While commentators in the health and technology sectors frequently tout the potential of video games to enhance patient involvement in their own healthcare and to provide avenues for interactive health education, this enthusiasm seems yet to be fully supported by developments in the health or gaming industries. Video games for health are a relatively new genre of ‘serious game’ and, thus, the body of literature dedicated to defining, analyzing, and theorizing them is currently quite limited in both depth and breadth. In Video Games for Health, Ivan Leslie Beale is particularly concerned with this deficit, and he wants to ensure that future approaches to creating media for health management follow rigorous standards that support a commitment to scientific validity. Centrally, Beale asks: how can we employ findings from the more established realm of educational video games in the development of the emergent sphere of video games for health? Because of Beale’s interest in developing this sphere, the text also takes up the broader task of defining the health genre of video game, and, in that respect, it breaks relatively new ground.

Beale’s work addresses the lack of attention paid to what tools, knowledge, and strategies video game developers need apply to the design of such games. Following from this, he seems intent on creating a formula to assess the efficacy of video games for health. In what follows, I will outline Beale’s methodology for the design and evaluation of video games for health, suggest some contributions that his text makes to the study of serious games, and raise what I interpret to be the text’s problematic emphases on learning and individual behaviour as primary foci for health interventions.

The psychoeducational intervention

In direct response to the scarcity of critical voices on this sort of gaming, Beale begins laying the framework for the design and creation of video games for health. This process, he says, necessarily involves collaboration between various subject matter experts, including game developers, academic researchers, and stakeholders such as healthcare practitioners and investors. As a side effect of theorizing the methodological facet of game design and evaluation, Beale also arrives at what I would call a tentative—and, in many ways, incomplete—definition of video games for health, as well as a rather narrow conception of the purpose these games serve. While a definition is, by nature, limiting, Beale’s focus on education and behaviour modification as the twin motivations of video games for health is limiting in an unproductive way.

Since I would prefer to avoid recreating one of the less pleasant aspects of Beale’s text for the reader, that being its decidedly procedural tone, I will refrain from rehashing the step-by-step instructions that Beale outlines. A brief summary of some key arguments should suffice.  The early pages of Video Games for Health set out to address the question of methodology. Beale’s approach to the problem of designing and evaluating games for health uses “relevant evidence-based principles from the broad discipline of experimental psychology, especially the psychology of learning and cognition” (3). In showing how these theories can be used in the context of video games for health, Beale focuses on what he sees as the purpose of serious games in general “to bring about changes in a learner’s attitudes and behaviours… [G]ame designs are therefore efficacious only to the extent to which they achieve such changes” (3). The best way to ensure the efficacy of such games, therefore, is by incorporating process evaluation—ensuring that game components have the “desired effect” on players—and outcome evaluation—establishing the game’s ability to support real-life learning—into game design and testing before games go to market (4). One of Beale’s expressed concerns—and a valid one—is that “for commercial developers [of video games for health], market acceptance might have priority over product integrity” (19).

In establishing the theoretical antecedents for game design, Beale emphasizes the importance of justifying a particular learning model upon which the game will rely. The two key distinctions he makes are between concrete and conceptual models and instructivist and constructivist models. Beale’s leaning is toward a conceptual instructivist model. Video games for health should be conceptual, in the sense that players learn knowledge or skills through fictional (rather than simulation-based) scenarios, in which in-game decisions can be transferred to real-life situations that will improve health management. While constructivist video games rely on self-guided exploration of the game world, providing players with a more open-ended structure that Beale says may be more compatible with “the complex cognitive constructs that underlie an individual’s illness perceptions,” Beale endorses an instructivist approach to game design (37). Seemingly, this choice is purely pragmatic and based on a sense of urgency in the context of critical health-related situations; not only should learning “take the most efficient path” in health situations, the instructivist approach also allows creators more direct control over health outcomes and game evaluation by giving them the ability to more obviously link programmatic in-game behaviour to real-life behaviour (37).

Along with these models, Beale highlights a few central concerns related to software design, notably generalizability (the potential for transfer of learning to settings outside of the game) and individualization (the game’s ability to accommodate differences in motivation, cognitive profiles, learning aptitude, and levels of prior knowledge and skills). This section focuses particularly on the importance of establishing preliminary objectives and identifying the needs of the target audience during game design. The discussion also provides a useful assessment of the suitability of various kinds of platforms and applications for health video games, particularly with regard to accessibility.

In the remainder of Video Games for Health, Beale provides a detailed breakdown of various strategies for maximizing both motivation and learning in gameplay, using evidence from studies performed by the author and other colleagues on the efficacy of educational games as learning tools. These strategies include the following: tailoring the rate of instruction to the learning rate of the individual learner and graduating the cognitive load (91, 96); maximizing successful performance and minimizing errors to facilitate “efficient learning that is free from the negative effects of failure” (92); timing reward-based or corrective feedback in such a way that maintains the connection between motivational, attentional, and learning and memory systems (94); continuously monitoring performance and recording events within the game, especially those related to behavioral objectives (101-2); and providing multiple examples, training contexts, and self-management strategies to promote generality of the targeted skills (102-109). In video games for health, these and numerous other strategies identified by Beale are embedded within activities, models, and scenarios based on health-related themes. “[I]llness, treatment, recovery, hope, optimism, self-care, [and] risky behaviors” are all central narrative tropes through which the game sets up behavioural objectives specific to the individual player’s needs (116).

Before expanding upon some criticisms of Beale’s work, I would like to note one of the text’s obvious strengths, that being the rather attentive and methodical way in which Beale breaks down a process of effective game design and evaluation. This is an appropriate time to note that Beale, himself, has an academic and professional background in learning psychology and learning disorders, which informs how he defines video games for health, that is, as “psychoeducational interventions” (5). To be more precise, he is referring specifically to video games that increase knowledge, self-help skills, and attitudes, the likes of which have been developed “for a range of chronic diseases such as asthma, cancer, obesity, cystic fibrosis, sickle cell disease, diabetes, as well as preventative issues such as safe sex” (6).  Unfortunately, Beale does not provide detailed case studies of any of these games, aside from the frequently cited example of Re-Mission (HopeLab, 2006), a video game for young adults undergoing cancer treatment. In my opinion, this is one of the major deficiencies of the text, especially since Beale, himself, endorses the creation of a body of literature surrounding video games for health. I would argue that this should involve, not only documentation on the part of creators, but also critique, analysis, and evaluation by researchers like Beale.

Serious games

When thinking about the question of serious games, my first thought is usually: can we really gamify everything?—Or, perhaps more presciently, should we? In certain contexts, such as literacy education (particularly for individuals with learning disorders), serious games seem ripe with potential. Much of this hinges on making learning more fun, multimodal, and engaging in ways that are tailored to the learner’s needs. But, in the context of health management, I find myself reluctantly wondering if video games (at least, the sorts of video games that this text isolates) really have a place. Some points that Beale makes in Video Games for Health support this speculation.

First, Beale mentions (almost in an aside) that video games for health must be sensitive to the fact that serious obstacles to learning can accompany health issues, including problems with sensory abilities, concentration, and skill performance (74). I think this is an excellent point, and one that I wish would have been addressed more thoroughly, since it presents a strong argument against video games for health. Granted, Beale’s purpose in writing this text is not to persuade the reader of the merits of video games for health, but, ostensibly, to guide the already initiated. Regardless, the author uses the aforementioned example of Re-Mission to note that many of the players, young persons with cancer, “said that they found it difficult to summons [sic] up the energy and concentration required to play the game successfully… [I]n the major clinical trial of Re-Mission, relatively few patients persisted with the game for more than an hour in total, even though they had access to the game for at least a month” (74). In attempting to appeal to younger players by recreating the “look and feel of a high quality commercial game,” the cognitive load placed on players of this third-person action game was apparently too taxing to allow for extended gameplay (33-4). Though I have not played the game, it would seem from Beale’s remarks that a major issue with Re-Mission lies in achieving a balance between entertainment, commercial appeal, and usefulness—a problem frequently identified in the scholarship on serious games.

Secondly, Beale reiterates the by now well-worn arguments regarding violence in video games, noting that the type of violent behaviour embedded within many entertainment games can condition players’ real-life behaviours and attitudes. While this is not the intention or ‘purpose’ of the game, he suggests, it happens anyway. Paradoxically, he notes, “academic games and health games struggle to produce learning that is generalizable to settings outside the game, even though they may explicitly teach the things they are hoping will be generalizable” (68). Whether or not violent video games lead to real-life violence is highly debatable, but if we set this contentious topic aside for a moment and think about what Beale is implying—that academic or health games struggle to produce learning—can we entertain the possibility that this difficulty extends from a wide disconnect between players’ expectations of the video game medium and the end products generated within the health or education industries? The end products to which I am referring are, specifically, video games consisting of operationally defined processes and outcomes intended to lead to behavioural modification.

More worryingly, Beale’s language seems frequently to reflect a purpose of psychological programming, rather than an interest in facilitating things like empathic social support or direct involvement in decisions related to care, factors to which scholars in psychology and health studies have pointed as important and influential for persons with illnesses. Problematically, Beale’s text seems to understand illness as a series of physiological and psychological indicators and, thus, it entirely dismisses opportunities to supportively intervene at the social or cultural levels.

Recovery as behaviour modification: a limited/limiting model

On a positive note, the collaborative impetus in Beale’s vision for the design and evaluation of video games for health forwards an endorsement for this essential aspect of the creation of serious games in general. Beale emphasizes the importance of involving healthcare practitioners (and not just health industry sponsors) directly in the design and development process, as key stakeholders. In the example of Re-Mission, game development incorporated the input of pediatricians, oncologists, and pediatric nurses. Not only are medical professionals instrumental because of their position as “gatekeepers controlling access to the game by potential users,” they also helped the creators of Re-Mission to determine the exigence, goals, and user base for the game (21). The step-by-step way in which Beale elaborates on the involvement of various subject matter experts in collaborative game design provides an effective model from which many serious game projects might benefit.

While the collaborators he mentions are crucial, I wonder what video games for health would look like if they incorporated the perspectives of social workers? How about chaplains? Or caregivers? Beale’s model could benefit from a drastic definitional widening, particularly with regards to what a game for health should achieve and whom it should target. While patient compliance with doctor recommendations regarding medications, courses of treatment, and health behaviours is certainly central to disease management, recovery, or rehabilitation, in many cases, noncompliance is not solely a result of inadequate knowledge or resources. Cultural and social factors must also be seen as inseparable from individuals’ acceptance (or non-acceptance) of—for lack of a better term—“doctor’s orders.”

Since an individual’s health and wellness are strongly influenced by the quality of their supportive relationships, we need to examine how the positive effects of other health-related media, particularly social media, might be incorporated into game scenarios. One obvious example appears in Jane McGonigal’s 2011 book Reality is Broken. In endorsing the participatory potential of games to create stronger social connectivity, McGonigal describes the example of SuperBetter, a game she created to help herself persevere through a challenging recovery from a serious concussion. She describes SuperBetter as “a superhero-themed game that turns getting better into a multiplayer adventure” (McGonigal 135). The game requires the involvement of supportive players (friends, colleagues, and family members) called allies who support the superhero on a set of five missions. Missions are focused on goals of staying optimistic, seeking out support from friends and family, and learning to read one’s symptoms; allies perform helpful tasks assigned by the superhero, such as making regular telephone calls, suggesting new challenges, offering entertainment, or providing positive, cheerful energy (McGonigal 135). Because the game leverages already-existing social networks, it not only strengthens these bonds, but it also helps caregiver-allies to overcome feelings of helplessness and forces the patient-superhero to ask for help where she normally would have felt apprehensive doing so. By providing tangible ways for the individual at the centre of the game to take steps toward recovery, and by creating opportunities for caring friends to help out, McGonigal suggests that the game creates meaningful social interaction that gamifies illness, helping individuals “take a more active role in their own recovery” (141). The key difference between this type of game and Beale’s psychoeducational intervention model is that SuperBetter turns the experience of illness, itself, into a game. Thus, unlike the examples in Beale’s text, McGonigal’s game avoids having to rely on potentially ineffective strategies like “symbolic self-modeling” or generality.

When dealing with certain kinds of chronic or terminal illnesses, individuals are faced with a plethora of factors over which they have little to no control. Beale’s text admirably hones in on how video games can assist individuals to control factors over which they do have direct influence, through both their knowledge and behaviour. In helping persons with illnesses to learn about and manage symptoms, medications, treatments, and self-care practices, the video game models that Beale proposes may serve a positive and productive purpose. However, the real strength of Beale’s text is the way in which it challenges game developers to enter their work into dialogue with the pre-established psychoeducational strategies of serious games and, thereby, build a base upon which future games can develop. In this way, Beale’s text itself serves a foundational purpose. In all likelihood, as intersections between the gaming and healthcare industries continue to develop, more complex and nuanced interpretations of the role of gaming within healthcare will also emerge to build upon Beale’s theoretical approaches and methodology.

Works Cited

Beale, Ivan Leslie. Video Games for Health: Principles and Strategies for Design and Evaluation. New York: Nova Science Publishers, 2011. Print.

McGonigal, Jane. Reality is Broken: Why Games Make Us Better and How They Can Change the World. New York: Penguin Press, 2011. Print.