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Design Principles for the Conceptualization of Games for Health Behavior Change

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This paper presents a list of principles that can be used to conceptualize games for health behavior change. These principles are derived from lessons learned after teaching two design-centered courses on Gaming and Narrative Technologies for Health Behavior Change. Course sessions were designed to create many rapid prototypes on specific topics coupling behavior change theory with iterative human-centered and game design techniques. The design task had two broad goals: 1) designing efficacious technologies, with an emphasis on short-term behavior change and 2) using narratives and game dynamics as vehicles for increased engagement and long-term sustained change. Example prototypes resulting from this design approach are presented.
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Design Principles for the
Conceptualization of Games for Health
Behavior Change
Abstract
This paper presents a list of principles that can be used
to conceptualize games for health behavior change.
These principles are derived from lessons learned after
teaching two design-centered courses on Gaming and
Narrative Technologies for Health Behavior Change.
Course sessions were designed to create many rapid
prototypes on specific topics coupling behavior change
theory with iterative human-centered and game design
techniques. The design task had two broad goals: 1)
designing efficacious technologies, with an emphasis on
short-term behavior change and 2) using narratives
and game dynamics as vehicles for increased
engagement and long-term sustained change. Example
prototypes resulting from this design approach are
presented.
Keywords
gaming, serious games, gamification, drama therapy,
narrative therapy, narratives, behavior change,
identity, personalization
ACM Classification Keywords
H.5.m. Information interfaces and presentation (e.g.,
HCI): Miscellaneous.
Permission to make digital or hard copies of all or part of this work for
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requires prior specific permission and/or a fee.
CHI’13, April 27 May 2, 2013, Paris, France.
Copyright 2012 ACM 978-1-4503-1952-2...$10.00.
Pablo Paredes
Berkeley Institute of Design
UC Berkeley
Berkeley, CA 94708 USA
paredes@eecs.berkeley.edu
Anuj Tewari
Berkeley Institute of Design
UC Berkeley
Berkeley, CA 94708 USA
anuj@eecs.berkeley.edu
John Canny
Berkeley Institute of Design
UC Berkeley
Berkeley, CA 94708 USA
jfc@cs.berkeley.edu
General Terms
Design, Experimentation, Human Factors
Introduction
Behavior Change apps and games must adhere to both
engagement and efficacy of the intervention. Several
studies have shown that CCBT (Computerized Cognitive
Behavioral Therapy) such as MoodGym [12], Beating
the Blues [13], among others, compare well with face-
to-face therapy. However, 2/3 of depressed patients
prefer therapy over drug treatment, but only 20% of
them actually start it, and 1/3 of those will quit [9].
Gaming has characteristics that enhance selective
attention [5], helping people pay attention to the main
message. Another characteristic is that games make
the learning process fun [7], which in turn increases
motivation [10] and emotional engagement [6].
Baranowski, et. al. [2] has shown success using games
for health behavior change. Some other gaming
examples focused on health are the Personal
Investigator [4] leveraging CBT for mental health, and
Superbetter.us [17] which leverages real-life social
support embedded into a superhero story. Lumosity’s
suite of games used for cognitive training [18] show
how cognitive techniques wrapped around mini games,
improve engagement, aiding efficacy over time [11].
Complementary to gaming literature, persuasive
technology has shown improved usability and
engagement for physical activity. The Ubifit system [3],
showed increased exercise levels using goal tracking
and metaphors. Other examples around life style
change such as Nike Plus [14], HeartMath [15] and
FitBit [16] show increased levels of engagement.
The challenge: Efficacy + Engagement
The challenge to merge efficacy and engagement can
be dissected into the following design dualities (Fig. 1):
Scientific vs. Iterative methods: A gap exists between
current clinical intervention development methods
based on the scientific method (hypotheses + statistical
validation) and iterative gaming and app technology
design. Usability design demands an approach that
favors exploring ideas based on prompt user feedback
through the construction of prototypes. Merging this
approach with a efficacy testing procedure is one of the
constraints used to design our course sessions.
Short vs. Long-term engagement: Short-term
engagement demands knowledge around decision-
making, emotional elements and personal skills, while
long-term engagement demands a deeper
understanding of identity and personality. A way to mix
behavior change with identity change is through
narrative-driven games. Such games use metaphors,
scenarios and stories that help develop the adoption of
new identities.
Content vs. Dynamics: Commercial apps, as opposed to
therapeutic interventions, do look for a more complete
user experience, which pays attention to execution as
well as engagement and identity details. However,
success is usually measured in terms of revenue
generation, rather than behavioral metrics. Merging
both the experience design (i.e. narrative elements)
with the game dynamics (i.e. behavioral elements) into
a coherent design that help develop real life skills is
another challenge to be considered.
Scientific
Short-term
Content
Dynamics
Long-term
Iterative
Figure 1 Efficacy +
Engagement game design
dualities
Design methodology
In this paper we present a set of principles for the
conceptualization of games for behavior change derived
from lessons learned after teaching two health and
wellbeing game design classes. The objective was to
maximize creativity under the constraint dualities
aforementioned. Each session consisted of two parts:
First hour - Theory/Base Knowledge: Behavioral
theories are presented by a specialist to later be used
as the basis of the design challenge. The session closes
with a brief discussion around the way such theories
can influence the design of new technology. Table 1
shows a list of the theoretical topics presented.
Second hour - Design challenge: Students must go
from problem assessment to a complete game concept
leveraging the theory presented. The exercise is divided
into four fast-paced parts:
- Narrative Storyboarding - Describe and storyboard
thedisempoweringnarrative and the counteracting
empoweringnarrative.
- Externalization - Intangible elements such as the
problems themselves and/or the feelings associated
with them must be externalized into enemies, scenes,
obstacles or other gaming elements. The skills needed
to overcome such problems should also be externalized
into weapons, skills or game dynamics.
- Game Design: Students are then requested to
design the game rules and to focus on game flow,
incorporating the narrative and externalized elements.
- Test, Role-playing and Critique: Finally, students
must test each other’s games, present their game with
a movie billboard as if it was being launched on TV,
present their storyboards and act their games out.
Prototype examples
At the end of the semester a complete game prototype
is presented using the relevant theories and design
elements learned during class. Among many others we
chose a few examples of the final projects.
- Monsters (Fig. 2) a simple two-player game based
on monsters and weapons. Concepts from drama
therapy are used to represent inner problems with
monsters and tangible tools and weapons represent
skills to destroy them. For example, “stress” could be a
flaming monster; player 2 helps you train by blowing a
torch, which in-turn can teach you to remember that to
kill stress you need to breath better.
- Scheherazade’s World (Fig. 3) a multi-player game
based on digital storytelling that aids in the prevention
of suicide by creating a community for at-risk young
women to share their stories. The One Thousand and
One Nights tells of a king named Shahryar, who would
marry a new wife each day and sentence yesterday’s
wife to death. Unlike previous wives, Scheherazade had
a secret weapon to keep her alive. Every night, she
would tell the king a story, only to end with a
cliffhanger each night. Because the king wanted to
know the rest of the story, he would spare her life for
another day. Through stories, she was able to survive.
- Semester Adventure (Fig. 4) a role-playing game
to reduce anxiety and improve time management
around test exams. The player follows an adventure as
a warrior that needs to gain powerful tokens by
defeating time wasting enemies, i.e. by fulfilling tasks
on time. Life stories theory indicates that people
assume new roles based on the way they define
themselves. A “warrior” role helps people to be active
and assertive, while a “victim” one makes the person
passive and receptive of disgrace.
Behavior Change Topics:
-Intro to Behavior
Change Theory
-Intro to Life Stories
-Body-Mind
Connection
-Positive Psychology
-Narrative Psychology
-Sports Psychology
-Anxiety, Depression
and Cognitive-
Behavioral Therapy
-Behavior Change in
Society
-Drama Therapy
-Neuroscience Games
-Trauma Narratives
-Improv-based Games
-Communitarian
Mental Health
Interventions
-Digital Storytelling
-Social Networking for
Behavior Change
Table 1 Behavior Change
and Narrative Topics taught
in addition to Gaming
Development and Human
Centered Design Topics
Principles for Conceptualization
The following principles offer a baseline for behavior
change game design. These principles can be used to
help game designers brainstorm, refine and select
game concepts. Participatory design with stakeholders
(specialists, users, etc.) is recommended during this
phase.
Understanding disempowering narratives
a. Narratives are lived - not only used to tell stories
about one self. People confront ideas and situations
based on the way they portray themselves. This is
observed in trauma patients who cannot overcome
the generalization of their disempowering
narratives. Understanding the narratives underneath
unhealthy behaviors will help design new
empowering gaming narratives that help change
unhealthy habits, eliminate generalizations and
organize thoughts around the appropriate context.
b. Focus on strengthsDesign around behavior
change can benefit from understanding people’s
current strengths, rather than imposing an ideal
model for functioning under a specific situation. A
key concept that describes the basis for behavior
change is what Bandura defines as self-efficacy [1].
In a nutshell, self-efficacy explains our self-
assessment and use of our current strengths.
However, discovering strengths demands
exploration not only of thriving experiences but also
of difficult experiences, where strengths are used to
be resilient and survive emotional or physical pain or
disgrace. Games could be designed to incorporate
ways to discover strengths used to adapt and
overcome challenges during the game flow.
Externalizing problems
c. Interpretation and introspectionPeople suffering
of behavioral problems rarely have time to better
understand their problems. Designers should
provide time lapses prompted by cues to help people
interpret problems and introspect. Games with
forced prompts for reflection could help increase
people’s awareness of their own thoughts and
problemshowever, a balance between action and
pause is important to avoid breaking game flow.
Furthermore, behavior change games ought to be
designed to be adaptive to changes in the problem
definition, as the game could help the user discover
the root cause of an initial superficial problem.
d. Problems as fictional enemiesExternalizing
problems into concrete game elements (i.e. objects,
monsters, obstacles, etc.) helps people understand
that a problem does not occupy every aspect of their
lives. It also helps the user understand the
characteristics of the problem, which in turn will
help derive possible solutions. Designers should
provide users with ways to externalize problems and
feelings into concrete game element(s) that can
later be destroyed or controlled. These element(s)
should have a clear metaphor (for example, stress
as an oppressive rock, or depression as glue that
impedes you to move) in order to aid the user to
discover newaffordancesof the problem at hand.
e. Materializing Skills into weaponsComplementary
to the materialization of problems, tools and
weapons, which represent the skills required to
overcome the problem, should also be materialized.
Such tools must carry a clean meaning that is
memorable and supports the notion that change is
possible via the use of the metaphors and game
mechanics associated with such weapons.
Figure 2 Monsters Game
Screen
Bedroom Write stories here
Sultan’s bedroom Listen to Scheherazade
Figure 3 Scheherazade’s
World Game Screens
Game Dynamics as Interventions
f. Progress as a proxy for self-efficacyEliciting
progression should be a key element of game design
for behavior change. Many times users need to
realize first that “change” is actually possible. If no
progress is perceived, the sensation of inefficacy is
perpetuated and therefore, any effort to develop
skills or motivations could be futile. The initial levels
must show the user that change, even if small,
exists. Game flow must be carefully designed to
maintain a belief that change being attained.
g. Social ValidationWithout social affirmation (i.e.
celebration and positive feedback) change may
seem part of our imagination. Game designers
should use social affirmation to promote self-
efficacy. Social influence (i.e. socially controlling
and affecting the gamer’s choices) could also be
used as a vehicle to drive change. However, this
latter approach runs the risk to make the user feel
that they were imposed a new reality by others,
therefore reducing or eliminating self-efficacy, which
in turn will not drive real and lasting change.
Conclusion
Differently to purely entertainment games, the
challenge around designing behavior change games is
to strive not only for engagement but also for efficacy.
A group of design principles for conceptualization is
derived from an experience-driven analysis of this
challenge. Overall, these principles can be used to
conceptualize games aimed towards sustained change.
Acknowledgements
We thank all the guest lecturers and students for
helping us build a creative and fun environment around
serious issues and their complex solutions.
References
[1] Bandura, A. Self-efficacy: Toward a unifying theory of
behavioral change. Psychological Review, Vol 84(2), 191-215, 1977
[2] Baranowski, T., Buday, R., Thompson, D., Baranowski, J.
Playing for Real: Video Games and Stories for Health-Related
Behavior Change. American Journal of Preventive Medicine, 2008
[3] Consolvo, S., Klasnja, P., McDonald, D., Avrahami, D.,
Froehlich, J., LeGrand, L., Libby, R., Mosher, K. and Landay, J.
Flower or a Robot Army? Encouraging Awareness and Activity with
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[4] Coyle, D., Matthews, M., Sharry, J., Nisbet A. and Doherty, G.
Personal Investigator: A Therapeutic 3D Game for Adolescent
Psychotherapy, International Journal of Interactive Technology and
Smart Education, 2(2):73-88, 2005
[5] Green, S. and Bavelier, D., Action video games modifies visual
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[6] Hsu, W., Lee, F, and Wu, M., Dessigning Action games for
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[7] Malone, T., What Makes Things Fun to Learn?: Heuristics for
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[8] Marks, I., Kavanaugh, K. and Gega, L., Hands-On Help:
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[9] Mohr, D., Vella, L., Hart, S., Heckman, T., and Simon, G., The
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[11] Scanlon, M., Drescher, D., and Sarkar, K., Improvement of
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Cognitive Training Program, Lumos Labs, 2007
[12] http://moodgym.anu.edu.au/welcome
[13] http://www.beatingtheblues.co.uk/
[14] http://nikeplus.nike.com/plus/
[15] http://www.heartmathstore.com/
[16] http://www.fitbit.com/
[17] https://www.superbetter.com/
[18] http://www.lumosity.com
Figure 4 Semester
Adventure Game Screen
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The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of per- sonal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of ob- stacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more de- pendable the experiential sources, the greater are the changes in perceived self- efficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and be- havioral changes. Possible directions for further research are discussed.