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Creating a serious game for health.

This research was supported by a grant from the National Institute on Minority Health and Health Disparities (RC2 MD004760).


The prevalence of chronic illnesses continues to increase as does the cost of such care. Teaching self-management skills is more effective than solely providing information and teaching technical skills at improving health outcomes. Serious games for health provide an opportunity to support learning and health-related behavior change using messages and experiences in an engaging and entertaining format. We developed eSMART-HD with the intention of improving interactions between patients with chronic disorders and their health care providers. This paper describes the factors that we considered when creating eSMART-HD, a serious game for health.

As the population ages, the prevalence of chronic illnesses, especially diabetes and hypertension, continue to increase. The National Diabetes Information Clearinghouse (2011) estimates that diabetes affects 25.8 million people of all ages or 8.3% of the U. S. population and 31.9% of adults, age 20 and older, have hypertension (National Center for Health Statistics, 2013). While health professionals provide some chronic illness care, the great majority of care is managed by the patients themselves. The Chronic Care Model (Wagner, 1998) suggests that improvements in healthcare outcomes will occur when patients are informed and activated and have productive interactions with a prepared, proactive healthcare team.

While traditional patient education offers information and technical skills, teaching self-management skills and opportunities to practice the behaviors, such as keeping a diary of information like blood pressure, weight, or blood sugar, are more effective than information only patient education at improving clinical outcomes (Bodenheimer, Wagner and Grumbach, 2002). Serious games for health provide an opportunity to support learning and health-related behavior change using messages and experiences in an engaging and entertaining format (Hawn, 2009). They are called "serious games" because, while entertaining, they are developed with specific learning and/or behavior change goals (Howell, 2005; Baranowski, Duday, Thompson & Baranowski, 2008; Zigmond, 2008; Adams, 2010).

Sophisticated games for health are being developed using a blend of science and art (Lewis, 2007) where "playing" makes sense to the players and the players' experiences unfold within a structured situation (Rodriguez, 2006). Common characteristics of serious games for health include that games are rule-based activities that involve challenges and active participation to reach goals, provide feedback on progress made toward the goals, are immersive and experiential, provide possible social and interpersonal influences (such as coaching where virtual characters coach directly) and a wide range of interfaces (balance boards, remote controllers, camera interfaces, accelerometers, GPS systems, range of sensors to measure physical parameters of the users) (Dror, 2008; Lieberman, Chamberlin, Medina, Franklin, Sanner, and Vafiadis, 2011). Planning for game development includes many elements (Table 1) (Lewis, 2007; Brox, 2011). The table identifies design considerations and our choices in the eSMART-HD implementation. Beyond consideration of its design elements, it is essential to identify whether one is using a expert/programmatic or participatory framework, or both, as the basis for development of the content and flow of the game (Russ, 2010). For example, if we were using an expert/programmatic framework for individuals with hypertension, we might use the American Heart Association's 5-step process to control blood pressure which includes (1) About High Blood Pressure, (2) Why HBP Matters, (3) Your Risk for HBP, (4) Symptoms, Diagnosis & Monitoring of HBP, and (5) Prevention & Treatment of HBP.

We chose a participatory framework where we engaged our target audience to mine their collective intelligence about their needs and what would support them (Howe, 2008; Moore, 2006) throughout all stages of game development. The experiences of members of our target audience were used to develop the script for the three virtual staff members at the clinic: the receptionist, the medical assistant, and the healthcare provider. A fourth avatar was used as a coach to support users in using a cognitive and behavioral strategy as they progress through each virtual visit.


We considered a range of approaches to developing eSMART-HD. Programmatic frameworks that may be used in game development range from clinical practice guidelines developed by experts in the field to behavioral categories such as the American Association of Diabetes Educators' AADE7[TM] Self-Care Behaviors (healthy eating, being active, monitoring, taking medication, problem solving, reducing risks, healthy coping) (Tomky, et al., 2008). Conceptual frameworks provide a broader guidance. For example, Lieberman's model suggests that challenge, motivation, role models, simulations, repetition and feedback improve mediating factors such as self-concepts, self-efficacy, knowledge and skills, and communication and social support that result in better health behaviors, better health and lower health care costs (Lieberman, 2001). eSMART-HD uses Lieberman's conceptual model as it walks users through visits with the virtual health care providers. We used stories and plots from focus groups in the community as recommended by other models that found that detailed story lines and plots lead to increased immersion and that this increases behaviors that lead to improved behavioral and physiologic outcomes (Thompson, et al., 2010; Thompson, Baranowski & Buday, 2010; Baranowski, Baranowski, Thompson & Buday, 2011).

The perception of being surrounded in an engrossing environment that feels real, or immersion, achieves presence and evokes emotions in users. This is important because emotion leads to arousal and improved memory (Caine, Caine, McClintic & Klimek, 2009).

Visible facial expressions of emotion (such as anger or fear) evokes physical arousal (Gaggioli, Mantovani, Castelnuovo, Widerhold & Riva, 2003). Other things that we considered were the use of 3-dimensional images, the quality of interaction, and the level of presence or the feeling that users had of actually being there. One choice related to presence is whether the individual interacting with (playing) the game sees it from a 1st person or 3rd person perspective. From a 1st person perspective, the game is seen thorough the users' eyes where a 3rd person perspective, the users' see themselves in the game (out of body experience). We chose the first person perspective to increase users' experience of making an actual visit to a healthcare provider. Serious games that employ immersion and engagement may be described as "edutainment" 17 with reinforcing sights and sounds leading to arousal (Dixon, Harrigan, Sandhu, Collins & Fugelsang, 2010). We included audio recordings from the clinical setting to increase arousal during the game. The recording included waiting room background sounds, the receptionist's keyboard clicking, doors opening and closing, and the vital signs monitor taking blood pressure. The edutainment aspect of the game improves memory of the experience.

Using a Community Participatory Approach

Another strategy that we used to develop the content for eSMART-HD and to overcome perceived barriers was to engage the intended users in the process. Individuals with chronic diseases know what people like themselves want and some know how to get it. Further, they can provide information about content that is relevant to themselves in the context of their daily lives.

Members of the community participated in each phase of development of eSMART-HD from identifying perceived barriers to care, to strategies to overcome the barriers, development and refinement of the scripts, to testing the game (Figure 1 above).

Using Principles of Universal Design

Our final consideration when designing this serious game for health is that many individuals who would benefit from these games have chronic conditions. Often technology-based health interventions are designed without consideration for those who might benefit from accommodation of some different ability or disability. Some patients with diabetes, for example, may have specific functional or sensory limitations such as having impaired vision and our goal is to develop a game to make things better for everyone. Williams and Moore suggested a few simple rules as guidelines for universal design for research so that those with various impairments are not further marginalized by exclusion (Williams & Moore, 2011). If simple rules about multiple options and plans to accommodate special needs are applied to serious games for health, designers would provide for multiple means to communicate information (both visually and orally) and multiple means of responding to the game such as predefined zones on a touch screen display for visually impaired persons. In the version of eSMART-HD that we report in this symposium, we provided closed-captioning for those who are hearing impaired but have not yet implemented the design for those who have serious visually impairment or are blind. While initially, the closed-captioning needed to be turned on for the user, we noticed that all users benefitted from the closed-captioning not just those with impaired hearing and have made it the standard for all users.

Developing the Serious Game for Health

We developed eSMART-HD with the intention of improving interactions between patients with chronic disorders and their health care providers. The embedded script in the game is based on data from eleven focus groups (Clochesy, Gittner, Hickman, Floersch & Carten) held throughout the community. Once developed, actors from a standardized patient program played the roles of receptionist, medical assistant and health care provider to test and refine the script prior to applying it to the game.

To ensure variability for the user, progression through the script each time was based on a combination of user choices, fixed and conditional probabilities resulting in a near impossibility to have precisely the same experience twice. As users moved from level to level, the communication with the receptionist, medical assistant and healthcare provider became more difficult.

Preliminary User Responses

Our team developed two different interfaces. The first using 3D avatars, fade outs between scenes and text-to-speech voice (which allowed for refining the script without re-recording voice). The second used a 3D environment where the avatars walked through the environment from the reception desk, to the waiting room, and then to the exam room. It used recorded speech.

Community members uniformly preferred the second environment where they "walked" through the environment and the recorded voice over the text-to-speech


This article describes our interprofessional team's engaging the community to develop eSMART-HD, a serious game for health. A simplified, single-level version is available for free download at:


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Table 1
Elements of Serious Games for Health

Element       Considerations       eSMART Implementation

Game          How the system       We used a "coach" avatar to support
mechancis     works                users; the cognitive and behavioral
                                   strategy in the game; imbedded
                                   instructional videos; the user walks
                                   a path through the encounter from
                                   receptionist to medical assistant to
                                   provider; a combination of user
                                   choices, fixed and conditional
                                   probabilities drive the
                                   implementation of the script.
Levels of     Multiple levels      Each time users "play" eSMART-HD
              of play              they advance one level within the
                                   game. With increasing levels of the
                                   game, there is decreasing support
                                   from the coach and increasing
                                   complexity so as the "game is
                                   played" over time it builds on
                                   previous experience and isn't
                                   perceived as repetitive which could
                                   lead to boredom and non-persistence
                                   in use.
Reward        Immediate            To provide immediate feedback and
(Feedback)    feedback             reinforcement, a visual display of
system                             achievement (or mastery) for
                                   each step in the cognitive and
                                   behavioral strategy that users have
                                   been taught and practice is located
                                   on the screen with a print out of
                                   overall performance provided at the
                                   end of each virtual visit.
Logging       Data collection      We designed the game automatically
              about use            collects data regarding all user
                                   choices and about chosen paths
                                   through the virtual clinic visit to
                                   assist us in future game
Graphics      Users prefer         We used high resolution images,
&             realistic images     realistic looking 3-dimensional (3D)
animation                          avatars and a continuous,
                                   naturalistic environment were used
                                   to allow users to "walk" to the
                                   receptionist and waiting room, and
                                   through the clinic to the exam or
                                   consultation room.
Sound         Computer or          We used natural sounding, recorded
              natural voices       voices. Closed-captioning always
                                   turned on, to assist both those with
                                   impaired hearing but also support
                                   users if they got distracted and
                                   didn't hear what was said by the
                                   coach, receptionist, medial
                                   assistant or healthcare provider.
User          Ease of use for      We selected a large touch screen (20
interfaces    all users            inches wide and 11.5 inches tall)
                                   computer since most everyone has
                                   experience with some touch screen
                                   device, whether at the gas station
                                   or automatic teller machine (ATM).
                                   Use of the mouse was optional. While
                                   this version of eSMART-HD was
                                   implemented on a computer kiosk,
                                   future design will allow for more
                                   universal access via laptops, tablet
                                   computers and smartphones.
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Article Details
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Author:Clochesy, John M.; Buchner, Marc; Hickman, Ronald L., Jr.; Pinto, Melissa D.; Znamenak, Kyle
Publication:Journal of Health and Human Services Administration
Article Type:Report
Date:Sep 22, 2015
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