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Computer Games for Obesity and Diabetes Prevention: Interfacing Behavior Change

Techniques to Game Elements

Written by Brian Mayrsohn, MS,


Research Assistants: Alexis MoffWilliam Butler, BS, Alexis MoffWilliam Butler,
Christopher Gates, Georges Khalil MPH

FIRE Mentors: Atsusi Hirumi, PhD. & David Metcalf, PhD.


University of Central Florida College of Medicine

2. Abstract
With the increasing burden of chronic diseases, such as obesity and diabetes, there is
a strong need for a low cost solution that can be individualized for patients. Games for
health are touted as that solution. A major benefit is that they can improve the delivery of
care across the healthcare continuum while also increasing reach and patients buy in.
Successful health games are based on theoretical frameworks which require the successful
implementation of game elements. However, terminology used by researchers is either
asynchronous, or totally lacking, making it difficult for others to refer to a consistent
approach. The purpose of this study is to bridge the gap between game designers and
behavioral scientists enabling them to create games based on behavior change gameelements (BCGEE) . These BCGEEs are optimally designed not only to be fun and
engaging, but also to be transformative. A tool was developed which merges these two fields
and creates a common language that could assist researchers and game designers in the
identification of BCGEE necessary to create more efficacious health games. The tool was
constructed using research obtained during a systematic review of the literature, the expert
guidance of one game designer, and three behavioral scientists that develop games for
behavioral change. The tool was then validated through one-on-one interviews with game
designers and behavioral scientists. A mixed method research approach was taken by
utilizing thematic analysis and Linkert scales to evaluate the transcripts obtained from the
interviews. The analysis of the transcripts led to redefining the game elements and links

between the two fields. By including all stakeholders, a common language was developed
that both fields can utilize to develop games for change.

3. Lay Abstract

Games for health have the potential to change the way patients engage nutrition and
physical fitness, and hopefully result in healthy behavior. Games for health is a relatively
new field and, like any new discipline, there are growing pains. There is not a common
terminology that all within the field use, and as a result, there is no universal standard at
which to build the industry on. The aim of this study is to create a tool that health game
developers can use to identify the correct terms and examples to make a successful
behavior change game.

4. Background:

Overview

With the increasing burden of chronic diseases, such as obesity and diabetes, there is
a strong need for a low cost preventative solution that can be individualized for patients.
Traditionally, behavioral change interventions aimed at changing physical activity and
eating patterns range from individual-based to community-level1 and demonstrate small to
moderate effects on weight loss2. Additionally, skill level, time commitment, and expenses
vary among health professionals which, when combined with the lack of program

effectiveness, reach, and sustainability, may account for the lack of substantial impact1.
While grass-roots style campaigns may have many obstacles, especially with respect to
scalability and manpower, leveraging the Internet to disseminate games for health may
prove to be a cost-effective and perhaps more efficacious alternative if augmented with in
person activities.

Unlike previous generations, smartphone devices and portable gaming consoles


ubiquitous nature allow gamers to virtually eliminate all downtime and grant access to tens
of thousands of games3. Today 183 million gamers log an average of at least thirteen hours
a week in the US alone3. Games could be a successful medium in which traditional
behavioral change techniques (BCT) are infused in attempt to alter malignant behavior
without disrupting normal lifestyles3. Michie et. al defines a BCT as an observable,
replicable, and irreducible component of an intervention designed to alter or redirect
causal processes that regulate behavior; that is, a technique is proposed to be an active
ingredient4. Internet-based games offer several advantages than their traditional inperson counterparts including reach, availability, and opportunities 5 for interactive
approaches6. Additionally, information and messages can be tailored to participants to
personalize the experience7. Furthermore, games provide a way for users to anonymously
seek out sensitive health information while making it fun and engaging8.

In the past video games have traditionally been placed in the home8 and health
games directed at preventing and treating childhood obesity were outside the home 9.
However, mobile technologys (e.g. smart phones, tablets, and wearable sensors) wide

availability and pervasiveness has paved the way to easily facilitate health games
infiltration throughout all aspects of ones daily routine10. Interestingly, the commercial
games implemented in arcades consist of exergames and exergaming stations, whereas
those distributed by researchers focus on nutritional behaviors11. The gaming industrys
preference towards PA games seems logical given the ease at integrating entertainment with
physical activity (PA) rather than tackling to complicated nature of applying theoretical
frameworks coupled with nutritional behavior education components.

Psychological theories have successfully been utilized as the foundation for


developing dietary and physical activity behavior change interventions and experiments
over the last century1214. Analogous to traditional interventions, video game dietary and
physical activity interventions rooted in behavioral theory can be an effective medium to
create behavior change15. Over the last decade, interventions delivered over the internet
that focus on physical activity1,2,6,1619 and diet2,1922 have become increasingly prevalent.
Games such as Diab, Zamzee, among other mobile and Wii games have shown to have a
significant impact on anthropometric and physiological measures and health behaviors23,24 .

Traditionally, entertainment education has been used in television to passively


change behavior. However, Internet games may offer great attention and credence due to
their immersive qualities2,19,21,25,26. Therefore, games delivered on this newly ubiquitous
platform are proving to be an effective strategy for embedding behavior change procedures
including modeling, skill development, self-regulatory behaviors, reward, and immediate
feedback19. These interactive components (e.g. avatar, quests, rewards, etc), referred to as

game mechanics or game elements (GE), have been defined as methods invoked by agents
for interacting with the game world27 and are the primary source of interactivity and
structure how video games proceed28.

Research has shown that simulation and scenario-based games are especially
effective in teaching skills for healthy lifestyle, prevention, and self-care as well as creating
a safe environment for users to rehearse new skills and to develop deeper understanding of
cause and effect28. When players rehearse skills in a simulation game, health-related
knowledge29, skills30, self-confidence31, and behaviors32 can improve. These processes foster
the development of new attitudes, emotional responses, risk perceptions, self-concepts, and
social connections, which can strengthen motivation for behavior change29.

Behavior change interventions are rooted in behavioral theories or frameworks,


such as social cognitive theory (SCT), self-determination theory (SDT), and transportation
theory (TT). Each theory requires a specific application of BCTs to accomplish behavior
change. Until recently, there has been wide use of disparate terminology in published
reports affecting the interpretation and comprehension of not only the experimental design
but also the results4. In fact, behavioral medicine researchers and practitioners have
expressed a low confidence in their ability to replicate previously established successful
diabetes prevention programs33. In response, Michie et al. developed a comprehensive
taxonomy of BCTs to create a common language that will improve the accuracy of
replication and facilitate the faithful implementation and development of behavioral
change interventions. The games for health field is experience a similar problem.

Games for health is a relatively new field composed of many disciplines. The game
architects salient objective is to systematically combine GEs in such a way that they create
a fun game. Without the fun factor, which also requires carefully applied game
mechanics and narrative, a health game will not be effective because of a simple premise: if
it is not fun, people will not play it. According to Dr. Pam Kato, former CEO of Hopelab, a
games for health company, any game mechanic can be successful as long as it is balanced
and/or supported by programming that executes it well, art that emotionally engages
players, game design that promotes ongoing engagement, and content that is presented in a
way that merges with all of the above seamlessly. However, GE definitions vary among
disciplines (e.g. game designers and behavioral scientists), so this research seeks to establish
a definition database of GE that people can refer to when developing games for health.
Additionally, when operationalizing these GE for use in behavior change interventions,
further complications arise.

While games developed are unique and utilize GEs creatively, the theoretical rational for
their effectiveness in behavior change can be narrowed down to a select few frameworks.
These include Social Cognitive Theory (SCT), Self-determination Theory (SDT), and
Transport Theory (TT)15. Many theories that independent researchers reference as the
mechanism behind their interventions success seem to overlap. However, theories and
change procedures were either applied differently or the terminology used was
asynchronous4,34. This was the case in both the games for health field as well as the
behavioral psychology field16,24. It is all too common for change procedures (e.g. tailoring)

as well as psychology theories and outcomes (immersion) to be labeled at GEs that actually
result from successful implementation of the elements which makes the authors explanation
of confusing and can lead to reduced fidelity in interpretation and application of lessons
learned4,24each of these BCTs are unique and carry varying degrees of relevance and
effectiveness, understanding which GEs are interfaced with which BCTs still remains
unclear. Researchers have categorized discrete lists of BCTs used in health4and messages
found in health promotion videos and identified principles of social influence 15, but there
are few available list of discrete GEs used in health behavioral change games28.

The purpose of this study is to bridge the gap between the designers and developers
and the behavioral scientists to enable them to create games based on behavior change
game-elements (BCGEE) that are optimally designed to be fun and engaging but also
transformative. The aim of this tool is to assist researchers, game developers, and game
designers in the identification of BCGEE necessary to create more efficacious games that
can create behavioral changes and ultimately better health outcomes. A foundational first
step for this work is to identify and define the most common GEs and BCGEEs found in
the games for health research and match them to BCT.

5.0 Methods:

A systematic review of the literature was performed and game element examples
(GEE) were identified and extracted. A standard definition for all GEs that matched the

corresponding GEE was developed, and intervention descriptions in primary studies were
coded for inclusion or exclusion of defined BCTs.

Definitions

Game Element Examples are defined as an example of a GE applied to a game.


Game Element Examples when used for behavior change will be termed Behavior change
Game Element Examples (BCGEE). GE are defined as methods invoked by agents for
interacting with the game world27. A BCT is defined by Michie et al. as an observable,
replicable, and irreducible component of an intervention designed to alter or redirect
causal processes that regulate behavior; that is, a technique is proposed to be an active
ingredient4.

How Game Element Examples were Identified

GEEs and their respective definitions were identified through a systematic review of
the games for health, entertainment education literature, and online databases. A web
search was conducted using PubMed and Google Scholar applying combinations of the
following keywords: games for health, game and behavior change techniques, games for
change, obesity, diabetes, health, fitness, mobile devices, mhealth. The studies that were
chosen for incorporation into the tool had demonstrated sufficient evidence that their game
applied an acceptable level of behavior science and that there was evidence supporting
improvements in health behavior, knowledge, self-efficacy, confidence, and other

determinants. Only games that were published in peer review journal articles were selected
for the review. There are renown experts in this field (e.g. Thomas Baranowksi PhD,
Pamela Kato PhD, Wei Peng PhD, Deborah Thompson PhD, Elizabeth Lyons PhD,
Amanda Staino PhD, Richard Buday) that apply behavioral science theories in game
design, all of which were either interviewed or provided guidance for this study. These
authors published papers which were included and considered the cornerstone standard of
game development by which all other published papers were compared to. GE definitions
were identified from published entertainment education and games for health literature
(i.e. 65 abstracts, 20 full length journal articles, select sections from five books) and a
definition database was developed. By focusing on the most discussed and understood GEs
in games for health research, we were able to retain accuracy in our definitions rather than
speculate on less researched concepts4,21,24.

The purpose of the tool was to identify the various GEs in use. Therefore, the
BCGEE became the starting point for the tool. This allowed the research to focus on which
GEs were actually being utilized by researchers and game developers. A BCGEE was
matched to a GE by identifying which GE definition from the definition database
encompassed the BCGEE. GE definitions were created using several sources, and the most
succinct, accurate definitions were utilized and iterated upon. It was our goal to provide the
end user with as much information as possible regarding the context in which that GE was
applied. We therefore included many quotes from the text in an attempt to recreate the
setting by which the author intended. If a study called a BCGEE by specific GE, but that
GE definition from our database did not match, we relabeled the proposed GE to fit the

BCGEE used by the game according to our established definitions. Further complicating
matters, some papers utilized BCGEEs without explicitly identifying them 16,24, therefore the
GE definitions guided us in further identifying BCGEE. This is a similar application of
Michie et als BCT taxonomy.

Moving one step further, in an attempt to combine the fields of behavioral science
with game science, connections between BCTs and GEs were made by operationalizing
Michie et al.s taxonomy of 93 BCTs. The definitions from that study have been validated
and are now the reference for behavioral science. Once a definition pair was made between
GE and BCTs, the BCT example from the taxonomy was assessed in relation to the
BCGEE, to confirm our proposed match.

In the RightWay Caf, for example, positive attitudes toward healthy eating are promoted
by providing positive feedback and rewarding points to players when they choose healthy food.
This BCGEE was termed a reward, and defined as "The player receives something
perceived as valuable (either intrinsic or extrinsic), or is relieved of a negative effect for
completing goals during the game." This GE definition matches nearly perfectly with Nonspecific reward, which is defined as: Arrange delivery of a reward if and only if there has
been effort and/or progress in performing the behavior (includes Positive reinforcement)

When there was not an obvious match between a GE and BCT, the BCGEE was
compared directly to a BCTthe procedure used following a successful definition pair
match. In several instances there was no clear match between BCT and GE, therefore the

GE under consideration required two or more BCTs to properly create an all-encompassing


link. The 2013 taxonomy has examples associated with each BCT, so in an effort to be
consistent and to maintain the taxonomy as the foundation for this tool, the examples were
incorporated verbatim. It is important to note that the 2013 taxonomy does not include
games for health interventions, or for that matter, interventions that utilized gaming
technology. This added to the burden of attempting to interface the two disciplines.

Following the completion of the prototype, in depth conversations with one behavior
scientist and two behavior change game design experts were conducted. They were each
asked a series of questions which can be found in appendix. These conversations were
important to creation of the prototype tool. Once the feedback from the three stakeholders
was integrated into the tool, the new iteration of the tool underwent rigorous scrutiny from
an expert panel. The expert panel was composed of a 5 game designers trained in game
design, and 6 games for health experts whose background includes psychology and game
design. 5 of the 6 psychology trained game researchers had a PhD. The questions to those
interviews can be found in the appendix. While the discussions were critical to validating
the language used in the tool, they also served to gather feedback from stakeholders who
are the target audience for the application of this tool.

6.0 Results:

The original tool created wasrevised considerably since it was initially


conceptualized. Conversing with the three early participants helped to shape the need,

purpose, and application of the tool. When speaking with the one of the original game
design experts, it was clear that he could not see the application of the BCT for an
intervention, and he asked for examples of the BCT to be included to provide a point of
reference how GEs could be utilized. Initially, the tool was composed of behavioral theories,
constructs derived from those theories, BCTs, and GE, and the BCGEEs. One of the
behavior scientists stressed the importance of switching the BCT reference from the 2008
taxonomy to the 2013 version. It was also expressed that the BCGEEs have to be easier to
understand, which led to a reworking of the BCGEEs into more concise, common
explanations as shown in Table 1. This transition required a reworking of the connections
between many of the BCGEEs because many of Michie et al.s termsespecially the more
generalwere refined and made more specific. Additionally, the 2013 taxonomy added
many new BCTs. For example, the GE Feedback was originally paired to the BCT
General Encouragement, however General Encouragement was not included in the
2013 taxonomy. Therefore pairing the Feedback GE with a BCT definition became more
complicated as shown in table 1.

In the original tool, feedback and feedback as a reward was one game element.
The fact that many of the participants, including Pam Kato, Patrick Feller, Alan Simons,
and Richard Buday, defined these as two distinct terms and made it clear that it should be
its own GE.. The game element was split into two separate terms. The definition of
feedback as a reward is related to the definition of feedback, but goes farther to include
feedback being used as a reward in gameplay. Feedback as a reward positively reinforces
the behavior being rewarded, according to Pam Kato and Wei Peng. The example of

feedback as a reward is one that shows the feedback upon completion of a goal and would
encourage players to repeat the behavior. The behavioral change techniques are the same
as that of feedback, because feedback as a reward is still feedback. The added technique
of non-specific reward [10.3] was chosen, because it gives the way in which feedback can be
used as a reward for the completion or progress towards a goal and the usefulness of that in
positively reinforcing behavior.

With respect to feedback, the expert panel all gave input on how feedback can be
implemented in games so it was included that it can be visual, written, touch, or auditory.
Furthermore, rightness and wrongness were removed from the definition due to
disagreement of feedback containing disagreeable connotations. Therefore, the phrase
information on game play performance was used because many of the interviewees Wei
Peng, Richard Buday, Alan Simons, and Pam Kato mentioned that feedback is simply the
displaying of information from the game to the player based on the interaction, without
providing judgment on the positive or negative qualities of that interaction. While it is true
that feedback can be used to inform someone of his or her in game successes, that would
express a narrower example of the GE being applied in a specific way by the game designer
and therefore addressing the quality of the feedback would limit its applicability.

The feedback example was derived from DIAB in which a player is given
information in the form of a score sheet that evaluates their performance. The BCT for
feedback is feedback on behavior [2.2] and feedback on outcome(s) of behavior [2.7],
because it shows that information is given to someone as a result of their actions.

GE Name
Feedback (Old)

GE Definition
Games provide information feedback. Feedback in learning or
playing games is designed to evoke the correct behavior, thoughts, or
actions. Games provide information upon which the player can act.
The information feedback is designed to indicate the degree of
rightness or wrongness of a response, action, or activity.
Feedback immediately informs the learner if he or she did the right
thing, the wrong thing, or somewhere in the middle but doesnt tell

Feedback

the learner how to correct the action.


Information on game play performance given to players during the
game. It can be visual, written, touch (vibration of a controller) or

GE Name
Feedback

auditory.
Behavior Change Game Elements Example
In DIAB, there is a fruit knowledge mini-game where fruits must be
distinguished from non-fruits and feedback is given to the player in
the form of a score sheet. All the correctly identified fruit appears
under a green check mark, whereas all the incorrect selections
appear under a red x.

Feedback (Old)

Instant feedback regarding whether the players choice is correct or


incorrect include sound effects and/or graphics. General feedback, to
enhance a sense of accomplishment and personal pride in a job well
done, is also included at various places in the video game and
included statements such as, Great! You picked well! Feedback is

also specific, positive, and realistic: Youve met goals before and
youll do it again. No ones asking you to be perfect, just try. (D)
BCT Name
General Encouragement

BCT Definition
Praising or rewarding the person for effort or performance without

(2008)

this being contingent on specified behaviors or standards of

Feedback on behavior

performance
[2.2] Monitor and provide informative or evaluative feedback on

[2.2] (2013) & Feedback

performance of the behavior (e.g. form, frequency, duration,

on outcome(s) of behavior

intensity) & [2.7] Monitor and provide feedback on the outcome of

[2.7] (2013)
performance of the behavior
Table 1. This table shows the old game element of Feedback and its corresponding BCT
definition pairings from the old taxonomy. It also presents the new iteration of the GE
definition and the new BCT pairing from the new taxonomy.

Avatar
In the original tool, an avatar was not one of the game elements defined. During the
interviews, the participants were asked to define dynamic avatar. Ross Shegog, Richard
Buday, Amanda Staiano, and Wei Peng all defined avatar separately from the definition of
dynamic avatar, which made it apparent that avatar needed to be defined as a game
element in itself. In the definition of avatar, the word representation is used to signify the
purpose of an avatar, because almost every participant used that word to say that the
avatar is a representation of the player, including Ross Shegog, Richard Buday, Amanda
Staiano, Wei Peng, Patrick Feller, Alan Simons, and Nate Yeller. The definition is taken
from Ross Shegog saying, An avatar is a virtual representation of the player in game

state. The two examples are from health games that allow a player to create a virtual
representation of them in the game they are playing. The behavioral change technique for
avatar was chosen as identity associated with changed behavior [13.5]. The player creates a
virtual identity of them and performs behaviors required of that new identity, during the
game.

See Figure 1 for the tool and the appendix for the rest of the edits made from the original
prototype to the current edition of the tool. Figure 2 is a visual representation of the
connections made between the BCTs and GEs.

7.0 Discussion:

This research is the first systematic analysis that sought to identify potentially
effective GEs used specifically for behavior change interventions in health applications. It
was therefore the aim of this study to highlight successful games that were effective in
positive health behavior change for designers to draw inspiration. A roundtable discussion
that included discussions from six world subject matter expertsthree of which
participated in this studyprovided examples on what they found to be effective and
ineffective GE for games for health. However, as of this writing, there are few publications
that discuss specifically successful GEs and define them in the context of improve diet and
physical activity.

Application of different GEs are critical to the success of a game. For example, in

game prompts can be an excellent way to remind the user to perform a task, but they can
also become annoying and ignored (similar to banner ads on a website). Thus, highlighting
the importance of strategically implementing each GE within a game and determining its
purpose with great intention. Lu et al. and Mayrsohn and Khalil emphasize the importance
of drawing inspiration from successful commercial games to create a behavioral change
game that is actually fun10,11.

The various combinations of GEs that most effectively drives specific behaviors to
change have not yet been fully elucidated. One large barrier that clearly prevents the
scientific community from identifying exact mechanisms is due to the use of inconsistent
terminology making it difficult to perform meta-analyses. Furthermore, studies not only
neglected to associate GEs and theoretical frameworks, but also neglected to label all GEs
used in the methods section or game description, making it increasing difficult to assess a
games attributes or replicate specific components that games implement16,24. This can be
because some researchers may consider a mechanism in a game to not be a GE, whereas
others consider aspects of game play to be GE when they are in fact not. Unless the games
are actually played, it is difficult to ascertain each GE included, and how it was utilized. A
reason for this is the page limit in peer-reviewed journals.

Creating a standardized set of GE definitions will clarify which techniques, or


combinations of techniques have been implemented, which will allow for a more precise
understanding of the study in question and will aide researchers in determining which GEs
are correlated with effective behavior change. By focusing on the most discussed and

understood GEs in games for health research, we were able to retain accuracy in our
connections rather than speculate on less researched concepts4,21,24. It was apparent from
our early conversations with game developers that including the theories and constructs
would be unnecessary for game developers because it is beyond the scope of their
knowledge, not to mention confusing.

There were instances where researchers used the term GE when referring to the
mechanics used in them game; however the terms were inconsistent with the GEs found in
literature. For example, the game Right Away Caf uses the terms interactive tailoring,
role-playing, the element of fun, and narrative to create a safe environment for users to
practice behavioral rehearsal21 when referring to GE, however interactive tailoring is the
result of the successful implementation of GE to personalize the game to the user.
Additionally, the element of fun is not a GE, but a result of applying GE successfully.

BCGEE and GE matches did not always withstand the scrutiny:

The BCGEEs contained in Escape from Diab were analyzed. The authors used
motivation statements in accordance with SDT, because they can help a player see the
relevance a behavior can have on something that carries importance to his or her life. They
sought to elicit this connection using value reason statements and internal motivation,
however there was no GE mentioned or defined in association with that. The database was
implimented and matched Diabe was matched to puzzle, which was defined as a mental
challenge with at least one correct solution state that the player must find35. After

interviewing the expert panel, we were mistaken in our pairing process. We ended up
removing the puzzle game element all together because a match was unable to be found.

There were also instances where we had overlapping GEs such as take risks and
trial and error. According to several participants, including Richard Buday, taking risks
was not considered a GE, so it was therefore removed from the list. Additionally, the term
riddle was originally used interchangeably with the term puzzle, but through the
interviews, 10 out of 11 people felt that the two were distinct GEs. Once BCGEEs and GE
were linked in the study, the next objective was to match BCTs from the taxonomy.

Matching Game Elements to Behavior Change Techniques

Matching GEs to BCTs proves difficult due to domain variability. Furthermore


BCTs were defined as behavioral change relates to traditional interventions, not game
interventions. For example, the In Game Prompt GE is defined as A virtual cue (Visual
or auditory) to influence a user to engage in a specific activity or behavior in the game. In
real life, there are no prompts that pop up, however there are certain triggers in a persons
environment to cue him or her to do something. For instance, a seatbelt light that triggers a
person to remember to wear a seatbelt or placing a favorite quote in ones kitchen to
remember a life idiom. Therefore two BCTs were identified including 1) Prompt/Cues and
2) adding objects to the environment both of which could satisfy our definition. In life,
these cues interject in a persons presence when a specific action is taken such as turning on

the car, and similarly in a game, these cues would not be triggered until the person enters a
room or a given level. Therefore, these similarities led us to match them together.

We also found, that while BCTs could be sufficiently matched to a BCGEE, it was
not always essential. For instance, the GE trial and error is defined as a process of
attempting to accomplish goals by trying different methods and discovering which one is
the most successful. Essentially it is a process by which we learn from our mistakes.
Therefore, one could argue that the BCTs that match feedback are 1) self-monitoring of
behavior or 2) Feedback on outcomes of behavior could be matched. Either one is
sufficient, but both encompass the global understanding of the term.

Another example is the game element Quest. A Quest is matched with


behavioral contract, defined by the [creation] a written specification of the behavior to
be performed, agreed on by the person, and witnessed by another, however a result of
completing the quest may be the BCT information about health consequences, Provide
information (e.g. written, verbal, visual) about health consequences of performing the
behavior. This phenomenon makes it difficult to match BCTs accordingly. Therefore, it
may be easier to match BCGEEs directly to BCTs, a notion that Marie Johnston alluded to
in a one-on-one interview

Leveraging game elements appropriately

When using this tool, it is important to note definitions and examples may be taken
out of context. In the games they were selected from, GEs are woven with the storyline and
applied with other GEs to enhance their effectiveness. Additionally, the underlying
effectiveness of one BCGEE compared to another is not clear, mainly because studies do
not remove one GE and study the effect because the success of a game is dictated by the
combination of GEs. Interestingly though, a game designer can use different GE to
accomplish similar results, however their effects can be amplified by applying them in
conjunction with psychosocial principles. For example, tutorials and role model NCs were
shown to be good methods for modeling behaviors or giving instruction, but what was not
mentioned was their effectiveness increases dramatically by creating animations or
characters who share similar phenotypic features as the user. Furthermore, children who
perceive themselves as similar to and empathize with the characters are more influenced by
the media context in which these characters appeared36. Analogous to role model NPCs,
using a phenotypically similar dynamic avatar that the user can empathize with can be an
effective behavior change tool. Essentially, the gaming experience is often greater than the
sum of individual GEs.

Dynamic avatars give positive feedback to the player on whether or not they are
performing the behaviors needed to achieve their goals. If the player performs the
behaviors of the game then the avatar will change in a positive way or vice versa. In health
games, dynamic avatars can be used to give information about health consequences 4. In a
health game, if you do not eat healthy, your avatar may become slow or weak. This
translates to information in real life about food choices and health consequences. Also, this

can be used by game designers to create discomfort and incompatible beliefs4. It will draw
attention to the difference between the behavior and consequences of that behavior and the
desired behavior and outcomes of the behavior4.

When targeting a specific behavior, different combinations or uses of GEs will have
varying degrees of efficacy. If the goal of the game was skills transferteaching a user a
new skillone could apply: Quests' can breakdown a complicated behavior and help a
player learn over a stepwise fashion, which builds on specific components. When the
specific components are combined it can culminate in a learned skill on a boss level.
Repetition could allow a user to practice multiple times until they gain memorizations37.
Cut Scenes would be able to explain a complicated behavior. All of these can demonstrate
a new skill, but it is important to note that each of these GEs has varying degree of
correlation between the element itself and skill transfer. For example, knowledge does not
necessarily correlate to skill transfer, but it is important in the teaching process24.
Interestingly, each of these GEs can be used separately, combined as all three, or some
variation, however the may be an ideal combination. Without a common language to define
all of the GEs and their corresponding BCT, it is difficult to assess which combination is in
proven to be most efficacious.

How to use this tool

While this tool could never substitute for collaboration between behavioral scientists
and game designers, it can serve as a guide for game designers. Combined with an off the

shelf game, it can empower researchers with a list of BCGEEs that can serve as a starting
point for producing behavior change games and provide research for game developers on
how to incorporate BCTs into their commercial games. Therefore this tool can be used in a
similar manner as a taxonomy. Meaning that the tool can be used to create a game instead
of pulling from ones brain, or use the definition pairs and BCGEEs provided to identify
GEs in other research papers for meta-analysis. This review is not exhaustive, but a first
step towards identifying the game elements utilized in one broad health domain, healthy
eating and physical activity.

Limitations

This tool can be used in several ways depending on the field and individual project. To
date, interviews have focused mainly around the tools accuracy, and not how one would
create a game from its contents. Some limitations of this tool were the selectivity of the
games chosen for incorporation. The games highlighted cater to younger generations,
therefore the scientific evidence will only support using the BCGEE for those ages.
However, the core principles and definitions behind the connections and definitions is still
accurate for all health games and experiments conducted towards varying populations
should be undergone. In order to apply the BCGEE to a different population, BCGEE can
be adjusted. Ultimately, this tool can be used to determine intervention content and to
facilitate communication between game designers, intervention designers, adopters, and
reviewers. This work demonstrates the feasibility of characterizing GEs utilized by games
designed to change behavior

Future Research:

One of the next steps for this research is to integrate GEs fun factor, or
acceptance, amongst players into the tool to better provide the end users with an
understanding of how the GE was received by the player during play. This additional
information will allow researchers to see not only which BCGEEs were successful in
changing behavior, but also which were used to make a game more fun and engaging for
users echoing the Entertainment Education approach21. This study is just the initial stages
of a much larger endeavor. This was a definitions of concept study to determine the best
methodology for categorizing BCGEEs, GEs and pairing them with BCTs. Further
research into the successful application of GE and BCGEEs within physical activity and
nutrition education games is warranted because new health games enter the market each
year.

This methodology can be applied to a variety of health topics and should be


considered for greater ease of access to information for game designers looking to develop a
successful game for health. See figure 3 for an example of how this tool can be applied to a
cancer adherence game, called Remission-2. A next step for this tool will be its successful
application to create a game for change. Currently, a startup company at the University of
Central Florida College of Medicine led by Co-Founders Alexander Eskandari, Zoran
Pavlovic, and Brian Mayrsohn, have operationalized this tool for the creation of their
behavior change health app called, MotiveAte. Further testing to determine the

effectiveness of that app should shed light on the role this tool can play in the development
of future games for health.

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9.0 Appendix

Question set 1:
Do you think that the Game Elements match the psychology behavior change technique. Do
you find that these definitions are helpful? How do you think this tool could be improved?

Question Set 2:
Gamer Questions
Questions to ask for each line item:

How do you define the game element, [e.g. Score Board?] in question?

To what extent do you feel that our definition matches your understanding of the
game element on our scale of Strongly Disagree to Strongly Agree?
o

If they dont agree follow up with why do you disagree, after they respond,
follow up what game-element would you say best fits our definition.

Here is our game element example, using our scale, to what extent to you feel it
matches or does not match the game element example.
o

If it does not match the game element example, ask them for an example that
they feel like would match.

Question to ask at the end:

On a scale of 1 to 4, how likely are you to utilize this tool.


On a scale of 1 to 4, 4 being highly likely, 1 being highly unlikely, how like would
you be to utilize this tool? What are your reasons for choosing this number?

In your opinion, what game elements are essential to creating an effective game for
health?

In what ways, if at all, would you use this tool?

Results from in-depth interviews:

Avatar
o Results
In the original tool, avatar was not one of the game elements defined.
During the interviews, the participants were asked to define dynamic
avatar. Ross Shegog, Richard Buday, Amanda Staiano, and Wei Peng
all defined avatar separately from the definition of dynamic avatar,
which made it apparent that avatar needed to be defined as a game
element in itself. In the definition of avatar, the word representation is
used, because almost every participant used that word to say that the
avatar is a representation of the player, including Ross Shegog,
Richard Buday, Amanda Staiano, Wei Peng, Patrick Feller, Alan
Simons, and Nate Yeller. The definition is taken from Ross Shegog
saying, An avatar is a virtual representation of the player in game
state. The two examples are from health games that allow a player to
create a virtual representation of them in the game they are playing.

The behavioral change technique for avatar was chosen as identity


associated with changed behavior [13.5]. The player creates a virtual
identity of them and performs behaviors required of that new identity,
during the game.
o Discussion
The behavioral change technique in avatar was chosen because when
you enter the game world, especially a health game, you are changing
your behavior for that game. The goal of health games is to help bring
about behavioral change. In order for this to be effective, behavioral
science points to the fact that someone needs to recognize themselves
as someone who participates in this new behavior or avoids an old
behavior. The use of avatars in games can really immerse the player in
the game, because they can see themselves, virtually, in the game. If
this is a health game, increased immersion in the game made lead to
more effective behavioral change. The player can truly see a
representation of themselves as someone who actively engages in

certain wanted behaviors or avoids unwanted behaviors.


Cut scenes
o Results
This game element is taken from the interview with Richard Buday.
He describes them as being a way to advance the storyline of the
game, in-between the players gameplay. The example of cut scenes is
taken from the game DIAB, which uses them to progress the storyline.
The behavioral change technique for cut scenes was chosen, because
cut scenes in games can be a healthy distraction from the behavioral
change that is trying to be implemented.

o Discussion
The game element, cut scenes, was created from the interview with
Richard Buday and was not in the original tool. Cut scenes in games
are extremely controversial. Richards opinion of cut scenes in games
is that they are a force fit. In his opinion, there is a difference
between immersion and presence. In games, the player is present in
the universe created. They are reacting instinctively, as the character
in the game, to the things that happen to them. In fiction, such as
movies and novels, the person is immersed in what is happening. The
person is vicariously connected to the protagonists. His opinion is
that both are extremely important, but they are different cognitive
processes. The game player is asked to learn through experience and
act instinctively and the novel reader is asked to see a character deal
with a problem instinctively and learn through reflection of that. He
says that the role of games is not to replace fiction and when we
ask a human mind to switch gears, between presence and immersion,
it can be uncomfortable. This is important to keep in mind for
someone creating a game for health. The behavioral science technique,
distraction, suggests that it is important for behavioral change to
allow the person to focus on something besides the unwanted
behavior. In the game, if the only focus is solely on the behavior that is
desired, it may become a trigger for unwanted behavior. Cut scenes
may be a good distraction during gameplay, but other behavioral
change techniques, such as identity associated with changed behavior

[13.5] suggest that a person needs to see themselves with a new


identity of someone who does not engage in unwanted behavior. If the
immersion, or presence, of the player in the game is decreased then

the behavioral change may not be as effective.


Dynamic avatar
o Results
The definition in the original tool for dynamic avatar was that it is an
avatar that changes appearance based on game play. During the
interviews, some of the participants strongly agreed with the
definition, Pam Kato, Ross Shegog, Amanda Staiano, Patrick Feller,
and Alan Simons, and others agreed, Richard Buday and Hunter
Hayes, but two participants disagreed, Wei Peng and Nate Yeller.
Although there was a majority of positive ratings almost every
participant mentioned that a dynamic avatar does not have to change
physically to be dynamic, Pam Kato, Richard Buday, Amanda
Staiano, Wei Peng, Patrick Feller, and Alan Simons. Patrick Feller
described it as being too limited, because it only discusses physical
appearance. The definition was widened to include disposition and
temperament. The definition includes that the dynamic avatar
changes based on players interaction in the game, because almost
everyone interviewed, Pam Kato, Ross Shegog, Amanda Staiano, Wei
Peng, Patrick Feller, Hunter Hayes, and Alan Simons, mentioned that
the dynamic avatar should change based on interaction with the game
or choices the player makes in the game. The example was chosen for
the original tool and rated as mostly strongly agree, Pam Kato,

Patrick Feller, and Hunter Hayes, and agree, Ross Shegog, Richard
Buday, Amanda Staiano, and Wei Peng. The original definition was
shortened, because interviewees commented that the definition was
too long and outside the scope of what a dynamic avatar is. The
behavioral change technique for dynamic avatar is body changes
[12.6], because the avatar changes in direct correlation to behavioral
changes in the game. The altering of structure can facilitate
behavioral change.
o Discussion
The example for dynamic avatar was originally based on the same
example, but included information about personally relevant
feedback. This is important, because dynamic avatars give positive
feedback to the player on whether or not they are performing the
behaviors needed to achieve their goals. If the player performs the
behaviors of the game then the avatar will change in a positive way or
vice versa. In health games, dynamic avatars can be used to give
information about health consequences [5.1]. In a health game, if you
do not eat healthy, your avatar may become slow or weak. This
translates to information in real life about food choices and health
consequences. Also, this can be used by game designers to create
discomfort and incompatible beliefs [13.3]. It will draw attention to
the difference between the behavior and consequences of that

behavior and the desired behavior and outcomes of the behavior.


Feedback
o Results

In the original tool, feedback and feedback as a reward was one game
element. The fact that many of the participants, Pam Kato, Patrick
Feller, Alan Simons, and Richard Buday, defined feedback and
feedback as a reward separately made it clear that it should be its own
element. In the definition of feedback the phrase information on
game play performance was used because many of the interviewees
mentioned these things, Wei Peng, Richard Buday, Alan Simons, and
Pam Kato. The interviewers all gave input on how feedback can be
implemented in games, so it was included that it can be visual,
written, touch, or auditory. The example of feedback is an example
from DIAB in which a player is given information in the form of a
score sheet that evaluates their performance. The behavioral change
technique for feedback is feedback on behavior [2.2] and feedback on
outcome(s) of behavior [2.7], because it does show that information is

given to someone as a result of their actions.


o Discussion
In creating the definition for feedback, it was taken into account the
different ways that a game can provide feedback. Hunter Hayes
pointed out during the interview that it is important for game
elements like feedback, score, and reminder to be in different forms,
such as visual, auditory, etc. For a game to be effective, especially a
health game that is attempting to implement behavioral change, it
needs to appeal to different types of players. Feedback is intended to
give information to the player, so the player may learn how to achieve

their goals. Players may be different types of learners and to be

effective it should appeal to different types of learning styles.


Feedback as a reward
o Results
In the original tool, the definitions for feedback and feedback as a
reward were one single game element. Many participants, such as
Pam Kato, Wei Peng, Hunter Hayes, and Alan Simons agreed that our
definition was a good definition for feedback, but that the two are
very different elements. Feedback is not necessarily a reward, Alan
Simons. The game element was split into two elements. The definition
of feedback as a reward is related to the definition of feedback, but
goes farther to include feedback being used as a reward in gameplay.
Feedback as a reward positively reinforces the behavior being
rewarded, according to Pam Kato and Wei Peng. The example of
feedback as a reward is one that shows the feedback upon completion
of a goal and would encourage players to repeat the behavior. The
behavioral change techniques are the same as that of feedback,
because feedback as a reward is still feedback. The added technique of
non-specific reward [10.3] was chosen, because it gives the way in
which feedback can be used as a reward for the completion or
progress towards a goal and the usefulness of that in positively
reinforcing behavior.
o Discussion
The definition of feedback as a reward was influenced by the
definition of reward. They are closely tied together. Many of the
interview participants, Pam Kato, Ross Shegog, and Patrick Feller,

discussed that the player needs to consider the reward to be valuable


in order for it to positively reinforce the behavior. This idea is seen in
the behavioral change technique, non-specific reward [10.3], as giving
the participant something they value in exchange for implementing
behavioral change.

Goals
o Results
In the original tool, goals was not one of the game elements defined. It
became a game element, because, during the interviews, many of the
participants asked us to define what was meant by goals in the game
element selectable sets of goals and suggested that it should be its own
game element for clarification, Richard Buday and Ross Shegog. The
definition is a compilation of the interviewees discussing other game
elements and using the term goal. Every participant used words about
goals that suggested goals were predetermined and could be
completed (have an end point). Ross Shegog defined goal as criteria
by which we measure success. The example of goals was chosen,
because it exemplifies an objective that a player needs to complete in a
game to be successful. The behavioral change techniques of goal
setting (behavior) [1.1] and goal setting outcome [1.3] show the
importance of predefined goals that can be completed in
implementing behavioral change.
o Discussion
Goals are closely tied into the game element quest. A quest is the
activity of achieving goals by overcoming obstacles, but a goal is the

objective a player is achieving. These are occasionally used

synonymously, but more often they are used to describe one another.
In game prompt
o Results
In the original tool, this was two game elements, virtual prompt and
in-app reminder. When defining an in-app reminder, most
participants it as a virtual queue or prompt in the game, Pam Kato,
Ross Shegog, Richard Buday, Amanda Staiano, Patrick Feller, and
Hunter Hayes. It was apparent that both game elements were not
necessary. An in-app reminder can be an example of a virtual prompt
being used, but it is not a game element alone. The definition of in
game prompt is compilation of the two elements and what the
participants said about each of them. The definition of virtual prompt
influenced this the most, because it received positive ratings. In game
was used instead of in-app, because in-app implies that it is only
fitting to games that are applications and not all games. The example
for in game prompt was chosen to show a specific, virtual cue that
informs players to participate in a specific behavior. The behavioral
techniques chosen for in game prompt show an introduction of
something into the environment that stimulates or facilitates a specific
behavior. Introducing stimulus into an environment can implement
behavioral change.

Level
o Results
In the original tool, level was not one of the game elements defined. It
was defined as levels of challenge. During the interviews, many of the

participants disagreed with using the term levels of challenge and said
that the term should just be level, Pam Kato, Wei Peng, Patrick Feller,
Hunter Hayes, and Alan Simons. The term levels of challenge was
changed to levels and the definition remained the same. The example
of a level is in the form of episodes in a game called DIAB. The
behavioral change technique, graded tasks [8.7] was used in this,
because it shows the nature of a level. There are tasks and once they

are performed, the person can move on to harder tasks.


Level of difficulty
o Results
In the original tool, level of difficulty was not one of the game
elements defined. When participants were asked to give the definition
for levels of challenge, most gave similar definitions that were very
different from the definition in the original tool, Pam Kato, Amanda
Staiano, Wei Peng, Patrick Feller, Alan Simons, and Hunter Hayes. All
of their definitions included varying degrees of difficulty or challenge
to complete a level or quest. This made it apparent that it needed to be
a game element. The example was chosen, because it shows the
varying degrees of difficulty that are created in a game to achieve a
goal. The behavior change techniques were chosen, because they show
the need for varying levels of difficulty to implement behavioral
change. The person needs set tasks that increase in difficulty and to

review or change the difficulty of the behavior change desired.


Multiplayer
o Results

In the original tool, this was the definition and example of multiplayer.
Pam Kato, Patrick Feller, and Hunter Hayes strongly agreed with the
definition and example and Wei Peng and Alan Simons both agreed
with the definition and example. The definition was kept as well as the

example. The behavioral change techniques were also kept.


o Discussion
Many of the people being interviewed brought up that multiplayer
can be ambiguous. It may or may not include games that allow other
players to affect the outcome of your game, this goes beyond the scope

of our definition.
Personalized goals
o Results
In the original tool, personalized goals was not one of the game
elements defined. When participants were asked to give ratings for the
example of selectable sets of goals, which included players developing
personal goals, most said that it was not an example of a selectable
goal, but it was an example of a personalized goal, Ross Shegog,
Richard Buday, Wei Peng, Patrick Feller, and Alan Simons. This was
developed into a separate game element and kept the example given
for selectable sets of goals, because the participants agreed that it was
a good definition for personalized goals. The definition for
personalized goals was created by using the definition for goal,
because it is a goal and then adding the personalized aspect to it from
several definitions given by interviewees. Amanda Staiano described
personalized goals as individually tailored goals. The behavioral
change techniques are the same as they are for goals.

o Discussion
Amanda Staiano brought up a good point, that it is important for
goals to be personalized to the player. In implementing behavior
change through a health game, it may increase immersion and success
if the player is able to see how the goals are personally relevant to
them. Peng found that having users develop personal goals
(specifically, calorie requirements and food preferences) and tailoring
a game to target their preferences was successful in helping players
select better food options. Personalized goals gets the player engaged

in their behavioral change.


Problem solving
o Results
The definition of problem solving is a compilation of the participants
definitions. The term process was chosen, because Patrick Feller,
Hunter Hayes, Wei Peng, and Richard Buday used terms that
signified it was the activity of figuring out solutions. Almost every
participant, Patrick Feller, Hunter Hayes, Alan Simons, Ross Shegog,
Pam Kato, Wei Peng, and Richard Buday described it as evaluating
an obstacle and deciding how to get past the obstacle. The example
was chosen, because it defines the process of problem solving and not
just obstacles or solutions to solving obstacles. The behavioral change
technique, problem solving [1.2], show the need for someone
implementing behavioral change to analyze the factors or obstacles of

the change and generate possible solutions.


Puzzle
o Results

In the original tool, this game element was riddle/puzzle. Almost


everyone interviewed defined them separately, Pam Kato, Nate Yeller,
Amanda Staiano, Richard Buday, Alan Simons, and Ross Shegog. Two
participants said that the definition fit for a puzzle and not a riddle
and that a riddle is a type of puzzle, but is not equivalent to a puzzle,
Richard Buday and Ross Shegog. The definition of riddle/puzzle was
kept, but slightly altered. The example was chosen, because it is an
example that shows the cognitive aspect, which almost every
interviewee said was important, Nate Yeller, Amanda Staiano, Ross
Shegog, Amanda Staiano, Richard Buday, Wei Peng, and Alan
Simons, that is involved in solving a puzzle. The behavioral change
technique, framing/reframing [13.2], shows the importance of
changing perspective and cognition involved in puzzles to figure out

how to implement a behavioral change.


Repetition resulting in habit formation
o Results
The definition of repetition resulting in habit formation was chosen to
include the word automatic, because Pam Kato, Amanda Staiano, Wei
Peng all said that word specifically. The definition in the original tool
included the phrase, gain a mastery over the game concepts,
mechanics, or ideas presented. That was taken out, because Wei
Peng, Pam Kato, and Alan Simons all disagreed that the repetition of
a behavior would allow the player to master game concepts and
mechanics. Behavioral practice/ rehearsal [8.1] and habit formation
[8.3] were chosen as the behavioral change techniques, because they

explain the use of repeating a wanted behavior to create a habit out of


it and implement that behavioral change.

Reward
o Results
The definition of reward was kept from the original tool, because
many interviewees strongly agreed with it, Ross Shegog, Amanda
Staiano, Patrick Feller, Alan Simons, and Hunter Hayes, and the other
interviewees agreed with it, Richard Buday, Wei Peng, Pam Kato,
Nate Yeller. The example was also kept from the original tool, because
many interviewees strongly agreed with it, Amanda Staiano, Pam
Kato, Patrick Feller, Alan Simons, Nate Yeller and Hunter Hayes, and
the other interviewees agreed with it, Richard Buday, Wei Peng, and
Ross Shegog. The example was altered a bit to show how points are
valuable in the game to the players, because Ross Shegog, Richard
Buday, and Nate Yeller all spoke about it. The behavioral change
technique was also kept, because it exemplifies the positive
reinforcement of behavioral change and that the reward is something
of value to the person.
o Discussion
Many of the interview participants, Pam Kato, Ross Shegog, and
Patrick Feller, discussed that the player needs to consider the reward
to be valuable in order for it to positively reinforce the behavior. This
idea is seen in the behavioral change technique, non-specific incentive
[10.6], as giving the participant something they value in exchange for
implementing behavioral change. The rewards in the game can be

intrinsic or extrinsic as in real life, but it is important that they are

valuable to the person for some reason.


Role model NPC
o Results
Pam Kato, Ross Shegog, Amanda Staiano, Wei Peng, and Hunter
Hayes strongly agreed with the original definition of role model npc
and Patrick Feller and Nate Yeller agreed with it. Alan Simons and
Richard Buday both strongly disagreed with it. The definition was
kept from the original tool, but a few words were altered. The
example was rated equally positive and negative by different
interviewees. The common factor in almost all of the interviews was
the idea that the role model npc does not necessarily have to look like
the player, which was in the original example. The behavioral change
techniques were chosen, because they show the use of demonstrating a
wanted behavior by someone a person might look up to and that they
can see the consequences of those actions through another person.
o Discussion
The example of role models sharing similar phenotypic features of the
player can be very effective, especially in a health game. It is
important for the player to relate to the role model npc and it may be
more effective for the role model npc to share similar phenotypic
features to the target population. If the player can see a
demonstration of someone similar to themselves performing the
behavior; it may seem more realistic that they can perform the

behavior too.
Score
o Results

The definition of score received fairly high ratings. Ross Shegog,


Patrick Feller, and Richard Buday all agreed with the definition and
Amanda Staiano, Wei Peng, Alan Simons, Nate Yeller, and Hunter
Hayes all strongly agreed with the definition. The definition was
altered to include displayed, because several participants, Nate Yeller,
Pam Kato, and Hunter Hayes, mentioned the importance of score
being displayed for the player to know how they are doing in the
game. The word progress was used instead of success, because
participants Amanda Staiano and Pam Kato mentioned that it does
not have to just represent success and that it may represent progress.
The example was chosen, because it exemplifies scores as being
displayed and an indication of progress. Many participants disagreed,
Ross Shegog, Richard Buday, Amanda Staiano, Wei Peng, Patrick
Feller, and Alan Simons, with our original example, because it did not
show how score relates to the game. The behavioral change techniques
were chosen and are very similar to those chosen for feedback and
reward. These techniques show the importance of giving someone

information on outcomes of a performance.


o Discussion
Scores and rewards are tightly connected. The score can be given to a
player as a reward in the game. The interviewees seem to point out
that score, like rewards, are important in context. It has to be

something that is valuable to the player.


Selectable sets of goals
o Results

The definition of selectable sets of goals was kept from the original
definition, because almost every person interviewed said that they
strongly agreed with it, Pam Kato, Ross Shegog, Amanda Staiano, Wei
Peng, Patrick Feller, Alan Simons, Nate Yeller, and Hunter Hayes.
There were two game elements in the original tool, selectable sets of
goals and selectable sets of goals, data inputting, and constant
tracking. In interviewing participants it was clear that the second was
not a game element needed in this tool. Many participants said the
example given for selectable sets of goals was more of an example of
personalized goals, Ross Shegog, Richard Buday, Wei Peng, Patrick
Feller, and Alan Simons, so the example was used for that game
element instead. Many participants said the example given for
selectable sets of goals, data inputting, and constant tracking was
more of an example of just selectable sets of goals, Pam Kato, Ross
Shegog, and Alan Simons, so the example was used for this game
element instead. The behavioral techniques for this one include goal
setting (behavior) [1.1] and action planning [1.4] to show the

importance of agreeing on a set goal and doing it.


Social Networking
o Results
The definition of social networking is based off of the definition in the
original tool. It is a condensed version of it, because Wei Peng and
Alan Simons agreed that it included too much information on what
supports social networks, but not defining what it is. The word
communication was added, because Wei Peng, Alan Simons, and Pam

Kato said that it was an important part of social networking. The


example was strongly agreed upon by these participants and kept
from the original tool. The behavioral change techniques were chosen,
because they show the importance of social roles in behavioral change.
Also, they are the same as the techniques for multiplayer. This is
because social networking and multiplayer, in health games, both use

important social support for implementing behavioral change.


Trial and error
o Results
The game element trial and error is a compilation of the definitions
for what was two game elements in the original tool, try and fail and
trial and error/take risks. Many of the interviewees equated try and
fail with trial and error, Pam Kato, Wei Peng, Alan Simons, and
Richard Buday. The definition of trial and error includes the word
process, because as Wei Peng said, trial and error, is a process where
you try and fail and then learn about what works and what didnt
work and finally succeed. You focus on the persistence of it and not
the learning. The example is actually the example from the game
element trial and error/ take risks and shows the process of trying
different foods to obtain the results desired. The game element of take
risks was eliminated from the list, because it is not equated with trial
and error, Pam Kato, Wei Peng, Alan Simons, and Richard Buday.
According to Richard Buday, it is inherent in all games. Taking
risks is a natural part in all game play and is not necessarily a game
mechanic. The behavioral change techniques were chosen, because

they show the process of performing a behavior and then monitoring


how effective the behavior was.

Tutorial
o Results
In the original tool, tutorial was not one of the game elements defined.
During the interviews, the participants were asked to rate the example
given for quest, Richard Buday, Wei Peng, and Hunter Hayes
mentioned that this was more of an example of tutorial, which can be
a quest, but a quest does not have to be a tutorial. Alan Simons
mentions tutorial during his interview also, which made it apparent
that tutorial needed to be a separate game element. The definition was
created based on the definition of tutorial given by Richard Buday,
Wei Peng, Hunter Hayes, and Alan Simons. The example used for
tutorial is a condensed version of the example given for quest in the
original tool. The behavioral change techniques exemplify the
teaching aspect of a tutorial and demonstration of behavior and what
that means for implementing behavioral change.

Quest
o Results
The definition of quest is very similar to the definition in the original
tool, because almost every person interviewed rated that they agreed
with the definition, Pam Kato, Ross Shegog, Richard Buday, Amanda
Staiano, Wei Peng, Alan Simons, Nate Yeller, Hunter Hayes, and
Patrick Feller. Many of the interviewees said that it should include
that there is an end and that there is an overall goal of a quest, Pam
Kato, Ross Shegog, Richard Buday, Amanda Staiano, and Hunter

Hayes. The example in the original tool for quest was perceived by
many people interviewed as being more of a tutorial, Richard Buday,
Wei Peng, and Hunter Hayes. The example was chosen to indicate that
a quest is something done by overcoming obstacles and has an
endpoint. The behavioral change technique, behavioral contract [1.8]
show the commitment to a task until that task is complete, like a
quest.