Health Video Games Spark Interest, Try to Gain Traction

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In the late 1990s, Thomas Baranowski, PhD, professor of pediatrics specializing in nutrition at the Baylor College of Medicine, Houston, applied for a grant. For years, he had been interested in finding ways to get children to change their diet and physical activity. He decided to try a video game, and he got the money to develop it.

It worked.

“We showed that kids who played that video game increased their consumption of fruits and vegetables by a serving a day—which may not sound like a lot, but that’s as good as anybody did at that time and just about as good as anybody has done since,” says Dr. Baranowski.

He is now editor of Games for Health, the first peer-reviewed academic journal for research on video games used for medicine and health, launched in 2012.

Dr. Baranowski

Today, he says there’s “every reason to believe that video games can in fact impact behaviors” through their effects on the psychosocial factors that lead to those behaviors. There’s also evidence that they even influence health outcomes.

Health & Gaming

It seems that more and more people in academia and the healthcare world are—ever so gradually—coming to the same realization. The Wii Fit system has been increasingly used for health purposes. Popular smartphone apps, such as Zombies, Run! have put health games in the spotlight.

Nintendo has plans to release next year its first quality-of-life device that will keep track of fatigue by monitoring sleep. Although the device is not a game, the move by the gaming giant does point to a growing overlap between health and gaming.

A growing number of scientists and specialists are forming companies to develop health games, said Debra Lieberman, PhD, director of the Center for Digital Games Research at the University of California, Santa Barbara. Researchers at the center study how people process and respond to digital media and games—cognitively, emotionally, socially and behaviorally—and they use these findings to develop new game-design strategies and technologies that are engaging and effective in such areas as entertainment, learning, public policy and health.

“Health games and other digital media designed to support patient self-care and clinicians’ delivery of care are important components of the burgeoning digital health field,” she says.

She hopes that more people will play well-designed health video games that motivate and support healthy habits and, when problems arise, lead to good adherence and health decision making. “The immersive and interactive world of a video game can be an especially effective environment for improving health behaviors and health outcomes in ways that cannot be achieved with such

‘If [games are] going to be accepted as a legitimate health-related intervention then we need to increase the sophistication of the research.’ —Dr. Baranowski

media as print and video, although these media can be designed to influence health behaviors in other important ways,” she says.

“In health games, players can take a first-person perspective as they make health-related decisions and experience the health consequences,” she says. “It’s trying things out, learning by doing and, thereby, gaining a deeper understanding of cause and effect. Players clearly see the link between their behaviors and their health. Also, games can be especially good at enhancing a sense of self-efficacy, or self-confidence, to carry out a health behavior, because players must rehearse that behavior repeatedly in a game until it becomes easier to do. They are striving to win the game, and if they must learn health skills and behaviors in order to win, they will try again and again until they succeed and then win the game. Our research has found that the self-efficacy gained by rehearsing skills during game play can translate into stronger self-efficacy for carrying out those skills and health habits in daily life.”

Research Support

With exercise so critical to managing symptoms for many people with rheumatic conditions and with a complex disease process to describe, games might be a particularly good fit in rheumatology.

In a 2011 study out of the University of Alabama, researchers enrolled 15 sedentary, African-American women with systemic lupus erythematosus (SLE), who were experiencing moderate to severe fatigue, in an evaluation of the Wii Fit game system in helping with symptoms.¹ The women participated in a fitness program using the Wii system three days a week for 30 minutes each session for 10 weeks. After 10 weeks, they reported their perceived fatigue, measured by the Fatigue Severity Scale, to be significantly reduced. Body weight and waist circumference were also significantly reduced.

There’s every reason to believe that video games can in fact impact behaviors through their effects on the psychosocial factors that lead to those behaviors. There’s also evidence that they even influence health outcomes.

“Findings provide preliminary evidence that Wii Fit motivates this population to exercise, which leads to alleviation of fatigue and reduced body weight, waist circumference, anxiety level and overall intensity of total pain experience,” researchers concluded.

Gather your defenses against a horde of invaders and take part in a war that’s as old as life itself. Immune Defense offers players the chance to employ real-time strategy on a nanoscale.

Another study found that virtual-reality telerehabilitation was associated with benefits in balance and posture control for multiple sclerosis patients.² Twenty-five controls received traditional physical therapy for 80 minutes, over two sessions, per week. Another 25 received telerehabilitation treatment with the Xbox 360 game console, monitored by videoconference. Researchers found an improvement in balance in both groups and concluded that the game “might serve as a successful therapeutic alternative in situations in which conventional therapy is not readily available.”

More Research Needed

These kinds of results are encouraging. But there is a lot of room for improvement in really understanding the effects that games can have on patients, in part because most of the games used are not made to order, according to a recent review article on the use of so-called “exergames” in multiple sclerosis.³

“The current work is contradictory, and there is no consensus with regard to training duration/intensity and the outcomes used to assess the clinical effectiveness,” concluded researchers from the University of Essex in the United Kingdom. “This in part is due to the off-the-shelf nature of the games used. A more satisfactory approach would be the development of bespoke games that match a clinical need.”

That’s a refrain heard throughout the games-for-health world. Just as often as the benefits are touted, so is the need for better research to firmly demonstrate the value of gaming in healthcare.

A meta-analysis of 54 studies on health-related serious digital games found small, positive effects on healthy lifestyle and the factors that determine that lifestyle.⁴ Effects on actual clinical outcomes were also significant, but much smaller. The analysis called for better evaluation of the components of games that have the greatest effects.

A recently published white paper on games for health for children said the top two research aims should be “adequately powered randomized clinical trials” on outcomes for a stronger empirical basis of game efficacy and on testing game design and behavior change features.⁵

Dr. Baranowski, the first author on the white paper, says it’s clear that “if [games are] going to be accepted as a legitimate health-related intervention then we need to increase the sophistication of the research.”

Funding Needed

The increased interest in health gaming has developed even as funding for these games has become more difficult. The primary source has been the National Institutes of Health, which now funds half as many submissions as it used to.

“The ability to get funding to do this kind of work has diminished remarkably,” he says. “I’m hoping that other kinds of institutions will come forward.”

Use of mainstream game devices, such as the Wii Fit and Xbox, for health purposes, has not translated into interest from commercial gaming companies in specifically developing health games. But that interest would be nice, says Dr. Baranowski.

Dr. Lieberman

“A problem with games for health that have been developed so far is that they reflect the expertise that’s available to us,” he says. “We do as well as we can, given the resources we have, but frankly we don’t have the $30 million that the game-development companies have when they develop their blockbuster, shoot-’em-up video games. Wouldn’t it be wonderful if somehow those companies got engaged in doing this kind of work?”

Melanie Stegman, PhD, a developer of video games designed to teach molecular cell biology, has evaluated the third-person-shooter game, Immune Attack, and used the data to design the strategy game, Immune Defense. These games were not specifically designed to be used by people with rheumatic conditions, although Dr. Stegman says they would likely benefit such patients, helping them better understand some of the biology behind their illness.

Her evaluation, in which study subjects played Immune Defense and controls played a different game, found that those who had played her game performed better on a test of cell biology and exhibited greater confidence in their knowledge of cell function.⁶

Overcoming Objections

Dr. Stegman

Dr. Stegman says she is aware of the hesitation many physicians have in using games as part of their care.

“There are many reasons why there are naysayers,” she says. “One of them is the idea of a game just makes you think of a kid in a basement shooting people.”

The road to greater acceptance is clear, she says. “I definitely think we need more rigorous evidence that games can teach, and we have provided that,” she says. “Now we are working to make our game more popular with game players aged 12 and older.”

Dr. Lieberman says it would be a good idea to make more rheumatology video games.

She says, “Rheumatology is a complex area—there are so many diseases and healthcare challenges related to prevention, diagnosis, delivery of care, patient education and patient adherence to treatment plan.

“It would be exciting to see rheumatology games that give the general public an overview of rheumatic diseases and how they affect the body, that aid and, in some cases even train, clinicians in this field, that deliver supplemental physical therapy and rehabilitation, and that immerse patients in game-based experiences that boost their knowledge and abilities, and also motivate and improve their self-care.”

Nintendo has plans to release next year its first quality-of-life device that will keep track of fatigue by monitoring sleep.

Age, Dr. Lieberman says, is no longer a major barrier when it comes to playing video games. She and her team conducted two nationwide representative sample surveys on video game use in the U.S. in 2010 and 2013, and found that a majority of people in every age group ranging from ages 1–93 played video games. In all, 77% of the U.S. population played video games in 2013, up from 68% in 2010.

“Our survey found that the fastest increase from 2010–2013 in the percentage of people who play video games was among people ages 60–93,” Dr. Lieberman says. “Now that video game interfaces are more intuitive and easier to use, people of all ages are enjoying games.”

Tom Collins is a freelance medical writer in South Florida.

8 Elements of a ‘Good’ Game

Making a health game might look easy, but …

Debra Lieberman, PhD, director of the Center for Digital Games Research at the University of California, Santa Barbara, is a huge supporter of using video games—and digital interventions in general—for health.

She has seen the power they can have. She knows what works. But she also knows what doesn’t work. And creating a good video game isn’t as easy as it looks. She says some outstanding health games have addressed diabetes self-management, asthma self-management, immunology, smoking prevention, cancer-treatment adherence, pain distraction, physical activity, cognitive and physical therapy, ADD, autism, PTSD and much more.

“Some organizations are making health games—well-meaning people trying to do what’s best—but their design team does not know how to promote health behavior change or improve health knowledge, nor do they know how to make a fun, entertaining and engaging game that people really want to play,” she says. “So you get games that aren’t impactful as health interventions and are not that much fun to play. I applaud the effort; however, to help make a health game both effective and fun, the design team needs input from various specialists, such as clinical practitioners in the health area, experts who know the interests and abilities of the target population, health promotion designers and researchers who know how to integrate behavior change strategies into the design of entertainment games, and can conduct user testing to make improvements during game development, and—very importantly—game designers and artists who know how to make great, compelling, challenging, fun games.”

So what makes a game work? Here are a few components to include in a basic toolkit:

A sense of user control and agency. “Players should have choices and a sense that they can make things happen in a game,” Dr. Lieberman says.
The ability to adapt to skill level. As players improve their skills, the game should adapt and become increasingly difficult so it will remain compelling and challenging. Likewise, if playing becomes so difficult that players cannot succeed, the game should adjust to become slightly easier to play so players won’t give up in frustration.
Rehearsal of skills with real application to the player’s own life. Some health games can be designed to hone skills that are relevant to the player’s lifestyle habits and health regimen. These games might challenge the player to develop and apply their knowledge and skills as they control their game character, or avatar, to carry out health behaviors in the course of a simulated typical day or week. The game can provide real-time feedback in context, showing the health benefits or drawbacks of the avatar’s behaviors.
Improvement of self-efficacy. Dr. Lieberman says, “Usually we know, or can easily find out, how to take care of our health or manage the self-care aspects of a chronic condition, but we may lack self-efficacy for carrying out a health behavior—the confidence and belief that we are able to do it. Games can improve self-efficacy by giving us opportunities to strive and then succeed, demonstrating to ourselves that we can overcome the obstacles we thought were impossible to handle. For example, some health behaviors may be time consuming, expensive, uncomfortable, boring or hard to do, and medications may have side effects. A game can give players a safe virtual world in which they can address those obstacles and rehearse new skills, and thereby gain the self-efficacy to carry out the health behaviors in their own lives, in spite of the obstacles.”
Characters that are similar to the player. “People tend to pay attention to and emulate the behaviors of characters that are similar to them in looks, demographics, lifestyle, culture, attitudes and so on,” Dr. Lieberman says, referring to the concept of homophily. “We can take homophily a step further and note that people tend to be interested in any character that has their health condition, even if the character doesn’t look like them.”
Entertainment value. Games are rule-based activities that involve challenge to reach a goal and that provide feedback on progress toward the goal. Health video games should offer compelling challenges in a way that is fun and/or involving.
Feedback. A good game provides immediate progress feedback and, when appropriate, a way to track feedback and progress over time. For example, a mobile game that supports a player’s workouts may provide feedback on a runner’s current speed and heart rate, and also keep a cumulative record of data about the runner’s previous workouts.
Teamwork. “Research on teamwork finds that team members will work harder and will persist for a longer period of time when the team depends on their efforts, because they do not want to let their teammates down,” says Dr. Lieberman. “Teamwork has been used successfully in certain health games to improve players’ motivation and effort.”

—Thomas R. Collins

Reference

Yuen HK, Holthaus K, Kamen DL. Using Wii Fit to reduce fatigue among African American women with systemic lupus erythematosus: A pilot study. Lupus. 2011 Oct;20(12):1293–1299.
2Gutiérrez RO, Galán Del Río F, Cano de la Cuerda R. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013;33(4):545–554.
Taylor MJ, Griffin M. The use of gaming technology for rehabilitation in people with multiple sclerosis. Mult Scler. 2015 Apr;21(4):355–371.
DeSmet A, Shegog R, Van Ryckeghem D. A systematic review and meta-analysis of interventions for sexual health promotion involving serious digital games. Games Health J. 2015 Apr;4(2):78–90.
Baranowski T, Blumberg F, Buday R. Games for health for children—Current status and needed research. Games Health J. 2015 Aug 11 [Epub ahead of print].
Stegman M. Immune attack players perform better on a test of cellular immunology and self confidence than their classmates who play a control video game. Faraday Discuss. 2014;169:403–423.