On the Development of Serious Games in the Health Sector
A Case Study of a Serious Game Tool to Improve Life Management Skills
in the Young
Tanja Korhonen
1,2
and Raija Halonen
2
1
Information Systems, Kajaani University of Applied Sciences, Kajaani, Finland
2
Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
Keywords: Serious Game, Health Game, Visual Novel, Life Management Skills.
Abstract: The current research focuses on serious games (SG) in the healthcare sector. The objective was to identify the
key phases in the design and development of SG and to study how serious game design takes into account
affective computing. The case study describes the development of Game of My Life (GoML), a visual novel
aiming to support the life management skills of adolescents. The game was developed in two phases using
iterative agile methods in cooperation with different stakeholders. The evaluation indicates that GoML can be
used as an effective discussion tool for professionals and patients in nursing and youth work. The results
support our existing knowledge of SG development and reveal that SG design takes into account affective
computing by nature: game design deliberately influences emotions in order to engage the players.
1 INTRODUCTION
Games can work as motivators and help to change
players’ behaviour (Baranowski et al., 2013; Ryan et
al., 2006). Digital games create a structured conflict
and provide an entertaining process for players to
resolve this conflict (Fullerton, 2014). Video games
allow the possibility not just to tell a story but also to
allow a player to live it (Rigby and Ryan, 2011).
Our research goal was to identify the key phases
of the design and development of serious games (SG)
with respect to affective computing. The research
goal was met with the help of two questions: What are
the key phases when designing and developing SG?
How does SG design take into account affective
computing?
Various definitions of serious games exist, but it
is commonly stated that SG refers to using games and
game technology for purposes other than pure
entertainment (Djaouti et al., 2011; Susi et al., 2007;
Zyda, 2005).
Serious games in healthcare may be one strategy
for coping with the increasing challenges of ageing
populations and chronic diseases (Arnab et al., 2013).
Related to this, Kemppainen, Korhonen and Ravelin
(2014) point out that health games can provide a new
method for maintaining and developing the health
capability of different age groups. An important goal
of health games is to provide new kinds of models for
self-help or rehabilitation (Kemppainen et al., 2014).
Affective computing (AC) aims to close the
communicative gap between human emotions and
computers by applying systems that recognise and
adapt to the user´s affective states. Computer games
usually provide very dynamic forms of human–
computer interaction since they are designed to offer
affective experiences that are influenced by player
feedback (Iovane et al., 2012; Yannakakis and
Togelius, 2011).
This paper presents the development of Game of
My Life (GoML) as a case study and is organised into
five major sections. Following this introduction, the
next section reviews the related work on serious
games. Section three presents the design and
development of GoML. Section four offers a
discussion, and section five provides conclusions.
2 RELATED WORK
This chapter presents the earlier knowledge related to
the current study. First, affective computing and
games are explained, followed by aspects of game
Korhonen, T. and Halonen, R.
On the Development of Serious Games in the Health Sector - A Case Study of a Serious Game Tool to Improve Life Management Skills in the Young.
DOI: 10.5220/0006331001350142
In Proceedings of the 19th International Conference on Enterprise Information Systems (ICEIS 2017) - Volume 3, pages 135-142
ISBN: 978-989-758-249-3
Copyright © 2017 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
135

design and serious games in healthcare. Finally, the
visual novel is introduced.
2.1 Affective Computing and Games
Computer games provide a valuable research setting
for human–computer interaction research,
particularly with respect to their design, interfaces
and design processes (Yannakakis and Togelius,
2011). As games often offer emotional experiences,
they are a good example of affective computing
(Yannakakis and Togelius, 2011). In 1995, Picard
defined affective computing as “computing that
relates to, arises from, and deliberately influences
emotion” (2010, p. 11). Yannakakis, Isbister, Paiva
and Karpouzis (2014) suggest that computer games
can best realise affective interaction. The rich content
of games, consisting of music, sound effects, audio,
virtual graphics and game mechanics, provides
obvious triggers for raising the emotions of players
(Yannakakis et al., 2014).
Research on player motivation attempts to
establish the psychological needs that games satisfy
and how different games fulfil these needs. This
provides information about both the positive and
negative experiences within games (Rigby and Ryan,
2011).
Malone and Lepper (1987) identified four major
factors that make a learning environment such as a
gaming activity intrinsically motivating: challenge,
curiosity, control and fantasy. These individual
factors motivate a player when playing alone, while
interpersonal factors such as cooperation,
competition and recognition motivate a player when
interacting with other players (Malone and Lepper,
1987).
The Player Experience of Need Satisfaction
(PENS) model details the satisfactions that hook
players to games. This model is based on the fact that
video games are considered most engaging when they
satisfy specific intrinsic needs: competence,
autonomy and relatedness. Competence refers to our
desire to grow abilities and gain mastery of new
situations and challenges. Digital games easily
provide highly engaging experiences in rich virtual
worlds, which brings immediacy and can satisfy
motivational needs such as competence and mastery.
Autonomy refers to our desire to take actions based on
our own decisions and not to be controlled by others.
There is a certain consistency in games: once a player
learns the rules, the outcome will consistently reflect
the player’s actions and expectations. Relatedness
reflects our need to have meaningful connections with
others (Rigby and Ryan, 2011). Density refers to the
ability of games to deliver competence and the other
needs at a high tempo and with a well-built feedback
system.
2.2 Game Design Aspects
Designing digital games involves psychological
aspects (Rigby and Ryan, 2011) as well as mechanical
and artistic aspects (Fullerton, 2014). According to
Rollings and Adams (2003), game design is a process
that includes imagining a game, defining how it
works, describing its elements and transmitting all
this information to the game development team. A
common element in digital game design is designing
systems of actions and outcomes where the game
responds easily to a player’s input (Salen and
Zimmerman, 2004).
The process of video game design involves
designing the content and rules in the pre-production
stage and designing the gameplay, environment,
storyline and characters in the production stage
(Bethke, 2003; Fullerton, 2014). Adams (2013)
divides the game design process into three parts: the
concept stage, which is performed first; the
elaboration stage, where most of the design details
are added and refined; and, finally, the tuning stage,
which involves polishing the game.
2.3 Serious Games in Healthcare
Social security systems and healthcare providers
differ among various countries and on a global scale,
with each market area having its own methods for
facilitating a healthy lifestyle (Kaleva et al., 2013).
There are many different stakeholders in the health
game market: hospitals, clinics, private practice
physicians, governments, corporations, other
organisations and individual consumers (Susi et al.,
2007).
Braad, Folkerts and Jonker (2013), Friess, Kolas
and Knoch (2014) and Deen, Heynen, Schouten, van
der Helm and Korebrits (2014) have all used similar
processes in serious game development in the health
sector. These processes all include a strong research
and analysis phase at the beginning. Involving
different stakeholders is also essential. An iterative
development process (or prototyping) is used, along
with user-group testing and an evaluation or
validation phase at the close of the game development
process.
Supporting players’ motivation and enhancing
behaviour change are key points in health game
design (Rigby and Ryan, 2011). It is essential to use
game elements like surprise and simulation to engage
players and enable immersion (Adams, 2013). In
addition, developing a health game needs a
multidisciplinary team to work successfully together
(Kemppainen et al., 2014). Brox, Fernandez-Luque
and Tollefsen (2011) suggest that it is important to:
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1. define both the target group and the main
objective;
2. design a game accordingly, using sound
game design principles;
3. utilise design elements to enhance learning
and persuasion;
4. collaborate with health professionals from an
early design stage;
5. involve patients, especially to improve
usability.
Iterative design is a play-based design model. It
emphasises playtesting and prototyping, which
allows players to be part of the game design. In
iterative design, a rough model of the game—a rapid,
interactive prototype—is created as early as possible.
This may have placeholder graphics, but it can be
played and evaluated. The user comments and
evaluations influence the game’s further design
(Salen and Zimmermann, 2004).
When designing serious games in healthcare, the
target group should be taken into account during the
development process (Brox et al., 2011; Braad et al.,
2013; Friess et al., 2014; Deen et al., 2014).
Professional knowledge is an essential part of the
development (Merry et al., 2012).
It is essential to include an assessment of serious
games’ usefulness and effectiveness in the
development process (Graafland et al., 2014).
Desurvire, Caplan and Toth (2004) outline a set of
design heuristics, which are guidelines that serve as
an evaluation tool specific to video games. According
to their definitions, the Heuristics for Evaluating
Playability (HEP) categories include: evaluating
game play; game story—plot and character
development; game mechanics; and game usability.
HEP is recommended for use in the early design
phase (Desurvire et al., 2004).
2.4 Visual Novel
A visual novel is a narrative-based digital medium
that players can guide by making decisions, thus
altering the outcomes. According to Lu (2013), it
enables a collective participation experience, even
though it is usually played alone. A visual novel is
more like a role-playing game than a simulation
(Cavallaro, 2010; Lu, 2013).
A visual novel consists of a soundscape, static
graphics or animations, immersive storytelling and
interactive decision-making moments that allow the
player to decide how the visual novel progresses. The
pace of the game’s progress is slow, and this gives the
players time to process their thoughts during the
gameplay. The genre is dependent on narrative and
dialogue. An engaging video game narrative enables
a personal experience for the players and creates their
affection for the characters (Cavallaro, 2010; Gabriel
and Young, 2011; Lu, Baranowski, Thompson and
Buday, 2012; Lu, 2013).
3 CASE STUDY: DEVELOPMENT
OF GAME OF MY LIFE
Game of My Life (GoML) is an online game in a visual
novel style that aims to support the life management
skills of adolescents aged 16–19 years.
3.1 User Needs and Analysis
The need for the game arose from youth psychiatry
experts who wanted new tools for approaching their
young (16–19 years) patients. The main objective was
to create a game that could be used as a tool in
conversations between experts and patients regarding
life management issues. The experts suggested that
the game be based on the Finnish theoretical
framework by Ylitalo (2011). This framework
describes a role map of a young person in the process
of becoming independent. The role map (Fig. 1)
includes five motivation roles, with subcategories for
goal-oriented roles and action roles.
Figure 1: Role map of a young person in the process of
becoming independent.
The game development process began by
searching for existing games in the market. The most
promising at the time (2012) was a PC game called
SPARX, which had been developed in New Zealand
for the treatment of mildly depressed adolescents and
used as a stand-alone self-help intervention. After
testing, it was decided that this game was not the kind
of tool that the youth psychiatry experts were looking
for to help in discussion with young patients.
The next step was to gather more information
about the life management skills of adolescents from
their own point of view, particularly regarding
On the Development of Serious Games in the Health Sector - A Case Study of a Serious Game Tool to Improve Life Management Skills in
the Young
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problems related to mental health and substance
abuse. This was done by qualitative research into six
young persons who participated in individual semi-
structured theme interviews. The research focused on
how these young people understood life management
and what challenges they had with it. It also gathered
their expectations for a game supporting life
management. The results showed that the young
people had difficulty understanding the term life
management skills but found it easier to understand
when it was called managing your everyday life. The
participants hoped that the developed game would
provide information on substance abuse, as well as on
the use of time and money.
These activities formed an analysis phase that
consisted of:
1. Cooperation with health professionals:
carrying out a preliminary requirements
analysis that defined the target group and
the main objective of the serious game
being developed.
2. Quick market research into similar
products.
3. Testing and reporting on the most
significant similar products.
4. Involving end users in order to find the
most problematic aspects that needed to
be covered in the game.
3.2 Game Concept
After understanding the user needs, the focus moved
to user–computer interaction and the game concept
design. It was decided that GoML should be a
network game, playable in a prototype phase on the
most used browsers and Android tablets. After a
literature search, a visual novel was selected as the
game genre. A visual novel can evoke feelings in
players, thus making it the powerful tool that the
experts were looking for. The narrative of the visual
novel had three characters (two male, one female), all
with three different storylines relating to their school,
home and free time. Each of these was based on the
“role map of a young person in the process of
becoming independent” (Fig. 1). To get a feeling of
interactive decision making, decision paths were
planned according to the storylines, with players
guiding the narrative by choosing from multiple
choices with a mouse (PC) or by tapping their finger
(tablet). It was agreed that, in order to provide
additional information, there would be external links
at the end of each storyline.
Restrictions due to budget, resources and timing
meant that this was a visual novel without
soundscape, with the maximum gameplay time for
each storyline limited to 15 minutes. The graphics for
GoML were simple and static and had a cartoon look
with a user interface like a book and easy-to-use
buttons.
The above features created the game concept for
this serious game, which could then be used for
further content creation.
3.3 Content Creation for the GoML
Demo
Serious games development uses a standard game
design process to develop an immersive game. This
involves designing the game play and flow as well as
the interactive narrative and dialogue.
The development of GoML began by finding an
appropriate art style and writing the first storyline.
The first team, consisting of three game development
students (a game designer and producer, a
programmer and an artist), developed the first demo
version during 2012.
The game design began with ideating among the
team and with a nursing lecturer and her students to
get more accurate content. The nursing students
brought valuable information about patient needs to
the process. The ideas were also presented throughout
the project to several stakeholders, including youth
psychiatry experts and game development
professionals. The game design document covered
the main idea for the whole game, but it was decided
that only the “Home” level of one character could be
included in the demo version. The design of the visual
novel also included the story writing, in which themes
from the “role map of a young person in the process
of becoming independent” influenced the content.
The art style was kept simple; it was cartoonish and
used light colours that would bring a positive
atmosphere to the game.
Since the game mechanics were simple and used
a web-browser platform, the production was carried
out using Adobe Flash. This allows for quite rapid
programming, and the executables are easily
available online.
The development process, as illustrated in Figure
2, was iterative, adapting forms of agile development
such as scrum. This enabled quick prototypes to test
the ideas so that the game could be presented to
different stakeholders.
After testing and feedback, the development
continued further. In several iterative steps, the demo
of GoML was presented to youth psychiatry experts
and tested by experts and patients; it was also
evaluated by an external professional.
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Figure 2: The iterative development process with GoML stages.
3.3.1 Testing of GoML Demo
The first playable GoML demo (see Fig. 3) consisted
of one storyline and one level (“Home”) relating to
one main character. The game was tested by youth
psychiatry experts and some of their patients, but due
to the limited content of the game, the main feedback
from the testing concentrated on suggestions for
improvement.
Figure 3: Concept art for GoML demo.
A psychology student from the University of
Chicago worked with the project team by providing
information related to the visual novel. He also
carried out, as part of his studies, a more
comprehensive analysis of the SG demo using a
modified version of the Heuristics for Evaluating
Playability (HEP). This included areas of game play
game story, game mechanics and usability with
several claims in each area. Claims were assessed by
using ratings in the range of 0–3 (0 = not found in
game, 1 = poor, 2 = fair, 3 = good/excellent) and
providing a written description, if applicable. The
main result of the evaluation was that the HEP results
could be used as a good base for the next phase of the
development of GoML.
3.4 Content Creation for GoML
The second phase of the GoML development started
in 2014 with a new game development team. The
extended project team also included a nursing student
and two senior lecturers (in game development and
nursing and healthcare).
The new multidisciplinary team began by
analysing the developed demo version and gathering
the testing and evaluation results. Based on these, the
major lines of development were decided upon and
prioritised. It was understood that the available time
and budget would limit the outcomes.
A booklike graphical user interface was added to
the beginning of the game, allowing the player to
choose a character from three options and to operate
in all three storylines (levels): school, home and free
time. It was decided that the main themes of the game
would be relationships, intoxicating substances,
economic skills, mental health, and daily life
activities. The background to all the storylines was
taken from the “role map of a young person in the
process of becoming independent” (Fig. 1). During
the story, the player would be able to make decisions
by choosing from several options. At the end of each
level, the player would be able to find additional
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information through external links related to the
themes of the story.
The aim of the game was to evoke new thoughts
and ways of thinking concerning daily-life decision
making and problem-solving situations. The players
would face the consequences of the choices they
made during the game.
Figure 4: New characters and colours.
The programming and tools used remained the
same, but there was a major change to the graphics in
this second phase. The art style used darker colours
and more robust characters, as presented in Figure 4.
This changed the whole atmosphere, thus making it
possible for a player to empathise with the characters.
In addition, the stories in GoML took on a new, more
realistic approach with a twist of darker shades: all
the characters had problematic backgrounds. It was
felt that the narrative’s collective assimilation would
be deeper if the players could find a means of
identification with the characters. Deeper character
descriptions were used and difficult issues in the
storyline were dealt with in order to evoke feelings in
the players, thus making the game more immersive
and effective.
3.4.1 Evaluation of GoML
The second version of GoML was tested in several
ways. It had already been under constant testing
through its availability on the website
(www.elamanipeli.com). At the end of the game,
there was a request to fill in a feedback form. This
brought only very general comments about the game.
In a qualitative study, nine young people (aged
18–22 years) who had some problems with life
management skills were interviewed after playing
GoML. According to the results, the interviewees
recognised different themes in GoML and openly
began to describe how they would act in similar
situations. GoML provoked discussion about very
difficult areas of life management such as lack of
sleep, problems at school and problems with
substance abuse. The study also showed that young
people as players tended to make decisions in the
game to see what might happen, often even making
opposite decisions from what they would do in life.
The interviewees brought up the need for more
choices that were not so obvious. The study thus
showed that GoML works as a discussion tool
between professionals and patients in nursing or
youth work: communication is easier when the
discussion concerns a third party (a game character).
The mental health professionals who participated
in the development process were provided with a
protocol on how to use GoML as a discussion tool in
their work with young people.
4 DISCUSSION
The objective was to identify the key phases in
designing and developing SG and to study how
serious game design takes into account affective
computing. Starting from serious games development
theory and based on previous literature about digital
serious games, especially visual novels and health
games, we used and further developed this knowledge
in a case study by creating a new serious game.
The game developed, GoML, can be used in
mental health work, social welfare work and youth
work as a tool for an adult and a young person to
evoke conversation and thoughts about life
management issues. It aims to help young adults to
reflect on their attitudes, thoughts and behaviour
concerning such issues.
We suggest that the analysis is one of the key
phases in designing and developing a health game. It
is essential to involve different stakeholders (such as
experts in the field) and end users (patients) as early
as possible in the game development process. A good
collaboration and an effective understanding of user
needs play a key role in finding the right triggers for
raising the emotions of players, thus leading to an
effective outcome.
In addition, a good concept for the health game
helps in the communication with different
stakeholders. An iterative development of a demo
version can be used as a proof of concept and tested
with end users. A visual novel style and well-
designed narrative can help players relate to the
characters, thus influencing their emotions.
The results support the previous work of Braad et
al. (2013), Friess et al. (2014) and Deen et al. (2014)
showing the importance of a strong research and
analysis phase at the beginning and emphasising that
a good understanding between the different
stakeholders is essential in serious game
development. The key phases of this study also follow
the guidelines for serious games development set by
Brox et al. (2011).
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We agree with Yannakakis and Togelius (2011)
who state that games can offer emotional experiences
and thus be good examples of affective computing.
We argue that serious games in the health sector
follow Picard’s (2011) basic definition of affective
computing. However, based on the understanding of
player motivation provided by Rigby and Ryan
(2011) and Malone and Lepper (1987), we would
offer the following definition: Serious game design
aims to influence intrinsically motivating factors in
order to deliberately influence emotions.
5 CONCLUSIONS
The key phases of the design and development of SG
are based on a profound analysis and good
understanding of the aim and players of the game
being developed. It is thus important to design
characters and narratives that players can assimilate.
Iterative development and various testing methods
make it possible to check during the development
whether the serious game is working as planned. SG
design takes into account affective computing by
nature: game design deliberately influences emotions
in order to engage players.
As a narrative-intensive visual novel, it was
possible to include in GoML different viewpoints
regarding life management issues. The “role map of a
young person in the process of becoming
independent” provided a sound theoretical
background for the storylines. GoML can be used in
nursing or youth work as a discussion tool to evoke
conversation and thoughts between professionals and
patients, and the game comes with a protocol for its
use.
We are continuing our research on the
development of serious games in the health sector.
The thorough evaluation and validation of GoML
needs to continue further. Identifying the key phases
of designing and developing successful SG continues
with other case studies. We also suggest that future
research into serious games should take into account
new platforms such as virtual reality that will move
affective computing to the next level.
ACKNOWLEDGEMENTS
One of the authors received funding from the Niilo
Helander Foundation in Finland.
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