing older adults’ physical, cognitive, and mental well-being. Second, because flexibility, upper body strength, and body mass index did not substantially improve in this study, game designers should consider designing games for older adults which could specifically improve these health attributes. Third, older adults should be aware that playing exergaming-based esports regularly can strengthen their physical attributes, increase their sense of enjoyment, and improve their cognitive functioning. Finally, all participants in the EG completed the entire intervention program with no one dropped out, which indicate that using Nintendo Swith™ Fitness Boxing as the exergaming-based esports is a suitable form of PA for older adults. This finding is in line with Valenzuela et al.’s ( 46 ) study which demonstrated that higher adherence level could be found for technology-based interventions over traditional physical exercises. Based on the findings, exergaming-based esports activity like Fitness Boxing might bring new approaches to the PA among older adults which could be promoted to other elderly centers in the future. Declarations Conflict of Interest The author reports no conflicts of interest in this work. Author Contributions Leung K. M. conceived the study, contributed to the methodology, supervised the project, managed resources, acquired funding, conducted the investigation, performed formal analysis, validated the data, carried out data visualization, and contributed to its review and editing. Shi Y. drafted the original manuscript, contributed to the methodology, performed formal analysis, validated the data, carried out data visualization, and contributed to the review and editing of the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors. Funding This study was supported by the General Research Fund. Acknowledgments (Not applicable) Availability of Data and Materials The dataset supporting the conclusions of this article is included within the article and its additional file. References Wong MY, Karmakar P, Almarzooqi MA, Rhodes RE, Zhang CQ, Ou KL, Yanping D, Chung PK, Alghamdi NA. The effects of walking on frailty, cognitive function and quality of life among inactive older adults in Saudi Arabia: a study protocol of randomized control trial by comparing supervised group-based intervention and non-supervised individual-based intervention. BMC Geriatrics (2023) 23:602-611. Leung KM, Chu W. eSports participation among Hong Kong middle-aged and older adults: a qualitative study. Hum Behav Emerg Technol (2023a) 2023:1-11. Leung KM, Chu W. 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Zhao, Y., Lin, Z. Umbrella platform of Tencent eSports industry in China. Journal of Cultural Economy. (2021)14: 9-25. Office of the Government Chief Information Officer HKSAR. Report on Promotion of E-sports Development in Hong Kong. https://www.legco.gov.hk/yr17-18/chinese/panels/itb/papers/itb20171211cb4-608-1-c.pdf. (accessed April 15, 2024). Cyberport. Report on Promotion of E-Sports Development in Hong Kong. Available online: https://www.cyberport.hk/files/5a8260c50c633354373178/EN_e-sports%20report.pdf [Accessed April 10, 2024]. Biegun J, Edgerton JD, Roberts LW. Measuring problem online video gaming and its association with problem gambling and suspected motivational, mental health, and behavioral risk factors in a sample of university students. Games and Culture. (2021) 16:434-56. Santos IKD, Medeiros RC, Medeiros JA, Almeida-Neto PF, Sena DC, Cobucci RN, Oliveira RS, Cabral BG, Dantas PM. Active video games for improving mental health and physical fitness—An alternative for children and adolescents during social isolation: an overview. Int J Environ Res Public Health (2021) 18:1641. Granic I, Lobel A, Engels RC. The benefits of playing video games. Am Psychol (2014) 69:66-78. Osmanovic S, Pecchioni L. Beyond entertainment: motivations and outcomes of video game playing by older adults and their younger family members. Games Cult (2016) 11:130-49. Kappen, D. L., Mirza-Babaei, P., & Nacke, L. E. (2019). Older adults’ physical activity and exergames: a systematic review. Int J Hum Comput Interac (2019) 35:140-67. Monteiro Pereira, A., Costa, J. A., Verhagen, E., Figueiredo, P., & Brito, J. (2022). Associations between esports participation and health: a scoping review. Sports Medicine, 52:2039-60. Andre TL, Walsh SM, Valladao S, Cox D. Physiological and perceptual response to a live collegiate esports tournament. Int J Exerc Sci (2020) 13:1418. DiFrancisco-Donoghue J, Werner WG, Douris PC, Zwibel H. Esports players, got muscle? Competitive video game players’ physical activity, body fat, bone mineral content, and muscle mass in comparison to matched controls. J Sport Health Sci (2022) 11:725-30. Gündoğdu S, Çolak ÖH, Doğan EA, Gülbetekin E, Polat Ö. Assessment of mental fatigue and stress on electronic sport players with data fusion. Med Biol Eng Comput (2021) 59:1691-1707. Kari T, Karhulahti VM. (2016). Do e-athletes move? a study on training and physical exercise in elite e-sports. Int J Gaming Comput Med Simul (IJGCMS) (2016) 8:53-66. Hai, L, Hou, H. Y., Zhou, C., & Li, H. J. The effect of exergame training on physical functioning of healthy older adults: a meta-analysis. Games for Health Journal (2022) 11: 207-224. Leung, K. M., Chung, P. K., & Hagger, M. S. The effects of light volleyball intervention programme in improving selected physical and psychological attributes of older adults in Hong Kong. International Journal of Sport and Exercise Psychology. (2020) 18: 1-12. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc (1991) 39:142-8. Chu LW, Pei CK, Ho MH, Chan PT. Validation of the abbreviated mental test (Hong Kong version) in the elderly medical patient. HKMJ (1995) 1:207-211. Rikli RE, Jones CJ. “Senior fitness test manual”. Champaign, IL (United States). Human Kinetics. (2013). Ackerman PL, Cianciolo AT. Cognitive, perceptual-speed, and psychomotor determinants of individual differences during skill acquisition. J Exp Psychol Appl (2000) 6:259-90. Wang RY, Zhou JH, Huang YC, Yang YR. Reliability of the Chinese version of the Trail Making Test and Stroop Color and Word Test among older adults. Int J Gerontol (2018) 12:336-9. Perrot, Alexandra, Pauline Maillot, and Alan Hartley. Cognitive training game versus action videogame: effects on cognitive functions in older adults. Games for Health Journal (2019) 8: 35-40. Suzuki, Hiroyuki, Sakuma, N., Kobayashi, M., Ogawa, S., Inagaki, H., Edahiro, A., ... & Awata, S. Normative data of the Trail Making Test among urban community-dwelling older adults in Japan. Frontiers in Aging Neuroscience (2022) 14: 832158. Xu S, Qiu D, Hahne J, Zhao M, Hu M. Psychometric properties of the short-form UCLA Loneliness Scale (ULS-8) among Chinese adolescents. Medicine (2018) 97:e12373. Alsubheen, Sanaa A., Oliveira, A., Habash, R., Goldstein, R., & Brooks, D. Systematic review of psychometric properties and cross-cultural adaptation of the University of California and Los Angeles loneliness scale in adults. Current Psychology (2023) 42: 11819-11833. Chung PK, Leung KM. Psychometric properties of eight-item physical activity enjoyment scale in a Chinese population. J Aging Phys Act (2019) 27:61-6. Huffman, M. K., Christ, S. L., Ferraro, K. F., Klenosky, D. B., Marceau, K., & Amireault, S. Questions to measure enjoyment of and satisfaction with physical activity: Are they appropriate for use in an older population?. Innovation in Aging (2021) 5: 1-11. Hobart JC, Williams LS, Moran K, Thompson AJ. Quality of life measurement after stroke: uses and abuses of the SF-36. Stroke (2002) 33:1348-356. Zhang Y, Bo QU, Lun SS, Guo Y, Liu J. The 36-item short form health survey: reliability and validity in Chinese medical students. Int J Med Sci (2012) 9:521-6. World Health Organization T. Global Recommendations on Physical Activity for Health. World Health Organization (2010). Hou HY, Li HJ. Effects of exergame and video game training on cognitive and physical function in older adults: a randomized controlled trial. Appl Ergon (2022) 101:103690. Smith ST, Schoene D. The use of exercise-based videogames for training and rehabilitation of physical function in older adults: current practice and guidelines for future research. Aging Health (2012) 8:243-52. Wadhwa G, Walia S. Effect of Nintendo WII brain training games on perceptual speed, working memory and spatial orientation in young adults. Int J Neurol Phys Ther (2018) 4:7-15. Hughes TF, Flatt JD, Fu B, Butters MA, Chang CC, Ganguli M. Interactive video gaming compared with health education in older adults with mild cognitive impairment: a feasibility study. Int J Geriatr Psychiatry (2014) 29:890-8. Ismail NA, Hashim HA, Ahmad Yusof H. Physical activity and exergames among older adults: a scoping review. Games Health J (2022) 11:1-17. Xu W, Liang HN, Yu K, Wen S, Baghaei N, Tu H. Acceptance of virtual reality exergames among Chinese older adults. Int J Hum Comput Interact (2023) 39:1134-148. Lee S, Kim W, Park T, Peng W. The psychological effects of playing exergames: a systematic review. Cyberpsychol Behav Soc Netw (2017) 20:513-32. Vorderer P, Hartmann T, Klimmt C. Explaining the enjoyment of playing video games: the role of competition. In Proceedings of the Second International Conference on Entertainment Computing (ICEC 2003); 2003, May; Pittsburgh. New York: ACM (2003). p. 1-9. Valenzuela T, Okubo Y, Woodbury A, Lord SR, Delbaere K. Adherence to technology-based exercise programs in older adults: A systematic review. Journal of Geriatric Physical Therapy. (2018) 41: 49-61. Additional Declarations No competing interests reported. Supplementary Files Exergamingforolderadultsdataset.sav Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5261729","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370526226,"identity":"935cd024-3b23-4bc4-a6b6-bac3521119b6","order_by":0,"name":"Leung Ka Man","email":"","orcid":"","institution":"the Education University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Leung","middleName":"Ka","lastName":"Man","suffix":""},{"id":370526227,"identity":"66fe4f7c-aaf8-41ba-a752-5c17dbbdc6b9","order_by":1,"name":"SHI YUCHEN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACCcYGIHmAgYG9ASpygGgtPCClCURpgZkskUCkFvnZzW3SPDV35MwlX6dJ/vzBIMd3I4F1wwc8WgzuHARqOfbM2HJ27jZpngQGY8kbCWw3Z+DTIpHYJs3bcDhxw22gFqDDEjcAtdzmweewGRAt9Rtunt0m+SOBoZ6gFoYbEC0JBjd4t0kAHQZkENBicCOx2XLOscOGG87kbrbmSZMwnHnmYRtev8jPSH94403NYXmD42c33vxhYyPPdzz52A18IQYELBJIHBAbHLl4ATMBI0fBKBgFo2DEAwCSc1Uz/G7lHgAAAABJRU5ErkJggg==","orcid":"","institution":"The Macau University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"SHI","middleName":"","lastName":"YUCHEN","suffix":""}],"badges":[],"createdAt":"2024-10-14 14:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5261729/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5261729/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82799692,"identity":"2b994671-fa44-49f3-9341-e4705eff36f5","added_by":"auto","created_at":"2025-05-15 11:01:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":635250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5261729/v1/04cf0876-9c88-49e4-8db3-ed7cf4574ee8.pdf"},{"id":69808085,"identity":"4c14696f-a5e3-4d82-a6c7-ba0aeb8468dc","added_by":"auto","created_at":"2024-11-25 12:15:59","extension":"sav","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":72633,"visible":true,"origin":"","legend":"","description":"","filename":"Exergamingforolderadultsdataset.sav","url":"https://assets-eu.researchsquare.com/files/rs-5261729/v1/401c0dd7926a016c69038ffe.sav"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exergaming-based Esports Intervention for Older Adults in Hong Kong: A Non-Randomized Controlled Trail Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eHong Kong\u0026rsquo;s aging population poses a considerable public health challenge. The overwhelming majority of older adults in Hong Kong do not meet the minimum standards for physical activity (PA) levels recommended by the World Health Organization (Hong Kong Special Administrative Region (HKSAR) Centre for Health Protection, 2023). According to the Census and Statistics Department of the HK SAR (2018), the number of individuals aged 65 or older is expected to increase to 2.16\u0026nbsp;million by 2031 and 2.56\u0026nbsp;million by 2041. Being physically inactive and having a sedentary lifestyle contribute to physiological, psychological, and cognitive health problems. The financial burden of cognitive health problems poses social challenges, including increased pressure on health-care and social welfare systems (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Due to the effects of net medical inflation, population growth, and aging (assuming service enhancement continues at historical levels), Hong Kong\u0026rsquo;s recurrent social welfare and health expenditure as a percentage of nominal GDP is projected to increase from \u003cspan\u003e$\u003c/span\u003e56.9\u0026nbsp;billion and \u003cspan\u003e$\u003c/span\u003e52.4\u0026nbsp;billion in 2014 and 2015 to \u003cspan\u003e$\u003c/span\u003e523.3\u0026nbsp;billion in 2041 and \u003cspan\u003e$\u003c/span\u003e563.6\u0026nbsp;billion in 2042 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A structural financial deficit may then occur within a decade.\u003c/p\u003e \u003cp\u003eIn examining the aging population and its social implications, studies have suggested various types of PA to promote active aging. In this context, esports, a competitive form of video gaming, has been promoted for its ability to improve physical, psychological, and social well-being (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Theoretically, exergaming which is comprised with two terms of \u0026ldquo;exercise\u0026rdquo; and \u0026ldquo;gaming\u0026rdquo;, is defined as one type of physical exercise integrating multiple video gaming attributes into physical activities and requiring players to move while they play (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It reinforces the need of physical exertion such as strength, balance, and flexibility activities (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Esports, which normally refers to organized competitive digital gaming that exists on a spectrum of professionalism with multiple organized and competitive aspects, is conceptualized with four core characteristics including the competitiveness, the application of physical and mental skills, the use of communication and information technology, and the interaction between individuals (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In this study, when competitive mode of play and interactive elements are integrated with physical and cognitive efforts in an exercise gaming environment, we propose exergaming as one form of esports.\u003c/p\u003e \u003cp\u003eThe acceptance and recognition of esports are reflected in the International Olympic Committee\u0026rsquo;s Olympic esports initiatives, which include organizing an esports forum in 2018 and creating the Olympic Esports Series in 2023. Esports is a fast-growing global industry that is particularly prominent in China and Hong Kong (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Since 2000, esports has exploded in popularity in China. Chinese esports revenue accounted for more than 18% of global esports revenue (USD\u003cspan\u003e$\u003c/span\u003e13.63\u0026nbsp;million) in 2018 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Capitalizing on this trend, the HKSAR government proposed esports as a new sector for economic development in 2017 and engaged in several initiatives to promote the development of the esports industry (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). For example, the HKSAR government provided more than HK\u003cspan\u003e$\u003c/span\u003e100\u0026nbsp;million to Cyberport, a digital technology community in Hong Kong, to promote esports by organizing esports events, empowering the esports industry, developing esports talents, making esports mainstream, and promoting a positive public image (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnlike traditional video gaming, which is often associated with negative consequences, such as excessive screen time, addiction, and sedentary behaviors (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), esports offer substantial benefits, including improved physical fitness and range of motion (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), increased stress relief and motivation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and enhanced social connectedness and interaction (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In this context, exergaming\u0026mdash;esports that combines exercise and video games\u0026mdash;has been studied for its contributions to health and wellness goals among older adults (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Monteiro Pereira et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) indicated that esports engagement encouraged active lifestyle habits and did not contribute to health problems, contradicting the conclusions of other studies regarding esports participation, although an association between esports practice and mental health problems was observed. Overall, esports participants exhibited improvements in PA levels and were generally physically active (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, although esports participation can have contradictory and occasionally deleterious effects on physical and emotional well-being, esports represents a promising alternative to traditional community-based activities promoting increased levels of PA.\u003c/p\u003e \u003cp\u003eTo date, the literature examining the effects of esports on health and well-being has put more focus on young populations, especially young students (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and young esports athletes (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Moreover, a scoping review conducted by Monteiro Pereira et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) investigating the associations between esports participation and health conditions revealed that all participants of the 33 included articles were young adults aged between 16 and 27 years. While the effects of esports on older adults have been studied in recent years, to participate exergaming-based esports represents a novel form of PA for older adults which are less investigated. A recent meta-analysis conducted by Hai et al. (2021) included 47 studies and revealed that exergame training could benefit older adults in multiple physical functioning aspects, such as balance, upper body strength, lower body strength, aerobic endurance, and gait (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, the competitive and interactive features of esports were missed in these studies. In Hong Kong, Leung and Chu (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) conducted a qualitative study on the perception of esports (e.g., e-swimming and e-car-racing games) among middle-aged and older adults and demonstrated that the physical benefits (attentiveness, strategic thinking, and memory function), psychological benefits (cognitive improvements and sense of achievement), and social benefits (social interactions and a sense of belonging) of esports participation could be explained using the theory of planned behavior, in which the intentions and attitudes underlying actions influence achievement-driven behavior. Their following qualitative study (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) further examined the esports perceptions and experiences of middle-aged and older adult participants in Hong Kong using a social marketing approach. Their study hypothesized that a community-based esports intervention that met the \u0026ldquo;five Ps\u0026rdquo; criteria (product, price, promotion, place, and people) encourage older adults to participate in esports, increase their PA levels, and improve their health. Although the video game used in these two studies were equipped with competitive and interactive elements, the seated and sedentary state of play mode could not be considered as exergaming-based esports. Based on the aforementioned studies, a clear research gap exists in examining the benefits of exergaming-based esports participation, including its effects on physical and psychological health, among older adults. Moreover, previous studies also suggested that older adults could gain a greater sense of enjoyment by experiencing competitive PA (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Therefore, to encourage active aging, the present study implemented an exergaming-based esports intervention embedded with competition elements for older adults. This study investigated the effects of exergaming-based esports participation on the physical fitness, cognitive function, and various psychological attributes (loneliness, PA enjoyment, and quality of life) of older adults. We hypothesized that exergaming-based esports significantly improves physical function, cognitive attributes, and psychological health.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003ch2\u003e2.1\u0026nbsp; \u0026nbsp; \u0026nbsp;Participants\u003c/h2\u003e\n\u003cp\u003eA convenience sampling strategy was employed to recruit participants.\u0026nbsp;Older adults from two branches (Kwun Tong and Hing Tin) of the Neighborhood Elderly Centre\u0026nbsp;in Hong Kong were targeted. All\u0026nbsp;recruited\u0026nbsp;participants were assigned to groups stratified by sex and experience with\u0026nbsp;exergaming-based\u0026nbsp;esports activities. The inclusion criteria were a) being aged 60 years or older, b) living independently in the community, c) not having a cognitive impairment, d) not participating in a structured PA\u0026nbsp;program\u0026nbsp;six months\u0026nbsp;preceding the study,\u0026nbsp;and e) earning passing scores on the Timed-Up-and-Go Test (24) and the Abbreviated Mental Test (25). Participants were required to complete the Timed-Up-and-Go Test within 20 seconds. A minimum score of six points on the Abbreviated Mental Test was required to qualify for this study.\u0026nbsp;The evaluations of participants were carried out by research assistants of the Education University of Hong Kong, who received a one-day training in the university one month prior to the recruitment and evaluation procedures. Besides, all research assistants were instructed to fully understand the meaning of each question under measures that employed in this study. They were responsible to answer potential questions raised by participants when completing the questionnaire in both pretest and posttest.\u0026nbsp;All participants provided written informed consent and were assured that their\u0026nbsp;personal\u0026nbsp;information would remain confidential.\u003c/p\u003e\n\u003ch2\u003e2.2\u0026nbsp; \u0026nbsp; \u0026nbsp;Measures\u003c/h2\u003e\n\u003ch3\u003e2.2.1\u0026nbsp;\u0026nbsp;Functional Fitness\u003c/h3\u003e\n\u003cp\u003eFunctional fitness was evaluated using the Senior Fitness Test developed and validated by Rikli and Jones (26). The\u0026nbsp;Senior\u0026nbsp;Fitness Test assesses older adults\u0026rsquo; ability to perform normal daily activities independently. The test comprises six parts. First, the back scratch test measures the distance between the two middle fingers when extended. Each participant was required to complete two trials, and the best distance was recorded. Second, a 30-second chair and reach test requires participants to sit on the edge of a chair with one leg bent and the other leg extended straight in front. The test measures the distance between the extended middle finger and the tip of the toe of the extended straight leg. Each participant was required to complete two trials for each leg, and the best distances were recorded. Third, an eight-foot up-and-go test involved participants standing from a seated position, walking as quickly as possible around a cone placed eight feet ahead and returning to their seats. Each participant completed two trials, and the shortest time to finish the test was recorded. Fourth, a 30-second chair stand-up test requires participants to stand from a fully seated position within 30 seconds repeatedly. Each participant was required to complete two trials, and the number of times they did so within the timeframe was recorded. Fifth, a 30-second arm curl test requires participants to lift a dumbbell with their dominant hand as often as possible within 30 seconds. Each participant was required to complete a practice trial followed by a test trial, and the number of repetitions completed was recorded. Sixth, a 2-minute step test involved participants raising each knee to the level of a marked point on the wall representing half the distance between their iliac crest and\u0026nbsp;patella\u0026nbsp;and completing full steps for 2 minutes. Each participant was allowed to do a practice trial followed by a test trial, and the number of full steps completed in 2 minutes was recorded. These tests were reliable (interclass correlation coefficient: .80\u0026ndash;.98) and valid, as demonstrated in content, construct, and criterion analyses (26).\u003c/p\u003e\n\u003ch3\u003e2.2.2\u0026nbsp;\u0026nbsp;Cognitive Function\u003c/h3\u003e\n\u003cp\u003eThe examination of participants\u0026rsquo; cognitive function included two cognitive tests, the number comparison test (NCT;\u0026nbsp;27) and the trail-making test (TMT; 28).\u0026nbsp;Both NCT and TMT have been widely used as a cognitive tool in examining older adults\u0026rsquo; attention and executive functions (29,30).\u0026nbsp;The number comparison test requires participants to identify inconsistent digital pairs by marking an \u0026ldquo;X\u0026rdquo; on them within a period of 90 seconds. Scores are calculated by subtracting the number of incorrect markings from the total number of correct markings. The TMT consists of two parts. For Part A, participants are asked to draw a line as quickly as possible that connects the numbers 1 through 25 written on a piece of paper in varying positions. Part B requires participants to draw a continuous line connecting dots in\u0026nbsp;ascending\u0026nbsp;order, alternating between dots associated with numbers (1 to 13) and letters (A to L). The time taken to complete both tasks was recorded.\u003c/p\u003e\n\u003ch3\u003e2.2.3\u0026nbsp;\u0026nbsp;Loneliness\u003c/h3\u003e\n\u003cp\u003eLoneliness was measured using a short version of the University of California, Los Angeles Loneliness Scale (ULS-8; 31), which has been psychometrically developed and evaluated for older adults in diverse language versions\u0026nbsp;(32). This scale consists of eight items evaluating whether participants feel devoid of social contact and assessing their level of loneliness (e.g., \u0026ldquo;I feel isolated from others\u0026rdquo;). Items are scored on a 4-point scale with endpoints ranging from 1 (\u003cem\u003enever\u003c/em\u003e) to 4 (\u003cem\u003ealways\u003c/em\u003e),\u0026nbsp;with\u0026nbsp;total scores ranging from 8 to 32. Higher scores indicate greater levels of loneliness. This scale demonstrated satisfactory internal consistency in this study, with a Cronbach\u0026rsquo;s alpha value of .81.\u003c/p\u003e\n\u003ch3\u003e2.2.4\u0026nbsp;\u0026nbsp;Enjoyment of PA\u003c/h3\u003e\n\u003cp\u003eLevel of enjoyment of PA was measured using the Chinese version of the Physical Activity\u0026nbsp;Enjoyment\u0026nbsp;Scale (PACES), which was developed by Chung and Leung (33).\u0026nbsp;This measurement has been validated as a well-fitting assessment tool to evaluate older adults\u0026rsquo; satisfaction with PA (34).\u0026nbsp;This scale comprises eight items scored on a 7-point scale with endpoints ranging from 1 (\u003cem\u003eI enjoy it\u003c/em\u003e) to 7 (\u003cem\u003eI dislike it\u003c/em\u003e). Four of the eight items (items 1, 4, 5, and 7) were reverse coded. Higher scores indicate greater levels of\u0026nbsp;PA\u0026nbsp;enjoyment. The scale demonstrated acceptable reliability and internal consistency (Cronbach \u0026alpha; = .92; 23). The mean scores for the eight items were calculated to yield a PA enjoyment score.\u003c/p\u003e\n\u003ch3\u003e2.2.5\u0026nbsp;\u0026nbsp;Quality of Life\u003c/h3\u003e\n\u003cp\u003eThe Short Form-36 (SF-36) Health Survey is widely employed to assess health-related quality of life among older adults (35). In this study, two subscales, social functioning (2 items) and emotional well-being (5 items), were used. These subscales assess motivation to participate in social activities, physical and emotional problems, and feelings of nervousness, depression, peacefulness, happiness, and calm over the preceding 4 weeks. Items are rated on a 5-point Likert scale, with higher scores indicating a superior state of health. The reliability and validity of the SF-36 questionnaire have been verified in Chinese participants (36).\u003c/p\u003e\n\u003ch2\u003e2.3\u0026nbsp; \u0026nbsp; \u0026nbsp;Intervention\u003c/h2\u003e\n\u003cp\u003eThe intervention programs were delivered over a period from July to September 2021\u0026nbsp;by registered instructors and a\u0026nbsp;research\u0026nbsp;assistant from the Education University of Hong Kong.\u0026nbsp;All the training sessions were carried out in\u0026nbsp;two branches (Kwun Tong and Hing Tin) of the Neighborhood Elderly Centre\u0026nbsp;in Hong Kong.\u0026nbsp;The intervention program comprised 16 training sessions, with 2 sessions per week each lasting 90 minutes. Participants were required to complete a 10-minute warm-up activity prior to starting and a 5-minute stretching and cool-down activity at the end of each session. The fitness video game \u003cem\u003eFitness Boxing\u003c/em\u003e, developed by Imagineer (Tokyo, Japan) for the Nintendo Switch\u003csup\u003eTM\u003c/sup\u003e console, was selected for participants to play. The reason of selecting \u003cem\u003eFitness Boxing\u0026nbsp;\u003c/em\u003ewas its integration of multiple physical and cognitive skills required to play. This game combined elements of physical exercise and music which required players to perform moves by following not only the on-screen cues of physical moves but also the rhythm of the music. Besides, its unique two-player mode could create competitiveness between players by comparing the points they got during the pairwise competition. Participants were required to use the Joy-Con motion controllers of the console to perform basic boxing skills, including punching, ducking, weaving, and stepping.\u0026nbsp;All participants were asked to take part in the training at the same time.\u0026nbsp;The play intensity was designed to range from low to moderate. A \u003cem\u003eFitness Boxing\u003c/em\u003e competition was arranged during the final three sessions. After the intervention, participants were expected to have gained a basic understanding of\u0026nbsp;exergaming-based\u0026nbsp;esports and a knowledge of basic boxing skills.\u003c/p\u003e\n\u003ch2\u003e2.4\u0026nbsp; \u0026nbsp; \u0026nbsp;Procedures\u003c/h2\u003e\n\u003cp\u003eWe applied a non-randomized controlled trail design in this study. The reason we selected non-RCT was because we expected that prospective participants were likely to have strong preferences of participating in the EG over CG, thus preventing the randomization.\u0026nbsp;Prior to the intervention, an instruction session was provided to all participants to explain the details of the intervention program. Participants were required to sign consent forms before the commencement of the intervention. After all participants provided written informed consent, they were divided into two groups: an\u0026nbsp;exergaming-based\u0026nbsp;esports group (EG) and a control group (CG). All participants were instructed to measure their height, weight, and body fat percentage using a Tanita machine (Model: BC-418) and to take the aforementioned fitness tests. Participants in the EG participated in the 8-week intervention, which began after the administration of the pretest.\u0026nbsp;A qualified boxercise instructor was recruited to teach and train participants\u0026nbsp;to learn\u0026nbsp;necessary\u0026nbsp;skills (i.e.,\u0026nbsp;straight punch, hook, uppercut, mixed punch, weave, and step)\u0026nbsp;in playing this game.\u0026nbsp;Meanwhile, a research assistant from the Education University of Hong Kong was arranged as an assistant of the boxercise instructor to help supervising these participants.\u0026nbsp;Finally, a \u003cem\u003eFitness Boxing\u003c/em\u003e competition was held in the final three sessions using a double-elimination bracket. After the 8-week intervention, participants completed measures using the same procedures as for the pretest. All the tests were conducted at the partnered centers.\u0026nbsp;The participants in the CG were instructed to maintain their normal daily activities. Data collection was approved by the Human Research Ethics Committee of the Education University of Hong Kong (Ref: 2019-2020-0468).\u003c/p\u003e\n\u003ch2\u003e2.5\u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Analysis\u003c/h2\u003e\n\u003cp\u003eData were analyzed using SPSS version 27.0. An analysis of covariance was employed to examine group effects on measures of physical and psychological attributes. In the analysis of covariance, the\u0026nbsp;independent\u0026nbsp;variable was the group (EG and CG), and the dependent variable was the posttest score of measures of physical fitness, cognitive functions, and psychological attributes. Pretest scores for each outcome were used as covariates; these scores were used to assess the aforementioned attributes. Subsequently, differences between groups were analyzed using pairwise comparisons with a Bonferroni correction. All effect sizes are reported as partial \u0026eta;\u0026sup2;. Alpha was set at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 for all statistical tests.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eParticipant sociodemographic data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Questions of sociodemographic information were put as the last section of the questionnaire. Participant were asked to complete this questionnaire after completing the intervention program. All sociodemographic questions were self-generated. A total of 54 older adults participated in our study (EG\u0026thinsp;=\u0026thinsp;24; CG\u0026thinsp;=\u0026thinsp;30). However, six participants did not complete the posttest; data from the remaining 48 participants (EG\u0026thinsp;=\u0026thinsp;24; CG\u0026thinsp;=\u0026thinsp;24) were included in our analysis. The mean age of the participants was 70.77 years (standard deviation [SD]\u0026thinsp;=\u0026thinsp;5.92). In total, 12 men (25%) and 36 women (75%) participated. Ages ranged from 60 to 88 years, with 19 (39.56%) and 16 (33.33%) participants falling within the age ranges of 65 to 69 and 70 to 74 years, respectively. Participant education levels were distributed as follows: four participants (8.33%) had only primary education, 27 (56.25%) had only secondary education, and 15 (31.25%) had tertiary education or above. Two participants did not disclose their education level. Regarding marital status, 60.41% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;29) were married, and 25% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12) were single; the remaining participants did not disclose their marital status. A total of 31 participants (64.58%) reported their financial status as \u0026ldquo;moderate,\u0026rdquo; and only 2 participants (4.17%) considered their income level \u0026ldquo;slightly high.\u0026rdquo; A private residence was the most common housing type (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarriage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohabitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing types\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate housing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome ownership scheme housing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic housing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean and SD values for the physical fitness, cognitive function, and psychological measures pretest and posttest are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In the analysis of pretest scores, no significant differences were observed between the EG and CG groups for any of the outcome measures. ANCOVA was performed to examine the differences in posttest scores between the EG and CG. For physical fitness, significant differences in posttest scores were identified, specifically on the chair stand-up test [F(1, 47)\u0026thinsp;=\u0026thinsp;11.44, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.20], the eight-foot up-and-go test [F(1, 47)\u0026thinsp;=\u0026thinsp;5.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.10], and the 2-minute step test [F(1, 47)\u0026thinsp;=\u0026thinsp;4.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.09].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans and standard deviations for measures between groups at pre- and post-test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCG (N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEG (N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChair stand-up (frequency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.46 (4.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.37 (5.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.08 (3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.79 (5.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.44***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.00***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArm curl (frequency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.71 (5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.71 (6.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.35 (5.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.00 (7.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChair sit and reach \u0026ndash; left (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.44 (10.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.99 (9.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.70 (11.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.40 (12.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChair sit and reach \u0026ndash; right (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.85 (10.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.23 (9.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.89 (10.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.52 (10.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEight-foot up and go (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.65 (1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.94 (1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.38 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.32 (1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo-minute step (frequency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87.00 (22.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.71 (17.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.38 (22.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e96.79 (20.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.65*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBack scratch \u0026ndash; left (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-2.02 (10.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.76 (10.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.33 (10.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.48 (9.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBack scratch \u0026ndash; right (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.26 (8.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.80 (7.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.32 (7.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.25 (7.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.85 (3.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.05 (3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.18 (3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.58 (3.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber comparison (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.25 (9.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.21 (8.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.13 (9.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33.00 (10.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.63*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT part A (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.76 (30.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.56 (30.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74.46 (33.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61.18 (15.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.30*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT part B (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.36 (21.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.76 (17.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.58 (19.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45.24 (18.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eULS-8 (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.21 (4.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.63 (4.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.38 (4.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.83 (3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACES (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.59 (1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.44 (1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.26 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.74 (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.93*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF-36 (score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote. *\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05; **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01; ***\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; CG, control group; EG, esports group; TMT, trail making test; ULS-8, University of California, Los Angeles (UCLA) Loneliness Scale; PACES, Physical Activity Enjoyment Scale. The post-test scores were adjusted via ANCOVA for difference in the pre-test scores.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Bonferroni pairwise comparisons revealed that participants in the EG had better lower body strength [M\u0026thinsp;=\u0026thinsp;19.79 (5.37)] and agility [M\u0026thinsp;=\u0026thinsp;5.32 (1.05)] and higher aerobic endurance [M\u0026thinsp;=\u0026thinsp;96.79 (20.69)] than did those in the CG. No significant between-group differences were observed in the arm curl test [F(1, 47)\u0026thinsp;=\u0026thinsp;0.88, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.35, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.02], the chair sit and reach test for the left [F(1, 47)\u0026thinsp;=\u0026thinsp;1.71, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.20, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.04] or right foot [F(1, 47)\u0026thinsp;=\u0026thinsp;0.86, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.36, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.20], the back scratch test for the left [F(1, 47)\u0026thinsp;=\u0026thinsp;0.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.92, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.00] or right hand [F(1, 47)\u0026thinsp;=\u0026thinsp;0.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.73, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.00], or body mass index [F(1, 47)\u0026thinsp;=\u0026thinsp;0.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.33, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.02].\u003c/p\u003e \u003cp\u003eSignificant differences in posttest scores were also observed regarding the level of enjoyment of PA [F(1, 47)\u0026thinsp;=\u0026thinsp;5.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.12], number comparison test [F(1, 47)\u0026thinsp;=\u0026thinsp;4.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.09], and TMT Part A [F(1, 47)\u0026thinsp;=\u0026thinsp;4.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.09].\u003c/p\u003e \u003cp\u003eThe Bonferroni pairsie comparisons indicated a higher level of enjoyment [M\u0026thinsp;=\u0026thinsp;5.74 (0.85)] and higher cognitive ability [number comparison test, M\u0026thinsp;=\u0026thinsp;33.00 (10.62); TMT Part A, M\u0026thinsp;=\u0026thinsp;61.18 (15.36)] for participants in the EG than participants in the CG. However, no significant group differences were observed in the results of the ULS-8 test [F(1, 47)\u0026thinsp;=\u0026thinsp;0.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.54, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.01] and the TMT Part B [F(1, 47)\u0026thinsp;=\u0026thinsp;.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.74, partial \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.00]. The full statistical results can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe present study investigated the effects of an 8-week\u0026nbsp;exergaming-based\u0026nbsp;esports intervention (exergaming) on physical fitness, cognitive functions, and psychological attributes among community-based older adults. Our findings revealed that the EG scored higher than did the CG on six outcome measures, specifically a) the\u0026nbsp;lower body strength (chair stand-up test), b)\u0026nbsp;agility and dynamic balance (the eight-foot up-and-go test), c)\u0026nbsp;aerobic ability\u0026nbsp;(2-minute step test), d)\u0026nbsp;cognitive functioning (the\u0026nbsp;number comparison test\u0026nbsp;and\u0026nbsp;the TMT), and\u0026nbsp;e) the\u0026nbsp;PA enjoyment\u0026nbsp;(PACES). However, no differences were observed between groups regarding flexibility, upper body strength and endurance, body mass index, or level of loneliness. These results partially support the hypothesis that greater lower body strength, agility and dynamic balance, aerobic ability, cognitive functioning, and PA enjoyment would be observed in\u0026nbsp;exergaming-based\u0026nbsp;esports participants than in their peers who did not play\u0026nbsp;exergaming-based\u0026nbsp;esports.\u003c/p\u003e\n\u003ch2\u003e4.1\u0026nbsp; \u0026nbsp; \u0026nbsp;Improvements in Physical Health\u003c/h2\u003e\n\u003cp\u003eSignificant improvements in lower body strength, agility, dynamic balance, and aerobic endurance were observed in the EG. These improvements were attributed to the physical intensity required to play \u003cem\u003eFitness Boxing\u003c/em\u003e during the 8-week intervention. Instructors taught various skills, including different punches (hook, uppercut, and mixed), ducking, weaving, and stepping. Participants were required to practice these skills during the intervention period. Additionally, specific training sessions and advanced skills sessions (teaching combinations of skills) were organized to increase the intensity of the practice sessions gradually. The duration of these sessions in the\u0026nbsp;exergaming-based\u0026nbsp;esports intervention program exceeded the World Health Organization PA guidelines (37) of engaging in a minimum of 150 minutes of moderate-intensity PA per week. This activity level likely accounts for the observed improvements in physical attributes in older adults in the EG. Moreover, our results align with those of a systematic review focusing on the associations between exergames and older adults\u0026rsquo; PA that revealed that older adults who played exercise-based or motion-sensing games exhibited improvements in physical functions such as balance, mobility, and agility (14). Another study on the effects of exergames and video game training on older adults\u0026rsquo; physical functioning also demonstrated significant enhancements in lower limb strength and balance among participants in the exergame training group (38). Our findings are consistent with those of a study that employed exergames involving motor\u0026nbsp;functioning\u0026nbsp;and balance in rehabilitation, suggesting the positive effects of\u0026nbsp;exergaming-based\u0026nbsp;esports participation in promoting physical health in older adults (39).\u003c/p\u003e\n\u003ch2\u003e4.2\u0026nbsp; \u0026nbsp; \u0026nbsp;Improvements in Cognitive Functions\u003c/h2\u003e\n\u003cp\u003eThe results of the present study reveal that EG participants\u0026rsquo; scores on the number comparison test and the TMT Part A significantly improved after receiving the\u0026nbsp;exergaming-based\u0026nbsp;esports intervention, indicating that the intervention provided cognitive benefits for these older adults. These findings are consistent with those of other studies indicating that exergame training positively affects older adults\u0026rsquo; cognitive functioning (38,\u0026nbsp;40). For instance, older adults trained using Nintendo Wii exergames demonstrated substantial improvements on the number comparison test and TMT Parts A and B (40). Moreover, Hou and Li (38) revealed that exergame training interventions enhanced cognitive functioning, specifically verbal memory, top-down attention, and learning efficiency, in older adults. One plausible explanation for these significant observed improvements in cognitive functions may be the complexity of exergames. By providing dynamic game content combining both cognitive and physical exercises during participation (41), the Nintendo Switch\u003csup\u003eTM\u003c/sup\u003e \u003cem\u003eFitness Boxing\u003c/em\u003e game used in this study typified a dynamic exergame with its requirement to continually monitor the screen and adjust the\u0026nbsp;player\u0026nbsp;character\u0026rsquo;s position to make appropriate responses using various motor skills. This complicated play style requires significant cognitive effort and is likely responsible for the cognitive benefits observed in the older adults in the present study.\u003c/p\u003e\n\u003ch2\u003e4.3\u0026nbsp; \u0026nbsp; \u0026nbsp;Improvements in PA Enjoyment\u003c/h2\u003e\n\u003cp\u003eParticipants in the EG scored higher on the PACES than did those in the CG, indicating greater PA enjoyment in the older adults who participated in the intervention. These results are consistent with those of studies using other exercise-based video games on different exergaming technology platforms, such as Nintendo Wii (40) and Microsoft Kinect (42), in addition to a study using interactive video dance games (43). Lee et al. (44) reported that enjoyment is the primary reason individuals play exergames. Unlike traditional video games, where participants only sit and manipulate a game controller, \u003cem\u003eFitness Boxing\u003c/em\u003e is an exercise-based game where participants must be active by engaging in a boxing match against human or computer opponents, an enjoyable type of PA.\u0026nbsp;Additionally, the \u003cem\u003eFitness Boxing\u003c/em\u003e competition for EG participants at the end of the intervention program may explain the increase in participants\u0026rsquo; enjoyment. This suggestion is consistent with the findings of Vorderer et al. (45) on the factors affecting enjoyment experienced by video game players that indicated competition as a key element responsible for players\u0026rsquo; enjoyment. Therefore, the \u003cem\u003eFitness Boxing\u003c/em\u003e competition in the final three sessions likely enhanced the experience and contributed to the players\u0026rsquo;\u0026nbsp;enjoyment.\u003c/p\u003e\n\u003ch2\u003e4.4\u0026nbsp; \u0026nbsp; \u0026nbsp;Limitations and Future Research\u003c/h2\u003e\n\u003cp\u003eThis study is the first to conduct an exergaming-based esports intervention program to assess physical fitness, cognitive functions, and psychological attributes among community-based older adults. Nevertheless, this study is not without limitations. First, participants were recruited through convenience sampling from two community centers for older adults only, and most participants resided near these centers and preferred to participate with friends from the same center. This situation may have introduced bias in participant recruitment. Second, the predominance of female participants (75%) limits the generalizability of the results. Future research should use a random sampling strategy from diverse locations to enhance the generalizability of the findings. Expanding the sample size and including multiple centers may also improve generalizability. Third, no follow-up measures were conducted to monitor older adults\u0026rsquo; exergaming-based esports participation and changes in physical and psychological measures. Because exergaming-based esports remains a novel form of PA for older adults in Hong Kong, researchers should conduct longitudinal studies with follow-up assessments to examine retention in exergaming-based esports participation and the effects of such participation on the maintenance of physical and psychological health. Fourth, future studies should use more objective measures of cognitive health, such as neuroimaging. Fifth, this study only examined the influence of exergaming-based esports on older adults\u0026rsquo; health, leaving the mechanism behind these health benefits unexamined. Future studies should examine the influence of the competitive nature of esports on these health benefits.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThe results of this study revealed that better lower body strength, better agility, higher aerobic endurance, higher enjoyment level and higher cognitive functioning were founded among participants in the EG, which partially supports that exergaming-based esports is effective in promoting older adults\u0026rsquo; physical, psychological, and cognitive health outcomes. This study\u0026rsquo;s examination of the benefits of exergaming-based esports participation on physical, cognitive, and psychological health outcomes in older adults has several practical implications. First, using the empirical evidence from this study, more centers for older adults can introduce exergaming-based esports activities to their members and gradually organize regular play sessions and competitions to enhance older adults\u0026rsquo; health. The need of physical movements, the complexity of the game, and the embedded competitive and interactive elements in this exergaming-based esports intervention are all unique attributes in contributing older adults\u0026rsquo; physical, cognitive, and mental well-being. Second, because flexibility, upper body strength, and body mass index did not substantially improve in this study, game designers should consider designing games for older adults which could specifically improve these health attributes. Third, older adults should be aware that playing exergaming-based esports regularly can strengthen their physical attributes, increase their sense of enjoyment, and improve their cognitive functioning. Finally, all participants in the EG completed the entire intervention program with no one dropped out, which indicate that using Nintendo Swith\u0026trade; \u003cem\u003eFitness Boxing\u003c/em\u003e as the exergaming-based esports is a suitable form of PA for older adults. This finding is in line with Valenzuela et al.\u0026rsquo;s (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) study which demonstrated that higher adherence level could be found for technology-based interventions over traditional physical exercises. Based on the findings, exergaming-based esports activity like \u003cem\u003eFitness Boxing\u003c/em\u003e might bring new approaches to the PA among older adults which could be promoted to other elderly centers in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of Interest\u003c/p\u003e\n\u003cp\u003eThe author reports no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eLeung K. M. conceived the study, contributed to the methodology, supervised the project, managed resources, acquired funding, conducted the investigation, performed formal analysis, validated the data, carried out data visualization, and contributed to its review and editing. Shi Y. drafted the original manuscript, contributed to the methodology, performed formal analysis, validated the data, carried out data visualization, and contributed to the review and editing of the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by the General Research Fund.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003e(Not applicable)\u003c/p\u003e\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the conclusions of this article is included within the article and its additional file.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWong MY, Karmakar P, Almarzooqi MA, Rhodes RE, Zhang CQ, Ou KL, Yanping D, Chung PK, Alghamdi NA. The effects of walking on frailty, cognitive function and quality of life among inactive older adults in Saudi Arabia: a study protocol of randomized control trial by comparing supervised group-based intervention and non-supervised individual-based intervention. 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(2018) 41: 49-61.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Older adults, esports participation, exergaming-based, intervention study, health promotion","lastPublishedDoi":"10.21203/rs.3.rs-5261729/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5261729/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eExergaming, refers to the video gaming with/without virtual reality which required the use of physical activity during gameplay, has been utilized as an emerging type of physical activity in improving older adults\u0026rsquo; physical and mental health. Exergaming can also be considered as esports when the competitive and interactive element is embedded in the gameplay. To date, the impact of exergaming-based esports on older adults\u0026rsquo; health and well-being conditions has been less investigated. This study aims to examine the effectiveness of exergaming-based esports intervention program in promoting older adults\u0026rsquo; physical, psychological, and cognitive health outcomes in Hong Kong. A total of 54 older adults were recruited and 48 (male\u0026thinsp;=\u0026thinsp;12; female\u0026thinsp;=\u0026thinsp;36) were finally retained for data analysis due to six of them did not attend the post-test. All participants were allocated into either an esports group (EG\u0026thinsp;=\u0026thinsp;24) and a control group (CG\u0026thinsp;=\u0026thinsp;24). EG participants were invited to participate in an eight-week exergaming-based esports intervention program consisting of 16 training sessions to learn and play the Nintendo Switch\u0026trade; \u003cem\u003eFitness Boxing\u003c/em\u003e game. A fitness boxing competition was embedded in the final three sessions. Besides, CG participants were instructed with their normal daily activity. Measures including Senior Fitness Test, the University of California, Los Angeles (UCLA) Loneliness Scale (ULS-8), the Chinese version of the Physical Activity Enjoyment Scale (PACES), the number comparison test and trail making test (TMT), and the Short Form-36 (SF-36) Health Survey were used to examine older adults\u0026rsquo; physical, psychological, and cognitive conditions. Analysis of covariance (ANCOVA) was used for data analysis. The results showed that EG participants had better lower body strength, better agility, higher aerobic endurance, higher enjoyment level and higher cognitive functioning. This study provides theoretical contribution by filling in the research gap of the investigation of the beneficial effects of exergaming-based esports in enhancing older adults\u0026rsquo; health conditions in Hong Kong. Besides, game designers are encouraged to design specific game types with competitive and interactive elements embedded for older adults to play and thus promote their emotional and cognitive well-being.\u003c/p\u003e","manuscriptTitle":"Exergaming-based Esports Intervention for Older Adults in Hong Kong: A Non-Randomized Controlled Trail Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 12:15:54","doi":"10.21203/rs.3.rs-5261729/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03ed7a3b-7fcd-4d9c-9b65-1ef1c7bd1139","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-15T10:53:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-25 12:15:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5261729","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5261729","identity":"rs-5261729","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}