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Digital Health – Game on

Lets’ start from here: ALL games are both fun and serious.

Cheap thrills or serious games?

This idea is so pervasive — that games are a waste of time that we will come to regret — that I hear it literally everywhere I go. (Jane McGonigal 2012)

Culturally, it is desirable to play games as children, but then less and less so – as we are becoming responsible, serious adults. However, many theorists hinted to the importance of games and playful behavior for adults, or, at minimum, they did not deny it. Vygotski (1978) himself considers games being the locus of cognitive, emotional, volitional evolution: “a child’s greatest achievements are possible in play, achievements that tomorrow will become her basic level of real action and morality”. Other theorists (i.e. Piaget, Erikson, Marcia, McAdams) had shown that identity and cognitive development are constantly shaping, so we continue to work on our actions, cognitive, emotional and moral development. As adults, we still need a “zone” (Vygotski 1978) for development.


The paradox of games

Typically, we do not engage in a game to fulfill a serious task – that is not to say that we could or should not (Csikszentmihalyi 1990).

Superficially, play bears little resemblance to the complex, mediated form of thought and volition it leads to. Only a profound internal analysis makes it possible to determine its course of change and its role in development. (Vygotski 1978)

There is a tendency of finding other terms for games outside entertainment.

“Serious games are simulations of real-world events or processes designed for the purpose of solving a problem” (Wikipedia). And then we have “gamification” (Deterding, Dixon, Khaled & Nacke 2011, Seaborn and Fels 2015)… Despite such efforts, none eludes the cultural attachments Jane was pointing out, so let me say it again:

ALL games are both fun and serious.


Games… seriously?

The legitimacy of using games in contexts other than childhood development is still not well accepted. Classical development theories do not approach adult games as such. But, if read carefully, there is a lot that implicitly and explicitly relates to adults – from cognitive (i.e. Piaget) to personality theories (Marcia, McAdams, Csikszentmihalyi). This academic article (Verenikina, Harris, Lysaght 2003) summarizes some, and it declines questions designers or researchers may ask when dealing with “serious games”. Bernadette Keefe (2016) does a great job in referring several resources for games in healthcare in her recent brilliant post.

Last but not least, there is a sea of knowledge and wisdom from the world of game designers.

These are taken from both experience and from the writings of others. Most are the sort of “Duh” things that many who have done this sort of game design take for granted, but others may be less intuitive. Many of the laws here were actually stated as such by others, and not by me. Raph Koster “laws of online world design”

In a recent talk, Koster talks about how much time these designers spend in discussing theories of development. During Interface Summit 2015, Michael Fergusson said he had spent a lot of time trying to understand why people do not change their lifestyle even when confronted with serious or the ultimate threat.

I’ve developed my own theory of game design I call ACUDO, an acronym for Agency, (progressive) Challenge, Uncertainty, Discoverability, and (recognizable) Outcomes. In the model, all of these elements must be present for the system to be experienced as something ‘playful’. I’ve also been strongly influenced by Raph Koster, and his theory of ‘fun’ as fundamentally a process of exploration or discovery. (Michael Fergusson 2016, email correspondence)

Plus, there is still a lot to understand from the already successful games. What really makes people play (i.e. World of Warcraft, Minecraft)? Could we leverage them for “serious” goals (i.e. Minecraft, Angry Birds, Tetris)?


In Digital Health, what’s your favorite game?

Digital Health opened space for innovation by stretching healthcare from illness to fitness and wellness and attracting various stakeholders. Therefore, we are seeing now more creative approaches coming to light.

Let’s see how games are currently penetrating the healthcare arena.

Academic education

From 3D models of the human body, collaborative learning, gamified information delivery systems and evaluation, to virtual reality… On the 14th of April, the first VR 360 degree surgery was broadcasted live from London Royal Hospital, performed by surgeon Shafi Ahmed.

Patient education

“Why don’t we actually push those ‘electronic brochures’, games, videos, whatever it is, to our patients who might benefit them. So we are definitely moving in that direction. […] I think that is a great use of technology and we should be doing a tone more […]. When the gates open in respect to this, I think it will be a flood”. (Timothy Ferris2014)

MySugr, a digital health company focused on diabetes, offers a good range of gamified patient education, including for children.

Patient feedback and self-evaluation

The Pain Squad is “a cop style game with assignments and rewards designed to entice patients/kids to document the painful factors of their illness in a fun and interactive way”.  Documenting pain is a process important for doctors, but otherwise difficult, tedious and of negative associations for children. You can imagine, adults would benefit just as much from a more pleasant way to document pain when required.

Patient evaluation

It is accepted that children communicate their emotions better symbolically. Thelittlepeople developed a game to evaluate the psychological state and design interventions for children fighting cancer. With a little creativity, you can evaluate physical symptoms even easier via gamified experiences.

Patient resilience

Distress has been officially recognized in Canada as the 6th vital sign in the context of cancer.

“Heightened distress is associated with worse patient outcomes in terms of worse health-related quality of life, lesser treatment adherence, lower satisfaction with care, and possibly lower survival.” (Howell and Olsen 2011).

Resilience is strengthened via education – many studies shows that education and health literacy relate to better health outcomes (i.e. Windrum & Garcıa-Goni 2008, Brown 1990). See also Prof. Pamela Kato’s recent Ted talk (2016) – How games help patients.

Treatment adherence

And, let’s admit it, the way to recovery is tedious, and plain boring – why not play a game instead? (Mihaiu, 2015)

Mira Rehab focuses on physical and neuro recovery, and preventative potential for frail population, but this question may well apply to other medical interventions (i.e. ayogo, Hope Lab).

Mental health

This area is also being tackled as having benefits from games. For instance, Tetris may contribute to reducing flashbacks in PTSD.

Playing “Tetris” after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact. (Holmes, James, Coode-Bate, Deeprose2009)

Such effect may be explained by the “discharge” and “recharge” effects of games (Huizinga and psychoanalytic theories), or by giving space to the subconscious mind to “digest” and compartmentalize trauma (Piaget and psychoanalytic theories). As we are talking Tetris, here are some questions: Would Candy Crush or Angry Birds render similar effects? How and what can we leverage in health from existing successful games?

Virtual Reality psychotherapy for anxiety related disorders is being explored (Opris, Pintea, Garcia-Palacios, Botella, Szamskozi & David 2011). Professor Daniel David is one of the pioneers of this field, leading such a research institute since 2010.

Lifestyle changes

It is common knowledge that many chronic diseases are caused or could benefit tremendously by lifestyle changes. Sense of control also contributes to resilience and self-efficacy – in that sense, apps (11Health or less medical ones for fitness/wellness) and games (Mira Rehab, ayogo), which provide feedback, reminders or visualizations of data improve engagement and better coping mechanisms resulting in better health outcomes or lifestyle changes.

Medical research

There are serendipitous discoveries when employing games in health, for instance Mira Rehab’s case study on a rare neurological condition.

But a lot of research can be done in various medical conditions by using gamification to foster research. Also, health or behavioral data captured via games could render relevant clinical information.

New research streams can develop, for instance a rapidly advancing neuro-cognitive research area is using robotics therapy – see the DREAM (Development of Robot-Enhanced Therapy for Children with AutisM spectrum disorders) project for instance.

Citizen science

As we see many areas of the medical field escaping its traditional confined spaces… research is not spared either. In a recent, fascinating study, Cancer Research UK (2015) proved that laypeople not only can, but are also willing to contribute to medical research. See the amazing range of games and apps they have developed in this space.


Play… in sickness and health

Games have great potential in healthcare (sickness to wellness) in tight connection with health education. When it comes to healthcare and lifestyle, games have to go beyond dopamine (Lewis-Ewans 2013), points and badges (Fergusson 2014)…, and ethical aspects have to be considered as in all health data contexts (Keefe 2016).

How do we go about understanding this potential and how do we go about fostering this nascent area? Questions for another day.

Until then,

Let’s play (Outside) – Moonlight Breakfast


About the Author:


Lorena Macnaughtan

Lorena Macnaughtan, MBA, MA is the ICEEhealth Event Director, a new track dedicated to Digital Health at ICEEfest, 10th of June, Bucharest, Romania. Additionally, she is writing her PhD thesis focused on Digital Health with the Horizon Digital Economy Institute, at the University of Nottingham. Lorena is no stranger to the world of “serious” games, via her BSc (Hons) in Psychology and her MA dissertation in advergaming. Find out more about her work via her website, or by following her on Twitter, LinkedIn or Facebook.

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