Games people play could be good for their health, sense of empowerment

Researchers work to create games that change behavior for better outcomes

Electronic games are good educational tools, says Hadi Kharrazi, MD, PhD, assistant professor at the School of Informatics at Indiana University-Purdue University Indianapolis.

In addition, these games increase patient empowerment, which helps change behavior, says Kharrazi.

He learned their value while working on his PhD in health information systems. During that time, he was involved in a program that used gaming environments for educational purposes.

The goal was to apply electronic games, combined with educational and behavioral change strategies, to a defined problem in the medical world.

With this goal in mind, the researchers built a game and applied it to the problem of adherence to treatment of children with Type 1 diabetes. The purpose of the game was to get the children to remember to take their insulin injection on time. After six weeks of game play, the children's adherence increased by 12%.

Kharrazi explains that the game was an experimental design with two groups of patients, one playing the game with the behavioral change elements built in, and the other group playing the same game without the elements.

The study was replicated for patients with another chronic condition, inflammatory bowel disease, with almost the same results.

"It was very interesting to see how a game could educate the patient, empower them, and finally change their behavior. It is important, because in the long term, all these chronic diseases and their side effects are becoming a more significant portion of the health care costs in the United States. So, one way to approach the problem is through the use of games, or interactive media, to empower those chronic patients," says Kharrazi.

A study of a game called "Bronkie the Bronchiasaurus" (Lieberman, 2001) showed that self-management of asthma was improved with game play, resulting in reduced hospital admissions and visits to the physician, says Kharrazi. During this game, children play as a dinosaur with asthma that must save his homeland. To accomplish this task, the dinosaur needs to avoid asthma triggers, such as dust and pollen, to keep asthma under control.

In a chapter in a book titled "Handbook of Research on Effective Electronic Gaming in Education" by Richard E. Ferdig, researchers Wei Peng and Ming Liu from Michigan State University wrote about the use of electronic games for health purposes.1

Some of the games reviewed for their effectiveness were in the categories of disease and risk prevention; self-management; therapeutic value; and fitness.

After their review of the research, they wrote: "Health care providers and researchers can take advantage of the unique characteristics of electronic games when the particular purpose of a health education or intervention program requires behavior rehearsal in a safe way."

In the book, they wrote that they found almost all the games effective in teaching related knowledge to the players.

Also, they stated that repetitive practice and habit formation is critical when trying to teach disease self-management.

Criteria for effective play

While electronic games look promising for education, Kharrazi says there are a couple of factors that must be addressed in order for games to be used effectively.

They must be accessible to patients. During his research, the games were available online, so players could access them through the Internet. A player would log in to play, and the number of times a patient used the game, as well as his or her moves, could all be tracked. However, this format might not work for highly sophisticated games.

Games for personal digital assistant (PDA) devices or an iPhone would make it possible for people to play the games during free time, such as a bus ride. People most often want to play a game during times they are bored, or for fun and entertainment, says Kharrazi.

A second challenge is finding a way to get the commercial game makers interested in health games. These gaming experts are needed, because creating a sophisticated game in an academic environment is difficult, according to Kharrazi. He says in order for a person to have a good learning experience, the attraction to a game must last at least six to eight weeks, so he or she will keep playing.

According to Kharrazi, researchers often obtain open-source games to work with or modify an existing game.

Corporations not that interested

Corporations are not that interested in creating health games, even though they don't need to create games from scratch. Kharrazi says they could modify sophisticated games they have on the market and make them suitable for different diseases.

A national conference on health games held in Boston for the past five years, called "Games for Health," attracts more and more researchers from the medical field but still lacks commercial representatives, he adds. In addition, the Robert Wood Johnson Foundation has implemented a game for health initiatives to provide resources for research, but there is not enough funding to create sophisticated games.

"A game should be interactive, motivating, and interesting. Otherwise, people won't interact with the game," explains Kharrazi.

He says commercial game makers may not want to work on health games, because they want to avoid the notion that games may change the behavior of the players. In the past, corporations were accused of making kids more violent with the interactive game play they created.

Interdisciplinary framework important

Kharrazi says that no matter who produces the games, it is important that they have an interdisciplinary framework. The production team should include game developers who can do the program coding; computer interaction specialists to determine appropriate interaction for adults as well as children; behavioral psychologists and people from education departments to determine the best strategies and methodologies for the best outcome; and appropriate medical professionals, such as physicians and nurses, who know the disease to be targeted. In addition, there must be people able to analyze the data.

"These people are all inter-joined, and they should all interact, so it is interdisciplinary research. It is not easy to do, and the research needs a lot of coordination and a place to test the games," says Kharrazi.

Peng and Liu, who wrote about the use of electronic games for health purposes, stated that game designers must work with health care providers and researchers in order to ensure the game features are based on theories, such as social cognitive theory. They add that health games that have been proven effective have a "theoretical underpinning for the design."

The School of Informatics at IUPUI has established the Games for Health Research Center to determine the impact of games on health-related lifestyle issues, of which Kharrazi takes part. Researchers are looking at the use of games for rehabilitation purposes, such as stroke patients; using games for cognitive rehabilitation; game use to address chronic disease self-management issues; and games for physical exercise.

"There are a lot of strategies and techniques you can use in a game environment to motivate people. Hopefully that motivation creates an intention, and that intention creates an actual behavior, which is the ultimate goal of clinical games. If you can change how the patient thinks - and also behaves - that will be the best outcome," says Kharrazi.


1. Ferdig, Richard E. Handbook of Research on Effective Electronic Gaming in Education, 2008: 388-401.


For more information on electronic health games and their development, contact:

• Hadi Kharrazi, MD, PhD, Assistant Professor, School of Informatics, Indiana University-Purdue University Indianapolis. E-mail: