Let's Play!: Mobile Health Games for Adults

Abstract

Researchers have designed a variety of systems that promote wellness. However, little work has been done to examine how casual mobile games can help adults learn how to live healthfully. To explore this design space, we created OrderUP!, a game in which players learn how to make healthier meal choices. Through our field study, we found that playing OrderUP! helped participants engage in four processes of change identified by a well-established health behavior theory, the Transtheoretical Model: they improved their understanding of how to eat healthfully and engaged in nutrition-related analytical thinking, reevaluated the healthiness of their real life habits, formed helping relationships by discussing nutrition with others and started replacing unhealthy meals with more nutritious foods. Our research shows the promise of using casual mobile games to encourage adults to live healthier lifestyles.

Full text

Let’s Play! Mobile Health Games for Adults
Andrea Grimes
1
, Vasudhara Kantroo
2
& Rebecca E. Grinter
1
School of Interactive Computing
1
& School of Literature, Communication and Culture
2
Georgia Institute of Technology
85 5
th
St. NW Atlanta, GA 30332
{agrimes, beki}@cc.gatech.edu, vasudhara@gatech.edu
ABSTRACT
Researchers have designed a variety of systems that
promote wellness. However, little work has been done to
examine how casual mobile games can help adults learn
how to live healthfully. To explore this design space, we
created OrderUP!, a game in which players learn how to
make healthier meal choices. Through our field study, we
found that playing OrderUP! helped participants engage in
four processes of change identified by a well-established
health behavior theory, the Transtheoretical Model: they
improved their understanding of how to eat healthfully and
engaged in nutrition-related analytical thinking, reevaluated
the healthiness of their real life habits, formed helping
relationships by discussing nutrition with others and started
replacing unhealthy meals with more nutritious foods. Our
research shows the promise of using casual mobile games
to encourage adults to live healthier lifestyles.
Author Keywords
Mobile games, casual games, health, food, nutrition,
behavior change, Transtheoretical Model.
ACM Classification Keywords
H5.m. Information interfaces and presentation (e.g., HCI):
Miscellaneous.
General Terms
Design, Human Factors.
INTRODUCTION
Ubiquitous computing (Ubicomp) research has shown that
pervasive technology can encourage people to engage in
healthy living. For example, researchers have designed
mobile, sensor-based applications that monitor behaviors to
provide people with a greater awareness of how healthfully
they are living [5,6]. Other researchers have designed and
evaluated exergames, which encourage exercise by
requiring the player to be physically active for play [12,13].
In our research, we have examined how mobile devices can
encourage adults to live healthfully through a different
game genre: casual (quick and easy to play) educational
games. We were motivated to explore this design space
because while previous research has shown the benefit of
educational games for children [2,3], little is known about
their impact for adults. Furthermore, many educational
health games have been developed for non-mobile
platforms: desktop computers and video game consoles. In
contrast, we explore the mobile phone as a pervasive
platform for play, and the implications of using this
platform together with the casual game genre to encourage
healthy living.
Specifically, we designed a casual nutrition game for
mobile phones called OrderUP! and conducted a real-world
evaluation of the game with 12 participants over a three
week period. Through pre- and post-intervention surveys,
interviews and a diary activity we studied how participants
reacted to the game and how they were affected by playing.
We use the Transtheoretical Model (TTM), a well-
established health behavior theory, to frame our results.
While numerous health behavior theories exist, the TTM is
one of the most widely used, and is particularly useful for
characterizing the processes of change that help people
transition towards healthier lifestyles. Our results point to
the ways in which playing OrderUP! helped our participants
engage in four such processes: consciousness raising, self-
reevaluation, engaging in helping relationships, and
counter-conditioning.
In the following sections we describe related work, the
design of OrderUP!, our study methodology and our results.
Through the design and evaluation of OrderUP!, we expand
Ubicomp’s understanding of how casual mobile games can
be used to encourage healthy thinking and actions in adults.
We conclude this paper by providing recommendations for
future research on casual mobile health games, specifically
discussing how they can be uniquely useful in encouraging
processes of change.
RELATED WORK
In the following sections we discuss related research on
health games and introduce the genre of casual gaming. We
conclude by providing a brief overview of the
Transtheoretical Model.
Games for Health
In Ubicomp-related fields, the majority of health-oriented
games have been exergames, applications that encourage
exercise because players must engage in physical activity to
play. For example, Mueller et al. [13] developed a variety
of fitness games that allow people to compete in structured
physical activity sessions (such as playing a ball game) with
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remote third parties. Höysniemi et al. [9] designed Shadow
Boxer, a boxing game in which the player controls their
characters by physically moving their arms to punch a
virtual target. Other exergames are more ubiquitous, in that
they extend outside of the confines of the living room or
gym, and into individuals’ everyday lives. As they go
through their days, such games record players’ physical
activity and physiological data (e.g., heart rate) and it is this
data that controls their progress in the game [5,8,13].
Exergames have proved quite effective (e.g., by helping
people increase caloric expenditure [17]), however much
less research within Ubicomp has focused on educational
games for health.
Such games have been given greater attention within the
medical domain, where researchers have designed a number
of electronic games that promote wellness by teaching
players about healthy living. Typically these games have
been designed for children. Our work is most similar to
previous research on health-related role-playing and
simulation games in which users play the role of someone
who is trying to engage in healthy behaviors. These games
allow players to explore behavioral alternatives and their
outcomes and consequences in a safe environment [14,19].
For example, researchers have designed games in which the
child’s character has to manage their diabetes (e.g., by
taking insulin injections) [3] and negotiate sexual decisions
with fictional partners (e.g., deciding to use contraceptives)
[19]. These games tend to be relatively time-intensive,
requiring anywhere from 20 minutes to many hours to
complete [2,3,19].
Previous research has shown that educational health games
effectively help children develop healthier eating habits,
better manage chronic diseases, and increase their health-
related knowledge [2,3,19]. While these benefits have been
documented for children, a recent study found that little
work has been done to design such games for the adult
population [2]. Yet, as the average game player in the U.S.
is 35 years old
1
, games may be a promising medium for
improving the health of adults. In addition, educational
health games have primarily been developed for stationary
gaming environments (e.g., desktop computers). We
contribute to previous work by exploring how an off-the-
desktop platform – the mobile phone – can be leveraged in
the design of educational health games for adults.
Casual Games
One area of gaming that is growing in popularity is that of
casual games. Casual games differ from traditional video
games in that they have simple rules, are easy to learn and
play, and require very little video game expertise [1]. They
are typically played in short bursts, and can be easily
stopped and restarted. For example, traditional video games
usually require 20 minutes to 2 hours to complete a level,
1
Entertainment Software Association, www.theesa.com/facts
whereas casual games typically take 1-10 minutes to
complete a level or an entire game. Solitaire and Tetris are
two canonical examples of this game genre. While some
casual health games have been developed, particularly for
children (e.g., www.playnormous.com), researchers have
rarely studied the impact that such games have on players’
health attitudes and behaviors.
Casual games tend to reach a broader audience than
traditional video games, for example, one report indicated
that approximately 50% of all casual game players are
women [1]. Also, unlike traditional video games which are
typically played at home, mobile casual games are
appealing because they act as an easy way for people to fill
time, for example, as they are waiting for friends or while
riding public transportation [11]. While some Ubicomp
researchers have designed casual games outside of the
health domain (e.g., [11]), the effectiveness of mobile
casual games for wellness has been virtually unexplored.
And yet, we argue that because casual games tend to have
broad demographic appeal and a low barrier to entry, it is
important to examine the ways in which they might help
people become healthier.
The Transtheoretical Model
We now describe the Transtheoretical Model (TTM), a
theory that we use to frame our results in this paper. The
TTM helps characterize how ready and willing a person is
to make changes to their health-related behaviors. This
theory identifies stages of change through which an
individual can progress as they begin to modify their habits.
These stages are temporal constructs that describe the
trajectory of behavior modification over time. They range
from precontemplation (the state of not thinking about a
change) to preparation (getting ready to make changes) and
maintenance (changes have been successfully adhered to
over time) [16]. Some shortcomings of the model include a
lack of consensus on how to best classify individuals into
stages [18]. Even with these limitations, the TTM has been
successfully used in a variety of health interventions, and
remains one of the most widely used health behavior
models. Previous Ubicomp researchers have used the TTM
to identify target users and examine how health systems
affect people who are in different stages of change [6,12].
Prochaska et al. [16] identified 10 processes of change that
help people move between stages. These processes are
things that people do to begin modifying problematic
behaviors, for example, consciousness raising (receiving
feedback and education about how to live healthfully), self-
reevaluation (assessing the healthiness of one’s current
behaviors), developing helping relationships (in which
health issues are discussed with others) and counter-
conditioning (substituting new activities for old). In this
paper, we show how our casual mobile health game helped
adults begin to engage in these processes of change.
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ORDERUP!: GAME DESIGN
We introduced OrderUP! as an unimplemented design
concept in our previous work [8]. We then iterated
extensively upon that concept to arrive at the final design,
which we modified through brainstorming meetings with
the research team and feedback sessions with HCI
researchers, game design experts and a dietitian. The work
we describe in this paper is distinct from our previous
research in that we present our revised and implemented
design and the results of our field trial of the game.
We implemented OrderUP! for the Nokia N95 cell phone
platform using Adobe ActionScript 2.0 and the Adobe
Flash Lite framework (see Figure 1). The customer
characters were created using Yahoo! Avatars. Players
interact with the game using buttons on the phone’s keypad.
In OrderUP!, the player assumes the role of a server in a
restaurant and her goal is to make meal recommendations to
customers as quickly and healthfully as possible. Doing so
allows the player’s character to keep her job in this fictional
setting. We chose this scenario because various health
organizations (such as the American Diabetes Association)
have indicated that learning how to make the healthiest
possible choices when eating at fast food and other
restaurant establishments is an important skill to develop
2
.
Our target audience in this work was African American
adults in the Southeastern United States (U.S.), as this
population disproportionately faces most diet-related health
problems (e.g., diabetes and obesity) [4]. Medical
researchers have consistently called for interventions
specifically designed to address these health disparities.
Furthermore, they have shown that by accounting for the
cultural uniqueness of eating patterns, these interventions
2
http://www.diabetes.org/food-nutrition-lifestyle/nutrition/meal-
planning/eating-out.jsp
can be made more effective [4]. As such, our goal was to
tailor our game design to incorporate distinctive African
American cuisine. Accordingly, in addition to general
American foods, soul food (traditional African American
cuisine) dishes also appear in OrderUP!.
There are 10 customer characters that appear repeatedly in
the game. Each customer starts with a health score of 100
points (which totals to 1000 health points for all 10
customers). For each customer, the player is presented with
three randomly chosen meal options (desserts, entrees or
side dishes). The player must decide which among these
options is the healthiest, and make that meal
recommendation to the customer. After the player makes a
selection, they receive stoplight feedback, that is, a green
light flashes if they have chosen the healthiest food, a red
light if they select the unhealthiest food, and a yellow light
if they have chosen something in between. We decided to
give feedback in this way because of the familiarity,
simplicity and ease of understanding that comes with the
stoplight metaphor: something that was critical to making
OrderUP! a casual game.
We derived a health value for each dish by gathering
nutrition data for a number of fast food items from popular
restaurant chains in the U.S. and by searching an online
recipe website
3
for the nutrition values of soul food dishes.
Examples of fast food included sandwiches, onion rings,
salads, mashed potatoes and yogurt parfaits while soul food
dishes included items such as collard greens, candied yams,
peach cobbler and black-eyed peas. The health value for
each food item was based upon the calorie, fat, saturated
fat, fiber, cholesterol, sodium and sugar content. Our goal
was to include foods that our participants might commonly
have access to when wanting to quickly eat out or when
wanting to eat traditional soul food dishes. While we could
3
http://allrecipes.com
Figure 1. OrderUP! screen shots. (Far left) Players receive opening screens that explain the premise of the game. (Middle and far right)
Players must choose the healthiest options for their customers from among the three dishes displayed at the bottom of the screen. At the top
right of the screen, 3 colored circles are displayed (red, yellow and green), providing “stoplight” feedback on the players’ choices. At the
top left of the screen, the total health points are shown and below that, the health points for this particular customer are displayed next to
the customer’s name. Beneath the customer’s total health points, the timer shows how much time has elapsed in the game.
243

have included many other types of foods as well, we chose
to narrow the data set to focus our study. In particular,
including cultural dishes allowed us to see if there is any
benefit in tailoring the game to our participants’ cultural
background in this way.
With every dish that the player chooses for a customer, that
customer’s health score decreases: the healthier the
selection made, the smaller the score decrement, and the
longer the player stays in the game. With this design
decision, our goal was to subtly point to the fact that
making the healthiest choices is important (hence healthier
choices mean a smaller decrement to the customer’s health
score), but continuously eating out may be detrimental to
one’s health over time (hence the fact that the customer’s
health score always decreases, no matter how healthy the
choice).
Each customer must be served within six seconds or they
will become aggravated and leave. In this case, the player
loses all the points associated with that customer. When the
health points of any customer goes below 40 points or the
total health points for all guests goes below 400 points, the
game ends. The job of the player is to make the healthiest
choices as often as possible, and therefore “keep her job”
longer. This duration also functions as the final score in the
game (measured in minutes and seconds). Thus, the higher
the final score (i.e. the duration of the game), the better the
player’s game performance. Forty seconds is an example of
a low final score in the game, whereas a much better final
score would be three or four minutes. In summary, the
player’s goal is to choose the healthiest foods possible, so
that she can keep the game running as long as possible.
METHOD
We conducted a real-world deployment of OrderUP! with
African Americans in the Atlanta, GA metropolitan area to
assess in what ways a casual mobile game can encourage
healthy eating. We gave 12 participants a Nokia N95 cell
phone with OrderUP! installed on it to use for three weeks.
During our first meeting with participants, we explained the
study, how to play the game and how to use the phone. At
this time, we placed each person’s existing SIM card in the
phone and they used it as their primary phone for the 3-
week study period. Participants were asked to play the
game at least once each week, but beyond that, we
encouraged them to play only as much as they were
interested in doing so.
We used surveys, diaries and interviews to triangulate how
OrderUP! impacted our participants nutrition-related
attitudes, thinking and actions. During our initial meetings,
participants completed baseline surveys in which they
provided basic demographic information, their thoughts on
nutrition and information about their eating habits. We also
asked them to describe their cell phone usage and their
experience and interest in playing electronic games.
Participants also filled out an exit survey at the end of the
study. In this survey, we repeated the questions on nutrition
and eating habits from the baseline survey to see if their
answers changed after playing the game. In addition, we
asked them questions about OrderUP!, for example, how
often they played it, how relevant the foods were to them as
an African American and how entertaining the game was.
Participants also completed short diary entries during the
study. These entries provided a snapshot of how well they
were playing and their reactions to the game. Once a week,
participants were asked to play OrderUP! and write down:
1) the date and time that they played the game, 2) where
they played, 3) their final score, 4) how entertaining the
game was and 5) if the game caused them to think about
their eating habits, and if so how. We collected these diaries
during our final meetings with the participants.
Finally, we conducted semi-structured interviews with each
participant after one week and after three weeks. (Due to
work commitments, one person was only able to complete
one interview at the end of the study.) We asked them
questions on topics including their overall experience
playing the game, its cultural relevance and how playing
affected their eating habits and healthy eating knowledge.
Analysis
We recorded all survey responses and diary entries and
computed descriptive statistics, looking for trends in the
data and examining how participants’ answers changed
between the baseline and exit surveys and across diary
entries. These descriptive statistics serve as a supplement to
our rich qualitative data. Finally, we conducted a thematic,
inductive analysis of the interview transcripts. We began by
applying descriptive codes to phenomena that we saw
arising in each transcript. We then iteratively clustered
these codes into higher-level category groupings until we
arrived at the themes that we will describe in this paper.
Participants
We had 10 female and two male participants. Four were
married and 10 had children. Seven participants were in the
38-54 age range, two in the 55 or older range, two in the
18-30 range and one in the 31-37 range. Most participants
reported their highest level of education as being a high
school diploma (or equivalent) or some college. Two had
college degrees and one had a graduate degree. The
majority of participants had a household income of $45,000
or below, and three had an annual income of $60k or
higher. Our participants had a range of occupations
including security guard (three were coworkers), childcare
provider and HVAC technician. All participants owned a
cell phone that they use two or more times daily. When
asked if they like playing electronic games, 10 agreed and
two somewhat disagreed. Six participants play cell phone
games multiple times each week, two play a few times each
month, and four basically never play.
RESULTS
Overall, most people said OrderUP! was fun and that they
would play it in the future. Table 1 shows participants’ high
244

and low scores, as well as the frequency with which they
played OrderUP, with all but two people playing at least a
few times each week.
The remainder of our results show how OrderUP! helped
our participants engage in four processes of change
identified by the TTM: consciousness raising, self
reevaluation, helping relationships and counter-
conditioning. Through these findings, we show how a
ubiquitous application (a game that pervades users’ lives
through its mobility) can help people take the initial steps
towards increased wellness.
Learning How to Eat More Healthfully
In our exit surveys and interviews 10 people said that
playing OrderUP! helped them to learn more about eating
healthfully. These results provide a preliminary indication
of the consciousness raising that happened for our
participants. Consciousness raising is a process of change
that occurs when people learn more about a health topic,
and it can be identified by assessing to what extent
individuals recall information from educational health
materials [16]. The following sections provide more insight
into how our participants began to engage in this learning
process.
Correcting One’s Previous Understanding
In OrderUP!, players must continuously choose the dish
that they think is healthiest. By receiving the stoplight
feedback that we mentioned previously, participants began
to see which foods were healthier. They were often very
surprised at what they saw. Specifically, eight participants
described how playing the game corrected their previous
understanding about which dishes were the healthiest
individually and as compared to other foods. They said that
playing OrderUP! helped them realize that they did not
know as much about eating healthfully as they thought. For
example, P4 said,
“Some of the foods we thought were healthy weren’t healthy.
(laughs) Like gravy & liver, that was one of them… The main
thing that I learned was some of the foods I thought were
healthy just weren’t healthy at all.”
Similarly, P11 mentioned learning that sherbet was a
healthier dessert than ice cream. P6 described thinking that
certain dishes were healthy because they contained
ingredients that seemed nutritious and then realizing that
they were not:
“They have…fried oysters on there and I thought that would
be healthy because it was seafood but apparently it was not.”
OrderUP! also helped participants to learn about the relative
healthiness of foods. Indeed, since players were presented
with a randomly generated list of three meal options for
each customer, the healthiest option in one list might turn
out to be the least healthy option in another list. For
example, P8 noted that when she served one customer, the
glazed donut was the healthiest option. Then, when she saw
the glazed donut appear again she assumed it would be the
healthiest even though the other two options in the list were
different. She then chose the donut and was surprised to see
that it was the worst choice. Thus, OrderUP! helped
participants to think not simply about the healthiness of
individual dishes, but how foods compare to others.
Learning How One Can Personally Eat Healthier
The previous examples show that people corrected their
understanding about dishes that are commonly available at
many fast food and soul food restaurants. Seven
participants went a step further and described not simply
what they learned, but how what they learned applied to
their lives. For example, P9 said she realized that peanut
brittle was a healthier option for her to choose than other
desserts. P8 described how OrderUP! expanded her
understanding of which foods she can eat if she wants to
make healthier choices when eating out:
“What I liked about [OrderUP!] is... it gives you an ideal - or
your worst and best choices of food to eat when you’re out
there.... You know, like when you’re out buying different
things you wanna make sure you stay health-conscious, and
[OrderUP!] gives you a choice.”
Participant
ID
Gender Low
Score
High
Score
Play
Frequency
P1 F 2:36 2:50 Multiple
times/day
P2 F 1:10 2:53 Few times/wk
P3 M 1:17 1:51 Once/wk
P4 F 2:30 2:41 Multiple
times/day
P5 F 1:06 2:37 Few times/wk
P6 F 2:10 3:15 Multiple
times/day
P7 M 1:21 3:20 Multiple
times/day
P8 F 2:59 3:32 Few times/wk
P9 F 1:52 2:10 Multiple
times/day
P10 F 1:26 2:49 Once/wk
P11 F 3:30 3:50 Multiple
times/day
P12 F 1:01 2:38 Few times/wk
Table 1. Participant overview including gender, the lowest and
highest reported score in their diaries (the amount of time that
they game lasted, in minutes and seconds), and how frequently
they played OrderUP! (as reported in their exit surveys).
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P6 said that while playing the game she tried to remember
the healthier items so that when she goes out to eat she can
choose them:
“I will know that I [should] choose the small yogurt and fruit
over [the] butter pecan ice cream.”
P1 mentioned that the game caused her and her family to be
interested in trying foods that they had never tried before:
“We didn’t even know what sorbet was. I mean, we’ve seen
it, but really never fooled with sorbet. ‘Cause I know sherbet,
I know ice cream. So the game kind of let us know – ooh, we
gotta find out what sorbet is anyway ‘cause we know sherbet
and we like sherbet.”
Thus, there were a variety of ways in which playing
OrderUP! helped participants gain ideas for how they can
eat more nutritiously in their everyday lives.
Analyzing & Trying to Understand
Another aspect of the consciousness raising process is
actually contemplating information that is obtained. We
found that OrderUP! facilitated this thinking because
participants did not just passively receive the information
shown in OrderUP!: they also engaged in analysis and
reasoning as they tried to understand why different foods
were healthier than others. They did this in a number of
ways, including thinking about the effects of preparation
and portions on healthiness and expressing a desire for
more feedback on the choices that they made in the game.
Portions & Preparation: Heuristics for Decision-Making
Half of our participants described how through playing the
game, they were led to consider how portions and
preparation methods affect the healthiness of foods. Indeed,
engaging in this type of reflection was an important part of
being able to play the game: participants used their
understanding of the distinguishing characteristics of each
dish to decide which ones would be the healthiest. For
example, P1 described having to think about the relative
healthiness of a medium sorbet and a large sherbet. The
game included a variety of other portion sizes as well, for
example players might be met with decision of choosing
between six chicken nuggets and a small hamburger. Some
people also mentioned using their understanding of
preparation methods when playing OrderUP!. P5 made
decisions based upon whether foods were fried or baked.
When trying to decide which dessert to choose, P6 reasoned
that the dish that contained fruit must be the healthiest, but
then realized that it actually wasn’t as nutritious as the other
options.
A Desire for More Feedback
Though we did find that participants used their previous
understanding of portions and preparation methods to make
their decisions, once they made these decisions most people
were not satisfied with the amount of information they were
given about why foods were healthier than others. The
stoplight feedback in the game simply tells people that their
choices were wrong, but it does not say which item would
have been a better choice or why. We consciously made the
design decision to have very lightweight feedback to ensure
that players felt that they were playing a game instead of
being lectured. Still most of our participants wanted more
feedback.
For example, P9 said that in the cases where she chose an
item that was not the healthiest, she would have wanted to
know which one was best:
“One time I chose the fish sandwich and it [turned out to not
be the best choice]. And when you think of a fish sandwich…
a plain regular fish sandwich like you go to McDonald’s or
whatever. You thinking that’s, you know, OK I’m doing good
[by choosing that]. Whereas that was not the case all the
time…So you know, I would like to know [what I should
have picked].”
Other participants also wanted to know more detailed
information about each food item. P2, P3 and P10
mentioned wanting to know which choices would have
been better to choose as well as nutritional information
(e.g., the calorie or fat content) about the menu items.
Players not only wanted more detailed feedback so that they
could make better choices in the game; some wanted to get
feedback for reasons separate from game play. For
example, P7 said having more detailed feedback would give
him useful information to take away from the game.
Similarly, P10 was disappointed that the game did not give
more feedback because she wanted to use that information
to improve her own eating habits. She said that if she had
this additional information she would modify her choices in
the following way,
“Like after every game I really wanted to know the calorie
count and the fat count in what I chose. ‘Cause I really
wanted to be able to change that in my own [life].”
Assessing the Healthiness of One’s Eating Habits
In the previous section, we described how some participants
wanted more feedback on their game choices so that they
could learn how to make better choices in their own lives.
Following on from this, in our exit surveys, all participants
indicated that at some point during the study, playing
OrderUP! led them to think about their own nutrition-
related behaviors. In doing so, they were engaging in the
self-reevaluation process of change in which people assess
themselves in light of their health-related behaviors. From
our participants’ diaries, we saw that there was a slight
change in the number of people who reported this effect
during their first, second and third week of game play: 10
people said that the game caused them to think about their
eating habits in the first week of game play, 11 in the
second week and eight in the third week.
Our interview results shed more light on this process of
reflection. P7 said that the game helped him to think about
nutrition, something he had not paid much attention to
previously:
246

“I was trying to lose weight but I wasn’t thinking about
[nutrition]. I was just thinking about the exercise…This made
me think… is that the right thing to be eating?”
P3 also reassessed his habits, as he said playing the game
caused him to think more about what he eats at restaurants.
P6 had this to say about eating out after playing,
“When I’m going out to get something to eat [I think to
myself] I should choose this sugar cookie over this brownie.
So actually it’s had me thinking a whole lot more than I did
[previously].”
For many participants, playing OrderUP! helped them to
realize how poorly they were eating. For example, P4 saw
one of her favorite dishes in OrderUP! and realized how
unhealthy it is:
“I love shrimp and grits... But you know, I’m like OK, I can
eat a little healthier. And plus I wanna lose some weight, so
[OrderUP!] kind of like put me on the right track.”
By playing OrderUP! P9 also realized that one of her
favorite dishes was not very healthy and this helped her to
see that it is important for her to try to change her habits,
“It made me think, it really did. I was just thinking about how
I need to stop eating a lot of that stuff. You know because it’s
not healthy. You be thinking it is. You know like the collard
greens [and] the ham hocks…that’s one of my favorite
dishes.”
P1 reflected upon her choices in the context of her family,
“When I struggled with picking the best food choices on the
game I thought about how I was making the wrong choices
for my husband and children when grocery shopping.”
Further analysis helped to uncover what aspects of the
game may have helped participants reflect upon their eating
habits. We found that overall, they felt that the content in
OrderUP! was culturally relevant. In particular, most felt
that the dishes in OrderUP! were relevant to them given
their African American cultural background and that they
are foods they normally eat. Thus, as participants felt that
they could identify with the foods in OrderUP!, this may
have helped them reflect upon the game in the context of
their own lives.
Discussing Nutrition with Others
Previous research has shown that social support is a critical
part of how individuals engage in healthy behaviors and
cope with health problems. In particular, the helping
relationships process of change is characterized by people
having others with whom they can discuss health topics and
who will listen to their challenges. Playing OrderUP! led
nine participants to have discussions about nutrition and
eating with people in their social network. These
discussions were on a variety of topics, including assessing
the healthiness of foods in the game and talking about
health more broadly. For example, for P3, playing the game
led him to talk about choosing healthy meals with his
family and friends. While at work, P8 and her coworkers,
who were also in the study, discussed their surprise over
which foods in the game were healthier. P9 was compelled
to encourage her friend to lose weight.
In addition, we found that the mobility of the game was an
important factor in stimulating discussions. The fact that the
game was on participants’ cell phones meant that they had
it with them in a variety of settings. This in turn made
OrderUP! available for social play, that is, as participants
let others play the game, and played the game themselves in
front of others. Such social play was a catalyst for health-
related discussions. For example, seven participants
mentioned letting their friends, family and coworkers try
out OrderUP!, which in turn sometimes led to health-related
discussions. For example, P11 allowed her adult daughter to
play the game and said that this led to conversations about
how to make healthy choices in their lives. In addition, P1
allowed her children to play the game, and that facilitated
family discussions about eating healthfully. After P6 shared
OrderUP! with her friend, the two women discussed
positive ways of actually increasing one’s body weight to a
healthy level.
Half of our participants said that playing OrderUP! in front
of others triggered people to ask them about the game. This
dialogue then sometimes led to health discussions. For
example, P7 said that as he played the game at work, his
coworkers would ask him about it. This then led to a
discussion about the extent of their nutrition knowledge. As
P7 told us this story, he seemed to feel that he knew more
about healthy eating than his coworkers and so for him,
having this discussion was a way of challenging them to
think about how much they know about nutrition.
When examining our survey data, we found that for seven
of our participants, their answer to the question, “I know
enough about healthy eating to give advice to my friends
and family” was more positive after playing OrderUP.
Thus, one of the reasons that participants engaged in
discussions about healthy eating with those in their social
network may be that they felt more confident in having
such discussions after playing the game. Given that we
discussed earlier how participants said playing OrderUP!
helped them learn about healthy eating, we believe that this
is a plausible conclusion.
Modifying Eating Habits
Finally, counter-conditioning is another process of change
in the TTM. This process happens as people begin to
substitute healthier actions for detrimental ones. In
analyzing our baseline survey data, we saw that prior to
playing OrderUP!, four participants said that the healthiness
of foods influences what they decide to eat. Our exit
surveys show that after playing OrderUP!, this number
increased from four to nine. Thus, we saw that five people
went from not considering the healthiness of foods, to
having that be one of the factors that affects their choice of
what to eat. This is one early indication that participants
began the process of counter-conditioning.
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Furthermore, most (eight) participants described the
specific ways in which playing OrderUP! actually led them
to eat differently. When interviewing participants, we were
careful to clarify instances when they felt that it was the
game play itself (and not other outside factors) that led
them to eat differently. P3 described how before the game,
he and his coworkers were trying to eat better while at
work, and that playing the game helped to reinforce for him
the need to engage in these healthier behaviors. P12
discussed how playing the game led her to eat more healthy
foods, for example, salads and fruits. Various participants
described replacing ice cream with sherbet, which is shown
as a healthier dessert option in OrderUP!.
Participants also described seeing foods that they ate appear
in OrderUP! as unhealthy options, and how this led them to
make changes to their eating habits. For example, P6 said:
“I love chicken and dumplings and I saw on the game that it
was like one of the worst [dishes]… So I’ve been trying my
best to stay away from a lot of bread and fried stuff.”
Playing the game also encouraged participants to try foods
that they had never tried before. For example, P4 discussed
purchasing a healthier version of ice cream,
“For the first time in my life, I bought sugar free ice cream.
Low fat, sugar free. I did!...And that came from the game.”
P8 also mentioned trying something that she had previously
refused to try:
“For years people have always told me, “here try this
broccoli, try this broccoli!” I’m like no I’m not trying this
broccoli! But last week was the first time in my 40 something
years, I ate broccoli. I ate it…And it was good! It was good.
(laughs)… So [the game] really helped.”
By playing OrderUP!, people were encouraged to change
their eating habits in general, to try the foods that they saw
were healthier in the game and to replace the unhealthy
foods that they were accustomed to eating. As we
discussed, our participants related to the foods in OrderUP!
both personally (because they are dishes that they eat) and
culturally (because many are common dishes in African
American cuisine). Because OrderUP! included foods that
players are familiar with, it helped them see which are less
healthy, and subsequently which foods they should eat less
of or in moderation. Furthermore, the game showed
healthier alternatives, specifically in the context of foods
that they typically eat. Thus, players not only received ideas
for foods to eat, but more importantly how to make
healthier choices relative to how they had been eating. In
addition, by seeing foods that they had never eaten in the
game, participants were encouraged to try new things.
DISCUSSION: CASUAL GAMES FOR HEALTHY LIVING
While our results came during a short-term study, they
show the initial ways in which playing OrderUP! helped
our participants engage in processes of change. And, as we
mentioned previously, the TTM indicates that these
processes can, over time, help people to make long-term,
lasting changes to their behaviors. Future longitudinal
studies can determine to what extent such long-term
changes may be facilitated by games such as OrderUP!.
Within Ubicomp and related disciplines, the processes of
change construct has not been as heavily examined as the
stages of change construct – a trend that has been seen
within medical literature as well [18]. Yet, studying the
impact of casual games on processes of change can help
address the challenge of conducting longitudinal studies of
cutting-edge technologies within Ubicomp. By focusing on
processes of change – which can be studied in a shorter
period of time – researchers can get an initial sense of how
well new applications impact the cognitive and behavioral
processes that are crucial for more sustained lifestyle
changes over time. Gaining this type of clarity, and
pinpointing which processes are best addressed by the
technology can provide the justification for conducting
larger, longer studies. Furthermore, researchers can better
understand what types of users a technology may best be
suited for, because different processes of change become
more relevant and critical depending on the stage of change
an individual is in.
In the remainder of this section, we articulate specific
directions for future Ubicomp research on designing casual
mobile games to help adults live healthier lives. In
particular, we describe how the casual and mobile
characteristics of such games may be uniquely useful in
addressing nine processes of change.
Consciousness Raising & Dramatic Relief:
Consciousness raising and dramatic relief are two related
processes within the TTM. While, as mentioned previously,
consciousness raising refers to people increasing their
knowledge about health-related behaviors, dramatic relief
refers to a deeper internalization of and emotional reactions
to this knowledge. In our study, the stoplight feedback
mechanism in OrderUP! gave participants a basic indication
of how healthy their selections were. This coarse level of
feedback led them to question and think about why
different food options were the healthiest. While some
participants saw this as a drawback of the game, it provides
us with insight into how feedback mechanisms in casual
health games can facilitate questioning and reflection. In a
casual game, the content should be easily digestible. We
offer, then, that a benefit of the casual game genre for
health is this: while other gaming genres may facilitate
more extensive and detailed information dissemination,
casual games can be used to spur questioning and analytical
thinking outside of game play. Such analytical thinking can
facilitate the consciousness raising process.
Furthermore, analytical questioning outside of game play
can encourage adults to think for themselves rather than
simply have information fed to them. Such questioning can
compel players to engage in more conscious, careful
processing of the game content versus a passive reception
of it. This is important because conscious processing of
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information has been shown to be more effective at helping
people engage in sustained attitude change [15]. By
engaging in this analytical thinking, adults may have the
opportunity to engage in the dramatic relief process as they
reflect upon the meaning of the information presented in the
game in the context of their own lives. We suggest that
future work further examine the usefulness of lightweight
feedback mechanisms as a feature of casual games.
Helping Relationships: While previous work has shown
how health games can stimulate social interaction for kids
[3], our work shows that casual mobile games are useful for
encouraging health-related interaction between adults as
well. Because OrderUP! was installed on participants’
mobile phones, they were able to access it in a variety of
settings, and this in turn helped spur discussion. Future
work should further examine how to design mobile health
games that take advantage of the fact that they may be
played in settings where people from the player’s social
network are physically present and available for discussion.
For example, designing games that bring up thought-
provoking topics could spur the player to engage in
dialogue with others. As we saw in our study, health-related
dialogue may help facilitate the helping relationships
process, in which people solicit encouragement, support
and understanding from individuals in their social network.
Counter-conditioning: The simplicity of the casual games
genre requires that straightforward information be
delivered. Complex recommendations for healthy living
would not fit in casual games, as the information presented
must be easy to absorb such that the game is quick and easy
to play. Thus, casual games are uniquely positioned to
provide useful ideas for healthy living that players can
easily understand and implement. This in turn makes them
useful for encouraging the counterconditioning process, in
which individuals begin replacing problematic behaviors
with healthier ones. For example OrderUP! helped our
participants to quickly see the relative healthiness of
different foods and have a better understanding of how to
make healthier choices when they visit restaurants. They
were then able to implement the basic strategies learned in
the game in their real lives. Of course, the ability to actually
make changes to one’s behaviors are mediated by a myriad
of factors (e.g., personal motivation, economic constraints,
etc.), however our point here is that the simplicity of casual
games can help people to get useful, actionable information
that can make it relatively easier to make changes.
Self-Reevaluation: Self-reevaluation is the process by
which people reflect on themselves, including what it
means for them to engage in healthy and unhealthy
behaviors. We suggest that future work examine the extent
to which the mobility of casual cell phone games facilitates
this process differently than stationary video games (e.g.,
those played on the computer or on a game console). As
people play mobile health games in different settings of
their everyday life, it may become easier for them to apply
the material to their own life and reflect upon their health-
related behaviors. For example, playing a game related to
asthma management while sitting outside on a day with
high smog levels (which is detrimental to an asthmatic
person’s breathing) may cause the content in the game to
come to life in a way that it would not have when playing at
one’s desktop computer.
Self-Liberation: Casual games are often played repeatedly
over time [10]. This may be due in part to the fact that the
barrier to playing these games is low (since they are easy to
play and typically take only a few minutes to complete).
For example, we found that half of our participants played
OrderUP! multiple times per day. This repetitive play leads
to repeated exposure to the game material over time. We
suggest that future work examine to what extent repeated
exposure facilitates the self-liberation process (in which
people accept personal responsibility for their behaviors
and commit to change) by helping people build up the
readiness to take responsibility for their actions and make a
change.
Stimulus Control & Social Liberation: As others have
found [11], we saw that the mobility of OrderUP! meant
that our participants played it in a variety of environments
and at various points during their day. The fact that game
play is interspersed throughout a person’s day means that
mobile health games may have a good chance of
reinforcing the importance of avoiding negative behaviors.
For example, some of our participants played OrderUP! at
work. Playing for a few minutes prior to taking a lunch
break may mean that the information gained in the game is
on their mind around the time that they have to decide what
to eat. Thus, future work should further examine to what
extent mobile games – because game play is interweaved
into an individual’s daily routines – can facilitate the
process of stimulus control, in which people begin avoiding
things that lead to negative behavior.
Future work should also examine how mobile games can
help facilitate the process of social liberation in which
people notice aspects of their environment that can help
them to be healthy. That is, does having the ability to play
mobile games out in the world in which one is actually
trying to engage in healthier behaviors make the game
material even more salient? For example, Fujiki et al. [7]
designed mobile physical fitness games and found that
through playing, some people began to walk up stairs more
to increase their physical activity. Future work should
further compare the impact of mobile versus stationary
games at helping people to notice environmental supports
for healthy living.
Reinforcement Management: Casual games are typically
easily rewarding, such that the game is fun even after only a
few minutes of play [10]. We offer that there is opportunity
to explore how rewarding players for positive health
behaviors in casual games translates into real-life rewards.
In particular, further research should examine how casual
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games can encourage the process of reinforcement
management in which people reward and praise themselves
for healthy behaviors. Previous research has shown how
rewards in mobile health applications can effectively
encourage physical activity [6]. We believe that there is
benefit in going one step further to examine how in-game
rewards can encourage reinforcement management in the
players’ real life. In particular, we suggest that since casual
games are inherently easily rewarding, they have the
opportunity to show players how to begin rewarding
themselves for small health-related victories in their own
lives.
CONCLUSION
We contribute to ubiquitous computing research by
presenting the results of our evaluation of OrderUP!, which
showed the impact that casual mobile health games can
have on adults. In particular, we have shown how playing
helped participants begin to engage in processes of change.
We hope that our results, together with the implications for
future research that we have provided will spur further
work in this area.
ACKNOWLEDGEMENTS
We thank REACH for Wellness, Ian Bogost, Cristina Caro
and Celia Pearce.
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