Hello everyone.
My name is Joshua Wong, and today I will be presenting our work entitled "Contemplative
Interactions: Exploring the Use of Defamiliarization in a Serious Game to Promote Reflective Thinking
about Personal Health."
This work is a collaboration with Pin Sym Foong, from the National University Health
System of Singapore, and Alex Mitchell from the National University of Singapore.
Globally, chronic diseases such as diabetes and cardiovascular disease are on the rise.
A lot of the rise is due to the increase in unhealthy lifestyle habits of people, such
as lack of exercise, sedentary lifestyles, changing dietary patterns and so forth.
Even though we know these are major problems, it's often very difficult for people to change
their personal health habits without outside help.
Trained health and lifestyle coaches are effective in tackling this problem, but they are often
expensive and limited by cost and availability of personnel.
So is there a scalable, digital solution that can help us overcome these barriers of limited
resources?
Now, in the TransTheoretical Model of Change, which is commonly used in the field of health
behavioural change, there are five steps to the change process.
Firstly, Pre-contemplation, which is when the person has not even considered change
or is unaware of the problem behaviour.
Then there is Contemplation, where they begin to consider the possibility of change, and
its pros and cons.
Then there comes Preparations to make a change, taking Action to enact that change, and finally
Maintenance to keep up the changed behaviour until it becomes a new lifestyle.
Most of the digital solutions for health behaviour change have focused on the latter three stages,
using tracked behaviour (such as diet or exercise trackers) to help people make changes to their
lives.
There are relatively few which focus on the first two stages - trying to motivate people
who have low awareness or low intrinsic motivation to contemplate change.
But that's what we're going to be focused on.
We draw on previous work done in the fields of Motivational Interviewing, which is a methodology
that has proven successful before at helping people change health habits, as well as work
on Serious Games and Interactive Narratives, which can be an engaging way to encourage
behaviour change and provoke insights into life situations.
Some key insights that were derived from our literature review were the following: In Motivational
Interviewing, it was important to help people re-evaluate values associated with problem
behaviour.
Also, to elicit from them or help them clarify their personal life goals, and then connect
those life goals to the advantages or disadvantages of change.
The main idea is to help clients find their own reasons for change.
In serious games and interactive narratives, we draw on two concepts - the idea of defamiliarization,
which involves disturbing the categorization process of routine thoughts or behaviour.
In other words, to break down routine thoughts by introducing a new element that requires
them to reflect.
And then poetic gameplay, which involves changing the normal actions a player can do in a game,
or the kind of feedback the game gives, into something that is unfamiliar in order to call
players' attention to the issues in the game's content.
So, our research question therefore is: How can defamiliarizaton and poetic gameplay be
used to design narrative-focused serious games, in order to promote contemplation about the
players' personal reasons for health?
Our research through design was split into two phases.
In the first phase, we explored several different ways of implementing poetic gameplay, three
of which are shown here: using All Undesirable Choices, giving the players Ineffectual Agency,
and changing the goals such that Winning is Losing.
For example, in the design exploration of Winning is Losing, we created a prototype
where players had to build a dam using rocks to block off a river.
Upon succeeding, we then changed the metaphor on the players, and it was revealed that what
they were doing was using cholesterol and fatty foods to block off blood flow in an
artery.
However, we decided that this design direction was too problematic, as it imposed our own
values of what "winning" and "losing" is onto the player, instead of eliciting from them
their values.
From our design explorations, we learned three things: First, that choosing between non-ideal
choices can promote a deeper re-evaluation of each choice.
Second, that the presence of a goal might promote reconsideration of the value of each
choice.
And third, that we as designers have to be careful not to impose our own values onto
the players.
All this fed into the second phase, where we designed a serious game to provoke people
into contemplation of health choices.
The game was called Family Priorities.
In the game, players took on the role of a 55-year-old widowed housewife caring for her
two adult children and her grandson.
Players would be presented with scenarios where they had to make choices that would
affect the health and happiness of the different family members.
After they had made choices, there would be visible feedback on their choices presented
to them in the form of text comments and facial expressions by their family members, as well
as changes to the meters that tracked the health and happiness of each member.
In the design of this game, we deliberately incorporated the following features: first,
there were no perfect choices.
Every decision had both negative and positive consequences, so there had to be tradeoffs
made.
Secondly, we tried to offer authentic, complex scenarios that reflected the multi-faceted
nature of health decisions that are made in context.
Thirdly, we tried to foreground longer-term values.
Halfway through the game, players would be presented with a choice of possible life goals
that their character might have.
After they chose a long-term goal, a new indicator would appear, which showed how many years
left they had to continue pursuing that goal before they grew too old.
Our methodology involves testing this game with 15 participants: 9 males and 6 females.
All of them were aged 40 and above, all with some experience of health risk factors such
as high blood pressure or cholesterol issues.
Not all of them were taking these health risks seriously.
We recorded videos of the screen while participants played the game, and then conducted a semi-structured
interview with them, getting them to answer questions about their thought process even
as they watched the video of their playthrough.
In this test, we had asked the participants to play through the game once, then they were
asked whether they would like to replay or not, and they would then play it a second
time, this time with the screen indicator tracking their long-term goal visible from
the start.
The results were quite varied and fruitful, but in the interest of saving time, I will
just share a couple of the more important ones.
If you wish to see the full results, please do read through the paper.
When we looked at how participants responded to the design feature of having no perfect
choices, we observed that participants felt initially frustrated, and then started generating
options and ideas outside of the given choices.
Some of them also drew upon their own life experiences to decide which tradeoffs were
best to make in any given scenario.
So for this feature, we found that quite a number of participants started exhibiting
dialogic reflection, which is a type of reflective thinking where people start to look for connections
between different pieces of experience - in this case, between the scenarios, the choices
offered and their own life experiences.
On the other hand, for the feature where we foregrounded longer-term values, there were
more mixed outcomes.
Some players were making habitual choices, but then after the revelation of a longer-term
goal and upon the second playthrough, they started to reconsider their choices in light
of the goal.
However, other participants did not identify with any of the life goals provided for the
game character and so were resistant to choosing priorities that did not match their own life
experiences.
In general, we found that our current implementation of the longer-term values, was somewhat flawed.
By presenting a fixed list of life goals to the players to choose from, instead of letting
players write their own, this may have impacted the players' ability to connect the longer-term
values to their own health situations.
Thus, there was no transformative reflections present.
So in conclusion, we explored how to promote contemplative thinking about personal reasons
for health change.
We explored a variety of poetic gameplay devices, resulting in a serious game that we then evaluated
with 15 players.
What we found was that the most productive approach appears to be offering the players
limited, imperfect choices, which stimulated them into demonstrating different kinds of
reflective thinking.
However, more work would need to be done to connect longer-term values to good implementations
to support processes of behaviour change.
Thank you for listening to my presentation, and if you have any further questions, please
do feel free to contact any of us, or read up on the paper to find out more.