Written by Moya Sayer-Jones from a conversation with Dr Stuart Smith. Stuart is a master engager, collaborating with users in the development of video games designed for better health outcomes. –
I was working at the School of Psychology, Trinity College in Dublin, when one of my Masters students came to see me. He was a volunteer at a spinal rehabilitation unit. He said, ‘Stuart, we can’t get the young guys to engage in their rehab’.
We went down to the unit and I saw all these young men in the prime of their life, their whole life ahead of them and suddenly they’ve had this catastrophic injury. Their bodies could no longer do what they wanted them to do. We asked them, ‘Why don’t you want to do your rehab?’ And the answer was ‘It’s so boring’. They were dealing with many complicated issues including depression so the idea of turning up for these laborious, repetitive exercises had no appeal at all.
We said to them, ‘Okay, what interested you prior to coming to rehab?’ Their answers were pretty much the same: driving cars, playing footie, drinking Guinness, chasing girls and playing video games.’
Well, we couldn’t do much about chasing the girls and the guys were doing their best in that realm anyway (there were plenty of attractive nurses about) but we did start thinking about how we might use their love of video games.
We took in a Sony Playstation. It was the kind of technology that the guys were already familiar with and Sony had just brought out a USB camera that plugged into the console allowing you to interact with the games by moving your body. In playing with these games, the guys were actually doing the sorts of movements that were required in their rehabilitation. The only difference was that they were now lining up to do them. The clinician was amazed, ‘ We don’t have to cajole them to come down anymore. It’s fantastic.’
It was one of those lightbulb moments in your career. I suddenly saw that there was some magic in video games: they could be a vehicle for engaging people in behaviours that they wouldn’t ordinarily motivate themselves to do.
I feel like dancing, dancing
I came back to Australia to work with Stephen Lord at Neuroscience Research Australia, researching postural instability and falls in older people. Stephen is one of the best falls researchers in the world.
Falls are one of the biggest determinants of a decrease in your independence. If you have a fall, you’re unlikely to go back to your own home. Even worrying about having a fall can send older people into a spiral of decline physically and mentally.
I asked Stephen ‘What’s our evidence base?’ and he said, ‘We know what makes people fall over and we know that exercise reduces the risk but we don’t know how to get them to do it.’
We found there were many possible reasons why older people don’t exercise. They can be worried about going outside, they don’t want to go to a gym because it’s expensive or they often simply don’t think they can physically do it. We thought about how we could get people moving in the comfort and security of their own home and of course I started thinking video games, video games. And particularly, dancing games. Dance would tune into their natural likes and motivations because it had been a huge element of their social life when they were younger: sometimes, 3 or 4 times a week they would have gone to a dance. And the technology was accessible. Gaming consoles connect to a TV which is the dominant technology in any older person’s home.
Engagement depends on understanding what people enjoy, what motivates and drives them.
You’ve always got to start from that point. We had asked ourselves: what is something that seniors will seek out because it’s enjoyable, rewarding and provides feedback immediately?
Learning about your users
We landed on an existing game called Dance Dance Revolution which was almost perfect. It was physically challenging and required mental concentration but off the shelf, it was too difficult for our group. We had to adapt it, slow it down, put in age appropriate music and most importantly, we needed to include our target users in the development. They would tell us what they wanted to see in this game as we designed it.
I love to talk. I went out to Lions Clubs, Probus, Rotary and other age appropriate user groups and I’d talk and talk about the research we were planning and asked if they were interested in coming to our offices and sitting down with us for an hour or two. We built up a cohort of older adults who were happy to spend time with us just talking about their life experiences and what interested them.
You need to build a trusting relationship to begin with. I take time to talk with people one on one: not even as a scientist but as another human.
There are gems in their life experience that are crucial to me understanding where they’re coming from. It breaks down our chauvinistic perspective. You have to see the world from the perspective of others so you can understand the problem.’
At first they were resistant to the idea of video games. You could see it in their body language. They’d sort of sit back and they’d say, ‘I hate those damn games. My grandkids are always just glued to a screen and not interacting with me.’ So the line I took was that humans throughout history have always loved games. It’s one of the ways we explore the world. I showed them some of the newer video games like Nintendo Wii where you can play tennis using body moves and that sort of smoothed over the real sceptics… ‘Oh hang on, there might be something interesting in this gaming thing after all.’
So there was this whole iterative development cycle. We first of all had to overcome the barriers about how they might use the technology and to do that we had to think about the rewards from their perspective. Again it comes back to the questions: what drives this person? What are their experiences and interests? And then we co-design from there.
This cohort stayed with us through the process as we trialled the changes and showed them the adaptations we were developing. For example, in one of the first versions of Dance Dance Revolution we had mistakenly used music that wasn’t interesting to them.
They said, ‘What’s that rubbish? We want the bands we grew up with to be in the games: the Beach Boys, the Rolling Stones.’
When we’d started, we’d been thinking predominately of the 80 pluses as our target group but most of the people coming were in the 65-70 group. So that was a good lesson and a reminder that you can’t be too chauvinistic with your own perspective about what people will want. The user has to absolutely drive the agenda. A person is much more likely to use something they’ve had a hand in designing rather than something designed by someone who doesn’t share their experience, some 20 year old kid developer for example.
The rewards of feedback
I had a lady once who was recovering from a stroke and she said to me, ‘Look, I’m really frustrated by this technology. I’m not getting the immediate feedback about how well I’m doing. Can you guys put that in?’
So I asked the programmers to adapt the design so that every game she played, she got immediate feedback and sure enough, on the next update it was there. When I saw her afterwards and I told her that this adaptation of the game was a direct consequence of her suggestion, she was thrilled. Her whole face lit up.
She knew she’d affected change, not just for herself but every other person who would be using that system… because everybody would be going through the same thought process that she was.
Development can take a long time too. Keeping people in the loop with incremental changes is what keeps them engaged long term.
In many sectors, the recipient of a service and what drives them hasn’t really been considered at all in the system. But now those recipients are active agents in those services. The power of the consumer is on the rise. They know more too about their own state of health and they’re making decisions based on their own discoveries, from the internet for example.
The more data and engagement we have, the more we can refine and individualise our responses. What does this person want? What will motivate them? What will be enjoyable and interesting to them? That’s true for mental health as much as physical heath.
It’s pretty simple really: we’ve just got to tap into what is fundamentally human.
Stuart Smith is Professor of Disruptive Technologies at University of the Sunshine Coast. He is increasingly applying his thinking to the Disability Sector.