Leveling Up Health: Trends in Games for Health from the Games for Change Festival

"The good physician treats the disease; the great physician treats the patient who has the disease." -- Sir William Osler, co-founders of Johns Hopkins Hospital, "Father of Modern Medicine"

Every patient undergoes treatment; it is the definition of being a patient in any medical institution. But this process can be daunting, overwhelming, and even scary, particularly in the cases of life-threatening or life-long ailments. Part of this is the severity of the case, and yet another component is the lack of understanding of complex treatment options. How does one motivate a patient to continue down a course of treatment, support their care, and also tackle the barriers to understanding the whole process?

One platform being used to tackle this dilemma is serious games. Serious games -- a term that loosely defines a subset of games whose intention is not strictly for entertainment value -- have been used for a range of purposes in pro-health behavior. In using video games for health (sometimes shorthanded as "G4H"), games are being used to promote healthy behavior and increase understanding of the health care process in patients. They are being used to address the whole needs of the patient, fostering empathy in those surrounding the patient and the broader community to help generate a supportive ecosystem of care. In short, serious game developers recognize that health does not end at the doctor's office, and are designing games to tackle all parts of a patient's experience.

To illustrate the diversity of applications, here are some of the examples from the 2018 Games for Change (G4C) festival. As a capstone event for showing how games can be used for pro-social reasons, the Games for Change (G4C) festival is held annually in June in New York City. This year, G4C was celebrating its 15th year anniversary, and key track at the festival has been games for health. The examples below are just some of the games showcased at the festival this year, but demonstrate the spectrum of practice in the approach for games for health.

Promoting Positive Behavior

Games can be used as a way to promote positive health behavior, namely by building motivation in patients to perform a behavior that is beneficial to their overall health and wellbeing. Commercially, this can be used with gamified apps like Fitbit or MyFitnessPal, where patients can set goals and then are motivated extrinsically to follow through with the app. These apps can serve as a compliment to doctors' directives to instructing the patient to get more exercise, and patients may be more motivated to modify behavior due to the structure of the app -- e.g. getting points, earning badges, and having a targeted goal.

But using games can provide an immersive experience that, when paired with an existing treatment plan, may increase the likelihood of patients following through with their treatment plans. Working off an intrinsic motivation to compete, improve, and feel good about themselves, these games can help patients on long roads to recovery.  

In this line of thinking, one game showcased at G4C this year was MyoBeatz, a game designed to help patients with neuromuscular prosthesis training through music and rhythm. Limb integration takes practice, and often this practice is long and monotonous -- as the game developers PlayBionic highlights in the trailer for the game. Patients may feel discouraged throughout the process of limb integration, so practitioners were looking for ways to help infuse motivation in their patients. By turning the task of limb integration into a game and setting it to music (resembling to this layman the very popular Dance Dance Revolution), the impact on patients was clear: the process is far more enjoyable.

Building Patient Understanding

Increasing patient understanding around treatment processes, options, and progress is a vital component to any health plan -- and has been a core component of many research agendas (c.f. Makaryus & Friedman, 2005). This goes beyond translating medical jargon to focusing on health literacy (Boodman, 2011). For example, how can a doctor explain health procedures, not only from a scientific perspective (why do you need a biopsy? what are we looking for and why?)  to even the more pragmatic experiences (what does biopsy mean, what are you going to do? ).

This is tenfold more complicated when the patient in question is a child.

However, serious games for health are seeking to promote health literacy, even among these vulnerable populations. An international example from this year's G4C Festival was Alpha Beat Cancer (e.g. the ABCs of cancer) a game developed in Brazil and designed for children who have cancer. This game seeks to help children understand what is going on in their own bodies (e.g. what is cancer?) and what is needed to fight it -- not just in treatments, but what the patient can do to help with recovery. It addresses a very real concern that a cancer diagnosis and treatment is packed with uncertainty and fear, especially for child patients.

The game itself looks like many a child's game. Bright, light, with bold pops of color with adorable little character, it nevertheless handles the topic with a straight, simple narrative. The design was informed by its core audience -- children, patients and their doctors -- so that cancer treatment is demystified and the science is made accessible to a young audience. Agency and self-efficacy through cancer treatment is often enough not something that children walk away with, but it is a goal this game.

Promoting Empathy and Understanding

To promote long-term positive health outcomes, it is not just about the patient but the ecosystem of support that surrounds the patient that is necessary to target. This includes not only family and friends, but also raising awareness in the broader community in an attempt to increase understanding and target potential stigmas. One obstacle that games have tried to address is building empathy in those not experiencing mental health conditions to dismantle stigmas around illnesses like depression.

One in five Americans have suffered from a mental health condition (MentalHealth.Gov, 2017). Family members and friends play a key role in a patient's medical journey starting from the initial diagnosis and potentially contributing to the long term success of a patient. But they can also be part of the heartache, as those suffering from mental health often encounter misunderstandings about their condition -- e.g. thinking depression is a personal weakness of the patient. By promoting understanding for not just the patient, but those four out of five Americans who have not suffered from a mental health condition, games are hoping to be part of the solution to mental health concerns.

At this year's G4C, mental health was approached in different ways through two games, Please Knock on My Door and Hellblade: Senua’s Sacrifice.

Please Knock on My Door addresses one of the more prevalent forms of mental illness, depression. According to the National Institute for Mental Health, "16.2 million adults in the United States had at least one major depressive episode."  A core symptom of depression is the draining effect of everyday actions -- socializing, eating and hygiene all come with a cost. Please Knock on My Door highlights these difficulties in play that is like an advanced form of Tamagotchi, where you are given control over someone who is suffering from depression and must experience both the difficulty of everyday tasks as well as the ways people with depression often mitigate their condition (e.g. through escapism). The game is set up to challenge base assumptions around mental health, raising the profile of one of the most common mental health concerns in the United States.

“Taking the lived experience of mental health populations [..] makes it so authentic, connected and honest” - @KelliNDunlap talking about Hellblade and the development process including medical professionals and people with lived experience of psychosis. #G4C18pic.twitter.com/LoICO93TKS

— Jane Cocks (@jatosha) June 28, 2018

In the case of Hellblade, instead of taking a third-person perspective of a character, players are challenged to work through the deteriorating mental state in a compelling first-person narrative. The game designers worked with researchers from the University of Cambridge and University of Durham, as well as patients at recovery facilities, to gain full depth to the condition of psychosis. The motivation was to go beyond using the symptoms of psychosis as a narrative plot point to actively try to destigmatize the condition. The game challenges the player to experience not just what the mental state of the main character, Senua, but reflect on how society perpetuated her condition. As Professor Peter Fletcher said in an interview with Science Focus, "It’s been refreshing to see a representation of psychosis in which the person isn’t just a sort of passive receptacle for madness. Senua is the hero of her own story, trying to make sense of her experiences and work her way through them – that’s incredibly destigmatizing" (Lloyd, 2017). For both these games, attempting to part of the solution to destigmatizing mental health is a key element.

These games are just some of the games from G4C this year, but showcase how games for health are being used to address an array of concerns with patients. Innovations in games allow for immersive narratives that can help destigmatize mental health conditions and make health concerns more approachable. They are being used not only to encourage patient wellness, but also to increase understanding between patients, doctors, and beyond. Games are one more useful tool in our desire to meet patients where they stand and to break down barriers and promote health.

References

Boodman, S. G. (2011). Helping Patients Understand Their Medical Treatment.  Kaiser Health News. Accessed from: https://khn.org/news/health-literacy-understanding-medical-treatment/

Makaryus, A. N., & Friedman, E. A. (2005, August). Patients' understanding of their treatment plans and diagnosis at discharge. In Mayo Clinic Proceedings (Vol. 80, No. 8, pp. 991-994). Elsevier.

MentalHealth.Gov (2017). Mental Health Myths and Facts. https://www.mentalhealth.gov/basics/mental-health-myths-facts

Lloyd, J. (October 2017). How Hellblade: Senua’s Sacrifice deals with psychosis. Science Focus. Accessed from: http://www.sciencefocus.com/article/mind/hellblade-senua%E2%80%99s-sacrifice-psychosis-interview