GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 4, Number 1, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2014.0083
Original Article
Games for Health: An Opinion Richard Buday, BArch, FAIA
Abstract
Almost 60 percent of Americans play videogames, which is a significant opportunity for health professionals to reach mass audiences. But although legions of fans spend countless hours playing entertainment games, player interest in health videogames quickly wanes. A good question to ask is, ‘‘Why?’’ A game developer with 20 years of experience offers his perspective on what may be limiting health games’ appeal and what can be done about it.
EyeToy (Sony, Tokyo, Japan), and Xbox Kinect (Microsoft, Redmond, WA)11 and created their own videogames specifically made for healthcare. Compared with the success of ‘‘America’s Army’’ in attracting new recruits, the ability of COTS and researcherdeveloped games to improve health has been modest. Nintendo’s ‘‘Brain Age’’ sold 19 million copies and spawned a host of follow-on titles and competitors, but brain-training games’ cognitive improvement capabilities are questionable. A 2013 review of children and adults found ‘‘short-term specific training effects that do not generalize.’’12 Studies of brain training of older adults with mild cognitive impairment found no difference in treatment and control groups.13 More than 100 million Wii consoles and 23 million Kinect units have been sold worldwide. Researchers have determined Wii and Kinect play can induce light to moderate bouts of physical activity,14 but studies show the effect is short lived (Fig. 1).14 Sedentary health videogames have shown efficacy improving nutrition in controlled studies15 and improvements in other health behaviors.16,17 Still, 15 or 20 years into the health videogame genre, effective COTS health game titles are few and far between. Research instruments that work in laboratories haven’t yet found a commercial market. As a designer working with behavior scientists for 20 years creating nutrition and physical activity behavior change games, I’ve formed opinions on why the health games genre has met limited success. The bottom line: Even when the science is right, health games may stumble on execution, boring or otherwise turning off videogame players who come seeking fun.18 Health game developers often make well-intentioned decisions that restrict the medium’s innate power to engage players.19 For example:
Introduction
A
1
mericans love playing videogames, and most do. From children to senior citizens, players are almost equally divided between genders. Videogame players liberally spend both time and money on games. More than $15 billion was spent on videogame titles in 2013.2 Games are now bigger than the film and music industries, making videogames a serious mass medium. Big advertisers have noticed. The Department of Defense annually spends hundreds of millions on traditional advertising programs.3 In 2002 the U.S. Army released a free-to-play videogame to attract new soldiers called ‘‘America’s Army.’’4 Developed at an overall cost of $33 million,5 ‘‘America’s Army’’ became a blockbuster hit. The role-playing shooter is credited with bringing in more recruits than all other Army advertising campaigns combined.6 Videogames evolved parallel to personal computers, but today they are inseparable. We carry games on the smartphone in our pocket, on the laptop or tablet in our briefcase, and on portable game players thrown in a backpack. We play them on home and work desktop computers and on dedicated consoles in our den. Videogames may soon arrive on our cable box7 and the digital media player connected to the family room television. Some videogames are playable on eyeglasses8,9 or wristwatches,10 and more are on the way. Videogames’ ubiquity and popularity offer health professionals access to the same mass marketing platform that piqued the Army’s interest. More important to health research scientists, perhaps, is the possibility that interactivity can deliver social marketing, health information, and behavior change. Research on commercial off-the-shelf (COTS) entertainment games’ ability to improve health may have started with the music game ‘‘Dance Dance Revolution’’ (Konami Digital Entertainment, El Segundo, CA), originally released in the late 1990s. Researchers have now studied the Wii console (Nintendo, Kyoto, Japan), ‘‘Brain Age’’ (Nintendo),
We make our serious intent too obvious
Good research builds on evidence. Years of behavioral research produced a large literature on how to transfer
Archimage, Inc., Houston, Texas.
1
2
BUDAY
FIG. 1.
The lifespan of an active videogame.
knowledge, change beliefs, attitudes, and intentions and, ultimately, modify behavior. Evidence-based health games are based on proven theories. Unfortunately, videogames struggle when conventional behavior models are poorly grafted onto gameplay. By definition a game must be fun, but fun isn’t a recurring theme in behavior change theory. Informational and behavioral messages can be disruptive when incongruously inserted into an entertainment experience. I suggest game-based learning occurs better through player experience than discourse. To maintain fun, a health videogame’s serious content should be presented indirectly, not overtly stated. It’s hard embedding behavior theory into a videogame without players noticing, but the goal of behavior change game developers should be just that. A measure of success would be formatively assessing if players were consciously aware of the game’s serious intent. If yes, go back to the drawing board, even if the members of the focus group indicate they don’t mind playing a videogame obviously intended to improve health. Health games are up against stiff competition in a world of discretionary time and dollars. Unless driven by need (therapy) or requirement (schoolwork), given a choice between fun and healthy, I believe most players will choose fun.
We make role-playing games about ourselves instead of our players
First-person role-playing videogame adventures altercast players (project their identity) as heroes in fictional universes. I’ve found health games sometimes assume players welcome thoughtful hints and comments from experts, much as professionals seek experts on topics outside their areas of expertise. The implicit bargain made between a game maker and a game player immersed in a fictional universe, however, is independent agency. I’ve noticed that information delivered from outside a game world (especially when offered by an authority figure who also lives outside the game) is disruptive to gameplay. Receiving a real-world message in the middle of a fantasy (i.e., ‘‘remember to drink water five times a day’’) can dilute the player’s self-perception as hero. Like turning up the house lights in the middle of an adventure film or cutting into a television drama with an advertisement, it breaks transportation, the feeling of being immersed in the game. Videogames depend on psychological flow.20,21 Once jolted out, it may be hard to reestablish. Authority can exert influence over a player in a videogame, but it’s better delivered through an in-game character, someone (or something) credibly integrated into the storyline. Maintaining
GAMES FOR HEALTH: AN OPINION
transportation in a storied world increases a player’s investment in its messages.22 To avoid breaking immersion and flow, consider communicating with players stealthily through established characters, using the art of storytelling or engineering opportunities for player self-discovery of the information. We make our serous games too safe
Blockbuster COTS games often appeal to the same sensibilities as Hollywood special effects films, dangling fantastical themes and sometimes shocking storylines to lure audiences. ‘‘America’s Army’’ is a war videogame comparable to the same COTS games lawmakers worry are harmful to children.23 Unless they are studying violence, I imagine most grant-funded health researchers would consciously avoid making anything like ‘‘America’s Army,’’ concerned that videogames and politics are an incendiary mix. I’ve witnessed health game developers pull their punches when it comes to storyline and gameplay mechanics, fearing controversy. Yet safety can be risky too. Critically important yet seemingly innocuous topics like nutrition can become political targets. Oklahoma Senator Tom Coburn’s annual Wastebook report frequently cites government-funded videogame-based research as low-priority and wasteful spending.24 In an ironic twist, the successful recruitment results of ‘‘America’s Army’’ have been offset by the U.S. Army’s turning away almost 30% of recruits,25 a statistic that mimics the 32% overweight population of American children.26 In the opinion of retired military leaders, many recruits are ‘‘Too Fat to Fight,’’27 suggesting more—not less—videogame-based health behavior change research is warranted. The visceral thrills and sensational drama of many COTS games belie a more powerful attraction than even Hollywood can claim. Role-playing games give players the ability to frequently and miserably fail, which is a strong ingredient for fun.28 In videogames, as in life, autonomy matters.29 The satisfaction that comes with figuring things out by one’s self, the pleasure of reaching one’s own conclusions, the emotions generated when proven right are hard to measure, but palpable. Bragging rights are attached to winning a game through one’s own devices. Coddle players in wholesome environments and minimize their ability to fail, and I believe many players will tune out. The Internet is filled with gamers’ dislike of being forced what to do (called playing an ‘‘on-rail’’ game).30 Videogames’ unique draw, their special ability to influence behavior in my opinion, is driven by nuance, subtlety, and a sense of independence, including the freedom to fail. We make player choice too prescriptive
Some health games, in my opinion, deliver health messages as journalism, where factual information is traditionally presented in an ‘‘inverted pyramid.’’ In newspapers and television news reports, the most important information is generally presented first (a primacy effect31) and the least important last.32 Effect is followed by cause, followed by details: Army Victorious!—A single squad crossing a river turned the tide. Details at eight.
3
Nonfiction often assumes that the first sentence, first page, or first chapter of information is the ‘‘power position.’’33 It’s been my experience that effective game persuasion works exactly opposite, more like how fictional information is presented. Fiction makes the last information delivered the most powerful (a recency effect34). A videogame version of the army’s victory would delay gratification of knowing who won and separate how. Game writers use suspense to keep players tuned in. Imagine an ‘‘America’s Army’’ version of the same mission: A U.S. Army division is on the march with the player in the role of commander. At first the commander’s mission seems a cakewalk. The player stumbles upon a wrinkled map lying on the ground and then finds binoculars on a dead soldier. The map makes clear the Army has the upper hand. The enemy is outgunned. But soon the Army is in retreat. Surprise: The enemy is stronger than anticipated. Setback after setback pushes the Army to the brink of disaster. The division is soon trapped along a river. All seems lost—until the player spots something on the horizon. The player remembers the binoculars. It’s a bridge, but it’s too small for the entire division to cross and escape in time. The player recalls the map. Is that a mountain pass on the other side? It looks like it leads to land behind the enemy. Hmm.It’s a crazy idea, but it just might work, the player thinks. In the height of battle (the equivalent of a novel or film’s climax) the player takes a small contingent of soldiers across the bridge, over the pass, and circles around the enemy. Against all odds, the player saves the day.
Seeds planted at the beginning of the game grew to fruition at the end. Feedback connecting cause and effect was separated, allowing the player to put two and two together when the need arose. Personally rewarding ‘‘ah-ha’’ moments followed. Like mystery novel readers or adventure film audiences, gameplayers enjoy figuring out how cause and effect are related more than having it pointed out to them. They smile in satisfaction when they discover they’re right. They want to know if their judgments and conclusions were correct. We assume our serious topic is interesting to players
There is an inconvenient truth underlying many serious games for health: Their serious topic may be unappealing to the target audience. My subjective view is that beyond healthcare providers, government and school officials, nutritionists, behavior scientists, and some parents, many children do not rank good nutrition and moderate bouts of daily exercise high on their list of priorities (if they did, there would be little need for serious games targeting childhood obesity). The Transtheoretical Model (TTM)35 considers behavior change a six-step process. Many health games assume players are Stage 2 ‘‘contemplators,’’ getting ready to start the healthy behavior, or are in Stage 3 ‘‘preparation,’’ ready to take immediate action. In my opinion, it’s likely that many (perhaps most) players are Stage 1 ‘‘pre-contemplators,’’ unaware of the need to change their behavior, underestimating reasons for change or overestimating problems they’ll encounter if they try. Offering drill and practice games for a desired behavior, game mechanics to help overcome barriers, gameplay to assist implementing intentions, and game moments to build confidence and overcome fear of failure may all be wasted on pre-contemplators. Stage 1 players are unaware, uninterested, and possibly antagonistic
4
toward the desired behavior. I doubt a videogame will change this. I believe serious games that do not account for topics considered unappealing to players will struggle to attract or maintain player interest. TTM pre-contemplators need convincing before training, a task I believe better suited to conventional storytelling through novels and films than gameplay. A humorous short story could be used to first make a topic attractive to an otherwise recalcitrant audience. So too could acknowledging the target audience’s resistance, or reframing the topic in a surprising and compelling way, or adopting any number of other techniques Madison Avenue uses to sell products to people who didn’t know they wanted them all of their lives. When designing a serious game it may be useful to acknowledge that one size won’t fit all. Tailoring a game to individual player characteristics could help (e.g., TTM Stage 2 player game settings versus Stage 3 player settings). A single game fully customizable to the complete spectrum of TTM phases would be a technical and financial challenge, but an integrated series of story and game interventions could be finely tuned. Consider offering compelling short stories, novels, or film to Stage 1 pre-contemplation audiences, exploration videogames to Stage 2 contemplators, preparation adventure games to Stage 3 players, training simulators to Stage 4 youth, drill and practice exercises to those in Stage 5 (maintenance), and short message service text reminders to Stage 6 (termination) graduates.
BUDAY
environments are toolkits for conventional videogame mechanics, not necessarily behavior change algorithms. High development cost could partly account for the difficulty in seamlessly integrating behavior theory with gameplay. But now, inexpensive game technology specifically intended for fun and health accessible to indie game developers without the hassle of console restrictions is on the horizon. Apple’s Health application,38 Google Fit,39 and other biosensing mobile technology could forever change the games for health landscape. Apple and Google are encouraging development of mobile health applications by opening up their application program interfaces to the world. I believe unrestricted developer access to mobile health technology will push game engines to integrate health sensing and biofeedback with traditional videogame mechanics. The result could be players deliberately purchasing health games for fun, eliminating the need for stealth messaging. The awkward mix of entertainment and health science may be about to melt into something palatable to both sides of the fun versus serious equation. If so, all of the existing games for health research and development, all of the experience we’ve gained so far, may reach full potential. The next 2–3 years should be very interesting. Author Disclosure Statement
No competing financial interests exist. References
We make our games too easy or too hard
Many games have teaching levels showing players exactly what to do, how, and when. This is called a tutorial, and sometimes tutorials are a good thing. But when games stay in tutorial mode, in a sense, never leaving players to their own devices, players get annoyed.18 Online game communities often complain of ‘‘coddling’’ and ‘‘hand-holding.’’ Videogames with mandatory tutorial levels, never-ending screen prompts, and constant tips, advice, or other assistive devices should be avoided unless required by the target audience (e.g., vision, hearing, mobility impaired, etc.). In my experience, too much help is a recipe for boredom. Conversely, some videogames are too hard to play, also leading to player frustration and boredom. It should be noted that game industry-wide, most players never finish their videogame, even successful COTS blockbuster titles.36 Serious games should not be held to a higher standard. Nevertheless, frequent testing of game mechanics with representative players can minimize gameplay that turn players off, such as mechanics too complex, puzzles too hard, or levels too long. The Road Ahead
The health game genre appears to me on the verge of reinvention. Independent developers trying to create games for consoles such as the Nintendo Wii and the Microsoft Xbox were once handicapped by manufacturer or publisher restrictions and the need for expensive developer kits. At launch, Microsoft’s Xbox 360 developer kit cost $10,000 each.37 Consequently, many de novo health games were produced for more affordable PCs, Web browsers, or mobile platforms. Even there, development cost could be substantial, partially because commercial game engines and software development
1. Entertainment Software Association. Essential Facts About the Computer and Video Game Industry. 2014. www.theesa .com/facts/pdfs/ESA_EF_2014.pdf (accessed October 11, 2014). 2. NPD Group. Research Shows $15.39 Billion Spent on Video Game Content in the US in 2013, a 1 Percent Increase over 2012. 2014. https://http://www.npd.com/wps/portal/npd/us/ news/press-releases/research-shows-15.39-billion-dollarsspent-on-video-game-content-in-the-us-in-2013-a-1-percentincrease-over-2012/ (accessed October 11, 2014). 3. U.S. General Accounting Office. Military Recruiting: DOD Needs to Establish Objectives and Measures to Better Evaluate Advertising’s Effectiveness. 2003. www.gao.gov/ htext/d031005.html (accessed October 11, 2014). 4. Wikipedia. America’s Army. http://en.wikipedia.org/wiki/ America’s_Army (accessed October 11, 2014). 5. GameSpot. America’s Army Bill: $32.8 Million. www .gamespot.com/articles/americas-army-bill-328-million/ 1100-6242635/ (accessed October 11, 2014). 6. Edery D, Mollick E. Changing the Game: How Video Games Are Transforming the Future of Business. Upper Saddle River, NJ: Pearson Education/FT Press; 2009. 7. Murphy D. Rumor: Comcast, Electronic Arts to Bring Games to X1 Cable Boxes. May 3, 2014. www.pcmag.com/ article2/0,2817,2457554,00.asp (accessed July 8, 2014). 8. Casti T. Here’s What Video Games Will Look Like on Google Glass. January 29, 2014. www.huffingtonpost.com/ 2014/01/29/google-glass-minigames-games-developers_n_ 4688236.html (accessed July 8, 2014). 9. Google. OK Glass, Play a Game. 2014. https://developers .google.com/glass/samples/mini-games (accessed September 30, 2014). 10. Tofel KC. Microsoft’s ‘‘Surface Watch’’ Will Reportedly Work with Xbox One and PCs, Not Just Phones. June 10,
GAMES FOR HEALTH: AN OPINION
11. 12. 13.
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18. 19. 20. 21. 22. 23.
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2014. http://gigaom.com/2014/06/10/microsofts-surfacewatch-will-reportedly-work-with-xbox-one-and-pcs-not-justphones/ (accessed July 8, 2014). Baranowski T, Maddison R, Maloney A, et al. Building a better mousetrap (exergame) to increase youth physical activity. Games Health J 2014; 3:72–78. Melby-Lervag M, Hulme C. Is working memory training effective? A meta-analytic review. Dev Psychol 2013; 49:270–291. Zhuang JP, Fang R, Feng X, et al. The impact of humancomputer interaction-based comprehensive training on the cognitive functions of cognitive impairment elderly individuals in a nursing home. J Alzheimers Dis 2013; 36:245–251. Barnett A, Cerin E, Baranowski T. Active video games for youth: A systematic review. J Phys Act Health 2011; 8:724–737. Baranowski T, Baranowski J, Thompson D, et al. Video game play, child diet, and physical activity behavior change a randomized clinical trial. Am J Prev Med 2011; 40:33– 38. Lieberman DA. Video games for diabetes self-management: Examples and design strategies. J Diabetes Sci Technol 2012; 6:802–806. Bussey-Smith KL, Rossen RD. A systematic review of randomized control trials evaluating the effectiveness of interactive computerized asthma patient education programs. Ann Allergy Asthma Immunol 2007; 98:507–516; quiz 516, 566. Buday R, Baranowski T, Thompson D. Fun and games and boredom. Games Health J 2012; 1:257–261. Gee JP. What Video Games Have to Teach Us About Learning and Literacy. New York: Palgrave MacMillan; 2007. Starks K. Cognitive behavioral game design: A unified model for designing serious games. Front Psychol 2014; 5:28. Choi D, Kim J. Why people continue to play online games: In search of critical design factors to increase customer loyalty to online contents. Cyberpsychol Behav 2004; 7:11–24. Green MC, Brock TC. The role of transportation in the persuasiveness of public narratives. J Pers Soc Psychol 2000; 79:701–721. Reisinger D. Senator: Let’s Study Violent Video Games— Again. December 20, 2012. www.cnet.com/news/senatorlets-study-violent-video-games-again/ (accessed October 11, 2014). Coburn T. Wastebook 2013. 2013. www.coburn.senate .gov/public//index.cfm?a = Files.Serve&File_id = d204730e4a24-4711-b1db-99bb6c29d4b6 (accessed October 11, 2014). CBS News. Retired Military Leaders Say This Generation Is ‘‘Too Fat to Fight.’’ 2012. www.cbsnews.com/news/ retired-military-leaders-say-this-generation-is-too-fat-to-fight/ (accessed October 14, 2014).
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26. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337:869–873. 27. Mission: Readiness. Too Fat to Fight. 2010. http://cdn .missionreadiness.org/MR_Too_Fat_to_Fight-1.pdf (accessed October 11, 2014). 28. Juul J. Playful Thinking Series. The Art of Failure: An Essay on the Pain of Playing Video Games. Cambridge, MA: MIT Press; 2013. 29. Sheldon, KM, Filak V. Manipulating autonomy, competence, and relatedness support in a game-learning context: New evidence that all three needs matter. Br J Soc Psychol 2008; 47:267–283. 30. Winstrom S. End the Slander Against On-Rail Games. End It Now. 2011. http://kotaku.com/5811749/end-the-slanderagainst-on-rail-games-end-it-now (accessed October 11, 2014). 31. Deese J, Kaufman RA. Serial effects in recall of unorganized and sequentially organized verbal material. J Exp Psychol 1957; 54:180–187. 32. Wikipedia. Inverted Pyramid. http://en.wikipedia.org/wiki/ Inverted_pyramid (accessed October 11, 2014). 33. Kress N. Elements of Fiction Writing—Beginnings, Middles & Ends, 2nd ed. Cincinnati: Writers Digest Books; 2011. 34. Hermann DJ, Geisler FV, Atkinson RC. The serial position function for lists learned by a narrative-story mnemonic. Bull Psychonom Soc 1973; 2(Dec):377–378. 35. Marshall SJ, Biddle SJ. The transtheoretical model of behavior change: A meta-analysis of applications to physical activity and exercise. Ann Behav Med 2001; 23:229–246. 36. Moriarty C. GDC: Most Players Don’t Finish Games. March 17, 2014. www.ign.com/articles/2014/03/17/gdcmost-players-donat-finish-games (accessed July 6, 2014). 37. Suddaby P. Making Indie Games on the Xbox One. 2013. http://gamedevelopment.tutsplus.com/articles/making-indiegames-on-the-xbox-one–gamedev-13415 (accessed July 8, 2014). 38. Shaughnessy H. The Revolution Hidden in the Apple Health Kit. June 17, 2014. www.forbes.com/sites/haydnshaughnessy/ 2014/06/17/the-revolution-hidden-in-the-apple-health-kit/ (accessed July 8, 2014). 39. Olson P. Exclusive: Google Wants to Collect Your Health Data with ‘Google Fit.’ June 12, 2014. www.forbes.com/ sites/parmyolson/2014/06/12/exclusive-google-to-launchhealth-service-google-fit-at-developers-conference/ (accessed July 8, 2014).
Address correspondence to: Richard Buday, BArch, FAIA Archimage, Inc. 4203 Montrose Boulevard, Suite 390 Houston, TX 77006 E-mail: [email protected]
Original Article
Games for Health: An Opinion Richard Buday, BArch, FAIA
Abstract
Almost 60 percent of Americans play videogames, which is a significant opportunity for health professionals to reach mass audiences. But although legions of fans spend countless hours playing entertainment games, player interest in health videogames quickly wanes. A good question to ask is, ‘‘Why?’’ A game developer with 20 years of experience offers his perspective on what may be limiting health games’ appeal and what can be done about it.
EyeToy (Sony, Tokyo, Japan), and Xbox Kinect (Microsoft, Redmond, WA)11 and created their own videogames specifically made for healthcare. Compared with the success of ‘‘America’s Army’’ in attracting new recruits, the ability of COTS and researcherdeveloped games to improve health has been modest. Nintendo’s ‘‘Brain Age’’ sold 19 million copies and spawned a host of follow-on titles and competitors, but brain-training games’ cognitive improvement capabilities are questionable. A 2013 review of children and adults found ‘‘short-term specific training effects that do not generalize.’’12 Studies of brain training of older adults with mild cognitive impairment found no difference in treatment and control groups.13 More than 100 million Wii consoles and 23 million Kinect units have been sold worldwide. Researchers have determined Wii and Kinect play can induce light to moderate bouts of physical activity,14 but studies show the effect is short lived (Fig. 1).14 Sedentary health videogames have shown efficacy improving nutrition in controlled studies15 and improvements in other health behaviors.16,17 Still, 15 or 20 years into the health videogame genre, effective COTS health game titles are few and far between. Research instruments that work in laboratories haven’t yet found a commercial market. As a designer working with behavior scientists for 20 years creating nutrition and physical activity behavior change games, I’ve formed opinions on why the health games genre has met limited success. The bottom line: Even when the science is right, health games may stumble on execution, boring or otherwise turning off videogame players who come seeking fun.18 Health game developers often make well-intentioned decisions that restrict the medium’s innate power to engage players.19 For example:
Introduction
A
1
mericans love playing videogames, and most do. From children to senior citizens, players are almost equally divided between genders. Videogame players liberally spend both time and money on games. More than $15 billion was spent on videogame titles in 2013.2 Games are now bigger than the film and music industries, making videogames a serious mass medium. Big advertisers have noticed. The Department of Defense annually spends hundreds of millions on traditional advertising programs.3 In 2002 the U.S. Army released a free-to-play videogame to attract new soldiers called ‘‘America’s Army.’’4 Developed at an overall cost of $33 million,5 ‘‘America’s Army’’ became a blockbuster hit. The role-playing shooter is credited with bringing in more recruits than all other Army advertising campaigns combined.6 Videogames evolved parallel to personal computers, but today they are inseparable. We carry games on the smartphone in our pocket, on the laptop or tablet in our briefcase, and on portable game players thrown in a backpack. We play them on home and work desktop computers and on dedicated consoles in our den. Videogames may soon arrive on our cable box7 and the digital media player connected to the family room television. Some videogames are playable on eyeglasses8,9 or wristwatches,10 and more are on the way. Videogames’ ubiquity and popularity offer health professionals access to the same mass marketing platform that piqued the Army’s interest. More important to health research scientists, perhaps, is the possibility that interactivity can deliver social marketing, health information, and behavior change. Research on commercial off-the-shelf (COTS) entertainment games’ ability to improve health may have started with the music game ‘‘Dance Dance Revolution’’ (Konami Digital Entertainment, El Segundo, CA), originally released in the late 1990s. Researchers have now studied the Wii console (Nintendo, Kyoto, Japan), ‘‘Brain Age’’ (Nintendo),
We make our serious intent too obvious
Good research builds on evidence. Years of behavioral research produced a large literature on how to transfer
Archimage, Inc., Houston, Texas.
1
2
BUDAY
FIG. 1.
The lifespan of an active videogame.
knowledge, change beliefs, attitudes, and intentions and, ultimately, modify behavior. Evidence-based health games are based on proven theories. Unfortunately, videogames struggle when conventional behavior models are poorly grafted onto gameplay. By definition a game must be fun, but fun isn’t a recurring theme in behavior change theory. Informational and behavioral messages can be disruptive when incongruously inserted into an entertainment experience. I suggest game-based learning occurs better through player experience than discourse. To maintain fun, a health videogame’s serious content should be presented indirectly, not overtly stated. It’s hard embedding behavior theory into a videogame without players noticing, but the goal of behavior change game developers should be just that. A measure of success would be formatively assessing if players were consciously aware of the game’s serious intent. If yes, go back to the drawing board, even if the members of the focus group indicate they don’t mind playing a videogame obviously intended to improve health. Health games are up against stiff competition in a world of discretionary time and dollars. Unless driven by need (therapy) or requirement (schoolwork), given a choice between fun and healthy, I believe most players will choose fun.
We make role-playing games about ourselves instead of our players
First-person role-playing videogame adventures altercast players (project their identity) as heroes in fictional universes. I’ve found health games sometimes assume players welcome thoughtful hints and comments from experts, much as professionals seek experts on topics outside their areas of expertise. The implicit bargain made between a game maker and a game player immersed in a fictional universe, however, is independent agency. I’ve noticed that information delivered from outside a game world (especially when offered by an authority figure who also lives outside the game) is disruptive to gameplay. Receiving a real-world message in the middle of a fantasy (i.e., ‘‘remember to drink water five times a day’’) can dilute the player’s self-perception as hero. Like turning up the house lights in the middle of an adventure film or cutting into a television drama with an advertisement, it breaks transportation, the feeling of being immersed in the game. Videogames depend on psychological flow.20,21 Once jolted out, it may be hard to reestablish. Authority can exert influence over a player in a videogame, but it’s better delivered through an in-game character, someone (or something) credibly integrated into the storyline. Maintaining
GAMES FOR HEALTH: AN OPINION
transportation in a storied world increases a player’s investment in its messages.22 To avoid breaking immersion and flow, consider communicating with players stealthily through established characters, using the art of storytelling or engineering opportunities for player self-discovery of the information. We make our serous games too safe
Blockbuster COTS games often appeal to the same sensibilities as Hollywood special effects films, dangling fantastical themes and sometimes shocking storylines to lure audiences. ‘‘America’s Army’’ is a war videogame comparable to the same COTS games lawmakers worry are harmful to children.23 Unless they are studying violence, I imagine most grant-funded health researchers would consciously avoid making anything like ‘‘America’s Army,’’ concerned that videogames and politics are an incendiary mix. I’ve witnessed health game developers pull their punches when it comes to storyline and gameplay mechanics, fearing controversy. Yet safety can be risky too. Critically important yet seemingly innocuous topics like nutrition can become political targets. Oklahoma Senator Tom Coburn’s annual Wastebook report frequently cites government-funded videogame-based research as low-priority and wasteful spending.24 In an ironic twist, the successful recruitment results of ‘‘America’s Army’’ have been offset by the U.S. Army’s turning away almost 30% of recruits,25 a statistic that mimics the 32% overweight population of American children.26 In the opinion of retired military leaders, many recruits are ‘‘Too Fat to Fight,’’27 suggesting more—not less—videogame-based health behavior change research is warranted. The visceral thrills and sensational drama of many COTS games belie a more powerful attraction than even Hollywood can claim. Role-playing games give players the ability to frequently and miserably fail, which is a strong ingredient for fun.28 In videogames, as in life, autonomy matters.29 The satisfaction that comes with figuring things out by one’s self, the pleasure of reaching one’s own conclusions, the emotions generated when proven right are hard to measure, but palpable. Bragging rights are attached to winning a game through one’s own devices. Coddle players in wholesome environments and minimize their ability to fail, and I believe many players will tune out. The Internet is filled with gamers’ dislike of being forced what to do (called playing an ‘‘on-rail’’ game).30 Videogames’ unique draw, their special ability to influence behavior in my opinion, is driven by nuance, subtlety, and a sense of independence, including the freedom to fail. We make player choice too prescriptive
Some health games, in my opinion, deliver health messages as journalism, where factual information is traditionally presented in an ‘‘inverted pyramid.’’ In newspapers and television news reports, the most important information is generally presented first (a primacy effect31) and the least important last.32 Effect is followed by cause, followed by details: Army Victorious!—A single squad crossing a river turned the tide. Details at eight.
3
Nonfiction often assumes that the first sentence, first page, or first chapter of information is the ‘‘power position.’’33 It’s been my experience that effective game persuasion works exactly opposite, more like how fictional information is presented. Fiction makes the last information delivered the most powerful (a recency effect34). A videogame version of the army’s victory would delay gratification of knowing who won and separate how. Game writers use suspense to keep players tuned in. Imagine an ‘‘America’s Army’’ version of the same mission: A U.S. Army division is on the march with the player in the role of commander. At first the commander’s mission seems a cakewalk. The player stumbles upon a wrinkled map lying on the ground and then finds binoculars on a dead soldier. The map makes clear the Army has the upper hand. The enemy is outgunned. But soon the Army is in retreat. Surprise: The enemy is stronger than anticipated. Setback after setback pushes the Army to the brink of disaster. The division is soon trapped along a river. All seems lost—until the player spots something on the horizon. The player remembers the binoculars. It’s a bridge, but it’s too small for the entire division to cross and escape in time. The player recalls the map. Is that a mountain pass on the other side? It looks like it leads to land behind the enemy. Hmm.It’s a crazy idea, but it just might work, the player thinks. In the height of battle (the equivalent of a novel or film’s climax) the player takes a small contingent of soldiers across the bridge, over the pass, and circles around the enemy. Against all odds, the player saves the day.
Seeds planted at the beginning of the game grew to fruition at the end. Feedback connecting cause and effect was separated, allowing the player to put two and two together when the need arose. Personally rewarding ‘‘ah-ha’’ moments followed. Like mystery novel readers or adventure film audiences, gameplayers enjoy figuring out how cause and effect are related more than having it pointed out to them. They smile in satisfaction when they discover they’re right. They want to know if their judgments and conclusions were correct. We assume our serious topic is interesting to players
There is an inconvenient truth underlying many serious games for health: Their serious topic may be unappealing to the target audience. My subjective view is that beyond healthcare providers, government and school officials, nutritionists, behavior scientists, and some parents, many children do not rank good nutrition and moderate bouts of daily exercise high on their list of priorities (if they did, there would be little need for serious games targeting childhood obesity). The Transtheoretical Model (TTM)35 considers behavior change a six-step process. Many health games assume players are Stage 2 ‘‘contemplators,’’ getting ready to start the healthy behavior, or are in Stage 3 ‘‘preparation,’’ ready to take immediate action. In my opinion, it’s likely that many (perhaps most) players are Stage 1 ‘‘pre-contemplators,’’ unaware of the need to change their behavior, underestimating reasons for change or overestimating problems they’ll encounter if they try. Offering drill and practice games for a desired behavior, game mechanics to help overcome barriers, gameplay to assist implementing intentions, and game moments to build confidence and overcome fear of failure may all be wasted on pre-contemplators. Stage 1 players are unaware, uninterested, and possibly antagonistic
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toward the desired behavior. I doubt a videogame will change this. I believe serious games that do not account for topics considered unappealing to players will struggle to attract or maintain player interest. TTM pre-contemplators need convincing before training, a task I believe better suited to conventional storytelling through novels and films than gameplay. A humorous short story could be used to first make a topic attractive to an otherwise recalcitrant audience. So too could acknowledging the target audience’s resistance, or reframing the topic in a surprising and compelling way, or adopting any number of other techniques Madison Avenue uses to sell products to people who didn’t know they wanted them all of their lives. When designing a serious game it may be useful to acknowledge that one size won’t fit all. Tailoring a game to individual player characteristics could help (e.g., TTM Stage 2 player game settings versus Stage 3 player settings). A single game fully customizable to the complete spectrum of TTM phases would be a technical and financial challenge, but an integrated series of story and game interventions could be finely tuned. Consider offering compelling short stories, novels, or film to Stage 1 pre-contemplation audiences, exploration videogames to Stage 2 contemplators, preparation adventure games to Stage 3 players, training simulators to Stage 4 youth, drill and practice exercises to those in Stage 5 (maintenance), and short message service text reminders to Stage 6 (termination) graduates.
BUDAY
environments are toolkits for conventional videogame mechanics, not necessarily behavior change algorithms. High development cost could partly account for the difficulty in seamlessly integrating behavior theory with gameplay. But now, inexpensive game technology specifically intended for fun and health accessible to indie game developers without the hassle of console restrictions is on the horizon. Apple’s Health application,38 Google Fit,39 and other biosensing mobile technology could forever change the games for health landscape. Apple and Google are encouraging development of mobile health applications by opening up their application program interfaces to the world. I believe unrestricted developer access to mobile health technology will push game engines to integrate health sensing and biofeedback with traditional videogame mechanics. The result could be players deliberately purchasing health games for fun, eliminating the need for stealth messaging. The awkward mix of entertainment and health science may be about to melt into something palatable to both sides of the fun versus serious equation. If so, all of the existing games for health research and development, all of the experience we’ve gained so far, may reach full potential. The next 2–3 years should be very interesting. Author Disclosure Statement
No competing financial interests exist. References
We make our games too easy or too hard
Many games have teaching levels showing players exactly what to do, how, and when. This is called a tutorial, and sometimes tutorials are a good thing. But when games stay in tutorial mode, in a sense, never leaving players to their own devices, players get annoyed.18 Online game communities often complain of ‘‘coddling’’ and ‘‘hand-holding.’’ Videogames with mandatory tutorial levels, never-ending screen prompts, and constant tips, advice, or other assistive devices should be avoided unless required by the target audience (e.g., vision, hearing, mobility impaired, etc.). In my experience, too much help is a recipe for boredom. Conversely, some videogames are too hard to play, also leading to player frustration and boredom. It should be noted that game industry-wide, most players never finish their videogame, even successful COTS blockbuster titles.36 Serious games should not be held to a higher standard. Nevertheless, frequent testing of game mechanics with representative players can minimize gameplay that turn players off, such as mechanics too complex, puzzles too hard, or levels too long. The Road Ahead
The health game genre appears to me on the verge of reinvention. Independent developers trying to create games for consoles such as the Nintendo Wii and the Microsoft Xbox were once handicapped by manufacturer or publisher restrictions and the need for expensive developer kits. At launch, Microsoft’s Xbox 360 developer kit cost $10,000 each.37 Consequently, many de novo health games were produced for more affordable PCs, Web browsers, or mobile platforms. Even there, development cost could be substantial, partially because commercial game engines and software development
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Address correspondence to: Richard Buday, BArch, FAIA Archimage, Inc. 4203 Montrose Boulevard, Suite 390 Houston, TX 77006 E-mail: [email protected]
