Social Work in Health Care

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Effectiveness of board game activities for reducing

depression among older adults in adult day care
centers of Taiwan: a quasi-experimental study

Bih-O Lee , Ching-Teng Yao & Chao-Fen Pan

To cite this article: Bih-O Lee , Ching-Teng Yao & Chao-Fen Pan (2020): Effectiveness of board
game activities for reducing depression among older adults in adult day care centers of Taiwan: a
quasi-experimental study, Social Work in Health Care, DOI: 10.1080/00981389.2020.1842576

To link to this article: https://doi.org/10.1080/00981389.2020.1842576

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SOCIAL WORK IN HEALTH CARE
https://doi.org/10.1080/00981389.2020.1842576

Effectiveness of board game activities for reducing

depression among older adults in adult day care centers of
Taiwan: a quasi-experimental study
Bih-O Lee, PhDa,b, Ching-Teng Yao, PhD c
, and Chao-Fen Pan, MSd,e
a
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan; bFaculty of Nursing, Universitas
Airlangga, Surabaya, Indonesia; cMaster Program of Long-Term Care in Aging, Kaohsiung Medical
University, Kaohsiung, Taiwan; dKaohsiung Medical University, Kaohsiung, Taiwan; eDepartment of
Industrial Engineering and Management, National Kaohsiung University of Science and Technology,
Kaohsiung, Taiwan

ABSTRACT ARTICLE HISTORY

Depression is common in older adults and is associated with an Received 6 March 2020
increased risk of cognitive impairment. To clarify the possible Revised 6 October 2020
roles of board game use in psychosomatic health promotion, Accepted 19 October 2020
this study evaluated the effects of board game activities in KEYWORDS
reducing depression in older adults. This was a quasi-experi­ Effects; board game; older
mental study. Purposive sampling was used to select 150 parti­ adults; adult day care
cipants aged 65 years and above with intact mental functions centers; depression
who were currently residing in adult day care centers. Seventy-
five participants who participated in 12 sessions of selected
board game activities were assigned to the experimental
group, and 75 participants who adhered to their ordinary activ­
ities were allocated to the control group. Structured question­
naires were used for data collection. The board game activities
showed promising effects on the depression levels of the inves­
tigated older adults living in adult day care centers. Therefore,
one possible beneficial effect of board game activities may be
reduced depression in older adults. The results of this study
provide support for the mediating role of board game activities
in the mental health of long-term care elders. Incorporating
board game activities into social work may help to make it
more diverse and innovative.

Introduction
Rapid population aging is a widespread global trend. The population of older
adults in Taiwan has increased progressively and accounted for 15.37% of the
total population as of January 2020 (Ministry of the Interior, Taiwan, ROC,
2020). Depression is a common psychological disorder among older adults. It
is related to chronic diseases, cognitive disorders, and increased mortality rates
(Alexopoulos et al., 2011). According to international epidemiologic surveys
conducted in many countries, the morbidity rate of depression among older
adults ranges from 13% to 23% (Eggermont et al., 2012). Studies have reported

CONTACT Ching-Teng Yao, PhD angusyao@kmu.edu.tw Master Program of Long-Term Care in Aging,
Kaohsiung Medical University, Kaohsiung 80708, Taiwan.
© 2020 Taylor & Francis Group, LLC
2 B.-O. LEE ET AL.

that older adults with brain, metabolic, and cardiovascular disorders, such as
dementia, Parkinson disease, diabetes, and strokes, are more likely to experi­
ence depression (Manthorpe & Iliffe, 2010; Rodda et al., 2011).
According to an epidemiologic survey regarding depression among older
adults in Taiwan, the prevalence rate of depression in older adults at the time
of the survey was 21.7%, with 6.2% of older adults experiencing severe
depression (Weng, Lin, & Chan, 2014). According to a report on the top 10
causes of death compiled by the Ministry of Health and Welfare in 2018, of the
suicide deaths in Taiwan, more than one-quarter were older adults aged
≥65 years, and depression was the main cause of suicide (Ministry of Health
and Welfare, Taiwan, ROC, 2019). Therefore, promoting the physical and
mental health of older adults has become an imperative goal in light of the
ever-growing older population. Increasing global awareness of the successful
aging concept has increased the attention devoted to older adult recreation
and active living (Granbom et al., 2017). Participation in leisure and social
activities is positively correlated with mortality rate reduction, quality of life
improvement, stress relief, depression relief, and positive emotions among
older adults (Iwasaki, 2003; Simone & Haas, 2013). In addition, participation
in such activities improves the mental health of older adults and thereby
reduces their perceived fragility (Wang et al., 2012).
Some studies on older adults have employed playing board games as a novel
activity for cognitive simulation. Research has found that board game activities
have positive effects on older depressive adults living in nursing homes
(Ouyang et al., 2015) and the community (Poelke et al., 2016), older patients
with depression receiving treatment in hospitals (Edel et al., 2017), and older
patients with cognitive impairment living in nursing homes (Yang et al., 2017).
In other words, a few studies have employed and evaluated board game
activities as interventions to improve depression-related syndrome in older
adults. However, only two previous studies used single group experimental
designs, while only one was a long-term cohort study. Unlike the other studies
in this area, this study is a long-term cohort study that utilizes a controlled
group design. The present study may provide valuable contributions regarding
the utility of using board game activities to reduce depression in older adults
living in day care centers.

Literature review
Board games and mental health among older adults
Board games are usually played on a table and require no electronic equip­
ment. Compared with other types of games, board games provide players with
a more interpersonal gaming experience, increase players’ engagement, and
encourage players to engage in higher order thinking. Table games are a type
 SOCIAL WORK IN HEALTH CARE 3

of leisure activity through which players can learn while participating and
experience a sense of achievement and excitement (d’Astous & Gagnon, 2007).
Studies have indicated that board games are one of the most exciting leisure
activities for older adults. Such games provide older adults with novel experi­
ences, requiring that they be active, plan ahead, and adapt to winning and
losing, features which typically result in enjoyment. Moreover, board games
allow the participation of family members, friends, and even strangers, which
facilitates intergenerational social interaction (Dartigues et al., 2013). Woods
et al. (2012) indicated that board games are a type of cognitively stimulating
activity that can stimulate the memorization and thinking abilities of older
adults, and various studies have verified that cognitively stimulating activities
considerably improve the cognitive functions, social interactions, communi­
cation, and quality of life of individuals (Cove et al., 2014). Caillois (2001a)
maintained that gaming is conducive to physical and mental development, and
according to the hierarchy of needs proposed by Maslow (1943), board game
activities allow older adults in adult day care centers to interact with their
communities and experience a sense of immersion and happiness through
role-playing, new relationships, and perceptions of unusual environments. For
institutionalized older adults who lack social stimuli, board games provide an
opportunity for social interaction. Board game activities are conducive to
players’ self-development and learning because they require problem-solving
and decision-making (Wright & Forrest, 2007). Such activities also require
considerable social interaction and communication, allowing players to
acquire new knowledge and skills and to establish new interpersonal relation­
ships (De Freitas & Griffiths, 2008; Kafai, 2006).

Research on the effects of board game activities on depression in older adults

Studies have indicated that board game activities help to reduce depression
and other health problems in older adults. For example, Poelke et al. (2016)
targeted adults aged ≥65 years in the United States who participated in a 12-
week program of leisure activities including board game activities; the results
indicated that the board game activities alleviated depression in the older
adults, including those with cognitive impairment. Another study involving
older adults with functional impairments and major depression was also
conducted. That study targeted 1429 older adults aged ≥60 years who partici­
pated in six leisure activities including handcrafts, games (e.g., board games),
singing, dancing, educational courses, and brain teasers. The results revealed
that active participation in leisure activities moderated the relationship
between functional impairment and depression, indicating that leisure activ­
ities can improve the mental health of older adults (Ouyang et al., 2015). In
another study, Yang et al. (2017) explored group board game activities as an
intervention for older adults in a nursing home in Taiwan, including the
4 B.-O. LEE ET AL.

effects of such activities on depression among older adults. Their study

targeted 11 participants, who participated in six sessions of group board
game activities. The results showed that the group board game activities
considerably improved the depression status of the older adults, and the
qualitative observations of the study also indicated that the activities expanded
the social networks and interpersonal relationships of the participants. Edel
et al. (2017) randomly assigned patients with severe depression to participate
in board game activities and explored the subsequent effects on the patients;
the results showed that the experimental group demonstrated a greater
decrease in depression than did the control group. Dartigues et al. (2013)
randomly selected 3337 adults aged ≥65 years residing in the southwest
regions of France and performed a 20-year longitudinal study to explore the
relationship between board game activities and depression. The results showed
that older adults who participated in board game activities were significantly
less likely to experience depression than were those who did not participate in
such activities, and that this reduction in depression risk was a long-term
effect. In addition, even after variables such as age, gender, marital status, and
physical conditions were controlled for, board game activities and depression
continued to be closely correlated.
In spite of the encouraging findings of the aforementioned literature, the
real effects and mechanisms of board game activities may require further
examination through studies employing two-group experimental designs in
different settings. To obtain more evidence in order to better inform social
work practice, this study sought to examine the effectiveness of board game
activities in reducing depression among older adults in day care centers.

Methods
Research design, location, and participants

The present study was a quasi-experimental study based on pre- and post-
tests. Purposive sampling was conducted in two adult day care centers in
southern Taiwan from October 2018 to January 2019. There are 32 adult day
care centers in Kaohsiung in southern Taiwan. In Taiwan, adult day care
centers are places where participants go for socializing and to benefit from
services during the day. According to the relevant regulations, the ratio of
social workers to older adults in such centers is 1:20, and the presence of a full-
time activity coordinator is also required. Social workers help the older adults
in question with case management in their daily lives, and leisure activities are
provided by the activity coordinators in the facilities or by volunteers from the
community. The ratio of social workers to older adults, the care center
environments, and the regular activities of such centers are all subject to
consideration. We selected government-funded adult day care centers and
 SOCIAL WORK IN HEALTH CARE 5

recruited participants from these two sites in the present study. To avoid bias,
the two adult day care centers were individually assigned to be the comparison
or intervention institution using a random number generator, and the recruit­
ment activities took place at the two sites on the same day. Social workers at
the adult day care centers referred to participants based on the study criteria.
Subsequently, the participants completed a form to consent to their involve­
ment in the study. The inclusion criteria for this study were as follows: (a) be
aged a minimum of 65 years, (b) be able to communicate in Mandarin or
Taiwanese, and (c) have scored ≥8 points on the Short Portable Mental Status
Questionnaire (SPMSQ) (Pfeiffer, 1975). The potential participants who
exhibited severe dementia or severe depression or were incapable of commu­
nication were excluded from this study.
The samples sizes for this study were calculated using G power software.
The alpha value was .05, the test force was 80, the effect size was 80, and the
estimated number of samples needed was 84. The study was conducted over
3 months and involved the aforementioned experimental and comparison
groups, which featured 76 participants each for a total of 152. For the parti­
cipants in the experimental group, board game sessions were conducted once
per week for 12 weeks and lasted 120 minutes each. Only those participants
who participated in a minimum of nine sessions were included in the data
analysis. Each session was led by the same researcher to ensure the consistency
of the intervention measures. Scale tests were conducted before the beginning
of and after the program. The comparison group participants participated in
regular activities (singing, drawing, and sports) in the adult day care centers
and received the same scale tests at the same time points as the experimental
group.

Instruments

The structured questionnaire adopted in this study comprised a table of

demographic questions (e.g., questions regarding the sex, age, education
level, religion, marital status, living conditions, and perceived health status
of the respondent) and the Geriatric Depression Scale – Short Form (GDS-SF).
The GDS-SF is a simplified form of the original Geriatric Depression Scale
created by Sheikh and Yesavage (1986) and is intended to examine the self-
perceived emotions of older adults in the preceding week to clarify changes in
their emotions during a therapeutic intervention. The version of the scale
employed in this study was a validated Chinese language version suitable for
Taiwanese respondents. The GDS-SF comprises 15 items and features binary
scores for a total score of 0–15; a higher score indicates a more severe case of
depression. The Cronbach’s α obtained from the pretest data was .89. The
depression assessments were given to the participants one week before and one
week after the intervention. Data regarding the cognitive functions of each
6 B.-O. LEE ET AL.

participant were collected at baseline during a face-to-face interview con­

ducted by a psychologist.

Intervention
The board game activities were conducted in a small group setting and were
randomly assigned to six teams of five or six people each. The intervention
group took part in board game activities during 12 sessions of 120 minutes
once a week. Before each activity, the general inspection of physical and
mental states was performed by a social worker to ensure the safety of the
participants during the activities. During an expert panel discussion involving
a psychologist, nursing professor, recreational therapist, and social worker, all
of whom were experienced in working with older adults, various board games
were selected for the sessions. Considering the attention statuses and life
backgrounds of the participants, 12 sessions of 120 minutes each were deemed
appropriate. The topics of the 12 sessions were as follows: (a) destined to
gather together, (b) memory quiz, (c) childhood memories, (d) unity is
strength, (e) speed test, (f) brainstorming, and (g) graduation ceremony.
Details of the board game program are shown in Table 1.

Research ethics
This study was approved by the Institutional Review Board of Jianan
Psychiatric Center, Ministry of Health and Welfare (JPC-IRB-18-031),

Table 1. Content of the board game program.

Week Name of Board
Number Name of Session Activity Goals Game
1 Destined to gather 1. Form the group and help all members get to know
together each other.
2. Introduce the activity goals and methods.
3. Establish rules for the group.
2–3 Memory quiz 1. Train group members to construct a visual space. Zicke Zacke
2. Enhance members’ memories. Huhnerkacke
3. Increase opportunities for interpersonal interaction
between members.
4–5 Childhood memories 1. Enhance members’ comprehension ability. Hisss
2. Strengthen members’ concentration.
6–7 Unity is strength 1. Enhance members’ hand coordination. Noah’s ark
2. Improve members’ thinking ability.
3. Strengthen members’ calculation ability.
8–9 Speed test 1. Train members’ response ability. Speed cups
2. Enhance members’ concentration.
3. Increase opportunities for interpersonal interaction.
10–11 Brainstorming 1. Improve members’ abstract thinking ability. Rummikub
2. Train members’ logical thinking ability.
3. Strengthen members’ decision analysis ability.
12 Graduation 1. Review the feelings felt when playing the board
ceremony games.
2. Discuss the activity that left the deepest impression.
3. Give feedback to each member.
 SOCIAL WORK IN HEALTH CARE 7

and was conducted with the consent of the two adult day care centers.
The participants were sampled from September 1 to December 31, 2019.
The researcher explained the objective and method of this study to the
participants and acquired written consent from the participants.
Questionnaires were distributed to the participants before and after the
12-week program. All of the research data were encoded to ensure the
anonymity of the participants and were used only for academic research
purposes. The participants were permitted to withdraw from a session or
to quit the study altogether during the research procedure for any reason
without having their rights to receive care affected.

Data analysis
The research data were filed and analyzed using SPSS 22.0 statistical software,
and a single-tailed test was used (α < .05). The chi-square test and indepen­
dent-samples t-test were used to compare the differences in the demographics
and cognitive functions of the two groups at baseline. The cognitive functions
of the two groups before and after the intervention were compared using the
paired t-test.

Results
Demographic information

In this study, there were a total of 152 participants, but two participants
quit during the study, for a loss rate of 1%. One participant in the
experimental group participated in only six of the board game sessions
because of physical discomfort, and one participant in the comparison
group was hospitalized and did not participate in the posttest. Therefore,
a total of 150 participants, including 75 in the experimental group and 75
in the comparison group, ultimately completed all parts of the study.
Among that total sample, 34 of the participants were male and 116 were
female, and their average age was 76.84 years. Furthermore, 35.4% had an
elementary school education, 88.4% were adherents of Taoism, 54.0%
were married, 54.7% were living with a spouse, and 39.4% were in good
condition. In addition, the average depression score of the participants
was 10.51. The results of the chi-square test or independent-samples t-test
showed that there were no significant differences between the distributions
of the participants in the comparison group and experimental group in
terms of the demographic characteristics or depression levels, and that the
two groups were homogeneous in terms of the above-mentioned variables
(Table 2).
8 B.-O. LEE ET AL.

Table 2. Basic properties comparison between intervention group and comparison group.
Intervention Group Comparison Group
(n = 75) (n = 75) pa/pb
Variables M SD N % M SD n %
Sex .068
Male 13 17.3 21 28.0
Female 62 82.7 54 72.0
Education .754
Illiterate 24 32.0 23 30.7
Elementary 23 30.7 30 40.0
> Junior High School 28 37.3 22 29.3
Religion .205
Taoism 72 90.0 65 86.7
Buddhism 3 4.0 10 13.3
Marital Status .060
Married 35 46.7 46 61.33
Widowed 40 53.3 29 38.67
Living Conditions .118
Living with Spouse 36 48.0 46 61.33
Living Alone 39 52.0 29 38.67
Perceived Health Status .357
Out of Condition. 15 20.0 22 29.3
Not Too Bad 25 33.3 29 38.7
In Good Condition 35 46.7 24 32.0
Age 76.99 8.08 76.69 7.86 .805
Depression Level 10.96 8.15 10.20 6.54 .552
pa = Chi-square test; pb = Independent-samples t-test

Table 3. Depression comparison between intervention group and comparison

group.
Pretest (T1) Posttest I (T2) T2–T1
Variables M (SD) M (SD) ta
Intervention Group 10.96(8.15) 6.64(6.39) ab −5.121***
Comparison Group 10.20(6.54) 11.39(8.64) 0.979
tb 1.727 3.934**
a
t = paired-samples t-test; t b = independent-samples t-test; a = Significant difference
between T2–T1; b = Significant difference between Experimental Group and Comparison
Group at T2.
**p < 0.01 *** p < 0.001

Efficacy of board game activities in improving older adults’ depression

In Table 3, p-values below 0.05 indicated a significant difference between
the phases of the intervention. A paired t-test was performed to examine
the effect of the intervention. The results showed that the pretest and
posttest mean scores of the intervention group for depression were 10.96
and 6.64, respectively. Therefore, the degree to which depression was
alleviated in the intervention group was significant (t = −5.121,
p = .000), and the degree of improvement was higher than that of the
comparison group (t = .979, p = .331). As to the experimental group, the
results were significant and decreased, meaning that with the passage of
time, the depression of the elderly participants decreased.
 SOCIAL WORK IN HEALTH CARE 9

Discussion
The aim of the present study was to explore the effects of a board game
activities intervention on the depression of older adults in day care centers.
This study showed that the board game activities intervention significantly
reduced the depression levels of the older adults in the intervention group.
The findings of this study were consistent with those of the study by Yang
et al. (2017), which indicated that group board game activities relieved the
depression of older adults living in a nursing home in Taiwan. Another
previous study found that an online self-help board game was effective at
reducing depression in healthy older adults in the community (Dartigues et al.,
2013). The current study has therefore shown that the utility of board game
activities for reducing depression includes not only community-dwelling
adults but also those attending day care centers. Moreover, a recent review
article showed that traditional board games could alleviate older adults’ cog­
nitive impairment, depression, and other health problems (Nakao, 2019). The
results of the present study also support the effectiveness of traditional board
games and extend their application to older adults with disabilities.
One previous two-group trial conducted by Edel et al. (2017) evaluated the
effects of short-term occupational therapy and board game activities in hospi­
talized patients with major depression. However, the board game activities
were applied with the control group in that study. The results indicated that
the occupational therapy was more effective than the board game activities,
which could arguably be seen as contradicting the findings of the present
study. However, the population and setting of this study were different from
those reported in Edel et al. (2017). Therefore, further studies may be needed
to identify the effects of board game activities in terms of different patient
groups and settings.
In Taiwan, most of the residents in day care centers are those who have
minor disabilities and dementia. Relatedly, playing board games could be
a form of art therapy, similar to miniature garden therapy (Ueda, 2002), for
such individuals, facilitating infinite internal manifestations within a narrow
space. Furthermore, board game activities may also yield beneficial effects
through psychological and behavioral pathways, such as reduced stress,
encouraging a better diet and healthier lifestyle, promoting psychological well-
being, and lowering inflammation, with these effects consequently reducing
the risk of developing various diseases that are associated with worse cognitive
function.
Finally, board game activities may have positive effects on improving
depression related to aging, especially in countries, such as Taiwan, with
a high prevalence of depression among older people. This study underscores
the importance of encouraging older adults to participate in board game
activities in order to reduce their levels of depression. By playing the board
10 B.-O. LEE ET AL.

game activities, the advantages that social interaction offers and the ease of
applying, and may be applicable as educational tools for social work profes­
sionals. The use of board games could thus be promoted for active aging
benefits because appropriate education programs with a board game compo­
nent would be useful for both preventive and therapeutic interventions for
psychological conditions.
This study had several limitations that must be taken into consideration.
First, the present study was a quasi-experimental study using convenience
sampling, which limits the external validity of the study. The observed results
need to be further investigated using more rigorously designed studies, such as
those with randomized controlled trial designs. Second, the intervention was
conducted in adult day care centers. As such, any generalization of the study
results to other institutions should be done with caution. Third, the outcomes
of this study, which were based on only the pretest results and the posttest
results obtained after the 12th week of the intervention, did not predict the
follow-up duration of the effects of the board game activities. Fourth, it is not
entirely clear which types of board games may have contributed to the out­
comes observed. In order for game-based research and design to improve,
future studies should examine the specific designs of board games and under­
stand how they work effectively. Specific board games could be promoted by
social workers and applied in older adults care in a variety of settings.
Furthermore, the board game activities in this study were only undertaken
once per week for 12 continuous weeks, and this number of gaming sessions
may not be adequate as an intervention. Thus, it would be worthwhile to
consider designing a series of studies to examine the relationship between the
intervention frequency and the duration of the board game program. Older
adults who are particularly vulnerable, such as those with chronic illnesses or
clinical depression, also need to be included in further studies. Finally, long-
term studies conducted in different institutions are needed to further confirm
the effectiveness of the investigated board game program.

Conclusion
This study applied board game activities in adult day care centers as an
intervention for older adults, the depression levels of whom were investigated
before and after the 12-week intervention. The findings showed that the
experimental group experienced more positive effects than the control
group. We therefore suggest that the investigated board game activities can
be used as a routine therapy or alternative therapy in day care centers. The
board game activities could be promoted for active aging benefits in caring for
older adults in the contexts of day care centers, nursing home facilities, and
hospitals. Incorporating board game activities into social work may also help
to make it more diverse and innovative.
 SOCIAL WORK IN HEALTH CARE 11

Acknowledgments
Sincere appreciation is the administrators and staff of the two adult day care centers for their
support and assistance, and to the 150 wonderful older adults for their generous participation.

Contributors
All authors meet the criteria for authorship, have approved the final article, and all those
entitled to authorship are listed as authors.

Disclosure
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit
(www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception
and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or
revising it critically for important intellectual content; and (3) final approval of the version to
be published.

Disclosure statement
The authors report no conflict of interests in this work.

Human subjects
Jianan Psychiatric Center, Ministry of Health and Welfare [JPC-IRB-18-031].

ORCID
Ching-Teng Yao, PhD http://orcid.org/0000-0002-0307-270X

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