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The Construction and Evaluation of a Design Framework for Narrative

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The Construction and Evaluation of a Design Framework for Narrative The Construction and Evaluation of a Design Framework for Narrative Games for Health Langxuan Yin Abstract A larger number of games for health were developed over the past two decades to provide an engaging way of health care and behavior change intervention. However, many problems with the design of these games, as well as with the methodologies used to evaluate them emerged: the games were generally designed without the consultation or direct involvement of a professional game designer, and created without the guidance of a proper game design framework; the health messages delivered in the games were mostly simple and knowledge-oriented and not crafted based on theories from behavioral medicine; and the evaluation studies were also poorly designed. To solve these problems, I define the DraGuNa (Drama-Guided Narrative Health Game) framework, a methodology that uses drama theory and sound principles from behavioral medicine to guide games for health design to solve the current problems in games for health. The dissertation introduces a methodology of game design, specifically developed for games for health, which addresses two key constructs: engagement – ensuring users stick with the game for the duration of the intervention; and adherence – ensuring users perform those actions in the game hypothesized by behavioral medicine theories to lead to health behavior change. The dissertation also provides a methodology to develop interactive narrative-based games based on existing story media, which also suggests a new path of research for the intelligent narrative community. Finally, the dissertation describes an experimental framework for testing the effects of a game on the two fundamental dimensions of player involvement in the intervention – engagement and adherence – and tests the relative contributions of each on health outcomes. Acknowledgements First and foremost, I owe this dissertation to my parents. The high hopes that my parents had of me and the strong sense of discipline that I grew up to embrace created the scholar that I am today. I’d like to thank my advisor, Timothy Bickmore, for the guidance he had given me throughout the long years of the Ph.D. program. I also want to thank former and current members of the Relational Agents Group, especially Zach Berwaldt, Juan Fernandez, Zhe Zhang, Lin Shi, Ha Trinh, Elizabeth Bates, Kathleen Totzke, for helping me conquering the challenges during the development of my dissertation and in my work as a research assistant. Thanks also go to two Ph.D.’s who graduated from my lab, Daniel Schulman and Laura Pfeifer Vardoulakis, for setting high scholarly standards and showing me what seemed impossible. I owe special thanks to Lazlo Ring, Angelo Cafaro, Joshua Bolduc, and Luke Farrer, for they are incredible friends, who gave me inspirations, wisdom and support when most needed, and, especially for someone like me, with no family and no relative around, a sense that I am not forsaken. I want to thank all of my friends who have offered me a job or referred me to their employers towards the end of the Ph.D. program. Securing a job offer helped me focus on my dissertation in the last two months of my degree. I must also thank my girlfriend Danhui Chu, for helping me through the darkest page of my life, keeping me concentrated on what is the most important, and encouraging me to rediscover the patience and tranquility in me that I thought for a time lost. Finally, I should mention the Count of Monte Cristo by Alexandre Dumas, for the book taught me something that made the completion of this dissertation possible, that is, the essence of all human wisdom: Wait and Hope. Contents Abstract ........................................................................................................................................ iii Acknowledgements ..................................................................................................................... iv Contents ....................................................................................................................................... v Chapter 1. Introduction ................................................................................................................ 1 Chapter 2. Health Behavior Change............................................................................................ 5 Chapter 3. Related Work ........................................................................................................... 10 3.1. Games for Health............................................................................................................ 10 3.2. Using Narrative for Health Behavior Change ................................................................. 26 3.3. Intelligent Narrative Technologies .................................................................................. 31 Chapter 4. DraGuNa: Drama-Guided Narrative-Based Health Game Design .......................... 37 4.1. The DraGuNa Framework .............................................................................................. 37 4.2. Promoting Adherence ..................................................................................................... 39 4.3. Promoting Engagement .................................................................................................. 52 4.4. Achieving engagement and adherence using intelligent narrative ................................. 64 4.5. Methodology for Adapting Existing Serial Stories for the DraGuNa Framework ............ 67 Chapter 5. Example Game: Adventures of the Atomic Submarine ........................................... 69 5.1. Story Choice ................................................................................................................... 70 5.2. Story Adaptation ............................................................................................................. 72 5.3. Intervention Incorporation ............................................................................................... 75 5.4. Engagement Techniques ................................................................................................ 77 5.5. Adherence Techniques ................................................................................................... 86 5.6. System Architecture ....................................................................................................... 93 Chapter 6. Evaluation of Adventures of the Atomic Submarine .............................................. 115 6.1. Study Conditions........................................................................................................... 116 6.2. Measures ...................................................................................................................... 122 6.3. Study Setup .................................................................................................................. 123 6.4. Hypotheses ................................................................................................................... 126 Chapter 7. Findings from the Experiment ................................................................................ 129 7.1. Participants ................................................................................................................... 129 7.2. Hypothesis Testing ....................................................................................................... 135 7.3. Exploratory Analyses .................................................................................................... 147 7.4. Qualitative Results ........................................................................................................ 163 7.5. Conclusions .................................................................................................................. 187 Chapter 8. Conclusion ............................................................................................................. 190 8.1. Lessons for Game Design ............................................................................................ 190 8.2. Contributions of This Thesis ......................................................................................... 192 8.3. Future Work .................................................................................................................. 194 Appendix A: Physical Activity Homework by Process of Change ........................................... 201 Appendix B: Basic Story of Bill Battle and the Atomic Sub ..................................................... 203 Appendix C: Characters in Adventures of the Atomic Submarine ........................................... 206 Appendix D: Questionnaires for the Evaluation Study ............................................................ 210 Appendix E: Interview Questions............................................................................................. 231 References .............................................................................................................................. 231 Chapter 1. Introduction The leading cause of death in the United States and in the world today is chronic disease (Yach et al. 2004), and lifestyle health behaviors—such as physical activity, diet, and smoking—are the most prominent contributors to these diseases and other causes of death (Mokdad et al. 2004, Mokdad et al. 2005, Schroeder 2007). Changing lifestyle health behaviors is a difficult, long-term process and often
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