GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 6, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0067
Clinical Briefs
Games for Health: Past, Present, and Future? Alan Au, PhD
Abstract
This article provides a review of selected past and present games for health. This will highlight some existing games for health and examine the relationship between health content and game technology. Because of this relationship, new technology trends may suggest future approaches to the application of videogame-based health interventions.
Introduction
T
he alternative use of videogames for non-entertainment purposes is not new. However, technology has changed over time and with it the potential to distribute new kinds of messages and interventions. To better understand future trends in games for health, this article will examine past and present efforts to harness the advantageous properties of games to influence health behavior change. This includes the use of custom-developed health games, as well as commercial off-the-shelf (COTS) software and hardware that can be repurposed for health interventions. Past, present, and future are defined in this article by access to operating systems and hardware and subsequently access to health games and their content. These definitions reinforce the concept of technology as a mediating factor in enabling access to different kinds of health interventions. By understanding the technology, different types of health-related content can be developed and disseminated. In addition to technological considerations, games for health have also changed over time to reflect society’s changing relationship with games and gameplay. While we may not fully understand the individual components that make games so captivating, an examination of past and present games for health can also highlight the strengths and weaknesses of using games to promote health content. Past Work in the games for health domain has its roots in past efforts to use games and simulation for training and education. The earliest simulations relied on expensive hardware and were restricted to large organizations, such as universities, with the resources to support them. However, the advent of the modern personal computer and home game consoles dramatically lowered the technical barrier to game development, allowing researchers and educators to focus on creating health-related content.
One example of an early health game was ‘‘Packy & Marlon,’’ developed for the Super Nintendo Entertainment System (Nintendo, Kyoto, Japan) in 1995. The game was created and published for use in a diabetes research study run at the University of California, Santa Barbara by Brown et al.1 ‘‘Packy & Marlon’’ was constructed as a side-scroller videogame with a health theme and diabetes-related resource management tasks. Similarly, ‘‘Squire’s Quest’’ was a nutritional health game developed at the Baylor College of Medicine in the early 2000s.2 ‘‘Squire’s Quest’’ was a story-based game where players made health-related gameplay choices to drive the narrative. These two examples were typical of education-based games that relied on commonly available hardware and traditional game mechanics, such as narrative storylines and reward systems. The health interventions were delivered via thematic content. While effective as targeted interventions, these games exhibited limited appeal and effectiveness as widespread health interventions. The traditional game mechanics made these health games appealing, but they also brought those games into competition with entertainment games, where they relied on the health-themed content and educator support to drive interest. In addition to promoting healthy behavior, games have also been used for rehabilitation purposes. This use was supported by several research studies demonstrating positive therapeutic outcomes as a result of gameplay.3 This has included the ongoing use of games as exposure therapy to treat phobias and posttraumatic stress disorder,4 as well as pain management for individuals undergoing burn recovery and physical therapy.5 In contrast to their informational counterparts in the behavioral health space, rehabilitation games relied on the audiovisual stimuli and patient interaction to provide direct health benefit. Because the play activity was directly tied to the health benefit, these games were highly effective as targeted interventions. At the same time, these games tended not to include traditional reward structures associated with entertainment gameplay. Therefore, they
Department of Biomedical & Health Informatics, University of Washington, Seattle, Washington.
449
450 depended on external motivation from a physician or therapist to provide context for the play experience. The history of games for health has been one of adapting game technologies and play mechanics for use in promoting health content. While successful from a research and therapeutic perspective, early games for health demonstrated the challenges involved in reaching a widespread audience. The use of commonly available hardware paved the way for adoption, but these games also relied heavily on external motivation from clinicians and educators. This will get easier as schools and hospitals integrate games into their toolsets, but one goal of games for health is to encourage players to seek out health-related content on their own. Present Games are becoming a ubiquitous part of our social landscape. As a result, player expectations are more complex, and the expectations about game production values are higher. The development of a targeted health game now requires more resources to meet player expectations and hold player interest. As an alternative, some researchers are investigating the use of COTS games for health benefit. This includes research into existing games to examine their health impact, such as the effect of games on brain plasticity6 and the effect of games on stress and anxiety reduction.7 Commercial developers have looked at new ways to extend the traditional gameplay experience with peripheral hardware, such as dance pads and guitar controllers. In the past, these hardware-based experiences originated in game arcades, where developers used custom controllers and novel gameplay experiences to attract players. This included arcade ¨ ta, Japan) and ‘‘Dance games like ‘‘Prop Cycle’’ (Namco, O Dance Revolution’’ (DDR) (Konami, Tokyo, Japan), which made extensive use of physical motion. ‘‘Prop Cycle’s’’ stationary bicycle controller did not successfully transition to the home market. However, the DDR dance pad controller did, most likely because of its low cost and minimal storage requirements. Although dance games were not originally intended as a form of exercise, there is research supporting their potential use as health interventions.8 As a result, dance games have found their way into physical education classes in the United States and the United Kingdom. At the same time, commercial developers are starting to experiment with health-related themes, like food and its effect on player appearance. For example, a food-based game mechanic can be found in commercial games like ‘‘Grand Theft Auto: San Andreas’’ (Rockstar Games, New York, NY) and ‘‘Fable’’ (Big Blue Box; Microsoft, Redmond, WA). While effective at highlighting the importance of dietary choices, the in-game health consequences are primarily cosmetic, and the health effects are subject to game balance considerations. Consequently, existing research into this aspect of commercial games has primarily been humanities-driven analyses of game themes. However, from a technological perspective, these games demonstrate that health consequences can be presented in an interactive fashion and that health-related behaviors can be directly integrated into gameplay mechanics. After all, the ability of games to provide immediate feedback about player choices is part of the appeal of games. While there are still traditional efforts to create targeted games for health, there is increasing interest in studying the health
AU implications of COTS games. The commercial search for novel gameplay has led to the development and popularization of new controllers and types of play. This potentially enables new types of health interventions, both intentional and incidental. Future The future is very difficult to anticipate, particularly given the speed with which game technology is changing. As with all technologies, it is subject to consumer preferences and business considerations. Even within the commercial games market, developers are not always certain which products will gain traction in the marketplace. Consider that the game industry doesn’t know what will work and what will not. For example, various past attempts to promote peripheral hardware have met with mixed results. For example, the SEGA ¨ ta) Activator motion controller failed, whereas the Sony (O (Tokyo) EyeToy was commercially successful. Fortunately, there is growing commercial interest in creating games with health-related content. Titles like ‘‘Brain Age’’ (Nintendo) and ‘‘Yourself!Fitness’’ (Respondesign, Portland, OR) were created to take advantage of consumer demand for self-improvement, both mental and physical. These commercial health games focus on a wide selection of health themes based on consumer demand, like smoking cessation and personal fitness. This partially relieves researchers from the burden of development, but the trade-off is reduced control over the health content. While it is certainly possible to adapt commercial games for health purposes, commercial games are not necessarily well suited for research purposes.9 However, because commercial developers are always looking for ways to distinguish their products in the marketplace, collaboration with the research community might be one way to engage players who are actively seeking health content. Commercial interest in health content also extends to mobile gaming platforms, such as tablet computing devices or mobile phones. Portable devices are ideal for real-time tracking of physical activity, as with commercial products like Nike + (Nike, Beaverton, OR) and the FitBit (San Francisco, CA). Unlike pedometers and activity monitors of the past, mobile computing devices add additional analysis and social features that can be used to make the experience more engaging. Advances in sensors and mobile computing also lend themselves well to the sorts of activities that games are good at supporting. This includes real-time instructions and feedback about health behaviors, as well as support for social content. This is important for health behaviors that rely on the portability and timely feedback that mobile devices can provide, such as smoking cessation.10 These applications support growing interest in the field of mobile health, which seeks to take advantage of portable computing to promote health. Mobile gaming is also important because it enables access to new populations where traditional computers and console gaming systems are otherwise unavailable. For example, the Freedom HIV/AIDS mobile health game developed by ZMQ Software (Delhi, India) is being deploying in developing areas within India. Examples like this highlight the impact that technology can have on reaching new audiences, and not just on the types of health content being presented. Looking towards the future of gaming technology, games for health research will undoubtedly include targeted
GAMES FOR HEALTH: PAST, PRESENT, AND FUTURE? interventions using sensors and mobile technology. With growing commercial interest in health content, there may also be research collaboration opportunities that combine research with commercial games and services. Conclusions Existing games for health demonstrate that targeted health games are an effective but increasingly resource intensive way to promote healthy behavior. Unfortunately, recent research indicates that simply providing access to health content may not be enough to promote behavior change.11 How then can we ensure that future games for health are effective? Research into COTS games has shown that they may influence health behavior, for better or worse. This remains a viable research path, particularly as commercial game developers show increased interest in health-related game content and engage with the research community. So where might the games for health field be going? The possibilities are driven by research and therapy as they have been in the past, but mobile games and sensors suggest new gameplay interactions and health interventions such as location-based play and activity monitoring. This is great for interventions that rely on timely feedback, and where the act of play is providing the health benefit. This harks back to the use of games for therapy and rehabilitation, but with the game trappings that promote engagement, both immediate and long term. The use of mobile games in developing areas highlights the appeal and access that games can provide, and thanks to early research-driven work, games are gaining traction within the school and hospital settings. In summary, there’s a convergence among research, education, therapy, and commercial development. With the advent of new controllers and mobile hardware, health content is no longer restricted to information delivered on a desktop computer or game console. This supports potential health interventions that rely on time and location, such as allergy awareness or sleep patterns. If the past was about content, and the present is about activity, perhaps the future is about engaging with health anytime, anywhere. Author Disclosure Statement No competing financial interests exist.
451 References 1. Brown SJ, Lieberman DA, Germeny BA, et al. Educational video game for juvenile diabetes: Results of a controlled trial. Med Inform (Lond) 1997; 22:77–89. 2. Baranowski T, Baranowski J, Cullen KW, et al. Squire’s Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med 2003; 24:52–61. 3. Primack BA, Carroll MV, McNamara M, et al. Role of video games in improving health-related outcomes: A systematic review. Am J Prev Med 2012; 42:630–638. 4. Rizzo A, Requejo P, Winstein CJ, et al. Virtual reality applications for addressing the needs of those aging with disability. Stud Health Technol Inform 2011; 163:510–516. 5. Hoffman HG. Virtual-reality therapy. Sci Am 2004; 291(2): 58–65. 6. Achtman RL, Green CS, Bavelier D. Video games as a tool to train visual skills. Restor Neurol Neurosci 2008; 26:435–446. 7. Russoniello CV, O’Brien K, Parks JM. The effectiveness of casual video games in improving mood and decreasing stress. J Cyberther Rehabil 2009; 2:53–66. 8. Murphy EC-S. The effect of aerobic exercise on endothelial dysfunction in overweight children [PhD dissertation]. Morgantown, WV: West Virginia University; 2007: 141. 9. Nitz JC, Kuys S, Isles R, Fu S. Is the Wii Fit a new-generation tool for improving balance, health and well-being? A pilot study. Climacteric 2010; 13:487–491. 10. Raiff BR, Jarvis BP, Rapoza D. Prevalence of video game use, cigarette smoking, and acceptability of a video game-based smoking cessation intervention among online adults. Nicotine Tob Res 2012 Sep 11 [doi: 10.1093/ntr/nts079]. 11. Baranowski T, Abdelsamad D, Baranowski J, et al. Impact of an active video game on healthy children’s physical activity. Pediatrics 2012; 129:e636–e642.
Address correspondence to: Alan Au, PhD Department of Biomedical & Health Informatics University of Washington HSC I-264, Box 357240 1959 NE Pacific Street Seattle, WA 98195 E-mail: [email protected]
Clinical Briefs
Games for Health: Past, Present, and Future? Alan Au, PhD
Abstract
This article provides a review of selected past and present games for health. This will highlight some existing games for health and examine the relationship between health content and game technology. Because of this relationship, new technology trends may suggest future approaches to the application of videogame-based health interventions.
Introduction
T
he alternative use of videogames for non-entertainment purposes is not new. However, technology has changed over time and with it the potential to distribute new kinds of messages and interventions. To better understand future trends in games for health, this article will examine past and present efforts to harness the advantageous properties of games to influence health behavior change. This includes the use of custom-developed health games, as well as commercial off-the-shelf (COTS) software and hardware that can be repurposed for health interventions. Past, present, and future are defined in this article by access to operating systems and hardware and subsequently access to health games and their content. These definitions reinforce the concept of technology as a mediating factor in enabling access to different kinds of health interventions. By understanding the technology, different types of health-related content can be developed and disseminated. In addition to technological considerations, games for health have also changed over time to reflect society’s changing relationship with games and gameplay. While we may not fully understand the individual components that make games so captivating, an examination of past and present games for health can also highlight the strengths and weaknesses of using games to promote health content. Past Work in the games for health domain has its roots in past efforts to use games and simulation for training and education. The earliest simulations relied on expensive hardware and were restricted to large organizations, such as universities, with the resources to support them. However, the advent of the modern personal computer and home game consoles dramatically lowered the technical barrier to game development, allowing researchers and educators to focus on creating health-related content.
One example of an early health game was ‘‘Packy & Marlon,’’ developed for the Super Nintendo Entertainment System (Nintendo, Kyoto, Japan) in 1995. The game was created and published for use in a diabetes research study run at the University of California, Santa Barbara by Brown et al.1 ‘‘Packy & Marlon’’ was constructed as a side-scroller videogame with a health theme and diabetes-related resource management tasks. Similarly, ‘‘Squire’s Quest’’ was a nutritional health game developed at the Baylor College of Medicine in the early 2000s.2 ‘‘Squire’s Quest’’ was a story-based game where players made health-related gameplay choices to drive the narrative. These two examples were typical of education-based games that relied on commonly available hardware and traditional game mechanics, such as narrative storylines and reward systems. The health interventions were delivered via thematic content. While effective as targeted interventions, these games exhibited limited appeal and effectiveness as widespread health interventions. The traditional game mechanics made these health games appealing, but they also brought those games into competition with entertainment games, where they relied on the health-themed content and educator support to drive interest. In addition to promoting healthy behavior, games have also been used for rehabilitation purposes. This use was supported by several research studies demonstrating positive therapeutic outcomes as a result of gameplay.3 This has included the ongoing use of games as exposure therapy to treat phobias and posttraumatic stress disorder,4 as well as pain management for individuals undergoing burn recovery and physical therapy.5 In contrast to their informational counterparts in the behavioral health space, rehabilitation games relied on the audiovisual stimuli and patient interaction to provide direct health benefit. Because the play activity was directly tied to the health benefit, these games were highly effective as targeted interventions. At the same time, these games tended not to include traditional reward structures associated with entertainment gameplay. Therefore, they
Department of Biomedical & Health Informatics, University of Washington, Seattle, Washington.
449
450 depended on external motivation from a physician or therapist to provide context for the play experience. The history of games for health has been one of adapting game technologies and play mechanics for use in promoting health content. While successful from a research and therapeutic perspective, early games for health demonstrated the challenges involved in reaching a widespread audience. The use of commonly available hardware paved the way for adoption, but these games also relied heavily on external motivation from clinicians and educators. This will get easier as schools and hospitals integrate games into their toolsets, but one goal of games for health is to encourage players to seek out health-related content on their own. Present Games are becoming a ubiquitous part of our social landscape. As a result, player expectations are more complex, and the expectations about game production values are higher. The development of a targeted health game now requires more resources to meet player expectations and hold player interest. As an alternative, some researchers are investigating the use of COTS games for health benefit. This includes research into existing games to examine their health impact, such as the effect of games on brain plasticity6 and the effect of games on stress and anxiety reduction.7 Commercial developers have looked at new ways to extend the traditional gameplay experience with peripheral hardware, such as dance pads and guitar controllers. In the past, these hardware-based experiences originated in game arcades, where developers used custom controllers and novel gameplay experiences to attract players. This included arcade ¨ ta, Japan) and ‘‘Dance games like ‘‘Prop Cycle’’ (Namco, O Dance Revolution’’ (DDR) (Konami, Tokyo, Japan), which made extensive use of physical motion. ‘‘Prop Cycle’s’’ stationary bicycle controller did not successfully transition to the home market. However, the DDR dance pad controller did, most likely because of its low cost and minimal storage requirements. Although dance games were not originally intended as a form of exercise, there is research supporting their potential use as health interventions.8 As a result, dance games have found their way into physical education classes in the United States and the United Kingdom. At the same time, commercial developers are starting to experiment with health-related themes, like food and its effect on player appearance. For example, a food-based game mechanic can be found in commercial games like ‘‘Grand Theft Auto: San Andreas’’ (Rockstar Games, New York, NY) and ‘‘Fable’’ (Big Blue Box; Microsoft, Redmond, WA). While effective at highlighting the importance of dietary choices, the in-game health consequences are primarily cosmetic, and the health effects are subject to game balance considerations. Consequently, existing research into this aspect of commercial games has primarily been humanities-driven analyses of game themes. However, from a technological perspective, these games demonstrate that health consequences can be presented in an interactive fashion and that health-related behaviors can be directly integrated into gameplay mechanics. After all, the ability of games to provide immediate feedback about player choices is part of the appeal of games. While there are still traditional efforts to create targeted games for health, there is increasing interest in studying the health
AU implications of COTS games. The commercial search for novel gameplay has led to the development and popularization of new controllers and types of play. This potentially enables new types of health interventions, both intentional and incidental. Future The future is very difficult to anticipate, particularly given the speed with which game technology is changing. As with all technologies, it is subject to consumer preferences and business considerations. Even within the commercial games market, developers are not always certain which products will gain traction in the marketplace. Consider that the game industry doesn’t know what will work and what will not. For example, various past attempts to promote peripheral hardware have met with mixed results. For example, the SEGA ¨ ta) Activator motion controller failed, whereas the Sony (O (Tokyo) EyeToy was commercially successful. Fortunately, there is growing commercial interest in creating games with health-related content. Titles like ‘‘Brain Age’’ (Nintendo) and ‘‘Yourself!Fitness’’ (Respondesign, Portland, OR) were created to take advantage of consumer demand for self-improvement, both mental and physical. These commercial health games focus on a wide selection of health themes based on consumer demand, like smoking cessation and personal fitness. This partially relieves researchers from the burden of development, but the trade-off is reduced control over the health content. While it is certainly possible to adapt commercial games for health purposes, commercial games are not necessarily well suited for research purposes.9 However, because commercial developers are always looking for ways to distinguish their products in the marketplace, collaboration with the research community might be one way to engage players who are actively seeking health content. Commercial interest in health content also extends to mobile gaming platforms, such as tablet computing devices or mobile phones. Portable devices are ideal for real-time tracking of physical activity, as with commercial products like Nike + (Nike, Beaverton, OR) and the FitBit (San Francisco, CA). Unlike pedometers and activity monitors of the past, mobile computing devices add additional analysis and social features that can be used to make the experience more engaging. Advances in sensors and mobile computing also lend themselves well to the sorts of activities that games are good at supporting. This includes real-time instructions and feedback about health behaviors, as well as support for social content. This is important for health behaviors that rely on the portability and timely feedback that mobile devices can provide, such as smoking cessation.10 These applications support growing interest in the field of mobile health, which seeks to take advantage of portable computing to promote health. Mobile gaming is also important because it enables access to new populations where traditional computers and console gaming systems are otherwise unavailable. For example, the Freedom HIV/AIDS mobile health game developed by ZMQ Software (Delhi, India) is being deploying in developing areas within India. Examples like this highlight the impact that technology can have on reaching new audiences, and not just on the types of health content being presented. Looking towards the future of gaming technology, games for health research will undoubtedly include targeted
GAMES FOR HEALTH: PAST, PRESENT, AND FUTURE? interventions using sensors and mobile technology. With growing commercial interest in health content, there may also be research collaboration opportunities that combine research with commercial games and services. Conclusions Existing games for health demonstrate that targeted health games are an effective but increasingly resource intensive way to promote healthy behavior. Unfortunately, recent research indicates that simply providing access to health content may not be enough to promote behavior change.11 How then can we ensure that future games for health are effective? Research into COTS games has shown that they may influence health behavior, for better or worse. This remains a viable research path, particularly as commercial game developers show increased interest in health-related game content and engage with the research community. So where might the games for health field be going? The possibilities are driven by research and therapy as they have been in the past, but mobile games and sensors suggest new gameplay interactions and health interventions such as location-based play and activity monitoring. This is great for interventions that rely on timely feedback, and where the act of play is providing the health benefit. This harks back to the use of games for therapy and rehabilitation, but with the game trappings that promote engagement, both immediate and long term. The use of mobile games in developing areas highlights the appeal and access that games can provide, and thanks to early research-driven work, games are gaining traction within the school and hospital settings. In summary, there’s a convergence among research, education, therapy, and commercial development. With the advent of new controllers and mobile hardware, health content is no longer restricted to information delivered on a desktop computer or game console. This supports potential health interventions that rely on time and location, such as allergy awareness or sleep patterns. If the past was about content, and the present is about activity, perhaps the future is about engaging with health anytime, anywhere. Author Disclosure Statement No competing financial interests exist.
451 References 1. Brown SJ, Lieberman DA, Germeny BA, et al. Educational video game for juvenile diabetes: Results of a controlled trial. Med Inform (Lond) 1997; 22:77–89. 2. Baranowski T, Baranowski J, Cullen KW, et al. Squire’s Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med 2003; 24:52–61. 3. Primack BA, Carroll MV, McNamara M, et al. Role of video games in improving health-related outcomes: A systematic review. Am J Prev Med 2012; 42:630–638. 4. Rizzo A, Requejo P, Winstein CJ, et al. Virtual reality applications for addressing the needs of those aging with disability. Stud Health Technol Inform 2011; 163:510–516. 5. Hoffman HG. Virtual-reality therapy. Sci Am 2004; 291(2): 58–65. 6. Achtman RL, Green CS, Bavelier D. Video games as a tool to train visual skills. Restor Neurol Neurosci 2008; 26:435–446. 7. Russoniello CV, O’Brien K, Parks JM. The effectiveness of casual video games in improving mood and decreasing stress. J Cyberther Rehabil 2009; 2:53–66. 8. Murphy EC-S. The effect of aerobic exercise on endothelial dysfunction in overweight children [PhD dissertation]. Morgantown, WV: West Virginia University; 2007: 141. 9. Nitz JC, Kuys S, Isles R, Fu S. Is the Wii Fit a new-generation tool for improving balance, health and well-being? A pilot study. Climacteric 2010; 13:487–491. 10. Raiff BR, Jarvis BP, Rapoza D. Prevalence of video game use, cigarette smoking, and acceptability of a video game-based smoking cessation intervention among online adults. Nicotine Tob Res 2012 Sep 11 [doi: 10.1093/ntr/nts079]. 11. Baranowski T, Abdelsamad D, Baranowski J, et al. Impact of an active video game on healthy children’s physical activity. Pediatrics 2012; 129:e636–e642.
Address correspondence to: Alan Au, PhD Department of Biomedical & Health Informatics University of Washington HSC I-264, Box 357240 1959 NE Pacific Street Seattle, WA 98195 E-mail: [email protected]
