Pioneering Ideas

Using Games to Support Children's Healthy Development: Opportunities & Challenges

We welcome Ann My Thai to our guest blogger series.

Ann My Thai is the Assistant Director of the Joan Ganz Cooney Center at Sesame Workshop and the co-author of Game Changer: Investing in Digital Play to Advance Children’s Learning and Health. Ann leads the Center's strategic partnership efforts with high tech and gaming industries, and oversees organizational growth and strategy. Before joining the Center, she served as a consultant for Education for Development, Vietnam, a nonprofit organization that develops informal educational programming for disadvantaged children in Ho Chi Minh City, Vietnam. Thai received her bachelor's degree in Political Science from Yale University and a master's degree in Business Administration from the Ross School of Business at the University of Michigan.

Readers of the Joan Ganz Cooney Center’s latest report, Game Changer: Investing in Digital Play to Advance Children's Learning and Health might be asking why we chose to discuss how digital games could advance both children’s learning and health in the same paper. Named for its founder, the Center’s roots lie in Sesame Street’s “whole child” approach, which encourages learning that supports many different aspects of a child’s healthy development—from literacy skills, to social and emotional development, to practicing healthy habits.  A solid base of research tells us that children who eat healthfully and are more physically active are also able to learn more easily.  It also tells us that children who suffer from health threats such as obesity do worse in school and are less successful later in life.  Given the inextricable ties between learning and health, and the parallel efforts in each field to harness the power of games, we wanted to address the potential role they might play in health and education reform together.

The idea that digital games might actually help improve children's learning and health is, in some quarters, a radical one, but for authors of the report, it is also a pragmatic one. The medium has a high penetration, with 97% of American teens playing computer or video games.  Furthermore, digital games are reaching children at younger and younger ages for longer periods of time.  The average child begins playing games at age 6, down from 8 years old a few years ago, and the amount of time a child plays on average more than doubles between age 6 and 9.  This level of play shows that it is no longer a question of whether we should enlist games in our learning and health efforts but how we may do so.  Game Changer aims to spark a productive dialogue about the opportunities and challenges of using games to support children’s healthy development.

To kick off this dialogue, we unveiled the report on Tuesday with the Woodrow Wilson Center for International Scholars at an event in Washington, DC.  It featured a panel of experts from industry, research, and policy and hosted nearly 100 participants and a web audience from these key sectors. 

A key insight raised at the event was the lack of training available to health researchers to engage in the type of multi-disciplinary game R&D requires. Dr. David Abrams, Executive Director of the Schroeder Institute at the American Legacy Foundation, which focuses on accelerating the reduction in tobacco use, especially for young people in the U.S. population, said that the health care sector has “not looked beyond itself” to consider the whole child in advancing children’s health. The current generation of health researchers is too often isolated from the broader perspectives or tangible incentives to engage in a multi-disciplinary approach.  

Some of the biggest challenges of the day—such as childhood obesity or the fourth grade reading slump—are too broad and complex to be addressed by the expertise of any one discipline.   These are problems couched in layers of social, economic and other environmental factors, as well as developmental factors distinct to each child.  Responding to these issues from a whole child perspective will demand greater investment toward funding and collaboration models and infrastructure that support multi-disciplinary collaboration.  Such investment is essential if we are to tap into the digital media that surrounds today’s children in a purposeful way.  

Marketing the Concept of Games for Health

We continue our guest blogger series with Nedra Weinreich. 

Nedra Weinreich is a social marketing consultant who helps nonprofits and government agencies strategically promote health and social issues through her company Weinreich Communications. She is the author of Hands-On Social Marketing: A Step-by-Step Guide, writes on social marketing issues at the Spare Change blog and is the director of Social Marketing University. Nedra has an MS degree in Health & Social Behavior from the Harvard School of Public Health.

Games for health intrigue me because they have such potential for achieving the behavior change-related objectives we in public health often struggle to reach - changing awareness and attitudes about an issue, educating people with key facts, building necessary skills, and even the holy grail of engaging in healthful behaviors during the course of the game. Health gaming shares the roots of its success with other entertainment education approaches (like health topic "product placement" in television plotlines) by engaging its players emotionally, embedding learning opportunities within fun activities, and allowing people to try out new skills (either vicariously or in actuality).

Forward-thinking people in the behavior change business know all this. Unfortunately, many others hear the words "digital health games" and either say, "Ho-hum, how exciting can a game about health be?" or immediately conjure up the negative stereotypes of video games as a cause of violence or sedentary behavior. Whether it's parents, teachers, children, health professionals, game producers or funders, all need to be on board for these products to be viable. Let's explore how to market the idea of games for health as a serious intervention for many different public health and medical challenges.

Good marketing is always based on research with the target audience, so a key first step should be to learn more about how each group views digital health games for children. What do they see as the key benefits? What would stand in the way of their adopting or supporting them? How might games for health best fit into their personal or professional lives? Clearly, each of the groups listed above would need different approaches to persuade them of the merit of these products. In fact, within each audience may be several subgroups; for example, parents of young children likely have very different concerns and experiences with digital games than those with teenagers. Teachers at each grade level have different learning objectives for their students. In any case, the more individuals from each audience are involved in the actual development of the games, the more likely they will be successful.

Let's look at the product itself. The way health games should be framed depends on to whom you are talking. For health professionals and funders, positive research results are the key. Focus on the games as an intervention that has demonstrated success (and work hard to accumulate the hard evidence to back up your claims). Parents and teachers will respond best to an emphasis on learning and skills building that will serve to help the kids stay healthy as they navigate through life. For kids? It's got to be all about fun. If it's not fun, the game needs at least to be interesting enough to capture their attention. And game producers will be concerned with one thing: are games for health marketable? The Wii and Wii Fit have been game-changers (pardon the pun) in their popularity and may open up many more doors in this direction.

We also need to determine the main barriers that stand in the way between each audience and its unbridled support and use of health games. Adults will need to give up their views of what games are and what they can be. Many may feel that information conveyed in the form of a game means that the importance of an issue is being downplayed, or may worry about these being just another video game with negative behavioral effects. Again, the way to break down these barriers is by emphasizing results in the form of health outcomes, compliance, patient satisfaction, or positive changes in other measures of knowledge, attitudes and behaviors. For kids, the kiss of death for any activity is if it's perceived to be boring, especially if it's billed as "good for you." Health games must be banana splits, not broccoli, and promoted to kids with the emphasis on "game" rather than "health."

From a marketing perspective, let's think about how best to fit games for health into people's lives. What are the times and places they will be most able and interested in playing or prescribing these games? Some key ideas, many of which are already being implemented, include making them portable so people can use them anywhere, making sure that the games fit with the consoles or equipment they already have, and finding ways to combine digital games with real-life situations. Health professionals need to know what games are available for various health conditions so they can match their patients with the right interventions, perhaps via a centralized database. And when the idea comes from their doctor, a parent can feel more comfortable with letting their kids play.

Promoting the concept of health games will also have to be targeted to each audience. Perhaps they will become more acceptable as a health intervention as more "clinical trials" of their outcomes are published in peer-reviewed journals. Skeptical parents, teachers and children may become more convinced of the benefits of games when given the opportunity to try them out themselves. Many a person has been convinced of the exercise value of the Wii after trying it out at a friend's house and realizing their muscles are sore afterward. Game producers may need specific incentives from funders or investors to move into what they perceive as less robust markets until they see the demand from consumers.

Working with organizations and public agencies to craft policies friendly to these new interventions can help create fertile ground for health games to bloom. For example, when certain games have been proven to improve health outcomes would health insurers extend coverage for purchasing them with a doctor's prescription (and send a Wii-fund as reimbursement)? Can we increase the number of school districts that have incorporated Dance Dance Revolution into their physical education curriculum?

Finally, building partnerships that reach across categories will be beneficial to all involved. Working with trusted organizations or familiar characters creates games that start from a strong position with consumers in all categories. Thanks to the Robert Wood Johnson Foundation for cultivating these alliances with key partners and building the foundations for games for health to emerge as a pillar of health interventions.

Fun, Kids & Evidence-Based R&D = Games for Health Success?

We continue our guest blogger series with Richard Tate of HopeLab.

Richard Tate is the Director of Communications and Marketing at HopeLab and a blogger on Sticky Notes, HopeLab’s official blog. 

HopeLab, maker of the groundbreaking Re-Mission videogame for teens with cancer, is an innovative nonprofit harnessing the power and appeal of technology to improve the health of young people. Their evidence-based, customer-focused development process delivers fun, effective products that measurably improve the health and quality of life of adolescents and young adults.

More than 30 years ago, Joan Ganz Cooney began to build the evidence base for entertainment technology as a tool for good in the lives of young people. From Cooney’s work, the groundbreaking program Sesame Street emerged, and the show quickly demonstrated the incredible power of harnessing the appeal of TV technology to achieve specific goals in children’s educational, behavioral and social development. The approach worked, and TV producers, critics and generations of viewers were persuaded.

Can we do the same for digital games? Most definitely. What will it take to get there? The Sesame Workshop’s Joan Ganz Cooney Center released a new report offering a roadmap forward. Based on my work at HopeLab with our Re-Mission video game for cancer and my own experience as a kid watching Grover and Big Bird after school, three things come to mind as essential components: fun, kids’ input and evidence-based R&D.

Focus on Fun: There’s a reason 97% of American teens play computer or video games (hint: it’s not because they’re looking for educational opportunities). It’s because games are fun. And “fun” doesn’t have to mean “pointless”. Quite the contrary. The creative freedom afforded by today’s game technology gives us an opportunity to produce content that’s immersive, highly entertaining AND targeted at specific outcomes in the “real” world. But if games aren’t fun, kids won’t play. And if kids won’t play, we can’t achieve the outcomes we’re after. That’s where many “serious game” projects seem to stumble. Looking back, I didn’t watch Sesame Street because I wanted to learn the alphabet. I just had a blast singing “C Is for Cookie” with Cookie Monster.

Kids First: How do we know what’s fun for kids? We don’t – unless we ask them. Too often, the fun factor – the essential ingredient for games – is forgotten when adults begin to layer education and learning opportunities into entertainment media based solely on academic research. The best, most reliable way to gauge what’s truly engaging and fun for kids is to engage them directly. In our experience at HopeLab, kids are great at generating ideas and honest with their opinions when given an opportunity to contribute. It’s why we invite them into our development process and incorporate their feedback every step of the way. Talking to kids is the best way for us all to ensure we’re on track to deliver games that are fun and effective in improving kids’ lives.

Evidence-Based R&D: Commercial video games for entertainment are largely developed based on the creative vision of industry experts. Games that aim to do more than entertain require both creative vision and evidence to inform objectives and validate outcomes. Data – scientific evidence that games work – has been the critical missing piece in catalyzing broad, systemic and sustained engagement in digital games development for health and education. For example, demonstrating through research that games can enable patients to better manage their health and reduce healthcare costs is essential to engaging the healthcare industry in creating games as tools for consumers.

Research also provides insights to the field on how to create games that work to achieved desired benefits.  Advances in health games research and development have largely been driven by the commitment and financial resources of major foundations like the Robert Wood Johnson Foundation, and individual philanthropists, like HopeLab founder and board chair Pam Omidyar. The government also has funded development of leading-edge, game-based virtual technology for training soldiers. HopeLab has generated compelling data on Re-Mission and how it works to improve kids’ health, but more needs to be done in the field. RWJF’s Health Games Research Project aims to do just that. It would be great to see others come forward in the public and private sectors to support more evidence-based development of health and education games in the coming years.

Games are a tremendously powerful part of our kids’ lives, and it’s within our control to make them tools for good. The new Cooney Center report is a timely assessment of how digital games might advance our efforts to improve the health and learning of young people. Wouldn’t it be great to look back on this time as the point at which digital games, like television, became a medium that both entertained us and improved our lives?

Developing and Sustaining Health Games—A Losing Battle?

We welcome Melanie Lazarus as part of our guest blogger series.  

Melanie M. Lazarus, MPH is the Director of Marketing for Archimage, a serious game developer with titles including Escape From Diab and Nanoswarm: Invasion from Inner Space. She is also editor of healthGAMERS, a blog designed to educate the public about the games for health field, and author of Monster’s Blog, the corporate blog for Playnormous Health Games. Melanie has a B.S. degree in Microbiology from UT-Austin and an MPH in Health Promotion and Behavioral Science from The University of Texas Health Science Center at Houston.

The video game industry is an influential one -- $13.5 billion influential. Improving the health of children through a messaging medium this big seems like an obvious idea. Unfortunately, as a developer in this space for several years, we’ve found that obvious does not always translate into easy.

Archimage began work in 2003 on two National Institutes of Health-funded video games for the prevention of obesity and type 2 diabetes in children: Escape from Diab and Nanowswarm: Invasion from Inner Space. Since then we have moved into the relatively unexplored area of online casual games for health with our subsidiary Playnormous Health Games. From our perspective, there are three significant barriers to the proliferation of health video games in today’s marketplace. I’m sure there are many more challenges to choose from, but the following have been the biggest we’ve faced.

Getting funded

Although there is strong interest in exploring video games for health among government funding agencies like the National Institutes of Health, many grant reviewers are not as committed. Video games for health use entertainment to deliver its medicine. The words “fun” and “games” are not universally appreciated in the medical and scientific research academies. We have been literally told (though the trend now seems to be on the decline) not to use those words in association with serious topics like “health” and “disease.” The press is full of negative comments about video games as both the cause and effect of teenage violence. Similar sentiments can be found in the hearts and minds of some grant reviewers. Getting funding for the creation and research of video games for health may be an uphill battle for some time.

Sustaining funds

As Director of Marketing for a serious game design firm, I always find it interesting to talk with decision makers about the health games market. More often than not I’m told, “Market? What market? No one can make money on these things. Why don’t you just try to get on Oprah? I bet she’d like health games.”

Indeed, Oprah probably would. But a market beyond grant-based video game research is a topic worth discussing in the business community too. No question about it, an economic foundation beyond grants must be found to sustain the video games for health movement. A working commercial model is also needed to provide the researchers and developers with health game experience with the means to produce ever more effective games. There can be huge funding gaps between formative research, product development, and the clinical trials required to get a video game tested and ready for market. This industry needs a commercial basis and viable distribution models. On a positive note, investors such as health insurance companies, pharmaceuticals, and the food industry giants are starting to look beyond the feel-good messages health games can provide. Unfortunately, that’s not the same as viewing video games for health as critical influencers on the lives of their patients, customers, and constituents.

Knowing what works, and why

The literature on how and why video games for health work is rather thin. Clinical efficacy trials are few and far between. There is no real history to give game developers the X + Y = Z formula needed to develop medically and cost effective health games. Some research has been conducted on how the brain reacts to violent games versus non-violent games via functional MRI studies, but what about other aspects of health games? Very little research has been done on what is fun, let alone how fun translates into positive health change. I hate to sound like a researcher, but more research needs to be done on this. And research takes funding.

Light at the end of the research tunnel

Investigators are starting to report their data on the effectiveness of health games, including Diab and Nanoswarm, which should be available in the next few months.  An increase in positive evidence for health games in the literature could underpin new rounds of funding, commercial interest, and venture capital support.  Furthermore, it is encouraging to see large institutions like the Robert Wood Johnson Foundation and the Joan Ganz Cooney Center showing an interest in the use of technology for the improvement of child health. The days of health games sitting on researcher back shelves may soon be over. Let’s move beyond initial formative research and start getting these games to market.

Guest Blogger Series: Views on Increasing the Use of Digital Games for Health

We started June off with a look at games for health in preparation for the 2009 Games for Health Conference. We attended, we tweeted, and we shared updates on some of the incredible developments that took place this year. Now we’d like to end the month by looking at the opportunities that games have in creating positive health outcomes among children.

Yesterday, the Sesame Workshop’s Joan Ganz Cooney Center released a new report on the power that video games can have in addressing some of the most pressing health challenges facing America’s children. The report outlines some strong evidence that games can make a positive impact on the health of our children – a great step. However, we also recognize that there is still work that needs to be done to increase the use of digital games for health.

With that challenge in mind, we posed a question to a panel of guest bloggers and invited them to share their point of view:

“There is a growing consensus that digital games can be deployed to support learning and behavior change for positive health outcomes among children. What do you think needs to be done to increase the use of digital games for this purpose?”

Over the next week, they’ll be posting their thoughts right here – we encourage you to leave your comments and take part in the conversation. 

A Declaration of Our Rights to Health Data

If you enjoyed Steve Downs’ recent post about the Open Notes project, here’s a group with related interests. Health Data Rights, a group of organizations, corporations and individuals, is calling for a people’s right to have and share health data. They assert, in part, that -

“We the people:

• Have the right to our own health data;

• Have the right to know the source of each health data element;

• Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; If data exist in computable form, they must be made available in that form; and

• Have the right to share our health data with others as we see fit.”

The group includes Dossia, GoogleHealth, FasterCures, Microsoft and PatientsLikeMe. The rights have been endorsed by Adam Bosworth, David Kibbe, Esther Dyson, Tim O’Reilly, Steve Case and nearly 300 other individuals.  If you’re interested in learning more, here’s their site: http://www.healthdatarights.org/

The Pioneer Portfolio team and the Robert Wood Johnson Foundation have been interested in liberating health data for a long time, as we think that liberated data enables innovation.

If you’re interested, you can follow the conversation about Health Data Rights on Twitter.  

Opening Physicians' Notes to Patients

Today’s Boston Globe ran a story (page one, no less!) announcing our grant to Beth Israel Deaconess Medical Center run a three-site demonstration of opening up physicians’ notes to patients.  That’s not just making labs, drugs, allergies, etc. available to patients – it’s giving them access to the actual notes that the physician records about a visit.  Now these notes are technically available now – under HIPAA each of us has a right to our full medical records (of which physician notes are a part), but the processing for obtaining them is often slow, cumbersome and even expensive in some cases.  Under this project, called Open Notes, patients will receive a secure email after the note has been completed and they can see it right away.  They’ll also be prompted to review the note prior to their next visit.  So instead of limiting access to the very determined, access will be easy for anyone who’s mildly interested.

Why would we fund this?  Several reasons, really.  First, is that at the Pioneer Portfolio, we’re very interested in patient-centered innovation.  Let’s face it:  virtually every trend suggests that people are going to have to become much more engaged in their care and in taking care of themselves.  And, as the pioneers of shared decisionmaking, patient centeredness, patient activation, online support groups and the health 2.0 community have shown us, real benefits come from this engagement.  So much of the energy and excitement in health care today is coming from the patient/consumer side of the equation.  So it’s a space where we believe we will find many innovations that can ultimately transform health.

Second, it’s an elegant system tweak that could really affect behavior.  It’s just a hypothesis at this point, but think about how the knowledge that a patient will read a note will affect how the physician writes the note.  Of course the effect will vary by individual, but this little tweak – with a very small marginal cost – takes a task that physicians do dozens of times a day and reframes it.  As my colleague Paul Tarini has pointed out, it says that this note is for the patient more so than about the patient.  Subtle but important.  My own bet is that this change could do more for influencing how physicians see their relationship with their patients than years of training on how to be more patient centered.  Of course I could be wrong!

And that brings me to the third reason.  This is a controversial idea that needs to be tested.  As we – and Tom Delbanco, the principal investigator on the grant – talked to people, we found strong opinions on both sides of the issue.  There are many people with a patient advocacy perspective who think this is so obvious, such a right and there should be no question about it.  And there are many physicians who think – for very plausible reasons – that this is a terrible idea.  As I said in the Globe article, there’s a bit of a religious character to the debate – you either believe one thing or the other and you believe it strongly.  But there’s been precious little evidence to inform that debate.  That’s why it’s important to do the study and do it on a large scale.

So we’re all excited about this project.  It’s a simple but powerful idea that deserves a real test.  And we hope it sparks enough discussion to raise some interesting and fundamental questions.

More on the App Store for EHRs

For those of you interested in this idea – of electronic health records working as platforms that support substitutable applications (see earlier posts here and here ) – Ken Mandl and Zak Kohane convened a small working group to come up with principles for fostering the development of an “iPhone-like” platform for healthcare information technology.  Check it out and come back here for discussion.

Positive Emotions, Diverse Social Networks and Social Status = Positive Health?

We’re pleased to announce what is sure to be another engaging program from the Penn Positive Health Lecture Series. On June 24^th, Dr. Sheldon Cohen, Ph.D., will lead a talk on the roles that positive emotion, diverse social networks and perceptions of social status play in morbidity and mortality.  

Dr. Cohen, who is the Robert E. Doherty Professor of Psychology at Carnegie Mellon University, has published work on the roles that stress and social networks can play in physical and mental health.  As part of his lecture he will discuss his experimental work where mental and biological predictors are assessed in healthy people before their exposure to the common cold virus.

The lecture series is part of the Positive Health project which is funded by the Pioneer Portfolio and led by Dr. Martin Seligman of the Positive Psychology Center at the University of Pennsylvania. 

If you have the opportunity to attend we’d love for you to share your thoughts.

Here are details:

Emphasizing the Positive: Positive Emotions, Diverse Social Networks, and Social Status Contribute to Lower Morbidity and Mortality

Date - Wednesday, June 24, 2009
Time - 12:00-1:00 p.m.
Location - Dunlop Auditorium, which is in Stemmler Hall at the University of Pennsylvania School of Medicine, Philadelphia
Free and Open to the Public 

Five Questions from Games for Health

After a few good nights’ sleep, I think I’ve finally started to process some of the intriguing concepts I took in at 2009 Games for Health. Newbie that I am, rather than offer my own rudimentary take on what’s happening out there, I want to use this post to just pass along a few nuggets that really made my ears perk up and pose some questions. I’m eager to become more involved in this space, so I’d love to hear any thoughts or nagging questions that other participants or observers took away from this conference. Thanks again to everyone who took a couple of minutes to talk with me last week, and please help me keep the conversation going!
 

• Steve Brown, CEO of 3Banana, posed the following as the fundamental design challenge of health games: “Games are for fun and health issues are an unwanted intrusion into our lives.” That could be interpreted as: because games are fun, they are more likely to compel certain people to deal with health issues; or as because games should be fun, people may consider the incorporation of health issues as an intrusion. How can the industry strike the right balance between former and the latter?

• Tim Chang of Northwest Venture Partners, speaking to a standing room only crowd, offered the VC’s perspective on short- and long-term opportunities for health games: “If a product does not tap into one of the seven deadly sins, it will not succeed.” Is this good advice for developers and other stakeholders? Why or why not?

• At the second morning plenary, an investor with a strong interest in cognitive games described a recent family retreat where a centerpiece of the entertainment was a Wii Fit. At one point 14 folks were playing together – including an 80-something who was particularly into it. So clearly, exergaming is heating up on many fronts. What other areas of health games may soon be ripe for the mainstream? What internal/external developments must unfold for this to happen?     

• At one point, there was reportedly a queue out to the door for the “accessibility suite,” where vendors were demonstrating products that allow people suffering different levels of paralysis to play health games. The devices were incredibly cool, but what really got me thinking was a video clip of an interview posing one question to game developers: "Have you ever thought about disabled people who play games?" Undeniably many have given thought to this question, but as you can see from "The One Question Interview" on the Able Gamers website, it seems many also have not. How would you rate the health games world on the accessibility question on a scale of 1 to 10, and what do you think are some of the key barriers and opportunities?

Finally, in addition to being my first real exposure to this field, Games for Health provided me my first opportunity to live tweet from a major event – and I was obviously far from alone. Since last Thursday there have been a combined close to 450 tweets from more than 100 people with the #gamesforhealth and #g4h09 tags – and the numbers keep growing. To find out what really has people talking, check out the streams yourself.

Well that’s it for now. More tidbits/questions to come…