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Leveraging the Proteus Effect to Motivate Emotional Support in a Serious Game for Mental Health

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Leveraging the Proteus Effect to Motivate Emotional Support in a Serious Game for Mental Health By Long Ting Chan A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Master of Science in Public Health and Health Systems Waterloo, Ontario, Canada, 2019 © Long Ting Chan 2019 i Author’s Declaration This thesis consists of material all of which I authored or co-authored: see Statement of Contributions included in this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Statement of Contributions Portions of the materials, ideas, tables, figures, and videos in this dissertation have previously appeared in the following peer-reviewed conference publications: Chan, L. T., & Wallace, J. R. (2018). Changing peer support attitudes with avatar-based gamification. Extended Abstracts of the 2018 CHI Conference on Human Factors in Computing Systems. https://doi.org/10.1145/3170427.3188497 Chan, L.T., & Wallace., J. R. (2018). Changing peer support attitudes with avatar-based gamification. Massachusetts Institute of Technology 3rd Symposium on computing and mental health: Understanding, engaging, and delighting users, 2018. Montreal. Chan, T., & Wallace, J. R. (2018). Changing peer support attitudes with avatar-based gamification. International conference on persuasive technologies 2018, waterloo. Chan, T. (2019). Do female avatars encourage mental health support in gamified peer to peer (P2P) cognitive behavioural therapy (cbt)? W3 represents: A research symposium, 2019. Waterloo. Chan, T. (2018). Designing for engagement in peer-to-peer support using cognitive behavioural therapy with gamification and the Proteus Effect. Inter-university workshop, 2018. Toronto. iii Abstract Researchers have explored how online communities can be leveraged for peer support, but general disinterest and a lack of engagement have emerged as substantial barriers to their use in practice. To address this gap, we designed Merlynne using the Elaboration Likelihood Model (ELM) and games user research, a serious game that motivates individuals to become peer supporters using the Cognitive Behavioural Therapy (CBT) techniques, through play. We conducted a mixed-methods, exploratory study to evaluate Merlynne’s design and specifically studied the Proteus Effect, hypothesizing that players using a stereotypically helpful avatar would have higher usage rates and a higher change in helping attitudes scores than players using a stereotypically unhelpful avatar. Merlynne had high engagement evidenced by usage rates and meaningful participant responses, and serious game techniques were used as effective cues for motivation. Emerging themes from thematic analysis of semi-structured interviews were supported with usage data and survey responses. We also found that avatar appearance influenced player-avatar connectedness and engagement through the frequency of empathy expressed in solutions. In reflecting on our findings, we discuss design challenges such as Ludonarrative dissonance, designing for emotional fatigue, and players’ overconfidence, and present design considerations such as using avatars to promote empathy for those seeking to motivate participation in mental health support and the use of serious game techniques to encourage participation in health interventions. iv Acknowledgements Individuals cannot produce knowledge alone, thus I thank previous researchers who have paved the way for this thesis’s contributions to be possible and members of the public health and human-computer interaction (HCI) community at the University of Waterloo for the valuable research direction. Thank you, Homewood Research Institute, Mississauga Catholic School Board, and Fanshawe College among others for industry and community feedback and thank you to the Games Institute at the University of Waterloo for fostering a supportive and social academic environment to enable interdisciplinary research. I also extend my gratitude to the international game development community for providing art assets in this research, namely: Calicumtrice for character sprites, Monika Ziska for music used in the tool in this thesis, and the numerous volunteers who contribute to Stack Overflow and Reddit to make game development accessible. Finally, thank you to all research participants, Dr. James Wallace for your supervision, and Dr. Mark Hancock and Dr. Chris Perlman for your time on my master’s thesis committee. v Table of Contents Declaration ................................................................................................................................................ ii Statement of Contributions ...................................................................................................................... iii Abstract .................................................................................................................................................... iv Acknowledgements ................................................................................................................................... v List of Tables ........................................................................................................................................... vi List of Figures ......................................................................................................................................... xii Terminology .......................................................................................................................................... xiv Chapter 1: Introduction ............................................................................................................................. 1 1.1 Chapter outline ................................................................................................................................ 2 1.2 Contributions ................................................................................................................................. 2 Chapter 2: Related works .......................................................................................................................... 3 2.1 Mental health .................................................................................................................................. 3 2.1.1 Cognitive behavioural therapy (CBT) ..................................................................................... 3 2.1.2 Computerised cognitive behaviour therapy (cCBT) ................................................................ 3 2.1.3 Adherence ................................................................................................................................ 4 2.2 Peer to peer (P2P) support .............................................................................................................. 5 2.3 Crowdsourcing for cognitive behavioural therapy (CBT) .............................................................. 5 2.3.1 Support on social media ........................................................................................................... 7 2.3.2 Threats and opportunities of online support ............................................................................ 8 2.3.3 Non-service user (NSU) inclusion in peer to peer (P2P) communities ................................... 8 2.4 Gender differences in support seeking ............................................................................................ 9 2.5 Elaboration Likelihood Model (ELM) ............................................................................................ 9 2.6 Serious games ............................................................................................................................... 10 2.6.1 Gamification with avatars ...................................................................................................... 12 2.6.2 Perceived agency ................................................................................................................... 12 2.6.3 Agents vs avatars ................................................................................................................... 12 vi 2.7 The Proteus Effect ........................................................................................................................ 13 2.7.1 Player characteristics ............................................................................................................. 14 2.7.2 Avatar characteristics ............................................................................................................. 15 2.7.3 The helpful stereotype ........................................................................................................... 15 2.8 Summary and implications ........................................................................................................... 21 Chapter 3: Rationale ............................................................................................................................... 22 3.1 Scholarly implications .................................................................................................................. 22 3.2 Applied implications ..................................................................................................................... 22 3.3 Research questions .......................................................................................................................
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