Video games have taken over the world of entertainment, but games and gamified experiences can also be leveraged to change behavior in pro-social ways, including to promote positive nutrition behaviors. For more than two decades, Jim Wexler has used games with leading companies to help them train staff and improve customer service.

Gaming “has become the predominant art form of the 21st century, the same way film was in the 20th century and the novel was in the 19th century,” Wexler said. “Why are games so wildly popular? To answer that question, you have to go all the way back to caveman days.

“The caveman would survive by mastering challenges: When the saber-toothed tiger was attacking or we needed fire, the challenge needed to be addressed. And the reward for succeeding and mastering the challenge was the hit of dopamine that goes to the brain.”

That hit of dopamine is pleasurable — and people will repeat a behavior to get it again. Games reliably produce it over and over again.

So, how can program designers and SBC strategists leverage gamification to improve nutrition behaviors? Wexler explained the fundamentals of gamification and offered some ideas.

Gamification 101: A quick primer

Inspire: Jim, maybe you could start by telling us just what is gamification?

Jim Wexler: Gamification is about inducing behavior, playfully or delightfully — not getting people to do stuff pedantically or by force, but by making it a joyful experience. The reason games are so popular and important is because they make us feel good, it's that simple. The way games deliver that feel-good response has been perfected by the gaming industry within game approaches to reward people for their successes. 

Gamification is the incorporation of that kind of thinking — game design thinking, game methodologies — into experiences. So, gamification is really a way to motivate people and change their behavior. 

Inspire: What are the fundamentals underlying gamification?

Wexler: The goal is to motivate people or induce certain behaviors. There are two kinds of motivation: extrinsic and intrinsic. An example of an extrinsic motivation is coupons. A coupon motivates me to purchase a chocolate bar. The motivation has nothing to do with the chocolate bar — only the money that I’ll save. When people think about games, they often think about the extrinsic rewards — the design attributes that drive rewards, such as points, levels, or leaderboards that track ranking. While all games have extrinsic motivators built into them to keep you going, the focus to drive learning and behavior change are intrinsic rewards and motivators.

There are key intrinsic motivational drivers in life, and at the core of the game design process:

The first motivator is mastering challenges and giving people a sense of continuous progress.

 

The second motivator is autonomy — the sense that I’m in charge, I am directing my own life. The dopamine flows when you recognize that you have the power and you are in charge of something.

 

The third one is a sense of meaning and purpose: I am doing something in the context of something larger than myself. This is certainly a motivating factor at the time of motherhood surrounding a newborn’s well-being.  

So, gamification mixes the intrinsic and the extrinsic. But it is the intrinsic motivations that drive sustainable behavior change, and that’s what we focus on.

Inspire: So you’re saying we should look at the behavior change issue we are tackling through a sort of “gamification lens.”

Wexler: Lens is right. It is a lens by which a learning organization surfaces the motivating triggers that underpin its content and makes them available to people. Gamification is like an amplifier — first, you need genuine sound to amplify. The good news is most clients have well-thought-through learning material, but they haven't thought about it with this lens.

When to use gamification

Inspire: So when should we apply this lens of gamification? It doesn’t always mean making a video game, right?

Wexler: That's what's funny about my business — people say they want “a game.” And they go right to, “Let’s just add the leaderboard.” That's extrinsic, the icing on the cake — that’s not the task at hand. We ask them what they’re trying to communicate, then we look into the motivators and barriers that might influence their audience.

Once motivation is thought through, then you find the genuine sound and you're ready to amplify your learning content into an appropriate medium, such as a piece of software, or a game, or a poster, or a training manual that guides an experience. You can use gamification away from the computer screen by using game techniques in real life, in a group setting, in a classroom, or at work. But most of my work is through a screen and user interface.

"Once motivation is thought through, then you find the genuine sound and you're ready to amplify your learning content"

Inspire: In our work, I can imagine that we might want to think about how we gamify practices around the training of frontline workers for nutrition counseling. It seems like there are endless possibilities of small and large-scale efforts where we might have more impact if we tap into these intrinsic motivators of the “players” of our games.

Gamification in action

Inspire: Can you share an example of a challenge that you had, how you gamified it, and where you were able to change behavior?

Wexler: Abbott Labs was challenged to help train parents on how to inject their children with a drug. We realized that the problem was twofold — parents didn't know how to deliver the medicine and, also, they were inhibited from doing so. On the first part, the game experience shared complex animations that showed quite clearly how to deliver the drug — the five steps to inoculating successfully at home. For the second part, we did some research and found out that the parents were inhibited because the kids were afraid, angry, and confused. The parents needed conversational tools to talk their kids through their resistance. These conversations were simulated to give the parents the experience and then best practice dialogue points to speak to their children effectively. By delivering a self-led toolbox that showcased these motivators, Abbott Labs was able to help patients help themselves and improve overall compliance.

Inspire: So, to tie this back to the principles you shared earlier, this example of gamification was about inducing behavior in the parents. The experience "playfully" improves how well they inject their children by empowering them to make choices (autonomy) and giving them feedback on their progress (mastering challenges) and how their choices benefit the children (purpose)?

Wexler: That’s the idea.

Gamification for nutrition

Inspire: So, let’s consider a real-world nutrition scenario that involves training. We want you to walk us through how you apply that gamification lens to training community health workers to effectively counsel mothers on feeding their young children. They often are equipped with flipcharts or other job aides and tools to give mothers, like a take-home feeding bowl that indicates how much and what kinds of food a child needs according to their age. But the skills to counsel mothers are often a challenge.

Wexler: The first step is to talk about the audience and the content. We’d start by talking about the different kinds of community health workers — what they know and don't know. Who are these community health workers? What’s their role and what’s their goal when it comes to supporting mothers with feeding? Who are they demographically? Where are they geographically? And how do you parse them — are some experts, while some are beginners? Are some dedicated zealots and caregivers and others less engaged? Who is our player (of the game) and how do they work?

Inspire: These kinds of questions are the same ones that we ask when developing materials for community health workers. We might even go so far as to develop “persona” profiles of different types of health workers. So, after identifying the different community health workers, then what?

Wexler: Yes, you probably have access to these answers already. If not, you’d need to talk to the best of the community health workers and get those responses from them. Each may have a different delivery style or response to different coaching. That’s what we're gathering and putting into the self-led experience. In teaching community health workers to more effectively do their jobs, we must understand the barriers to learning and how to change them before we even deal with the content.

We have three factors in the game. The first is the mothers — their types, what they say, how their objections are overcome, how they are empathized with, what motivates them.

Secondly, there are the community health workers whose performance we're trying to improve — the different types with different levels of knowledge.

The third piece is the resource material itself. Is the bowl presented differently for different mothers and different community health worker types? Understanding that and looking for thematics there is key. We may see a common thread across all mothers: they're enthusiastic, they do care, they're status-oriented and want to share their elevated knowledge with the community. There may be shared thematics for the community health workers, too. To determine them, we need good access to expertise and confirming data sets.

"We must understand the barriers to learning and how to change them before we even deal with the content."

Since the bowl and the flip chart are resources that they currently use, it may make sense to leverage the bowl as a game object if we were making a video game. Maybe there's something playful about it — spinning it could determine which topics are discussed.

Inspire: OK, from that point, then what? You know your audiences and have in hand the materials or tools that they are using, where would you go from there?

Wexler: Once the information and materials have been gathered, they get synthesized. Knowing who the audience is, what barriers they face, and what we want them to absorb defines the game’s elements, and usually informs the game designer what style of game it will be.

In this example scenario, since we are reinforcing the soft skills of the community health worker, the gameplay might be a conversation from the point of view of the health worker. As different types of mothers appear, the player responds using branching dialogue with three response choices: the right choice, the okay choice, and the very much wrong choice. These branching dialogue trees deliver multiple conversational outcomes. If I choose the better path, the outcome involves positive feedback, perhaps a satisfactory debriefing, and more game points. Further visualization of the positive feedback could include a visual of a baby that gets healthier and healthier as the conversation progresses. If I select the neutral or negative conversation paths, the outcome could lead to an impasse or the mother ending the conversation, leading to remedial coaching, and fewer game points.   

For learning reinforcement, we often finish with outcome-based coaching tips that reflect on the health worker’s specific conversation choices. Another learning reinforcement is to depict “what good looks like” through a short experience of a proper interaction, using a video-based or graphic scenario, so they can see and model good behavior. Below is an example of branching dialogue and outcome-based coaching from one of our recent games that was created to help sales associates know the good, better, and best way to handle clients.

Inspire: So, if we were talking about developing this experience as an interactive video game, we would come to you with insight about who we're trying to reach, the kind of things that we want them to do, a lot of data about what they might be doing right or wrong, and the barriers that are getting in the way of our desired behaviors. And then we would figure out how to simulate the skills that they need to develop in ways that are negative and positive in a sort of guided conversation with branching dialogue. And then put people in these various scenarios and give them feedback on how they're doing.

Wexler: Correct. Understanding the content and learning goals is essential. The experience itself — the game style, the tone, and pacing, how it looks, how the coaching tips are delivered, how scores and rewards work — these things would emanate from our understanding of the content, the audience, and their readiness to learn.  

Inspire: Couldn’t we use a similar approach if we were creating live learning experiences in our trainings with community health workers?

Wexler: True the content would likely be the same, but a key benefit of delivering a self-led digital experience is message control. When the game puts all the health workers on the same page, sharing in a unified body of content, the outcome data and feedback becomes actionable, providing measurable results in use and performance improvement. As changes in procedure or new best practices arise, they can be efficiently integrated and shared with everybody. If done correctly, the game design should deliver the content iteratively to assure the health workers remain engaged.

"... the game style, the tone and pacing, how it looks, how the coaching tips are delivered, how scores and rewards work — these things would emanate from our understanding of the content, the audience, and their readiness to learn."  

The game should reinforce the health workers’ sense of autonomy, reinforcing that they're in control, that they are in charge of their ability to help the mothers and improve their job performance. 

For a sense of purpose, the game should speak to them personally and motivationally, underscoring that they’re part of something larger than themselves, a field team of caregivers whose hard work helps 10,000 babies grow stronger each year.

Inspire: I hesitate to ask this question, but the prospect of a game to develop nutrition counseling skills is quite inspiring. So, what kind of investment is needed in terms of time and financial resources to develop a game like this — just a ballpark estimate?

Wexler: Once the learning requirements have been identified, and the assets gathered and approved, game development and testing can take three months and range from $50k to several times that amount, depending on content readiness and complexity and requirements for data and reporting.

Inspire: I can see scenarios where a digital game would be preferable, and other scenarios where lower-tech solutions could build on these same ideas to make trainings more effective and engaging. Jim, thank you very much for taking the time to tell us about gamification.

If you have had positive experiences applying these gamification principles, we’d love to hear about them in the comments!