Games for Health

Health science has been embracing gaming as a meaningful way to communicate, educate, and as a mechanism to deliver treatment [1,2]. There has been a growing interest in both serious games for health and gamified health interventions [3], especially those concerning the treatment, rehabilitation, and management of chronic disease patients [4], as these games for health have shown potential for positive impact on health-behavior change.

Some research on the effectiveness of serious gaming for health promotion revealed an overall increase in healthy lifestyle adoption across several health domains [2] and that gameplay may induce a positive emotional experience and help facilitate satisfaction and self-esteem [4]. Effect sizes found on behavior after playing a serious game were small and comparable to the effect sizes of other computer-delivered interventions. Such effects of serious games for health were highest on knowledge outcomes, while smaller than expected on self-efficacy outcomes. Overall, the effectiveness of a health game was found to improve when game development had a theoretical foundation in behavioral prediction and game theories [5].

In order to create a full picture of the effectiveness of games for health, broader intervention characteristics should perhaps be evaluated, such as user experience and perceived relevance [6]. Some of the research into the effectiveness of games for health investigates the process during gameplay [7,8] while other research focuses on process after gameplay [5,9]. I would argue that the perceived appeal of any game for health belongs in this list of “broader intervention characteristics” and that measurements should also be made BEFORE gameplay.

excerpt of my paper The Effect of a Health Game Prompt on Self-efficacy: Online Between-Subjects Experimental Survey – freely available here

References

  1. Sharifzadeh N, Kharrazi H, Nazari E, Tabesh H, Edalati Khodabandeh M, Heidari S, et al. Health Education Serious Games Targeting Health Care Providers, Patients, and Public Health Users: Scoping Review. JMIR Serious Games 2020 Mar 05;8(1):e13459 [FREE Full text] [CrossRef] [Medline]

2. Kato PM. Video Games in Health Care: Closing the Gap. Review of General Psychology 2010 Jun;14(2):113-121. [CrossRef]

3. Johnson D, Deterding S, Kuhn K, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: A systematic review of the literature. Internet Interv 2016 Nov;6:89-106 [FREE Full text] [CrossRef] [Medline]

4. Sardi L, Idri A, Fernández-Alemán JL. A systematic review of gamification in e-Health. J Biomed Inform 2017 Dec;71:31-48 [FREE Full text] [CrossRef] [Medline]

5. DeSmet A, Van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014 Dec;69:95-107 [FREE Full text] [CrossRef] [Medline]

6. Verschueren S, Buffel C, Vander Stichele G. Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights. JMIR Serious Games 2019 May 02;7(2):e11565 [FREE Full text] [CrossRef] [Medline]

7. Brockmyer JH, Fox CM, Curtiss KA, McBroom E, Burkhart KM, Pidruzny JN. The development of the Game Engagement Questionnaire: A measure of engagement in video game-playing. Journal of Experimental Social Psychology 2009 Jul;45(4):624-634. [CrossRef]

8. Burgers C, Eden A, van Engelenburg MD, Buningh S. How feedback boosts motivation and play in a brain-training game. Computers in Human Behavior 2015 Jul;48:94-103. [CrossRef]

9. Garcia Pañella O. Game design and e-health: serious games put to the test. In: Advancing Cancer Education and Healthy Living in Our Communities (Putting Visions and Innovations into Action: Selected Papers from the St. Jude Cure4Kids® Global Summit 2011). Amsterdam, The Netherlands: IOS Press; 2012.

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Before the paper Effect of a Health Game Prompt

There are two stories here.
One is the story of the content of the paper and this is pretty straight forward. It started reading a paper and wondering about something:
…reading the work of Brooks, it seemed to me that prompting a game for health is also a call to be excited amidst anxious content and I wondered if a game for health might be considered arousal congruent cognitive reappraisal? If so, this perspective could help to explain some of the attraction to games for health and their effects on self-efficacy.
Diving into this question I found out more about cognitive reappraisal and self-efficacy and even found a diabetes specific self-efficacy scale (not in paper). I found more work and interesting examples of games for health and well-being. While investigating measurements for well-being I found a Flourishing scale. When I thought I had a good idea of the relevant concepts and their measures I formulated a simple online experiment. I ran it, analysed it and wrote up the process. It felt so good to throw my considerations at reality and collect data. I dipped my toes in the micro-task market by using MTurks. There was some struggling and getting to grips with mediation analysis. I was surprised – and initially very frustrated – by the answer to my overall question and am very grateful that I included a measure that might offer an explanation for these unexpected responses. The results offer a minute contribution to the better understanding of using games for health. Please read it and let me know what you think https://games.jmir.org/2021/1/e20209/

Then there is a second story of the emotional context of this paper. This centres around a PhD that did not end well. When this paper was in a very early stage, I quit the PhD. This was a hard decision but I had lost all faith in ever getting to a positive ending and I still think it was the right decision. However, letting go of what I had been holding onto meant I fell down further.  Chronic pain, depression, physical therapy, mindfulness based cognitive behavioural therapy, a lovely psychologist at the pain clinic all followed each other. A process taking over two years. Starting during my PhD and ending long after.
And somewhere on my computer and nagging in the back of my mind was this paper. Sort of finished – but unpolished. Hours of my life already in it, the effort of all the people that had participated already in it and the method/experiment/result simple truths regardless. It’s not the ideas, the experiment or the correlations fault. What I love about science – and chase in effect research – is something that exists above, beyond and outside of me.
But every time I opened this document waves of emotion came with it. Even so, I returned to work on these pages. First this was a great smack in my face. None of the statistical analysis were clear in my mind and my ability to focus was shredded. This confrontation with a new me that could no longer understand the old me was horrible. Over time and a lot of emotions I re-read and re-did my own work until I re-understood. Then I tried to improve the paper.
Thankfully, I have some amazing friends. One is a health researcher and a data wizard, one is a statistician for social sciences and one is a games researcher. I worked on the pages until I thought they were good enough to be shown. My friends read it and returned it to me with comments. Normal comments that made it better – no fundamental flaws, nothing crazy. All three told me they thought it was about one-round-of-improvements away from trying to get it published. I took all their comments and made it better.
Now, there is almost four years in between me ending the PhD and me sending this paper in to be judged by JMIR Serious Games. The first year-and-a-half I didn’t touch it. Another year of painfully and sporadically confronting myself with myself and then a long time of working on it in between the rest of life. A life that has nothing to do with academia anymore. After submission, another year follows that includes a revise-and-resubmit, a global pandemic and an editor-switch before getting it published in my first-choice journal.
Five years and such a long emotional journey for such a small, simple paper. 

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Learning strategies and metacognition

In very broad strokes there are three kinds of learning strategies:
rehearsal,
elaboration
and organisational.

Rehearsal is the much used ‘rinse and repeat’ approach of content repetition or rote learning.
Elaboration might include the use of mnemonics, paraphrasing or summarizing content. These elaboration strategies lead to a deeper level of processing and better comprehension of the content as compared to rehearsal strategies (Pintrich, 2002).
Applying organizational strategies means connecting content elements by note-taking or, for example, creating a mind-map.

Metacognition is applied in the planning, monitoring and regulating of various learning strategies.  This metacognitive knowledge of different learning strategies and their (conditional) application seems to be involved determining the transfer of learning. ‘Transfer’ refers to the ability of using knowledge learned in one setting or situation, in another setting or situation (Bransford & Schwartz, 1999).

The demand of metacognition on working memory is two-fold:

  • The problem solving thoughts
  • Monitoring and regulating the thinking about the problem solving thoughts

In a teacher-student situation, the demand on working memory might be shared as the teacher offers cognitive resources for the actual problem solving or for the monitoring and regulating. This sharing of working memory resources is an application of distributed cognition (Schwartz et al., 2009).

 

 

Christoph, L. H. (2006). The role of metacognitive skills in learning to solve problems.

Weinstein, C. E., & Mayer, R. E. (1986). The teaching of learning strategies. Handbook of research on teaching, 3, 315-327

Pintrich, P. R. (2002). The role of metacognitive knowledge in learning, teaching, and assessing. Theory into practice, 41(4), 219-225

Bransford, J. D., & Schwartz, D. L. (1999). Rethinking transfer: A simple proposal with multiple implications. Review of research in education, 61-100

Schwartz, D. L., Chase, C., Chin, D. B., Oppezzo, M., Kwong, H., Okita, S., Wagster, J. (2009). Interactive metacognition: Monitoring and regulating a teachable agent. Handbook of metacognition in education, 340-358

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A Framework for developing Serious Games for Health

The paper Developing Theory-Driven, Evidence-Based Serious Games for Health: Framework Based on Research Community Insights by Verschueren and colleagues provides a well-researched framework for developing any serious game and especially one for health/wellbeing purposes.

Their research into efficacy and best-practices in game development is poured into a framework with five stages

It all starts with asking the right questions, finding out what is relevant to your goals and preferable forming a hypothesis & thereby setting metrics, early on in development. Gather data from research, interviews and observation. Get your players, health care professionals and other stakeholders involved but not every step of the way begs the same kind of involvement. Test, iterate, test, iterate… and always keep your eyes on what you’ve determined as your goal and what was relevant to this. And finally, if you can, test your hypothesis.

I really recommend this paper – great read with good guidelines to follow!

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PhD Gaming to cope

Gaming has promise.
In order to fulfil its didactic promise we need to understand exactly what goes on while people are ‘in game’ and how this joyful experience can be used to facilitate positive behaviours – such as functional coping strategies.
In my research I will be investigating the concepts of motivation, control beliefs such as self-efficacy and knowledge processing on a metacognitive level. My hypothesis is that the transfer of in-game behaviour and experiences to ‘real life’ behaviour and experiences can best be facilitated on a metacognitive level (as well) in order to manifest.

The (un)proving of such an hypothesis, leads to the question of measurement. Currently, there is no decent measurement for transference of in-game behaviour and experiences to ‘real life’ behaviour and experiences which takes into account the interactive nature of a game environment and the more abstract knowledge levels that might be the key to behavioural success.
This research aims to add to and deepen effect research of gaming.
Concepts
• Transference
• Metacognition
• Coping strategies
Game environments
• Exergames
• Alternate Reality Gaming
• Massively Multiplayer Online
Methodological issues
• Interactive environments
• Mediated modelling

The research is done under the supervision of Prof. Ute Ritterfeld and jun. Prof. Matthias Hastall of the Faculty of Rehabilitation Science at the Technical University of Dortmund. Here you will find the original proposal Gaming to cope – a three year plan written by me and accepted by the TU Dortmund in the fall of 2013.

summer 2015 Two years in and of course, things look different than they did at the start. Deepening of the concept of ‘strategic knowledge’ and discovering ‘meta-cognition’. Finding ‘resilience’ and different types of ‘stress or arousal’ – doing an online priming experiment and adding PROCESS – mediation, moderation and conditional process analysis – to the research toolbox. Please find some of the pieces I wrote along the way here:

Recipe for serious gaming (in health care)
Reality is broken – McGonigal – book review
VR and games as therapeutic tools
A knowledge taxonomy
Barriers to health appeals
So you think you can… Self-efficacy, health and reappraisal

Summer 2016 I ended the PhD without finishing it. Below you can find results from an online experiment I worked on and some other writings:

Does a game prompt make us excited?
Keep your arousal high
Rehabilitation thinking in game design
If you have any questions or possibilities for collaboration, contact me anytime.

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A tale of two papers

Writing, submitting and publishing a paper contains the best of times and the worst of times. There is great pleasure in getting your thoughts down on paper, hammering on them with earlier research and the critical eyes of all the available authors, editors and peers and putting them to test of  scientific method. We’ve gone through this process twice now with Bloom’s revised taxonomy and five psychotherapeutic games.

One of the thoughts at the centre of my research for a Philosophical doctorate, was that greater transference of game content into life beyond, might be achieved when a game would address a meta-cognitive level. This is an interesting higher level of cognition where your actions are decided – possibly by you. All very well, but first we needed a solid determination of this meta-cognition and when it was happening during gaming before we can start testing it’s power of transference. I found the Revised Bloom’s Taxonomy which included a category for meta-cognition and wondered if this might be suitable to task.

While discussing such considerations with a fellow Horizon2020 reviewer and game researcher,  who seemed interested in this concept of meta-cognition, we came up with a plan: Let us try this taxonomy on five different psychotherapeutic games and see what we get. We did this work and shaped our results into the paper Looking for Metacognition subsequently send to GALA 2016 (International Conference on Games and Learning Alliance) where it was reviewed, accepted and won 3rd place in the best paper competition.

Rejoice! This distinction also meant that we were invited to publish an extended version of our paper in the IJSG (International Journal of Serious Games) special edition. I saw fit to use this opportunity to confront a limitation of our work that had been bothering me – if I wanted to use this Revised Bloom’s Taxonomy across different games to identify meta-cognition for further analysis, I needed to prove that it had intercoder reliability. We decided that adding the process of TESTING our application of the taxonomy on the five games would provide enough of an extension – and that we were in need of more researchers to perform the coding with us. Luck was with us, as two more befriended researchers considered this work to be interesting enough to pursue, and on we continued with the four of us.

Headlong into trouble. Our process of applying the taxonomy proved itself as highly subjective and we concluded that this taxonomy was entirely unsuitable for the kind of work we had had in mind for it. This was not what we had expected – but a question once asked must content itself with the answer it receives. We described our process in detail and sent out our findings to IJSG to be peer-reviewed. Our work was returned to us with many comments. Most of which greatly added to the structure and clarity of the paper. Most of the critique of our peers was much appreciated and the paper was changed accordingly. Some comments threw out our process under ‘bad methodology’ due to the results we obtained. One of our peers felt that if the taxonomy did not meet the criteria of intercoder reliability, we should work on a protocol until it did meet the criteria and that that paper might be a work worth publishing. We disagreed.

Now, our paper wasn’t the greatest of works. No great academic achievement, no awards were awaited by any of us. Certainly, there was much to improve and with the help of another round of reviewing, improve it we did. And yet comments remained that we could not bend to without disavowing our results. We disagreed. We were notified that our work would not be published.

So our combined efforts lay in vain. Restructured, debated and refined into a simple point being made in great detail. No great revelatory work, but I felt none the less that it was work that would contribute in a small way to a greater understanding in our discipline. I happened upon a journal (International Journal of Computer Games Technology) that matched the interests of our work, practiced publishing open to everyone and willing to waive the payment it usually required. Quickly, I adapted our work one more time, to the style demands of the publication, and notified my fellow researchers as we send out hope once more. The editor returned that they were interested in our work and once more it moved onwards to be critiqued by our peers. We received the comments of just one reviewer. Most of the comments were small and adhering to them improved the work further, some of the comments questioned the method due to the results. We disagreed.

We were notified that that our work would be published: Using the Revised Bloom Taxonomy to Analyze Psychotherapeutic Games.

So here we stand – at the end of a road that took two years. A road that has seen much debate and effort of all kinds, for which we are grateful. At the end we can conclude simply that the thoughts we had did not pass the act of being tested – which is helpful, as it prompts us to look elsewhere. If we are to find what is efficient we also need to distil what is unsuitable.

Both papers – and other work – might also be found here

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