Pioneering Ideas

Bringing our Game to TED – 6 Days and Counting

For the first time, RWJF and Pioneer are a sponsor of the annual Technology, Entertainment and Design conference, kicking off next week in Long Beach, Calif. 

In exploring the opportunity, we thought a range of issues and people supported by Pioneer might be interesting to TED – what we landed on was a look at of the games for health field, how it might transform health and where it’s going in the future.

The intersection of video and computer games and health and health care boils down to a pretty interesting question: what possibilities open up when you approach health as a design challenge?  It’s one we’ll be digging in to at TED, as our luncheon event features world-renowned designer, researcher, artist and thinker John Maeda, president of the Rhode Island School of Design.  Joining him is Pam Omidyar, co-founder of the Omidyar Network and of HopeLab, the group that launched the sophisticated, fun and effective kids’ cancer game, Re-Mission.  We’re really honored to have them with us.

John and Pam will hand it over to Ben Sawyer of Games for Health to lead TEDsters through a mini-game jam.  Ben will be joined by game designers Noah Falstein of The Inspiracy and Larry Holland of Totally Games…they’ll lead TEDsters through a structured brainstorm process that lets the audience throw out ideas for where a game solution might really push progress on a big health or health care challenge. Then, for the next day and a half, the game designers will feed that input in to their creative process, rapid-fire sketching out pathways to solutions until they emerge with a compelling health game concept by the last day of TED.  We’ll also have a “Lab” space with an exhibit designed by the super-talented team over at Daylight Design, which will guide TED attendees through the Now, Near and Next breakthroughs in the health games field. 

I’m really excited by all that I’ll hear that I know I can’t begin to expect…the unanticipated connections to the kind of social change that RWJF and Pioneer is after.  Nancy Barrand, Paul Tarini and I will be there and posting daily updates to the blog – we hope you’ll join along for our first TED and shoot us some comments and questions.

Announcing our newest Pioneer/Changemakers competition (nudge, nudge...)

People can be so…so…so stubborn. They know the right thing to do—eat servings of fruits and vegetables every day—they just don’t do it. Or they don’t get around to doing it. Or they do it for a little while—exercise for 30 minutes every day—and then they stop doing it. Or their environment creates barriers to doing it.

One way to think about it is that, often, life gets in the way doing the right thing. The kids, the job, the economy (“What the hell? Where did my 401k go??) all compete for time and attention. And sometimes, it’s not life, but the choice itself that gets in the way. Any of you who spent time trying to help an older parent figure out what choice to make under Medicare Part D knows what I mean when I say some choices are just too complicated. When faced with making a complicated choice in real life, many of us end up making choices that aren’t the best ones we could make.

We’ve launched a global competition looking for “nudges,” innovative little pushes – that help people make better decisions regarding their own health and the health of others. The competition is co-sponsored by Ashoka’s Changemakers project and is based on the ideas put forth by Richard Thayler and Cass Sunstein in their book Nudge. Here’s an example of a nudge focusing on wearing motorcycle helmets: instead of making helmet-wearing mandatory, you permit people to ride without a helmet…but only if they qualify for a special helmet-less motorcycle license. To qualify, they’d need to pass a class that improves their riding skills and they’d have to carry an extra amount of insurance. The goal is not to remove someone’s ability to make choices, but, rather to “nudge” them in the direction of the better choice.

If you think you have a good nudge, you can enter the competition here. 

So simple...so stunning...such a struggle

Somebody sent me this image of a handprint featured in this week's New England Journal of Medicine.  So stunning.

 

Why?  The handprint was taken from an ungloved health care worker after performing an abdominal exam on a patient -- the pink area on the left represents MRSA colonies grown from the handprint.  Image B shows a second hand imprint obtained from the worker, after those same hands were treated with alcohol foam.  The resulting culture tested negative for MRSA.  So simple.

And still such a struggle for well-meaning care providers to take the necessary preventive steps.  Arghhh.  Innovations emerging from the Plexus Institute's positive deviance initiatives offer one promising path to a solution.  Last month, they were highlighted in the New York Times "Year in Ideas" for their success in changing processes that enable the right behaviors in hospitals' assault on MRSA infections.

Where might new innovations emerge to break through seemingly intractable problems like this?  Perhaps from the new idea competition  we launched yesterday with Ashoka's Changemakers to find those who are designing effective "nudges" that help people make better health decisions.  Paul Tarini will be writing more about the vision behind this competition, but if you're curious, check it out and join the search for simple but elegant breakthroughs that might prevent the next case of someone checking in to the hospital and winding up with a MRSA autograph stamped on his or her body.

Debra Lieberman on Health Games Research’s new Call for Proposals

Today, Health Games Research released their second Call for Proposals: Health Games Research: Advancing Effectiveness of Interactive Games for Health. We will wrap up our week-long conversation with Debra Lieberman, Ph.D., director of Health Games Research, with a discussion about this new funding opportunity.

Debra, can you tell us about the types of grants that will be available through this Call for Proposals?

The focus of the Call for Proposals (CFP), both during the first round of funding and now, is on research that will discover principles of health game design. This year the funding limit is higher: $300,000.  The money must be used primarily for research and only a small percentage of the grant – no more than 25 percent of the funding – is permitted to be used for developing game software or technology that will be used in the study   Also, like last year, the research must focus on a physical activity game that motivates people to get up and move, and/or on a self-care game that motivates people to engage in prevention, lifestyle improvement, self-management of chronic conditions or adherence to their treatment plan.  As we saw last year, these guidelines keep the program focused, yet they are not so restrictive that we don’t see a wide range of research issues addressed, game platforms used, game genres, research questions or study populations in the funded projects.

Are there specific things that you’re looking in this round of grantees?

We are looking for projects that focus on physical activity games and self-care games. The games may appear on any platform, with any genre, but they must be well designed and have theory or evidence demonstrating the game’s effectiveness.   

How can people learn more about this funding opportunity?

The complete Health Games Research Call for Proposals is available at http://www.healthgamesresearch.org  Additionally, there will be two optional web conference calls for potential applicants on February 11, 2009 (3 p.m. ET) and February 19, 2009 (4 p.m. ET).  Proposals are due by 3 p.m. ET on April 8, 2009. The conference calls are great opportunities for potential applicants to learn more about the program and to ask questions about the CFP requirements.

 Are there any tips you want to share with potential applicants?

The best tip I can give is to encourage applicants to read the Call for Proposals carefully and make sure that all the criteria and requirements have been met. Make sure your research team has the skills required to carry out the proposed project and that you are realistic about the budget and time line. Be sure to provide a good theory-based justification for your research plan, too. What are your hypotheses? Are they based on any theoretical knowledge and findings that already exist, and how are you taking your study to the next level? And be sure to include a dissemination plan for your work and explain how your findings will help us improve health games in the future

Thanks so much to Debra for taking the time to talk with us.  Health Games Research is taking on some really exciting work and we look forward to following the progress of the project's grantees. 

More from our conversation with Debra Lieberman

Today, we continue our discussion with Debra Lieberman to learn more about the Health Games Research national program and the work of the program's twelve grantees.

Debra, can you give us an update on the first round of grants?

We selected 12 grantees in the first round of funding for Health Games Research last May. The 12 grantees, awarded up to $200,000 each, are leading one- to two-year studies of games that engage players – ranging in age from eight to 98 – in physical activity games or games that motivate them to improve their self-care.  For example, our grantees at the University of Southern California are testing the role of social support and coaching, delivered on line, in improving and maintaining a healthy lifestyle. They have developed a game that uses players’ friends and family as coaches.

A team at the University of South Carolina is looking at physical activity games, such as Dance Dance Revolution and Wii Fit, as therapy interventions for people who have had a stroke. Many patients receive physical therapy for a set period of time after a stroke, but there is a need for continuing physical therapy after the initial therapy sessions are done. Perhaps there is a game-based solution for ensuring ongoing therapy for stroke patients.

A team from the Maine Medical Center is investigating family interactions around the popular dance pad game Dance Dance Revolution with families that have at least one overweight child. The grantees are asking the questions, how do family interactions affect the child’s physical activity and what effects does the child have on the family’s activity? 

What has surprised you about the first round of grantees?

I’m not surprised, but I’ve been very pleased at the diversity of grantees’ areas of expertise and populations of focus. Many of our grantee research teams include medical experts, game designers and researchers so they are well equipped to develop powerful, effective health games.  The populations they are studying range from children to seniors, from people dealing with addictions and substance abuse to those dealing with chronic conditions. One of our grantees is studying seniors’ responses to stationery bikes that enable them to bike through virtual worlds. Another grantee is developing a game to motivate Cystic Fibrosis patients to engage in respiratory exercises and to inhale their medications.  So, I’m very pleased with the variety and scope of these projects and I should add that we are learning a lot from all twelve grantees.

How will Health Games Research impact health and health care in the short term, and in the long term?

At Health Games Research, we are working in the short term to help build the field by supporting high-quality research that will lead to the creation of impactful games. We want to build interest in the creation and use of health games, and we want people to see how much learning, understanding and behavior change can be stimulated by a fun, exciting, well-designed game.

In the long term, we will provide research findings and resources that will enable many more people and organizations to design and produce effective health games – especially on some of the newer game technologies.  For example, games can now receive input from sensors and monitors, such as GPS devices that identify players’ geographic location, accelerometers that record how much walking they have done that day and heart rate monitors that report aerobic activity.  What fun to integrate these kinds of data into the state of a game, with an eye toward health promotion and behavior change! 

I also expect to see our research influence the design of mobile health games and games delivered on electronic toys or robots. Almost any interactive technology could provide a health game if designed with a little creative ingenuity and a solid foundation of theory, evidence, and understanding of the way people respond to games cognitively, emotionally, socially and physically. I believe that our research will lead to better game design and by engaging the health care community, policy-makers and game designers in this effort, our program will potentially lead increase the uses and effects of games for health behavior change.

Tomorrow, we will post the last part of our interview with Debra in addition to the new Call for Proposals being released by the Health Games Research program.

Talking with Debra Lieberman: Building the research on how games improve health

Today, we continue our discussion with Debra Lieberman to learn more about how Health Games Research is working to advance the research and design of health games and is contributing to building the health games field.

Debra, yesterday you introduced us to Health Games Research and its efforts to build the research for the health games field. Today, can you share any examples of games that highlight the potential for games to improve health?

Two games, both that I helped design, come to mind.  The first is Packy & Marlon.  Made for the Super Nintendo platform in the mid-1990’s, Packy & Marlon is a diabetes self-management game that was designed to reduce the stigma of diabetes among children and teens, increase their diabetes knowledge and self-care skills, foster communication with family and friends and improve self-efficacy for diabetes self-management.  The game centers on two diabetic elephants, Packy and Marlon, who arrive at diabetes summer camp and discover that rats and mice have marauded the camp and scattered all the food and diabetes supplies.  Players, taking the role of the two elephants, must search through the mountains, rivers, forests, playgrounds and haunted cabins to find these items, select a balanced diet of three meals and three snacks a day, measure their blood glucose and take insulin. 

We conducted a clinical trial with diabetes outpatients, ages 8 to 16. Participants were given a Super Nintendo console and were randomly assigned to receive Packy & Marlon or an entertainment video game that had no health content.  After six months of having the game at home, there was no change in number of annual diabetes-related urgent care and emergency room visits among the group that received the entertainment game. We found that the treatment group that received Packy & Marlon reduced their urgent care and emergency room visits by 77 percent.

 The second Nintendo game I helped design is the asthma self-management game, Bronkie the Bronchiasaurus.  In this game, players take on the role of Bronkie, a male dinosaur, or Trakie, a female dinosaur,  who are trying to save their planet and recover a mighty wind machine that keeps away deadly dust. The characters have asthma and the player must guide them through the game where they have to avoid asthma triggers, such as dust, pollen, smoke, furry animals, and sneezer characters who intermittently sneeze out cold viruses.  Players must check their character’s peak flow (breath strength) and take medications if they have bumped into too many triggers.  The asthma-related activities in the game provide almost unlimited opportunity to rehearse asthma self-management skills. The game was tested in clinical trials and found reductions in player's asthma-related urgent care and emergency visits of about 40 percent. The game also reduced children’s missed school days and parents’ missed workdays due to their child’s asthma by about 40 percent as well.

Another well known and well-researched health game is the cancer education game, Re-Mission. Designed to explore the inside of various cancer patients’ bodies, the player takes the role of a nanobot named Roxxi, who blasts away cancer cells with chemotherapy and delivers other treatments to the patient. Clinical trials found that the game increased cancer patients’ cancer knowledge, self-efficacy for cancer self-care, and adherence to one’s treatment plan.

How are you hoping to engage health care providers and game developers in the work of Health Games Research and its grantees?

Health Games Research aims to improve the quality and impact – and of course, the quantity – of basic research that will help us understand how people respond to specific features of health games cognitively, emotionally, socially and physically. This will help us discover principles of health game design to use in developing future games. We want this research to stimulate more interest and involvement in the field, and to set high standards of quality for research and for health games.      

We know that health care providers want evidence that treatments they recommend to their patients are efficacious—that they work. If a health care provider is going to prescribe a game to their patients, or implement games in their clinics, they’re going to want to know if those games work, include current medical information and were designed with state-of-the-art techniques. They need data in order to take a game seriously.  To engage health care providers, we must be able to respond to their requirements for data and evidence regarding a particular game’s effectiveness and, more generally, we must be able to show them the wide variety of health games and their benefits and clinical outcomes as evidenced in research so far.

This type of research is essential in the health care industry, but it is usually not required in the game publishing industry, so it is our job to demonstrate the benefits of applying research toward the design and production of games meant to change health behaviors.   We want to encourage game developers to invite researchers and behavioral health specialists to be part of the design team, even at the earliest stages of game design, to help determine the goals of the game and to use theory and research findings as the basis for health-related design decisions. Without dampening a game’s creative spirit and uniqueness, the goal is to integrate game design elements that are known to improve health.

Check back tomorrow for part three of our interview with Debra Lieberman and an update on the work of the current round of Health Games Research grantees.

Where's the revolution?

In Sunday’s Washington Post, Health Reporter David Brown wrote a very interesting thought piece, We All Want Longer, Healthier Lives. But It's Going to Cost Us. He outlines the “steady, predictable, relentless growth” we’ve seen in health care costs since the end of World War II. He says the time of cheap innovations that can produce the longer, healthier lives we all desire—clean water, vaccines, antibiotics—is past. Citing work by David Cutler at Harvard, he writes, “In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.” The next gains, Brown suggests, will come at even greater price.

There are some things we could do to shift the curve down, to save some money. Bringing down administrative costs, for instance. Or prevention, thought he notes prevention hasn’t been demonstrated to be any cheaper in the long run. Ultimately, though, on our current path, “We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish.”

Unless…

Brown suggests the current collision course sounds similar to that proposed by English Parson Thomas Malthus in the 18th century. Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society,” in which he projected a point in time where population growth would outstrip food production capacity. His analysis made a lot of people nervous.

But there were two things Malthus failed to imagine: “The first was that scientific agriculture would eventually double, triple and quintuple crop yields,” Brown writes. “The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.”

We need a similar revolution in healthcare to avoid the collision between our desires for long and healthy lives and what those lives will cost, Brown says. Where it will come from, he doesn’t know.

So: Where will that revolution come from? Advances in genomics? Proteomics and diagnostics? New business models ala Clayton Christensen’s recent book, The Innovator’s Prescription? Any and all thoughts welcome.

Conversation with Pioneers: Debra Lieberman

This week, as part of our Conversations with Pioneers series, we talk with Debra Lieberman, Ph.D., Director of Pioneer’s Health Games Research national program.  Debra is a lecturer in the Department of Communication at the University of California, Santa Barbara, and also a researcher in the university’s Institute for Social, Behavioral, and Economic Research (ISBER).  Her research focuses on process es of learning with interactive media, especially in the areas of health communication, interactive games for learning, and children’s media.

This Thursday, January 15, Health Games Research will release its 2009 Call for Proposals. The CFP will provide an opportunity for universities, government agencies, medical centers and nonprofit organizations to submit proposals for research projects that will investigate how health games can be designed and used to improve players’ health behaviors and health outcomes.

We thought this would be the perfect time to check in with Debra to learn more about the program, the first round of grantees and her expectations for Health Games Research’s new grant solicitation. We will feature our conversation with Debra here on the blog over the next few days.

Debra, can you tell us a little bit about the background and mission of Health Games Research?

Health Games Research is a national program of the Pioneer Portfolio aimed at advancing the research and design of digital games intended to improve people’s health. About $2 million was awarded to 12 grantees in the first round of funding in 2008, and our second round of funding – awarding roughly another $2 million – will be announced this Thursday.

Our mission is to improve the quality and impact of interactive games that are designed or used to improve players’ health-related behaviors and outcomes.  To reach this goal, we support research that will identify evidence-based principles of health game design, which can then be implemented in future health games.  Our current grantees are investigating a variety of design principles involving, for example, (1) how best to provide performance feedback, from a game and from other people, to players who are trying to improve their eating habits; (2) methods for engaging players in interactions with fictional characters and immersing players in a compelling story, to motivate them to get more physical activity; and (3) strategies for using an “exergame” such as Wii Fit or the dance pad game Dance Dance Revolution to help stroke victims develop better balance and range of motion.  In addition to awarding and supporting grants, Health Games Research provides information and resources related to health games, and serves as a champion for and builder of the field.

How did you become involved in the health games field?

I have always been passionate about the use of media for learning and behavior change. I have worked in this area for 35 years, beginning with educational television, when I worked and trained with the Sesame Street researchers and producers while studying at the Harvard Graduate School of Education in the early 1970s. There, I learned about the Sesame Street approach to designing educational media, which integrates researchers into the design process. In this approach, there is respect for both the art and the science of media design. The creative team is free to be creative and the research team contributes its expertise about the capabilities and interests of the audience, and how they learn, and it conducts research during the formative stages of design to make sure the audience is learning.  Together the team develops a product that is not only entertaining and fun, but also evidence-based, field tested, and educationally effective.

I worked in educational television in the ‘70s, and in the ‘80s I worked in educational software and got my Ph.D. in communication research at Stanford.  After a short time teaching at Indiana University, my life circumstances brought me back to Silicon Valley where, in the early ‘90s, I became involved in health games, joining a company as their VP of research to help them figure out how to design Nintendo games that would improve players’ prevention and self-care behaviors in areas such as diabetes, asthma, and   smoking prevention. This work brought together so many of my interests in learning, behavior change and interactive media in ways that could potentially make a difference in people’s lives.  And our games were successful!  Our diabetes self-management game, Packy & Marlon, reduced players’ diabetes-related urgent care and emergency visits by 77 percent. 

Why Games?

As I see it, games are the most interactive form of media we have today. A good game gives players a great deal of control, more than many other forms of interactive media, and feeds back information to players about all the actions they have taken and choices they have made. Games engage players by offering a challenge to reach a goal, and players often get hooked on that challenge, striving to get a better score, trying to get their character to the next level, or developing strategies to beat their opponent or whatever it is that really gets them involved…it’s that challenge! Interactive games are popular because they are deeply engaging.  These days, we spend more money on games than we do on movies. And people willingly spend a lot of their leisure time playing them. This is where many people live, and it is in an incredibly interactive and rich environment for learning, skill development, skill rehearsal, and other activities that, when well-designed – remember the Sesame Street approach – can motivate and support significant health behavior change.

Check back tomorrow for the second part of our interview with Debra.

About Debra Lieberman

Debra Lieberman, Ph.D., is a communication researcher at the Institute for Social, Behavioral, and Economic Research at the University of California, Santa Barbara (UCSB).  Her research focuses on processes of learning and behavior change with interactive media, with special interests in interactive games, health media, and children's media.  At UCSB, Debra directs the Health Games Research national program funded by the Robert Wood Johnson Foundation’s Pioneer Portfolio to advance the design and effectiveness of interactive games intended to improve health.  Debra has published widely and she consults for health organizations, education agencies, and media and technology companies to help design and evaluate interactive media for entertainment, learning, and health.