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“Constant Pressure of Having to Perform”: Exploring Player
Health Concerns in Esports
Daniel Madden
madden.da@northeastern.edu
Northeastern University, CAMD
Boston, MA
ABSTRACT
Esports is a rapidly growing industry, generating interest from re-
search disciplines including marketing, social sciences, and human-
computer interaction. Despite its continued growth, there is a lack
of studies surrounding the health of esports players. Previous work
on the subject is limited, as research has only recently begun to
explore the potential factors aecting physical and psychological
wellness. Using an exploratory mixed-methods approach, a series
of semi-structured interviews (n = 10) and an online survey (n = 68)
were used to identify the biggest health concerns among esports
players. The results demonstrate a better understanding of issues
regarding physical and psychological wellness according to the
players. Moving forward, we suggest the HCI community adapts
mindfulness, ergonomics, and social-emotional learning as methods
for supporting player’s health concerns.
CCS CONCEPTS
• Human-centered computing → HCI design and evaluation
methods; Empirical studies in HCI.
KEYWORDS
Esports, Mental Health, Physical Health, Wellness, Video Games
ACM Reference Format:
Daniel Madden and Casper Harteveld. 2021. “Constant Pressure of Having to
Perform”: Exploring Player Health Concerns in Esports. In CHI Conference
on Human Factors in Computing Systems (CHI ’21), May 8–13, 2021, Yokohama,
Japan. ACM, New York, NY, USA, 14 pages. https://doi.org/10.1145/3411764.
3445733
1 INTRODUCTION
Esports has rapidly gained interest from millions of viewers all
around the world, generating billions of dollars in estimated prot [
66
,
79
]. The viewership of these events has surpassed some of the
largest sporting events, such as the Super Bowl [
95
] and NBA -
nals [
102
]. This explosive growth has led to specialized arenas for
competitions, as well as sponsorship deals and revenue [
62
,
121
]
that have made esports a legitimate career option, even gaining
consideration as a sport by the International Olympic Committee.
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CHI ’21, May 8–13, 2021, Yokohama, Japan
© 2021 Association for Computing Machinery.
ACM ISBN 978-1-4503-8096-6/21/05.. . $15.00
https://doi.org/10.1145/3411764.3445733
Casper Harteveld
c.harteveld@northeastern.edu
Northeastern University, CAMD
Boston, MA
As esports continues to gather greater attention, research con-
tinues to expand. This has included sociology, media studies, and
human-computer interaction (HCI), to name a few [
106
,
118
]. Re-
searchers have sought to understand the performance gap that ex-
ists between casual gamers and esports professionals [
8
,
102
,
103
] as
well as the intensive training required to develop skills necessary to
compete at the professional level [
56
,
60
,
105
]. Esports also presents
a unique medium of computer competitions, leading to research in
aspects of team dynamics [
72
,
119
], team formation [
43
], and the
high levels of toxicity within online competitions [4, 40, 85, 123].
Despite the rising popularity of esports, studies of health issues
among players have only recently emerged. In traditional sports,
sports science and medicine is committed to understanding the
health needs of athletes, as they face dierent stress and health
issues than the general population [
7
]. Yet in esports, despite the
long hours and intense training required to reach the professional
level [
46
,
60
], research in understanding the impact such activity
has on players’ health is limited. Current research suggests that
esports is comparable to traditional sports [
41
,
62
], but there are
nuances in the screen time and level of activity that present unique
challenges for player health. Unlike traditional sports, the time
spent at practices or in competitions is not “active,” but sedentary,
requiring competitors to remain in front of a screen for several
hours at a time. While excessive screen time has been documented
to have negative impacts on cognitive health, sleep, and other psy-
chological issues [
33
,
113
,
124
,
127
], there is no clear documentation
of these issues arising in esports. This lack of knowledge has led
to speculation and competing views on the physiological eects
within esports [96].
This paper uses an exploratory mixed-methods approach [
25
] to
examine the key health issues aecting physical and psychological
wellness from the perspective of players. Step one of the study
consisted of semi-structured interviews with professional esports
players (n=10) designed to explore daily routines, physical issues,
and mental health issues as they relate to experiences within es-
ports. Using the results of the interviews, a preliminary theoretical
model was developed to illustrate the main factors aecting health.
This model was explored further through the use of a survey devel-
oped to better understand how these varying factors relate to each
other. Participants for the survey were recruited from a variety of
high-level competitions and tournaments to increase the sample
size. Results were used to demonstrate the greatest health factors
currently impacting esports players.
The results present several areas of health concerns among es-
ports players requiring attention from the community. Better train-
ing regiments and increased support may present solutions to many
CHI ’21, May 8–13, 2021, Yokohama, Japan
of the physical and psychological strains players face. Addition-
ally, the HCI community may adapt previous work in ergonomics,
mindfulness, and social-emotional learning, to meet the unique
challenges concerning health among the players.
2 BACKGROUND
This paper explores the health risks in esports from the perspective
of its players. With this in mind, this section begins by dening
the eld of esports and showing the high intensity and specialized
skills that separate esports athletes from the casual gamer. This
is then compared to the high intensity of traditional sports, while
highlighting the dierence in approach to the health of the players.
Finally, we introduce some of the initial explorations into esports
and health, as well as why further investigation is necessary.
2.1 What is Esports?
One of the earliest denitions of esports is by Wagner [
125
] who
denes it as “an area of sports activities in which people develop
and train mental or physical abilities in the use of information and
communication technologies”. While the denition of esports is
still widely debated among scholars [
41
,
106
,
118
], Wagner intro-
duces the importance of training and skills that are necessary to
compete in the eld. A more recent denition is by Hamari and
Sjöblom [
53
] who dened esports as “the umbrella term used for or-
ganized competitive digital gaming that has taken on the aesthetics
of professional sports,” focusing on the comparison of digital com-
petitions to more traditional athletic events. Alternatively, Türkay
et al. [
123
] focused on dening esports through the digital medium
where “the primary aspects of the sport are facilitated by electronic
systems.” The debate in denitions highlights the diversity of the
eld, as well as the unique challenges such combination of elec-
tronic systems and competitions create.
2.1.1 More Than an Average Gamer. Esports players compete in
a wide variety of games, including rst-person shooters (FPS) like
Call of Duty [
2
] and Overwatch [
14
], multiplayer online battle arena
(MOBA) games, including League of Legends [
108
] and Smite [
55
],
racing games, sports games, other genres. While many of these
games are available to casual gamers, esports has separated them-
selves through higher levels of overall skill and understanding [
60
,
105
]. The essential skills necessary to compete at the highest levels
include what is dened as high functioning motor skills [
56
,
65
,
103
]
and reaction times [
57
,
72
,
112
]. Additionally, esports players dif-
fer from casual gamers as they follow a rigorous practice routine
with hours dedicated to developing and improving their overall
gameplay [46, 51, 59, 60, 109].
2.1.2 Esports and Sports Comparisons. The high-levels of com-
petition and practice requirements have led many researchers to
examine the similarities between esports and traditional sports [
51
,
62
,
109
]. Similar to traditional sports, esports competitions are team
based, formed around cooperation and communication necessary
to achieve victory [
72
,
93
,
120
]. The tournaments and leagues have
gained international attention, leading to team branding, sponsor-
ship deals, and contracts resembling that of modern day sports
leagues [
26
,
44
,
79
,
82
,
121
]. The branding has even occurred at the
Madden and Harteveld
collegiate and amateur levels, replicating the formation of other
amateur leagues of sports [68, 129].
Due to the presentation styles and marketing tactics, researchers
have given special consideration to spectator motivations within
esports [
27
,
99
]. Previous work has used scales for measuring sport
spectator motivation as it occurs within esports viewership [
53
]. Re-
search has sought to understand spectators from the stands [
19
,
88
]
as well as the unique addition of online streaming [
27
,
100
,
101
,
114
,
128
]. The unique experience of online streaming has led to research
surrounding consumers to focus specically on how to enhance the
overall viewing experience for those watching online [
18
,
73
,
75
].
An additional aspect of esports is the social nature of the event due
to the medium of digital competitions. Nearly all esports players
have to interact with other competitors and teammates online to
some degree [
43
,
100
,
129
]. However, this increased socialization
has been exploited, resulting in toxic environments and interactions
becoming a widely accepted aspect of esports play [
4
,
40
,
85
]. This
extra toxicity has forced esports players to face additional men-
tal strains during competitions and practices and develop mental
fortitude [5, 46, 54, 57].
2.1.3 Toxicity. As previously mentioned, esports provides unique
interactions that occur online. This has led esports players to expe-
rience what is considered to be “toxic” environments. Regardless
of one’s age or level of play, online interactions during competi-
tions tend to have toxic members [
85
] often in the form of general
harassment or aggressive comments [
4
,
123
]. This behavior is espe-
cially common among female gamers [
40
,
67
,
120
] due to gendered
stereotypes [
92
,
111
] and male dominance in the eld. The negative
atmosphere and gendered dierences add strain to a eld that al-
ready requires high levels of mental fortitude to participate [
57
,
71
].
2.2 Esports and Health
Although limited, research has recently begun exploring the health
of esports players. The current literature available can be broken
down into examinations of daily routines, physical issues, and
psychological issues.
2.2.1 Esports Routine. Current literature on routine centers around
survey research on the presence of exercise, as well as theories on
sleep’s contribution to esports. Surveys surrounding exercise found
that collegiate players may exercise, but such routine does not re-
late back to esports [
66
,
97
]. However, theoretical work suggests
that exercise should be incorporated for the betterment of perfor-
mance and health of all esports players [
84
,
126
]. Similarly, work
has suggested sleep would benet players based on the benets it
provides to cognitive and physical levels [
15
,
16
], though this has
yet to be empirically evaluated in the eld.
2.2.2 Pain and Inactivity. Physical health work that has previously
been conducted used surveys to document pain and injury common
among esports participants. Research has consistently found neck
pain, hand pain, and back pain are common issues esports play-
ers have experienced [
31
,
49
]. This is in line with concerns from
the public health community that sedentary activity is negatively
impacting esports players [
58
,
126
]. However, research has yet to
provide mitigating factors for such issues.
“Constant Pressure of Having to Perform”: Exploring Player Health Concerns in Esports
2.2.3 Psychological Wellness. Currently, psychological research
involving esports players has examined their mental factors [
89
]
and motivations [
5
,
46
]. However, the current state of psychological
research is limited [
6
], requiring further exploration and under-
Gender Age Most Recent Years of Ex- Active
Community perience Status
P1 Male 25 Smite 6 years Active
P2 Male 24 Smite 5 years
Retired
P3 Male 23 Overwatch 3 years
Retired
P4 Male 24 Starcraft 2 6 years
Retired
P5 Female 26 Tekken 6 years Active
P6 Female 31 CS:GO 5 years Active
P7 Male 29
World of War-
3 years Active
craft
P8 Male 23 2k NHL 3 years Active
P9 Male 25 PUBG 5 years Active
P10 Male 28
League of
3 years
Retired
Legends
standing for researchers and medical professionals alike [23, 94].
2.3 Health in Related Fields
While health research in esports is limited, other elds have medical
practices that may be applied to esports. The stress and rigorous
practice required of esports players is comparable to traditional
sports, though the sedentary nature is a better comparison to ca-
reers with high-computer usage. Research on health issues in these
elds may provide practices that may be adapted to benet and
better understand player health.
2.3.1 Health in Traditional Sports. Similar to esports, traditional
sports feature high intensity competitions and rigorous practice
schedules. However, unlike esports, traditional sports is an older
eld that has developed research pertaining to physical and mental
health.
In examining physical health, special attention has been given
to understanding and mitigating the injuries players may expe-
rience [
36
,
38
,
39
,
87
]. Research has examined players’ general
training routines [
47
,
81
] and their connection to injuries and over-
training [
45
,
74
]. Additionally, work in physical health has demon-
strated the benets of nutrition to routine, as it aids in both recovery
and competitive performance [
48
,
52
,
122
]. Medical studies have
also conducted psychological research regarding sports leading to
the development of the unique eld of sports psychiatry [7, 9, 83].
2.3.2 High Computer Usage. While traditional sports present simi-
larities to that of esports, esports has the unique challenge of being
a sedentary activity. Low levels of movement and increased screen
time may cause health risks comparable to research on high com-
puter usage. Levels of screen-time have increased as technology
has continuously developed. Whether among children or adults,
excessive screen-time is health concern that negatively impacts
mental health, cognitive function, and sleep [
33
,
113
,
124
,
127
]. Ad-
ditionally, high-levels of computer usage, a requirement in esports,
is connected to strains and musculoskeletal issues [
3
,
10
,
28
,
37
].
These injuries have led researchers to consider preventative er-
gonomics in reducing the strain and risk caused by excessive com-
puter use [
17
,
20
,
70
,
86
,
117
], though such practice has yet to be
applied in esports.
3 INTERVIEW METHOD
In exploring the health issues in esports, interviews were used as
the rst step of the study. We began with interviews of professional
players to create a detailed understanding of the factors aecting
their health. Transcripts provided content that was used to develop
a theoretical model depicting key factors surrounding health in
esports.
3.1 Participants
Through email and messages on public proles, a total of ten pro-
fessionals agreed to participate in the interviews. Of the ten inter-
viewed, eight of them were male, with ve competing in North
CHI ’21, May 8–13, 2021, Yokohama, Japan
Table 1: Interview Participants
American servers, and the other ve competing primarily in Eu-
rope. The average age of participants was 25.8 years (SD = 2.70)
with an average of 4.67 years of competitive experience (SD = 1.32).
Participants competed in a variety of games, including StarCraft
II [
13
], Overwatch [
14
], World of Warcraft [
12
], 2k NHL [
1
], and
others. Each member interviewed competed in professional level
tournaments for income, or was signed to a long-term contract
by professionally recognized teams during their career. Among
the participants, the variety of gameplay provided insights to sev-
eral aspects of esports. Participation was voluntary; interviewees
could opt out at any time. Table 1 provides an overview of the ten
interview participants.
It is important to note some of the participants included in the
initial interview were previous esports competitors who had left
the professional scene. Their given reasons for quitting esports
and their experiences while active are valid stories that will help
to better understand the wellness surrounding players in the eld.
As demonstrated later in the results section, the experience of ex-
players provides understanding of where the esports community
needs to improve in order to support player wellness.
3.2 Protocol
Because of the variety of locations participants compete and live in,
interviews were carried out over Discord. These interviews were
recorded and transcribed for use in the content analysis and to build
a model depicting health in esports. A semi-structured interview
approach was taken, as it would provide in-depth information from
respondents experiences necessary to explore the health issues [
11
].
Using previous work, a set of seventeen questions were originally
broken up into three main categories that had initially been in-
vestigated in the eld: daily routine [
66
], physical pain [
31
], and
psychological strains [
89
]. The interview protocol was designed to
further develop previous ideas and create a better understanding of
how player’s view their well-being in esports. As interviews were
completed, support was added to the protocol as a sub-section, as
participants spoke of the support, or lack of support, in esports in
connection to wellness. Each interview lasted about thirty minutes.
CHI ’21, May 8–13, 2021, Yokohama, Japan
4 INTERVIEW RESULTS
Results collected through the interview process were used to create
a theoretical model depicting areas of health and the main factors
eecting each category. The information compiled contributed to
understanding the main themes presented in the original interview
protocol: Routine, Physical Health, Psychological Wellness, and
Support. This process was done by carrying out a content analy-
sis of all ten interview transcripts, broken up and categorized by
subset themes that appeared in the four larger categories. Further
explanation of the themes is discussed in the following sections.
4.1 Daily Routine
Daily routine relates to eating habits, exercise, practice time and
frequency, as well as sleep schedule. While some players mentioned
dierences between their o-season and on-season habits, much of
the information provided was a consistent routine centered around
improving and progressing as a professional in esports.
A typical routine was broken down into practice and sleep, with
extra activities occasionally being added. Practice was reported any-
where from two hours a day, to upwards of 12 hours per day. The
most common reported practice time was six hours (n = 3). In the
most extreme case, the hours were broken down into 110 hours over
a given week, as World of Warcraft [
12
] esports is a “marathon” de-
manding a “high-intensity of mental energy” (P7, male, 29). Coupled
with practice, sleep schedules varied greatly amongst the partici-
pants. Anywhere from 12am until 2am was a common time to go to
bed, with wake-up times occurring anywhere from 7am until 11am.
One participant was an outlier, reporting their sleep beginning
at 4am. Their late sleep pattern was due to a lifestyle structured
around streaming, their main source of income (P4, male, 24). Only
two participants mentioned any harm or negative eects from poor
sleep (though it is unclear if other health issues mentioned in the
physical and psychological sections are connected to their limited
sleep).
Outside of training and sleep schedules, routines diered. Only
three participants (P1, P5, P8) reported exercising daily. The exercise
ranged anywhere from mild cardio work to daily gym sessions. In all
three cases, they engage in exercise for personal health, unrelated
to esports. The same can be said for nutrition, in which participants
either had not thought of it, or carried out a basic meal plan for
personal reasons unrelated to esports.
4.2 Physical Health
Questions on physical health were written to explore player’s ex-
perience as it related to previous literature, such as (1) injuries
or physical pain they experienced [
31
], as well as any ways they
may have mitigated such issues. Additionally, participants were
asked if they had any plans relating to (2) exercise or nutrition, an
uncommon practice according to these professionals.
4.2.1 Physical Pain. After speaking on daily routine, participants
were asked about their physical health as it relates to esports. For
most participants, this included some form of physical injury con-
nected to long hours of competition. Injuries experienced included
back pain, body aches, and varying cases of eye problems, such
as general fatigue and eye dryness, consistent with ndings in
Madden and Harteveld
previous work [
31
]. One participant mentioned seeking out a chi-
ropractor due to pain impacting their daily activities (P3, male, 23),
while another met a doctor to treat severe wrist pains and muscle
damage (P10, male, 28). Another participant noted that they would
get massive headaches that would start in their eyes and then “force
my entire brain to physically hurt” (P5, female, 26). Participants who
observed physical pain often equated their issues to long sessions
with poor posture, or over-extended screen time.
Those participants who began experiencing large amounts of
issues began developing strategies to mitigate these negative eects.
This would include taking breaks such as “walking around a bit to
try not getting blood clots” (P7, male, 20) or creating a better set-up
to reduce stress on the body, such as “how you sit in the chair, where
your desk is, how your monitor is, how my wrists are set up” (P7,
male, 20). In some cases, as explained by P4 and P2, participants
took extended periods of breaks from esports, up to weeks at a time,
to recover.
4.2.2 Exercise and Nutrition.
“The most common problem I’ve noticed with pro play-
ers is obesity or malnourishment. They spend so much
time of their life in front of a computer or distracted or
focused on winning a computer game, and not enough
about staying healthy physically” (P1, male, 25)
Exercise was not common among the esports professionals, with
only three participants reporting it as part of their routine. One
member plays hockey on a regular basis (P8), another uses the
elliptical (P6), and a third goes to the gym regularly with their entire
esports team (P1). Between these three participants, experiencing
physical pain was minimal while partaking in esports.
Nutrition was similar, as only three participants (P1, P5, P6) re-
ported having some form of diet or nutrition. P5 explained that they
tried eating healthy most days, then cut out “anything heavy” be-
fore tournaments and major competitions. However, the other two
participants said their nutrition was part of maintaining a healthy
lifestyle, unrelated to their performance in esports. In regards to
nutrition, a more common response was that they either never
considered it, or simply did not have time. One participant recalled
“[having] Dunkin Donuts every morning for breakfast because I had to
practice my game, so I didn’t have time to make food” (P10, male, 29).
It was commonly neglected due to the busy schedule of esports.
4.3 Psychological Wellness
Questions on psychological wellness followed questions on phys-
ical health. During these questions, participants reported greater
diculties surrounding their psychological wellness. All partici-
pants commented on (1) high levels of stress and anxiety, while a
few participants recalled their experiences with (2) burnout or the
unique challenges of (3) being a female gamer.
4.3.1 Stress and Anxiety.
“The constant pressure of having to perform and being
self-motivated puts a lot of stress on people. I never
enjoyed anything outside of gaming because I thought
I shouldn’t be doing this; I’m wasting my time” (P4,
male, 24)
“Constant Pressure of Having to Perform”: Exploring Player Health Concerns in Esports
Stress was experienced in high levels by all participants, though
the factors that contributed to that stress varied from one player
to the next. Preparation and anxiety surrounding the start of tour-
naments was one of the more common factors contributing to
participants’ stress, with clear adverse eects. One participant got
“rashes before tournaments” (P1, male, 25) while another “tried to
eat breakfast and right before the picks and bans, we had to pause
the game so I could go into the back room and throw up” (P2, male,
24). This stress was self-inicted by the individuals’ competitive
drive, resulting in extreme loads of pressure being placed upon
their performance in every match setting.
Along with being a professional gamer, the added stress of rev-
enue was a major psychological factor (P1, P4, P5, P8, P10). Par-
ticipants often survived exclusively on the revenue they received
from playing well, whether it be from winning tournaments, or
from streaming on sites like Twitch. They explained that in esports,
sponsorship and viewership change often. This requires players to
constantly be performing well and creating an entertaining match
to continue to bring in paychecks.
4.3.2 Symptoms of Burnout. Many participants noted symptoms
of burnout as a major psychological strain they faced during their
esports careers. These symptoms were connected to the life-balance
that players face, managing both their careers and outside life.
Due to the long hours of team practice and additional solo work,
other parts of life, such as their social life, often suered. Isolation
was a major factor some players considered as having a negative
impact on their psychological wellness, with one player calling their
online relationships “very shallow friendships” (P4). Four out of ten
interviewees had quit esports (P2, P3, P4, P10). Those who quit
esports had an average career lasting 4.75 years (SD = 1.26), before
the mental drain or poor life balance led them to leave esports.
One contributor to symptoms of burnout is the lack of activity
coupled with long intense sessions of competition. Practices took a
major mental toll, often forcing players to remain focused and hyper
vigilant for the four to six hours they were playing every day. Even
among participants remaining active in esports, their gaming career
was constantly on their mind. One participant “could not fall asleep
because my mind was still just thinking about the game” (P6, female,
31). The combination of mental fatigue and general stationary state
brought about questions on motivations behind participating in
esports. Those that quit decided they no longer wanted to compete,
as they were no longer “satised” or “happy” with their chosen
career.
The negative atmosphere was an additional contributing fac-
tor to symptoms of stress and burnout participants experienced.
This negativity came from the players in the form of “toxicity and
anger...it happens all the time” (P6, female, 31), or from spectators.
As one participant explained, “Twitch spectators are mean; they don’t
give a fuck about the players” (P2, male, 24). As previously men-
tioned, they found that, unless you were on a team, the practices
and streaming can be socially isolating. Interactions were limited
to online ones, often carried out anonymously through chats and
social media. Spectators were often negatively commenting and in-
sulting players during their streams, forcing them to ignore the chat
or grow upset. This toxicity often enhanced many of the negative
psychological symptoms players experienced as professionals.
CHI ’21, May 8–13, 2021, Yokohama, Japan
4.4 Being a Female Gamer
“Even though we’ve proven time and time again that it
has nothing to do with gender, there’s less of us on the
scene because of mentalities like that” (P5, female, 25).
In addition to facing the stress of competition and intense train-
ing times, both female participants had additional comments on the
added stress of being a female gamer. In general, there are fewer
female competitors participating in esports at the professional level
than male competitors. Because of this, female participants have
to constantly prove themselves and their legitimacy in the eld.
Due to the lack of other female participants, they have to “look out
for yourself and make sure you have cool, supportive people that will
always be in your corner” (P5, female, 25) as others constantly doubt
their abilities.
4.5 Support
Support was added to the interview protocol after it came up mul-
tiple times in the rst interviews. Participants had diering views
on support, as it (1) related to family and friends while (2) being
absent among teams and organizations they had been a part of.
One of the main sources of support was reported as family mem-
bers and friends (i.e., parents, signicant others, a close group of
friends, etc.). Many participants talked about the visual support
their family and friends showed as active members of the audi-
ence at important matches, driving to dierent events with the
participants, or just being in the area during practices. Additionally,
they would provide listening and emotional support to participants
during hard times, such as going through a change of teams (P2,
male, 24), or facing symptoms of depression (P4, male, 24). In P4’s
experience, a major factor in the symptoms of mental illness was
the lack of support and community in esports. Because competi-
tions, streaming, and tournaments were all conducted virtually,
human interaction was minimal. The computer element dehuman-
ized the communication and sense of togetherness provided in team
atmospheres or traditional sports.
By contrast, participants generally commented that the teams
and sponsors did not provide any form of physical or emotional sup-
port during the players’ time as professionals. One player believed
it was due to money, with smaller teams lacking the necessary
funds to provide legitimate supportive services for them (P5, fe-
male, 26). However, other players admitted that even if they had
resources from their teams available to them, they were unsure if
they would reach out and use them. Still, players noted that they
would have liked a form of a mental coach, or connections beyond
just a team captain. Many of the players entering the esports pro-
fessional scene are young individuals, and having better support is
“crucial to helping these players navigate through esports” (P2, male,
24).
Because of this lack of support, those who received professional
aid (P2, P5) had to nd the assistance on their own. Their time and
resources were used to nd some form of doctor or psychologist that
could provide assistance in handling the psychological stress and
damage they were experiencing through their time as a professional
esports player. In their experience, participants said there was a
complete lack of resources or advice surrounding how to handle
CHI ’21, May 8–13, 2021, Yokohama, Japan
Figure 1: Health in Esports Model - Post Interview: The theo-
retical model provides an outline of the factors inuencing
esports health according to the players. Stress is emphasized
as it was the most common issue discussed regarding psy-
chological wellness. Additionally, Support was added to the
model as interview participants continued to mention their
networks of support (or lack thereof).
their psychological wellness, or what to expect should it begin to
deteriorate.
4.6 Initial Health in Esports Model
After analyzing the interviews, we developed a theoretical health
model (see Figure 1) to show the main themes and contributing
factors outlined by the players. The major themes examined were
Physical Health and Psychological Wellness, as well as Daily Rou-
tine and Support. Daily routine was found to be a small contributor
to the health of esports players, while support and psychological
wellness were emphasized by all those interviewed. Additionally,
the constant reference to various support groups required further in-
vestigation, leading to its addition within the surveys that followed.
Through use of the surveys, we begin to demonstrate connections
between the various factors of health for esports players, explained
in the following section.
5 SURVEY METHOD
The survey was developed using the main themes that appeared
from the health model at the end of Step 1 (see Figure 1). The survey
was distributed to a wider sample of esports players at collegiate,
amateur, and semi-professional levels. While some aspects of the
professional scene (i.e., revenue) are not present at lower levels
of competitive esports, the time commitment, tournament setting,
and pressure to win are consistent. For this reason, factors such as
screen time, stress, and team composition can still be observed and
evaluated. Questions sought to further explore the psychological
and physical health issues that were being reported in the interview
process, with the aim of understanding how these issues may be
connected.
5.1 Well-Being Instruments
In investigating psychological well-being and overall stress, esports
research is limited. Currently, there is no clear scale of measure-
ment for examining the psychological impact of esports. Therefore,
Madden and Harteveld
we used previously veried scales from psychological research to
determine levels of wellness and stress among survey participants.
In psychology, well-being is dicult to dene, though it is agreed
than an accurate measurement needs to account for psychologi-
cal, social, and emotional well-being [
32
,
34
]. Because of this need,
the Mental-Health Continuum-Short Form (MHC-SF) was chosen.
The questionnaire accounts for all three well-being factors (psy-
chological, social, and emotional) while providing reliable results
accounting for more than just mental illness [
69
,
76
]. Additionally,
due to its self-reporting applications, it was ideal for an online
survey [80].
In addition to general well-being, we wanted to further examine
the inuence of stress, as it was mentioned among all ten interview
participants. To measure stress, we used the Perceived Stress Scale
(PSS). This instrument is the most widely used tool for measuring
stress [
21
] as it measures stress based on the respondents perception
of life situations [
107
]. In the case of esports, we believed using
this tool would provide the most accurate details on respondent’s
perception of stress.
5.2 Survey Design
The survey was broken down to reect the major health factors
outlined during the interview process. The rst section consisted
of open questions on daily routine, asking players about their sleep
schedule, training routine, frequency of practices, and whether they
have nutritional or exercising routines. Additionally, participants
were asked to report the daily hours (0-24) they performed these
activities.
Section two explored the physical health among participants.
Questions were used to gauge the player’s overall view on their
health, as well as what they believed was the greatest health issue
among esports players. A multiple choice question was then used
to investigate frequency of injuries and pain, such as those initially
described in the interview process. The section concluded by asking
players to describe any professional help they may have sought out
while dealing with their pain.
The third section focused on the psychological wellness of the
participants. Questions were designed to explore the major factors,
especially stress, highlighted by the interview participants. This
section of the survey included the previously described question-
naires (MHC-SF and PSS) to measure the overall well-being and
stress among participants. The MHC-SF returned an acceptable
internal reliability (
α
= .83) similar to previous studies carried out
using the instrument [
69
,
76
], as did the PSS (
α
= 0.73). The section
of the survey was completed by adding questions to investigate
overall stress and support from various social groups discussed by
interview participants. These questions used a 7-point Likert Scale
in which participants self-evaluated the level of stress and support
they received from family, friends, self, teammates, coaches, and
spectators.
The survey was completed by asking general background infor-
mation, including age, region where participants competed, genre
of games participants competed in, as well as the highest rank they
achieved. This was placed at the end of the survey to avoid potential
biases that may arise from early identication in surveys.
“Constant Pressure of Having to Perform”: Exploring Player Health Concerns in Esports
5.3 Participants
Because professional esports athletes are dicult to contact, the
survey was administered to a broader range of esports players with
competitive experience at collegiate, semi-professional, and ama-
teur tournaments. To ensure their level of competitive experience,
questions were placed for participants to identify their highest
ranking, tournament experience, and team experience. Those who
provided responses without tournament experience or competitive
experience were not used in the survey analysis. Participants were
recruited by sharing the survey through social media (Twitter, Face-
book groups), online chat forums (Reddit, Discord), and e-mails
with collegiate, semi-professional teams, and professional teams.
All participants that answered the survey did not participated in
the original interviews.
The survey was open from March 5 to April 1, 2020. While
Qualtrics recorded a total of 78 responses, 68 were used for data
analysis after meeting criteria for experience in esports. Similar to
the interview participants, a majority of participants were located
in North America (37) and Europe (16). Additionally, a majority
of the participants were male (53), though this is to be expected
as esports players are primarily male [
120
]. As with the interview
sample, the participants of the survey included a wide variety of
competitive genres including: FPS (36), MOBA (10), and Strategy (8),
to name a few. This variety was important as the esports population
includes several genres of games and regions. Consistency between
the participants in both the survey and interview process allows for
comparisons to be made between the two studies. All participants
competed in collegiate (15), semi-pro (24), amateur (22), or even
professional (7) tournaments. The survey respondents had a lower
average age at 22.9 years old (SD = 3.36) though there was greater
variance.
Microsoft Excel was used to clean up the survey data and re-
sponses, while R Studio was used as the primary analysis tool. The
software was used to calculate basic means and standard deviations
for daily routine questions, as well as scoring the formal surveys
included in the protocol (MHC-SF, Perceived Stress Scale). The sur-
veys, once veried for reliability, were then compared through a
correlation analysis.
6 SURVEY RESULTS
After completing the interviews, a survey was administered to a
larger sample of participants. The survey included qualitative data
to provide further details on major health concerns and trends
in esports; quantitative data, including the survey instruments,
was used to provide descriptive statistics within the health model
factors. A correlation analysis was used to begin understanding the
connection between the examined factors.
6.1 Major Issues
During the survey, participants were asked (as were the profession-
als during the interview) what they deemed to be the most pressing
health concern facing esports players. Of the 68 participants, 21
mentioned mental health (including depression or burnout) as their
primary concern. As was the case during the interviews, psycho-
logical wellness continued to be a major factor players believed
was an immediate issue in esports. Other major concerns among
CHI ’21, May 8–13, 2021, Yokohama, Japan
Figure 2: Mental Health Question - “Select any symptoms of
the following you’ve experienced related to esports”
Figure 3: Survey response on pain - “Select Any you’ve expe-
rienced related to esports”
players included obesity and nutrition (n = 10), exercise (n = 10),
and sleep (n = 9).
Survey participants were also asked what motivates them to com-
pete in esports. The most common answer was to be competitive
and “win” (n = 15). Based on the interviews, this motivation may
contribute to the overall stress and pressure players face. Competi-
tions and tournaments brought out the most adverse eects when
speaking with professionals. Those competitions may create similar
symptoms of stress and anxiety among the participants, noted in
Figure 2. 24 participants reported experiencing symptoms of anx-
iety, and 16 mentioned symptoms of depression. However, when
asked in a follow up: “Have you ever received help for your mental
health symptoms,” only one participant out of the 68 included in
the sample reported seeking any professional help.
6.2 Player’s Perspectives
Responses for daily routine included how many hours participants
spent practicing, sleeping, and exercising every day. Participants
practiced an average of 5.03 hours each day (SD = 4.77) similar to the
hours reported by the professional gamers in the interviews. Sleep
was reported as an average of 7.11 hours (SD = 2.30) each night, and
exercise averaged 1.53 daily hours (SD = 1.63). Additionally, partici-
pants most commonly reported following their routine ve times
out of the week, matching the schedule reported by professional
participants in part one of the study.
As was the case with the interview protocol, survey questions
then asked participants to describe pain or injury they had encoun-
tered in esports. Figure 3 shows the distribution of participants
based on the physical pain they reported having relating back to
their experience in esports. Eye Fatigue was the most common
response (27 participants) while wrist pain, back pain, and general
fatigue were close behind (26 participants), corroborating previous
work on injury in esports [
31
,
49
]. Issues such as time management,
CHI ’21, May 8–13, 2021, Yokohama, Japan
poor set-ups, and lack of breaks presented in the interviews may
explain the common responses among survey participants.
Through use of previously developed instruments investigating
mental health, participants scored an average of 49.28 (SD = 6.31)
in the Mental Health Continuum-Short Form (MHC-SF). In terms
of positive well-being, this places them in a relative middle range,
where participants are neither “ourishing” or “languishing” [
69
].
The second scale, the Perceived Stress Scale (PSS), returned an
average score of 27.74 (SD = 4.11). The PSS is broken up into three
categories of scoring, ranging from low stress (0-13), moderate
stress (14-26) and high stress (27-40), placing the average participant
on the line of moderate to high perceived stress. This aligns with
the relative level of stress discussed by interview participants.
The survey questionnaire was completed using a set of Likert
scales set-up to investigate the level of perceived support versus
stress participants felt from various groups. These support groups
were based on information provided by interview participants; the
average results are shown in Table 2. When evaluating perceived
stress, individuals felt self-inicted pressure created the highest
level of overall stress (M = 4.50, SD = 1.72). Responses to support
evaluated family (M = 4.23, SD = 2.03), friends(M = 4.60, SD = 1.97),
self (M = 4.65, SD = 1.99), coaches (M = 4.21, SD = 2.19), and team
members (M = 4.79, SD = 1.88) providing similar levels of support.
Spectators were given the lowest levels of stress (M = 2.19, SD = 1.69)
and support (M = 2.92, SD = 2.05). Survey participants may ignore
spectators in a similar manner mentioned by professionals during
the interview. However, since participants are not professional, they
may also have less interaction with streaming or spectators, which
may account for the lower overall scores.
Table 2: Perceived Stress and Support, in M (SD)
Stress Support
Family 3.44 (1.89) 4.23 (2.03)
Friends 2.48 (1.50) 4.60 (1.97)
Self 4.50 (1.72) 4.65 (1.99)
Coaches 2.27 (1.70) 4.21 (2.19)
Team 3.19 (1.70) 4.79 (1.88)
Spectators 2.19 (1.69) 2.92 (2.05)
6.3 Creating Connections
The overall results of the survey supported many of the concerns
originally mentioned in the interviews. Common themes continued
to appear similar to those placed in the theoretical health model (see
Figure 1). To understand how those themes could potentially con-
nect, correlation analysis was run to compare the relation between
health factors. Much of the data was not normally distributed. For
this reason, correlation analysis was carried out using Spearman’s
method.
6.3.1 Daily Routine Correlations. The rst set of correlations exam-
ined the daily routine practices and their potential relationship to
the overall health measured with previously validated instruments.
The resulting correlations are presented in Table 3. The correlation
analysis showed no signicance between many of the daily routines
Madden and Harteveld
Table 3: Daily Routine Correlations
P S E H DT MHC-SF PSS
Practice (P) 1
Sleep (S) -.1 1
Exercise (E) -.05 0.17 1
Health (H) .08 .10 .09 1
Days Training (DT) .35** -.01 .02 -.12 1
MHC-SF .08 .10 -.05 .25 .27 1
PSS -.08 -0.04 -.16 -.28* -.10 -.60*** 1
* p < .05; ** p < .01; *** p < .001
and their relation to the various health measures. Hours spent prac-
ticing esports, sleeping, and exercising appear to be independent of
the perceived stress, mental wellness, and general health of many
of the participants. Unsurprisingly, the MHC-SF and PSS showed
a strong negative correlation to one another. This connection is
to be expected, as stress is often associated with lower levels of
mental wellness [
29
]. There was a strong positive correlation be-
tween the hour’s players practiced and the number of days they
trained, suggesting people who practice more also do it more often.
This is explained by comparing the variety of dierent levels of
competitors participating in the survey: as players participate in
higher levels of competition, their obligations