Phase 1: What are the Stressful and Rewarding Aspects of Games for Health?
The first study in Phase 1 was conceived in the theoretical framework of stress research (AGPHA) (Khalili-Mahani and De Schutter 2019), and we expected that motivation to engage with unfamiliar challenges would depend on the degree to which players counterbalanced the initial stress of learning a new (supposedly brain-enhancing) game against its potential reward (expected by the participant).
On the post-game questionnaire, almost everyone stated that the experience of different sessions (in Phase 1) was enjoyable and interesting (Khalili-Mahani et al. 2020). However, some games were more stressful to some than others. A recurring source of frustration was performance, especially in individuals who cared about cognitive benefits, and valued scoring high. Another source of stress was lack of flow. If a game’s visuals were too intense (crowded, confusing, distracting), or if the game dynamics were not rewarding or too challenging to learn, that would be frustrating. Nevertheless, despite acknowledging the potential benefits of the games for cognitive, emotional or physical stimulation, almost everyone preferred their non-digital hobbies and enrichment programs (craft, music, exercise, social play).
Table 1 summarizes some of these findings. The most salient problems stated were risk of addiction, steep learning curve, generational gap in interest and technology literacy, and lack of appropriate or personalized aesthetics. The most frequently stated rewarding aspects were relaxation, distraction, stimulation and potential for intergenerational connection. A recurring suggestion was that game activities would be useful in senior homes for people who were frailer and socially isolated. Another recurring suggestion was that the interfaces, technical jargon and game instructions needed to be simplified. One participant suggested that this could be remediated by introducing games in libraries.
Phase 2: What is Serious About Different Genres of Games?
Based on the observation in Phase 1 that the value of games for the majority of older adults was limited to their cognitive and relaxing features, and that the generational gap in cultural or aesthetic appreciations of games were pervasive, we conceptualized Phase 2 and set up a community program, a free Game Clinic Course to discuss the potential healthcare applications of serious games. Activities in this course are listed in Table 2. All classes were attended by the PI and at least 3 young students (< 30 years of age), and 7 older adult participants (> 65 years of age). The same activity was offered in Phase 3 as well, but the emphasis was not just on health. At the end of the class, we asked everyone to write about how this class changed their perspective about games. Specifically, we asked them to reflect on how the class made them connect to their past, and how they envisioned games being relevant to their future. Six of the participants offered short write ups. Excerpts of the writing are presented below:
Connecting to the Past and Connecting to the Future
To link the idea of digital games to the experience of play rekindled memories of childhood and provided a new dimension to the ways in which digital games can serve a serious purpose.
Rose (who often talked about her age, 84), an extremely active participant with no history of digital playing prior to joining the class wrote:
When Eileen and Rebecca gave their presentation [about how they programmed games], my brain lit up: [to propose a game about] Storytelling and Scavenger Hunt. [In my childhood] story telling was always about verbal sharing of the stories. My mother played a game where she would shout out: “Once upon a time…”, and when we heard that, we would run to her; she would explain the rules, and tell us what we were going to talk about. She would start a story and then pass it on to the next person. We would have to wait until next session to see how we did, but this encouraged us to think as a team about one subject. [Rose, 84 years]
The games that she most enjoyed during our sessions were the car racing, word puzzles and trivia games. She found exercise games to be potentially useful, but not to her, since she was already active in the PERFORM Centre’s gym. Additionally, she proposed that a Scavenger Hunt game and an Escape Room would be interesting to her.
Thea (did not reveal her age, but was retired), who preferred the materiality of creativity over any electronic or digital experience, wrote of her childhood being defined by her playful spirit, which saved her in older age from the trauma of sexual assault. About the Game Clinic class, she wrote:
This course has been a godsent to me. (1) It has allowed me to nurture the playful side of me. (2) It has opened me to better understanding and becoming less intimidated by digital technology. (3) It introduced me to a nice group of people–breaking my isolation (in which I am a little too comfortable); giving me something to look forward to; a stimulant for my curiosity and addiction to learning; You are never too old to play or to have fun. [Thea]
Suzan (69, who was also a participant in Phase 1) wrote:
I have to admit that I was surprised that the study (Phase 1) would kindle what is now a renewed interest in gaming. [Suzan, 69 years]
Recalling playing her first internet game in the early 90s, on their first family computer, Suzan continued:
I didn’t have any interest in Pacman, a bunch of creatures eating up blobs, but we had a really interesting game called Where in the World is Carmen Sandiego. This game tests the player’s knowledge about different countries and gives clues to the player to figure out where the villain (Carmen Sandiego) has gone in order to arrest her and her allies. [Suzan, 69 years]
Suzan found the class as a worthwhile activity as it introduced her to several genres of new games that would help her perfect her problem-solving skills, and she was especially intrigued by storytelling games. “It has brought up questions for me about the impact of games on seniors, both good and not so good”. She wrote:
Good in that it keeps the mind alert and up to date with the world of the younger generations. Not so good could include addiction to both games and the computer, which could lead to cutting the senior off from the real world. [Suzan, 69 years]
Anna (> 65 years of age but did not specify), who described her childhood as a sober one preferentially spent on reading books, reminisced about discovering Wii games with her children and grandchildren. She wrote:
Retirement comes with an endless amount of leisure time. Having discovered the world of games recently has given me new ways to enjoy that time and even to work on mental health issues like memory and concentration. I have new things to talk about with children and grandchildren and have earned some ‘creds’ for trying out new experiences. Coming to the workshops and sharing play a has changed the way I look at games, not just as something for other people but something I can share with peers. I like the challenge that word or trivia games present, and I like the fun-rush of the racing, or dance games. I’m still trying out the narrative games - I have something called Murder in the Alps on my tablet, but they take a bit more concentration than I have just now. [Anna, > 65 years]
George, 92, who in the first meeting stated his dislike for computers and technology, acquired his own tablet by the end of the class and downloaded his favorite games (trivia and word puzzles). He wrote:
Since enrolling in (10-weeks) Games, as I am good in spelling, I have found Wordtrip, Wordscapes, Word Search, Word Swipe, Word Stacks. Of course, all these games are challenging and addictive. If one is not careful, these games can cost one a lot of money. To avoid spending money, you can earn rewards by spinning the wheel or watching videos for 30 s. When watching videos, you should divert your eyes off the screen. I will continue to find other games which spike my interest. [George, 92 years]
In fact, this introductory class triggered an interest to offer games as part of a wellness routine in senior’s lives. Suzan wrote:
Your idea to open up a gaming center for seniors is fantastic! […] to build some community events into this center which could include teaching people about new games, how to play them, etc. Sort of like an ongoing game clinic! [It] could help out less fortunate seniors who can’t afford a computer or tablet. Often school boards change their computers when the existing ones are still functional. Maybe a donation system could be set up. [Suzan, 69 years]
Phase 3: What Older Adults Taught our Design Students?
For the third and final phase, we repeated the same process as described for Phase 2, but invited 65 + year old individuals to participate in a research project, to help us find what is the serious in which type of game. In this phase, we explicitly shifted away the discussion about games from the health context and towards critical reflections about the significance of the games as cultural and communicative media. We were interested in identifying first, what constitutes the “serious” in the playing, and also what may be the cultural barriers to adoption of digital games in the lifestyles of older adults.
Who Were the Study Participants and What They Wanted?
We ran two sets of classes for Group 1, and Group 2. Those who joined our third call were younger, recently retired, and proficient with usage of technology. The responders were mostly women. Group (1) included a retired journalist, a retired computer programmer, a retired literature teacher (male), a working graphic designer, and two young game studies and one young engineering graduate students (Age < 30 years).
Group (2) included a retired designer, a retired social worker, a retired professor, a retired journalist and working writer, a self-described hermit (sex male, gender non-binary), and a working yoga teacher (age range 65–75), and four students from creative art therapy (age range 30’s), none of whom were familiar with or previously interested in games.
Our first question to the participants was “What interested you to join the study?” The majority indicated their interest in ‘finding a cognitively stimulating activity’, ‘curiosity about the topic’, and ‘desire to remain engaged in what the young research these days.’
Cultural Stereotypes Exclude Seniors from Game Culture
The first important finding of this phase was that that the gamer culture is not inclusive to older adults (nor to younger adults who were not interested in games and had a negative opinion of games to begin with). One of our young game designers (student in Communication Studies) remarked:
My experiences as a girl who plays video games cross over with the experiences of these seniors in many ways. Video games tend to be marketed to young masculine audiences (Carly Kocurek 2015). Although this is being challenged by indie games and casual games, the spaces for different kinds of play in video games are often not communicated to these audiences. After all the sessions together, most of our participants admitted to being interested in playing more video games, but not knowing how to access them. Part of the challenge here, and that we realized throughout the workshop, is that there are not many efforts made to advertise to older audiences.
Another game designer (student in Computation Arts), who was introduced to gaming by her grandmother “wielding magic and fighting evil in games like The Legend of Zelda”, commented that many negative stereotypes around gender and age permeated the medium of game. She admitted that the experience in the game clinic revealed that she too “was not immune to presuming that she knew her [older] gaming audience”. She was surprised to learn how niche game design marketing remains:
Although the participants greatly enjoyed trying the games that we shared, they had mostly not heard of them at all prior to this intervention. What this means to me as a game designer is that many groups of people, particularly our seniors, continue to be alienated from our play experiences that are mostly marketed online.
Cultural Accessibility is More Important Than Mechanical Accessibility
As expected, it was clear that the younger game players underestimated the difficulty of game mechanics for older players. One (Communication Studies) wrote:
The more accessible games were always easier for participants to get invested in than those that required knowing how to use a controller or a keyboard—knowledge I realized I take for granted as someone who grew up with these technologies.
Another game designer student commented on a need to simplify instructions:
When designing games, we the designers often assume that certain conventions are known by the prospective player; that ‘A’ means jump, that you move left to right across the screen, etc. However, for people who have little to no prior experience with games, these things are not known. Moreover, assuming and failing to explain these conventions alienates new players from being able to fully enjoy an experience.
A third student (Communication Studies) noted that to presume that technology is the only impediment to game adoption by older adults, blinds us to the fact that we do not take time to reach out and teach them about the affordances of games:
While many of the seniors that came to the program were relatively tech savvy, they showed interest in what new technologies were being developed and wanted to understand the appreciation that others had towards tech. To clarify, they were not inept at technology, but were curious to other interactions they could have with it.
One of the most important findings in Phase 3 was for students to discover that access is too often overlooked not only in game design, but also in game marketing and dissemination. For instance, our participants were not familiar with indie games. When we introduced games such as the Old Man’s Journey, Lieve Oma, or Night in the Woods, they found them as interesting story-telling techniques, even though they lacked in the polished visual pleasures of a video-based story, and the excitement and short-term winnable excitements of games. Nevertheless, they acknowledged the artistic and creative potential of the indie games.
That games could be personalized was the feature that triggered most imaginations. One participant in Phase 1, a highly active one, still working as a freelance accountant, and a competitive (social) dancer of 79 years of age, emphasized that although she recognized the potential value of games for rehabilitation and cognitive training, she would still not play games for fun (unless they became personalized-for instance if the music and the genre of dance game were selected from her youth). The most poignant point made by another participant was:
if you want to make a game for seniors, make one for my 90-year-old mother, that makes her believe she is improving her scores, even if she is not scoring higher.
The idea that games had the possibility of being customized to not only physical needs, but also cultural preferences of users was intriguing to participants. One participant (the male who called himself a hermit), was very familiar with Huizinga and emphasized the distinction between play and games. He was completely uninterested in games (and in fact refused to play any). Yet, he indicated that he took part in our class because he believed that the youth were spending too much time on computers, and he wanted to encourage game makers to create games that promote cooperation, towards solving the climate crisis. Thus, the intergenerational gaps were not only in mechanical accessibility of the game, but also in stereotypical misunderstandings and cultural disconnections about the definition of games.
Creating Safe Spaces to Learn and Trust is Important
In Phase 3, two participants dropped out after the first session: one, because our activity was not geared towards brain health; second, because the individual preferred to exercise. Both these individuals had come to the class with a negative attitude towards games, as being wasteful, and mind-numbing. However, the ten who remained (including the ‘hermit’ who came in with a critically constructive attitude), demonstrated remarkable willingness and flexibility to revisit some of their beliefs about the addictiveness and uselessness of certain games. Some of the participants were shyer than others in testing out new technologies, but everyone tried them-unless they perceived a physical risk of falling, for example in playing the exergames.
A student commented:
I think part of the reason behind their willingness was that the Game Clinic provided a very safe space to mess around with and learn different technologies, without judgment. But this work did not stop at the workshop level; participants also admitted to downloading some of the games at home and continuing to play on their own time. They also spoke about having the ability to now talk to their grandchildren about their games and finding value in these conversations. The workshop even inspired some of the participants to get more involved in creative and academic practices on their own time, such as writing stories, creating worlds, as well as signing up for further classes.
This was reiterated by another student:
Watching participants consistently return, learn, experience, and share their thoughts on games created a meaningful space for dialogue. By creating a space welcoming to new game players, the clinic allowed older adults to bring in their ideas and opinions into the space. As a facilitator, watching people interacting with games, helping them understanding the games expectations and supporting them in their play (as ally or rival), created a positive learning and knowledge dissemination environment for the study.
This observation by students was validated by an E-lecture (via skype at the Milieux Institute for Arts, Culture and Technology) conducted by Bob de Schutter. He presented the topic of Gaminiscing (reminiscing via a game), and gave a demonstration of the game play, but also the process of creating his new game: Brukel—a game he created based on his grandmother’s reminiscing about her childhood in Belgium, in the frontlines of the Second World War, when her family’s house had come under the Nazi Occupation (https://www.brukelgame.com/.) This presentation was lauded as the highlight of all other activities—until we presented the VR in the next session. When asked about the conclusion of this class, one participant said: “I had no clue that games are so varied, and because they are so varied, it is hard to give only one impression about them.”
Another participant wished she had brought her game-playing grandchildren along (they were at all times invited) to this session. Discussions after this phase continued well after the class had adjourned—and everyone was proposing either a narrative for a similar game from their personal experience, or alterations to the Brukel: “It would be interesting if the game also included a few scenes from the perspective of the German soldier”, one said.
What Kind of Serious Games Would Matter?
In the final session of the class we offered a virtual reality (VR) tour guided by a VR artist and educator at the Milieux Institute for Art, Culture and Technology (Marco Antonio Luna Brahona). We presented a range of VR experiences in the following order (theBlu by Wevr Inc.; Pearl by Google Inc., the Lab by Valve, and Tilt Brush by Google). While these experiences were not games (other than the Lab), they provided an opportunity for presenting even more technologically complex media experiences that could be gamified and invited all to imagine such possibilities.
Indeed, participants immediately drew a connection between VR and Brukel, as one indicated: “This technology might let you see the perspective of others in the last week’s game”. Three participants found the experience of theBlu of therapeutic value. Two participants who tried Pearl talked about how they felt emotional about the story. After Pearl, one commended that the immersive nature of the medium might have a potential for curing racism. She also discussed how she wished someone reconstructed into VR, a heritage building (now turned into luxury condominiums) in which she worked as a young girl. This idea was reiterated by another participant who offered a history tour of Montreal (in Group 1 of Phase 3). He thought that VR had a great potential for teaching history, or providing people access to museums and galleries that they could not travel to.
At the end, Noah (70 years) who participated in Phase 1 and the three last sessions of Phase 3 (a social player, but not a digital player) reiterated his commitment to help bring our class to a local senior’s community centre. Two participants from the second group of Phase 3, indicated that they wanted to write to the university to ask for the class to be extended. When we mentioned that classes were going to happen in a living lab (that will be set up in a mall with high number of senior customers), two offered to tend to the space as volunteers and guides. The prospect of having access to the VR in that space was most appealing-reiterating the point that to provide access and education about new technologies should be prioritized for seniors.