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Designing Games to
Improve Health Behaviors:
Evidence-based Principles and Strategies
Presentation:
Games for Change Festival, New York
Debra Lieberman, Ph.D.
Director, Center for Digital Games Research
UC Santa Barbara
June 28, 2018

Games
Interactive, adaptive, immersive,
impactful experiences
Challenge to reach a goal
Feedback on progress
New platforms, displays,
sensors, data sources

Media are similar to real life
 We feel “present” in media worlds
 Games can have compelling stories and
characters, interactions, transactions,
simulations, constructions, collaborations,
social connections with other people
 Games can be embodied in robots, plush toys
 We experience media events
 Our emotional responses to media events and
events in real life are remarkably similar

Researcher’s role in game design
 Specify the game concept and goals
 Evidence-based game design strategies to achieve goals
 Proposals for grants, investments, gifts
 Play testing and game revision during production
 Evaluation research to measure outcomes
 Publish and present evaluation research findings
 Help the design team keep up with current research

(1) Specify the game concept and goals
Know target players
 Interests, abilities, culture
 Self-concepts
 Game platforms & genres they prefer
 Formal or informal setting for game play
 Current health behaviors and health risks
 Barriers to good health behaviors (lifestyle, prevention, self-care)
 Do they want to improve this health behavior? Why or why not?
 (Players should be design partners!)

Behavioral wish-list from medical experts
 Patient behaviors that must change
 What patients need to know/understand
 Attitudes that patients could change
 Self-concepts that would benefit patients
 What motivates patients to improve behaviors

Which behaviors  Game goals and
can a game improve? intended outcomes

Focus the design on specific outcomes
How will game play enhance the outcomes?
Standalone game or integrated with other media,
games, or direct experiences?
 Must one game achieve all outcomes?

Mediating factors can change behavior
Game  Mediating  Behavior  Health
factor outcome
Examples of mediating factors
 Perceived susceptibility
 Perceived stigma
 Skill development
 Self-efficacy; response efficacy

From Interactive Games to Outcomes
Game playing  Improved mediating factors  Improved outcomes
Better
health
behaviors
• Prevention
• Selfcare
• Adherence
• Clinical
utilization
Better
health
Better
quality of
life
Lower
healthcare
costs
Health
video
games
• Challenge
• Motivation
• Role models
• Simulations
• Repetition
• Feedback
Self-concepts
Communication
&
social support
Knowledge
&
skills
Self-efficacy

Evidence-based design
Draws from theory and research findings to improve:
 Engagement
 Motivation
 Attitude change
 Self-concept change
 Learning
 Skill development
 Behavior change

Engagement
Elaboration Likelihood Model
 (ELM) – Involvement
Transportation Theory
Homophily
 Attention to characters like me
Self-referential encoding
 Learn as the content pertains to me
Tailoring, personalization,
adaptiveness, feedback

Social connection is
engaging
Self Determination Theory
Social comparison (leaderboard)
Social support, coaching
Teach a character

Motivation
Extrinsic / Intrinsic
 Points, level-ups vs. deep personal goals
 Different messaging for each
 Tie them together
Game challenge is motivating
 In the game and in daily life behaviors
See yourself as avatar
 Self-modeling – exercise and lose
weight – transfers to actual exercise
 Future self – save more for retirement

Attitude change
Empathy
 Your avatar cannot avoid homelessness
 Your avatar struggles with health issue
Procedural rhetoric
Vicarious experience – Re-Mission
 Social Cognitive Theory
 Improves self-efficacy for cancer care
 Players without cancer now see it as a
serious problem – inspired to improve
lifestyle habits

Self-concept change
Rehearsal  Self-efficacy
Role modeling
Feedback on success
Avatar of self
 Experiment with new identities
and feel empathy
 Aspirational avatar, project one’s
ideal identity and experience it
 The Proteus Effect

Learning and skill development
Simulations of real-life challenges
 Climate games – use resources
wisely or not – see consequences
 Health games –treat a patient (or self
as avatar) – see effects
Feedback tied to interests, values
Become your avatar
 Hellblade challenges the player to
think like a psychotic, in order to win

Behavior change
Rehearsal of habits, skills, adherence
Game as springboard for discussion
Two-player, cooperative challenges
Stages of Change – five stages
 Player segmentation
Inspired, mobile game, quit smoking
 External accountability
 Friends hold you accountable
 Friends cheer you on, celebrate

Behavior change – sensors
Mindlight, for anxiety-disordered
children ages 8-12
 Players must overcome their fears
 Neurofeedback headset
 Respond to scary events, threats
 Practice relaxation, focus, attention
allocation
 Develop new habits of mind

Behavior change – narrative
Dramatic stories are engaging,
arousing, transporting, memorable
 We care about the characters
 First-hand experience when our own
avatar is a character
 Emotional and physiological responses
 Stories enhance attention, immersion,
persuasion, learning, skill transfer, recall
of facts

Behavior change – neurogames
diagnose, treat, and assess cognition
 Project Evo for ADHD – improves
attention and control
 Storytelling and feedback
 Challenges and rehearses neural
systems
 Adapts to player’s abilities
 FDA approval

Behavior change – active games
Require physical activity
 Physical activity is the interface
 Or real-world activities supported
by mobile content, AR, VR, robots
 Can improve physical activity
habits, social connections,
cognitive functioning, cardio-
vascular health
 Tele-rehabilitation

Behavior change – inter-generational

Behavior change – better communication
with medical team about health concerns

A few overarching principles and strategies
Didactic content is the least of it
Player experience is key – in the game and outside it
Focus on a few specific goals for behavior change
 Be redundant – design several game features and game mechanics to
address each goal
Address player’s intrinsic values and motivations
Iterative testing and redesign are essential
A game can be fun and effective – don’t squelch the fun
Learning, skill development, striving, problem-solving, failing/retrying
are fun – not stealth, not broccoli covered in chocolate sauce!

Proverb
Tell me and I forget.
Show me and I remember.
Involve me and I understand.

Thank you
Debra Lieberman, Ph.D.
Director, Center for Digital Games Research
UC Santa Barbara
debra.lieberman@ucsb.edu
www.cdgr.ucsb.edu
Twitter: @DebLieberman
Twitter: @GamesResearch

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Designing Games to Improve Health Behaviors: Evidence-based Principles and Strategies

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Designing Games to Improve Health Behaviors: Evidence-based Principles and Strategies