GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 3, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2014.0079
Roundtable Discussion
Serious Games for Health: Features, Challenges, Next Steps Moderators: Fran C. Blumberg, PhD,1 and Lauren C. Burke, MS1 Participants: Celia Hodent, PhD,2 Michael A. Evans, PhD,3 H. Chad Lane, PhD,4 and Jesse Schell, MS 5,6
As articles in this journal have demonstrated over the past 3 years, serious game development continues to flourish as a vehicle for formal and informal health education. How best to characterize a ‘‘serious’’ game remains somewhat elusive in the literature. Many researchers and practitioners view serious games as capitalizing on computer technology and state-of-the-art video graphics as an enjoyable means by which to provide and promote instruction and training, or to facilitate attitude change among its players. We invited four distinguished researchers and practitioners to further discuss with us how they view the characteristics of serious games for health, how those characteristics differ from those for academic purposes, the challenges posed for serious game development among players of different ages, and next steps for the development and empirical examination of the effectiveness of serious games for players’ psychological and physical well-being.
Fran C. Blumberg and Lauren C. Burke: So, what do you see as the key characteristics, mechanics, or features that make up a successful serious game? What game have you come across that best exemplifies these features? H. Chad Lane: When we are talking about cognitive gain as the primary measure of success, the most successful serious games tend to be those that adhere to good instructional design principles (e.g., demonstration of skills, feedback on performance, appropriate scaffolding and fading). That is, to promote cognitive learning you need to go ‘‘old school’’: Be clear about what is being taught, show the student how to do it, give him or her practice with feedback, and promote reflection on that learning. Games that do that teach well. Although knowledge gains will always be important to investigate, I think we are finally beginning to see more evolved perspectives on learning and what we hope to achieve with games. For example, health behavior change researchers have understood for decades that telling people something (e.g., ‘‘Smoking is bad for you’’) is not enough. There are really complicated things going on inside people, and knowledge
simply can’t stand alone in helping them. We have to at least address emotions, attitudes, interest, and social and cultural influences. The reason games are relevant to this discussion is that the very best ones rely on these components—that is, they engage players emotionally, socially, and culturally, in ways that traditional learning environments perhaps cannot. Studies looking at the positive consequences of playing videogames have gained in prominence in the last 5 years (see Granic et al.1). If I had to pick a psychological construct as a substrate for the cognitive, motivational, social, and emotional benefits, I’d pick engagement. That is, good games seem to pull people in and keep them there, and game designers are quite good at this. They provide challenge and judiciously dole out the rewards in way to promote sustained interest. The best example of all of this that I often cite is ‘‘Re-Mission’’ (www.re-mission.net/), a shooting game set inside the human body that involves the identification and destruction of cancer cells. In a controlled study, kids with cancer who played were empowered and felt that it gave them a way to fight back. They loved playing and adhered to their medication more reliably.
1
Division of Psychological & Educational Services, Fordham University, New York. Epic Games, Cary, North Carolina. 3 North Carolina State University, Raleigh, North Carolina. 4 University of Southern California, Los Angeles, California. 5 Carnegie Mellon University, Pittsburgh, Pennsylvania. 6 CEO, Schell Games, Pittsburgh, Pennsylvania. 2
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Michael A. Evans: From my perspective, a few of the key features of successful serious games include (a) proper balance between player skills and game challenge, (b) provision of timely feedback that allows the player to reflect on and learn from success and failure, and (3) healthy doses of friendly competition that allow players to compare performances as well as to learn from more skilled peers. Overall, designers of recreational games understand these features well, and the best videogames deploy these in varying combinations and at opportune times. It would be to the serious game designers’ benefit to understand, explore, and deploy these features to the benefit of the players as well as the field itself. Although it’s a rather simple game, ‘‘Pearl Diver,’’ developed by smart folks at New Mexico State University, implements all of these features in a concise way (see http://mathsnacks.com/app.php#03). Another example, this one much more involved and having the benefit of experienced recreational games designers and psychologists, would be ‘‘DragonBox,’’ which proposes to teach young persons the principles of algebra (see www.dragonboxapp .com/). Jesse Schell: There is a great deal of variety in the world of serious, or transformational, games. Everything from games for preschoolers to games for corporate training falls under the heading ‘‘serious games,’’ so it can be very difficult to point to a universal set of features that make for success. That said, there are a few things that are definitely common among the games that really work:
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Play is educational by essence, and we play because we find pleasure in doing the activity itself, not for an extrinsic incentive only. Therefore, the key characteristic to successful serious games is to allow the player to experience ‘‘serious’’ material in concrete, meaningful, and playful situations. Serious gaming should allow players to learn, without being taught, through their gaming experience. One of the pioneers of serious gaming is Seymour Papert, mathematician and educator. Papert spotted the educational potential of computer games as early as the 1960s and saw in the computer a powerful machine that children could use to create and manipulate any content. Instead of having the computer program the child, Papert wanted the child to program the computer. Along with a group of colleagues and students at MIT, he created the Logo computer language that allowed children to control a virtual turtle in a playful approach. While engaged in a digital drawing activity, the children had to teach the turtle to do certain things, such as to draw a square shape. Geometry was then made accessible to the child, in a way that the ‘‘knowledge is acquired for a recognizable personal purpose’’ because the ‘‘child does something with it.’’2 The mechanics of a serious game must therefore enable a playful and meaningful learning-by-doing experience. And that experience should be intrinsically rewarding, by reminding us how pleasurable it is to discover new things. I would like to know more about the key features of successful serious games that Michael mentioned above. Michael A. Evans: I see these features as follows:
1. A focus on transformation. The games that really make a difference are clearly organized around the change they want to bring about in the player, and they have a strong theory about the best way to use a game to enact that change. The game ‘‘Battleship Number Line’’ by Derek Lomas, for example, works off the theory that repeated practice making estimates on a number line will have far-reaching effects on a child’s mathematical abilities. 2. Joy of doing at the heart. Games that ‘‘trick’’ the player into doing something he or she doesn’t enjoy don’t usually work, or don’t work very long. Games that find and enhance the fun in these activities have a much greater chance of success. Nike + has done a very good job of creating game-like scoring systems and leaderboards that make running for exercise feel like a competitive and cooperative game with friends. 3. Don’t do too much. It is very tempting to cram an entire curriculum into your game. This generally leads to something that is clearly ‘‘pretending to be fun.’’ Genuine fun comes from taking one small thing and building up an elaborate system of challenge and exploration around it. This lets the player focus on the fun and gives him or her time to really engage deeply and thoroughly with a single topic—and that is what games are best at: Deep engagement. Celia Hodent: Play is critical to the development and sustainability of our affective, cognitive, and social abilities. When children—and adults—play, they experiment with new and usually more complex situations than in real life.
Proper balance between player skills and game challenge. In effect, this is a recapitulation on Csikszentmihalyi’s principle of flow and a basic psychological principle that any serious game designer worth his or her salt would capitalize on at all times when developing a new game. From my own experience design, developing, and testing serious games, my sense is that the less-experienced designer, oftentimes an academic from fields not specifically trained in the art-and-craft of game design, tends to make games too hard for the player, resulting in quick abandonment. Provision of timely feedback. This, again, is a wellestablished principle going back to behavioral psychology that every good game designer should leverage wherever possible. Particularly in the realm of serious games, where oftentimes there is a goal for intentional learning of some sort, it is to the designers’ advantage to deploy a mechanic that allows the player to make moment-by-moment informed decisions in the game that not only lead to progress in the game, but ideally result in some type of more robust takeaway that in the area of education we might refer to as learning. In many ways, this feature couples well with the one mentioned above. Healthy doses of friendly competition. Given that I often work in classroom settings, it is oftentimes a challenge to introduce a serious game that has competition embedded, either directly through one-on-one or multiplayer interactions or through the use of leader boards that broadcast who has done best on a particular mission, level, or title. Nevertheless, I encourage
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serious game designers to stay true to this principle and propose creative ways for friendly competition of serious games, particularly where the friendly competition serves as an incentive to persist and do better next time. In the realm of serious games for health, this would seem to be a desired feature to execute. Although its popularity has waned in recent years, the novelty of ‘‘Wii Sports Resort’’ allowed for this feature to demonstrate its value. Fran C. Blumberg and Lauren C. Burke: What are the challenges for developing a game that successfully promotes a child’s or adult’s physical or psychological wellbeing? H. Chad Lane: I’m a fairly recent arrival in this area of research and probably not the best person to ask. My background is on artificial intelligence–based educational technologies, such as intelligent tutoring systems. So coming from that cognitive perspective, I’d say the greatest challenge we have lies in sensing noncognitive learner states accurately. For example, how can we infer with confidence that a learner is frustrated? Our nonverbal behaviors generally reflect our physical and psychological well-being, and so we need our technologies to understand those input channels. There have been significant advances in affective computing over the last decade using technologies such as eye and face tracking, physiological monitoring, posture detection, and more. For example, my colleagues at the University of Southern California have made significant strides in combining features such as gaze, speech, and posture to infer emotional states relevant to psychological well-being (see https://www.youtube.com/watch?v = ejczMs6b1Q4). I fully expect this kind of work to only improve and become more pervasive in the serious games space. Michael A. Evans: One of the greatest challenges, particularly for promoting the well-being of children, is to ensure that serious games are thoroughly grounded in theories of cognitive science and developmental psychology. Recreational game designers are well informed of what makes for compelling gameplay by exploiting what is known about feedback and reward systems extracted from principles of behavioral psychology. What proves to be more challenging is focusing equally on the changes in children that could affect their cognitive and emotional development. Doing so requires developing games that promote their physical and psychological well-being. Perhaps even more challenging is to develop a serious game that promotes physical well-being, as the human factors position for successful game design, as far as I can tell other than a minor attempt by Nintendo with the Wiimote (as noted above), is to focus on capitalizing on well-founded, welltrodden psychological principles such as those extolled in Raph Koster’s A Theory of Fun for Game Design.3 What I will say here, and pick up in a response to another question below, is that two trends that could counter this well-established posture are alternate reality games and mobile games. Jesse Schell: To embark on a transformational change as deep and important as improving one’s well-being, you have
to have a solid theory of how your game system is going to address that. Once you have that theory, you then need to execute on it in a way that draws players in, so that they take the experience seriously. Finally, you need to find a way to test whether the game is making a difference with the players. Celia Hodent: Designing a playful experience with any videogame is very difficult. The concept of ‘‘fun’’ itself is hard to grasp. It’s a common misconception that the medium itself—because it’s attractive, fashionable, and relatively new—is enough to bring a playful experience. However, even the most experienced developers can struggle to design a videogame that will be appealing to their audience, that will stand out among the competition, and that will sustain engagement over time. In fact, a whole new field dedicated to improving humancomputer interaction, the user experience field, is now embraced by an increasing number of studios to help the developers nail down the essence of ‘‘fun.’’ Psychologists, neuroscientists, and user-researchers are dissecting the player’s perspective, behavior, needs, and emotions to help the designers create a more compelling gaming experience. So the greatest challenge for developing a serious game is to stay fun while really promoting specific physical or psychological real-life benefits. Merely transposing paper school exercises into an interactive medium, wrapped in an attractive yet sometimes deceptive promise of making learning fun, cannot do the trick. Chances are that the material won’t be genuinely educational if it’s not meaningful, and/or that the ‘‘game’’ will not likely be fun, and therefore not engaging enough. Serious games have the same great challenge as all the other games: They have to be playful, engaging, and fun, while providing a real educational frame on the top of it. Fran C. Blumberg and Lauren C. Burke: Do you see the development of serious games to promote a player’s health knowledge as different from those that might be used to promote more school-based knowledge? H. Chad Lane: I certainly do see it is as different, but definitely not separate. In fact, I think there are many successful educational technologies out there that are probably not maximizing their impact because they do not yet incorporate things like health, mood, stress, and so on. For me, a key aspect of health education that makes it special is that it is almost always possible to convey content in ways that are highly relevant to the learner. Specifically, all learners have a body and make decisions that impact it on a daily basis. If we can link personal goals of learners (e.g., ‘‘I want to play soccer in high school’’) to their health education experiences, then refer back to them frequently, then we should see consistently better motivation to learn. I’m not saying this is easy, but it does set health education in a somewhat unique position. My thoughts are based somewhat on Rich Mayer’s jaw-dropping studies showing that the simple use of personal pronouns lead to improved learning over nonpersonalized content4 (e.g., ‘‘Blood flows through your heart’’ versus ‘‘Blood flows through the heart’’). In sum, if you want an educational game that helps promote an understanding of health or anything related to physiology, I think the first step
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is to figure out how to get the learner to frame everything in terms of his or her own body. Michael A. Evans: My only experience in this area came from work on an alpha version of a game-simulation designed to promote middle and high school students’ knowledge of infectious diseases. The game, ‘‘Disease Science Investigators’’ (see dsidc.vbi.vt.edu), still focused more on the school-based knowledge of infectious diseases, computational biology, and simulation science. My intuition is that serious games designed to promote a player’s health knowledge could be more challenging as a potential goal would be to intend to change behavior, whether it be proper dietary practices, exercise regimens, or responsible sexual behavior. Unlike school-based knowledge, which often is measured through rote testing, the criteria for success could be more easily established. For me then, a healthy distinction (pun intended) would be to view serious games to promote school-based knowledge as focusing on declarative knowledge, meaning that what was learned in the game could be expressed through symbols such as words and pictures. A serious game intended to promote health knowledge might have an additional burden to focus on procedural knowledge where the player might need to demonstrate through action the changes in behavior. This distinction does not have to be artificially emphasized, but one would hope that a serious game for health would want to strive for long-lasting effects to the benefit of the player. Jesse Schell: Health knowledge is something very personal; this is both an advantage and disadvantage. It is an advantage because the game topics have the potential to be very relevant to the player’s life. However, it is also a disadvantage, for ‘‘health knowledge’’ is often ineffective at getting people to change their habits. Celia Hodent: Not really. The process stays the same: The gameplay mechanics must be defined according to the knowledge that needs to be tackled, in a meaningful and engaging way. In both cases it can be difficult to offer a fun experience when the subject (health or school-based knowledge) can very quickly raise anxiety for some people. Finding a compelling way to motivate even the most reluctant audience can be really challenging in all cases. Fran C. Blumberg and Lauren C. Burke: Is it harder or easier to develop a serious game for adult or child players? H. Chad Lane: Designing in developmentally appropriate ways will always matter (e.g., reading ability), but I think that both adults and children pose challenges that make them interesting. For example, with children it is important to quickly spark interest (else they will find something better nearby), whereas adults may be more willing to invest some initial time if they know how the experience will help them. So can’t really answer the ‘‘harder or easier’’ question directly, but can say I have really enjoyed working on games for middle school learners because they seem to still enjoy fantasy (e.g., games that violate physics and our reality), but have the ability to track complex situations and problems. On this topic, let me add that while the ‘‘digital native’’
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concept amassed an enormous following over the last decade, I think the distinction will have a rapid decline in the approaching decades. This is simply a natural evolution as those in their early 40s right now grew up with games and computers as a part of their lives. Also, although the digital native arguments were quite convincing, I never found what I thought was rigorous evidence to back it up as a foundational construct. Michael A. Evans: I have little experience developing serious games for adults. Consequently, I would say that children do not pose a more challenging audience, but merely have different criteria to judge a serious game fun. One thing that I have noticed is that children will tolerate slight inconsistencies in an interface or game narrative if the core mechanics are engaging and enjoyable. On the other hand, children are becoming more and more sophisticated when it comes to recreational games, and therefore the polish of even shorter, very focused games must have a level of production that compares with other titles, say, on the Apple App Store. Jesse Schell: It is generally harder to develop games for adult players, because while children are learning machines who are used to exploring, adults are much more easily confused and less interested in exploring in a playful way. Celia Hodent: Again, both present great challenges, but developing a serious game for a child adds another layer of complexity as children don’t have the same cognitive capacities than adults, and adults are the ones developing these games. It’s already a challenge for an adult to develop a game for another adult who has a different perspective. For example, game developers creating a game to encourage physical activity do not necessary love to jog. Rather, they are intrinsically motivated to work out and don’t necessarily understand the struggle it represents to some people. Therefore, they have to take a step back to try to understand their audience’s perspective. When developing a game for children, serious or not, developers also have to understand how children think and process information, because their cognition is not the one of a miniature adult. Having a strong knowledge of child development is critical when creating games for children, even more so when these games want to be educational. Fran C. Blumberg and Lauren C. Burke: What is the future of serious games? Do you see changes in how they will be used? In what venues will they be adopted? For what new audiences will they be adapted? H. Chad Lane: The research community, foundations, and funding agencies seem pretty committed to pursuing games as a vehicle for improving education. I certainly appreciate this interest and think it is appropriate. One only needs to watch a 10-year old on an Xbox [Nintendo, Kyoto, Japan] or PlayStation [Sony, Tokyo, Japan] to witness how powerful deep emotional engagement in an experience can be. We need to understand that universal observation better, though. We need to continue to look at it from different perspectives (e.g., socially, emotionally, neuroscientifically) and talk about what it means for education and society. I am worried that as researchers we have locked ourselves into the idea of
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games too tightly, though. It really doesn’t matter for the commercial sector, obviously, but for academics interested in health, education, and behavioral outcomes, the baggage of ‘‘games’’ doesn’t seem to be going away (Congressional reports continue to come out identifying anything with ‘‘game’’ or ‘‘virtual’’ in the title as wasteful spending). I think our focus should always be on the learner experience and what constitutes a positive influence. Games or not, we need to design digital and virtual technologies that use the techniques that help us achieve our goals. We need to elevate the rigorous aspects of the studies we run and openly discuss implications and when things don’t fit our theories. None of this answers the questions above, so I will add that recent studies of technology adoption suggest there will be no declines in their use. As long as these trends hold, there will obviously be continued increases in games and social technologies. I can’t even imagine a different future. Michael A. Evans: In terms of serious games that focus on educational outcomes, whether used in classrooms or more for remedial purposes, I am cautiously optimistic that we are entering an era in which academic designers are becoming more sophisticated in the development of high-quality games (those that could compete on some levels to recreational games), and that recreational game developers are becoming more interested in game mechanics and features that serve only to keep players engaged with the core features of the game, thinking about how what is learned in a game could potentially be transferrable to contexts more academic in nature. In terms of audience, I do hope that more serious games are developed that serve young women and African American and Latino students. Also, I do hope that academics and industry developers can work together to expand the range of genres, for example, games built more on narrative structure such as ‘‘Phoenix Wright,’’ that could lend themselves to more academic pursuits. Jesse Schell: There are many futures for serious and transformational games. With the widespread use of tablets, they will find their place in the classrooms and homework for preschool, K–12, college, and corporate training. As the design of education continues to improve, games will be one tool of many that help make for optimal educational experiences and outcomes. Celia Hodent: Hopefully, we are not heading towards extrinsically motivating games only. Serious games that only use external rewards (i.e., badges, points) to motivate the audience to keep playing (learning) will fail to promote learning as intrinsically fun and motivating. Ideally, we’ll reach the full potential of videogames as a medium to promote meaningful and playful learning, rather than applying a ‘‘gamified’’ rigid template to any ‘‘serious’’ subject. Fran C. Blumberg and Lauren C. Burke: Are you working on any game now that has ramifications for promoting physical or psychological health? Can you tell us a little about it? How is their design different from your games for increasing knowledge? H. Chad Lane: In fact, I am! As part of a highly interdisciplinary team and funded by NIH’s SEPA [National Institutes
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of Health’s Science Education Partnership Award] program, I am helping to build ‘‘Virtual Sprouts,’’ a tablet-based game that teaches the science of gardening and seeks to promote dietary health behavior change. Our focus is on 4th–6th graders from underserved parts of Southern California (the focus of our studies anyway—we would love kids worldwide to play). It builds on the existing program, LA Sprouts, which provides educational content to existing urban gardens in Los Angeles. The aims of the application are to (1) provide practice in applying the basics of gardening, such as watering plants and providing sunlight, and (2) encourage creativity and interest in preparing healthy meals at home, such as salsa, frescas, and smoothies. We are sometimes asked how a videogame (which seems at odds with promoting physical activity) is appropriate for health behavior change, and our response is that we want to vie for time that kids already spend playing games. If some of this time can be spent in ways that lead to positive choices later (e.g., actually gardening outside), then there is value. If the game can encourage kids to ask their parents to help in the kitchen or even prepare food for the rest of their family, then we think this is all very much appropriate. Our game positions kids in a magical garden where they can grow fruits and vegetables with a purpose—they take their work into a virtual kitchen and prepare meals for a panel of virtual agent judges. Throughout the game, a ladybug named Dottie is there to help. If they succeed, they are rewarded with new powers and more opportunities in the game. The role of fantasy and feedback are both essential in the game, and both seek to promote cognitive and behavioral outcomes. We are evaluating the game in six LA schools and hope to have preliminary findings available soon. Michael A. Evans: As I mentioned earlier, we have just completed a technical demonstration of the game called ‘‘Disease Science Investigators’’ (see http://dsidc.vbi.vt.edu/) for the National Institutes of Health, which was tangentially interested in promoting physical and psychological health. I will note that the Centers for Disease Control and Prevention has just produced a game along very similar lines, called ‘‘Solve the Outbreak,’’ that could be used as a useful reference for games within this genre. Jesse Schell: Schell Games has recently developed two different games that are designed to promote both physical and psychological health. ‘‘PlayForward: Elm City Stories’’ was a project we did with Yale University to reduce HIV [human immunodeficiency virus infection] in young teens by helping them to prepare for the realities of an inner-city teenage life. We also created ‘‘Tunnel Tail’’ with the BEST Foundation, a game presented as pure entertainment that through its storyline and gameplay helps children learn about patterns of addiction and strategies for saying no to unhealthy pressures. While both these games have a knowledge component, their primary purpose is to change habits through a number of different means involving practice, safe experimentation, and feedback loops. Fran C. Blumberg and Lauren C. Burke: Given the discussion thus far, what type of research do you think is needed to advance our understanding of how to develop effective games for health?
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H. Chad Lane: I think we need more integrative research to push things forward. Our answers covered some serious ground in this exercise, and I did not sense that any fundamental disagreements were present. This suggests that more work is needed in making sense of how to use games that brings these different views together. For example, I was the only person to bring up affect detection technologies, while several others mentioned ‘‘fun’’ and experience—the technology should be used to push theory, and experimental psychology needs to sit in the middle as the judge. We need rigorous science coupled with the creativity of the commercial sector to work towards a better understanding of what it is we are trying to do, and what we really want to do to improve health, performance in school, and general well-being. Michael A. Evans: Earlier I mentioned that I thought that two potentially positive trends in game design that could benefit the development and influence of games for health are alternate reality games and mobile games. In essence, an alternate reality game comes close to combining interactive fiction with a scavenger hunt; a recent example coming out of MIT and the Smithsonian is ‘‘Vanished’’ (see http:// vanished.mit.edu), where players work with scientists to solve puzzles and unlock mysteries related to holdings at the Smithsonian Institution in Washington, DC. The encouraging features of the game include requiring players to traverse physical space in the process of engaging with the game. Unlike traditional recreational game design requirements, the game could not be won by merely remaining stationary in front of a screen. I use recent advancements in the Apple iOS 8 through ‘‘HealthKit’’ as an example. Serious games could leverage this upcoming application programming interface to introduce features that monitor weight, exercise levels, blood pressure, and medication schedules. The overall challenge from a research perspective is that conventional psychological assessments would, potentially, need to be combined with those derived from fields including anthropology (e.g., requiring more extensive, nonclinical protocols as players traverse spaces over days or weeks with alternate reality games) and medicine (e.g., adopting rather large-scale randomized controlled trials that leverage data acquired by mobile devices). Although there are intense challenges at hand, hopefully these trends in game design and opportunities for more sophisticated research methods and protocols will inspire researchers and designers in the area of games for health. Jesse Schell: I think the most important research about games for health concerns games that are meant to change habits in a long-term, persistent way. It is not unusual for a novel health game to capture a player’s interest for a number of weeks, which sounds like a success, but soon he or she drifts away from it, and whether it made any lasting impact is uncertain. Understanding the techniques that go beyond engagement to create lasting transformation will make a tremendous difference in the creation of games for health. Celia Hodent: It would be interesting to examine how to improve the efficiency of games for health and to measure the experience these games offer. It’s still a challenge to assess
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the level of emotion and engagement that any given game can provide, but worthwhile to pursue for games that aspire to offer health or educational benefits. Fran C. Blumberg and Lauren C. Burke: We thank our discussants for sharing their experience and views. We invite our readers to also consider next steps for serious games for health development and research and look forward to seeing the fruits of those efforts in G4HJ! References
1. Granic I, Lobel A, Engels RCME. The benefits of playing video games. Am Psychol 2014; 69:66–78. 2. Papert S. Mindstorms: Children, Computers, and Powerful Ideas. New York, NY: Basic Books; 1980: 21. 3. Koster R. A Theory of Fun for Game Design, 2nd ed. Sebastapol, CA: O’Reilly Media; 2013. 4. Mayer RE, Fennell S, Farmer L, Campbell J. A personalization effect in multimedia learning: Students learn better when words are in conversational style rather than formal style. J Educ Psychol 2014; 96(2):389.
Brief Biosketches Celia Hodent, PhD, holds a PhD in cognitive psychology, with a specialization in the development of intelligence in children and adults. Early in her career, Celia stepped aside from academic research to work with an educational toy manufacturer, VTech. Celia joined Ubisoft Paris in 2008 to help the editorial team translate neuroscience knowledge into game design features. She later worked for Ubisoft Montreal and LucasArts. She joined Epic Games in July 2013 to help guide the studio toward improved user experience practices. Celia’s main focus is to use psychology and neuroscience knowledge concretely to solve design problems and make sure the player experience is always enjoyable and emotional. She can be reached at Celia.Hodent@ epicgames.com Michael A. Evans, PhD, is an Associate Professor of Digital Learning & Teaching and a Friday Institute for Educational Innovation Research Fellow at North Carolina State University. His research, teaching, and service focus on the development and research of engaging integrative STEM [science, technology, engineering, and mathematics] curricula and programs for underserved, underperforming middle school youth. In support of this work, he is Principal Investigator on two current National Science Foundation–sponsored projects.
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The GAMES Project (DRL 1118571) develops learning games for tablets and other mobile devices, focusing on prealgebra readiness, proficiency, and engagement states. Studio STEM (DRL 1029756) is an informal engineering designbased science-learning program that leverages social media to enhance inquiry. Dr. Evans is a co-founder of the HumanCentered Design Interdisciplinary Graduate Education Program, a Fellow at the Institute of Creativity, Arts, and Technology, and Affiliate Faculty in the Center for HumanComputer Interaction. He received his PhD in Instructional Systems Technology from Indiana University and BA/MA in Psychology/Cognitive Psychology from the University of West Florida. He can be reached at [email protected] H. Chad Lane, PhD, is a Research Scientist and Director for Learning Sciences Research at the University of Southern California’s Institute for Creative Technologies (www.ict.usc.edu). He also holds an adjunct faculty appointment in the University of Southern California’s Rossier School of Education. His research involves application of artificial intelligence techniques to educational problems, with a focus on entertainment technologies and intelligent tutoring systems. Chad received his PhD in Computer Science in 2004 from the University of Pittsburgh. More information about Chad is available at http://people.ict.usc.edu/*lane
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Jesse Schell, MS, is the CEO of Schell Games, a leader in creating transformational games. Since starting his company in 2002, he has grown it into the largest and most successful game development company in Pennsylvania. Under his leadership, Schell Games has produced an amazing array of innovative, transformational, and award-winning entertainment experiences for some of the world’s most respected brands, such as Disney, SeaWorld Parks and Entertainment, Amplify, Yale University, Lionel LLC, and The Fred Rogers Company. Jesse currently serves as Distinguished Professor of Entertainment Technology at Carnegie Mellon University’s Entertainment Technology Center, where he teaches game design. He authored the critically acclaimed book, The Art of Game Design: A Book of Lenses, which captured Game Developer magazine’s coveted ‘‘Front Line Award’’ for 2008. Prior to starting Schell Games, Jesse was the Creative Director of the Disney Imagineering Virtual Reality Studio, where he worked and played for 7 years as designer, programmer, and manager on numerous projects for Disney theme parks and DisneyQuest. More information about Jesse is available at www .jesseschell.com and via Twitter: @jesseschell
Roundtable Discussion
Serious Games for Health: Features, Challenges, Next Steps Moderators: Fran C. Blumberg, PhD,1 and Lauren C. Burke, MS1 Participants: Celia Hodent, PhD,2 Michael A. Evans, PhD,3 H. Chad Lane, PhD,4 and Jesse Schell, MS 5,6
As articles in this journal have demonstrated over the past 3 years, serious game development continues to flourish as a vehicle for formal and informal health education. How best to characterize a ‘‘serious’’ game remains somewhat elusive in the literature. Many researchers and practitioners view serious games as capitalizing on computer technology and state-of-the-art video graphics as an enjoyable means by which to provide and promote instruction and training, or to facilitate attitude change among its players. We invited four distinguished researchers and practitioners to further discuss with us how they view the characteristics of serious games for health, how those characteristics differ from those for academic purposes, the challenges posed for serious game development among players of different ages, and next steps for the development and empirical examination of the effectiveness of serious games for players’ psychological and physical well-being.
Fran C. Blumberg and Lauren C. Burke: So, what do you see as the key characteristics, mechanics, or features that make up a successful serious game? What game have you come across that best exemplifies these features? H. Chad Lane: When we are talking about cognitive gain as the primary measure of success, the most successful serious games tend to be those that adhere to good instructional design principles (e.g., demonstration of skills, feedback on performance, appropriate scaffolding and fading). That is, to promote cognitive learning you need to go ‘‘old school’’: Be clear about what is being taught, show the student how to do it, give him or her practice with feedback, and promote reflection on that learning. Games that do that teach well. Although knowledge gains will always be important to investigate, I think we are finally beginning to see more evolved perspectives on learning and what we hope to achieve with games. For example, health behavior change researchers have understood for decades that telling people something (e.g., ‘‘Smoking is bad for you’’) is not enough. There are really complicated things going on inside people, and knowledge
simply can’t stand alone in helping them. We have to at least address emotions, attitudes, interest, and social and cultural influences. The reason games are relevant to this discussion is that the very best ones rely on these components—that is, they engage players emotionally, socially, and culturally, in ways that traditional learning environments perhaps cannot. Studies looking at the positive consequences of playing videogames have gained in prominence in the last 5 years (see Granic et al.1). If I had to pick a psychological construct as a substrate for the cognitive, motivational, social, and emotional benefits, I’d pick engagement. That is, good games seem to pull people in and keep them there, and game designers are quite good at this. They provide challenge and judiciously dole out the rewards in way to promote sustained interest. The best example of all of this that I often cite is ‘‘Re-Mission’’ (www.re-mission.net/), a shooting game set inside the human body that involves the identification and destruction of cancer cells. In a controlled study, kids with cancer who played were empowered and felt that it gave them a way to fight back. They loved playing and adhered to their medication more reliably.
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Division of Psychological & Educational Services, Fordham University, New York. Epic Games, Cary, North Carolina. 3 North Carolina State University, Raleigh, North Carolina. 4 University of Southern California, Los Angeles, California. 5 Carnegie Mellon University, Pittsburgh, Pennsylvania. 6 CEO, Schell Games, Pittsburgh, Pennsylvania. 2
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Michael A. Evans: From my perspective, a few of the key features of successful serious games include (a) proper balance between player skills and game challenge, (b) provision of timely feedback that allows the player to reflect on and learn from success and failure, and (3) healthy doses of friendly competition that allow players to compare performances as well as to learn from more skilled peers. Overall, designers of recreational games understand these features well, and the best videogames deploy these in varying combinations and at opportune times. It would be to the serious game designers’ benefit to understand, explore, and deploy these features to the benefit of the players as well as the field itself. Although it’s a rather simple game, ‘‘Pearl Diver,’’ developed by smart folks at New Mexico State University, implements all of these features in a concise way (see http://mathsnacks.com/app.php#03). Another example, this one much more involved and having the benefit of experienced recreational games designers and psychologists, would be ‘‘DragonBox,’’ which proposes to teach young persons the principles of algebra (see www.dragonboxapp .com/). Jesse Schell: There is a great deal of variety in the world of serious, or transformational, games. Everything from games for preschoolers to games for corporate training falls under the heading ‘‘serious games,’’ so it can be very difficult to point to a universal set of features that make for success. That said, there are a few things that are definitely common among the games that really work:
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Play is educational by essence, and we play because we find pleasure in doing the activity itself, not for an extrinsic incentive only. Therefore, the key characteristic to successful serious games is to allow the player to experience ‘‘serious’’ material in concrete, meaningful, and playful situations. Serious gaming should allow players to learn, without being taught, through their gaming experience. One of the pioneers of serious gaming is Seymour Papert, mathematician and educator. Papert spotted the educational potential of computer games as early as the 1960s and saw in the computer a powerful machine that children could use to create and manipulate any content. Instead of having the computer program the child, Papert wanted the child to program the computer. Along with a group of colleagues and students at MIT, he created the Logo computer language that allowed children to control a virtual turtle in a playful approach. While engaged in a digital drawing activity, the children had to teach the turtle to do certain things, such as to draw a square shape. Geometry was then made accessible to the child, in a way that the ‘‘knowledge is acquired for a recognizable personal purpose’’ because the ‘‘child does something with it.’’2 The mechanics of a serious game must therefore enable a playful and meaningful learning-by-doing experience. And that experience should be intrinsically rewarding, by reminding us how pleasurable it is to discover new things. I would like to know more about the key features of successful serious games that Michael mentioned above. Michael A. Evans: I see these features as follows:
1. A focus on transformation. The games that really make a difference are clearly organized around the change they want to bring about in the player, and they have a strong theory about the best way to use a game to enact that change. The game ‘‘Battleship Number Line’’ by Derek Lomas, for example, works off the theory that repeated practice making estimates on a number line will have far-reaching effects on a child’s mathematical abilities. 2. Joy of doing at the heart. Games that ‘‘trick’’ the player into doing something he or she doesn’t enjoy don’t usually work, or don’t work very long. Games that find and enhance the fun in these activities have a much greater chance of success. Nike + has done a very good job of creating game-like scoring systems and leaderboards that make running for exercise feel like a competitive and cooperative game with friends. 3. Don’t do too much. It is very tempting to cram an entire curriculum into your game. This generally leads to something that is clearly ‘‘pretending to be fun.’’ Genuine fun comes from taking one small thing and building up an elaborate system of challenge and exploration around it. This lets the player focus on the fun and gives him or her time to really engage deeply and thoroughly with a single topic—and that is what games are best at: Deep engagement. Celia Hodent: Play is critical to the development and sustainability of our affective, cognitive, and social abilities. When children—and adults—play, they experiment with new and usually more complex situations than in real life.
Proper balance between player skills and game challenge. In effect, this is a recapitulation on Csikszentmihalyi’s principle of flow and a basic psychological principle that any serious game designer worth his or her salt would capitalize on at all times when developing a new game. From my own experience design, developing, and testing serious games, my sense is that the less-experienced designer, oftentimes an academic from fields not specifically trained in the art-and-craft of game design, tends to make games too hard for the player, resulting in quick abandonment. Provision of timely feedback. This, again, is a wellestablished principle going back to behavioral psychology that every good game designer should leverage wherever possible. Particularly in the realm of serious games, where oftentimes there is a goal for intentional learning of some sort, it is to the designers’ advantage to deploy a mechanic that allows the player to make moment-by-moment informed decisions in the game that not only lead to progress in the game, but ideally result in some type of more robust takeaway that in the area of education we might refer to as learning. In many ways, this feature couples well with the one mentioned above. Healthy doses of friendly competition. Given that I often work in classroom settings, it is oftentimes a challenge to introduce a serious game that has competition embedded, either directly through one-on-one or multiplayer interactions or through the use of leader boards that broadcast who has done best on a particular mission, level, or title. Nevertheless, I encourage
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serious game designers to stay true to this principle and propose creative ways for friendly competition of serious games, particularly where the friendly competition serves as an incentive to persist and do better next time. In the realm of serious games for health, this would seem to be a desired feature to execute. Although its popularity has waned in recent years, the novelty of ‘‘Wii Sports Resort’’ allowed for this feature to demonstrate its value. Fran C. Blumberg and Lauren C. Burke: What are the challenges for developing a game that successfully promotes a child’s or adult’s physical or psychological wellbeing? H. Chad Lane: I’m a fairly recent arrival in this area of research and probably not the best person to ask. My background is on artificial intelligence–based educational technologies, such as intelligent tutoring systems. So coming from that cognitive perspective, I’d say the greatest challenge we have lies in sensing noncognitive learner states accurately. For example, how can we infer with confidence that a learner is frustrated? Our nonverbal behaviors generally reflect our physical and psychological well-being, and so we need our technologies to understand those input channels. There have been significant advances in affective computing over the last decade using technologies such as eye and face tracking, physiological monitoring, posture detection, and more. For example, my colleagues at the University of Southern California have made significant strides in combining features such as gaze, speech, and posture to infer emotional states relevant to psychological well-being (see https://www.youtube.com/watch?v = ejczMs6b1Q4). I fully expect this kind of work to only improve and become more pervasive in the serious games space. Michael A. Evans: One of the greatest challenges, particularly for promoting the well-being of children, is to ensure that serious games are thoroughly grounded in theories of cognitive science and developmental psychology. Recreational game designers are well informed of what makes for compelling gameplay by exploiting what is known about feedback and reward systems extracted from principles of behavioral psychology. What proves to be more challenging is focusing equally on the changes in children that could affect their cognitive and emotional development. Doing so requires developing games that promote their physical and psychological well-being. Perhaps even more challenging is to develop a serious game that promotes physical well-being, as the human factors position for successful game design, as far as I can tell other than a minor attempt by Nintendo with the Wiimote (as noted above), is to focus on capitalizing on well-founded, welltrodden psychological principles such as those extolled in Raph Koster’s A Theory of Fun for Game Design.3 What I will say here, and pick up in a response to another question below, is that two trends that could counter this well-established posture are alternate reality games and mobile games. Jesse Schell: To embark on a transformational change as deep and important as improving one’s well-being, you have
to have a solid theory of how your game system is going to address that. Once you have that theory, you then need to execute on it in a way that draws players in, so that they take the experience seriously. Finally, you need to find a way to test whether the game is making a difference with the players. Celia Hodent: Designing a playful experience with any videogame is very difficult. The concept of ‘‘fun’’ itself is hard to grasp. It’s a common misconception that the medium itself—because it’s attractive, fashionable, and relatively new—is enough to bring a playful experience. However, even the most experienced developers can struggle to design a videogame that will be appealing to their audience, that will stand out among the competition, and that will sustain engagement over time. In fact, a whole new field dedicated to improving humancomputer interaction, the user experience field, is now embraced by an increasing number of studios to help the developers nail down the essence of ‘‘fun.’’ Psychologists, neuroscientists, and user-researchers are dissecting the player’s perspective, behavior, needs, and emotions to help the designers create a more compelling gaming experience. So the greatest challenge for developing a serious game is to stay fun while really promoting specific physical or psychological real-life benefits. Merely transposing paper school exercises into an interactive medium, wrapped in an attractive yet sometimes deceptive promise of making learning fun, cannot do the trick. Chances are that the material won’t be genuinely educational if it’s not meaningful, and/or that the ‘‘game’’ will not likely be fun, and therefore not engaging enough. Serious games have the same great challenge as all the other games: They have to be playful, engaging, and fun, while providing a real educational frame on the top of it. Fran C. Blumberg and Lauren C. Burke: Do you see the development of serious games to promote a player’s health knowledge as different from those that might be used to promote more school-based knowledge? H. Chad Lane: I certainly do see it is as different, but definitely not separate. In fact, I think there are many successful educational technologies out there that are probably not maximizing their impact because they do not yet incorporate things like health, mood, stress, and so on. For me, a key aspect of health education that makes it special is that it is almost always possible to convey content in ways that are highly relevant to the learner. Specifically, all learners have a body and make decisions that impact it on a daily basis. If we can link personal goals of learners (e.g., ‘‘I want to play soccer in high school’’) to their health education experiences, then refer back to them frequently, then we should see consistently better motivation to learn. I’m not saying this is easy, but it does set health education in a somewhat unique position. My thoughts are based somewhat on Rich Mayer’s jaw-dropping studies showing that the simple use of personal pronouns lead to improved learning over nonpersonalized content4 (e.g., ‘‘Blood flows through your heart’’ versus ‘‘Blood flows through the heart’’). In sum, if you want an educational game that helps promote an understanding of health or anything related to physiology, I think the first step
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is to figure out how to get the learner to frame everything in terms of his or her own body. Michael A. Evans: My only experience in this area came from work on an alpha version of a game-simulation designed to promote middle and high school students’ knowledge of infectious diseases. The game, ‘‘Disease Science Investigators’’ (see dsidc.vbi.vt.edu), still focused more on the school-based knowledge of infectious diseases, computational biology, and simulation science. My intuition is that serious games designed to promote a player’s health knowledge could be more challenging as a potential goal would be to intend to change behavior, whether it be proper dietary practices, exercise regimens, or responsible sexual behavior. Unlike school-based knowledge, which often is measured through rote testing, the criteria for success could be more easily established. For me then, a healthy distinction (pun intended) would be to view serious games to promote school-based knowledge as focusing on declarative knowledge, meaning that what was learned in the game could be expressed through symbols such as words and pictures. A serious game intended to promote health knowledge might have an additional burden to focus on procedural knowledge where the player might need to demonstrate through action the changes in behavior. This distinction does not have to be artificially emphasized, but one would hope that a serious game for health would want to strive for long-lasting effects to the benefit of the player. Jesse Schell: Health knowledge is something very personal; this is both an advantage and disadvantage. It is an advantage because the game topics have the potential to be very relevant to the player’s life. However, it is also a disadvantage, for ‘‘health knowledge’’ is often ineffective at getting people to change their habits. Celia Hodent: Not really. The process stays the same: The gameplay mechanics must be defined according to the knowledge that needs to be tackled, in a meaningful and engaging way. In both cases it can be difficult to offer a fun experience when the subject (health or school-based knowledge) can very quickly raise anxiety for some people. Finding a compelling way to motivate even the most reluctant audience can be really challenging in all cases. Fran C. Blumberg and Lauren C. Burke: Is it harder or easier to develop a serious game for adult or child players? H. Chad Lane: Designing in developmentally appropriate ways will always matter (e.g., reading ability), but I think that both adults and children pose challenges that make them interesting. For example, with children it is important to quickly spark interest (else they will find something better nearby), whereas adults may be more willing to invest some initial time if they know how the experience will help them. So can’t really answer the ‘‘harder or easier’’ question directly, but can say I have really enjoyed working on games for middle school learners because they seem to still enjoy fantasy (e.g., games that violate physics and our reality), but have the ability to track complex situations and problems. On this topic, let me add that while the ‘‘digital native’’
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concept amassed an enormous following over the last decade, I think the distinction will have a rapid decline in the approaching decades. This is simply a natural evolution as those in their early 40s right now grew up with games and computers as a part of their lives. Also, although the digital native arguments were quite convincing, I never found what I thought was rigorous evidence to back it up as a foundational construct. Michael A. Evans: I have little experience developing serious games for adults. Consequently, I would say that children do not pose a more challenging audience, but merely have different criteria to judge a serious game fun. One thing that I have noticed is that children will tolerate slight inconsistencies in an interface or game narrative if the core mechanics are engaging and enjoyable. On the other hand, children are becoming more and more sophisticated when it comes to recreational games, and therefore the polish of even shorter, very focused games must have a level of production that compares with other titles, say, on the Apple App Store. Jesse Schell: It is generally harder to develop games for adult players, because while children are learning machines who are used to exploring, adults are much more easily confused and less interested in exploring in a playful way. Celia Hodent: Again, both present great challenges, but developing a serious game for a child adds another layer of complexity as children don’t have the same cognitive capacities than adults, and adults are the ones developing these games. It’s already a challenge for an adult to develop a game for another adult who has a different perspective. For example, game developers creating a game to encourage physical activity do not necessary love to jog. Rather, they are intrinsically motivated to work out and don’t necessarily understand the struggle it represents to some people. Therefore, they have to take a step back to try to understand their audience’s perspective. When developing a game for children, serious or not, developers also have to understand how children think and process information, because their cognition is not the one of a miniature adult. Having a strong knowledge of child development is critical when creating games for children, even more so when these games want to be educational. Fran C. Blumberg and Lauren C. Burke: What is the future of serious games? Do you see changes in how they will be used? In what venues will they be adopted? For what new audiences will they be adapted? H. Chad Lane: The research community, foundations, and funding agencies seem pretty committed to pursuing games as a vehicle for improving education. I certainly appreciate this interest and think it is appropriate. One only needs to watch a 10-year old on an Xbox [Nintendo, Kyoto, Japan] or PlayStation [Sony, Tokyo, Japan] to witness how powerful deep emotional engagement in an experience can be. We need to understand that universal observation better, though. We need to continue to look at it from different perspectives (e.g., socially, emotionally, neuroscientifically) and talk about what it means for education and society. I am worried that as researchers we have locked ourselves into the idea of
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games too tightly, though. It really doesn’t matter for the commercial sector, obviously, but for academics interested in health, education, and behavioral outcomes, the baggage of ‘‘games’’ doesn’t seem to be going away (Congressional reports continue to come out identifying anything with ‘‘game’’ or ‘‘virtual’’ in the title as wasteful spending). I think our focus should always be on the learner experience and what constitutes a positive influence. Games or not, we need to design digital and virtual technologies that use the techniques that help us achieve our goals. We need to elevate the rigorous aspects of the studies we run and openly discuss implications and when things don’t fit our theories. None of this answers the questions above, so I will add that recent studies of technology adoption suggest there will be no declines in their use. As long as these trends hold, there will obviously be continued increases in games and social technologies. I can’t even imagine a different future. Michael A. Evans: In terms of serious games that focus on educational outcomes, whether used in classrooms or more for remedial purposes, I am cautiously optimistic that we are entering an era in which academic designers are becoming more sophisticated in the development of high-quality games (those that could compete on some levels to recreational games), and that recreational game developers are becoming more interested in game mechanics and features that serve only to keep players engaged with the core features of the game, thinking about how what is learned in a game could potentially be transferrable to contexts more academic in nature. In terms of audience, I do hope that more serious games are developed that serve young women and African American and Latino students. Also, I do hope that academics and industry developers can work together to expand the range of genres, for example, games built more on narrative structure such as ‘‘Phoenix Wright,’’ that could lend themselves to more academic pursuits. Jesse Schell: There are many futures for serious and transformational games. With the widespread use of tablets, they will find their place in the classrooms and homework for preschool, K–12, college, and corporate training. As the design of education continues to improve, games will be one tool of many that help make for optimal educational experiences and outcomes. Celia Hodent: Hopefully, we are not heading towards extrinsically motivating games only. Serious games that only use external rewards (i.e., badges, points) to motivate the audience to keep playing (learning) will fail to promote learning as intrinsically fun and motivating. Ideally, we’ll reach the full potential of videogames as a medium to promote meaningful and playful learning, rather than applying a ‘‘gamified’’ rigid template to any ‘‘serious’’ subject. Fran C. Blumberg and Lauren C. Burke: Are you working on any game now that has ramifications for promoting physical or psychological health? Can you tell us a little about it? How is their design different from your games for increasing knowledge? H. Chad Lane: In fact, I am! As part of a highly interdisciplinary team and funded by NIH’s SEPA [National Institutes
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of Health’s Science Education Partnership Award] program, I am helping to build ‘‘Virtual Sprouts,’’ a tablet-based game that teaches the science of gardening and seeks to promote dietary health behavior change. Our focus is on 4th–6th graders from underserved parts of Southern California (the focus of our studies anyway—we would love kids worldwide to play). It builds on the existing program, LA Sprouts, which provides educational content to existing urban gardens in Los Angeles. The aims of the application are to (1) provide practice in applying the basics of gardening, such as watering plants and providing sunlight, and (2) encourage creativity and interest in preparing healthy meals at home, such as salsa, frescas, and smoothies. We are sometimes asked how a videogame (which seems at odds with promoting physical activity) is appropriate for health behavior change, and our response is that we want to vie for time that kids already spend playing games. If some of this time can be spent in ways that lead to positive choices later (e.g., actually gardening outside), then there is value. If the game can encourage kids to ask their parents to help in the kitchen or even prepare food for the rest of their family, then we think this is all very much appropriate. Our game positions kids in a magical garden where they can grow fruits and vegetables with a purpose—they take their work into a virtual kitchen and prepare meals for a panel of virtual agent judges. Throughout the game, a ladybug named Dottie is there to help. If they succeed, they are rewarded with new powers and more opportunities in the game. The role of fantasy and feedback are both essential in the game, and both seek to promote cognitive and behavioral outcomes. We are evaluating the game in six LA schools and hope to have preliminary findings available soon. Michael A. Evans: As I mentioned earlier, we have just completed a technical demonstration of the game called ‘‘Disease Science Investigators’’ (see http://dsidc.vbi.vt.edu/) for the National Institutes of Health, which was tangentially interested in promoting physical and psychological health. I will note that the Centers for Disease Control and Prevention has just produced a game along very similar lines, called ‘‘Solve the Outbreak,’’ that could be used as a useful reference for games within this genre. Jesse Schell: Schell Games has recently developed two different games that are designed to promote both physical and psychological health. ‘‘PlayForward: Elm City Stories’’ was a project we did with Yale University to reduce HIV [human immunodeficiency virus infection] in young teens by helping them to prepare for the realities of an inner-city teenage life. We also created ‘‘Tunnel Tail’’ with the BEST Foundation, a game presented as pure entertainment that through its storyline and gameplay helps children learn about patterns of addiction and strategies for saying no to unhealthy pressures. While both these games have a knowledge component, their primary purpose is to change habits through a number of different means involving practice, safe experimentation, and feedback loops. Fran C. Blumberg and Lauren C. Burke: Given the discussion thus far, what type of research do you think is needed to advance our understanding of how to develop effective games for health?
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H. Chad Lane: I think we need more integrative research to push things forward. Our answers covered some serious ground in this exercise, and I did not sense that any fundamental disagreements were present. This suggests that more work is needed in making sense of how to use games that brings these different views together. For example, I was the only person to bring up affect detection technologies, while several others mentioned ‘‘fun’’ and experience—the technology should be used to push theory, and experimental psychology needs to sit in the middle as the judge. We need rigorous science coupled with the creativity of the commercial sector to work towards a better understanding of what it is we are trying to do, and what we really want to do to improve health, performance in school, and general well-being. Michael A. Evans: Earlier I mentioned that I thought that two potentially positive trends in game design that could benefit the development and influence of games for health are alternate reality games and mobile games. In essence, an alternate reality game comes close to combining interactive fiction with a scavenger hunt; a recent example coming out of MIT and the Smithsonian is ‘‘Vanished’’ (see http:// vanished.mit.edu), where players work with scientists to solve puzzles and unlock mysteries related to holdings at the Smithsonian Institution in Washington, DC. The encouraging features of the game include requiring players to traverse physical space in the process of engaging with the game. Unlike traditional recreational game design requirements, the game could not be won by merely remaining stationary in front of a screen. I use recent advancements in the Apple iOS 8 through ‘‘HealthKit’’ as an example. Serious games could leverage this upcoming application programming interface to introduce features that monitor weight, exercise levels, blood pressure, and medication schedules. The overall challenge from a research perspective is that conventional psychological assessments would, potentially, need to be combined with those derived from fields including anthropology (e.g., requiring more extensive, nonclinical protocols as players traverse spaces over days or weeks with alternate reality games) and medicine (e.g., adopting rather large-scale randomized controlled trials that leverage data acquired by mobile devices). Although there are intense challenges at hand, hopefully these trends in game design and opportunities for more sophisticated research methods and protocols will inspire researchers and designers in the area of games for health. Jesse Schell: I think the most important research about games for health concerns games that are meant to change habits in a long-term, persistent way. It is not unusual for a novel health game to capture a player’s interest for a number of weeks, which sounds like a success, but soon he or she drifts away from it, and whether it made any lasting impact is uncertain. Understanding the techniques that go beyond engagement to create lasting transformation will make a tremendous difference in the creation of games for health. Celia Hodent: It would be interesting to examine how to improve the efficiency of games for health and to measure the experience these games offer. It’s still a challenge to assess
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the level of emotion and engagement that any given game can provide, but worthwhile to pursue for games that aspire to offer health or educational benefits. Fran C. Blumberg and Lauren C. Burke: We thank our discussants for sharing their experience and views. We invite our readers to also consider next steps for serious games for health development and research and look forward to seeing the fruits of those efforts in G4HJ! References
1. Granic I, Lobel A, Engels RCME. The benefits of playing video games. Am Psychol 2014; 69:66–78. 2. Papert S. Mindstorms: Children, Computers, and Powerful Ideas. New York, NY: Basic Books; 1980: 21. 3. Koster R. A Theory of Fun for Game Design, 2nd ed. Sebastapol, CA: O’Reilly Media; 2013. 4. Mayer RE, Fennell S, Farmer L, Campbell J. A personalization effect in multimedia learning: Students learn better when words are in conversational style rather than formal style. J Educ Psychol 2014; 96(2):389.
Brief Biosketches Celia Hodent, PhD, holds a PhD in cognitive psychology, with a specialization in the development of intelligence in children and adults. Early in her career, Celia stepped aside from academic research to work with an educational toy manufacturer, VTech. Celia joined Ubisoft Paris in 2008 to help the editorial team translate neuroscience knowledge into game design features. She later worked for Ubisoft Montreal and LucasArts. She joined Epic Games in July 2013 to help guide the studio toward improved user experience practices. Celia’s main focus is to use psychology and neuroscience knowledge concretely to solve design problems and make sure the player experience is always enjoyable and emotional. She can be reached at Celia.Hodent@ epicgames.com Michael A. Evans, PhD, is an Associate Professor of Digital Learning & Teaching and a Friday Institute for Educational Innovation Research Fellow at North Carolina State University. His research, teaching, and service focus on the development and research of engaging integrative STEM [science, technology, engineering, and mathematics] curricula and programs for underserved, underperforming middle school youth. In support of this work, he is Principal Investigator on two current National Science Foundation–sponsored projects.
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The GAMES Project (DRL 1118571) develops learning games for tablets and other mobile devices, focusing on prealgebra readiness, proficiency, and engagement states. Studio STEM (DRL 1029756) is an informal engineering designbased science-learning program that leverages social media to enhance inquiry. Dr. Evans is a co-founder of the HumanCentered Design Interdisciplinary Graduate Education Program, a Fellow at the Institute of Creativity, Arts, and Technology, and Affiliate Faculty in the Center for HumanComputer Interaction. He received his PhD in Instructional Systems Technology from Indiana University and BA/MA in Psychology/Cognitive Psychology from the University of West Florida. He can be reached at [email protected] H. Chad Lane, PhD, is a Research Scientist and Director for Learning Sciences Research at the University of Southern California’s Institute for Creative Technologies (www.ict.usc.edu). He also holds an adjunct faculty appointment in the University of Southern California’s Rossier School of Education. His research involves application of artificial intelligence techniques to educational problems, with a focus on entertainment technologies and intelligent tutoring systems. Chad received his PhD in Computer Science in 2004 from the University of Pittsburgh. More information about Chad is available at http://people.ict.usc.edu/*lane
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Jesse Schell, MS, is the CEO of Schell Games, a leader in creating transformational games. Since starting his company in 2002, he has grown it into the largest and most successful game development company in Pennsylvania. Under his leadership, Schell Games has produced an amazing array of innovative, transformational, and award-winning entertainment experiences for some of the world’s most respected brands, such as Disney, SeaWorld Parks and Entertainment, Amplify, Yale University, Lionel LLC, and The Fred Rogers Company. Jesse currently serves as Distinguished Professor of Entertainment Technology at Carnegie Mellon University’s Entertainment Technology Center, where he teaches game design. He authored the critically acclaimed book, The Art of Game Design: A Book of Lenses, which captured Game Developer magazine’s coveted ‘‘Front Line Award’’ for 2008. Prior to starting Schell Games, Jesse was the Creative Director of the Disney Imagineering Virtual Reality Studio, where he worked and played for 7 years as designer, programmer, and manager on numerous projects for Disney theme parks and DisneyQuest. More information about Jesse is available at www .jesseschell.com and via Twitter: @jesseschell
