MEDINFO 2004 M. Fieschi et al. (Eds) Amsterdam: IOS Press © 2004 IMIA. All rights reserved
Towards Integration of Computer Games in Interactive Health Education Environments: understanding gameplay challenge, narrative and spectacle Toomas Timpkaa,b , Gabriella Graspemoa,b, Linda Hasslinga,b, Sam Nordfeldtb,c, Henrik Erikssona a
Department of Computer and Information Science, Linköping University, Linköping, Sweden b Department of Health and Society, Linköping University, Linköping, Sweden c Department of Molecular and Clinical Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
Toomas Timpka, Gabriella Graspemo, Linda Hassling, Sam Nordfeldt, Henrik Eriksson related behaviours, e.g. towards a sedentary life-style and increased fast-food consumption. Therefore, new methods and tools for behavioural health interventions are urgently called for.
Abstract Context: There is an alarming progress in the health status of the young in western countries, and new methods and tools for behavioural health interventions are urgently called for. Objective: To explore how computer game designs can be integrated in the development of Interactive Health Education Environments. Design: Qualitative analyses of adolescents’ experiences of playing an action-adventure computer game, using data from indepth interviews. Results: A model is presented, where the gameplaying experience is connected to four components of computer games. Playing computer games was found to mainly be motivated by the challenges and competition represented in the gameplay scripts. Conclusions: Interactive health education environments can be improved by implementing challenging gameplay scripts, spectacular technical features and narratives.
The ambition of this study is to explore how computer games can be designed for integration in Interactive Health Education Environments. The specific aim is to employ qualitative research methods for exploring associations between computer game components, as they are perceived by adolescents, and cognitive or emotional experiences. The associations can thereafter be used in interactive environments to modify health-related behaviors. Even though educational multimedia are today well known in health informatics [5-8], computer games represent a relatively unexplored area in the field [9,10]. Therefore, a brief overview of current issues in computer game design is provided.
Background Computer games are customarily categorised by content into genres. In the action-adventure genre, the state-of-the art computer games provide fast-paced and story-driven gameplay with cinematic cut-frame sequences integrated into the presentation [11]. Designers of games usually seek to keep players engaged by story-telling and scripts at three levels [12]. A long-term narrative encompasses the entire game and provides an overall rationale for the gameplay. It usually involves a set of characters, such as an easily recognizable hero and a number of representatives of an opposing evil force. Medium-term narratives are integrated in the overall story and have often the structure of a task appointed to a game character, while the short-term narratives are related to a specific situation or event (such as escaping from a nuclear plant on fire). The status of narrative has, however, been a controversial topic in game design. Narrative has, on the one hand, been regarded as an ’indispensable’ quality, being either explicitly (by cut-frame sequences that interrupt gameplay) or implicitly (by textual messages or narrators included in the gameplay context) brought into games. Nevertheless, some game theorists contend that narratives are redundant and inadequately and unnaturally brought into game design from other media areas, e.g., literature and cinema [13]. Meanwhile, another central characteristic of computer games, the employment of spectacular visual features, has evident correspondence to the use of ’spectacle’ in other media forms. For instance, the actionadventure game Max Payne [14] uses slow motion ’bullet-time’
Keywords: Health education, Computer games, Educational technologies, System requirements, Qualitative studies.
Introduction Computer games represent a recent contribution to the media available for communication in entertainment and education. During 2002, the sales of video and computer games in the US accounted for almost USD 7 Billion, and the gaming industry has outgrown its traditional cinema-movie counterpart. The largest consumer groups are adolescents and young adults. In Europe, children play computer games about a half hour every day [1]. In the U.S., about nine out of ten middle-class adolescents play computer games regularly, those characterized as containing action-adventure being the most preferred [2]. In parallel, there is an alarming progress in the health status of the young in western countries. For instance, the number of obese children is increasing dramatically, leading to negative consequences in terms of both increased morbidity and decreased well-being [3]. While diabetes Type 2 was almost non-existent in children only a few decades ago, today it accounts for a significant share of new diabetes cases that occur before adulthood [4]. But maybe the most alarming fact is that the alterations in health patterns appear to be related to corresponding negative changes in health-
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Initially, both subjects were passively observed during their gameplay for about three hours each. Following the observation sessions, questions were asked during gameplay at two separate individual sessions, both lasting about one hour. Based on the interview guide, questions were asked about gameplay behaviour during the first session, and about background knowledge during the second. Issues considered to be the most sensitive were placed in the middle of the sessions. Finally, in a last session that was conducted while not playing the game, questions were asked about attitudes towards and experiences of computer gameplay. All interview sessions were video recorded, and later transcribed. The transcription from the video film resulted in about 20 text pages.
and ’dodge-time’ features that enable action to be slowed down to a point at which the player can dodge bullets in a similar manner as in recent Hollywood films such as The Matrix. Moreover, a typical characteristic of the gameplay in action-adventure games is that they are situated in a few basic settings, e.g. neonlit cityscapes, metal corridors with exposed piping or steel catwalks with pools of molten metal [15]. Such environments have also cinematic associations, to tech-noir and science fiction, but they are mainly attractive for computer games due to that processing capacity can be allocated to gameplay instead of visual background details.
Methods
In the analysis, the data were first divided into the categories defined by the interview guide. The data were searched for relevant aspects connected to the original research questions. In the second phase of the analysis, the data from all categories were used in analyses of general perception patterns and to identify design implications. Tentative categories for structuring the data were formed. Phrases in which any of these categories were concerned were marked in the interview material. Finally, to get an overall perspective of the different experiences and design implications, the findings were restructured into general concepts. A first set of results was reviewed by the subjects, and their comments were used to finalize the analysis.
The study was based on the qualitative analyses of adolescents’ experiences of playing an action-adventure computer game, using data from in-depth interviews. The game Max Payne was chosen as the study exemplar from the genre, due to that it had been given positive reviews in both expert journals and mass media. The main character in the game, a former police officer, experiences a family disaster early in the story. In the remaining game the user has to guide the avatar that represents the main character to reveal the truth behind the tragic incident. The game ends if either the truth is successfully revealed or if the main character is killed. In-depth interviews are an established method for investigating previously unexplored areas of human experience and understanding [16]. In this study, the interview situation was to be adapted to children’s perception and communication patterns. An interview content guide was constructed based on the available literature on computer games. The guide was designed based on the understanding that it is more important to be invited into the computer gameplay culture than to use a predefined interview structure. It covered three topic areas with regard to gameplay: behaviour, addressing subtopics ranging from setting to strategies; knowledge, addressing what was regarded as necessary to know for playing computer games and the sources for this knowledge; and finally, attitudes and understandings, addressing subtopics ranging from motivational factors for gameplay to evaluations of game details and design components.
Results Gameplay The game was immediately recognized by the subjects as belonging to the action-adventure genre. This meant that cues already learnt by playing similar games could be applied, e.g., with regard to narrative framework (types of characters, story outline) and avatar control mechanisms (sequences of directionkey strokes combined with mouse movements). The main reason that the action-adventure computer game genre was found to be interesting by the subjects was that the games represented a challenge: ’to play a good [adventure] game is just like climbing a mountain. When you have finished the game, the attraction vanishes.’ Excitement was found in the act of balancing the challenge to finish the game with the stress and frustration faced in demanding gameplay situations. In other words, the core of the gameplaying experience was to first create and thereafter master stress and distress. For the game to be interesting, both subjects emphasized that it was important to feel that is was possible to master the challenge. Correspondingly, both subjects chose to play at a level of difficulty that they felt was suited to their skills. Nonetheless, safe play strategies, i.e., when the subjects are in optimal control of situations, were seldom employed. Instead, a strategy of taking major risks and frequently saving games was used by both subjects. The latter tactic was applied to avoid replaying long sequences when the avatar is ’killed’, and the game is aborted to an unsuccessful end. But even though the gameplay made the subjects repeatedly violate their lay understanding of the laws of physics, nature, and health (for instance, they laughed at curing wounds with pain-killers), they disapproved of ’game cheating’, and always followed the rules implicit in the
The criteria for recruitment to the study were being male adolescents and having experience of playing the game chosen for the study. A convenience sample was recruited for the study, consisting of two boys aged 13 and 17 years, respectively. The subjects described their motives for playing computer games as defeating boredom, ’when nothing else is happening’ or ’just having fun.’ They seldom or never replaced other activities, such as meeting with friends or participating in sports, with gameplaying. Their choice of playing the particular game was based on information found on the internet. Before the study was initiated, the parents were approached for an informed consent. The boys and their parents were informed that they could end participation in the study at any time, and have the data erased. No financial compensation for participation was provided. Data collection was performed by a professor of social medicine and health informatics. Before the interview sessions, the main author played the game chosen for the study for about 6-8 hours. Thereafter, the data collection was implemented in four steps.
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understand and repelling. Both stated that they disapproved of the main character’s ’personality’ ('Max is blooming crazy!), they found the narrative space ghastly, and the avatar physiology ridiculous (’You regain health by taking pain-killers—well, sure!’). In a broader perspective, the statements make it easy to assume that the subjects had established an aversion to real life contexts even vaguely similar to the narrative space displayed in the game.
game design when solving tasks and problems, ‘it’s just as in sports, cheating takes away the fun’. Immersion The narrative space in which the story unfolds was recognized by the subjects as taken from big-city detective films, e.g., the movies based on the luckless Philip Marlowe character. The subjects had initially learnt about these films from quotes in the game manual, and the references were enforced by the presentation of the characters and the gameplay graphics (representing a dark stylized city) when entering the game—the scenery at the beginning of the game makes you feel low.
Design implications: a subjective game model The interview data showed that the gameplay experience depended not only on the game as it was presented to the subjects, but also on the cultural-informational context from which it was perceived to have originated. The computer game genre, in the actual case action-adventures, constituted together with genres from related media a framework for interpretation of what was primarily perceived during gameplay. Here the computer game genres (ranging from 'first-person shooters' to strategy games) were distinctly dissimilar from film genres (ranging from horror to love films). This difference was partly due to the fact that the games also depend on alternative interactive features, e.g., avatar control techniques. Based on this pre-understanding, the comprehension of a computer game upon which the gameplay experience is based can be described as constituted by four components (Figure 1). From a system designers perspective, it is necessary to address the critical issues in each of these game components, and also be able to define their relation to the desired behavioural and emotional outcomes. The first component, the narrative space provides the environment for the gameplay. This virtual environment includes dynamic constituents, such as a "physics" and an "avatar physiology". The narrative presents the motives and rationales for the actions taken during gameplay. The narrative may include elements such as a summary (a brief telling of the story substance), orientation (time, place, situation, participants), complicating action (sequence of events), evaluation (significance and meaning of the action, attitude of the narrator), resolution (what finally happened), and coda (returns the perspective to the present) [17,18]. Moreover, non-narrative spectacular features supply additional motivation and entertainment. These features often display or make possible actions, events and visual perspectives that are impossible or hard to experience in real life, e.g., a first-person perspective of walking through an exploding building. The gameplay scripts are however the core of the game. These scripts represent the challenge in gameplay, i.e., the central aspect of the game. At present, the scripts are usually limited to management of alternative action sequences in a number of stereotypical settings, e.g., shoot-outs, pathfinding, and street-racing. The challenge may consist of problem-solving within a closed narrative, but it may also involve open competition against opposing contenders in multi-player settings.
Even though they could relate to the narrative space, both subjects described a noticeably low third person identification with the main character in the game. When asked if he could recognize himself as the main character, the younger subject laughed: ’Are you kidding? Max is an avatar, for Christ’s sake! I control him’. The avatar was thus recognized as a particular animated character under the subject’s immediate control, a type of immaterial marionette, having only a visual reference to living creatures and humans. Both subjects stated that it was easy for them to make the avatar ‘behave’ as they intended: ‘You can almost do it without thinking’. This perception of control over the avatar was also displayed by that both commented with amusement on a situation in the game when the main character complained to himself: ’Well, it’s fun as hell to be a computer game character’. The subjects described no problems with this mixture of realism in the narrative space, on the one hand, and the surrealism in the gameplay and avatar animation, on the other. Being ’killed’ in the game, for instance, had for them a restricted and contextual in-game meaning related to problem-solving: ’you don’t mourn an avatar. Maybe you just think ”Shoot, it was 30 minutes since I last saved the game [meaning that I have to re-play a long sequence]”.’. The presentation of the narrative based on cinematic cut sequences, ’comic strips’ and texts was appreciated by both subjects. Nevertheless, the foundation of the gameplay was still described as ‘shooting anyone you can see’, i.e., finishing the game. Therefore, at a deeper level, there was the perception that the narrative lacked emotional realism, and had been introduced as an excuse for the shoot-out gameplay. For instance, a typical comment, stated by the older subject, was that in real life: ‘vengeance [even in an extreme situation as in this story] does not justify shooting 300 people.’ Hence, without the challenges found in the user-controlled gameplay sequences, the entire game would have been, in the main, uninteresting to the subjects. Morals and interpretations Having finished the game, the moral learned was found unclear by the subjects. ’I haven’t learnt any message from this game’, the older subject commented. One reason may be that the narrative and characters did not represent an easily recognizable manichean setting (a world strictly divided into belonging to either good or evil forces). Instead, there were indications that the game had an impact at an emotional level. These observations can be interpreted as if the game left an impression on the subjects of having explored a surreal world that they found hard to
Discussion The ambition of this study was to explore how concurrent computer game designs can inform the development of Interactive Health Education Environments. The specific aim was to employ qualitative research methods for exploring associations be-
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in the design of Interactive Health Education Environments, e.g., to increase the motivation to finish learning sequences.
tween computer game components, as they are perceived by adolescents, and cognitive and emotional experiences. A model is presented, where the gameplaying experience is connected to four components of computer games. As in previous studies [15], it was found that playing action-adventure computer games was mainly motivated by the challenges and competition represented in the gameplay scripts. The narrative component was regarded as underdeveloped and secondary to the interactive gameplay, while spectacular features of technical nature added excitement to the gameplay. By providing the framework for interpretation, the prevalent mass media culture, mediated through game and film genres, had a significant influence on the gameplay experience. The observation that challenges attract the attention of adolescents, in particular males, has previously been reported [19]. Looking into the mechanisms of challenge, playing computer games seem to particularly represent 'processes of anxiety and control' [20]. Hence, in the context of Interactive Health Education Environment design, the results of this study suggest that challenge and competition should be considered as central motvational features.
Studies of computer game use and their interaction with surrounding social practices have been reported for more than two decades [15,20,23]. Computer games have been expected to have particularly powerful effects due to the high attention levels of players and the identification of players with characters on the screen. Recent meta-analyses of the causal influence of these games on overt behaviour have however showed conflicting results, e.g. with regard to violence and aggression [24]. One reason for the diverging results can be the use of different study methods and populations. Another factor that potentially influences the possibility to draw reliable conclusions is that stable inter-personal identities are seldom possible to identify in children younger than 14 years of age. Among young adolescents, the foreclosed group is the most common recognizable identity category, i.e. when the identity is mainly influenced by parents and significant others [25]. The intrinsic maturation processes in children and adolescents, leading to development of a stable identity and self, thus make it difficult to conclude causal influences on behaviour from external sources, such as computer games. These facts have to be taken into regard when interpreting the present results, and also when features from computer game design are considered in the development of interactive health education environments. Further studies of computer games in the health education context are therefore warranted.
Em otional G ameplay experience and behavioural outcom e design
Acknowledgments
G ameplay script Narrative
(Technical)
This work was supported by the Knowledge Foundation in Sweden, through the Information Technology in Health Care (ITHS) program.
Gam e design
Spectacle
References
Narrative space
Computer game genre
O ther media
[1] Livingston S, Bovil M (eds.). Children and their changing media environment. An European comparative study. London: Lawrence Erlbaum Associates, 2001. Genre com position
[2] Funk J. Reevaluating the impact of video games. Clin Pediatrics 1993;32:86-90.
genre(s)
[3] Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003;289:1813-9.
Figure 1 - Structural model of associations between perceived computer game components and gameplay experience displayed by design levels.
[4] Fagot-Campagna A, Pettitt DJ, Engelgau MM et al. Type 2 diabetes among North American children and adolescents: an epidemiological review and public health perspective. J Pediatr 2000;136:664-72.
Piaget had found the that children up to 12 years of age embrace ’animism’, i.e., that they commonly ascribe non-living objects life and human characteristics [21]. More recently, this observation has been modified by several researchers. In the main, the critique is directed at children not ”really” believing that toys, such as stuffed animals, are ”alive”, but that they only use the corresponding linguistic expressions in order to construct ”playable” fantasy worlds [22]. In particular, this confusion can appear when the child is exposed to new objects, which she has not yet been able to incorporate into her use of language. The results of this study support the view that children and adolescents normally do not believe that computer game avatars are 'alive', and that they easily can discriminate between real and virtual worlds. This finding suggests that, if implemented with consideration, avatars engaged in also spectacular gameplay events can be used
[5] Popescu VG, Burdea GC, Boucit M, Hentz VR. A virtual reality-based telerehabilitation system with force feedback. IEEE Trans Inf Technol Biomed 2000;4(1):45-51. [6] Shegog R, Bartholomew LK, Parcel GS, Sockrider MM, Masse L, Abramson SL. Impact of a computer-assisted education program on factors related to asthma self-managemt behaviour. J Am Med Inform Assoc 2001;8:49-61. [7] Berridge E, Roudsari A, Taylor S, Carey S. Computer-aided education of patients and family practice professionals in the personal care of diabetes. Comp Meth Prog Biomed 2000;62:938-46.
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[8] Marsella SC, Johnson WL, and LaBore C. Interactive Pedagogical Drama for Health Interventions. In: Proceedings of the 11th International Conference on Artificial Intelligence in Education, Sydney, Australia, 2003. [9] Brown SJ, Lieberman DA, Germeny BA, Fan YC, Wilson DM, Pasta DJ.Educational video game for juvenile diabetes: results of a controlled trial. Med Inform 1997;22(1):77-89. [10]Lieberman DA.Management of chronic pediatric diseases with interactive health games: theory and research findings. J Ambul Care Manage. 2001 Jan;24(1):26-38. [11]King G, Krzywinska T (eds.). Screenplay cinema/videogames/interfaces. London: Wallflower, 2002. [12]Swartout W, van Lent M. Making a game of system design. CACM 2003;46(7):32-9. [13]Eskelinen M. The gaming situation. Gaming Studies 2001;1(1). [14]Allen M. Max Payne first impressions. Gamespot. Available at http://www.gamespot.co.uk/stories/news/ 0,2160,2087148,00.html. [15]Poole S. Trigger happy: the inner life of videogames. London: Fourth Estate, 2000. [16]Patton MQ. Qualitative research and evaluation methods. Newbury Park: Sage Publications, 1990. [17]Riessman CK. Narrative Analysis. Thousand Oaks, CA: Sage Publications 1993. [18]Labov W. The transformation of experience in narrative syntax. In: Labov W. Language in the inner city: Studies in the Black English vernacular. Philadelphia: University of Pennsylvania Press, 1972; 354-396. [19]Beneke T. Proving manhood. Berkeley: University of California Press, 1997. [20]Robins K, Levidow L. Socializing the cyborg self: the Gulf War and beyond. In Hables Gray C (ed). The Cyborg Handbook. New York: Routledge, 1995, ; 119-25. [21]Piaget J. The child’s perception of the world. Totawa, N.J.: Littlefield, 1975. [22]Holland V, Rohrman N. Distribution of the feature [+ Animate] in the lexicon of the child. J Psycholinguistic Res 1979;8:367-78. [23]Turkle S. The second self. Cambridge, Mass.: MIT Press, 1984. [24]Sherry JL. The effect of violent video games on aggression: a meta-analysis. Human Communication Research 2001;27:409-31. [25]Allison B, Schultz JB. Interpersonal identity formation during early adolescence. Adolescence 2001;36:509-34. Address for correspondence Toomas Timpka MD. PhD., Department of Computer and Information Science, Linköping University, SE-581 83, Linköping, Sweden. Email:
[email protected]
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