Running head: DIABETES VIDEO GAME

A White Paper for the Design of a Diabetes Video Game forthe

Appalachian Ohio Region

Nathan Dutton, Howard Fisher, Todd Harper, Shane Tilton &Seth Weinberg

School of TelecommunicationOhio University

Radio-Television Building #2009 South College St.Athens, Ohio 45701

740-593-4870

from the Winter 2006-2007 section of

TCOM 804: Seminar in Media Research

DIABETES VIDEO GAME

Table of Contents

Abstract..................................................3Introduction..............................................4The Appalachian Region of Ohio............................8Mass Media Health Communication Strategies...............14Television..............................................14Radio...................................................15Internet................................................16Print...................................................18Effective Strategies....................................19Problems to Overcome....................................20

Serious Health Games.....................................21Glucoboy................................................21Nanoswarm...............................................24The Larger Picture......................................25

Recommendations for Future Progress......................26Overview................................................26The County Fair.........................................27The diabetic player-avatar..............................29Mini-games, character interaction, and fair activities..31The game and the family.................................33

References Cited.........................................36

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Abstract

The purpose of this white paper is to propose a novel and innovative method of communication (video games) to address a serious health problem (Type II diabetes) affecting the Appalachian Ohio region. Issues of the digital divide will be addressed within the context of this paper with regards to access and government initiatives. This paper will also show a health model designed to look at diabetes as a familyhealth situation, as opposed to a personal health problem. There will be a brief introduction to the nature of the problem. This will be followed up by an analysis of the Appalachian Ohio region. The paper will then discuss diabetes and how the Family Health Model addresses some of the issues associated with diabetes. Previous models of health communication will be analyzed to determined strengths and weaknesses of those models. A look at serious health games will finish the review of the problem in context. The paper will end with a list of recommendations that the authors believe can provide a new approach to health communication with a focus on the family and allowingnew channels of communication.

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Introduction

Appalachia is a unique region in the United States of

America. Physically, it is a 200,000-square-mile region that

follows the spine of the Appalachian Mountains from southern

New York to northern Mississippi (CDC, 2002). Approximately

23 million people live in the 410 counties of the

Appalachian Region; 42 percent of the Region’s population is

rural, compared with 20 percent of the national population.

Although it is currently experiencing a reduction in poverty

rates throughout the region, Appalachia is still one of the

poorest areas of the country, standing 1.2% higher than the

national poverty rate.

Appalachia has many positive qualities, but its poor,

rural nature makes it particularly vulnerable to certain

problems. For example, Appalachia has been hit harder with

diabetes than most areas in the United States. In West

Virginia, a state entirely within Appalachia that is

representative of the region, 9.4% of all people have been

diagnosed with diabetes (National Center for Chronic Disease

Prevention and Health, 2005). Considering the fact that

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diagnosis is a major problem in Appalachia, the real

percentage of people with diabetes in West Virginia is

probably higher.

Diabetes is a national problem, but is more prevalent

in Appalachia for several reasons. Preventing diabetes

includes being educated on the subject, exercising and

eating a proper diet. Two major reasons why diabetes is

common in Appalachia are the region’s poverty, and lack of

quality public education about the disease. The population

is uninformed about diabetes, and cannot afford the

nutritious food necessary to avoid diabetes even when they

are informed.

It is not only Appalachia’s rural, poor nature that

makes diabetes a large problem. Social interactions, and

basic misunderstandings prevalent throughout Appalachia

contribute to the pervasiveness of the diseases.

The National Center for Disease Control (CDC) conducted

a qualitative study in West Virginia to understand Diabetes

in Appalachia. The widespread belief in West Virginia is

that diabetes is self-induced through “laziness”

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(inactivity) and “eating too much sugar” (lack of self-

discipline.) The population understands that there are

hereditary factors, but that understanding is very limited.

For example, some participants believed that diabetes skips

a generation and others believed that they were not at risk

for diabetes without the hereditary factor. These beliefs,

that diabetes is self-induced and that it puts a strain on

the family, contribute to a sense of shame and guilt

surrounding the disease that may cause people to avoid

treatment. Because of these cultural misunderstandings, and

the shame and guilt that accompany the disease, people

rarely seek treatment or information. This reticence is

exacerbated because “social interactions are negatively

affected by having diabetes” (Tessaro, Smith & Rye, 2005).

These behaviors, combined with an inability to

recognize symptoms, were cited as a major barrier to early

detection and diagnosis of diabetes in West Virginia. One

cultural factor that prevents early detection is that many

people do not go to the doctor because they were raised that

way. The greatest barrier to early detection, however, is

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poverty. People do not have the resources to get to the

doctors, let alone pay for care once they are there.

The study indicated that lack of knowledge, from both

the patient and the doctor, was a major cause of diabetes.

Families with a diabetic member were found to be the most

knowledgeable. This makes it clear that the game must reach

out to families without diabetes as well as those with a

diabetic member.

We have received a challenge. How do we use video game

technology to communicate diabetes prevention and management

information to poor families in rural Appalachia? Before

answering the question, it is important to note that this

video game is part of a greater effort to target diabetes in

Appalachia. This videogame will be part of a total health

package that includes diabetes manuals for health

professionals, videos of diabetes information, and many

other resources. The game does not have to solve the problem

of diabetes all by itself. There are a number of obstacles

given the nature of this challenge and are listed as

follows:

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Our target audience is poor and cannot always afford topurchase healthy foods for their diabetic member.

Non-diabetic members of the family may not understandthe necessity for the game.

Non-diabetic members may not understand the how their

lifestyle affects diabetic members. The family member with diabetes may not be the one who

controls the diet of the family.

Given the chosen medium, we will be targeting families

that have a diabetic member and a nominal access to

technology. Our access point will be kids, age 9-14.

Through them, we will reach out to the entire family. This

scope of work brings up a variety of problems.

To answer all of these questions, we designed a

research question involving our medium and desired result.

The research question is as follows: what about video games

allows them to effectively and innovatively communicate

health information in ways that other methods have not? By

answering this question, we can design a game that utilizes

the innovative communication strategies of videogames to

address the above questions.

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Diabetes is a complicated problem and any attempt to

address it requires a thorough understanding of the disease

in its cultural context. To make useful suggestions for the

educational diabetes video game, this paper will give a

robust account of the diseases. First, the paper will place

the disease in the context of Appalachia. It will consider

the following questions:

What unique qualities of Appalachia will affect thisproject?

How will we design a game that appeals to ruralAppalachian culture?

How is the family dynamic different in Appalachia fromthe rest of the nation?

Second, the paper will investigate diabetes as a family

disease and explore a family health model. The questions

addressed in this section are as follows:

What is the family health model?

How does diabetes work within the family?

How will we design a game that appeals to all membersof the family?

How is ‘family’ defined in rural Appalachia?

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Third, the paper will study previous attempts at using

digital learning games to address this problem. This

section attempts to address the following question:

What lessons have we learned from other attempts atmaking health games?

The white paper will study health communication

strategies to determine what has worked in the past and what

has failed.

What other health communication strategies have beenused and how successful were they?

What ideas can we appropriate from other methods ofhealth communication strategies?

The findings in these sections will be used to answer the

research question and inform suggestions to the design of

the video game. A final section will compile all game design

suggestions.

The Appalachian Region of Ohio

The Appalachian region of the United States is an area

of perceived social and intellectual “backwardness.” This

perception is portrayed in the media (i.e. “Snuffy Smith”,

skits on “Saturday Night Live”, “Deliverance”, etc.) showing

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the people who live in this area to be culturally inept and

unable to handle the “modern world”. It is possible to show,

through statistics provided by the Appalachian Regional

Commission (ARC) that these people are double or even triple

disadvantaged as compared to the rest of the United States.

There is an attempt through political channels to try to

provide the area with better Internet service and other

telecommunication products that could present increased

economic stability to the area.

The Appalachian region of Ohio is defined as most of

Southeastern Ohio. The Appalachian region is defined in Ohio

as a 12,000-square-mile region that follows the spine of the

Appalachian Mountains. This includes all of West Virginia

and parts of 12 other states: Alabama, Georgia, Kentucky,

Maryland, Mississippi, New York, North Carolina, Ohio,

Pennsylvania, South Carolina, Tennessee, and Virginia (ARC,

2007). This region includes Ohio in the northern boundary of

the Appalachian Mountain system (Williams, 2002). It was

explored and developed during the westward expansion of the

United States. Log cabins, factories, taverns and canal

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locks are the visual artifacts that tell the story of an

area against a backdrop of rolling green mountains. An

occasional column of smoke from a factory forces its way

upward against the blue. The log cabins, cutting through

this thick, dense forest, are one of the most iconic symbols

of this region. The cabin shows how pioneers used the land

and developed it to become one of the first outposts in the

Northwestern Territories (ibid) This resourcefulness led

some of the early observers of this region to call it an

“alternative America” which implied a different type of

resourcefulness that was not found in America. This

description created a sense of otherness that still in place

today. This “otherness” forms the foundation of many

stereotypes that are present today.

The Appalachian region of Ohio is a historical and

culturally significant area of the United States. This

region reflects the central modality of the nation. It is

often called “the hearth of the nation” and represents a

culturally diverse population (Williams, 2002, p. 13). The

natural and artificial markers within this region allow

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visitors a glimpse into the industrial background of

Appalachia. The history of this region is formed by three

major influences: the mining of coal, the lumber industry

and the introduction of farming and livestock to the region.

These three influences formed the basis of most communities

within the region. The introduction of the railroad to this

area in the 1830’s to 1850’s allowed for the quick delivery

of products from these industries and also allowed more

people to enter the region. The Baltimore and Ohio Railroad

opened up the region and allowed more immigrants to come and

settle down in Ohio. Immigrants established villages within

the region that were similar to the ones in their home

countries. Many towns within the aptly named “Black Diamond”

region of Ohio adopted customs and traditions from their old

life to their new life in Ohio. The Black Diamond is the

area near the middle of the southern part of Appalachia

Ohio. It is called the Black Diamond region because that was

the nickname they gave coal. Many of these customs and

traditions revolved around the family structure. The

culture of early Appalachian life was a homogenization of

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European -American and Native American values and cultures,

which reflected the nature of harsh mountainous land they

inhabited. Much of the culture developed in this era focused

on the protection of the family in this environment.

Today, the Appalachian Ohio region is similar to other

Appalachian regions in other states. The wealth and success

of Appalachia depends on the availability of resources, the

availability of a work force and how well the Appalachia

region is connected to the outside world (Caudill, 2001).

The boom of the region was best reflected in the early

1900’s. It was during this time that development began in

the region and provided the infrastructure that is in place

today. The roads, railroads and towns that are in Appalachia

today represent part of the “Golden Age” of the coal

industry. However, it was not only the people of the region

enjoying this new found wealth and prosperity, it was the

companies that were developing this region that were gaining

the most from the wealth, and could be argued, hurting the

people in this region the most.

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Many of the workers in this region were earning $4.00

for an eight-hour shift in 1927. This represented a great

increase of wealth to the people, as less than a decade

before they were only earning $1.40 for an eight-hour shift

(ibid). However, the companies were charging their workers

exorbitant prices at their company stores. This shift of

monetary control caused more worker debt and an inability to

pay the company back. Companies’ control of the workers’

wealth was one of the major reasons for widespread poverty

within this region (ibid).

Another problem was also accruing around the same time:

the increase in health related problem to the workers. The

health of the workers and the environment was in decline

during the Great Depression and World War II as pollutants

filled the region, air and atmosphere (ibid). Other health

issues that were present in this area included diphtheria,

scarlet fever, whooping cough, measles and smallpox. The

reason these diseases were more significant in the

Appalachian region was because of the lack of access to

medicine and medical resources and because of the increase

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of natural disasters that occurred within this region

(ibid). The area was often cut off from the outside world

because the flash floods and rockslides would damage and

blockade vital connector roads. While the companies within

the region were concerned with the outside appearance of the

towns and villages they had created, there seem to be little

or no concern for the health of the people living in those

areas. Very few resources were placed towards community

health and public health. When the bust of the coal industry

occurred around the late 1950’s to early 1960’s, the health

care system of the region was in shambles (ibid).

It is in the Appalachian region of Ohio that a person

is more likely to find related families living within a

short distance of one another. It is not unusual to find

three or four generations living within walking distance

(Weller, 1995). Common traits developed from some of these

family lines. These traits defined this region. The first of

such traits is the sense of individualism with regards to

the family structure. It was commonplace in the late 19th

century to early 20th century for families to maintain

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limited contact with their neighbors. There were several

reasons for this limited contact. These include neighbors

living up to a half-mile away, terrain being very hilly and

hard to travel as well as the weather, especially during the

winter. Any of these obstacles could prevent people from

leaving their homes. These underlying factors encouraged

self-sustainability. People had to make it without the help

of their neighbors. This could be seen as a contradiction to

the development of towns and villages. However, those living

within the urban areas were weary of outside forces

especially those forces that are government entities (See

Weller, 1995, pg. 58-86 & Caudill, 2001, pg. 273-304 vs.

Weller, 1995, pg. 102- 120 & Williams, 2002, pg. 301-304).

Another key trait that is common among those living

with the Appalachian region is the rooted sense of

traditionism. There is almost a static nature to those who

live within the region. The day-to-day social interactions

of those living within towns and villages are virtually the

same. The routines of everybody, regardless if they live in

the urban or rural parts of the region, are the mechanisms

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that drive the everyday lives of these people. However, the

younger members within this society are more likely to

become dissatisfied with this mechanical life and explore

the “outside world.” They would typically be the first ones

to adapt to new technologies. They would also be more likely

to be the progressive members of society, looking at change

as a way to improve the way of life. The older members

within the society would be deemed regressive. It is the

older members that would be most likely to stick with the

traditions within the region, as opposed to accepting the

“national and homogenized traditions” (Weller, 1995, p. 36).

The influence of changing communication technology is

another important issue to discuss when describing the

Appalachian region of Ohio. As newer communication

technology diffuses through society, issues of access and

how access affects social change will be focal points of

research. According to Jan van Dijk (2005), the Appalachian

region would be defined as truly unconnected due to the lack

of motivational and material access. There is educational

inequality as less than 55% of the citizens 25 years or

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older in the Appalachia region have a high school diploma

compared to 71% national average (Appalachian Rural

Education Network, 2002). Also, there is a higher level of

poverty in the Appalachian region compared to the rest of

the United States. There is the belief among the truly

unconnected that there is no need for new technology; 54% of

those in the subgroup belief this. 53% do not want new

technology in their lives (van Dijk, 2005). However, van

Dijk starts to make the argument that having the hardware

available affects interest and use of the newer technology.

A stratification and tripartite participation model reflects

the current superstructure of the mediated communication

society. The unconnected and excluded populace must make

social network links to advance towards “the participating

majority” (van Dijk, 2005, p. 143).

Resistance to these initiatives can form internally

between power groups in the community and/or through stress

inadvertently created by the policies. Resistance is also

one of the indictors of the overall process of social

change. Drucker (1996) discussed how change affected lower

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class workers in general at the beginning of the 20th

century. Blue-collar workers were the unit of study in the

social question in the early 1900’s. Measurements of

resistance in the groups, which included adaptation to city

life (e.g. the formation of urban areas from formally rural

areas) and adaptation to new technology on the job, were

used to address broader social topics. These blue-collar

workers have been in decline since the late 1970’s. This is

especially true in the Appalachian region, as many of the

blue-collar jobs that built up local economies have

disappeared.

While the Appalachian Ohio region is not as

economically depressed as those regions in West Virginia and

Kentucky, there is still a higher level of unemployment and

poverty. The question that can be asked within the context

of the overarching theme is how does the economical

depression within the area impact the broader social

programs that are being introduce to help address health,

technological and other public good problems? As a follow-up

to this question, issues of internal/community activism must

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be addressed to understand how social programming can best

help the region. Activism, specifically the idea of self-

help activism, is used to promote pro-social change. Self-

help activism is defined as the ability of members with a

community to understand the nature of a major program that

affect their community and have the tool internally to

address the problem (O’Dell, 2005). It is this spirit that

one needs to develop to make any program successful.

Mass Media Health Communication Strategies

The mass media have been used in various forms to

communicate health-related messages to audiences around the

world. Some of these forms have been more successful than

others, and some have been used by corporations to promote

unhealthy lifestyles. This section breaks down some of the

ways in which the mass media have been used to communicate

health-related messages, provides details of those

strategies deemed successful by research or experience, and

concludes with a look at potential problems using the mass

media to promote health-related messages.

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Television

Over the years, the television medium has communicated

several health-related messages with varying degrees of

success. Television was used effectively to promote

HIV/AIDS awareness in South Africa (Dube & Ocholla, 2005).

Specifically, the information produced for television did

not rely overly-much on a fear message. Instead, the

messages provided educational information and a motivational

perspective aimed at encouraging behavior modification.

Several of the messages were also produced with local,

student involvement and addressed local concerns.

A 1999 study (Dejong & Wallack) analyzed the use of

television as a vehicle for communicating anti-drug messages

to a United States audience, primarily targeting teenagers.

The researchers discovered that, while the method was used

effectively to promote awareness among its target audience,

the campaign fell short in several key prevention

strategies. First, the campaign did not model skills or

provide other information necessary for behavior change;

second, the campaign provided an insufficient focus on

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promoting drug treatment or citizen involvement; and third,

there was no corresponding major investment in non-media-

related drug-treatment programs or community-based

prevention programs to support the messages delivered by the

media.

Radio

Radio has been used extensively to promote health-

related messages. Radio was a key component of an HIV/AIDS

awareness campaign in South Africa (Dube & Ocholla, 2005).

That campaign was commended for its use of local talent to

produce the broadcasts and to tailor the messages to a local

audience’s needs.

Several radio programs have also been produced within

the United States to communicate health-related messages.

WMMT-FM in Kentucky produced a 12-part series on diabetes

identification and prevention (Living with a killer, 2007).

The radio program Diabetes Talk Radio airs on radio stations

around the United States and takes a humorous approach to

health information (Diabetes Talk Radio, 2006). The radio

program Family Health also broadcasts across the United

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States, but it takes a more serious approach to health

information, relying on listener emails to generate topics

(Family Health, 2007). Little research has been conducted on

the effectiveness of these radio messages within the United

States, but there effectiveness in other countries implies a

potential effectiveness in this country.

Internet

With the worldwide popularity of the Internet, more

health-related information is being provided to more people

via this medium. A 2005 study (Hesse, et al) revealed that

63% of the US adult population reported ever going online.

Of that percentage, 63.7% reported that they sought health-

related information from an online source at least once in

the past 12 months.

Several websites are willing to provide just such

information. Online health-related sources include cross-

platform sites operated by other media such as radio

stations (Healthcare services in Appalachian Kentucky,

2004), regional-promotion websites that include region-

specific health information (Appalshop, 2007), foundation-

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sponsored sites (A record of accomplishment in community

health care and media, 2007), and corporate-sponsored sites

(WebMD, 2007).

Researchers recommend several techniques communication

professionals can use to better assist people searching for

health-related information on the Internet. These techniques

include: maintaining easily-accessible contact information

through a variety of channels; providing related links to

other sites with further information; providing clear

background information on the organization supplying the

online information; keeping the information current by

regularly updating main pages; providing downloadable

images, video, and audio related to health information; and

providing links to local/regional health providers who could

be of further assistance to website visitors (Cernohous,

2004).

Some of the above-mentioned websites make use of some

of these techniques, while others do not. The “Healthcare

Services in Appalachian Kentucky” site that is maintained by

WEKU-FM radio station was last updated November, 2004.

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Contrast that with the Appalshop website that was updated in

January, the Sound Partners website that was updated Feb.

15, or the WebMD site that appears to be updated on an

automated schedule. By contrast, however, both the Appalshop

and the Healthcare Services in Appalachian Kentucky websites

provide links to regionally specific businesses and

individuals, a service that neither Sound Partners nor WebMD

employs. All four sites offer some form of either

downloadable content and/or subscription-based email

newsletters.

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Print

While modern mass media have garnered a great deal of

attention, more traditional forms of mass communications

have been used effectively to communicate health-related

information. A 2000 study (Tillgren, et al) revealed that

targeted mass mailings can be quite effective. The

researchers used targeted mass mailings to successfully

recruit women for a smoking-cessation program.

Furthermore, print has been shown to have an effect on

consumers’ health-related attitudes – and, by extension, a

possible effect on their health-related behaviors. A 2006

study (Burton, et al) revealed that patrons of fast-food

restaurants, when presented with nutritional analyses of

typical fast-food fare and relative value statements

regarding the nutritional value of various fast-food items,

expressed shock at the analyses and a desire for healthier

choices.

Print materials have also been shown to be quite

effective at reaching educators, themselves often

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instrumental in the dissemination of health-related

materials. Dube and Ocholla (2005) reported that printed

materials (books, periodicals, and pamphlets) were used by

82% of South Africa academic institutions to communicate

health information. Comparatively speaking, they report

that print media is easy and inexpensive to produce, and it

plays a significant role in empowering people with health-

related information (Dube & Ocholla, 2005).

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Effective Strategies

Some communication strategies have been shown to be

effective when using the mass media to distribute health-

related information, and these strategies should be

considered when designing the diabetes game:

• The information presented should provide more than justan awareness of the problem; it should also provide theinformation necessary to promote successful behaviorchange (Burton, et al, 2006; Dejong & Wallack, 1999).Simply providing information that makes the gamer awareof diabetes will not be as successful as providinginformation to the gamer regarding how to help managediabetes.

• The messages presented should allow the targetaudiences to identify with a positive, attractive imageof his/her self; or it should provide the targetaudiences with a positive sense of well being (Pollay,2000). The videogame should allow the gamer toidentify with a positive, attractive image of his/herself and provide the gamer with a positive sense ofwell-being.

• Mass media messages can be quite effective when they

target specific audiences as opposed to targetingeveryone (Tillgren, et al, 2000). The videogame shouldbe targeted at a specific audience and not to“everybody.” The designers should know a specificdefinition of the target audience.

• Electronic sources of information can be especiallyuseful for their ability to provide timely, updatable

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information (Dube & Ocholla, 2005). The videogameshould be able to be updated or to reach updatableinformation through the Internet, expansion packs, etc.

• Print media can be especially useful for their abilityto provide easy and relatively inexpensive means ofcommunication that are often respected by the educationcommunity (Dube & Ocholla, 2005). The videogame wehave been charged with designing should be supported byprint publications that will be respected by authorityfigures.

Health communication strategies are most effective whenthey model behavior in different stages of development.Specifically, health-related information can beeffectively imparted to a mass audience bydemonstrating positive, negative, and transitional rolemodels (Rao, 2007). The videogame will be mosteffective when following this strategy, allowing theplayer to participate in and/or view the positive andnegative aspects and effects of diabetes management aswell as allowing the player to participate in and/orview the struggles and effects of transitioning towarda more positive model of diabetes management.

Problems to Overcome

As with all forms of communication, the mass media have

their own inherent problems to be overcome. These potential

problems should be addressed by the design of the game:

• Mass media health messages can be quite ineffectivewhen tied to insufficient relationship-buildingprograms with the intended audience (Muturi, 2005).The final videogame design should be supported byexternal relationship-building endeavors to reach thetarget audience.

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• Mass media health messages can be quite ineffectivewhen the intended audience fails to fully comprehendthe message being presented (Muturi, 2005). Alldiabetes-related messages contained within thevideogame should be presented in a way that can be bestcomprehended by the target audience.

• Mass media health messages can be quite ineffectivewhen the senders of the message fail to take intoaccount the mythologies, values, and norms of theintended audience (Muturi, 2005). The videogamedesigners need to be informed of the target audience’smythologies, values, and norms so as to best deal withthem in the game when (if) they might arise.

• Effective health-related messages communicated via massmedia channels are often mediated by opinion leadersimportant to the target audience, and the impact ofthese opinion leaders can produce less effective (or atleast more random) results (Schuster, et al, 2006).While there is probably little way to deal with thispotential problem from an in-game perspective, thevideogame designers must acknowledge that the game’smessages may have less than the desired impact becauseof such restrictions.

• Mass media health messages can be used just aseffectively by industries promoting counter messages,such as the tobacco industry’s effective marketingcampaigns (Pollay, 1999). Those groups promotinghealth messages contrary to the intended message ofthis campaign could easily use videogames to do it. Infact, Burger King did just such a thing in November andDecember of 2006 with their trio of XBox and XBox 360games that promoted the Burger King brand to gamers.

• The intended audience may have limited access to moremodern mass media channels (Dube & Ocholla, 2005). Any

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videogame produced for the intended audience must takeinto account the fact that the audience may havelimited access to the technology necessary to make fulluse of the game’s features and messages.

• Even when the intended audience has adequate access tomass media, they may not have the adequate skills (ornecessary desire) to interact with the media,especially the more modern computers and internet (Dube& Ocholla, 2005). Any videogame produced for theintended audience must take into account the fact thatthe audience may have limited access to the skills ormotivation necessary to make full use of the game’sfeatures and messages.

• Few, if any, of the ethical implications of a messageare ever discussed prior to the dissemination of themessage, often resulting in poor or incorrect messagesbeing transmitted (Guttman & Salmon, 2004). Anyvideogame designed must be designed in such a way as totake into account potential ethical implications ofmessages being transmitted. Miscommunication from thegame could be just as detrimental to the audience’shealth as receiving no message at all.

Serious Health Games

The idea of using video games as part of health care is

nothing new, and for as long as there has been an interest

serious games there has also been an interest in serious

health games. The Serious Games Initiative has an entire

section of their organization devoted to Games for Health,

which explores numerous aspects of the intersection between

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DIABETES VIDEO GAME

health and video games. Likewise, the idea of using video

games in connection with diabetes is nothing new; serious

games developers such as Guidance Interactive and Archimage

both have projects - Glucoboy and Nanoswarm, respectively -

that are designed to be a part of the prevention, care,

and/or management of the disease. The goal of this section

of the white paper is to look at these other games that to

see what we can learn that is applicable to our own project.

Glucoboy

Glucoboy, developed by Guidance Interactive, is a device

that doubles as both a blood sugar meter and a cartridge for

a Nintendo Gameboy. Apparently Paul Wessel, the device’s

creator, has a son with diabetes who carries a Gameboy with

him wherever he goes, and Wessel’s idea was to create

something that would connect these two parts of his son’s

life. As a Gameboy Cartridge, Glucoboy offers a handful of

games that are designed to be interactive experiences for

diabetic game players. As diabetics use the device to

measure their blood sugar they earn points for good tests,

and more points for testing regularly. Once earned points

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DIABETES VIDEO GAME

can be spent within the games to unlock new content, power

up in-game characters, and purchase other kinds of

advantages. In this way Glucoboy serves as an added

incentive to manage the disease effectively; those players

that manage their disease better get more out of the game.

In addition to being an incentive Guidance Interactive

touts Glucoboy as a focus of community and community

formation:

Kids use the Internet everyday and it is thecommunication mechanism of choice for millions ofpeople the world over. Guidance Interactive has createda closed and safe environment for kids to meet others,get advice, chat, and compete.

To this end the creators of Glucoboy wanted to create more

than just a set of games, but a safe online environment for

diabetic game players the world over. The existence of a

small number of third party websites such as myglucoboy

suggests that Guidance Interactive has at least been

somewhat successful in their community forming aspirations.

So what can we learn from Glucoboy that is salient to

our own project? In particular there are certain aspects of

the Glucoboy model that we may want to emulate, but there are

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DIABETES VIDEO GAME

also potential faults, or pit-falls in that model that we

would want to avoid. Specifically incorporating real life

management of the disease into the game, and an emphasis on

community and communication are elements we want to see in

our own game, and yet sticking to the Glucoboy model too

closely will get us into trouble.

In regards to community, for example, Glucoboy serves as

a center for community because it draws on a medium of

communication (the Internet) that its players already use.

Guidance Interactive, therefore, only has to create a new

space within an existing, and familiar medium, to foster

communication amongst its target audience. In our case, we

also want to foster community and communication amongst

users, but instead of the Internet as an existing and

familiar medium, we have the complex lines of communication

in an Appalachian family. In some cases these lines of

communication will already exist, and be familiar, and like

Guidance Interactive we just need to draw upon them. In

other cases, however, our game may have to create new, or

rely on unfamiliar lines of communication. As such, we can

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DIABETES VIDEO GAME

learn something from the larger Glucoboy community, but our

job is a little more difficult.

In regards to incorporating real life management of

diabetes into the game the model of offering an in-game

incentive for players who manage their disease well is

useful and practical idea. However, in the case of Glucoboy,

this is ultimately the only interaction with the disease the

game has. In other words, the Glucoboy games themselves are

ultimately only an incentive and do not educate or inform

about diabetes, or teach about how to manage the disease.

The games reward players who manage the disease well, but

information about how to manage the disease must come from

outside the game. While having built in incentives for real

life actions is good, and can have a positive effect on

people’s management of the disease, our goal is to create a

game that also offers educational and practical information

about the disease and how to deal with it.

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Nanoswarm

Nanoswarm, developed by Archimage, is a video game

about type 2 diabetes set for a 2008 release. Though the

game is not yet out there is a surprising amount about it

available, specifically, and especially, in regards to its

design goals. Unlike Glucoboy, which is targeted at players

who have diabetes, Nanoswarm has an explicit goal of

prevention. In an interview about Nanoswarm, Victoria

Thompson, one of the doctors working on the project,

outlined the basic goals of the game as follows:

[With] Nanoswarm, we want players to: (1) recognizethe role that diet and physical activity play in thedevelopment of obesity and, (2) adopt healthy diet andexercise behaviors -- specifically, increasing theirintake of fruit and vegetables and increasing physicalactivity.

It is the hope of the designers, then, that by targeting the

kinds of lifestyle habits and choices that contribute to

type 2 diabetes, the game will have a positive impact on the

lifestyles of the people who play it. Unlike Glucoboy the

content of the game is, on some level, about diabetes.

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DIABETES VIDEO GAME

It is important to note that though the content of

Nanoswarm is about diabetes prevention and real-life habits

and choices, the game embeds this content in a fictional

narrative that Archimage describes as a sci-fi action

adventure. As such, though the game seeks to make a positive

impact on people’s real-life situations, the narrative of

the game does not mirror real-life. From the same interview,

Dr. Thompson describes how this aspect of the game was

intentional, and done specifically to emphasize fun, and to

make the game more effective:

Kids, (actually, video game players of any age) morethan anything else want to have fun. We’re trying toremain very faithful to the implicit bargain we’remaking with players: “this is a game, and playing thisgame will be fun.” It would be easy to make a “game”that overtly delivers didactic knowledge through heavy-handed lecturing and tests.

This, however, would be better defined as courseware,not a video game. Our challenge, and the challengefacing any serious game developer, is figuring out howgameplay and interactive storytelling can stealthilychange people’s lives.

The primary lesson we can take from Nanoswarm is that

serious health games do not have to emulate real-life in

order to have a positive impact on the lives of its players.

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DIABETES VIDEO GAME

Such games can, in other words, draw on a wide array of

fictional narratives and still educate, inform, and help

people. This fact allows the designers of such games to use

“fun” as the overall deciding factor in choosing a fictional

narrative for their games. Since Nanoswarm is not yet

released it is worth noting that there are successful

serious health games that have followed this approach, the

most notable example being Re-Mission. Re-Mission is a game

about cancer that plays like a shooter and, like Nanoswarm,

uses a sci-fi narrative. Also like Nanoswarm, Re-Mission uses

this sci-fi narrative to teach patients about cancer, and to

offer methods for managing and coping with the disease.

The Larger Picture

Individually each of these games has lessons to offer

our own project, but taken together these games offer a

problem that our project will have to address. Specifically,

these games are tailored for the technologically savvy; they

do good work but they do it for people who are already

“plugged in” to video games and, in some cases, even more

advanced communications technologies. Glucoboy’s focus on

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DIABETES VIDEO GAME

fostering an Internet community, for example, is a strong

indication of the device’s target audience. As the above

quote from Guidance Interactive indicates, the company seeks

to create an Internet community out of kids who are already

Internet users. Likewise, Nanoswarm’s sci-fi narrative is a

strong indication of its target audience, as the sci-fi

setting would be one that is familiar, and thus comforting,

to veteran game players. Both of these games, in other

words, are designed from the beginning for people who

already play video games, and this separates them radically

from our own project. As such, though we can learn much from

the lessons of these games, our own game is ultimately going

to have break new ground and tread where these games have

not.

Recommendations for Future Progress

Our goal in mapping the unique Appalachian health

context has been to create a framework for understanding how

a video game can be effectively designed to address the

unique challenges faced by diabetics and their families in

Appalachia. The question that arises from this is, how can a

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DIABETES VIDEO GAME

video game be designed that takes those various contextual

influences into account? What are the properties and goals

of that video game which fulfill the needs our research has

described?

This section of the paper addresses our suggestions,

ideas, and concepts to answer those questions. Using a

narrative form, we map out the “space” of the game: its

qualities, goals, and properties. Bullet points and short

descriptions are used to give a summary of those broad

strokes.

Overview

The model we have chosen to adopt is a game featuring a

player-designed diabetic character that moves through a

role-playing game-like setting based on a local county fair.

The avatar combines exploring and interacting with the

aspects of the fair – games, information, and interacting

with other fairgoers and family – with the management of

blood sugar in order to put learning about how diabetes

works on the level of everyday routines.

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DIABETES VIDEO GAME

The game focuses on three major types of activity: the

management of blood glucose levels, the playing of mini-

games and fair activities, and interacting with the various

non-player characters (NPCs) present at the fair. Through

these three major activity areas, the game provides

information about the everyday routines and effects of

diabetes and teaches the player – diabetic or not – about

living with the disease in a naturalistic rather than top-

down fashion.

The County Fair

One of the most basic structural levels that must be

addressed is the space the game represents. This space

describes not only setting, but also colors all other

aspects of the game: the types of activities the game

contains, the physical context of the characters in the

game, and the dimensions of the game’s universe.

We chose “the County Fair” as an effective setting for

the game. As an artifact of the Appalachian region in

specific and the United States in general, the idea of a

local festival or fair is both familiar and enticing to our

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DIABETES VIDEO GAME

target audience. It represents a space where many different

characters can interact naturally, allows for multiple types

of play activity, and represents a site where many of the

everyday decisions diabetics make about food consumption and

activity are foregrounded. As a site of family activity, the

County Fair also emphasizes family interaction as well.

Since many Appalachian families don’t follow a particular

nuclear family structure, the fair is a place where any type

of family can participate without privileging one type of

family over another. Similarly, family members of different

generations can all find something of interest in a broad

setting such as the fair, promoting intergenerational

interest.

Gameplay at the fair centers around controlling a

player-designed avatar as s/he navigates the virtual space.

The avatar, as a diabetic, must manage his/her disease

through food choices and resource management, activities

common to the county fair setting. In doing so, the player

navigates mini-games and interacts with other characters at

the fair and thus engages the disease on an everyday level.

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DIABETES VIDEO GAME

As a timeless, safe space, the fair allows the player to

model choices and behaviors, judge their results, and see

the effects of the disease without harm to the self.

The county fair represents a context that promotes and

emphasizes self-sustainability, something highly valued by

Appalachian culture. As a site where agriculture, local

organizations and culture, and citizens all meet, the fair

is a place where products and culture of the region come

together. Likewise, as a large public gathering, the county

fair frequently serves as a locus of communication for

Appalachian organizations and families. Information, news,

and concepts move between disparate families in that social

setting, making it effective for our goal of imparting

useful information as well. This phenomenon is represented

by the various NPCs that inhabit the fair, ranging from

informative doctors to other diabetics trying to manage

their disease while enjoying the fair (much as the player is

doing).

In terms of game structure, the county fair is a

container space for the numerous mini-games and individual

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DIABETES VIDEO GAME

tasks that make up actual gameplay. Because the fair

features a number of activities – such as food services,

information booths, rides, and games of skill – the greater

game itself can feature a number of different activities

while remaining thematically consistent. On another level,

the fair, as a virtual space, also allows for the inclusion

of games and activities that move beyond traditional fair

activities as well. The fair setting serves as a framework

and justification for the basic gameplay structure.

In summary, the county fair is an effective setting for

the following reasons:

• The fair is a familiar and appealing setting inAppalachian culture.

• It is a safe and timeless space for exploringinformation and behaviors about diabetes.

• As a setting with diverse activities, the fair isfriendly to many types of families and isintergenerational.

• Information moves naturally through the communalsetting, emphasizing learning.

• The fair allows for a number of gameplay elements – NPCinteraction, multiple mini-game activities – thataddress the Appalachian context.

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DIABETES VIDEO GAME

The diabetic player-avatar

In the game, the player controls an in-game character

(his/her avatar) that s/he designs. We feel that allowing

the player to design his/her own character would increase

engagement, emphasize personal involvement, and allow the

player to personalize the information s/he receives in the

game. Similarly, allowing the player to design his/her own

character bases the in-game representation on the player’s

self-concept, rather than an identity constructed by the

game designer that may or may not reflect the identity and

values of the player.

The only externally-delineated characteristic of the

avatar is being diabetic. Although the game is targeted at

children, in many Appalachian families it is not the child

that is the diabetic member; in fact, many players of the

game will not be diabetic. However, by overlaying diabetes

onto an otherwise self-created character, the game gives

players an opportunity to understand how diabetes affects

the individual even if they are not diabetic; in short, it

puts the player in a diabetic’s shoes. The game, as a safe

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DIABETES VIDEO GAME

virtual space for enacting behaviors, gives the player the

opportunity to understand how diabetes can affect the

individual without risk of harm to him/herself. Similarly,

by conflating being diabetic with being the game’s “hero,”

the game constructs diabetes as normal and manageable rather

than abnormal or as a source of shame. The presence of

diabetic NPCs that interact with the avatar also serves to

emphasize this. Since self-reliance and self-sufficiency are

valorized in Appalachian culture, this is important; rather

than being a source of weakness, diabetes is made into a

part of everyday life.

Primarily, the player engages the disease through blood

sugar management. Through an interface resembling a blood

glucose monitor, the player must test and monitor his/her

blood sugar. In-game activity and exercise – such as

participating in the various mini-games available at the

fair – simulate the effect of real-world activity on blood

sugar as well. Likewise, the foods that the player chooses

to eat have an effect on blood sugar similar to their real-

world equivalents. The results of the blood sugar management

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DIABETES VIDEO GAME

thus have an effect on the other play activities in the

game; poor management may slow the player down from fatigue

during mini-games, while effective management maintains a

state of good health that allows the player to enjoy the

game normally.

Thus the primary point of resource management in the

game is food; different foods have different in-game costs,

take up certain amounts of the limited space in the

character’s backpack, and have different short and long term

effects. By allowing the player to see the effect of his/her

food and activity choices, the game promotes learning about

and improvement of real-life models of management. The game

shares information and models management skills on the

everyday level by focusing on behaviors with real-life

analogs. Rather than a top-down, didactic approach to

education, the game accepts diabetes management as something

that happens on a routine level.

The player-created diabetic avatar is an effective learning

tool because it:

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DIABETES VIDEO GAME

• Personalizes the player’s experience by allowing forhis/her self-concept to be reflected.

• Puts the player in the shoes of a diabetic, even ifs/he is not.

• Makes the consequences of effective or ineffectivemanagement apparent on an everyday level and in a safespace.

• The diabetic hero helps to counter feelings of shamethat can be culturally associated with chronic diseases(such as diabetes) in Appalachian culture.

• Teaches management techniques and imparts informationon the level of everyday lived experience.

Mini-games, character interaction, and fair activities

Working in concert with blood glucose management is the

ability of the player to interact with the fair. Effective

management is the means by which the player is able to enjoy

the various mini-games – small, less complex games within

the larger game – that the fair setting allows for; how well

the player manages his/her blood sugar has a direct and

obvious impact on mini-game performance. The two activities

work together to keep the game interesting and fun, while

imparting information on diabetes management at the same

time. Non-player characters, as a third influence, allow the

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DIABETES VIDEO GAME

player to interact with the world and receive information in

a different way.

Mini-games are “games within games;” they are less

complex, more simplistic play activities with their own

gameplay rules that are contained within the framework of

the larger game. For example, the county fair is the macro-

level game; a booth where the player can dunk for apples or

throw a ball at targets to win prizes are mini-games. In the

county fair context, mini-games represent the various

activities that a player can do at the fair: rides, games of

skill, and the like. The model of a larger game framework

with a number of mini-games contained within it is well-

reflected in current commercial game titles. Games like

Mario Party or Warioware are examples of such.

In order to broaden the appeal of the game and allow

for many types of players to enjoy it, the mini-games

available at the fair will be diverse both stylistically and

in the skill required to play them. For example, some may be

tests of mathematical skill like Sudoku, while others are

more action-oriented such as a ring toss or skee-ball game.

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DIABETES VIDEO GAME

Because the fair is a virtual space, the mini-games can

range from traditional fair activities to less realistic

ones as well. By varying style, content, and skill types,

the mini-games can engage players of all types.

Players are rewarded for success in mini-games with

virtual currency that allows them to unlock content, win

prizes they can use to customize their character, and

acquire other similar rewards. This motivates players to

continue playing mini-games (and thus to keep managing their

glucose so they can do so effectively) and gives the player

a sense of accomplishment. For example, a player may be

motivated to earn enough “tickets” to buy a large stuffed

teddy bear, or win a t-shirt for the avatar to wear. Mini-

games also interact with the blood glucose management

activity. Participating in mini-games can tire a character

out, sap their reserves, or cost in-game currency that could

otherwise be used for buying food. Thus the two systems are

integrated and co-dependent.

Along with mini-games, the fair also features a number

of different non-player characters that the player can

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DIABETES VIDEO GAME

interact with. These can take a number of different forms: a

young diabetic girl trying to manage her disease, a nurse or

doctor in a first aid tent, a carnival barker, or the owner

of a mini-game booth are just a few of the possible

examples. NPCs can impart game world information,

information on diabetes, a sense of place or flavor for the

fair, and the like. A rich cast of NPCs can enhance the

feeling of the fair and gives the player a chance to use

some of the knowledge s/he has acquired over the course of

the game. The aforementioned diabetic girl, for example, may

ask the player for advice on how to manage her blood sugar,

giving the player an opportunity to engage the information

on an interpersonal level.

Similarly, the NPCs are a way to reflect Appalachian

culture while at the same time creating an environment where

diabetes is normal and not a source of shame. If the various

characters at the fair are, for example, managing their

disease or helping the player to manage his/her disease,

they create a context where diabetes is everyday and normal.

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DIABETES VIDEO GAME

Mini-games and non-player characters contribute to the

game’s effectiveness by:

• Bringing a diverse amount of activity for players toengage in.

• Interacting with the blood glucose management activityto put diabetes in the context of routines.

• Rewarding the player for success in the game and thusencouraging repeat play.

• Bringing information to the player through a diversecast of non-player characters.

The game and the family

As the research cited above emphasizes, the family is

both important to Appalachian culture, as well as being part

of the everyday context the family health model emphasizes.

Thus, the inclusion of the family into the game world is an

important design goal; as diabetes is a family disease that

affects the entire household, it’s important for the game to

address that context. The game should encourage

communication, collaboration, and even competition between

family members in order to create dialogue. The family must

be woven into other game design elements in order to

accomplish that.

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DIABETES VIDEO GAME

For example, on the level of the avatar, it’s important

that it not only be player-created, but also that the player

and his/her family have the opportunity to create the family

as well. Just as we noted that self-created avatars are

based in the player self-concept, self-created family member

characters center the family in the game world. The family

avatars can be created by the player alone, or more ideally,

the family can work together to each create an individual

avatar. Similarly, one of the goals of the game is to

reflect Appalachian culture and avoid valorizing a

particular family structure; by allowing for the entire

family to be player-created, the game can reflect any of a

number of different family models without privileging any

single one.

The design of the various mini-games encourages family

play and engagement in a number of ways. For example, the

diversity of tasks can make the game accessible to a wide

variety of individuals with varying skills and experiences.

The game’s reward structure encourages competition as well;

for example, by saving high scores on various mini-games,

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DIABETES VIDEO GAME

various family members can compete to get the best score and

thereby engage the game together. Through competition and

collaboration, the game can make inroads for inter-family

member communication.

Additionally, we propose the addition of the family

home as a second, connected space to the county fair. The

home can then serve as a focal point for family

communication that works inside the game world. For example,

family members playing at different times can leave notes

for each other on the kitchen table, create a communal

“bank” of resources or prizes the entire family can share,

and serve as a home base that connects the family inside the

game world. The hope is that, by using the game itself as a

method of communication, it would encourage not only family

communication but also communal use of the game as well.

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