As the designer of the other diabetes game in the competition I want to provide some support to the folks building the Glucoboy.
If I understand your post correctly, you are suggesting that because negative reinforcement is used in TV advertising about cigarettes works on you that negative reinforcements in a game will work on children with diabetes. My apologies if that is not what you meant, but that is my take away from your post on the 10th.
There are two things in question, one, the media, games vs. TV and two, the problem, stopping kids from smoking, vs. getting kids to manage their disease for their whole life.
On the question of scholarly literature there is loads of stuff on the use of positive and negative reinforcement in behavior change. Most of this is focused on human interaction. They also usually describe situations where the person in question either cannot or does not want to defect (leave the situation). For example a child who is acting up at school may experience negative reinforcement of the behavior, but she cannot leave school.
One of the reasons people play games is lots of positive reinforcement. Rewarding players is a very important aspect of good game design. If you look at successful game design the games in question constantly provide positive messages and experiences. Play World of Warcraft for 5 minutes and you will have received several new items. Getting stuff is positive reinforcement.
TV is different, it is not interactive, advertising is delivered in a short time frame. I am not certain there is any negative reinforcement going on in the “you don’t always die from tobacco” ad. Reinforcement is different from messaging, which is what the advertising is doing. TV can say ‘don’t do this” but it cannot say “or I will give you an unpleasant experience.”
A game can give you an unpleasant experience, for example it can kill your character and undo the effort you just made over the last 30 minutes. When this happen people often call it a bad game and stop playing. Since Glucoboy is trying to help these kids stay alive causing them to defect is very, very counterproductive.
Getting into the smoking Vs type I diabetes management I think we are dealing with two very different problems. The smoking ads need to stop a kid (really an adolescent, at least I hope so) from starting an expensive habit that is bad for his health.
The anti cigarette ad is saying “smoke, and you will look like this” and then shows some pretty ghastly images. There is a threat of negative reinforcement in the future, but his TV cannot do something bad to the teenager watching if it sees him light up a cigarette.
On the other hand Glucoboy needs to help a child, often under the age of 10, to adopt a very strict set of personal behaviors that are time consuming and often painful to implement.
One problem with diabetes management is the classic trade off between short and long term benefits. Patients with diabetes who manage well get a long healthy life. But today they get stuck with a needle and can’t eat loads of cookies. To a six year old the answer is obvious, anything past next month is a long time, needles hurt, and cookies are good. If the six year old did not have diabetes this answer would be very sensible, but she does, so its not.
Negative reinforcement would work on the lines of “if you eat the cookies we will do something bad to you in the game.” Well if the kid is smart she will eat the cookies (rewarding) and then go do something fun and skip the game altogether.
Positive reinforcement from Glucoboy says “if you skip the cookies and take the needle some good things will happen to you right now.” ( Sorry to put words in Glucoboy’s mouth, but I am pretty sure I am right on this.) One of the things that makes games such a potentially powerful tool for diabetes self management is the immediacy of the reward. For someone trying to manage diabetes this is a big change from the old short term pain/long term reward experience.
Glymetrix and Glucoboy are both working to make this change happen, to very different groups of people with different forms of diabetes, but both using games as tools. The approach has great potential and I look forward to seeing Glucoboy success stories as the product rolls out.
Thanks for posting a good question and giving us a chance to tackle it.
Having followed the discussion in relation to how to use video games in order to establish compliant behaviors and the invention of Glucoboy within the therapeutic area of diabetes, I am now wondering whether you know of any existing electronic devices and/or games to ensure compliant behavior in asthmatic children?
I ask, as I am currently a student finishing a paper on recent innovations within medical devices. I have especially looked into the possibility of merging software games and mobile phones in order to accommodate to the increasing need of ensuring compliant behavior in asthmatic children.
This as I find computer games and video games interesting as compliance devices, but see a need to be on the forefront with children’s’ behavior and recognize that they can be argued to use their mobile phones (which many children today possess) as a toy.
Hence, why not think in terms of merging health games and mobile phones?
Does anyone in here know of any existing attempts to do this?
Yes, we are using mobile for effectively for health, environment, disaster managemnent, and education. Games are excellent way to enage kids and youth. And mobile device...it is a trainer free device, doesn't need formal learning, you just start using it and learn quickly. Our experience has shown that it is successful not only in the urban areas but in the rural masses as well. Even semi-literate masses in our regions like India, South Asia or Africa has been using mobile effecienlty for communication, information and learning purposes.
Today, it is the best suited technology for any kind of information dissemination...it lies in your pocket and is very close to your Heart!!
But do you know of any specific attempts to reconcile medical compliance and the use of mobile phones?
For example within the therapeutic area of asthma as well as in other areas?
Tom, I asked the question about reinforcement because I was going to bring a broader question about reinforcement into the general discussion. I was NOT AT ALL saying that "because negative reinforcement is used in TV advertising about cigarettes (and) works on (me), negative reinforcements in a game will work on children with diabetes." Saying that set of things would require my believing a whole range of things that (in reality) I don't believe and would require my presuming a great deal (concerning my own wisdom, the universality of my experience, etc) that, in reality, I don't begin to presume.
I think it makes most sense for me to continue my line of query in the general discussion part of the competition, rather than here.
Thanks Tom for that clarification. I think we see things in the way that you are presenting it as well.
A big thing, is the immediacy. Like Tom mentioned, a child is thinking about now, and 5 minutes from now, not 15 years from now. The immediacy of a postive reward will generate a behavoir pattern that will help 15 years from now.
In games like World of Warcraft, or Everquest (not so affectionatly called Evercrack for the reasons I am about to describe), the game designers employ a very simple Pavlovian reward mechanism. Kill a worm, get a bonus, kill a frog, get a bonus, kill 2 wolves, get a bonus, and so on until their "character" has gained 10 levels in 2 hours. The player feels a sense of accomplishment while being trained in the mechanic of kill->reward. So later in the game, the same player is now playing 20 hours before getting the same bonus, as the game is designed with a logarithmic scale of kill:reward.
To be true to the operant conditioning, I think we are actually talking about positive reinforcement vs. punishment here. Punishment is when the character dies and you lose some of that valueable experience. A strict negative reinforcement model would be one in which the character in the game is constantly losing power or points UNLESS you test well.
We have been getting some great reports from the field in our test launch that the system is working as it was designed to. Kids are excited about the opportunity to get these in game rewards for something they have to do anyways. And it is seeming like they are wanting to test well, so that they can advance in the game, which of course is the goal.
We are aiming for long term behavior modification through short term rewards.
Thanks, Andrew. You've just made the point I was going to make: that what you (earlier) and Tom were calling negative reinforcement differs in meaningful ways from what psychologists define as negative reinforcement. As you just clarified, "A strict negative reinforcement model would be one in which the character in the game is constantly losing power or points UNLESS you test well." A definition Wikipedia provides (and I include here, as it's easily to hand) is "Negative reinforcement is an increase in the likelihood of a behavior when the consequence is the removal of an aversive stimulus. Turning off (or removing) a shock when a rat presses a bar is an example of negative reinforcement (if this increases the likelihood of the rat pressing the bar in the future)." This week a psychologist confirmed that psychologists still believe that negative reinforcement can be as encouraging of behavioral change as (certain kinds of) positive reinforcement. Do you know otherwise? As I mentioned to Tom, I asked re reinforcement because I was eager to prompt a broader question about reinforcements in games to the Changemakers community in general. I think it makes most sense for me to continue this part of the conversation in the General Discussion section of "Why Games Matter" rather than in the middle of the discussion of your entry.
You've been helpful in describing why you made the design you decisions you did (eg. deciding (for the most part) NOT to make the games vehicles for teaching kids lots about the disease itself; deciding to develop a reward system in your game rather than using negative reinforcement). Yet, because the reward system is disconnected from content that teaches kids about diabetes, I wonder: can you really expect that (as you wrote) "The immediacy of a postive reward will generate a behavoir pattern that will help 15 years from now."? If a kid tests his blood because he knows that the test will give him 5 points in the clown (not diabetes) arcade game he's playing now, why should you expect him to do any testing at all once he's no longer playing the game? If the game dissociates testing and health benefits, how do you expect that him/her to associate testing and health benefits later in life?
I'm eager to hear your responses.
Best,
Diane
Changemakers
The Glucoboy is designed to be part of a system that helps generate compliant behavoir. We have really only delved into the Glucboy itself here, because the topic is Video Games.
There are other products that seek to educate the end user about disease or condition. In the game Re:mission for instance, the player is attacking cancer cells, thus learning about how cancer spreads and how the body fights cancer. This is helpful the the children playing because it gives them hope that they can conquer the cancer. It is an educational and entertaining peice of software. Does is cure cancer? Perhaps not directly, but it seems to be having some effect on recovery.
We decided that children living with diabetes are going to get constant reminders from parents, and care providers about what they are supposed to do. And in fact, our website that is forthcoming has a lot of support and education built in. In order to have the maximum impact, we have designed two characters, Kyle and Kate to be the face of the support for Glucoboy. It is designed so that children are getting tips and hints from someone that is more of a peer than an adult "telling them what to do". Kyle is an 18 year old who was diagnosed with diabetes at age 18, and Kate is his older sister who helped him and was close to him though his teens. This way, we can address issues of both the patient, and the support network and yet, be removed from the process.
We will see how well it works. Of course, there are mechanisms in place to help us know when kids have questions that are life or health endangering.
That is a glimpse into the "system" that Glucoboy is a part of. As for the Glucoboy itself, it is designed to change behavior and not necessarily educate.
You raise a good question about why would a child continue when no longer playing the game. Very good indeed. For this very reason, we included two full games, and the 3 mini-game. This should keep their interest longer than a standard game. That said, they still will tire of those games. This is where the web community comes into focus. The Glucoboy, when plugged into a PC via the USB port, will connect the user to the web community. Their blood glucose data is stored in a secure database where parents and providers can analyze via flash based charting, or print PDF reports, get reports faxes, etc. This happens in the background while the child is logged into the Myspace like web community. The points that they accumulate in the video game can also be used in the web community to purchase new designs for their personal page, new "modules" like chat, pictures, etc for their page and what not. This portion is perhaps much deeper than the Glucoboy itself, because it is designed for 12-18 month retention.
The key for us, is to establish habits. Habits of bringing your blood glucose meter everwhere you go, habits of testing after meals, etc. I wouldnt say that the game dissociates health benefits from testing, it just doesnt associate them. Test well, get a reward. Test well, get a reward, test well, get a reward... hopefully, the conditioned respone will be that they test well, without a reward in the long run.
...but if, they still need rewards as they age, we are working on that too ;)
Thank your entry. Two things:
1. Your August 21st explanation of Glucoboy in response to Diane in the discussion was a helpful addition to the information in your entry. Would you consider adding similar explanation to the official entry?
2. I would really like to see you fill in the personal bio section so that we can have a better sense of who you are and where you're coming from.
Keep up the good work.
Dana Frasz
Changemakers Team
I'm thinking about a role playing game in which a certain role, or character (I think its called the druid, or the healer or something), can only be activated by a series of A1c readings from a glucometer.
If you design the game to include such things as:
1) Groups with healers, have significant advantages.
2) Only valid data readings from a glucometer allow the healer player to be active.
3) The more the A1c readings, and the healthier the readings are, the better is the healers power.
4) The healer has significantly greater impact while on CV exercise equipment.
You will have designed a game in which groups of people actively seek out people with A1c monitoring regimes (which suddenly gives them special status and reinforces their feelings of self-worth), diabetics will be motivated to make regular readings and keep them at healthy levels (also will be encouraged by the group to do so). Furthermore, there would be good incentive for them to do CV exercise, and for the group to appreciate that and encourage it.
My understanding is that the single most effective tool for controlling, PREVENTING and undoing the damage from (Type II) diabetes, is cardiovascular exercise.
How much work to develop a compelling game version of your video for CV exercise equipment?
While the GLUCOBOY is targeting Type 1 diabetes, and will be the most effective in that arena, we do recognize that Type 2 is an epidemic and have some solutions for this as well.
Your understanding is correct in as much as I understand it as well.
What the GLUCOBOY does, is use tools that many people have and can easily access, namely the Nintendo Game Boy Advance® Systems. We have some ancillary products that are in development that will augment the GLUCOBOY system and address many of the excercise questions.
The cool thing about the games that we have developed (2 full length games, and a mini arcade in every GLUCOBOY device) are that they are easily accessible, and very compelling. We have made them to be in par with games in the marketplace. We have pursued a path that steers us away from using the game to educate and inform, rather, using the game as the incentive to generate compliant behavior. You will only find minimal, almost subliminal clues to diabetes management in the video game. We have found that kids can smell an educational game a mile away and generally dont want to play them. But a game that is just fun, that causes them to test well and generate good habits... They seem to dig it.
Thank you for your entry, Andrew; while quite good, it prompts some questions.
First: You say that the industry fails to do something that's central to Glucoboy -- namely, address the root of why people with diabetes don't test their blood regularly. Your statement sure prompts me to wonder WHY they don't test their blood regularly and specifically HOW Glucoboy does address this root cause. Your answering promises to enable us (reading) to better appreciate the type and the bredth of innovation Glucoboy really provides.
Second: I wonder what your plan for training health care providers is, as it stands. I'm whether the training seems to you a problem because there is no plan, or because the plan you have feels to you inadequate, or something else altogether.
Third: do you have a plan in mind for addressing the questions/concerns re insurance companies? (I've asked these last 2 questions in case the concersn might be some w/which the Changemaker community might provide some help...)
Fourth, as a big fan of the concrete, I wonder whether you might not want to include some more precise numbers of people who promise to be aided by Glucoboy. By providing a number -- even if just for a restricted area -- you'd give readers a better basis for understanding the scope of the change Glucometer promises to provide.
Finally: while I don't typically point to typos, i just wanted to point out the one in your entry's title (complaint instead of compliant), since the title prompts the reader to expect a game quite different than the one you describe...
Prompting questions in a forum like this is vital to its success so I welcome any such dialog. Let me try to address the questions raised by Diane as best as I can.
Question, the First:
There are a number of reasons that people do not test their blood as often as they should. And it depends on the age range discussed. Anything from laziness to cost of test strips can factor in when discussing an adult person with diabetes. When dealing with adolescents, some of those factors change. Laziness is replaced by a reminding parent (which is often seen as a nagging parent and leads to another reason for low testing), cost is replaced by a parent that will do anything for their child to be healthy.
Some of the key factors, are kids that lose their meters, kids that dont want to test because of the pain involved, kids that dont test because of the stigma at schools, and what not. This could prompt a very wide discussion indeed.
My point is that a faster, more accurate, smaller meter does very little to help a child that does not want to prick their finger 6 times a day. It does very little to address the fact that people ask questions and point fingers when someone has to test and then inject something into their blood in a public school. While advances in the medical industry are certainly amazing, we wanted to address something more on the core level. What can help kids towards compliant behavior?
We believe that the GLUCOBOY, while it will not eliminate pain, will cause kids to test more becuase they are rewarded to do so. Perhaps I didnt explain well, but the "frequency of testing" and the test scores themselves are run through an algorhythm that generates a point value. We call them GlucoseReward Points, or GRPs. These GRPs can be spent to unlock video games, open up new levels, purchase items in the game, etc. The video game is built into the meter, so the same meter that tests your blood can also play these games.
We are also reducing a stigma because kids now have something cool to talk about. Something that makes them unique, namely, a video game that no one else has and will want to play.
Question the Second:
We have a series of modules that will be used to train care providers. We have the mechanism to do so. I think the problem lies in the fact that we have to convince those providers that our meter will actually help the child. We have some groups planned that will demonstrate that we do in fact increase compliance, but again, we need to get that out to the providers. We have an interesting marketing conundrum in that, the child has to want the device, the parent has to purchase it, and the provider has to recommend it. That really comes down to 3 different marketing plans, 3 different marketing venues, and 3 different education pieces. Not to mention that each country that we tackle has a different structure for care providers, how materials and tools are distributed, and even how the device and test strips are distributed as well.
Question the Third:
This is one that we are working on, and again, is dependant on country. One country we are working at sellign in, for instance, will reimburse the meter and strip cost, but only to the first meter that is registered by the patient. So a scenario in which the patient switches to our platform is a bit tricky. So we are working through this part, but it requires being flexible as no one plan will fit all.
Question the Fourth:
I will work on getting some data here. I have data for the countries we are planning on launching in and the next tier countries, but I would like to look at other markets in the global space and give a better estimate. Lets just take a small market in one country. The country has a population of about 16 Million people, and there are 7000 children with diabetes in our target age. So 7000 is the number of people who we are targeting. But the product will actually help all diabetics in the country, though Type 1 is more of what we are targeting in the initial round.
Since our product is aimed at the 6-14 year old, male and female market (great care has been taken to insure that we have a video game and web community that is not male skewed), that is of course the target, but we anticipate that many outside of the age range will want to play the game and use the product.
I hope helps and I will continue to monitor this so that we can have a good dialog.
I think you're saying that a player's in-game performance (e.g score, opportunities to play new levels, etc) is affected by his/her out-of-game behavior - that s/he wins game points for testing his/her blood. If so, it seems as though Glucoboy goes to the rootS (since you name several) of why kids don't test and creates a new set of incentives to prompt testing.
Re the problems you anticipate (re training health care providers): i wonder why you don't think you can employ the great buzz your innovation has already prompted in the mainstream press AND the industry (given what you call your daily requests for the Glucoboy and "the international retailers and distributors internationally... competing for exclusivity") to avoid the costs for marketing and education that others with less "buzzed" products need to spend. In 2004, the Kerry and Bush campaigns came to realize that, for many ads, they needed to pay for only one ad-run; they saw they could trust the mainstream press to take enough interest in the ad to run and/or chat about it on all the news programs -- giving them/their ad millions of dollars worth of free publicity. Thus, they could hold their money and devote it to producing more ads-- in some cases, ads that responded to the talk generated by the news programs' in the running of their ads. I'd wonder whether your own marketing strategy might not be similarly (ummm) strategic in that you anticipate employing what free publicity your game release will generate and devoting more of your resources to the gaps the pre-existing structures and networks don't provide, etc. Or is there something I'm missing?
I wonder whether you had a chance to see yesterday's NYT article on Diabetes -- one shocking enough to have become the most requested article of the day (from the website)(http://www.nytimes.com/2007/08/20/health/20diabetes.html?em&ex=1187841600&en=f7b182684c4d472d&ei=5087%0A)
I know that Glucoboy is intended for people with Type 1 diabetes, while the article concentrates on problems associated with Type 2; and from what I've read and understand, the real benefits Glucoboy offers are not those that would help offset the real problems outlined in the article. Yet, if I'm wrong, I hope you'll say so; and if you can see ways in which Glucoboy might be adjusted to aid the Type 2 population, I hope you'll let me (and the Changemakers community) know. (Of course I realize that whether one would find a market for a game targeted to type 2 diabetes sufferers -- who are largely digital immigrants and NOT gamers-- is an entirely separate question....)
We have been very careful to make the point system by truly rewarding. We want kids to be rewarded for testing, and are being very cautious to use positive and not negative reinforcement. For example, you will never be penalized in the game for not testing often enough. The mechanism is pretty cool. The Video Game portion of the Glucoboy asks the Meter portion of the device what the test results have been. Then those results are converted to the Glucose Reward Points (these will become GuidanceReward Points when other products are intruduced).
Inside the Glucoboy are 2 full games and a mini aracade. Immediately, the player can access Knock Em Downs, a quirky adventure game. They can unlock Lost Star Saga with the points they have earned, and they can unlock each of three games in the arcade with points. Additionally, the player can convert points into "currency" to be used in each of the games. If you were playing Knock Em Downs and you needed to upgrade from a Teddy Bear shooter to a Bubble Gum gun, then you might need extra "tokens" to purchase that upgrade. You can convert GRPs to tokens in this case. In Lost Star Saga, the currency is crystals that you can convert GRPs into. Perhpas that is a little better insight as to how this all works to incentivise the player.
We fully intend to employ the buzz and energy around the product. One of my concerns is that while buzz and energy might sway a user to want the device, the provider may be more skeptical that it will actually help generate compliance. This is where we need to (and are) putting energy into demonstrating that there is an appreciable difference in compliance when a Glucoboy is used.
I also am a bit concerned about the effectiveness of advertising in this space. We are targeting a small segment of the population and need to tailor the message differently for each group we need to reach. For instance, and I hope I dont give the competition too many ideas here, but I was recently at the American Association of Diabetes Educators show. This of course, is focused on the care providers, which tends to be middle aged women. Most of the booth "design" was very clean lines, strong colors, bold statements which appealed very much to me, but by and large, a female audience is not swayed by the same things. When targeting that audience, the booth should be more inviting, energetic, playfull and compassionate.
The same way, when messaging to kids and parents, the message is completely different. In the end, we will be tremendously successful and the buzz will carry a lot of weight. But we need to make sure that we are making a difference in the marketplace and I'm not sure that buzz will always communicate what we want to communicate.
Great points, though that we have certainly considered. My background is one of marketing for a major household name and we used buzz worthiness to the maximum. We were able to market to kids, even when the parent is the purchaser because the kid will be so vocal in what they want. For the Glucoboy, we can follow some similar models but we do have to communicate to the parent that this will help their child, and to the provider that we are on their side and here to help them as much as we can.
We certainly have plans to reach the Type 2 market, and I do believe that the Glucoboy can help in those situations. The fact that Type 2 diabetics do not need to test as often means that they might progress more slowly though the game, but we can still use the Glucoboy to help address the concerns that people with type 2 diabetes face. We recognze that Type 2 diabetes is and will be an epidemic. We have other programs and efforts in this area as well. What we are facing with Type 2 is largely a communications issue. Finding the people who have Type 2, or even those who are pre-diabetic, and communicating proper care, can be quite a challenge, especially with the social economic makeup of many of that population. But it is an exciting challenge. The interesting thing there, is that you can, with proper care actually correct some of the problems (taking about pre-diabetics in particular here). And that makes is a very urgent market indeed.
Fourth, as a big fan of the concrete, I wonder whether you might not want to include some more precise numbers of people who promise to be aided by Glucoboy. By providing a number -- even if just for a restricted area -- you'd give readers a better basis for understanding the scope of the change Glucometer promises to provide.
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Thanks for your reply. A range of things (conversations, projects, entries) keep bringing me back to the issue of reinforcements... and I realize that while I know that game makers like you and others working to prompt behavioral change in kids are careful to include only positive reinforcements and to avoid penalizing kids for neglecting parts of their care, I'm less familiar with the scholarly literature that indicates that's really the optimal way to go. I wonder: are there specific articles or researchers to which you might point me? I wonder why - if there's such universal agreement among psychologists that one ought not show kids how negative action, or passivity, contribute to ill-health, the anti-smoking campaigners have come up with the incredibly powerful advertisements they have -- particularly of late? (While I'm neither a smoker nor a child, I'd have a tough time understanding how anyone could start smoking after seeing, say, the man sing "you don't always die from tobacco" through a mechanical voice box...)
In rereading, I realized that you'd not mentioned much about the content of game play... While I know that a player's score is affected by his diabetes-related treatment, I don't think you told us whether any of the games played on Glucoboy actually talk about, or teach players about, the disease. Do they? and if so: does the positive "spin" extend itself to the game story too?
I look forward to hearing your responses.
Diane
Changemakers
I can't say whether or not there is research pointing to the benefits of positive reinforcement over negative. From our perpective, we decided that we would take the positive approach for a number of reasons.
Paul Wessel, the founder and inventor of Glucoboy, has a son who was diagnosed with diabetes at a very young age. Paul (and many other parents of children with diabetes) had trouble getting kids to test their blood on a regular basis. The very fact that a child has to become a human pin cushion is enough to detract children from wanting to test. Additionally, the child, at age 6-14 doesnt see a long term benefit from testing. That type of forward thinking is generally not a characteristic of young children. So rewarding them is the mechanism we chose to stick to. There is enough negative reinforcement happening at the parent to child level, and we chose to leave it there.
Another point in out decision is the very nature of video games. Many games, if not most, are left unfinished by the player. Reasons for this range, but two of the reasons are that people get stuck in a tough place, or they lose interest. Games are like many things in that, once you step away for a while, you almost forget that the game existed, and when you do try to get back into it, you may have forgotten much of the mechanics and the hows of the game. This is why intensive Massively Multiplayer persistent world games have a core following, but at some point, people hit the wall of progress and either start over, or find a new game, or quit entirely. This is also a reason for the rise in casual or addictive games.
I dont know how much the anti-smoking ads are helping. Anti-drug ads are certainly not curbing drug use in the US. Kids of that age are just not forward thinking enough to imagine that they could end up like people on the ads. As adults, we see through different lenses. Just as we joke about kids in their teens "knowing everything" they also have an "indestructable" mentality. I venture to guess that if we were to reward kids with music downloads and cell phone minutes for avoiding drugs, alchohol, and tobacco, we would see greater levels of compliance.
Content of game play. We made a decision to avoid direct diabetes education while in the gaming world. When the player begins, they are in their room. From time to time, two of our key characters pop in and ask them a multiple choice diabtes related question, but this remains outside of the games. These diabetes questions are random but will pop up more frequently when the child has been testing less. They can earn in game points by answering correctly.
There are 3 casual or mini-arcade games that can be unlocked with points (again, generated by testing). These games are shooter, action, arcade style games that are good for quick and repeated game play. The other two games Knock Em' Downs and Lost Star Saga are deeper and take longer to complete.
In the Knock Em' Downs game, the player is in a world where the carnival has gone awry and the knock down clowns are loose. As a player you need to collect all the clowns. There is no diabetes related content, meaning, you do not use an insulin gun to shoot a sugar monster or the like. But we have implemented subtle reminders such as eating a small snack when energy levels are low.
Lost Star Saga is a science fiction role playing game, and again, there is little diabetes content outside of the fact that some evil characters attack the eyes and feet.
This was a calculated decision. We have found in discussions with children that they can smell an education game a mile away and are not as interested. We wanted to make a game that kids would love to play, and one that their friends would want to play, but couldnt. We wanted kids with diabetes to feel that there was something just for them.
Diane,
As the designer of the other diabetes game in the competition I want to provide some support to the folks building the Glucoboy.
If I understand your post correctly, you are suggesting that because negative reinforcement is used in TV advertising about cigarettes works on you that negative reinforcements in a game will work on children with diabetes. My apologies if that is not what you meant, but that is my take away from your post on the 10th.
There are two things in question, one, the media, games vs. TV and two, the problem, stopping kids from smoking, vs. getting kids to manage their disease for their whole life.
On the question of scholarly literature there is loads of stuff on the use of positive and negative reinforcement in behavior change. Most of this is focused on human interaction. They also usually describe situations where the person in question either cannot or does not want to defect (leave the situation). For example a child who is acting up at school may experience negative reinforcement of the behavior, but she cannot leave school.
One of the reasons people play games is lots of positive reinforcement. Rewarding players is a very important aspect of good game design. If you look at successful game design the games in question constantly provide positive messages and experiences. Play World of Warcraft for 5 minutes and you will have received several new items. Getting stuff is positive reinforcement.
TV is different, it is not interactive, advertising is delivered in a short time frame. I am not certain there is any negative reinforcement going on in the “you don’t always die from tobacco” ad. Reinforcement is different from messaging, which is what the advertising is doing. TV can say ‘don’t do this” but it cannot say “or I will give you an unpleasant experience.”
A game can give you an unpleasant experience, for example it can kill your character and undo the effort you just made over the last 30 minutes. When this happen people often call it a bad game and stop playing. Since Glucoboy is trying to help these kids stay alive causing them to defect is very, very counterproductive.
Getting into the smoking Vs type I diabetes management I think we are dealing with two very different problems. The smoking ads need to stop a kid (really an adolescent, at least I hope so) from starting an expensive habit that is bad for his health.
The anti cigarette ad is saying “smoke, and you will look like this” and then shows some pretty ghastly images. There is a threat of negative reinforcement in the future, but his TV cannot do something bad to the teenager watching if it sees him light up a cigarette.
On the other hand Glucoboy needs to help a child, often under the age of 10, to adopt a very strict set of personal behaviors that are time consuming and often painful to implement.
One problem with diabetes management is the classic trade off between short and long term benefits. Patients with diabetes who manage well get a long healthy life. But today they get stuck with a needle and can’t eat loads of cookies. To a six year old the answer is obvious, anything past next month is a long time, needles hurt, and cookies are good. If the six year old did not have diabetes this answer would be very sensible, but she does, so its not.
Negative reinforcement would work on the lines of “if you eat the cookies we will do something bad to you in the game.” Well if the kid is smart she will eat the cookies (rewarding) and then go do something fun and skip the game altogether.
Positive reinforcement from Glucoboy says “if you skip the cookies and take the needle some good things will happen to you right now.” ( Sorry to put words in Glucoboy’s mouth, but I am pretty sure I am right on this.) One of the things that makes games such a potentially powerful tool for diabetes self management is the immediacy of the reward. For someone trying to manage diabetes this is a big change from the old short term pain/long term reward experience.
Glymetrix and Glucoboy are both working to make this change happen, to very different groups of people with different forms of diabetes, but both using games as tools. The approach has great potential and I look forward to seeing Glucoboy success stories as the product rolls out.
Thanks for posting a good question and giving us a chance to tackle it.
Tom Hunter
Glymetrix
Tom and Diane
Having followed the discussion in relation to how to use video games in order to establish compliant behaviors and the invention of Glucoboy within the therapeutic area of diabetes, I am now wondering whether you know of any existing electronic devices and/or games to ensure compliant behavior in asthmatic children?
I ask, as I am currently a student finishing a paper on recent innovations within medical devices. I have especially looked into the possibility of merging software games and mobile phones in order to accommodate to the increasing need of ensuring compliant behavior in asthmatic children.
This as I find computer games and video games interesting as compliance devices, but see a need to be on the forefront with children’s’ behavior and recognize that they can be argued to use their mobile phones (which many children today possess) as a toy.
Hence, why not think in terms of merging health games and mobile phones?
Does anyone in here know of any existing attempts to do this?
Thanks for an interesting debate!
Caroline Thorsen
Yes, we are using mobile for effectively for health, environment, disaster managemnent, and education. Games are excellent way to enage kids and youth. And mobile device...it is a trainer free device, doesn't need formal learning, you just start using it and learn quickly. Our experience has shown that it is successful not only in the urban areas but in the rural masses as well. Even semi-literate masses in our regions like India, South Asia or Africa has been using mobile effecienlty for communication, information and learning purposes.
Today, it is the best suited technology for any kind of information dissemination...it lies in your pocket and is very close to your Heart!!
But do you know of any specific attempts to reconcile medical compliance and the use of mobile phones?
For example within the therapeutic area of asthma as well as in other areas?
Tom, I asked the question about reinforcement because I was going to bring a broader question about reinforcement into the general discussion. I was NOT AT ALL saying that "because negative reinforcement is used in TV advertising about cigarettes (and) works on (me), negative reinforcements in a game will work on children with diabetes." Saying that set of things would require my believing a whole range of things that (in reality) I don't believe and would require my presuming a great deal (concerning my own wisdom, the universality of my experience, etc) that, in reality, I don't begin to presume.
I think it makes most sense for me to continue my line of query in the general discussion part of the competition, rather than here.
Best,
Diane
Changemakers
Thanks Tom for that clarification. I think we see things in the way that you are presenting it as well.
A big thing, is the immediacy. Like Tom mentioned, a child is thinking about now, and 5 minutes from now, not 15 years from now. The immediacy of a postive reward will generate a behavoir pattern that will help 15 years from now.
In games like World of Warcraft, or Everquest (not so affectionatly called Evercrack for the reasons I am about to describe), the game designers employ a very simple Pavlovian reward mechanism. Kill a worm, get a bonus, kill a frog, get a bonus, kill 2 wolves, get a bonus, and so on until their "character" has gained 10 levels in 2 hours. The player feels a sense of accomplishment while being trained in the mechanic of kill->reward. So later in the game, the same player is now playing 20 hours before getting the same bonus, as the game is designed with a logarithmic scale of kill:reward.
To be true to the operant conditioning, I think we are actually talking about positive reinforcement vs. punishment here. Punishment is when the character dies and you lose some of that valueable experience. A strict negative reinforcement model would be one in which the character in the game is constantly losing power or points UNLESS you test well.
We have been getting some great reports from the field in our test launch that the system is working as it was designed to. Kids are excited about the opportunity to get these in game rewards for something they have to do anyways. And it is seeming like they are wanting to test well, so that they can advance in the game, which of course is the goal.
We are aiming for long term behavior modification through short term rewards.
Thanks, Andrew. You've just made the point I was going to make: that what you (earlier) and Tom were calling negative reinforcement differs in meaningful ways from what psychologists define as negative reinforcement. As you just clarified, "A strict negative reinforcement model would be one in which the character in the game is constantly losing power or points UNLESS you test well." A definition Wikipedia provides (and I include here, as it's easily to hand) is "Negative reinforcement is an increase in the likelihood of a behavior when the consequence is the removal of an aversive stimulus. Turning off (or removing) a shock when a rat presses a bar is an example of negative reinforcement (if this increases the likelihood of the rat pressing the bar in the future)." This week a psychologist confirmed that psychologists still believe that negative reinforcement can be as encouraging of behavioral change as (certain kinds of) positive reinforcement. Do you know otherwise? As I mentioned to Tom, I asked re reinforcement because I was eager to prompt a broader question about reinforcements in games to the Changemakers community in general. I think it makes most sense for me to continue this part of the conversation in the General Discussion section of "Why Games Matter" rather than in the middle of the discussion of your entry.
You've been helpful in describing why you made the design you decisions you did (eg. deciding (for the most part) NOT to make the games vehicles for teaching kids lots about the disease itself; deciding to develop a reward system in your game rather than using negative reinforcement). Yet, because the reward system is disconnected from content that teaches kids about diabetes, I wonder: can you really expect that (as you wrote) "The immediacy of a postive reward will generate a behavoir pattern that will help 15 years from now."? If a kid tests his blood because he knows that the test will give him 5 points in the clown (not diabetes) arcade game he's playing now, why should you expect him to do any testing at all once he's no longer playing the game? If the game dissociates testing and health benefits, how do you expect that him/her to associate testing and health benefits later in life?
I'm eager to hear your responses.
Best,
Diane
Changemakers
Good question Diane.
The Glucoboy is designed to be part of a system that helps generate compliant behavoir. We have really only delved into the Glucboy itself here, because the topic is Video Games.
There are other products that seek to educate the end user about disease or condition. In the game Re:mission for instance, the player is attacking cancer cells, thus learning about how cancer spreads and how the body fights cancer. This is helpful the the children playing because it gives them hope that they can conquer the cancer. It is an educational and entertaining peice of software. Does is cure cancer? Perhaps not directly, but it seems to be having some effect on recovery.
We decided that children living with diabetes are going to get constant reminders from parents, and care providers about what they are supposed to do. And in fact, our website that is forthcoming has a lot of support and education built in. In order to have the maximum impact, we have designed two characters, Kyle and Kate to be the face of the support for Glucoboy. It is designed so that children are getting tips and hints from someone that is more of a peer than an adult "telling them what to do". Kyle is an 18 year old who was diagnosed with diabetes at age 18, and Kate is his older sister who helped him and was close to him though his teens. This way, we can address issues of both the patient, and the support network and yet, be removed from the process.
We will see how well it works. Of course, there are mechanisms in place to help us know when kids have questions that are life or health endangering.
That is a glimpse into the "system" that Glucoboy is a part of. As for the Glucoboy itself, it is designed to change behavior and not necessarily educate.
You raise a good question about why would a child continue when no longer playing the game. Very good indeed. For this very reason, we included two full games, and the 3 mini-game. This should keep their interest longer than a standard game. That said, they still will tire of those games. This is where the web community comes into focus. The Glucoboy, when plugged into a PC via the USB port, will connect the user to the web community. Their blood glucose data is stored in a secure database where parents and providers can analyze via flash based charting, or print PDF reports, get reports faxes, etc. This happens in the background while the child is logged into the Myspace like web community. The points that they accumulate in the video game can also be used in the web community to purchase new designs for their personal page, new "modules" like chat, pictures, etc for their page and what not. This portion is perhaps much deeper than the Glucoboy itself, because it is designed for 12-18 month retention.
The key for us, is to establish habits. Habits of bringing your blood glucose meter everwhere you go, habits of testing after meals, etc. I wouldnt say that the game dissociates health benefits from testing, it just doesnt associate them. Test well, get a reward. Test well, get a reward, test well, get a reward... hopefully, the conditioned respone will be that they test well, without a reward in the long run.
...but if, they still need rewards as they age, we are working on that too ;)
Thank your entry. Two things:
1. Your August 21st explanation of Glucoboy in response to Diane in the discussion was a helpful addition to the information in your entry. Would you consider adding similar explanation to the official entry?
2. I would really like to see you fill in the personal bio section so that we can have a better sense of who you are and where you're coming from.
Keep up the good work.
Dana Frasz
Changemakers Team
Andrew and Diane:
I'm thinking about a role playing game in which a certain role, or character (I think its called the druid, or the healer or something), can only be activated by a series of A1c readings from a glucometer.
If you design the game to include such things as:
1) Groups with healers, have significant advantages.
2) Only valid data readings from a glucometer allow the healer player to be active.
3) The more the A1c readings, and the healthier the readings are, the better is the healers power.
4) The healer has significantly greater impact while on CV exercise equipment.
You will have designed a game in which groups of people actively seek out people with A1c monitoring regimes (which suddenly gives them special status and reinforces their feelings of self-worth), diabetics will be motivated to make regular readings and keep them at healthy levels (also will be encouraged by the group to do so). Furthermore, there would be good incentive for them to do CV exercise, and for the group to appreciate that and encourage it.
Mark Martens, President
Pantometrics, Ltd
Deleted and moved to the reply section of the comments below.
Andrew:
My understanding is that the single most effective tool for controlling, PREVENTING and undoing the damage from (Type II) diabetes, is cardiovascular exercise.
How much work to develop a compelling game version of your video for CV exercise equipment?
Mark Martens, President
Pantometrics, Ltd
While the GLUCOBOY is targeting Type 1 diabetes, and will be the most effective in that arena, we do recognize that Type 2 is an epidemic and have some solutions for this as well.
Your understanding is correct in as much as I understand it as well.
What the GLUCOBOY does, is use tools that many people have and can easily access, namely the Nintendo Game Boy Advance® Systems. We have some ancillary products that are in development that will augment the GLUCOBOY system and address many of the excercise questions.
The cool thing about the games that we have developed (2 full length games, and a mini arcade in every GLUCOBOY device) are that they are easily accessible, and very compelling. We have made them to be in par with games in the marketplace. We have pursued a path that steers us away from using the game to educate and inform, rather, using the game as the incentive to generate compliant behavior. You will only find minimal, almost subliminal clues to diabetes management in the video game. We have found that kids can smell an educational game a mile away and generally dont want to play them. But a game that is just fun, that causes them to test well and generate good habits... They seem to dig it.
Thank you for your entry, Andrew; while quite good, it prompts some questions.
First: You say that the industry fails to do something that's central to Glucoboy -- namely, address the root of why people with diabetes don't test their blood regularly. Your statement sure prompts me to wonder WHY they don't test their blood regularly and specifically HOW Glucoboy does address this root cause. Your answering promises to enable us (reading) to better appreciate the type and the bredth of innovation Glucoboy really provides.
Second: I wonder what your plan for training health care providers is, as it stands. I'm whether the training seems to you a problem because there is no plan, or because the plan you have feels to you inadequate, or something else altogether.
Third: do you have a plan in mind for addressing the questions/concerns re insurance companies? (I've asked these last 2 questions in case the concersn might be some w/which the Changemaker community might provide some help...)
Fourth, as a big fan of the concrete, I wonder whether you might not want to include some more precise numbers of people who promise to be aided by Glucoboy. By providing a number -- even if just for a restricted area -- you'd give readers a better basis for understanding the scope of the change Glucometer promises to provide.
Finally: while I don't typically point to typos, i just wanted to point out the one in your entry's title (complaint instead of compliant), since the title prompts the reader to expect a game quite different than the one you describe...
I look forward to hearing from you.
Best
Diane
The Changemakers Team
Prompting questions in a forum like this is vital to its success so I welcome any such dialog. Let me try to address the questions raised by Diane as best as I can.
Question, the First:
There are a number of reasons that people do not test their blood as often as they should. And it depends on the age range discussed. Anything from laziness to cost of test strips can factor in when discussing an adult person with diabetes. When dealing with adolescents, some of those factors change. Laziness is replaced by a reminding parent (which is often seen as a nagging parent and leads to another reason for low testing), cost is replaced by a parent that will do anything for their child to be healthy.
Some of the key factors, are kids that lose their meters, kids that dont want to test because of the pain involved, kids that dont test because of the stigma at schools, and what not. This could prompt a very wide discussion indeed.
My point is that a faster, more accurate, smaller meter does very little to help a child that does not want to prick their finger 6 times a day. It does very little to address the fact that people ask questions and point fingers when someone has to test and then inject something into their blood in a public school. While advances in the medical industry are certainly amazing, we wanted to address something more on the core level. What can help kids towards compliant behavior?
We believe that the GLUCOBOY, while it will not eliminate pain, will cause kids to test more becuase they are rewarded to do so. Perhaps I didnt explain well, but the "frequency of testing" and the test scores themselves are run through an algorhythm that generates a point value. We call them GlucoseReward Points, or GRPs. These GRPs can be spent to unlock video games, open up new levels, purchase items in the game, etc. The video game is built into the meter, so the same meter that tests your blood can also play these games.
We are also reducing a stigma because kids now have something cool to talk about. Something that makes them unique, namely, a video game that no one else has and will want to play.
Question the Second:
We have a series of modules that will be used to train care providers. We have the mechanism to do so. I think the problem lies in the fact that we have to convince those providers that our meter will actually help the child. We have some groups planned that will demonstrate that we do in fact increase compliance, but again, we need to get that out to the providers. We have an interesting marketing conundrum in that, the child has to want the device, the parent has to purchase it, and the provider has to recommend it. That really comes down to 3 different marketing plans, 3 different marketing venues, and 3 different education pieces. Not to mention that each country that we tackle has a different structure for care providers, how materials and tools are distributed, and even how the device and test strips are distributed as well.
Question the Third:
This is one that we are working on, and again, is dependant on country. One country we are working at sellign in, for instance, will reimburse the meter and strip cost, but only to the first meter that is registered by the patient. So a scenario in which the patient switches to our platform is a bit tricky. So we are working through this part, but it requires being flexible as no one plan will fit all.
Question the Fourth:
I will work on getting some data here. I have data for the countries we are planning on launching in and the next tier countries, but I would like to look at other markets in the global space and give a better estimate. Lets just take a small market in one country. The country has a population of about 16 Million people, and there are 7000 children with diabetes in our target age. So 7000 is the number of people who we are targeting. But the product will actually help all diabetics in the country, though Type 1 is more of what we are targeting in the initial round.
Since our product is aimed at the 6-14 year old, male and female market (great care has been taken to insure that we have a video game and web community that is not male skewed), that is of course the target, but we anticipate that many outside of the age range will want to play the game and use the product.
I hope helps and I will continue to monitor this so that we can have a good dialog.
Thanks for your responses, Andrew.
I think you're saying that a player's in-game performance (e.g score, opportunities to play new levels, etc) is affected by his/her out-of-game behavior - that s/he wins game points for testing his/her blood. If so, it seems as though Glucoboy goes to the rootS (since you name several) of why kids don't test and creates a new set of incentives to prompt testing.
Re the problems you anticipate (re training health care providers): i wonder why you don't think you can employ the great buzz your innovation has already prompted in the mainstream press AND the industry (given what you call your daily requests for the Glucoboy and "the international retailers and distributors internationally... competing for exclusivity") to avoid the costs for marketing and education that others with less "buzzed" products need to spend. In 2004, the Kerry and Bush campaigns came to realize that, for many ads, they needed to pay for only one ad-run; they saw they could trust the mainstream press to take enough interest in the ad to run and/or chat about it on all the news programs -- giving them/their ad millions of dollars worth of free publicity. Thus, they could hold their money and devote it to producing more ads-- in some cases, ads that responded to the talk generated by the news programs' in the running of their ads. I'd wonder whether your own marketing strategy might not be similarly (ummm) strategic in that you anticipate employing what free publicity your game release will generate and devoting more of your resources to the gaps the pre-existing structures and networks don't provide, etc. Or is there something I'm missing?
I wonder whether you had a chance to see yesterday's NYT article on Diabetes -- one shocking enough to have become the most requested article of the day (from the website)(http://www.nytimes.com/2007/08/20/health/20diabetes.html?em&ex=1187841600&en=f7b182684c4d472d&ei=5087%0A)
I know that Glucoboy is intended for people with Type 1 diabetes, while the article concentrates on problems associated with Type 2; and from what I've read and understand, the real benefits Glucoboy offers are not those that would help offset the real problems outlined in the article. Yet, if I'm wrong, I hope you'll say so; and if you can see ways in which Glucoboy might be adjusted to aid the Type 2 population, I hope you'll let me (and the Changemakers community) know. (Of course I realize that whether one would find a market for a game targeted to type 2 diabetes sufferers -- who are largely digital immigrants and NOT gamers-- is an entirely separate question....)
I look forward to hearing from you.
Best,
Diane
Changemakers
We have been very careful to make the point system by truly rewarding. We want kids to be rewarded for testing, and are being very cautious to use positive and not negative reinforcement. For example, you will never be penalized in the game for not testing often enough. The mechanism is pretty cool. The Video Game portion of the Glucoboy asks the Meter portion of the device what the test results have been. Then those results are converted to the Glucose Reward Points (these will become GuidanceReward Points when other products are intruduced).
Inside the Glucoboy are 2 full games and a mini aracade. Immediately, the player can access Knock Em Downs, a quirky adventure game. They can unlock Lost Star Saga with the points they have earned, and they can unlock each of three games in the arcade with points. Additionally, the player can convert points into "currency" to be used in each of the games. If you were playing Knock Em Downs and you needed to upgrade from a Teddy Bear shooter to a Bubble Gum gun, then you might need extra "tokens" to purchase that upgrade. You can convert GRPs to tokens in this case. In Lost Star Saga, the currency is crystals that you can convert GRPs into. Perhpas that is a little better insight as to how this all works to incentivise the player.
We fully intend to employ the buzz and energy around the product. One of my concerns is that while buzz and energy might sway a user to want the device, the provider may be more skeptical that it will actually help generate compliance. This is where we need to (and are) putting energy into demonstrating that there is an appreciable difference in compliance when a Glucoboy is used.
I also am a bit concerned about the effectiveness of advertising in this space. We are targeting a small segment of the population and need to tailor the message differently for each group we need to reach. For instance, and I hope I dont give the competition too many ideas here, but I was recently at the American Association of Diabetes Educators show. This of course, is focused on the care providers, which tends to be middle aged women. Most of the booth "design" was very clean lines, strong colors, bold statements which appealed very much to me, but by and large, a female audience is not swayed by the same things. When targeting that audience, the booth should be more inviting, energetic, playfull and compassionate.
The same way, when messaging to kids and parents, the message is completely different. In the end, we will be tremendously successful and the buzz will carry a lot of weight. But we need to make sure that we are making a difference in the marketplace and I'm not sure that buzz will always communicate what we want to communicate.
Great points, though that we have certainly considered. My background is one of marketing for a major household name and we used buzz worthiness to the maximum. We were able to market to kids, even when the parent is the purchaser because the kid will be so vocal in what they want. For the Glucoboy, we can follow some similar models but we do have to communicate to the parent that this will help their child, and to the provider that we are on their side and here to help them as much as we can.
We certainly have plans to reach the Type 2 market, and I do believe that the Glucoboy can help in those situations. The fact that Type 2 diabetics do not need to test as often means that they might progress more slowly though the game, but we can still use the Glucoboy to help address the concerns that people with type 2 diabetes face. We recognze that Type 2 diabetes is and will be an epidemic. We have other programs and efforts in this area as well. What we are facing with Type 2 is largely a communications issue. Finding the people who have Type 2, or even those who are pre-diabetic, and communicating proper care, can be quite a challenge, especially with the social economic makeup of many of that population. But it is an exciting challenge. The interesting thing there, is that you can, with proper care actually correct some of the problems (taking about pre-diabetics in particular here). And that makes is a very urgent market indeed.
Fourth, as a big fan of the concrete, I wonder whether you might not want to include some more precise numbers of people who promise to be aided by Glucoboy. By providing a number -- even if just for a restricted area -- you'd give readers a better basis for understanding the scope of the change Glucometer promises to provide.
_____
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Thanks for your reply. A range of things (conversations, projects, entries) keep bringing me back to the issue of reinforcements... and I realize that while I know that game makers like you and others working to prompt behavioral change in kids are careful to include only positive reinforcements and to avoid penalizing kids for neglecting parts of their care, I'm less familiar with the scholarly literature that indicates that's really the optimal way to go. I wonder: are there specific articles or researchers to which you might point me? I wonder why - if there's such universal agreement among psychologists that one ought not show kids how negative action, or passivity, contribute to ill-health, the anti-smoking campaigners have come up with the incredibly powerful advertisements they have -- particularly of late? (While I'm neither a smoker nor a child, I'd have a tough time understanding how anyone could start smoking after seeing, say, the man sing "you don't always die from tobacco" through a mechanical voice box...)
In rereading, I realized that you'd not mentioned much about the content of game play... While I know that a player's score is affected by his diabetes-related treatment, I don't think you told us whether any of the games played on Glucoboy actually talk about, or teach players about, the disease. Do they? and if so: does the positive "spin" extend itself to the game story too?
I look forward to hearing your responses.
Diane
Changemakers
I can't say whether or not there is research pointing to the benefits of positive reinforcement over negative. From our perpective, we decided that we would take the positive approach for a number of reasons.
Paul Wessel, the founder and inventor of Glucoboy, has a son who was diagnosed with diabetes at a very young age. Paul (and many other parents of children with diabetes) had trouble getting kids to test their blood on a regular basis. The very fact that a child has to become a human pin cushion is enough to detract children from wanting to test. Additionally, the child, at age 6-14 doesnt see a long term benefit from testing. That type of forward thinking is generally not a characteristic of young children. So rewarding them is the mechanism we chose to stick to. There is enough negative reinforcement happening at the parent to child level, and we chose to leave it there.
Another point in out decision is the very nature of video games. Many games, if not most, are left unfinished by the player. Reasons for this range, but two of the reasons are that people get stuck in a tough place, or they lose interest. Games are like many things in that, once you step away for a while, you almost forget that the game existed, and when you do try to get back into it, you may have forgotten much of the mechanics and the hows of the game. This is why intensive Massively Multiplayer persistent world games have a core following, but at some point, people hit the wall of progress and either start over, or find a new game, or quit entirely. This is also a reason for the rise in casual or addictive games.
I dont know how much the anti-smoking ads are helping. Anti-drug ads are certainly not curbing drug use in the US. Kids of that age are just not forward thinking enough to imagine that they could end up like people on the ads. As adults, we see through different lenses. Just as we joke about kids in their teens "knowing everything" they also have an "indestructable" mentality. I venture to guess that if we were to reward kids with music downloads and cell phone minutes for avoiding drugs, alchohol, and tobacco, we would see greater levels of compliance.
Content of game play. We made a decision to avoid direct diabetes education while in the gaming world. When the player begins, they are in their room. From time to time, two of our key characters pop in and ask them a multiple choice diabtes related question, but this remains outside of the games. These diabetes questions are random but will pop up more frequently when the child has been testing less. They can earn in game points by answering correctly.
There are 3 casual or mini-arcade games that can be unlocked with points (again, generated by testing). These games are shooter, action, arcade style games that are good for quick and repeated game play. The other two games Knock Em' Downs and Lost Star Saga are deeper and take longer to complete.
In the Knock Em' Downs game, the player is in a world where the carnival has gone awry and the knock down clowns are loose. As a player you need to collect all the clowns. There is no diabetes related content, meaning, you do not use an insulin gun to shoot a sugar monster or the like. But we have implemented subtle reminders such as eating a small snack when energy levels are low.
Lost Star Saga is a science fiction role playing game, and again, there is little diabetes content outside of the fact that some evil characters attack the eyes and feet.
This was a calculated decision. We have found in discussions with children that they can smell an education game a mile away and are not as interested. We wanted to make a game that kids would love to play, and one that their friends would want to play, but couldnt. We wanted kids with diabetes to feel that there was something just for them.