1. No category

HOW TO PLAY YOUR WAY TO HEALTH
Designing a game for diabetes education and behavior change
By
Xiangxiang Zeng
16 December 2013
A thesis submitted to the
Faculty of the Graduate School of
University at Buffalo, the State University of New York
In partial fulfillment of the requirement for the
degree of
Master of Fine Arts
Department of Media Study
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ACKNOWLEDGMENTS
I would like to thank my advisor Prof. Dave Pape, and other thesis committee members,
Prof. Roy Roussel and Prof. Stephanie Rothenberg, for all the support throughout the thesis
process, as well as their great teaching and guidance during the past three years. I am honored to
have studied with them.
I also want to thank all my friends in and outside Department of Media Study, University
at Buffalo, who have contributed considerably to the completion of my degree. It is an honor to
have worked with Steven Nappa, Devin Wilson, Derek Curry, John Longanecker, John Bono,
Dien Vo, Nathanael Marquardt, Cheng Cheng, Yuling Xie, Wayne Weiai Xu, Steven Fox, Hans
Baumgaertner, Jake Cassel, Feon Fei, Alba Jaramillo, Xinhui Zhan, Ruoxi Zhang, Nicole Lee,
Sam Avery, and my other peers in the master program. They are all fantastic artists, thinkers and
writers. I am thankful for the generosity of them sharing their intelligence and wisdoms with me,
and also for the friendship that is always being strong and trustworthy.
Last but not the least, I would like to thank my parents Li'ao Wang and Fantao Zeng, for
their unconditional love and support in my life. Being a normal family in China, it was not an
easy decision for them to send me over to the other side of the earth for higher education; they
love their son so much that they were willing to go through the financial stress to help their son
to pursue his dream. Also, I am thankful for them shaping me with all the universal values that
make me able to communicate in an international community and never lose who I really am.
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TABLE OF CONTENTS
ACKNOWLEDGMENT...................................................................................................
ii
ABSTRACT........................................................................................................................
iv
CHAPTERS........................................................................................................................
1
I.
INTRODUCTION.........................................................................
1
II.
SERIOUS GAMES AND HEALTH............................................
2
III.
THEORETICAL FRAMEWORK............................................... 9
IV.
DIABETES MELLITUS...............................................................
V.
VI.
19
DIABETES GAME PROJECTS.................................................. 32
CONCLUSION..............................................................................
39
REFERENCES................................................................................................................... 40
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ABSTRACT
Using video games to improve people's health condition is an increasing trend in the
healthcare industry, as research keeps showing the evidence of their effectiveness in this area. In
the academic world, this type of games falls under the genre of serious games: games that are
educational rather than merely entertaining, and video games for health are developed to target
different diseases. Diabetes in particular has had a certain amount of special attention. This is, no
doubt, due to the fact that diabetes is one of the most common chronic diseases that is presently
affecting a large and ever increasing population across the globe. Video games designed to
facilitate diabetes education have been around since the 90s, and just like other serious games,
diabetes games also showed effectiveness in promoting patients' health.
Most of the existing research regarding serious games applies a scientific focus to
evaluate outcomes in relation to patient behavior. The effectiveness of these games is measured
by the collection over time of different data and statistics. Serious game design and study is a
hybrid entity composed of many different disciplines, including fields of both science and art.
Although such study does heavily rely on science, there is a need to hear from the artistic
perspective as all concepts and science have to be presented in an artistic way in order to be
effective.
In this context, game design can be a form of artistic practice So far, not too much has
been done to examine the design aspects of games for health and how these affect a patient's
receptiveness to proper treatment of their disease. This research targets game design for diabetes
promotion and education, looking at the design aspects of diabetes games. It will not only
explore the theoretical framework that support those games behind the scene, but will also
examine elements of games, including narrative, interaction design, game mechanics design,
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character design, and how theories and practice work together to create experience that are both
entertaining and educational.
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1. Introduction
Can video games improve your health? The answer is yes. Much of the research in this
area shows that video games can have a positive impact on improving people's health. People
can be given an enhanced awareness of their health problems and persuaded to change their
behavior for a better quality of life. Video games for health promotion are becoming more
popular recently. Games, such as RE-MISSION, Escape from the Diab, have effectively helped
patients successfully deal with their disease and improved coherence of treatment for that
disease.
Video games that deal with diabetes have been around since the 90s. Many patients with
diabetes who have played these games have been observed to have benefited from them, and
have successfully handled their diabetes as a result. A lot of research on these games specifically
evaluates their effectiveness by applying a scientific focus on the outcomes of those games
regarding patient behavior. Data and statistics, in relation to patients' reception of the games and
the information they are trying to convey, are gathered by scholars and researchers to evaluate
their effectiveness. However, almost no research pays attention to the artistic aspects of these
games, especially from the perspective of a game designer. Although studying diabetes games
does heavily rely on science, there is a need to hear from the artistic perspective as all concepts
and science have to be presented in an artistic way. This research aims to look at design aspects
of games for diabetes education through the perspective of a game designer. Based on a practicebased research methodology, it tries to combine art and science, theories and practice, and
explore the strategy of creating an effective diabetes game.
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2. Serious Games and Health
2.1 Serious Games
Serious games are, "a mental contest, played with a computer in accordance with specific
rules that use entertainment to further government or corporate training, education, health, public
policy, and strategic communication objectives" (Zyda, 2005).
In 2002, a project called "Serious Games" that aimed to improve the development of
games of public policy debates was launched by the Woodrow Wilson International Center.
After that, serious games, as a unique genre of video games, became more widely recognized
(Jackson, 2004). In 2008 in the Serious Games Summit, serious games were defined as,
"applications of interactive technology that extend far beyond the traditional video game market,
including: training, policy exploration, analytics, visualization, simulation, education, and health
and therapy" (Susi, Johannesson & Backlund,2007). Michael and Chen (2006) describe serious
games as "games that do not have entertainment, enjoyment, or fun as their primary purpose";
Susi, Johannesson and Backlund (2007) highlight that serious games transfer knowledge and
techniques "in traditionally non-game markets such as training, product design, sales, marketing,
etc."
The conceptions of serious games vary from person to person in the academic world;
however, there is a consensus that serious games are using entertaining methods to achieve
serious goals. Players are exposed to serious information while participating in the game activity.
Through the simulation of the real world, realized by digital technologies, players are educated
with knowledge and skills that they can use in their real life without risking, for example,
elements of time, cost, and danger. Currently, serious games are used in many fields, including
education government, military, healthcare, and so on. 24 Blue is a video game developed to
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train soldiers with skills necessary for safe operations on an aircraft carrier1. Government in
Acton teaches how government functions, and introduces challenges and everyday experiences of
governing2. RE-MISSION deals with improving cancer treatment coherence for youth, and
psychological stress caused by that cancer3. Sid Meier's Railroad Tycoon simulates the business
of running a railway company, teaching people skills and introducing challenges of doing such
type of business4. SimCity is also considered as an educational game as it teaches urban planning
and management5. Firefighter Training: The REVAS Process trains firefighter with skills of safe
rescue6.
2.2 Attributes of Serious Games
Serious games have proved that they can be used for learning and training purposes.They
can effectively disseminate information, and encourage behavioral changes (Wang & Singhal,
2009 ; Prensky, 2003; Kato, Cole, Bradlyn & Pollock. 2008). In this section, the attributes of
serious games are examined in an effort to understand why serious games work.
Serious games have attributes that all other video games have, but not all of them
contribute to achieving the serious goals of the games. We can hardly find violence, bloody
scenes, or overly sexual characters in serious games, but other attributes of entertainment games
do greatly contribute to achieving serious outcomes.
Attribute #1: Immersive learning environment
1
24 Blue, http://www.breakawaygames.com/serious-games/solutions/defense/
Government in Action, http://www.mhpractice.com/products/GinA
3
RE-MISSION, http://www.re-mission.net/
4
Sid Meier's Railroads, http://www.2kgames.com/railroads/
5
SimCity, http://www.simcity.com/
6
Firefighter Training: The REVAS Process, http://www.3dseriousgamesandsimulations.com/showcase/firefightersimulation/
2
3
Serious games provide an immersive environment where players learn through practice
within a context of practice, instead of learning passively outside the context of practice (Zielke
et al, 2009; Wang & Singhal, 2009). Traditional classroom education may employ multiple
media to gain a better learning outcome; besides lectures, teachers may also use videos or slide
shows to help students better understand the content they are teaching. In spite of that, students
still mainly learn by listening and watching, and they are asked to memorize certain things.
Benjamin Franklin has said "tell me and I forget. Teach me and I remember. Involve me and I
learn." Merely watching, listening, and passively doing is not the best way of giving education.
Serious games create the deepened involvement by simulating a field-related situation, and
learners are self-motivated to participate in the game activities. Once learners feel they are
engaged and actively participating, they learn better (Ritterfeld, Shen, Wang, Nocera & Wong,
2009).
Attribute #2: Interactivity
Interactivity distinguishes video games from other media forms. It enables the
communication between players and the game systems (Ritterfeld et al 2009). Players constantly
interact with a game system, and in turn, the game system gives feedback in response to the
players' action. Such interaction enhances the sense of involvement of players as it is presented
through a combination of audio, video, graphic, and haptic, voice and motion, all of which
transmits information almost immediately, resulting in a deepened involvement (Kennedy G,
2004; Wang & Singhal, 2009). Interactions involve learners also by allowing players to rehearse
and practice their skills. Consequences are demonstrated in front of them in a very short period
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of time (Ritterfeld et al 2009; Lieberman, 2001). As I mentioned earlier, when learners are better
involved, they learn better.
Interactions within a game usually include exploring the virtual environment of the game,
interacting with objects and characters (both Non-player characters and other players' characters),
finding clues and solving puzzles (Ritterfeld et al 2009). Those interactions either simulate a
certain situation players may encounter in their real life, or teach skills that players need in real
life, and thus transmit knowledge and technique through a learners' participation in the game.
Attribute #3: Narrative engagement
Narrative functions as the motivation to play and it engages people in game activity.
Narratives are used to provide the sense of location, identity, mission, and ability (Adam
s, Mayer, MacNamara, Koenig & Wainess, 2012). Usually the serious content is contextualized
through narrative. Stories have the power to draw people's attention. People also feel associated
with characters in a story. The storytelling in digital games is usually more complicated than the
traditional ones such as film and TV drama, as it is interactive and could develop in different
ways. When the player is given agency by the game, he or she is able to make choices based on
his or her own thoughts. Different choices will lead to different outcomes, and a learning process
is going on while player is exposed to those outcomes.
2.3 Serious Opportunity for Health
On average, young people spend almost 11 hours a day engaged with digital media
content in their everyday lives, including 1.5 hours playing video games (Rideout, Foehr, &
Roberts, 2010). 84% of today's eighteen year old college students own a personal computer, 25%
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of these own more than one (Oblinger, 2004). By the time children reach the age of twenty-one,
on average, they would have spent 10,000 hours playing video games, as well as 10,000 hours
using their cell phones (Oblinger, 2004). As the new media networks become increasingly
pervasive, networks such as app and play stores (IOS, Android), Xbox LIVE, Facebook, etc,
people have more opportunities to receive accurate, up-to-date healthcare information through
gaming anytime, anywhere in their everyday lives (Patterson, Wolfenstein, Millar, Halverson &
Squire, 2011). Such a high rate of exposure to media devices provides the opportunity to use
video games as a medium to deliver healthcare information to a large and young audience.
In the 90s, game designers started to create games for health education and promotion,
and those games increasingly attracted public attention (Lieberman, 2009; Peng & Liu,2008).
Health games deal with a wide range of health issues. For example, Catch the Sperm is a game
that deals with the issue of HIV prevention; Created by HopeLab, RE-MISSION is a 3D shooting
game that helps patients with cancer gain knowledge of cancer treatment, enhances their
adherence to the treatment process, and, in return, increases the survival rate (Kato et al, 2008).
Bronkie the Bronchiasaurus is a video game that teaches children how to control their asthma7.
Escape from the Diab is designed to lower the risk of obesity and type 2 diabetes by
demonstrating proper meal plans (Lu, Thompson, Baranowski, Buday & Baranowski. 2012).
2.4 Significance of the Study
Diabetes is one of the most common chronic diseases in many countries regardless of
race, ethnicity, gender and age. The World Health Organization indicated that in 2010300
million people worldwide are suffering from diabetes, and the number is likely to double in the
next two decades (Al-Qazaz, Hassali, Shafie, Sulaiman & Sundram, 2010). In 2011, the number
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http://www.mobygames.com/game/bronkie-the-bronchiasaurus
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of diabetics reached 14.7 million in Africa8, 52.6 million in Europe9, 92.4 million in China10, and
over 25.8 million in United States11.
Even though such a large population is suffering from diabetes, appropriate selfmanagement and medical intervention can help effectively control the disease, and facilitate
living a healthy life (Gatt & Sammut, 2008). In order to decrease this trend, patients need to
demonstrate good self-management skills, including changing their lifestyle in various ways,
such as regulating diet, regularly exercising, monitoring glucose levels, and managing
medication (Amoako, Skelly, & Rossen, 2008). In addition, patients need to take into
consideration the psychological stress accompanied with this disease. Once people are diagnosed
with diabetes, they face a series of lifestyle changes that can be traumatic and very stressful
(Amoako et al, 2008 ; Xu, Toobert, Savage, Pan & Whitmer, 2008).
Games for diabetes education have been in use since the 1990's. Several games, such as
Packy and Marlon, Escape from Diab, have shown evidence that they effectively reduce the
complications caused by poor self-management, and have the ability to increase the patients'
knowledge of the diseases, and improve patients' quality of life (Thompson et al, 2010; Brown,
et al, 1997). Evidence also shows that serious games give people the ability to cope with
psychological problems caused by diabetes. Boyle et al, have found that video game therapies
have the potential to reduce aggression, anxiety, autism and other psychological problems (Boyle,
Connolly & Hainey, 2011). RE-MISSION, for example, was proven to have a positive impact on
players' confidence so that they have suffered less from psychological problems caused by
diabetes (Kato et al, 2008).
8
International Diabetes Federation, http://www.idf.org/diabetesatlas/5e/africa
International Diabetes Federation, http://www.idf.org/diabetesatlas/5e/europe
10
International Diabetes Federation, http://www.idf.org/press-releases/idf-press-statement-china-study
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American Diabetes Association, http://www.diabetes.org/diabetes-basics/diabetes-statistics/?loc=DropDownDBstats
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However, most existing research has applied a scientific focus on the outcomes of
diabetes games. Many of them examine related theories to interpret the statistics or behaviors of
the players' persuaded by diabetes games. Little has been done, however, to look at the game
design aspect of diabetes games. Game design occurs through many different phases, and
incorporates a variety of concerns. Game designers have to answer questions such as "what is a
good design strategy to create effective diabetes games"; "what is the role of storytelling in
games"; "how it connects to persuading change"; "what are the goals in diabetes games"？
The purpose of this research is to explore the design strategy for diabetes games by
combining theory and practice. Game design involves several phases of design from concept,
story, character, art, to game mechanics, interaction, and "the magic circle". When games have to
serve the goal of seriousness, the game design also has to follow certain rules to guarantee its
effectiveness in this serious purpose. This research will employ a practice-based approach, not
only in order to examine theories that support serious games behind the scene, but also to
analyze current diabetes games and game design, and to suggest a design strategy for diabetes
games.
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3. Serious Game Theoretical Framework
As is introduced in the previous section, serious games simulate reality without being
limited to a certain time and space, and engage people with the storytelling and interaction, but
these features of serious games are not directly connected to promoting people's health. To better
understand how serious games promote health, a theoretical framework is needed. Michigan
State University game experts describe serious games as lying at the heart of "theory, content
and game design"12, which implies the importance of theory in serious games study. Here in this
section, all the theories of serious games won't be systematically laid out, but will only be
examined to answer three questions:
1. How can serious games be entertaining and educational at the same time?
2. How are messages transmitted between video games and players?
3 How do people benefit from video games in terms of promoting health condition?
3.1 Game Theories
3.1.1 Flow Theory
The Flow Theory was first introduced by Csikszentmihalyi (1975); it was originally
discussed in studying people's behavior in activities such as chess, dance, and other art
performance (Kiili, 2005). Flow Theory, which is also called optimal experience, refers to a
psychological state in which someone is so involved in an activity that nothing else seems to
matter to them anymore (Kiili, 2005). To have a flow experience in an activity, there should be a
balance between the skills of the participant and the challenges given by the activity. Otherwise,
participants would either feel bored if their skills are way above the challenges of the tasks, or
they would feel frustrated or anxious if the tasks are way beyond their abilities to accomplish.
12
http://seriousgames.msu.edu/
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Either of these conditions would lead the player's loss of interest in that activity (Kiili, 2005 ;
Boyle et al, 2011; Chen, 2007).
Flow state provides the foundation of games being entertaining as people are selfmotivated in certain activities, including playing video games. Enjoyment is the key to selfmotivated behaviors. When players are in a flow state, they are most likely to: have a sense of
control, have a loss of self-consciousness, lose track of time, receive immediate feedback, and
know what goals they have to achieve (Kiili, 2005). In addition, they are thinking "in the
moment" because they are highly focused on the current task (Kiili, 2005; Boyle et al, 2011;
Chen, 2007).
This theory also functions to guide game design. In games, players advance to different
levels, and enhance their abilities (attack, defense, speed, etc) by using coins or points they earn
when they finish tasks. Meanwhile, the tasks themselves become more and more difficult as
players are going through them. New challenges keep emerging and players have to improve
their skills, or change their strategies to win. Usually games that embody this theory are
commercially successfully in the market and draw public's attention. Examples include Angry
Birds, Cut the Rope, and Where's My Water.
Flow theory can serve as a guideline for serious games designers who want to create an
engaging game experience as the first step to learning. When people are in a flow state in game
activity, they process the information they receive from the game more in-depth, and improve
their skills through trial and error. Serious games designers should create this type of experience
for players. When people are trying hard to improve their skills in serious games, they are
learning and practicing skills. The skills in serious games are usually designed to apply in
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players' real lives, and for diabetes education, these skills might include testing blood sugar, and
injecting insulin.
3.1.2 Identity Theory
Psycholinguist James Paul Gee has developed his "Identity Theory" through lengthy
research on educational games. According to him, in the "player plays as the virtual character"
relationship, the player identifies himself or herself in three different way: a virtual identity (as
virtual character), a real-world identity (as player), and projective identity, which is the most
important one. Projective identity refers to a new identity that people value and can project
themselves into while playing video game so that they invest themselves heavily in it (Gee,
2004). For example, characters in video games are not real, but as a player controls the main
characters, he or she projects his or her desire, fantasy, and personality onto the virtual character
so that even if the characters are not real, they act more like the player who controls them, or act
the way the player wants them to. Such a projective identity can be offered in two ways: The
system can pre-design a character for the player that will evoke the players' fantasies, desires,
and pleasures so that the player would assume this role. Or the player can customize the
character and develop a whole new life experience of his or her own in the game world (Gee,
2004).
How are these identity issues connected to video games and learning? Firstly, how people
identify themselves sometimes can exert a strong influence on what they are willing to learn, or
what information they want to process. For example, people who identify themselves as mature
adults are less likely to learn the skills offered by a kids' game. Those who identify themselves as
Asians are more likely to maintain Asian culture in different countries. Secondly, people tend to
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establish a seemingly face-to-face relationship with media characters, and such a relationship is
defined as parasocial interaction, by Horton and Whol (1956). In this relationship, people feel the
media characters are more like friends in real life, and, in turn, spend more time to maintain such
relationships (Horton & Wohl, 1956; Perse & Rubin, 1989). Nowadays, video games are able to
create an environment where people experience a parasocial interaction with an embodied self
(Jin & Park, 2009) so that they can be influenced by the "new identity" they take on video
games.
In reality, people will or will not do or learn certain things sometimes based on how they
identity themselves, but video games enable the new identity for players to project themselves
onto so that they become someone else. Once they "become" somebody else, things that are
related to their new identity become more appealing and justifiable to learn or process. This
theory reveals the relationship between identity and learning, and can serve as guidance for the
designer in creating characters. Designers not only need to consider the external game
environment, rule, mechanics, but also they have to think about what characters players are
going to play with. Once players successfully project themselves onto the game characters,
learning is more effectively carried out. Good diabetes video games should provide characters
that engage players on this projective level.
3.1.3 ARCS Motivational Model
The ARCS motivational model was developed by John.M.Keller, who applied motivation
strategy to instruction. According to John, there are four elements that greatly inspire the people
to learn and maintain the interest in it; they are Attention, Relevance, Confidence, and
Satisfaction. Attention refers to the necessity thatthe content of instruction, no matter how it is
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presented, should capture one's interest and arouse curiosity. Relevance refers to the necessity
that content of the lesson must be connected to the goals of the learners, their past experience and
interest, and their preferred way of learning. Confidence refers to the necessity that learning is
achieved by forming positive expectations for accomplishment. Satisfaction reinforces such
feelings of success (Keller, 1987).
ARCS motivational model was developed primarily for classroom education; however,
serious games seem a perfect environment to implement the strategy of motivating to learn.
Video games themselves are fun, interactive, and use diverse forms of media. Video games also
have stories, conflict, and they are participatory. All those features make them easy to capture
people's attention. As serious games are closely related to a specific issue and target specific
audiences (for example diabetes games are targeting an audience that has diabetes or has some
other close relation to this disease, for example a patients' family and friends, doctors). These are
closely relevant to the players, for example, they feel that the information from a certain medium
could help improve their child or patient's health condition, or they have similar stories as those
characters in that medium. When players have the sense of relevance, they are motivated to
learn. Serious games give the sense of flow if they are well designed, and that greatly enhance
players' confidence in completing each levels. Satisfaction comes from the feedback and reward
in games and those positive experiences can be carried over from the game to real life.
3.2 Learning Theories
3.2.1 The Role of Narrative
The narrative is widely considered an important factor in enhancing the teaching potential
of serious games. It primarily functions to provide motivation to play, and it engages people in
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game activity. Narrative is used to provide the sense of location, identity, and mission of the
game (Adams et al, 2012), and the content of the game's message is contextualized through
setting, characters, missions, and gameplay (Wang & Singhal, 2009). Malone (1980) points out
that challenge and fantasy are the two main elements that cultivate the engagement of the
players. The challenge keeps the player going forward; after overcoming each level, the player
receives a sense of accomplishment, peaking their interest in the next level to come. The fantasy,
which is a type of a fictional narrative, captivates the players by transporting them from the real
world to a virtual one, where things can happen that are not possible in the real world (Dickey,
2006).
What's more, narrative also engages people by evoking player's empathy with the
character, which Michele Dickey defined as "emotional proximity". Emotional proximity refers
to the "empathy and identification the player feels toward his or her character in a game", and it
is usually established because of the similarity between the player and the character, or because
of the change or growth of the character together with the player during the game (Dickey M.
2006). When the character models changes in value or behavior, players also experience these
changes and these changes solidify the lesson of the game (Baranowski, Buday, Thompson, &
Baranowski, 2008).
The study of the relationship between media characters and audiences was first
introduced by Horton and Wohl (1956). According to their study, there is an illusion of a face-toface relationship between media characters and people who consume the media. In this
illusionary relationship, media consumers will interact with a character just as they do with their
friends in real life; this interaction is defined as a para-social interaction. When the audiences
frequently expose themselves to a character over time, they establish an emotional connection
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with that character and feel the intimacy with them. In return, they devote more time to
maintaining this relationship with the character (Horton & Wohl, 1956). Such interaction
reinforces the characters' value for the audience, as well as their behavioral modeling (McQuail,
Blumler, & Brown 1972).
The study of avatar-based games has provided the foundation for this thesis. Jin (2009)
conducted research on the relationship between independent self-construal, self-presence, and
para-social interaction in avatar-based games. He points out that independent self-centered
interaction can influence the depth of the para-social relationship between players and their
“virtual self” (i.e., player's avatars). Jin and Park (2009) argue that players play games in an
environment that can facilitate their experiences in terms of observing and interacting with the
embodied self, which in return, establishes the para-social interaction with the embodied self.
Because of para-social interaction, players can thus be influenced by the embodied self (i.e.,
avatar).
3.2.2 Techniques of Narrative in Games
Video game genres usually include role playing, action, simulation, first-person shooter,
sport, racing, puzzle, and strategy games (Dickey, 2006). So far, there is no research that
formulizes the methods of creating a story that fosters learning through play for each genre. All
the genres are differing in degree and manner of their integration, with respect to their use of
narrative (Dickey, 2006).
Usually, action games, role play games, and adventure games are the genres that heavily
rely on stories. A back-story and cut scenes are commonly used in these types of video games to
develop a story (Dickey, 2006; D.Koenig, 2008). The back-story refers to the storytelling at the
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beginning of a game, basically giving players the historical context of the storyline, and usually
is presented in forms such as video, animation, or several paragraphs text at the beginning of the
game that introduces the main conflict and the main characters (Dickey, 2006). Cut scenes refer
to the sections of narrative revealed between events during game play, and mainly function to
further the story (D.Koenig, 2008).
In order to promote behavioral change, games should be directly concerned with the
subject they are trying to explain, and the characters should model the desired changes
(Baranowski et al, 2008). As Baranowski et al explain, one of such models that are used to
address this issue presents the conflicts between good characters and evil characters. The ways
characters overcome the conflicts can effectively create changes in the player (Baranowski et al
2008).
3.3 Learning and Behavior Change Theories
Social Cognitive Theory
The social cognitive theory is widely cited as the theoretical foundation for video games
regarding behavioral changes (Baranowski et al 2008). According to Singhal, Cody, Rogers and
Sabido's study, there are two main processes concerning how people learn. The first is that
people learn through their direct experience; they form their own perception of things by the
reward and punishment resulting from their actions. However, as this process can be tedious and
sometimes leads to injury and wasted time, an alternative is to learn from the success or failure
of others (Singhal, Cody, Rogers, & Sabido, 2004). In other words, people can learn simply by
"watching" others take actions and learn from their consequences. Media is an effective vehicle
that helps people learn from others first, because media can easily widespread knowledge,
16
values, or a new style of behavior to a large audience; secondly, media can portray and represent
the social norms and structure in a way that potentially motivates people (Singhal et al, 2004;
Thompson et al 2010; Thompson et al 2007).
Elaboration Likelihood Model
The elaboration likelihood model was developed by social scientists Richard E. Petty and
John Cacioppo. It proposes that people can change their attitudes through two different routes of
influences: central route and peripheral route (Petty & Cacioppo, 1986.). The central route refers
to the persuasion process that involves relatively high elaboration, leading to a deepened
thoughtful processing of information; the change will resist other counterattacks. While the
peripheral route involves a relatively low elaboration, resulting in low motivation for change and
superficial processing of information that can be susceptible to counterattacks (Petty, &
Cacioppo, 1986.) The amount of effort and attention on the persuasive issue is determined by the
person's ability and motivation. Ability refers to that person's previous knowledge and
understanding, whereas motivation is associated with personal relevance, interest, and
competitiveness (Thompson et al 2007). The elaboration likelihood model also points out that a
more attractive, trustworthy and likable "message source" can lead to more effective persuasion
(Petty & Cacioppo, 1986).
Self-determination Theory
The self-determination theory is also widely cited as a theoretical foundation for using
video games to influence people's behavior (Thompson et al 2010; Thompson et al 2007).
According to Ryan, Deci's study (2000), motivation determines whether a behavior will be
17
performed or not. Behaviors could be either intrinsically motivated, or extrinsically motivated.
The intrinsically motivated behavior can lead to better performance, persistence and creativity
due to the high level of interest, excitement, and confidence of the person, while extrinsically
motivated behavior is performed because of external reasons, such as a deadline, threats, or set
goals (Thompson et al 2007; Ryan & Deci, 2000). The sense of competence, autonomy, and
relatedness determines if the behavior is motivated intrinsically or extrinsically (Ryan & Deci,
2000). High levels of competence, autonomy, and relatedness result in an intrinsically motivated
behavior while low levels result in an extrinsically motivated behavior (Thompson et al 2007).
In sum, serious games, just like other video games, are entertaining as they give players
joy while they are in flow state while in the activity of play. Players are given the opportunity to
be someone else or a different me in the virtual world and that is how they feel engaged. An
appealing story is also a factor that engages players, and the message is conveyed by the story as
well. From watching others to participating in stories, players perceive messages and learn from
their success and failure. Then, they apply what they have learned their real life.
18
4. Diabetes Mellitus
4.1 Diabetes Overview
Diabetes Mellitus, or simply diabetes, is a combination of diseases caused by the
dysfunction of the body in producing or using insulin, resulting in a high level of blood sugar.
Elevated blood sugar, in turn, causes various consequences such as blindness, limb amputation,
heart disease and depression13.
There are three main types of diabetes. Type 1 diabetes results from the inability of the
body to produce insulin, which is the hormone which regulates the glucose levels in the blood
(Rother, 2007). About 5% of the total diabetes population has this form of diabetes, and it is
usually found in children and young adults14. Genetics is the main factor that causes type1
diabetes, and other factors may include environment and infection (Rother, 2007). With regular
insulin injection, diabetes patients can still live a normal life.
Type 2 diabetes is the most prevalent type of this disease. Patients with type 2 diabetes
are not able produce enough insulin, or their body refuses to use insulin that it produces (Rother,
2007). People with type 2 diabetes may be treated with insulin for a certain period. But in many
instances insulin may not be necessary and their diabetes can be controlled through their diet.
Possible symptoms of both types include increase of thirst, frequent urination, increased hunger,
blurry vision, and numbness in hands or feet, and could possibly cause cardiovascular and
macrovascular diseases in long term (Sarwar et al,2010; Ray et al, 2009). Besides genetics and
environmental factors, type 2 diabetes is usually associated with obesity, lack of physical
activities, bad dietary habit, and stress (Risérus, Willett & Hu, 2009; Hu et al, 2001;
Ciechanowski, Katon, Russo, & Hirsch, 2003; Tuomilehto et al, 2001).
13
14
American Diabetes Association, http://www.diabetes.org/
American Diabetes Association, http://www.diabetes.org/
19
As mentioned above, diabetes patients not only need to deal with the physical symptoms
but also the psychological problems accompanying this disease. Considering that patients need to
change their dietary habit, start to exercise regularly, and monitor their blood sugar, they can feel
exceedingly stressed because of those changes to their daily routines (Amoako, et al., 2008; Xu
et al, 2008). Stress and depression can have a significant impact on the health outcomes
(Ciechanowski et al, 2003). For example, depression can possibly decrease adherence to dietary
change, adherence to medication, and increase health care costs (Ciechanowski, Katon, & Russo,
2000). Even choosing a place for vacation or what is safe to eat can cause stress for diabetes
patients (Reichenbach & Maish, 2006). Depression and stress also exist in the process of medical
treatment (Peyrot et al, 2005), however, researchers and healthcare providers usually don't pay
much attention to these psychological issues (Yang, Li, & Zheng, 2009).
Diabetes is one of the most common chronic diseases worldwide; it affects people of all
races, ethnicity, gender or age. International Diabetes Federation reports that by the year of 2010,
300 million people worldwide were affected by diabetes, and in the US, $376 billion was needed
to provide healthcare support for those people, which was 11.6% of total world healthcare
expenses15. According to National Diabetes Fast Sheet (released Jan 26, 2011), 25.8 million
people in the United States have diabetes, which is 8.3% of the total population. Among the 25.8
million people, 7.1% are Caucasian Americans, 8.4% are Asian Americans, 12.6% are African
Americans, 11.8% are Hispanics. By 2011, 14.7 million adults in the African regions were
estimated to have diabetes; about 8.1% of the adult population in Europe also had diabetes,
15
International Diabetes Federation, http://www.idf.org/diabetesatlas
20
which were about 52.6 million people16. In China, the number of people with diabetes is
predicted to reach about 0.5 billion by the year of 203017.
Diabetes is manageable with appropriate self-management and medical intervention, even
though diabetes is not able to be cured (Gatt & Sammut, 2008; Tuomilehto et al, 2001). Patients
are still able to live a healthy life with successful self-management, which refers to a complex set
of behavioral changes, including dietary adjustments, engagement in physical activity, and
management of diabetes medications (Risérus, Willett & Hu, 2009; Tuomilehto et al, 2001). All
of these changes must be integrated into their daily routine (White, Smith & O'Dowd, 2007).
4.2 Self-management and Care
People with either type 1 diabetes or type 2 diabetes face a series of lifestyle changes and
medical treatment. Different people may have different treatment and changes according to their
own situation. Besides the medication prescribed by the doctors, there are things that patients can
do themselves to improve their health condition.
Patients of both type 1 and type 2 diabetes have to know how to check their blood
glucose level(Cooke & Plotnick, 2008). If you are a diabetic your glucose level is an essential
factor of your health, as either a high level or a low level of blood glucose can cause serious
health problems. These include shakiness, blurred vision, fatigue, and fast heartbeat, or even a
coma and death in severe cases (Cooke & Plotnick, 2008). It is recommended that patients
should keep a record of their everyday glucose level so that doctors will know how well their
treatment plan is working.
16
17
International Diabetes Federation, http://www.idf.org/diabetesatlas
International Diabetes Federation, http://www.idf.org/press-releases/idf-press-statement-china-study
21
Type 1 diabetes patients are required to inject insulin regularly, as their bodies stop
producing it (Cooke & Plotnick, 2008). Some type 2 diabetes patients also need to inject insulin
to help their body properly use it. Insulin, chemically as a type of protein, cannot be taken orally,
because it would be broken down into and denatured within the acidic environment of the
stomach18.
Meal planning is another essential part of self-management skills to control diabetes
(Cooke & Plotnick, 2008). Carbohydrates lie at the center of this issue. Diabetes does not limit
patients from eating a variety of foods, but too much carbohydrate intake will increase the blood
glucose level (Risérus et al, 2009). So it is very important for patients to know what foods
contain how much carbohydrate, and how much they should have every day to maintain a
healthy life. To roughly track how much carbohydrate patients take in everyday, they must have
the basic knowledge of how much carbohydrate each kind of food contains (Cooke & Plotnick,
2008; Risérus et al, 2009).
There are three main kinds of carbohydrates: starch, sugar and fiber. Different foods
contain different amounts of those kinds of carbohydrates. Starch is mainly from vegetables,
such as potatoes, rice, peas, and corn. The source of sugar is either from natural existing sugar in
milk or fruit, for example, or from added sugars such as in fruit cups, cookies, and ice cream.
Fiber is from non-animal products, such as whole grains and nuts19. A healthy meal plan for
diabetes control should maximize the portion of non-starchy vegetables, and include smaller
portions of everything else (Cooke & Plotnick, 2008).
Exercise is crucial in managing diabetes too. During exercise, the body is able to decrease
glucose from a different path other than using insulin, and this is how patients lower their blood
18
19
American Diabetes Association, http://www.diabetes.org/
American Diabetes Association, http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting/
22
glucose level in a more natural way (Cooke & Plotnick, 2008). However, with type 1 diabetes,
patients also need know how to balance the insulin intake while they are going to exercise.
Insulin functions to remove the glucose, and exercise does the same as well, so if they are not
balanced there is a chance that the patients may suffer hypoglycemia (low blood glucose)20.
4.3 Diabetes Games Design Goal
Diabetes game design should be based on the facts about diabetes We can organize these
facts into four categories: "knowledge", "skills", "procedure", and "methods". Knowledge refers
to the information about diabetes that all patients need to be aware of, such as types, symptoms
and complications. Skills include testing the blood glucose level, and identifying different food
that raises or lowers blood glucose level. Procedure deals with the process of monitoring blood
glucose, medical treatment, everyday care, and communication with the medication team;
methods refer to the proper methods to maintain a healthy life such as meal planning and
exercising.
Goals that target basic knowledge include:
A. Users will be able to learn about the symptoms and complications of early, middle, and late
phases of diabetes.
B. Users will be able to learn about the system of glucose level.
C. Users will be able to learn about the possible outcomes of the disease.
D. Users will be able to learn about the treatment and care.
Goals that target the basic skills include:
20
American Diabetes Association, http://www.diabetes.org/food-and-fitness/fitness/physical-activity-isimportant.html
23
A. Users will be able to master the basic skills and techniques of testing their own glucose level.
B. Users will be able to improve their ability to communicate with their medication team.
Goals that target the skills and self-care methods include:
A. Users will be able to recognize healthy and unhealthy food, and plan meals.
B. Users will be able to master methods of self-care
C. Users will be able to improve their self-management ability and have the ability to change
their lifestyle.
4.4 Target Audience
The primary audience should be people living with diabetes. For this group dealing with
diabetes already has become a routine part of their lives, and they need the information and skills
to maintain a healthy life. There are some diabetes games that directly targeting information for
either type1 or type 2 treatment and care, such as Escape from the Diab, Packy and Malone, and
a select few other games, such as Insulot, that also specifically target the skill of calculating
calories, especially in regards to their effects on insulin levels. However, almost no game enables
an information exchange between players, or between players and doctors. This leads to the
assumption that there could be other potential audiences including patients' family and relatives,
people who want information regarding the prevention of the disease, researchers, or those who
do not live with diabetes but want to master the knowledge of it. Researchers may want to study
the behavior the players exhibit in the game. Ensuring that the game is designed with these
specific target groups in mind is essential, not only in creating a successful serious game, but
also in ensuring that the maximum number of potential clients can benefit from the game.
24
4.6 Current Serious Games for Diabetes
In this section, a game review is provided to analyze how video games are designed to
accomplish their goals, and how stories are told in games to model and persuade behavior
change.
Captain Novolin
Captain Novolin was released in 1992. It teaches children self-management skills, as well
as the nutritional facts about foods that they might see every day. This game has a very
straightforward storyline regarding the diabetes21. Captain Novolin, the main character, is on a
mission to save the mayor of his city, who is kidnapped by the evil aliens of junk food. He has
diabetes himself, so he has to control his meals under the doctors' instruction to stay healthy. The
doctors plan all his meals, and he can only eat foods which ensure that his glucose level is in the
safe zone. Otherwise he will die. The player controls Novolin in his process through levels of
missions in which he has to either avoid the alien junk food, or take the junk food down by
hitting the top part of junk food characters. If the captain is hit by the evil junk food he will lose
his health points, and eventually he will die. The captain has to eat the healthy food but each of
the healthy items cannot be eaten twice or his glucose level would be out of the safe zone. Some
bonus points can be gained if the captain answers the diabetes-related questions correctly in
game.
Back in the 90s, this game could strike players as entertaining, as back then there was not
much diversity of gameplay and gaming consoles. The message is clearly conveyed by the
21
http://www.youtube.com/watch?v=o_qKg55n3-A&feature=fvwrel;
http://www.youtube.com/watch?v=Wdfg3vuPa60&feature=fvwrel
25
storyline, and players are exposed to diabetes-related information throughout the game, such as
what food is good or bad for them as diabetes patients, as well as how food is associated with
blood glucose levels. The game models good food and bad food by presenting the junk food with
an evil face, while the good food has a cute shape and moves like an angel. The bonus questions
are very easy to answer, because the correct answers are made rather obviously. It's highly
possible that people who do not have proper knowledge of the subject yet would still choose the
correct answers. This is a good way of emphasizing the correct answers, instead of confusing
children with wrong answers.
The "emotional proximity" the player has with the character, however, is still at a
comparatively low level. First, the characters look stubborn and less vivid. They repeat the same
actions, while retaining some facial expression. Walk and jump are the only actions Captain
Novolin can take, resulting in a diminished sense of his humanity. He is more like an object that
is used to complete missions, instead of being emotionally connected with the players.
Another problem of this game is that it does not engage the player at the level of the flow
state. Throughout the game, players control only one character, which does not require the player
to increase his abilities. Enemies are the same so players don't have to improve their skills of
playing the game either. Once they master the skills of overcoming the challenge, it's more likely
that players will lose their interest even the game is not finished.
This game is less likely to be considered as story driven even though there is a simple
main story. The story of this game seems irrelevant to diabetes since saving a major has nothing
to do with managing the disease. There is no use of clues or hints which would make it less
attractive to the players as it fails to arouse emotions such as curiosity and worry. The story also
fails to successfully convey a mood, and the plot is poorly constructed, resulting in a predictable
26
storytelling. If people feel indifferent to a story, they are less likely to pay attention to the
message it conveys. As a result, this game merely increases discussions about diabetes between
children and their parents, and among the children, instead of successfully changing children's
behavior (Dashazo, Harris & Pratt, 2010).
Packy and Marlon
Packy and Marlon is an adventure video game that teaches children self-management
skills and nutritional knowledge for diabetes type 1. Packy and Marlon, two elephants with
diabetes, are going to a summer camp where rats and mice have invaded and scattered all the
food and medical supplies around different areas of the camp. Packy and Marlon are on a
mission to save the summer camp while maintaining their good blood glucose level, injecting a
certain amount of insulin, and finding food that contains the right number of food exchange,
according to the meal plan before each level.
The 24 levels of play happen in 4 days, with six levels in each day that involves
breakfast, lunch, dinner, and morning, afternoon and bedtime snacks. Each level has a meal plan.
Players must choose the insulin plan, monitor and respond to the changes in blood glucose, and
control eating food during the game. If one player exceeds their intake of food, it can lead to the
lack of food for the other player, as the total amount will not change. A colored information bar
on the top of the screen indicates if the players choose the proper amount of food and the right
type of food. Red numbers mean the players have selected too much food, while green numbers
indicate they selected just the right amount. The Logbook module shows how well players
manage their glucose level; it records the amount of insulin taken, a series of glucose levels, and
the number of food they eat during the game.
27
Packy and Marlon is a more advanced game than Captain Novolin even though they are
published by the same publisher. It is a typical platform game. Not only can Pack or Marlon
walk and jump, but they also shoot bullets of water drops, peanuts, and apples. Different bullets
have different level of damage on enemies. There are a number of different bats, rats and ghosts
as enemies, and they act and attack very differently: some of them may fly in the air, some of
them walk on the ground and jump, and the other may swim in the water. Each level has a theme
graphically; players can find interior, exterior environments of different kinds. The each
environment is big and there are hidden plots, non-player characters, and objects players can
explore.
This game has similar problems as Captain Novolin. The characters look less vivid, as
there is not much facial expression. They repeat the same move and attack during the entire
game. Players can hardly relate themselves to the characters. But Packy and Marlon gives more
of a sense of flow than Captian Novolin, as there are levels of different themes, and different
ways of jumping around or swimming around in each level. Nonetheless, characters do not gain
new abilities and remain the same way of attacking and moving, resulting in that the gameplay
remains the same. Same image are repeatedly used for cut scenes of all levels.
The storytelling of this game is not satisfying either. Just like in Captian Novolin, the
story is not appealing or motivating to players. This is first because a story about elephants
saving a summer camp seems irreverent to managing diabetes. Secondly, the story is too plain;
there is no creating a mood, or creating clue, hint for a turning point. Not much dialogue in game
makes it sense of story. The main goal (beating rats and bats) is too unrelated to managing and
players may ignore the diabetes part of the message.
28
Escape from the Diab
Escape from the Diab is a 3D third-person perspective video game that targets the
audience of type 2 diabetes (Thompson et al 2010). The game tells a story of an athletic
adolescent, DeeJay. He falls through a magical door to a dark world ruled by King Etes, who is
the evil king of that place. People are provided with free but unhealthy food there, and banned
from doing all physical activities. Being fit and different from the people in the world, DeeJay is
arrested by the king and put in jail, where he meets a group of friends who decide to escape to a
"Golden City" where everybody can eat and live healthily. As DeeJay is the only fit and healthy
person, DeeJay starts to train people, and introduces healthy eating regimens and physical
activities in order to escape. Delina is another key character. She is the leaders of the escape
groups, who supports DeeJay and encourage other members to change their diet and becomes
active.
In the game, players have to answer questions that reflect their diet and activity
preference. The game system converts the information into the response options according to
player's characteristics in order to give the player a sense of self relevance (Thompson et al
2010). Players also have to go through mini games to learn related skills, such as how to
distinguish good food and bad food, how to make healthy diet and activity choices, and how to
choose the proper food proportions based on the calories. The game also has a problem solving
module that requires players to choose a barrier they anticipate before they accomplish a task.
Escape from the Diab, is to date, the most recent and most advanced video game for
diabetes education and behavior change (released in 2006, and currently being)22. Theoretical
frameworks and the model for behavior change are broadly used in this game (DeShazo et al,
2010). The elaboration likelihood model suggests that the "message source" (i.e. the video game
22
http://www.escapefromdiab.com/
29
characters) can effectively persuade only when it is attractive, and likeable (Petty & Cacioppo,
1986). People learn through watching the characters perform certain behavior and receive a
positive or negative reward. This has the ability to persuade the player to/not to perform a certain
behavior (Bandura, 1986). In this game, DeeJay models the positive behaviors. Being an athlete,
DeeJay is good at choosing a healthy diet and engaging physical exercise. His goal is to train his
friends with all the skills and knowledge of being healthy, and persuades and encourages them to
change behaviors through dialogue. Delinda, the female protagonist, serves as a strong
persuasive role as she is supportive of DeeJay. She sides with his ideas and suggestions; in
return, she encourages her friends to change. Two other characters in the game model the
transitional roles as they listen to Delinda and DeeJay. As they encounter barriers and overcome
them, they all finally gain the fitness level needed to escape. With all the persuasion from the
non-player characters, the game gives a sense of reality and believability. This allows the player
to believe that they can be like them if they change their behavior. King Etes and his guards are
the antagonists. They are unlikable, evil-looking bad guys who model the negative behaviors.
In the game, the players have to choose goals to work on. This is a multi step process, in
which players must choose their desired intentions and how they wish to accomplish this.
Allowing players this freedom of choice serves to make these goals more believable and
enhances the player's internal motivation, because these goals are based on the player's personal
values. This is derived from the self determination theory, which states that relatedness enhances
the intrinsic motivation to perform a behavior (Ryan & Deci 2000). After goals have been set,
the player is presented with a set of barriers to these goals. These barriers are devised of common
excuses used by youth to avoid exercise or dietary change. The player must then choose the
solution they believe to best fit their situation. For example, goal: I want to drink more water
30
with meals, barrier: I have no bottled water in my house, solution: I must ask my parent to buy
bottled water next time they are at the grocery store.
Escape from Diab also uses "mini-games" within the context of the whole game. These
mini games are designed to teach useful skills, such as how one should distinguish between what
is real fruit and what is not (i.e. strawberries versus strawberry-flavored gelatins) and what the
relationship is between food portions and caloric intake.
INSULOT is a three-window slot machine game. It is designed to teach the relationships
among glucose level, food and insulin dosage (Aoki, Ohta, Okada, Oishi, & Fukui, 2005).
INSULOT simulates the postprandial glucose levels using algorithms. It calculates the
“carbohydrate grams” in food, and then uses the "insulin-to-carbohydrate" ratio to estimate how
much food can be absorbed by insulin, and then subtracts the absorbed “carbohydrate grams”
and calculates the final carbohydrate level in the body (Aoki et al 2005). This cell phone game
serves to targets those with type 1 diabetes. It does not have a story line; it simply demonstrates
its message through the use of images.
31
5. Diabetes Game Projects
5.1 Dia-beat-its
Dia-beat-its is a board game project I made to address the issue of diabetes, and its
connection to junk food. The goal of this board game is to strike down the junk food restaurants
named "Burger Joint," by the collaboration of three players in randomly selected roles, including
"Government", "Organization" and "Individual" (This game accommodates only 3 players).The
setup consists of a board that represents a network of cities in the USA, a deck of city cards, a
deck of action cards, a deck of role cards, tokens of four different colors (threat level, which has
four levels including green, blue, yellow and red; red is the highest threat level, green is the
lowest threat level), small houses representing the restaurants, and pawns for the players. This
game starts out with each player drawing one city card that determines where they start, three
actions cards, and then, five city cards and place one Burger Joint on each city that is drawn. At
last, place the corresponding diabetes markers (threat level) on and around those cities as follow:
- A red marker on each city with a Burger Joint.
- A yellow marker on each city between two cities or more containing a Burger Joint.
- A blue marker on each city touching only one city with a Burger Joint.
- A green marker on each city with no connection to a city containing a Burger Joint.
At the beginning of each turn, a player draws two action cards before taking any action.
Then he/she takes four actions that include moving to connected cities, playing action cards,
exchange action cards (available only when two players are in the same city), or however they
want to combine the three. After a loop, two city cards must be drawn, and a Burger Joint must
be added to each city. Then the threat level on each city goes up by one (except green ). If one
city has three Burger Joints, that means a diabetes breakout, which not only brings up the threat
32
level to red immediately, but also the threat level in neighboring cities. Once two breakouts
happen, players all lose the game. To win the game, players work together either to strike down
all the Burger Joints on the board, or turn all the threat level to green.
The deck of action cards contains several kinds that do different things. Insulin Injection
and Insulin Injection Enhancement are the basic "attack" cards that bring threat level down by 1
(or 2 if Insulin Injection and Insulin Injection Enhancement are used together). The airplane card
takes a player to any city on the board; government cards (raising taxes) are the "Government"
player's specific ability to remove a restaurant from the city he/she is in right away (2 if
government card and government enhancement card are played together); organization cards
(anti junk food campaign) are the "Organization" player's specialty that stops the threat level
from going up for a loop, while individual cards (exercise) are to turn all the threat levels into
green (except those that are already green), and the "Individual" player is the one capable of
using them.
There are also "bad" cards inside the deck of action cards, including Economy Booming
cards and Lack of Exercise cards. An Economy Booming card places two Burger Joints in two
cities that are drawn; a Lack of Exercise card turns all the yellow threat level right up to red; they
are executed immediately. However, a Heaven's Wrath card enables players with a God-like
power that can remove a Burger Joint at any time during the game if any player has it. It is not
confined to certain roles or counted as one of the players' four actions.
5.2 Concept behind the Game
This board game has its meaning in reality, as it translates reality into the game
mechanics. This has two important consequences. First, diabetes is closely associated with how
33
much junk food people eat. This issue is addressed through connecting the threat levels (markers,
a meter system that corresponds to the local population of diabetes patients) to the restaurants:
the more restaurants a city has, the higher the diabetes population in that city. Secondly, the
power of related parties of society to control diabetes is translated into action cards that do
different things on different levels. Raising taxes on the junk food business is a method that can
be implemented only through government's action. Organizations, such as American Diabetes
Association, conduct research and educate the public with what they have found to improve the
quality of life. Individuals make choices on their eating habits and lifestyle that directly influence
their health condition. Those are the translations that connect the board game to reality.
Despite this connection between the game and reality, however, I personally do not
consider it as a serious game; rather, it is more of what Ian Bogost has defined as a persuasive
game.
Dia-beat-its is not a serious game on several levels. First, it is because the academic
world tends to define a serious game as interactive technology-based, and dia-beat-its has
nothing to do with digital technology. Second, even in a broader definition, serious games are to
teach, educate or train through play, but I do not believe dia-beat-its teaches, educates or trains
anything like a typical serious game, such as RE-MISSION or Escape from the Diab. There
seems to be some economic and political education or consideration in this game, but it totally
ignores the accuracy of what it is conveying. Junk-food restaurants do not necessarily bring up
the population of diabetes. Raising taxes does not necessarily strike down a business but it might
come with other, unintended side effects that hurt society and economics. It simply translates
reality into mechanics with exaggeration, which is a device of effective persuasion. So I
concluded that dia-beat-its is a persuasive game.
34
In Ian Bogost's book Persuasive games: The Expressive power of Videogames (2007), Ian
developed this concept of procedural rhetoric, using process as persuasive expression. He mostly
targets the computational procedural rhetoric in his book, saying that the computer program is a
procedural expressive rhetoric medium that does what text rhetoric, image rhetoric and other
rhetoric can do together. The McDonalds' game, as an example, shows how games procedurally
persuade players to respond, and thus, to be convinced through an expressive process. Dia-beatits works similarly. Although the process is comparatively shorter than the McDonalds' game,
players have a procedure to go through in order to strike down the restaurants. For example, the
"Government" player has to go to a city that has a diabetes population, and then "raise the taxes"
on the junk food business to remove a restaurant. To remove the restaurant quickly and win the
game, the "Government" player has to be constantly moving to places, storing cards for the right
turn to play, exchanging cards with other players for the right one, or there would be more
restaurants being added back to the board. Through the seemingly justifiable interaction, this
game makes a procedural argument that government has the responsibility and power to control
the diabetes condition, and raising taxes on this type of business is one of the tools government
can use to do this. Furthermore, procedure is also used to form how people perceive and take
actions to respond to that perception. For example, nowadays many people would go searching
for their remote control to turn on the TV for half an hour, instead of simply walking over to the
TV set and turning it on. This is because they perceive the process of turning on a TV requires
them to first get a remote control, and then press the button to turn it on. It is the same with the
board game. Once a game procedure teaches players to perceive a process in a certain way, they
potentially adopt that process and apply it to real life. For example, Dia-beat-its teaches an
individual to exercise regularly first, and then he/she is able to effectively have control over
35
his/her health condition. So in real life, if they come across any junk food, they might respond
refusing to take it, and exercising to avoid health problems.
John B Watson, an American psychologist, has done an experiment entitled "little Albert"
where he conditioned an infant to fear a white rat. But this experiment also unintentionally
trained the child to to fear anything white and fuzzy. The white rat was the child's favorite
animal, but when the rat appeared John would hit a metal bar over and over again to make the
child cry. The child started to fear the white rat (conditioned response), and then he feared
anything that was white and fuzzy (unintentional response) ( Watson J.B.& Rayner, R, 1920).
This experiment shows that when people learn to behave conditionally, they might also
unintentionally learn to fear some other aspect of this condition. Games, including board games,
work in a similar way. They put the players in a certain context and they learn to behave through
trial and error. Players learn skills and strategy that they potentially apply in reality. This is one
level of persuasion that is described by Ian Bogost as procedural rhetoric of games. Also, the
players sometime learn something else that the game does not intend to teach. For example, I had
a couple of friends play/test dia-beat-its, and later, some of them came back and told me that
sometimes when they saw a weather forecast on TV with a map of the United States with squares
showing the temperature, with squares that tell the temperature, they said "That just looks so
much like your board. Every time I see a map like that, I think of your board game". This sounds
like a joke, but it does reflect that the game did create an abstract connection between a U.S. map
and junk food, that helps strengthen the effect of the procedural persuasion.
5.3 Betes-Buster
36
Betes-Buster is another game concept that shows some of my ideas and thoughts on
diabetes game design. It is an online virtual community that puts all diabetes-related people
together, including people who live with diabetes, those who want to prevent from diabetes,
those who medically deal with diabetes, and those who are curious about diabetes. The goal of
this online virtual world is to first educate people with skills and knowledge relating to diabetes,
and secondly, to persuade them to change their behavior and lifestyle in general to maintain a
healthy lifestyle. The game starts with a player being at his/her home, with his/her glucose level
and hunger level in a normal range. There are five places the player can go to. They are a
hospital, a park, a mall, a gym and the player's home. The hospital is where the player can meet
with other peer players, play mini games that simulate insulin injection and so on, and connect to
the doctors for help. At the park, the player can also meet with other players and play games
together. There is also an interior space in the park which any player can sign up for and have
parties. The gym is the place where the player "exercises". Mini games at the gym simulate
exercise that helps control a patients' diabetic condition. At the mall, the players can purchase
items to decorate their home, or have a party with. Home is the place where the player eats, rests
and checks his/her glucose level at. All the money is from the mini games that reward the players
that win it.
The key concept of this game is to bring Social Support to a playful virtual world. Social
support refers to the help and support from a supportive group. The forms of help and support
vary from emotional and informational to tangible.23 Social support can potentially solve many
problems regarding healthcare and wellness. It helps reduce stress, and forms a sense of
companionship. Also, the supportive group may offer tangible help, such as financial assistance.
Many studies have reviewed the computer-based social support group, including online forums,
23
http://www.pinniped.net/uchino2006.pdf
37
chat rooms, e-mail lists and so on. Those studies have proven that those social support groups are
effective in helping out each other with people's health problems. The advantages of online
supportive groups include, first, it brings a large number of people together that communicate.
This enables information and perspectives to be shared by everyone. Secondly, it breaks down
barriers such as time, location, disability, privacy and so on.24 In recent years, people started to
establish supportive groups in Second Life, an online virtual community. Beside all the
advantages computer mediated support has, the avatar-to-avatar communication gives more of a
sense of engagement, avoidance of misunderstanding, and a deepened sense of friendship.25
By bringing in social support, Betes-Buster aims to solve several problems. First, the
social support in Second life, even though it has proved its effectiveness , has less sense of play
as Second Life is not a game based on the virtual world. Betes-Buster, however, is a game based
virtual world where players can either play games alone or collaboratively. In other words, it can
function just like other videogames that educate, train, and persuade to change behavior. Second,
diabetes is a chronic disease that many of the patients have to deal with for their entire life, and
Betes-Buster, as an endless game. Like The Sims, it has the flexibility to update and change to
meet the needs of diabetes patients at different phases of the disease. Third, through the
connection with different people, including doctors, and the real-time feedback, people are
guaranteed that they are getting the right information and other form of support.
24
25
http://www.tandfonline.com/doi/abs/10.1207/s15327027hc1102_2#.UsF5L_RDu3A
http://onlinelibrary.wiley.com/doi/10.1111/j.1083-6101.2011.01543.x/pdf
38
6. Conclusion
The serious games are a unique genre of video games, closely guided by theories of
learning and behavior and incorporating serious content. They have shown their effectiveness in
health promotion, persuading players to change their behavior, and are capable of influencing the
public more generally. As diabetes is a serious health problem across the globe, using video
games to improve diabetes patients' health condition can be invaluable. Most existing games for
diabetes followed theories and guidelines discovered previously; however, they lack diversity of
genre, graphically need to be improved, and are out of date due to the drastic changes in
technology.
It is obvious that more research needs to be done in this area. So far, most of the existing
video games for diabetes are in the adventure genre, and all employ a similar storytelling
structure. However, video games have many different kinds of genres and whether adventure
games are the only genre that is effective in promoting diabetes education is questionable. It
would be interesting to explore what other genres can be used for diabetes education. In addition,
whether narrative is needed for these genres is also an excellent topic for further research.
Furthermore, how the narrative in different genres should model behavior change through its
characters is equally important for further research.
Research should continue to characterize the goals for diabetes education through video
games. What has been left out is addressing the psychological depression that accompanies
patients when dealing with disease. This issue should be considered as one of the goals when
developing a video game for diabetes. Researchers should also examine why players resist
behavior change even though they are exposed to the games persuasion and demonstration
strategies.
39
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