Better health through video games

Ninety-seven percent of young Americans—including the five children of Lynn E. Fiellin, M.D. ’96, HS ’00—play video games. According to the Entertainment Software Association, the industry’s top trade group, 155 million Americans play video games with names like Call of Duty, Grand Theft Auto, and Madden NFL 15. What if, thought Fiellin, associate professor of medicine (general medicine) and in the Child Study Center, she could harness that fascination with video games to teach adolescents to avoid risky behaviors that could lead to HIV infection or drug addiction?

While there is a long-standing debate about the negative effects of video games (they’re sedentary, they encourage obesity, they can be addictive), the use of games to promote health is growing. Studies have shown that video games can deliver health promotion and interventions, and pharmaceutical companies, nonprofits, foundations, and the National Institutes of Health are exploring these possibilities. With a grant from the National Institute of Child Health and Human Development, Fiellin has assembled a team of researchers, game designers, community partners, and educators to create PlayForward: Elm City Stories. The tablet-based game consists of 16 hours of play in which teens in after-school, school-based, and summer programs create a virtual character who faces risky scenarios—like taking a relative’s prescription pills—to explore possible outcomes based on their actions and how those actions might affect their future. Elm City Stories, along with three other games designed to prevent tobacco and marijuana use, HIV infection in young women, and substance abuse in teens, emerged from the lab that Fiellin created in 2009. play2PREVENT (p2P)

Now, Yale has launched the Center for Health & Learning Games, which will house the p2P lab and partner with departments across the university and organizations nationwide to create and test additional games aimed at changing health behaviors and improving science, math, and other skills. The center will also offer training in game design in these areas. “While other schools have programs for developing games, this is the first I know of at a medical school and the first, I believe, that’s trying to fuse best practices for learning games and games for behavior change, which are often found in separate silos,” said Ben Sawyer, co-founder of the game consulting firm Digitalmill and a pioneer in the field of “serious” games—games designed for purposes other than entertainment. Marientina Gotsis, co-founder and director of the University of Southern California Creative Media & Behavioral Health Center, a research unit between the School of Cinematic Arts and the Keck School of Medicine, said that although some academic collaborations have produced games in health in the past eight years, none have led to the creation of formal centers or research units.

Although newly established, the center’s work is well underway. Fiellin and deputy director Kimberly Hieftje, Ph.D., associate research scientist in medicine (general medicine), have established partnerships with pediatricians, emergency room physicians, obstetrician/gynecologists, and others. The center is collaborating with Yale’s math department, educational games developer Yogome, and Amplify, an educational services company that is testing learning games in India in collaboration with The Global Education & Leadership Foundation. The center is also partnering with Peer Health Exchange, a national organization that teaches health education to high school students, to conduct implementation pilot studies to examine the integration of the game into their curriculum. In addition, Fiellin and her team will work with the Tobacco Centers of Regulatory Science (TCORS) at Yale and at USC, modifying their PlayForward game to collect data from teens on their attitudes, perceptions, and knowledge of e-cigarette and other tobacco product use.

The center grew out of Fiellin’s conviction that there is a need both for games that foster learning and behavioral change and for research that shows that this approach works. It’s not enough to develop a creative game with educational content, as Fiellin and her team found out when they created Elm City Stories. They hired a leading game design firm, Schell Games of Pittsburgh, Pa., to help them develop the game. While the partnership was successful from the start, both sides found it challenging to develop a game that would engage players and spark behavior changes that would lead to a reduced risk of HIV infection. So they drafted a series of game playbooks, guidebooks that incorporate established psychological theories into the gameplay. For example, minigames—games within the larger game—encourage players to consider their future goals and aspirations, learn to assess situations and think ahead, acquire knowledge (like debunking the myth that you can’t get pregnant the first time you have sex), navigate peer relationships, and prioritize in order to maximize long-term benefits. “Our work is very much based in science,” said Fiellin. “Just like any science project, you need a lab manual to help you get a good result.” Now they use this approach for all of their games, which they then test in randomized controlled trials. “There have to be some data behind this,” noted Fiellin. “You wouldn’t want your child taking a medicine that hasn’t been tested.”

The Yale center will build and test prototypes and then present them to game developers for final full development, in much the same way that biotech companies manufacture drugs and devices developed in academia. “It will be a research and prototyping factory rather than a full-fledged game factory,” said Sawyer, who has worked with Fiellin since the beginning.

The center will also provide increased training around game design as a structured educational experience. The p2P lab, which will be incorporated into the center, has already worked with more than 25 interns and trainees, ranging from high school students to postdoctoral associates. These activities will be expanded, and discussions are underway to develop classes on the psychological constructs of games as well as other topics.

Using technology to improve access to care—especially with such hard-to-reach groups as adolescents is a powerful concept, according to Linda C. Mayes, M.D., Arnold Gesell Professor in the Child Study Center, who has worked with Fiellin on adapting games for children. Access to games that are well constructed and engaging may be better yet. “Playing a good game is like reading a good novel,” said Hieftje. “It can have a lasting impact.”