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J Edu Health Promot 2022,  11:351

The feasibility study of Internet-assisted play therapy to resolve psychological disorders in primary healthcare settings: A qualitative study

1 Psychological Counseling and Leadership Group, Department of Educational Sciences, Faculty of Education, Istanbul Kültür University, Istanbul, Turkey
2 Department of Public Health, Asadabad School of Medical Sciences, Asadabad, Iran
3 Department of Health Education and Health Promotion, School of Health, Ardabil University of Medical Sciences, Ardabil, Iran
4 Mental Health Group, Deputy for Health, Ardabil University of Medical Sciences, Ardabil, Iran
5 Department of Community Dentistry, School of Dentistry, Ardabil University of Medical Sciences, Ardabil, Iran

Date of Submission05-Apr-2022
Date of Decision11-May-2022
Date of Acceptance16-May-2022
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. Masoud Shabani
Department of Community Dentistry, School of Dentistry, Ardabil University of Medical Sciences, Ardabil
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_480_22

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BACKGROUND: Play therapy is an intelligent tool in cognitive–behavioral therapies. In today's world, the Internet and technology play a key role in all aspects of people's life including mental health. The present study explores the feasibility of using Internet-assisted play therapy to solve children's psychological issues in primary healthcare systems.
MATERIALS AND METHODS: The present qualitative research was conducted by the content analysis approach on 20 experts working in the healthcare centers, who were selected purposefully. The sample was saturated with these 20 participants. Data were collected through semi-structured interviews and were coded manually. Then, they were analyzed in the Atlas.ti software package.
RESULTS: The results revealed 15 themes and 10 sub-themes. The themes included (1) safety, (2) efficiency, (3) client-orientedness, (4) organizational growth, (5) time, (6) effectiveness, (7) justice-orientedness, (8) access, (9) feedback, (10) analysis, (11) children's computer game room, (12) reward, (13) group game, and (14) capability to be integrated into other electronic programs.
CONCLUSION: It seems that Internet-based play therapy is plausible to be used as a service in primary healthcare to tackle the psychological problems of children in the target population if the challenges related to the exploratory themes are taken care of.

Keywords: Cognitive behavior therapy, Internet, mental health, play therapy

How to cite this article:
Shabani SM, Darabi F, Nejaddadgar N, Azimi A, Shabani M. The feasibility study of Internet-assisted play therapy to resolve psychological disorders in primary healthcare settings: A qualitative study. J Edu Health Promot 2022;11:351

How to cite this URL:
Shabani SM, Darabi F, Nejaddadgar N, Azimi A, Shabani M. The feasibility study of Internet-assisted play therapy to resolve psychological disorders in primary healthcare settings: A qualitative study. J Edu Health Promot [serial online] 2022 [cited 2023 Sep 27];11:351. Available from: https://www.jehp.net//text.asp?2022/11/1/351/360025

  Introduction Top

The UN Convention on the Rights of the Child recognizes play as a right for all children because it can contribute to their physical, emotional, social, and cognitive development[1] Play is a key activity with an essential role in the development of a healthy mind and brain in children.[2] Children express their emotional communication through play; indeed, play provides children with an opportunity to exhibit their thoughts and emotions.[3] Play therapy is a way to cope with children's emotional stresses. In fact, the problems are revealed by play and the hidden emotions are unmasked during play with the guidance of the therapist.[4],[5]

With the increasing growth of the Internet, most psychoanalysts and psychotherapists are taking the opportunity to improve their activities.[6],[7] Presently, Internet-based cognitive-behavioral therapies, backed with vigorous evidence, have been provided for most psychological issues.[8],[9] Axline[10] proposes eight principles for play therapy: (i) developing a warm and friendly relationship with the child, (ii) accepting the child, (iii) establishing a comfortable nurturing atmosphere for the child, (iv) recognizing and reflecting the feeling of the child, (v) not interfering with the child's actions and allowing the child to do what he or she wants, (vii) recognizing that play has a progressive path, and (viii) establishing some limitations to support a real therapy.[3]

Training to improve computer-based health behaviors that can be used through the web, for the more than 100 health programs in the system, nothing has been done yet, and the introduction of training in its new form is a completely new program and for the first time used in the system. Also, the focus on cultural realities in the preparation of the program causes a completely new program to be introduced in this field, and it can almost be said that at present, in accordance with the health programs in our system, computer and Internet game training has no place. The need for such programs is absolutely essential. Therefore, given the significance of play and Internet-assisted play therapy and because this service is experimentally offered in the healthcare system of Iran for the first time, the present study aims to explore the feasibility of integrating play therapy into the primary healthcare services by identifying and disclosing its requirements in different aspects.

  Materials and Methods Top

Study design and setting

The present study was qualitative research that was conducted by the content analysis approach in 2019. The research population was composed of all healthcare experts from the Ardabil University of Medical Sciences.

Study participants and sampling

The sample was randomly taken from heterogeneous expert groups including staff experts and experts working in comprehensive healthcare centers. To observe the heterogeneity, the stratified sampling technique was employed for which two strata were defined: (a) staff experts of the healthcare network and (b) healthcare experts in comprehensive healthcare centers. Eventually, 10 people from the first group and 10 people from the second group were selected as key informants for interviews by the purposeful sampling technique with their own consent. The participants had a working record of over 4 years and to ensure their familiarity with computer games, the experience of playing computer games by, at least, one family member was a key criterion to be included in the study. The sample was saturated with these 20 participants. A topic guide form was used to collect data as the draft version so that the interview questionnaire included some open-ended questions. In addition to the review of the literature, some experts were asked to provide advice. Then, two healthcare experts, who were not in the sample, were asked to comment on the significance of the questions. Then, the questionnaire was modified accordingly. Finally, three questions were finalized as follows to ask the participants during the interviews

  • What do you think about the use of computer and Internet games as a new approach to orienting positive behaviors to prevent diseases and/or treat psychological disorders in healthcare centers?
  • What requirements do you think it needs as a service integrated into primary healthcare?
  • What are its pros and cons?

The participants were interviewed face-to-face in a semi-structured design by a research team member at their working place when they were not engaged in serving the clients and had free time. The interviews were recorded with two electronic recorders and then, they were transcribed. As well, the important points during the interviews were jotted and the key issues derived from each interview were recorded in a specific form in brief. The form included the key specifications of the participant, the place where the interview was conducted, organizational position, interview date and time, and other necessary information. At the end of each interview, this form and the recorded file were presented to the participant to be checked and modified if required. The time predicted for each interview was about 40 min.

Data collection tool and technique

The data were analyzed by a neutral expert who had some research experience in qualitative research and content analysis. The expert analyzed the data in the ATLAS.ti (One of the software in qualitative data analysis is for coding and classifying codes and finally determining the components and sub-components introduced by the University of Berlin, Germany. In this study, the version of ATLAS.ti v9.1.3.0 x64 used) scientific software Development GmbH package proceeds through the steps of content analysis including (1) familiarization, (2) identification of a thematic framework, (3) indexing/coding, (4) charting, and (5) mapping and interpretation.

Ethical consideration

Ethical clearance was taken from the Institute Ethical Committee and informed written consent was taken from each participant for this study (IR.ARUMS.REC.1398.654).

  Results Top

The content analysis of the interviews with the 20 selected experts resulted in producing 15 themes and 10 sub-themes, which are described in [Table 1]. Most participants emphasized that owing to its inherent characteristics, play is an effective way to treat psychological disorders in children.
Table 1: The themes and sub-themes derived from the analysis of interviews with healthcare experts as to the requirements for the use of computer games to treat psychological disorders of children within the healthcare system of the healthcare service centers

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  Discussion Top

The results show that computer games are an active training method to teach health-promoting behaviors and are an effective way to solve the psychological problems of children. The growing use of the Internet has provided an opportunity to make easy contact with the target group and population to use educational and therapeutic games. In this respect, the World Health Organization (WHO) has also developed guidelines for the use of the Internet and e-services in healthcare systems.[11]

O'Conner[12] has presented 11 processes for play therapy, which were divided by Shirk and Russel into three main groups of cognitive, emotional, and interpersonal processes.[13] The game should, indeed, provide the child with good recognition of the situation so that the expected behavior can be provoked in the child by having effective emotion.

Most services that are provided for mental health in healthcare systems are based on the cognitive-behavioral theory, which tries to improve cognition and help the client's self-care.[14],[15] Similarly, game therapy uses the cognitive–behavioral approach and needs 6–8 sessions based on the intensity of the disorder to treat psychological disorders and improve the mental health of the children and this requires frequent visits to the healthcare center.[16],[17] Thus, most mental health service providers try to use the Internet as an easy-to-access environment for the clients to get training/consulting and therapeutic services.[18],[19],[20],[21]

An advantage of using games in healthcare environments is that they reduce the children's stress and prepare them to get healthcare services at hospitals and healthcare centers.[22],[23],[24] Research has well shown the effectiveness of play-based interventions in coping with stress and alleviating anxiety and negative emotions, thus this method will be very effective in preparing the children for more invasive and frightening healthcare interventions.[25] For example, dental services in healthcare centers are some of the most stressful processes with negative emotions, and play therapy has proven to be effective in preparing children for these services.[4]

One of the limitations of this study was the dissatisfaction of some participants in recording audio and the need to select another participant. Also, another limitation was the lack of knowledge of the participants about some of the questions, which to solve this problem, it was necessary to indirectly provide more explanations about the question, which required more time.

  Conclusion Top

It seems that Internet-assisted play therapy is plausible to be used as a service in primary healthcare to tackle the psychological problems of children in the target population. If the challenges related to the exploratory themes are considered. It is recommended to use qualitative research to use Internet-based games to promote health behaviors in other areas of personal and social health as well as environmental health. Also, conduct a small study with a comprehensive and valid questionnaire to assess the feasibility of using online games for health education and the establishment of healthy health behaviors in children. To integrate service into the health care system, it is better to use the benefits of quantitative and qualitative research.


The authors would like to express their deep gratitude to all experts of the Healthcare Deputy of the Ardabil University of Medical Sciences for their kind cooperation in the research.

Financial support and sponsorship

This study was financially supported by the Research Deputy of Ardabil Medical Sciences Faculty Code of the approved plan 3220 and code of ethics IR.ARUMS.REC.1398.654.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1]


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