Playing games is the prototypical example for an intrinsically motivating activity and motivation in healthcare is a pivotal issue. Each year, billions of dollars are spent to move our behaviors in a healthier direction to avert crisis such as obesity, diabetes, cardiovascular disease and other costly and painful afflictions. Leveraging the motivational dynamics of gameplay to energize and sustain people through behavior change is a challenging yet profound solution.
In this talk, Dustin DiTomasso double-taps into the techniques game designers use to motivate, engage and reward players through a game’s lifecycle combining a playful approach with structured behavior change conventions.
Slides from Designing Behavior Changing Games
Sketchnotes from Designing Behavior Changing Games
Paul Goode provided us with two pages of sketch notes. Here is page one:
And, here is page two:
Transcript from Designing Behavior Changing Games
Today I’m going to do a little experiment. This is usually a half-day workshop. But I’ve taken it to a 45-minute talk for today. So, we’ll hit on the levels of behavior change theory, game theory, and how to put the two together. As I mentioned, I’m VP of experience design for an experience design consultancy. I work out of the Boston office. And a large amount of the jobs and clients that I serve deal directly with behavior change, making behavior change games and games designed as a sort of design construct.
Today, specifically, going to talk about behavior change and focus it a bit on health and healthcare, how we can use good behavior change protocols and constructs and marrying those with areas that overlap with game design and put those together to create systems for change. So three things. Primer on behavior change theory. Games theory, and putting it together. So let’s dive in.
Fogg’s Behaivor Grid
Anyone here how many folks here are familiar with Fogg behavior grid? BJ Fogg‘s work? Only acouple? Great. Fogg is definitely worth looking into if you haven’t already. He is a researcher out of Sanford. He deals a lot in creating and breaking habits in habit design.
Fogg’s created a system that says there are 14 or 15 different ways to effect change in behavior change. Those are in this grid and also you can consider it this way: that there are behaviors over time. And when we’re looking to effect the change and effect behaviors of people, we want to consider a few things:
What is the behavior that we’re looking to change?
Is it a new behavior?
Do we want somebody to do something better?
Do we want them to do it differently?
Do we want to do more of something, less or something, or do you want them to stop?
So if you think about smoking cigarettes, right? A pack maybe from cutting down, doing left of, to stop. So there’s a path there. Do we want people to do these behaviors one time, in a range of time, six times, five times, one week? Or is that change happening today and forever.
Different Design Strategies
There are different strategies for each one of those. Games play a large part of it to get people to engage. Let’s take a look at the essential components for a behavior to occur. So, in a lot of the behavior change science, there’s a lot of theories. They may differ a little bit. But the key here is that there are three ingredients that need to happen in order for a behavior to occur.
A person needs to have the capability to form the behavior.
The motivation to perform the behavior.
The opportunity to perform the behavior.
All of those three things need to be in line for behavior to occur. Let’s take a look at one of those.
Capability to Form Behavior
So, capability really is the psychological or the physical ability to perform something. Right? Does the person have the knowledge to do the skills? Goal setting that we can do to help them move along. Planning, coping with conflict, and setting of goals and self-monitoring of behavior. A lot of theories talk about motivation being a small component of what makes us react. So there are two kinds of behaviors:
Reflective behaviors, which are things we think about, cognitive processes, and
Reflexive behaviors, which things that are automatic, habits, twitches
We’re going to deal more with reflecting things, or behaviors that people think about. Behaviors that people can start to work to control. With that motivation, you can build awareness of the benefits (and the harms) of the behaviors. It leads to confidence, growth, self-efficacy, and change. You want to build that throughout your systems and games.
Social approval is important. It has a big effect on behavior and motivation as well. Of course, opportunity. Do we have the opportunity to perform the behavior and things like that, our triggers, cues, an alarm goes off, you wake up, right? That’s a trigger. You can set alarms and do things throughout the day. Do you always do you always start your email after you have a copy? That’s a behavior. That leads to a trick or anything that happens over time. And then, of course, less of an opportunity, things like barriers, we want to try to remember barriers, space for action, timing and routine as well.
Motivation to Form Behavior
Let’s talk a little bit about motivation as a psychology construct. Folks talk a lot about two kinds of motivation, extrinsic and intrinsic. A lot of us know this. But there are multiple versions of motivation. There’s more than just extrinsic and intrinsic. There’s also a continuum of motivation, right?
So we have on the left-hand side a motivation which is no desire to act, no motivation. Then we go to the beginning of extrinsic motivation where people are motivated to act on external choices, external rewards, punishments, things like that. From there, you can internalize it. For example, parents, we’re hard on kids to go to school. They go to school, they go to college and get a degree that they weren’t interested in. That’s a form of control. That’s the form of regulation, that’s intrinsic but you externalize it.
From there, you getting more internal behaviors, internal motivation, identify, meaning that we believe in the behavior, you believe in the actions and the norms and the values something that you’re doing or you’re not. After that is integrated, meaning it’s become a part of your life. And from there, it is purely intrinsic motivation. There are few things that we do on a day-to-day basis that are purely motivated by intrinsic motivation. Games are one of them. There’s no real world value for playing the game. So it’s purely intrinsic. It’s joy, it’s love. All of the things, besides procreation, sex, things like this are intrinsically motivated, purely.
Our goal a lot of times in behavior change is people aren’t ready they’re not ready to take on the big intrinsic so they fall on the extrinsic range. So the goal is to pull people closer to the internal and intrinsic motivation. We do it through activity, motivations to get people to internalize those values. The closer we can get them to that intrinsic section, the better the more lasting change will be. So I’m not going to go through this.
Opportunity to Form Behavior
But if you look at some behavior change techniques, we’ll see things like goal setting, action planning, self-monitoring, feedback, social support, skills development, triggers, and a whole list of things. If you think about this, right? These are very much qualities of games.
Games have goal setting. Games have action requirements. They give you feedback. They have tasks that give you difficult over time. They grow, you’ll still grow. The more you grow, the hotter the game gets, the bigger the challenge is. Plus if you have two player game, social game, you’re bringing in the pieces of social support, influence, the social norms and behaviors as well as things like stress management.
So, for us as designers and thinking about behavior changes, it’s our sort of job to create these games or systems that allow people or players to build their motivation and to self-regulate their behavior. Meaning, get people into a system, give them things to do to sort of build towards that behavior change.
Taking a big change like stopping smoking, for example, and breaking that down from do you smoke 30 packs a day? What is the path to cut that down to zero? Losing weight, is there a diet and exercise sort of plan? Dealing with cancer, dealing with remission? Understanding the things that you need to do, such as take your medication.
How do we sort of build these behaviors that are hard to do, keep them engaged and keep people to create a system to support that so it’s self-regulation and autonomy and intrinsic motivation? So, to break it down to a couple of pieces, for me, the role of behavior change games, where it fits in, is, one, create novelty and interest for uninteresting activities. So it’s very much not that exciting to give yourself a blood test every day, right? It’s not that interesting. It’s not that interesting to take medication every day. It’s not that interesting to exercise and to diet.
So if we can wrap this in a format that creates interest and engagement around activities that are going to be for the better good, that’s where behavior change games lie. They provide planning, structure, and goal setting routines. It creates a framework for discipline, things to do and a clear path towards achievable roles. It facilitates those feelings of autonomy and intrinsic motivation. We say that games are intrinsically motivating behavior and activity, then, again, wrapping the behavior change around this builds that intrinsic desire. It builds the valuing system to make your changes and do the activities that people need for change.
Also, it develops the skills, right? So games, they get better over time. Part of behavior change is to sort of develop those skills to deal with the change. Right? What do I need to know? What don’t I know. What do I need to know? How do I get better at the behaviors? It provides a feeling of competence. So, again, as confidence builds, a lot of times in the beginning you don’t know what to do. We don’t know if we can do it. We don’t know if I’ll be able to lose 30 pounds.
Am I going to be able to stop smoking? Reduce my debt on my credit card? Are there things that I can do? So you get in, small victories, small achievable moments that builds momentum and confidence. By creating feedback, people will monitor it. You can see that you’re improving, which drives motivation and that is sort of escalating back to the goal achievement. So competence is huge.
And then lastly, I think, as we all know that it provides a platform for social support and influence that we see in all sorts of social media, especially gaming, as well as behavior change to see that huge influence that other people, positive or negative, so the idea is to strive for the positive effect on other people’s behavior. So that’s it. That’s sort of your 10-minute debriefing on behavior change. So let’s go in to sort of games and just to let you know, what I’m talking about.
What is a Game?
There’s a lot of debate over what constitutes a game, what’s the definition of a game. If you Google it, you’ll come up with tons and tons of different definitions. What I like to think about it is a voluntary rules bound experience of competitive strife towards discrete goals or outcomes, right?
There’s challenge here. There’s things to overcome. There’s things to improve. Things like competition, challenge, and then, of course, there’s goals and outcomes, right? What’s the goal of the game, what’s the outcome of the high score. And in the real world, you know, are there benefits to the behavior change? So take a quick look at a couple of games that are out there at the moment.
Mindbloom is a game by Aetna. And I think this is now free. Used to be you had to be a member and sign up. Now you can check this out. There’s also a mobile version that’s just been launched. Gives you key areas of your life. Goal setting, planning, what kinds of things do you want to achieve? Do I look after my relationships, improve my health, my career. It gives strategies and actions, it creates the plan view that you can do and develop over time and sort of moving more towards planning your ultimate life. But it does it in a game manner.
Health Month is a game by Buster Benson which is a new game that starts every month if you jump in on it. It allows you to choose from a number of behaviors or goals. And much of these are based around doing something more often or doing something less. So increasing starting or increasing and reducing or stopping. And it deals a lot with sort of diet and exercise and bad habits like, you know, smoking, things like this. And it has its own sort of mechanic if you start to miss days, it will lock you out and it has a social group on it where you then have to kind of you earn points and you earn the rewards and other people can sort of buy you back into the game. It creates a social connection.
Goalpost is a new sort of smoking cessation game that’s come out. Again, won’t go into it too much. But you can check it out, sign up, it’s free. But, again, it gives you strategies, tactics, community, and actions are important because it will help you on your path to smoking cessation. Remission is a little different. It’s an immersion style of game. Sort of a shooter but it’s for kids that are dealing with cancer. And in the game, there’s the little nanobot on the left. You shoot around a body and you destroy cancer cells. That sounds great and good. This leads to two questions:
What are you learning?
What are we teaching somebody in this game?
There are messages around coping, sort of explains to kids what they’re going through, what they’re going to deal with. They learn about what their life is going to be like. What chemotherapy is going to be like. What do they have to do for follow-up. As a stress reduction in a coping mechanism, they can blast imaginary cancer cells. So it’s good.
Studies show it has helped to improve mood, improved adherence to going through chemotherapy. It improves the attitude that kids have when they have to go through and have their treatments. So, there’s been a wealth of positive experience from it.
Where Do You Start to Build a Behavior Change Game?
Let’s jump in to putting this together. So, to do this, to think about what are the behaviors that we want to change, what sort of domain, what categories. Can we turn it to a game? Can a game be built around this to create effective and lasting change?
One, identify the key behaviors of people. Is it eating too much? Eating poorly? Not exercising? Being sedentary? Not taking medications, not looking after your chronic care condition. Not paying your bills. Do I need help with credit cards? So, what are those behaviors? Who needs to do what differently, when, where, and how? How does this revolve around your life in this situation? Why do those behaviors occur?
So we’ll talk about it a little bit. But a big piece is going to be doing user research in order to get an understanding, getting to know the target audience, and getting a large variety of reasons why people are doing or not doing things and why they want to change. But doing that research will help you immensely.
What needs to change for the behavior to occur? Is it the environment, the attitude, is it social constructs? What are these things that need to change? And look for techniques that we sort of looked at before that can be used to bring the change about.
And, mostly, can it be turned into a game.
No matter what, when you’re thinking about taking regular change theory and constructs and thinking about can this be turned into a game, can you think about the three questions, the answer is yes, right?
If the behave your can be learned or modified, it can be turned into a game.
If the player’s progress over time can be measured, you can turn it into a game.
If feedback can be delivered in a timely manner, you can turn it into a game.
So, from here thinking first about who is the game for? Understanding demographics is important in this case. Is it is it an older woman, a man with a child? Is it somebody what are their values, right? What kind of gaming is appropriate for them? What are they familiar with? What’s the context? Is there a story? Is there a fantasy?
Is it more of a sort of game like remission or a board game style get aggressive action, let them check in, escalate the challenge over time, go closer and closer to the change. The way I like to think about games is very much on the scope in thinking about how board games work rather than how full on sort of PlayStation or XBox games work. You get a lot more mileage on how to structure the activities and reward systems through that.
Key items you need to think about really quickly. What are the current bad behaviors that a person might have? What’s the motivation state? Where do they fall on the continuum? These folks are changing for themselves. They want to change, they’re ready to change. Or has a loved one or a doctor said you need to do these things, you need to prevent their help. Or are they doing it for themselves.
Understanding what that motivational state is and how to build it to a more intrinsic state. What are the skills and the abilities? What are the things that they will need to do in order to be able to change? And what do they have sort of already in their possession that we can leverage? Do they have goals? And I say fuzzy goals because, again, people don’t think about, you know, change and sort of concrete methods.
They know I want to feel better. I want to lose weight, I want to look better. So understanding what this goal really means helps a lot. What are the barriers to success? How can we drop barriers?
Three People To Consider in Your Games
You need to think about demographics. Here are a couple of things to note. Do we have personas? But also thinking about how people in a system relate to game levels, right? And the structure in the game are there. So there’s these sort of levels. There are NOOBS, people new to the system. And they’re challenged not so much by the behavior and the things that you want them do, but they’re challenged by learning how to play the game.
Learning how to play in the beginning is the game of the NOOB. Understanding what to do, what’s expected, understanding how often they need to check in. Make the NOOB more efficient you focus on getting the people in and getting them productive, make the on-boarding really easy. Teach them by doing, showing, create tutorials and lower the barriers of success, increase the success and how it works and how it affects their lives.
Unlike NOOBS, the PLAYERS are the folks who have been in the system for a while. They have successes, setbacks. These are the Gameday folks. This is where the design goes in. If you think of design terms, if anybody has read Coopersburg and he talks about this is the focus of the design and the designer, same thing in game design. This is a perpetual intermediate. The person in the middle is where all of the time goes from structuring activities and rules, feedback, those kinds of things.
Then, a third part, we don’t think about a lot and I think not game that’s the ELDER, or people who have been in the system for a long, long time. They may have they may have reached their goals, reached their sub goals. What do we do with these people, right? If the system isn’t directly speaking to them, they’ve completed everything they need to complete. But they’re valuable to have in the system.
The ELDERS are folks you want when you think of creating communities tend to become sort of mentors, team leaders, you can use these people to leverage how to grow and adapt your system. There’s definitely value in the elder game. If you look at keeping these folks in the game, this is a good thing. To do that, you can create more difficult games for them. You can give them the governance privileges, let them make rules, form teams, be team leaders. Let them make challenges. Dispense their expertise with new people and compare them with the new people in the beginning to get new people up and rung.
Setting Goals for Your Games
From there, structuring. We talked about goals and the ultimate objective, right? This gives us sort of a good example. We have the nice sort of hard climb. The two-person climb is important. There’s a little dip in the middle. Give people a little break. You reach the top of that first summit. You’re exhausted. You kind of want a little bit of a break. There’s a slight swoop after that. Then, you have a bridge, something new, a piece of novelty, and this new challenge to cross.
And then, you know, this big long sort of journey up to that ultimate peak. It displays the scaffolding of a challenge and sort of the goals. When you think of creating goals, the ultimate objectives for your game, there’s three things that we want to consider:
Goals are concrete. In this way, you understand exactly and clearly what they need to do.
Goals have an end. You know the end state (zero cigarettes, increased your lung capacity).
Goals are achievable. You are rewarded for doing something.
We are not only rewarding within game terms, such as feedback rewards, but in real terms of real outcomes. They need to also feel that they’re getting something out of it. They need to see that their health is improving, back up the promises that the behavior changes and the games don’t often get to.
How do you break the giant goals down to achievable concrete steps? So you think about people sort of get their own ultimate goal and how do you break that in to long-term, short-term, day-to-day activities getting as granular as possible. What do they need to accomplish? How do you break it down?
So, if you think about say losing weight, how do you break that down? I’m going to lose 50 pounds. Can I do it in the day? Probably not. It will be a three-month challenge. What do I need to complete within three months? What’s the goal? How do I get to that goal? It’s going to be a combination of diet and exercise. There is going to be an element of sleep. How do I break that down to a weekly basis, right? What do I need to complete in a week, a day, what do I need to complete three times next week, breaking that down to the small chunks that lead to the same kind of goal is where we want to go. Try to make the end goals as exciting as possible.
Setting Rules and Boundaries to a Game
Rules and boundaries are a big part of game design. As designers, we don’t need to think about rules a lot. Personally, I think developers do this a lot more. But the one thing you can consider here is sort of the best way to learn about keeping about game rules is really to analyze games. Think about think about Tic-Tac-Toe and what those rules are.
Think about the rules of monopoly. Think about any game and sort of write down those rules. Study them. Think about how that works and think about applying that to the big change games.
Modes of play in game design is important. Different modes of play allow for multiple ways that you can engage people in the system and to bring in other people. Is it a single player game? Am I playing by myself? Do I want people to share? The support in my change is that multiple people versus the system or the player versus player.
I challenge somebody to improve their running mileage. Can I challenge someone to, you know, quit smoking faster? Can I challenge someone to increase their overall health, wellness, and well-being?
Unilaterally, are there ways where multiple people can compete against one person? You think of games of tag, one versus many. Multiple versus each other. Or, is there a team-based competition? Is there room for teams? Very typically, health change in companies and organizations are team-based challenges. Right? The first team to achieve 100,000 steps gets a $50 gift card or something like that. Be careful with these kinds of things. We’ll talk about it quick.
Team-based challenges are motivating, engaging people like this. Or is it cooperative. Many people play against the system. What skills are we developing?
Setting Up a Learning Component to a Game
A huge part of games is the ability to teach the learning component that is wrapped within games and gaming. So thinking about what skills do people need to be successful at this game. What are all of the mental skills that someone needs to possess? The physical skills? The social skills?
If you can identify what the core skills are, and think about what skills people are coming in to the game with and how to grow and develop those, this is a great place to be, a great place to start. Creating tasks and activities based around the skills and being able to increase the skills and grow them over time is really good.
Setting Up Action in a Game
From there, we have action. What are some of the things that people need to do? The moves or tasks that people need to move daily, weekly, monthly, hourly, over time to improve and move forward not only in the game but success. A great way to do this is to think about all of the possible things that people could do in the context of the change. So, again, if it’s a health and wellness weight loss sort of game or program, what are things people can do? Run, swim, they can eat better, they can eat less. So bring in all of those things, bring them on the table. Then prioritize. Put them in an order.
If it’s walking, right? Do I walk a half a mile, quarter mile they say half a mile twice a week. Three mile, five miles, how do we grow that over time. With that, with the actions, you want to think about how we can attract and measure this. In the huge sticking point at this point is how to get input, data. Personal data to systems, right? We’re not quite there yet. It’s not perfect.
There is a barrier any time you ask a person with a report and enter I do this to the system. I ran half a mile, I hate this. I burned 31 calories. That’s a barrier. People drop off over time if it’s too difficult. There’s a ton of devices to make this easier. The slides are available. You can check out what the devices do. And then there’s help that show how correct data and present the fact. One part of the input is showing the output. What’s the actionable data.
When I enter something, I want to see the data back in chart, reports, graphs. Do I want to be able to plot my progress over time? If that progress is improving, it will build my confidence and self-efficacy. And, I will continue to sort of progress and move through the system.
I recommend you read a book by Jesse Schell called “the Art of Game Design” a book of lenses. It’s a great primer on game design but it has lenses you can use to think about if I’m applying competition to whatever it is, what effect does that have on the player or the user. If I create a leveling system, what effect will that have? How do I play towards people’s curiosity? How do I make them curious about the next thing that’s going to happen?
Lenses that you can look at anything you design. How to get through it quickly? Lens of chance kind of explains which introduces randomness and probability. What kind of effect is that that we have? Well, why do we want to do this? Because when people are not expecting anything, you know, it preys on that curiosity factor.
As well as when people think they have a chance of succeeding or winning, it’s a response where Dopamine fires off and people feel really good. So that’s what drives the slot machines. People continue to play slots because the chance of winning, the random invariable reward ratio that keeps them there. It’s not even a win. It’s a “chance” of winning.
Setting Up Feedback Loops
Let’s talk about feedback loops. The essential thing about feedback loops is that every action has some form of feedback in a game. So, if we’re asking someone to confirm they took a medication, you know, as prescribed. So it sounds exciting. But it exists, right? There needs to be a feedback loop in the system that says, do they not do it or do we not know? We need to provide appropriate feedback, right?
Feedback is meaningful information that people can act upon, usually giving them recognition and outcome. If they have achieved it, you know, big, juicy, reward and feedback. Give them immediately the next step. What’s the next thing for them to do. It becomes a cycle. Some action, sort of your rules, what happens, yes, no, we don’t know.
Feedback creates a loop, where a response to information and outcomes leads someone to the next thing to do. It keeps them in the game, motivated, and in a continuous loop. Don’t let there be any sort of pauses between completing an action without knowing what the next action is.
Test Your Games As You Create Them
And really kind of go into the last piece really quickly that I think a lot of folks here are used to this mantra. Platforms and systems are never really done, especially with games. The goal here is it’s essential to play/test your games while creating. You don’t have to do high-fidelity games. You can do prototyping with index cards and paper.
What is the action you want someone to take? How’s the system going to respond? What’s the feedback? What’s the next thing? How does it work over time? You put it on cards. Play it with your groups. Great if you have content strategy experts. People adding content. Add developers and rules, play out all of the scenarios and test it there.
From there, from paper, you can go prototyping, from prototyping, you go live from feedback of the actual game. So it’s essential to test play over time. Game culture does this a ton, especially all sort of web-based social games, Zynga, anything they use off of analysis and feedback. Facebook games, social games. Game titles for X-Box. There’s a huge, huge testing that goes through this.
We have a few minutes for questions. Any questions?
Question and Answer
QUESTION: Hey, real quickly, my son is really into this game called Skylander, right? It’s where you have to buy action figures and to play the game, you uh have to put it on a platform, then you put it on a platform, it appears on at least on the Wii system but available on all systems. It combines a tactile element to a game thing.
How do you see that developing in the future because we are tactile creatures that the importance of having something to touch and hold and hang on to and purchase in relation to the game? How do you see that developing in the future?
DUSTIN: The beauty of that is anything that you can get in other gaming terms, not too much, but any time you can get someone to buy accessories for another game, that’s a computer business model. But it’s going to be huge. There’s a large movement of augmented reality gaming. And this kind of game, if you think about health games, pervasive games, there’s real world and there’s game world and it’s kind of a mixture, a merger of these.
Any time artifacts are the devices that can be the conduit between those two worlds, it will continue to increase, especially if the device in this market things like fit and Nike plus and things that are that big. An action figure that goes on or a fit bit tracks all my calories and things like this. The device market and accessory market is huge. Going to keep improving.
QUESTION: What about games for senior citizens?
DUSTIN: Yeah. Seniors. There’s a lot of so inactivity is a problem. So things that can get people up and moving. Even the Mii dancing and the Wii fit, it’s great. Start slow and easy. That’s a great market for seniors. Things that deal with cognitive functioning, so improving your memory. Improving your skills is sort of brain games if you will. Also huge. If you think about immersion style games that you know, there tends to be a good amount of depression and loneliness.
So any games that can sort of connect seniors with other seniors, family members is awesome if they visit. Simple puzzle games that they could play online with a family member or someone they care about helps that will help the mental model, brain functioning, as well as depression and wellness. Things that connect. Things that get you moving. Things that get seniors moving are awesome targets.
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