Computer gGames for o Obesity and dDiabetes pPrevention: Interfacing bBehavior cChange tTechniques to gGame eElements

Written by Brian Mayrsohn, MS,

Research Assistants: Alexis MoffWilliam Butler, BS, Alexis MoffWilliam Butler, Christopher Gates, Georges Khalil MPH

FIRE Mentors: Atsusi Hirumi, PhD. & David Metcalf, PhD.

University of Central Florida College of Medicine

2. Abstract

With the increasing burden of chronic diseases, such as obesity and diabetes, there is a strong need for a low cost solution that can be individualized for patients. Games for health are touted as that solution. A major benefit is that they can improve the delivery of care across the healthcare continuum while also increasing reach and patients buy in. Successful health games are based on theoretical frameworks which require the successful implementation of game elements. However, terminology used by researchers is either asynchronous, or totally lacking, making it difficult for others to refer to a consistent approach. The purpose of this study is to bridge the gap between game designers and behavioral scientists enabling them to create games based on behavior change game-elements (BCGEE) . These BCGEEs are optimally designed not only to be fun and engaging, but also to be transformative. A tool was developed which merges these two fields and creates a common language that could assist researchers and game designers in the identification of BCGEE necessary to create more efficacious health games. The tool was constructed using research obtained during a systematic review of the literature, the expert guidance of one game designer, and three behavioral scientists that develop games for behavioral change. The tool was then validated through one-on-one interviews with game designers and behavioral scientists. A mixed method research approach was taken by utilizing thematic analysis and Linkert scales to evaluate the transcripts obtained from the interviews. The analysis of the transcripts led to redefining the game elements and links between the two fields. By including all stakeholders, a common language was developed that both fields can utilize to develop games for change.

3. Lay Abstract

Games for health have the potential to change the way patients engage nutrition and physical fitness, and hopefully result in healthy behavior. Games for health is a relatively new field and, like any new discipline, there are growing pains. There is not a common terminology that all within the field use, and as a result, there is no universal standard at which to build the industry on. The aim of this study is to create a tool that health game developers can use to identify the correct terms and examples to make a successful behavior change game.

4. Background:

Overview

With the increasing burden of chronic diseases, such as obesity and diabetes, there is a strong need for a low cost preventative solution that can be individualized for patients. Traditionally, behavioral change interventions aimed at changing physical activity and eating patterns range from individual-based to community-level1and demonstrate small to moderate effects on weight loss2. Additionally, skill level, time commitment, and expenses vary among health professionals which, when combined with the lack of program effectiveness, reach, and sustainability, may account for the lack of substantial impact1. While grass-roots style campaigns may have many obstacles, especially with respect to scalability and manpower, leveraging the Internet to disseminate games for health may prove to be a cost-effective and perhaps more efficacious alternative if augmented with in person activities.

Unlike previous generations, smartphone devices and portable gaming consoles ubiquitous nature allow gamers to virtually eliminate all downtime and grant access to tens of thousands of games3. Today 183 million gamers log an average of at least thirteen hours a week in the US alone3. Games could be a successful medium in which traditional behavioral change techniques (BCT) are infused in attempt to alter malignant behavior without disrupting normal lifestyles3. Michie et. al defines a BCT as an observable, replicable, and irreducible component of an intervention designed to alter or redirect causal processes that regulate behavior; that is, a technique is proposed to be an active ingredient4. Internet-based games offer several advantages than their traditional in-person counterparts including reach, availability, and opportunities5for interactive approaches6. Additionally, information and messages can be tailored to participants to personalize the experience7. Furthermore, games provide a way for users to anonymously seek out sensitive health information while making it fun and engaging8.

In the past video games have traditionally been placed in the home8 and health games directed at preventing and treating childhood obesity were outside the home9. However, mobile technologys (e.g. smart phones, tablets, and wearable sensors) wide availability and pervasiveness has paved the way to easily facilitate health games infiltration throughout all aspects of ones daily routine10. Interestingly, the commercial games implemented in arcades consist of exergames and exergaming stations, whereas those distributed by researchers focus on nutritional behaviors11. The gaming industrys preference towards PA games seems logical given the ease at integrating entertainment with physical activity (PA) rather than tackling to complicated nature of applying theoretical frameworks coupled with nutritional behavior education components.Psychological theories have successfully been utilized as the foundation for developing dietary and physical activity behavior change interventions and experiments over the last century1214. Analogous to traditional interventions, video game dietary and physical activity interventions rooted in behavioral theory can be an effective medium to create behavior change15. Over the last decade, interventions delivered over the internet that focus on physical activity1,2,6,1619 and diet2,1922 have become increasingly prevalent. Games such as Diab, Zamzee, among other mobile and Wii games have shown to have a significant impact on anthropometric and physiological measures and health behaviors23,24 .

Traditionally, entertainment education has been used in television to passively change behavior. However, Internet games may offer great attention and credence due to their immersive qualities2,19,21,25,26. Therefore, games delivered on this newly ubiquitous platform are proving to be an effective strategy for embedding behavior change procedures including modeling, skill development, self-regulatory behaviors, reward, and immediate feedback19. These interactive components (e.g. avatar, quests, rewards, etc), referred to as game mechanics or game elements (GE), have been defined as methods invoked by agents for interacting with the game world27 and are the primary source of interactivity and structure how video games proceed28.

Research has shown that simulation and scenario-based games are especially effective in teaching skills for healthy lifestyle, prevention, and self-care as well as creating a safe environment for users to rehearse new skills and to develop deeper understanding of cause and effect28. When players rehearse skills in a simulation game, health-related knowledge29, skills30, self-confidence31, and behaviors32 can improve. These processes foster the development of new attitudes, emotional responses, risk perceptions, self-concepts, and social connections, which can strengthen motivation for behavior change29.

Behavior change interventions are rooted in behavioral theories or frameworks, such as social cognitive theory (SCT), self-determination theory (SDT), and transportation theory (TT). Each theory requires a specific application of BCTs to accomplish behavior change. Until recently, there has been wide use of disparate terminology in published reports affecting the interpretation and comprehension of not only the experimental design but also the results4. In fact, behavioral medicine researchers and practitioners have expressed a low confidence in their ability to replicate previously established successful diabetes prevention programs33. In response, Michie et al. developed a comprehensive taxonomy of BCTs to create a common language that will improve the accuracy of replication and facilitate the faithful implementation and development of behavioral change interventions. The games for health field is experience a similar problem.

Games for health is a relatively new field composed of many disciplines. The game architects salient objective is to systematically combine GEs in such a way that they create a fun game. Without the fun factor, which also requires carefully applied game mechanics and narrative, a health game will not be effective because of a simple premise: if it is not fun, people will not play it. According to Dr. Pam Kato, former CEO of Hopelab, a games for health company, any game mechanic can be successful as long as it is balanced and/or supported by programming that executes it well, art that emotionally engages players, game design that promotes ongoing engagement, and content that is presented in a way that merges with all of the above seamlessly. However, GE definitions vary among disciplines (e.g. game designers and behavioral scientists), so this research seeks to establish a definition database of GE that people can refer to when developing games for health. Additionally, when operationalizing these GE for use in behavior change interventions, further complications arise.

While games developed are unique and utilize GEs creatively, the theoretical rational for their effectiveness in behavior change can be narrowed down to a select few frameworks. These include Social Cognitive Theory (SCT), Self-determination Theory (SDT), and Transport Theory (TT)15. Many theories that independent researchers reference as the mechanism behind their interventions success seem to overlap. However, theories and change procedures were either applied differently or the terminology used was asynchronous4,34. This was the case in both the games for health field as well as the behavioral psychology field16,24. It is all too common for change procedures (e.g. tailoring) as well as psychology theories and outcomes (immersion) to be labeled at GEs that actually result from successful implementation of the elements which makes the authors explanation of confusing and can lead to reduced fidelity in interpretation and application of lessons learned4,24each of these BCTs are unique and carry varying degrees of relevance and effectiveness, understanding which GEs are interfaced with which BCTs still remains unclear. Researchers have categorized discrete lists of BCTs used in health4and messages found in health promotion videos and identified principles of social influence15, but there are few available list of discrete GEs used in health behavioral change games28.

The purpose of this study is to bridge the gap between the designers and developers and the behavioral scientists to enable them to create games based on behavior change game-elements (BCGEE) that are optimally designed to be fun and engaging but also transformative. The aim of this tool is to assist researchers, game developers, and game designers in the identification of BCGEE necessary to create more efficacious games that can create behavioral changes and ultimately better health outcomes. A foundational first step for this work is to identify and define the most common GEs and BCGEEs found in the games for health research and match them to BCT. 5.0 Methods:

A systematic review of the literature was performed and game element examples (GEE) were identified and extracted. A standard definition for all GEs that matched the corresponding GEE was developed, and intervention descriptions in primary studies were coded for inclusion or exclusion of defined BCTs.

Definitions

Game Element Examples are defined as an example of a GE applied to a game. Game Element Examples when used for behavior change will be termed Behavior change Game Element Examples (BCGEE). GE are defined as methods invoked by agents for interacting with the game world27. A BCT is defined by Michie et al. as an observable, replicable, and irreducible component of an intervention designed to alter or redirect causal processes that regulate behavior; that is, a technique is proposed to be an active ingredient4.

How Game Element Examples were Identified

GEEs and their respective definitions were identified through a systematic review of the games for health, entertainment education literature, and online databases. A web search was conducted using PubMed and Google Scholar applying combinations of the following keywords: games for health, game and behavior change techniques, games for change, obesity, diabetes, health, fitness, mobile devices, mhealth. The studies that were chosen for incorporation into the tool had demonstrated sufficient evidence that their game applied an acceptable level of behavior science and that there was evidence supporting improvements in health behavior, knowledge, self-efficacy, confidence, and other determinants. Only games that were published in peer review journal articles were selected for the review. There are renown experts in this field (e.g. Thomas Baranowksi PhD, Pamela Kato PhD, Wei Peng PhD, Deborah Thompson PhD, Elizabeth Lyons PhD, Amanda Staino PhD, Richard Buday) that apply behavioral science theories in game design, all of which were either interviewed or provided guidance for this study. These authors published papers which were included and considered the cornerstone standard of game development by which all other published papers were compared to. GE definitions were identified from published entertainment education and games for health literature (i.e. 65 abstracts, 20 full length journal articles, select sections from five books) and a definition database was developed. By focusing on the most discussed and understood GEs in games for health research, we were able to retain accuracy in our definitions rather than speculate on less researched concepts4,21,24.Comment by William Butler -: Who considered them a gold standard? Perhaps replacing with a sentence like These authors were deemed significant given the amount of cross-references by other authors in their field.

The purpose of the tool was to identify the various GEs in use. Therefore, the BCGEE became the starting point for the tool. This allowed the research to focus on which GEs were actually being utilized by researchers and game developers. A BCGEE was matched to a GE by identifying which GE definition from the definition database encompassed the BCGEE. GE definitions were created using several sources, and the most succinct, accurate definitions were utilized and iterated upon. It was our goal to provide the end user with as much information as possible regarding the context in which that GE was applied. We therefore included many quotes from the text in an attempt to recreate the setting by which the author intended. If a study called a BCGEE by specific GE, but that GE definition from our database did not match, we relabeled the proposed GE to fit the BCGEE used by the game according to our established definitions. Further complicating matters, some papers utilized BCGEEs without explicitly identifying them16,24, therefore the GE definitions guided us in further identifying BCGEE. This is a similar application of Michie et als BCT taxonomy.Moving one step further, in an attempt to combine the fields of behavioral science with game science, connections between BCTs and GEs were made by operationalizing Michie et al.s taxonomy of 93 BCTs. The definitions from that study have been validated and are now the reference for behavioral science. Once a definition pair was made between GE and BCTs, the BCT example from the taxonomy was assessed in relation to the BCGEE, to confirm our proposed match.

In the RightWay Caf, for example, positive attitudes toward healthy eating are promoted by providing positive feedback and rewarding points to players when they choose healthy food. This BCGEE was termed a reward, and defined as "The player receives something perceived as valuable (either intrinsic or extrinsic), or is relieved of a negative effect for completing goals during the game." This GE definition matches nearly perfectly with Non-specific reward, which is defined as: Arrange delivery of a reward if and only if there has been effort and/or progress in performing the behavior (includes Positive reinforcement) When there was not an obvious match between a GE and BCT, the BCGEE was compared directly to a BCTthe procedure used following a successful definition pair match. In several instances there was no clear match between BCT and GE, therefore the GE under consideration required two or more BCTs to properly create an all-encompassing link. The 2013 taxonomy has examples associated with each BCT, so in an effort to be consistent and to maintain the taxonomy as the foundation for this tool, the examples were incorporated verbatim. It is important to note that the 2013 taxonomy does not include games for health interventions, or for that matter, interventions that utilized gaming technology. This added to the burden of attempting to interface the two disciplines. Following the completion of the prototype, in depth conversations with one behavior scientist and two behavior change game design experts were conducted. They were each asked a series of questions which can be found in appendix. These conversations were important to creation of the prototype tool. Once the feedback from the three stakeholders was integrated into the tool, the new iteration of the tool underwent rigorous scrutiny from an expert panel. The expert panel was composed of a 5 game designers trained in game design, and 6 games for health experts whose background includes psychology and game design. 5 of the 6 psychology trained game researchers had a PhD. The questions to those interviews can be found in the appendix. While the discussions were critical to validating the language used in the tool, they also served to gather feedback from stakeholders who are the target audience for the application of this tool.

6.0 Results:

The original tool created wasrevised considerably since it was initially conceptualized. Conversing with the three early participants helped to shape the need, purpose, and application of the tool. When speaking with the one of the original game design experts, it was clear that he could not see the application of the BCT for an intervention, and he asked for examples of the BCT to be included to provide a point of reference how GEs could be utilized. Initially, the tool was composed of behavioral theories, constructs derived from those theories, BCTs, and GE, and the BCGEEs. One of the behavior scientists stressed the importance of switching the BCT reference from the 2008 taxonomy to the 2013 version. It was also expressed that the BCGEEs have to be easier to understand, which led to a reworking of the BCGEEs into more concise, common explanations as shown in Table 1. This transition required a reworking of the connections between many of the BCGEEs because many of Michie et al.s termsespecially the more generalwere refined and made more specific. Additionally, the 2013 taxonomy added many new BCTs. For example, the GE Feedback was originally paired to the BCT General Encouragement, however General Encouragement was not included in the 2013 taxonomy. Therefore pairing the Feedback GE with a BCT definition became more complicated as shown in table 1. In the original tool, feedback and feedback as a reward was one game element. The fact that many of the participants, including Pam Kato, Patrick Feller, Alan Simons, and Richard Buday, defined these as two distinct terms and made it clear that it should be its own GE.. The game element was split into two separate terms. The definition of feedback as a reward is related to the definition of feedback, but goes farther to include feedback being used as a reward in gameplay. Feedback as a reward positively reinforces the behavior being rewarded, according to Pam Kato and Wei Peng. The example of feedback as a reward is one that shows the feedback upon completion of a goal and would encourage players to repeat the behavior. The behavioral change techniques are the same as that of feedback, because feedback as a reward is still feedback. The added technique of non-specific reward [10.3] was chosen, because it gives the way in which feedback can be used as a reward for the completion or progress towards a goal and the usefulness of that in positively reinforcing behavior.

With respect to feedback, the expert panel all gave input on how feedback can be implemented in games so it was included that it can be visual, written, touch, or auditory. Furthermore, rightness and wrongness were removed from the definition due to disagreement of feedback containing disagreeable connotations. Therefore, the phrase information on game play performance was used because many of the interviewees Wei Peng, Richard Buday, Alan Simons, and Pam Kato mentioned that feedback is simply the displaying of information from the game to the player based on the interaction, without providing judgment on the positive or negative qualities of that interaction. While it is true that feedback can be used to inform someone of his or her in game successes, that would express a narrower example of the GE being applied in a specific way by the game designer and therefore addressing the quality of the feedback would limit its applicability.

The feedback example was derived from DIAB in which a player is given information in the form of a score sheet that evaluates their performance. The BCT for feedback is feedback on behavior [2.2] and feedback on outcome(s) of behavior [2.7], because it shows that information is given to someone as a result of their actions.

GE NameGE Definition

Feedback (Old)Games provide information feedback. Feedback in learning or playing games is designed to evoke the correct behavior, thoughts, or actions. Games provide information upon which the player can act. The information feedback is designed to indicate the degree of rightness or wrongness of a response, action, or activity. Feedback immediately informs the learner if he or she did the right thing, the wrong thing, or somewhere in the middle but doesnt tell the learner how to correct the action.

FeedbackInformation on game play performance given to players during the game. It can be visual, written, touch (vibration of a controller) or auditory.

GE Name Behavior Change Game Elements Example

FeedbackIn DIAB, there is a fruit knowledge mini-game where fruits must be distinguished from non-fruits and feedback is given to the player in the form of a score sheet. All the correctly identified fruit appears under a green check mark, whereas all the incorrect selections appear under a red x.

Feedback (Old)Instant feedback regarding whether the players choice is correct or incorrect include sound effects and/or graphics. General feedback, to enhance a sense of accomplishment and personal pride in a job well done, is also included at various places in the video game and included statements such as, Great! You picked well! Feedback is also specific, positive, and realistic: Youve met goals before and youll do it again. No ones asking you to be perfect, just try. (D)

BCT NameBCT Definition

General Encouragement (2008) Praising or rewarding the person for effort or performance without this being contingent on specified behaviors or standards of performance

Feedback on behavior [2.2] (2013) & Feedback on outcome(s) of behavior [2.7] (2013)[2.2] Monitor and provide informative or evaluative feedback on performance of the behavior (e.g. form, frequency, duration, intensity) & [2.7] Monitor and provide feedback on the outcome of performance of the behavior

Table 1. This table shows the old game element of Feedback and its corresponding BCT definition pairings from the old taxonomy. It also presents the new iteration of the GE definition and the new BCT pairing from the new taxonomy.

AvatarIn the original tool, an avatar was not one of the game elements defined. During the interviews, the participants were asked to define dynamic avatar. Ross Shegog, Richard Buday, Amanda Staiano, and Wei Peng all defined avatar separately from the definition of dynamic avatar, which made it apparent that avatar needed to be defined as a game element in itself. In the definition of avatar, the word representation is used to signify the purpose of an avatar, because almost every participant used that word to say that the avatar is a representation of the player, including Ross Shegog, Richard Buday, Amanda Staiano, Wei Peng, Patrick Feller, Alan Simons, and Nate Yeller. The definition is taken from Ross Shegog saying, An avatar is a virtual representation of the player in game state. The two examples are from health games that allow a player to create a virtual representation of them in the game they are playing. The behavioral change technique for avatar was chosen as identity associated with changed behavior [13.5]. The player creates a virtual identity of them and performs behaviors required of that new identity, during the game.

See Figure 1 for the tool and the appendix for the rest of the edits made from the original prototype to the current edition of the tool. Figure 2 is a visual representation of the connections made between the BCTs and GEs.

7.0 Discussion:

This research is the first systematic analysis that sought to identify potentially effective GEs used specifically for behavior change interventions in health applications. It was therefore the aim of this study to highlight successful games that were effective in positive health behavior change for designers to draw inspiration. A roundtable discussion that included discussions from six world subject matter expertsthree of which participated in this studyprovided examples on what they found to be effective and ineffective GE for games for health. However, as of this writing, there are few publications that discuss specifically successful GEs and define them in the context of improve diet and physical activity.

Application of different GEs are critical to the success of a game. For example, in game prompts can be an excellent way to remind the user to perform a task, but they can also become annoying and ignored (similar to banner ads on a website). Thus, highlighting the importance of strategically implementing each GE within a game and determining its purpose with great intention. Lu et al. and Mayrsohn and Khalil emphasize the importance of drawing inspiration from successful commercial games to create a behavioral change game that is actually fun10,11.Comment by William Butler -: Citation needed.

The various combinations of GEs that most effectively drives specific behaviors to change have not yet been fully elucidated. One large barrier that clearly prevents the scientific community from identifying exact mechanisms is due to the use of inconsistent terminology making it difficult to perform meta-analyses. Furthermore, studies not only neglected to associate GEs and theoretical frameworks, but also neglected to label all GEs used in the methods section or game description, making it increasing difficult to assess a games attributes or replicate specific components that games implement16,24. This can be because some researchers may consider a mechanism in a game to not be a GE, whereas others consider aspects of game play to be GE when they are in fact not. Unless the games are actually played, it is difficult to ascertain each GE included, and how it was utilized. A reason for this is the page limit in peer-reviewed journals.

Creating a standardized set of GE definitions will clarify which techniques, or combinations of techniques have been implemented, which will allow for a more precise understanding of the study in question and will aide researchers in determining which GEs are correlated with effective behavior change. By focusing on the most discussed and understood GEs in games for health research, we were able to retain accuracy in our connections rather than speculate on less researched concepts4,21,24.It was apparent from our early conversations with game developers that including the theories and constructs would be unnecessary for game developers because it is beyond the scope of their knowledge, not to mention confusing.

There were instances where researchers used the term GE when referring to the mechanics used in them game; however the terms were inconsistent with the GEs found in literature. For example, the game Right Away Caf uses the terms interactive tailoring, role-playing, the element of fun, and narrative to create a safe environment for users to practice behavioral rehearsal21 when referring to GE, however interactive tailoring is the result of the successful implementation of GE to personalize the game to the user. Additionally, the element of fun is not a GE, but a result of applying GE successfully.

BCGEE and GE matches did not always withstand the scrutiny:

The BCGEEs contained in Escape from Diab were analyzed. The authors used motivation statements in accordance with SDT, because they can help a player see the relevance a behavior can have on something that carries importance to his or her life. They sought to elicit this connection using value reason statements and internal motivation, however there was no GE mentioned or defined in association with that. The database was implimented and matched Diabe was matched to puzzle, which was defined as a mental challenge with at least one correct solution state that the player must find35. After interviewing the expert panel, we were mistaken in our pairing process. We ended up removing the puzzle game element all together because a match was unable to be found.

There were also instances where we had overlapping GEs such as take risks and trial and error. According to several participants, including Richard Buday, taking risks was not considered a GE, so it was therefore removed from the list. Additionally, the term riddle was originally used interchangeably with the term puzzle, but through the interviews, 10 out of 11 people felt that the two were distinct GEs. Once BCGEEs and GE were linked in the study, the next objective was to match BCTs from the taxonomy.

Matching Game Elements to Behavior Change Techniques

Matching GEs to BCTs proves difficult due to domain variability. Furthermore BCTs were defined as behavioral change relates to traditional interventions, not game interventions. For example, the In Game Prompt GE is defined as A virtual cue (Visual or auditory) to influence a user to engage in a specific activity or behavior in the game. In real life, there are no prompts that pop up, however there are certain triggers in a persons environment to cue him or her to do something. For instance, a seatbelt light that triggers a person to remember to wear a seatbelt or placing a favorite quote in ones kitchen to remember a life idiom. Therefore two BCTs were identified including 1) Prompt/Cues and 2) adding objects to the environment both of which could satisfy our definition. In life, these cues interject in a persons presence when a specific action is taken such as turning on the car, and similarly in a game, these cues would not be triggered until the person enters a room or a given level. Therefore, these similarities led us to match them together.

We also found, that while BCTs could be sufficiently matched to a BCGEE, it was not always essential. For instance, the GE trial and error is defined as a process of attempting to accomplish goals by trying different methods and discovering which one is the most successful. Essentially it is a process by which we learn from our mistakes. Therefore, one could argue that the BCTs that match feedback are 1) self-monitoring of behavior or 2) Feedback on outcomes of behavior could be matched. Either one is sufficient, but both encompass the global understanding of the term.

Another example is the game element Quest. A Quest is matched with behavioral contract, defined by the [creation] a written specification of the behavior to be performed, agreed on by the person, and witnessed by another, however a result of completing the quest may be the BCT information about health consequences, Provide information (e.g. written, verbal, visual) about health consequences of performing the behavior. This phenomenon makes it difficult to match BCTs accordingly. Therefore, it may be easier to match BCGEEs directly to BCTs, a notion that Marie Johnston alluded to in a one-on-one interview

Leveraging game elements appropriately

When using this tool, it is important to note definitions and examples may be taken out of context. In the games they were selected from, GEs are woven with the storyline and applied with other GEs to enhance their effectiveness. Additionally, the underlying effectiveness of one BCGEE compared to another is not clear, mainly because studies do not remove one GE and study the effect because the success of a game is dictated by the combination of GEs. Interestingly though, a game designer can use different GE to accomplish similar results, however their effects can be amplified by applying them in conjunction with psychosocial principles. For example, tutorials and role model NCs were shown to be good methods for modeling behaviors or giving instruction, but what was not mentioned was their effectiveness increases dramatically by creating animations or characters who share similar phenotypic features as the user. Furthermore, children who perceive themselves as similar to and empathize with the characters are more influenced by the media context in which these characters appeared36. Analogous to role model NPCs, using a phenotypically similar dynamic avatar that the user can empathize with can be an effective behavior change tool. Essentially, the gaming experience is often greater than the sum of individual GEs.

Dynamic avatars give positive feedback to the player on whether or not they are performing the behaviors needed to achieve their goals. If the player performs the behaviors of the game then the avatar will change in a positive way or vice versa. In health games, dynamic avatars can be used to give information about health consequences4. In a health game, if you do not eat healthy, your avatar may become slow or weak. This translates to information in real life about food choices and health consequences. Also, this can be used by game designers to create discomfort and incompatible beliefs4. It will draw attention to the difference between the behavior and consequences of that behavior and the desired behavior and outcomes of the behavior4.

When targeting a specific behavior, different combinations or uses of GEs will have varying degrees of efficacy. If the goal of the game was skills transferteaching a user a new skillone could apply: Quests' can breakdown a complicated behavior and help a player learn over a stepwise fashion, which builds on specific components. When the specific components are combined it can culminate in a learned skill on a boss level. Repetition could allow a user to practice multiple times until they gain memorizations37. Cut Scenes would be able to explain a complicated behavior. All of these can demonstrate a new skill, but it is important to note that each of these GEs has varying degree of correlation between the element itself and skill transfer. For example, knowledge does not necessarily correlate to skill transfer, but it is important in the teaching process24. Interestingly, each of these GEs can be used separately, combined as all three, or some variation, however the may be an ideal combination. Without a common language to define all of the GEs and their corresponding BCT, it is difficult to assess which combination is in proven to be most efficacious.

How to use this tool

While this tool could never substitute for collaboration between behavioral scientists and game designers, it can serve as a guide for game designers. Combined with an off the shelf game, it can empower researchers with a list of BCGEEs that can serve as a starting point for producing behavior change games and provide research for game developers on how to incorporate BCTs into their commercial games. Therefore this tool can be used in a similar manner as a taxonomy. Meaning that the tool can be used to create a game instead of pulling from ones brain, or use the definition pairs and BCGEEs provided to identify GEs in other research papers for meta-analysis. This review is not exhaustive, but a first step towards identifying the game elements utilized in one broad health domain, healthy eating and physical activity.

Limitations

This tool can be used in several ways depending on the field and individual project. To date, interviews have focused mainly around the tools accuracy, and not how one would create a game from its contents. Some limitations of this tool were the selectivity of the games chosen for incorporation. The games highlighted cater to younger generations, therefore the scientific evidence will only support using the BCGEE for those ages. However, the core principles and definitions behind the connections and definitions is still accurate for all health games and experiments conducted towards varying populations should be undergone. In order to apply the BCGEE to a different population, BCGEE can be adjusted. Ultimately, this tool can be used to determine intervention content and to facilitate communication between game designers, intervention designers, adopters, and reviewers. This work demonstrates the feasibility of characterizing GEs utilized by games designed to change behavior

Future Research:

One of the next steps for this research is to integrate GEs fun factor, or acceptance, amongst players into the tool to better provide the end users with an understanding of how the GE was received by the player during play. This additional information will allow researchers to see not only which BCGEEs were successful in changing behavior, but also which were used to make a game more fun and engaging for users echoing the Entertainment Education approach21. This study is just the initial stages of a much larger endeavor. This was a definitions of concept study to determine the best methodology for categorizing BCGEEs, GEs and pairing them with BCTs. Further research into the successful application of GE and BCGEEs within physical activity and nutrition education games is warranted because new health games enter the market each year.

This methodology can be applied to a variety of health topics and should be considered for greater ease of access to information for game designers looking to develop a successful game for health. See figure 3 for an example of how this tool can be applied to a cancer adherence game, called Remission-2. A next step for this tool will be its successful application to create a game for change. Currently, a startup company at the University of Central Florida College of Medicine led by Co-Founders Alexander Eskandari, Zoran Pavlovic, and Brian Mayrsohn, have operationalized this tool for the creation of their behavior change health app called, MotiveAte. Further testing to determine the effectiveness of that app should shed light on the role this tool can play in the development of future games for health. Comment by William Butler -: Has this name changed?

8.0 Literature Cited

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9.0 Appendix

Question set 1:Do you think that the Game Elements match the psychology behavior change technique. Do you find that these definitions are helpful? How do you think this tool could be improved?

Question Set 2:Gamer QuestionsQuestions to ask for each line item: How do you define the game element, [e.g. Score Board?] in question? To what extent do you feel that our definition matches your understanding of the game element on our scale of Strongly Disagree to Strongly Agree? If they dont agree follow up with why do you disagree, after they respond, follow up what game-element would you say best fits our definition. Here is our game element example, using our scale, to what extent to you feel it matches or does not match the game element example. If it does not match the game element example, ask them for an example that they feel like would match.Question to ask at the end: On a scale of 1 to 4, how likely are you to utilize this tool. On a scale of 1 to 4, 4 being highly likely, 1 being highly unlikely, how like would you be to utilize this tool? What are your reasons for choosing this number? In your opinion, what game elements are essential to creating an effective game for health? In what ways, if at all, would you use this tool?

Results from in-depth interviews: Avatar Results In the original tool, avatar was not one of the game elements defined. During the interviews, the participants were asked to define dynamic avatar. Ross Shegog, Richard Buday, Amanda Staiano, and Wei Peng all defined avatar separately from the definition of dynamic avatar, which made it apparent that avatar needed to be defined as a game element in itself. In the definition of avatar, the word representation is used, because almost every participant used that word to say that the avatar is a representation of the player, including Ross Shegog, Richard Buday, Amanda Staiano, Wei Peng, Patrick Feller, Alan Simons, and Nate Yeller. The definition is taken from Ross Shegog saying, An avatar is a virtual representation of the player in game state. The two examples are from health games that allow a player to create a virtual representation of them in the game they are playing. The behavioral change technique for avatar was chosen as identity associated with changed behavior [13.5]. The player creates a virtual identity of them and performs behaviors required of that new identity, during the game. Discussion The behavioral change technique in avatar was chosen because when you enter the game world, especially a health game, you are changing your behavior for that game. The goal of health games is to help bring about behavioral change. In order for this to be effective, behavioral science points to the fact that someone needs to recognize themselves as someone who participates in this new behavior or avoids an old behavior. The use of avatars in games can really immerse the player in the game, because they can see themselves, virtually, in the game. If this is a health game, increased immersion in the game made lead to more effective behavioral change. The player can truly see a representation of themselves as someone who actively engages in certain wanted behaviors or avoids unwanted behaviors. Cut scenes Results This game element is taken from the interview with Richard Buday. He describes them as being a way to advance the storyline of the game, in-between the players gameplay. The example of cut scenes is taken from the game DIAB, which uses them to progress the storyline. The behavioral change technique for cut scenes was chosen, because cut scenes in games can be a healthy distraction from the behavioral change that is trying to be implemented. Discussion The game element, cut scenes, was created from the interview with Richard Buday and was not in the original tool. Cut scenes in games are extremely controversial. Richards opinion of cut scenes in games is that they are a force fit. In his opinion, there is a difference between immersion and presence. In games, the player is present in the universe created. They are reacting instinctively, as the character in the game, to the things that happen to them. In fiction, such as movies and novels, the person is immersed in what is happening. The person is vicariously connected to the protagonists. His opinion is that both are extremely important, but they are different cognitive processes. The game player is asked to learn through experience and act instinctively and the novel reader is asked to see a character deal with a problem instinctively and learn through reflection of that. He says that the role of games is not to replace fiction and when we ask a human mind to switch gears, between presence and immersion, it can be uncomfortable. This is important to keep in mind for someone creating a game for health. The behavioral science technique, distraction, suggests that it is important for behavioral change to allow the person to focus on something besides the unwanted behavior. In the game, if the only focus is solely on the behavior that is desired, it may become a trigger for unwanted behavior. Cut scenes may be a good distraction during gameplay, but other behavioral change techniques, such as identity associated with changed behavior [13.5] suggest that a person needs to see themselves with a new identity of someone who does not engage in unwanted behavior. If the immersion, or presence, of the player in the game is decreased then the behavioral change may not be as effective. Dynamic avatar Results The definition in the original tool for dynamic avatar was that it is an avatar that changes appearance based on game play. During the interviews, some of the participants strongly agreed with the definition, Pam Kato, Ross Shegog, Amanda Staiano, Patrick Feller, and Alan Simons, and others agreed, Richard Buday and Hunter Hayes, but two participants disagreed, Wei Peng and Nate Yeller. Although there was a majority of positive ratings almost every participant mentioned that a dynamic avatar does not have to change physically to be dynamic, Pam Kato, Richard Buday, Amanda Staiano, Wei Peng, Patrick Feller, and Alan Simons. Patrick Feller described it as being too limited, because it only discusses physical appearance. The definition was widened to include disposition and temperament. The definition includes that the dynamic avatar changes based on players interaction in the game, because almost everyone interviewed, Pam Kato, Ross Shegog, Amanda Staiano, Wei Peng, Patrick Feller, Hunter Hayes, and Alan Simons, mentioned that the dynamic avatar should change based on interaction with the game or choices the player makes in the game. The example was chosen for the original tool and rated as mostly strongly agree, Pam Kato, Patrick Feller, and Hunter Hayes, and agree, Ross Shegog, Richard Buday, Amanda Staiano, and Wei Peng. The original definition was shortened, because interviewees commented that the definition was too long and outside the scope of what a dynamic avatar is. The behavioral change technique for dynamic avatar is body changes [12.6], because the avatar changes in direct correlation to behavioral changes in the game. The altering of structure can facilitate behavioral change. Discussion The example for dynamic avatar was originally based on the same example, but included information about personally relevant feedback. This is important, because dynamic avatars give positive feedback to the player on whether or not they are performing the behaviors needed to achieve their goals. If the player performs the behaviors of the game then the avatar will change in a positive way or vice versa. In health games, dynamic avatars can be used to give information about health consequences [5.1]. In a health game, if you do not eat healthy, your avatar may become slow or weak. This translates to information in real life about food choices and health consequences. Also, this can be used by game designers to create discomfort and incompatible beliefs [13.3]. It will draw attention to the difference between the behavior and consequences of that behavior and the desired behavior and outcomes of the behavior. Feedback Results In the original tool, feedback and feedback as a reward was one game element. The fact that many of the participants, Pam Kato, Patrick Feller, Alan Simons, and Richard Buday, defined feedback and feedback as a reward separately made it clear that it should be its own element. In the definition of feedback the phrase information on game play performance was used because many of the interviewees mentioned these things, Wei Peng, Richard Buday, Alan Simons, and Pam Kato. The interviewers all gave input on how feedback can be implemented in games, so it was included that it can be visual, written, touch, or auditory. The example of feedback is an example from DIAB in which a player is given information in the form of a score sheet that evaluates their performance. The behavioral change technique for feedback is feedback on behavior [2.2] and feedback on outcome(s) of behavior [2.7], because it does show that information is given to someone as a result of their actions. Discussion In creating the definition for feedback, it was taken into account the different ways that a game can provide feedback. Hunter Hayes pointed out during the interview that it is important for game elements like feedback, score, and reminder to be in different forms, such as visual, auditory, etc. For a game to be effective, especially a health game that is attempting to implement behavioral change, it needs to appeal to different types of players. Feedback is intended to give information to the player, so the player may learn how to achieve their goals. Players may be different types of learners and to be effective it should appeal to different types of learning styles. Feedback as a reward Results In the original tool, the definitions for feedback and feedback as a reward were one single game element. Many participants, such as Pam Kato, Wei Peng, Hunter Hayes, and Alan Simons agreed that our definition was a good definition for feedback, but that the two are very different elements. Feedback is not necessarily a reward, Alan Simons. The game element was split into two elements. The definition of feedback as a reward is related to the definition of feedback, but goes farther to include feedback being used as a reward in gameplay. Feedback as a reward positively reinforces the behavior being rewarded, according to Pam Kato and Wei Peng. The example of feedback as a reward is one that shows the feedback upon completion of a goal and would encourage players to repeat the behavior. The behavioral change techniques are the same as that of feedback, because feedback as a reward is still feedback. The added technique of non-specific reward [10.3] was chosen, because it gives the way in which feedback can be used as a reward for the completion or progress towards a goal and the usefulness of that in positively reinforcing behavior. Discussion The definition of feedback as a reward was influenced by the definition of reward. They are closely tied together. Many of the interview participants, Pam Kato, Ross Shegog, and Patrick Feller, discussed that the player needs to consider the reward to be valuable in order for it to positively reinforce the behavior. This idea is seen in the behavioral change technique, non-specific reward [10.3], as giving the participant something they value in exchange for implementing behavioral change. Goals Results In the original tool, goals was not one of the game elements defined. It became a game element, because, during the interviews, many of the participants asked us to define what was meant by goals in the game element selectable sets of goals and suggested that it should be its own game element for clarification, Richard Buday and Ross Shegog. The definition is a compilation of the interviewees discussing other game elements and using the term goal. Every participant used words about goals that suggested goals were predetermined and could be completed (have an end point). Ross Shegog defined goal as criteria by which we measure success. The example of goals was chosen, because it exemplifies an objective that a player needs to complete in a game to be successful. The behavioral change techniques of goal setting (behavior) [1.1] and goal setting outcome [1.3] show the importance of predefined goals that can be completed in implementing behavioral change. Discussion Goals are closely tied into the game element quest. A quest is the activity of achieving goals by overcoming obstacles, but a goal is the objective a player is achieving. These are occasionally used synonymously, but more often they are used to describe one another. In game prompt Results In the original tool, this was two game elements, virtual prompt and in-app reminder. When defining an in-app reminder, most participants it as a virtual queue or prompt in the game, Pam Kato, Ross Shegog, Richard Buday, Amanda Staiano, Patrick Feller, and Hunter Hayes. It was apparent that both game elements were not necessary. An in-app reminder can be an example of a virtual prompt being used, but it is not a game element alone. The definition of in game prompt is compilation of the two elements and what the participants said about each of them. The definition of virtual prompt influenced this the most, because it received positive ratings. In game was used instead of in-app, because in-app implies that it is only fitting to games that are applications and not all games. The example for in game prompt was chosen to show a specific, virtual cue that informs players to participate in a specific behavior. The behavioral techniques chosen for in game prompt show an introduction of something into the environment that stimulates or facilitates a specific behavior. Introducing stimulus into an environment can implement behavioral change. Level Results In the original tool, level was not one of the game elements defined. It was defined as levels of challenge. During the interviews, many of the participants disagreed with using the term levels of challenge and said that the term should just be level, Pam Kato, Wei Peng, Patrick Feller, Hunter Hayes, and Alan Simons. The term levels of challenge was changed to levels and the definition remained the same. The example of a level is in the form of episodes in a game called DIAB. The behavioral change technique, graded tasks [8.7] was used in this, because it shows the nature of a level. There are tasks and once they are performed, the person can move on to harder tasks. Level of difficulty Results In the original tool, level of difficulty was not one of the game elements defined. When participants were asked to give the definition for levels of challenge, most gave similar definitions that were very different from the definition in the original tool, Pam Kato, Amanda Staiano, Wei Peng, Patrick Feller, Alan Simons, and Hunter Hayes. All of their definitions included varying degrees of difficulty or challenge to complete a level or quest. This made it apparent that it needed to be a game element. The example was chosen, because it shows the varying degrees of difficulty that are created in a game to achieve a goal. The behavior change techniques were chosen, because they show the need for varying levels of difficulty to implement behavioral change. The person needs set tasks that increase in difficulty and to review or change the difficulty of the behavior change desired. Multiplayer Results In the original tool, this was the definition and example of multiplayer. Pam Kato, Patrick Feller, and Hunter Hayes strongly agreed with the definition and example and Wei Peng and Alan Simons both agreed with the definition and example. The definition was kept as well as the example. The behavioral change techniques were also kept. Discussion Many of the people being interviewed brought up that multiplayer can be ambiguous. It may or may not include games that allow other players to affect the outcome of your game, this goes beyond the scope of our definition. Personalized goals Results In the original tool, personalized goals was not one of the game elements defined. When participants were asked to give ratings for the example of selectable sets of goals, which included players developing personal goals, most said that it was not an example of a selectable goal, but it was an example of a personalized goal, Ross Shegog, Richard Buday, Wei Peng, Patrick Feller, and Alan Simons. This was developed into a separate game element and kept the example given for selectable sets of goals, because the participants agreed that it was a good definition for personalized goals. The definition for personalized goals was created by using the definition for goal, because it is a goal and then adding the personalized aspect to it from several definitions given by interviewees. Amanda Staiano described personalized goals as individually tailored goals. The behavioral change techniques are the same as they are for goals. Discussion Amanda Staiano brought up a good point, that it is important for goals to be personalized to the player. In implementing behavior change through a health game, it may increase immersion and success if the player is able to see how the goals are personally relevant to them. Peng found that having users develop personal goals (specifically, calorie requirements and food preferences) and tailoring a game to target their preferences was successful in helping players select better food options. Personalized goals gets the player engaged in their behavioral change. Problem solving Results The definition of problem solving is a compilation of the participants definitions. The term process was chosen, because Patrick Feller, Hunter Hayes, Wei Peng, and Richard Buday used terms that signified it was the activity of figuring out solutions. Almost every participant, Patrick Feller, Hunter Hayes, Alan Simons, Ross Shegog, Pam Kato, Wei Peng, and Richard Buday described it as evaluating an obstacle and deciding how to get past the obstacle. The example was chosen, because it defines the process of problem solving and not just obstacles or solutions to solving obstacles. The behavioral change technique, problem solving [1.2], show the need for someone implementing behavioral change to analyze the factors or obstacles of the change and generate possible solutions. Puzzle Results In the original tool, this game element was riddle/puzzle. Almost everyone interviewed defined them separately, Pam Kato, Nate Yeller, Amanda Staiano, Richard Buday, Alan Simons, and Ross Shegog. Two participants said that the definition fit for a puzzle and not a riddle and that a riddle is a type of puzzle, but is not equivalent to a puzzle, Richard Buday and Ross Shegog. The definition of riddle/puzzle was kept, but slightly altered. The example was chosen, because it is an example that shows the cognitive aspect, which almost every interviewee said was important, Nate Yeller, Amanda Staiano, Ross Shegog, Amanda Staiano, Richard Buday, Wei Peng, and Alan Simons, that is involved in solving a puzzle. The behavioral change technique, framing/reframing [13.2], shows the importance of changing perspective and cognition involved in puzzles to figure out how to implement a behavioral change. Repetition resulting in habit formation Results The definition of repetition resulting in habit formation was chosen to include the word automatic, because Pam Kato, Amanda Staiano, Wei Peng all said that word specifically. The definition in the original tool included the phrase, gain a mastery over the game concepts, mechanics, or ideas presented. That was taken out, because Wei Peng, Pam Kato, and Alan Simons all disagreed that the repetition of a behavior would allow the player to master game concepts and mechanics. Behavioral practice/ rehearsal [8.1] and habit formation [8.3] were chosen as the behavioral change techniques, because they explain the use of repeating a wanted behavior to create a habit out of it and implement that behavioral change. Reward Results The definition of reward was kept from the original tool, because many interviewees strongly agreed with it, Ross Shegog, Amanda Staiano, Patrick Feller, Alan Simons, and Hunter Hayes, and the other interviewees agreed with it, Richard Buday, Wei Peng, Pam Kato, Nate Yeller. The example was also kept from the original tool, because many interviewees strongly agreed with it, Amanda Staiano, Pam Kato, Patrick Feller, Alan Simons, Nate Yeller and Hunter Hayes, and the other interviewees agreed with it, Richard Buday, Wei Peng, and Ross Shegog. The example was altered a bit to show how points are valuable in the game to the players, because Ross Shegog, Richard Buday, and Nate Yeller all spoke about it. The behavioral change technique was also kept, because it exemplifies the positive reinforcement of behavioral change and that the reward is something of value to the person. Discussion Many of the interview participants, Pam Kato, Ross Shegog, and Patrick Feller, discussed that the player needs to consider the reward to be valuable in order for it to positively reinforce the behavior. This idea is seen in the behavioral change technique, non-specific incentive [10.6], as giving the participant something they value in exchange for implementing behavioral change. The rewards in the game can be intrinsic or extrinsic as in real life, but it is important that they are valuable to the person for some reason. Role model NPC Results Pam Kato, Ross Shegog, Amanda Staiano, Wei Peng, and Hunter Hayes strongly agreed with the original definition of role model npc and Patrick Feller and Nate Yeller agreed with it. Alan Simons and Richard Buday both strongly disagreed with it. The definition was kept from the original tool, but a few words were altered. The example was rated equally positive and negative by different interviewees. The common factor in almost all of the interviews was the idea that the role model npc does not necessarily have to look like the player, which was in the original example. The behavioral change techniques were chosen, because they show the use of demonstrating a wanted behavior by someone a person might look up to and that they can see the consequences of those actions through another person. Discussion The example of role models sharing similar phenotypic features of the player can be very effective, especially in a health game. It is important for the player to relate to the role model npc and it may be more effective for the role model npc to share similar phenotypic features to the target population. If the player can see a demonstration of someone similar to themselves performing the behavior; it may seem more realistic that they can perform the behavior too. Score Results The definition of score received fairly high ratings. Ross Shegog, Patrick Feller, and Richard Buday all agreed with the definition and Amanda Staiano, Wei Peng, Alan Simons, Nate Yeller, and Hunter Hayes all strongly agreed with the definition. The definition was altered to include displayed, because several participants, Nate Yeller, Pam Kato, and Hunter Hayes, mentioned the importance of score being displayed for the player to know how they are doing in the game. The word progress was used instead of success, because participants Amanda Staiano and Pam Kato mentioned that it does not have to just represent success and that it may represent progress. The example was chosen, because it exemplifies scores as being displayed and an indication of progress. Many participants disagreed, Ross Shegog, Richard Buday, Amanda Staiano, Wei Peng, Patrick Feller, and Alan Simons, with our original example, because it did not show how score relates to the game. The behavioral change techniques were chosen and are very similar to those chosen for feedback and reward. These techniques show the importance of giving someone information on outcomes of a performance. Discussion Scores and rewards are tightly connected. The score can be given to a player as a reward in the game. The interviewees seem to point out that score, like rewards, are important in context. It has to be something that is valuable to the player. Selectable sets of goals Results The definition of selectable sets of goals was kept from the original definition, because almost every person interviewed said that they strongly agreed with it, Pam Kato, Ross Shegog, Amanda Staiano, Wei Peng, Patrick Feller, Alan Simons, Nate Yeller, and Hunter Hayes. There were two game elements in the original tool, selectable sets of goals and selectable sets of goals, data inputting, and constant tracking. In interviewing participants it was clear that the second was not a game element needed in this tool. Many participants said the example given for selectable sets of goals was more of an example of personalized goals, Ross Shegog, Richard Buday, Wei Peng, Patrick Feller, and Alan Simons, so the example was used for that game element instead. Many participants said the example given for selectable sets of goals, data inputting, and constant tracking was more of an example of just selectable sets of goals, Pam Kato, Ross Shegog, and Alan Simons, so the example was used for this game element instead. The behavioral techniques for this one include goal setting (behavior) [1.1] and action planning [1.4] to show the importance of agreeing on a set goal and doing it. Social Networking Results The definition of social networking is based off of the definition in the original tool. It is a condensed version of it, because Wei Peng and Alan Simons agreed that it included too much information on what supports social networks, but not defining what it is. The word communication was added, because Wei Peng, Alan Simons, and Pam Kato said that it was an important part of social networking. The example was strongly agreed upon by these participants and kept from the original tool. The behavioral change techniques were chosen, because they show the importance of social roles in behavioral change. Also, they are the same as the techniques for multiplayer. This is because social networking and multiplayer, in health games, both use important social support for implementing behavioral change. Trial and error Results The game element trial and error is a compilation of the definitions for what was two game elements in the original tool, try and fail and trial and error/take risks. Many of the interviewees equated try and fail with trial and error, Pam Kato, Wei Peng, Alan Simons, and Richard Buday. The definition of trial and error includes the word process, because as Wei Peng said, trial and error, is a process where you try and fail and then learn about what works and what didnt work and finally succeed. You focus on the persistence of it and not the learning. The example is actually the example from the game element trial and error/ take risks and shows the process of trying different foods to obtain the results desired. The game element of take risks was eliminated from the list, because it is not equated with trial and error, Pam Kato, Wei Peng, Alan Simons, and Richard Buday. According to Richard Buday, it is inherent in all games. Taking risks is a natural part in all game play and is not necessarily a game mechanic. The behavioral change techniques were chosen, because they show the process of performing a behavior and then monitoring how effective the behavior was. Tutorial Results In the original tool, tutorial was not one of the game elements defined. During the interviews, the participants were asked to rate the example given for quest, Richard Buday, Wei Peng, and Hunter Hayes mentioned that this was more of an example of tutorial, which can be a quest, but a quest does not have to be a tutorial. Alan Simons mentions tutorial during his interview also, which made it apparent that tutorial needed to be a separate game element. The definition was created based on the definition of tutorial given by Richard Buday, Wei Peng, Hunter Hayes, and Alan Simons. The example used for tutorial is a condensed version of the example given for quest in the original tool. The behavioral change techniques exemplify the teaching aspect of a tutorial and demonstration of behavior and what that means for implementing behavioral change. Quest Results The definition of quest is very similar to the definition in the original tool, because almost every person interviewed rated that they agreed with the definition, Pam Kato, Ross Shegog, Richard Buday, Amanda Staiano, Wei Peng, Alan Simons, Nate Yeller, Hunter Hayes, and Patrick Feller. Many of the interviewees said that it should include that there is an end and that there is an overall goal of a quest, Pam Kato, Ross Shegog, Richard Buday, Amanda Staiano, and Hunter Hayes. The example in the original tool for quest was perceived by many people interviewed as being more of a tutorial, Richard Buday, Wei Peng, and Hunter Hayes. The example was chosen to indicate that a quest is something done by overcoming obstacles and has an endpoint. The behavioral change technique, behavioral contract [1.8] show the commitment to a task until that task is complete, like a quest.