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A Game to Deal With Alcohol Abuse (Jib): Development and Game Experience Evaluation

A Game to Deal With Alcohol Abuse (Jib): Development and Game Experience Evaluation Background: Alcohol abuse is the primary cause of (public) health problems in most parts of the world. However, it is undeniable that alcohol consumption is a practice that is widely accepted socially in many places, even being protected by law as a cultural and historical heritage. The issue of alcohol abuse is complex and urgent, and consequently, it is necessary to create innovative approaches such as the proposal explored in this study. Objective: This study aimed to explore the development and evaluation of a serious game for smartphones to present a novel approach to address the issue of alcohol abuse. Methods: A serious game was developed to instill the consequences of alcohol abuse into the player through experimentation in the game. In the game, the consequences of alcohol use are demonstrated by increasing the game speed that gives an illusion of fun but also leads to a premature death. The evaluation employed an assessment based on the Alcohol Use Disorders Identification Test (AUDIT) and the Game Experience Questionnaire (GEQ). The participants belonged to the university student’s house. Results: The game development process has been presented, including its mechanics and gameplay. The game has the style of action and adventure games in which the player controls an indigenous avatar that can deflect or attack opponents coming his or her way. The game evaluation comprised an assessment based on 23 participants, aged 20 to 29 years. According to the AUDIT assessment, 18 participants reported having a low or nonexistent degree of alcohol dependence and 5 declared average dependence. Regarding their habit of playing games on smartphones, 9 participants declared they have this habit of playing (habitual players), and among the 14 that did not have this habit of playing (nonhabitual players), 3 participants declared not having a smartphone at all. The GEQ core assessment showed a higher positive affect among the participants with a habit of playing games, scoring 2.80 (habitual players) on a scale of 4.0 versus 1.61 (nonhabitual players), and higher tension as an opposite relationship of 0.81 (nonhabitual players) versus 0.37 (habitual players). The overall GEQ evaluation showed that the game presents a more positive than negative affect on all users, besides showing the other desirable characteristics of serious games. Conclusions: We present a new way of dealing with the issue of alcohol abuse through a game designed for smartphones. It promotes an overall positive user experience, having a greater impact on users accustomed to games. The proposed approach has its niche, though it is still a minority in the evaluated population. Further research should explore new game features, such as new styles, to make the game more attractive to a wider audience, in addition to performing an in-depth study on the effects of playing it. (JMIR Serious Games 2019;7(4):e11151) doi: 10.2196/11151 https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al KEYWORDS alcohol abuse; serious game; software design; proof of concept evaluation of some factor over another. Thus, it is feasible to relate a game Introduction to other human activities, as all have rules (of society or a particular environment), participants, successes, and failures Background (of tasks or procedures involved). Alcohol abuse is the primary cause of (public) health problems An indigenous hero is considered for the setting of the game. in Brazil. According to the World Health Organization (WHO), It is worth noting that alcohol abuse also extends in Brazil to in 2012, about 3.3 million deaths or 5.9% of all deaths recorded the indigenous sphere of society. Langdon [5] points out that on the planet were attributable to alcohol consumption [1]. The because of the process of inclusion of the indigenous people in abusive consumption of alcoholic beverages is the component the broader society, they have begun to substitute or add the cause of more than 200 types of diseases and injuries. distilled beverage into their everyday life. The consequences Alcoholism represents harm to private health, public health, of this change have also been addressed by Viertler [6] and and the economy as a whole. The estimated annual cost of Guimarães and Grubits [7], demonstrating that alcohol abuse alcoholism is £20 billion in the United Kingdom and more than is the main cause of addiction diagnoses, accidents, and cases US $200 billion in the United States. Brazil loses around 7% of violence against other members of the community, including of its gross domestic product per year because of excessive the use of various weapons and incidence of fatal victims. The consumption of alcoholic beverages. The cost estimated in 2014 indigenous theme also brings out the problem in these societies reached R$372 billion [2]. to a wider audience as intervention in this area is also not an However, it is undeniable that alcohol consumption is a part of easy task and lacks attention in a broader sense. many cultures, being a practice that is widely accepted socially As Ingold [8] points out, the learning process is about the in most parts of the world. In Brazil, the spirit cachaça (a type education of attention. Thus, as a child, learning is consolidated of distilled spirit made from fermented sugarcane, the most through games and toys. Through them, the study by Ritterfeld popular distilled alcoholic beverage in Brazil) is even protected et al explains [9], “children exploit and accumulate the world, by law for its distinguished characteristics (Brazilian Presidential improving their skills and abilities” because they are extremely decree n.6871/2009) and is considered a part of national cultural motivating activities. However, later in elementary school, there and historical heritage. The issue of alcohol abuse is complex is a clear separation between learning and fun, making learning and urgent, and consequently, it is necessary to create innovative somewhat unmotivating and unpleasant. This is because approaches such as the proposal explored in this study. motivation dictates the learning flow—when motivation ends, Objectives learning and the act of playing also end [10]. The main aim of this study was to explore the possibilities Electronic games have been proposed to make learning offered by new technologies to address this relevant issue. motivational as they have the ability to communicate concepts Numerous successful cases have been found in the literature and facts of many subjects effectively and allow people to employing serious games in dealing with relevant health care recreate themselves in new worlds and achieve recreation and issues [3]. Considering the growing use of smartphones, the deep learning at the same time. That is, they are capable of creation of a serious game for smartphones takes advantage of creating a dramatic representation of the studied situation this important channel of communication to innovate an [4,10,11]. intervention for such issues. Such games are called educational games. However, they do Our proposal was to employ new technologies to raise awareness not always achieve their goal as many prioritize the educational about the consequences of alcohol abuse, promoting or entertainment components separately. A methodology is used empowerment of the individual, traditional cultures, and social specifically for the development of serious games that are games responsibility. The authors believe that a suitable means for this that use the artistic medium of the game to deliver a lesson or is a playful educational tool, that is, a serious game. In this teach about some subject so that both components are balanced sense, the user is allowed to experience the option of drinking [9]. and modifying the gameplay, eventually increasing the fun factor, but also showing the consequences, such as the premature According to Michael and Chen [11], a serious game should termination of the game (player’s death in the game). contain some elements related to design and development itself, including the following: (1) simple (intuitive)—usable by people who have little or no experience with digital games, (2) adequate Methods simulation—both in terms of realism and difficulty, and (3) Design Rationale progress analysis—it allows the player to formulate strategies, in case he or she learns what the game wants to pass to achieve Game development is based on the premise that games are greater progress in the game. strongly linked to reality. According to Abt [4], a game has some core elements such as rules, participants, information, To achieve these desirable characteristics, the development was gains, and losses. It is also possible to assimilate factors such divided into 3 stages: (1) planning, (2) prototyping, and (3) app as competition, opposition, and maximization or minimization consolidation. The whole process was documented in the Game https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Development Document, which contains all the necessary of all the alternatives, determines the level of alcohol information for game development, such as an execution dependence of the interviewee. The risk degree of dependency, flowchart, the definition of gameplay, and references and potential consequences, and intervention recommendation for inspiration. This paper has presented a consolidated version of the interviewee are classified according to 4 levels. The the Game Development Document, highlighting the main correspondence among scores and the meaning of their risk concepts employed in the game with regard to mechanics, level is shown in Table 1. gameplay, and implementation. The Game Experience Questionnaire (GEQ) [13] was used for the postintervention evaluation. It consists of a questionnaire Field Evaluation composed of 3 modules: the core, the postgame, and the social The game evaluation was carried out with students from the modules. The questionnaire has simple and direct questions student residence of the Federal University of São João del-Rei. about the player’s thoughts and feelings, such as “I felt happy” This residence is the student housing provided by the university and “I felt angry.” The core module has questions regarding for low-income students under the university’s official assistance feelings and beliefs that the interviewee had while playing. In program. All participants were volunteers and had to sign a the postgame module, the questions are focused on when the participant consent form, which described the general purpose player stopped playing. In this way, the participant demarcates of the study and stated the research procedures according to the level of agreement with the corresponding sentence on a international and Brazilian ethical research laws and principles. scale from 0 to 4, where 0 means no agreement and 4 means a The results are opinions declared by the participants and were lot of agreement. disclosed anonymously. The proposed evaluation consisted of 3 stages: 2 questionnaires (pre- and postintervention) and a Only the core and postgame modules were used as the proposed 20-min intervention phase of user interaction with the game. game does not have social interactions. The participants No further explanation about the game was provided, leaving answered them after the intervention stage. In each module, a the exploration process up to the participants. When the group of questions defined a component to be analyzed, and participants asked about a specific game element, the feedback the final calculation of it was given by the simple average of was an incentive for them to explore and test the interface to the questions. The total average of the components was given figure out the answer. by the simple average of all the individual components of the interviewees—with results ranging from 0 to 4. In this case, 0 The preintervention interview was performed to characterize means that there is no presence of that component and 4 means the participant by collecting information such as age, sex, and there is a lot of it. their level of alcohol dependence. To identify the level of alcohol dependence of the users, the Alcohol Use Disorders Finally, the postintervention evaluation consisted of 3 questions Identification Test (AUDIT) was employed. The WHO to evaluate the design of the app concerning the visual and sound recommends the use of AUDIT [12] as a simple, brief method resources and the available information about the game (such of screening for excessive drinking. Its questionnaire contains as tutorials and information about the project) and about the 10 multiple-choice questions with 5 choices each. The controls. A scale from 0 to 4 was also used at concordance assessment works as a sum of points acquired by each levels, where 0 meant weak and 4 meant optimal. alternative—from 0 to 4—and the final result, that is, the sum Table 1. Risk level scores with regard to alcohol consumption behavior according to the Alcohol Use Disorders Identification Test assessment. Score Risk level 0-7 Inexistent: low-level drinking or abstinence 8-15 Low: alcohol use in excess of low-risk guidelines 16-19 Medium: harmful and hazardous drinking Over 20 High: alcohol dependence first one but using the Unity Graphic Engine (ie, Unity3D) for Results its implementation. Development The game was deployed on the Android operating system because of its popularity. The development of an app through The Game Development Document details the proposed native language is the development of an Android app modeling and the definition of the rules, basic interface, and exclusively using the Android Software Development Kit or other details. The details of the graphics and sound features Android Native Development Kit. This allows for efficient were being defined along with the game development. In total, development as the developer has direct access to all the tools 2 versions were developed. The first prototype was made in the of the device. Access to all tools allows you to design the app Massachusetts Institute of Technology (MIT) AppInventor in the best possible way for the operating system, maximizing platform, but its development was discontinued because of the user experience. However, this environment requires mastery performance issues. The last prototype is the evolution of the of the platform’s native language and its tools. All physical modeling involved in the app must be developed. For easy game https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al development, many platforms can be found in the Android The proposed game follows the style of action and adventure ecosystem that assist developers in creating new games. games, in which the player controls an indigenous avatar who can deflect or attack opponents coming his or her way. It has 3 A study was carried out on game development platforms screens: the initial menu screen, an information display screen available for the Android system. The most promising ones about game rules and the project, and the screen that contains were MIT AppInventor and Unity Graphic Engine. the game. The initial menu screen, described in Figure 1 (left), The MIT AppInventor platform is an Android app development allows you to move to any other screen within the app and to platform supported by Google and maintained by the MIT exit the app. The about screen, shown in Figure 1 (right), allows (United States). It has a drag-and-drop system where users the user to return to the initial menu screen (using the return select, drag, and fit blocks that determine a line or method of button in the upper left corner). Information regarding the game execution in an interaction area. It is an open-source license screen (and the game itself) is described in the following environment that is easy to learn, with the freedom to run the subsections. It is important to note that all graphics and sounds program for any legal purpose. are available on the internet under the Creative Commons license. At first, the authors chose the MIT AppInventor platform for prototyping because of the small learning curve and the need The instructions presented in the about screen (Figure 1 [right]) to set implementation details. It was a straightforward can be translated as follows: About the Game – “JIB is a game implementation of what was designed. However, because of created to address the issue of alcoholism, allowing the player performance issues when the game had to perform fast updates to experience the consequences of alcohol abuse through the of the graphic elements on the screen (ie, the game starts game. The indigenous theme has been explored to compose the experiencing unexpected screen update errors), a more robust hero of this game, creating a narrative contextualized in the platform was needed. Therefore, the game’s final version was forest. The effects of using alcohol can be perceived by fully implemented using the Unity Graphic Engine. It took a increasing the game speed and giving an illusion of more fun while to learn this new platform, but the process of prototyping but also by showing that alcohol abuse might lead to premature in AppInventor to achieve better implementation later in Unity death.”; and How to Play “Move the Indian by touching the was shown to be effective to enable fast prototyping, especially lower half left and right of the screen and shoot by touching the considering programmers without much experience in game center of the screen. Opponents will appear at the top of the development, and produce a better game in terms of quality on screen, and you must act. Be careful with the drinks, it can be a more robust platform. tasty, but the alcohol level will rise, and it will change you.” https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 1. Two screens of the proposed game: (left) first screen; (right) about the game screen (in Portuguese). The user interaction consists of using a touch screen, where his or her way. Opponents appear on the upper edge of the areas are defined for interaction and arrangement of the elements device screen, and when they reach the lower end, they of the game. Figure 2 (right) presents a schematic of these areas disappear. Some defined opponents are the snake, the jaguar, in comparison with the game screen (Figure 2 [left]: (1) move and the drink. Once the Indian comes in direct contact with the character to the left, (2) shoot the arrow, (3) move character to snake or the jaguar, the game ends. If the arrow hits an opponent, the right, (4) restart the game, (5) enable or disable the sound the player gets a score that is added and displayed on the screen. in the game, (6) enable or disable the display of indicative signs When the player consumes the drink, it increases the points and of the action buttons, (7) display the player’s current score, (8) speed of the game, which in a way also increases the fun. The return to the home screen, and (9) indicate current alcohol idea is that drinking causes the player to slow down compared consumption level). with the world, that is, the other elements get faster. The player, as already mentioned, controls an indigenous avatar who can deflect or shoot arrows at the opponents that appear in https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 2. User interface with interaction elements positioning: (left) game play screen; (right) sensible areas of the interface for user interaction. The opponents use a system for continuous displacement, launch of an opponent, the counter of the chosen and adjacent explained in Figure 3, to avoid the overlap and improper lane is incremented. Counters are decreased when an opponent collision of opponents on the screen. The lanes have counters passes a safety range (represented by the horizontal blue dashed associated with them to notify their availability (or not). At the line closer to the top in Figure 3). https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 3. Enemy movement lanes in the game screen. degree of dependence, and 5 declared an average dependence. Evaluation No participant declared a high degree of dependency. Data were collected from a total of 23 participants, 12 of whom Of the 23 participants, only 3 did not have a smartphone. Among were male and 11 were female. The participants’ ages ranged those who owned a smartphone, 11 did not use it for games. from 20 to 29 years, although 2 participants preferred not to declare their age. Regarding the degree of dependency identified Game Experience Questionnaire by the AUDIT questionnaire [12], 5 claimed not having any The GEQ [13] was used to gain an understanding of user alcoholic dependence, 13 reported having a low or nonexistent experience with the game. Overall, 2 GEQ modules were used: core and postgame. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al First, the elements of the questionnaire should be understood. during the game. All core elements of the GEQ are presented According to Johnson et al [14], the components—competence, in Table 2. stress, negative affect, and positive affect—are self-explanatory. The GEQ postgame questionnaire was used to identify how the Negative affect and positive affect refer to the user experience. player felt after playing. This questionnaire is composed of 4 For example, a user may feel good or unmotivated about the variables: positive affect, negative affect, tiredness, and return game. Challenge aims to present data regarding the amount of to reality. Positive affect is related to the satisfaction, victory, effort, difficulty, and pressure felt by the user during the game. and power of the user after playing. In contrast, the negative Tension is related to the player’s frustration while playing the affect addresses the user’s bad experiences after playing. game. Flow aims to identify how interested the user was during Tiredness is related to the user’s exhaustion during the game. the game. Immersion shows how immersed the user was with Finally, the returning to reality component addresses the user’s the story and elements of the game. Finally, competence is disorientation after a gaming period. Table 3 presents the related to the player’s ability and how well he or she performed postgame elements and related questions. Table 2. Core Game Experience Questionnaire components and response options. Core Game Experience Questionnaire components Response options Immersion I was interested in the game’s story It was aesthetically pleasing I felt imaginative I felt that I could explore things I found it impressive It felt like a rich experience Flow I was fully occupied with the game I forgot everything around me I lost track of time I was deeply concentrated on the game I lost connection with the outside world Competence I felt skillful I felt competent I was good at it I felt successful I enjoyed it Negative affect It gave me a bad mood I thought about other things I found it tiresome I felt bored Tesnion I felt annoyed I felt irritable I felt frustrated Challenge I thought it was hard I felt pressured I felt challenged I felt time pressure I had to put a lot of effort into it https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Table 3. Postgame Game Experience Questionnaire components and response options. Postgame Game Experience Questionnaire components Response options Positive affect I felt revived It felt like a victory I felt energized I felt satisfied I felt powerful I felt proud Negative affect I felt bad I felt guilty I found it a waste of time I felt that I could have done more useful things I felt regret I felt ashamed Tiredness I felt exhausted I felt weary Returning to reality I found it hard to get back to reality I felt disoriented I had a sense that I had returned from a journey (total=1.64), challenge (total=1.26), negative affect (total=1.03), Analysis and, finally, tension (total=0.64). In the combination of the 2 Analyses of the results from the core and postgame GEQ classes, it can be noted that the positive affect component had questionnaire (Tables 2 and 3, respectively) are presented as a relatively higher score than the negative affect component. follows. The mean score was calculated for each component in Only the components, challenge, negative affect, and tension, both questionnaires. The average score was calculated for 3 reached scores below the mean (mean 1.44). different classes of users: nonhabitual players, habitual players, With regard to the results obtained through the GEQ postgame and total. Table 4 presents the results of the core questionnaire questionnaire for nonhabitual players, the positive affect for the 3 distinct classes. component reached the highest score (nonhabitual players=0.75). As shown in Table 4, the highest score found among users who Negative affect was lower than the positive affect (nonhabitual declared themselves to be nongamers was the positive affect players=0.5). The lowest value found was related to the return component (nonhabitual players=1.61), followed by flow and to reality component (nonhabitual players=0.43). The tiredness competence components (nonhabitual players=1.54). However, component obtained a relatively high value in comparison with although the positive affect component obtained a higher score, the other components (nonhabitual players=0.68). The results it was similar to the negative affect component (nonhabitual referring to the GEQ postgame questionnaire for the 3 distinct players=1.25). Tension component was the one with the lowest classes are presented in Table 5. score (nonhabitual players=0.81). The scores of the components, For the habitual players class, the component with the highest competence (nonhabitual players=1.54), immersion (nonhabitual score was the positive affect (habitual players=1.17), followed players=1.44), and challenge (nonhabitual players=1.33), were by the components return to reality (habitual players=0.48), higher than the general mean (mean 1.25). negative affect (habitual players=0.2) and, finally, tiredness The highest score was of the positive affect component (habitual (habitual players=0). Positive affect reached a score considerably players=2.8), followed by competence (habitual players=2.18), higher than negative affect. The components below the immersion (habitual players=1.96), flow (habitual players=1.89), arithmetic mean (mean 0.46) were negative affect and tiredness. challenge (habitual players=1.16), negative affect (habitual The following scores were obtained for the 2 combined classes players=0.69) and, finally, tension (habitual players=0.37). It (nonhabitual players and habitual players): positive affect should be noted that in this evaluated class, the positive affect (total=0.95), return to reality (total=0.47), tiredness (total=0.43), component scored considerably higher than the negative affect and negative affect (total=0.40). Only the positive affect component. The scores obtained in the components, tension, component had a score above the arithmetic mean (mean 0.56). negative affect, and challenge, were below the arithmetic mean However, this score was responsible for an increase in the mean. (mean 1.57). The users also evaluated the proposed game interface in 3 A combination of the 2 classes (nonhabitual players and habitual aspects: (1) defined controls for the game, (2) quality of the players) was also performed. The positive affect component graphics and sound, and (3) game information about the project had the highest score (total=2.08), followed by the components, and how to play. The simple arithmetic mean of these aspects competence (total=1.79), flow (total=1.68), immersion was calculated and is presented in Table 6. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Table 4. Core Game Experience Questionnaire average scores for the 3 classes. Core Game Experience Questionnaire Nonhabitual players, mean Habitual players, mean Total, mean Negative affect 1.25 0.69 1.03 Positive affect 1.61 2.80 2.08 Challenge 1.33 1.16 1.26 Tension 0.81 0.37 0.64 Flow 1.54 1.89 1.68 Immersion 1.44 1.96 1.64 Competence 1.54 2.18 1.79 Table 5. Postgame Game Experience Questionnaire average scores for the 3 classes. Core Game Experience Questionnaire Nonhabitual players, mean Habitual players, mean Total, mean Positive affect 0.75 1.17 0.95 Negative affect 0.50 0.20 0.40 Returning to reality 0.68 0.68 0.43 Tiredness 0.43 0.48 0.47 Table 6. The average of usability aspects based on evaluation. Aspect Values (mean) Game control 2.86 Graphics and audio resources 3.09 Available information 2.05 An important feature of this experiment was the division of Participant 22 had the highest negative affect score among all participants into those who are habitual players and those who the participants. Participant 11, on the contrary, obtained a score are not (nonhabitual players). It should be taken into account for positive affect within the average, which was not expected, that the analyses performed by players tend to produce less given his or her level of tension. variation as these participants have a basis for comparison with previous experiences. Discussion During analysis of the results, it was verified that the participants Related Studies more accustomed to playing games did not feel challenged by Although there is a vast body of literature available regarding the Jib game. This can be explained by the difficulty of the game serious games applied to health care, this is a recent topic, and as the game does not have an increasing level of difficulty and therefore, there are only a few pieces in the literature related to can be saturated very quickly, using few iterations. Another serious games that deal with alcohol abuse. factor that potentially influenced the perceived level of challenge in the game was self-declared competence. Gaibler et al [15] presented a study that addresses the effect of alcohol on safe driving activity, especially in the young age The score of the immersion component was significant, even group (between 14 and 27years). The app, a serious game, is a though the game was simple. Participants used to play games racing game in the third person, where the intention is to reach reported a good experience in this component. The returning to the final goal safely, avoiding alcoholic beverages in the process. reality component scored 0 among participants who are habitual Our proposal shares the principle of alcohol consumption players. The authors believe that the habit of playing more affecting the gameplay. In this game, the players are challenged complex games had a great influence on this component as the by lowering their game vision according to the level of sense of reality of these people may be less influenced by Jib, intoxication. In our proposal, varying the game speed offers a and they could easily discern their virtual experience from the more dramatic consequence to the user experience, leading to real one (returning to reality). In such cases, serious games with a premature end of the game. Nonetheless, this paper is limited low complexity can possibly generate more significant results to a discussion of some preliminary and promising results. in people who are nonhabitual players. Rodriguez et al [16] conducted a systematic review related to In total, 2 participants were identified as outliers (participant serious educational games aimed at the consumption of alcohol 11 and 22). Both of them had much higher stress levels (tension) and other drugs by adolescents. The search for papers was than the other participants. This component possibly had an carried out in research portals. According to the authors, 8 influence on the negative and positive affect components. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al papers related to the consumption of alcohol, cannabis, tobacco, Although the current results are not yet conclusive as to whether methamphetamine, ecstasy, and other drugs were found. In their game is effective regarding its purpose, the study shows addition, 6 other papers addressed the use of other drugs. exciting findings of the suitability of serious games. Serious However, only one of the papers showed a decrease in the games seem to be suitable to exercise new skills, but the frequency of drug use. The authors highlight the need for further evaluation of its effectiveness is still a major challenge. investigation and development of serious educational games, Nevertheless, their results, and our results, suggest that this is such as the one presented in this paper. a promising way, and further research is required to disclose and assess its potential. Boendermaker et al [17] applied gamification techniques similar to a cognitive bias modification of attention (CBM-A) training Conclusions task to draw attention away from images of alcoholic beverages. The paper presented the development of a serious game for The applied training task is called a visual probe task [18,19] smartphones aimed at addressing the issue of alcohol abuse. that consists of the use of pairs of images, where one presents The main purpose was to call the player’s attention to the an important stimulus to the alcoholic beverage and another consequences of alcohol abuse through experimentation in the one a neutral stimulus (something nonalcoholic). The activity game. The authors do not have the illusion that people would consisted of 4 sessions, with at least a 1-day difference between cease drinking immediately but do intend to contribute to the sessions, for 2 weeks. The study was aimed at undergraduate awareness of this social problem. students (96 students, mean age 21.2 years). The authors To evaluate the proposed approach, an assessment based on identified the problems of excessive alcohol consumption of AUDIT and GEQ was carried out with residents of a student’s the candidates by using questionnaires. The authors concluded house. The proposed evaluation consisted of 3 stages: 2 that the innovation proposed in their study was insufficient to questionnaires (pre- and postintervention) and 1 intervention the task of motivating adolescents in training when compared stage, which consisted of 20 min of exposure to the game. The with conventional CBM-A training. They believe that one of users were divided into groups based on their habit of gaming the motivations for such an outcome is related to the expectation in the data analysis. that a game should be fun, a feature that was not the focus of their study. In this study, the focus is on building a game that The quantitative analysis presents a high degree of positive is fun and fosters educational drive, but no analysis regarding affect concerning the participants who declared themselves to user motivation to play the game or gameplay consequences have the habit of playing, although they did not have a high has been performed. level of challenge because of the low difficulty and small learning curve. Overall (among all participants), the positive More recently, Boendermaker et al [20] developed and evaluated affect score was twice that of the negative affect. In this way, a serious game aimed at increasing behavioral control in the authors believe that the Jib game obtained a proper adolescents and thereby helping them to improve control over evaluation in the 2 different groups of participants, considering their alcohol use. The studied compared the game training to a the limitations of this first version of the game. game placebo and a nongame training version in a randomized controlled trial. The study sample was 185 adolescents (mean In the future, the authors expect to continue to develop Jib and age 14.9 years) assessed for 4 weeks. As a result, the game to increase the level of difficulty and application of the game. variants were shown to motivate adolescents beyond the level New experiments should also be conducted using different of the nongame version. The exercised skill, behavioral control, groups of users, such as indigenous people in urban contexts, improved significantly over time, but this effect was also present and exploring the variations between gender, age, and family in the game placebo. Yet, as baseline drinking levels were low, background related to the issue of alcohol abuse. The net effect no significant training effects on drinking behavior were found. of the gaming experience, with the implied alcohol use and fun, Our study also employs a sample that has been characterized needs to be better studied and its suitability verified especially by having a low baseline on drinking. The authors believe the regarding addicts. Further research should also explore new game activities alone may have had a beneficial impact on the game features, such as new styles, to make it more attractive to measures of behavioral control. a wider audience, in addition to performing an in-depth study on the effects of playing the game. Acknowledgments The authors would like to thank Caroline Vaczy, for conducting proofreading, the reviewers, for the valuable feedback, and the Federal University of São João del-Rei, for the support partially funding the publication fees. Conflicts of Interest None declared. References 1. World Health Organization. Global Status Report on Alcohol and Health. Geneva, Switzerland: World Health Organization; https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al 2. Correio Braziliense. 2015. Brazil Loses 7.3% of PIB With Excessive Alcohol Consumption URL: http://www. correiobraziliense.com.br/app/noticia/economia/2015/01/18/internas_economia,466870/ brasil-perde-7-3-do-pib-com-consumo-excessivo-de-bebidas-alcoolicas.shtml [accessed 2018-02-05] [WebCite Cache ID 6x06jpO9Y] 3. Arnab S. In: Dunwell I, Debattista K, editors. Serious Games For Healthcare: Applications And Implications. Hershey, Pennsylvania, USA: IGI Global; 2012. 4. Abt CC. Serious Games. Lanham, Maryland: University Press Of America; 1987. 5. Langdon EJ. What to Drink, How to Drink, and When to Drink: The Sociocultural Context of Alcoholism Among Indigenous Populations. In: Proceedings of the Seminar on Alcoholism and STD / AIDS Vulnerability among the Southern, Southeast, and Mato Grosso do Sul People. 2001 Presented at: Seminar on Alcoholism and STD / AIDS Vulnerability; 1997; Londrina, PR, Brazil p. 83-97 URL: http://bvsms.saude.gov.br/bvs/publicacoes/021anais_seminario.pdf 6. Viertler RB. Interethnic living and alcoholism among the Bororo: results of a survey. Rev Tellus 2002 Apr;2(2):9-38 [FREE Full text] [doi: 10.20435/tellus.v0i2.8] 7. Guimarães LA, Grubits S. Alcoholism and violence in indigenous ethnic groups: a critical view of the Brazilian situation. Psicol Soc 2007;19(1):45-51. [doi: 10.1590/S0102-71822007000100007] 8. Ingold T. From the transmission of representations to the education of attention. In: Whitehouse H, editor. The Debated Mind: Evolutionary Psychology Versus Ethnography. Oxford, United Kingdom: Berg Publishers; 2001:113-153. 9. Cody M, Vorderer P, Ritterfeld U. Serious Games: Mechanisms and Effects. New York: Routledge; 2009. 10. Gee JP. What Video Games Have to Teach Us About Learning and Literacy. Basingstoke, United Kingdom: Palgrave Macmillan; 2003. 11. Michael D, Chen S. Serious Games: Games That Educate, Train, and Inform. Boston, MA, USA: Course Technology PTR; 12. Babor F, Higgins-Biddle JC, Saunders JB, Monteiro MG. World Health Organization. 2001. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care URL: https://www.who.int/substance_abuse/publications/audit/en/ [accessed 2018-02-01] [WebCite Cache ID 6wuXNWsa1] 13. Ijsselsteijn WA, de Kort YA, Poels K. Eindhoven University of Technology. 2013. The Game Experience Questionnaire URL: https://research.tue.nl/en/publications/the-game-experience-questionnaire [accessed 2019-09-11] 14. Johnson D, Wyeth P, Sweetser P, Gardner J. Personality, Genre and Videogame Play Experience. In: Proceedings of the 4th International Conference on Fun and Games. 2012 Presented at: FnG'12; September 4-6, 2012; Toulouse, France p. 117-120. [doi: 10.1145/2367616.2367633] 15. Gaibler F, Faber S, Edenhofer S, von Mammen S. Drink & Drive: A Serious but Fun Game on Alcohol-Induced Impairments in Road Traffic. In: 7th International Conference on Games and Virtual Worlds for Serious Applications. 2015 Presented at: VS-Games'15; September 16-18, 2015; Skovde, Sweden p. 1-5. [doi: 10.1109/VS-GAMES.2015.7295771] 16. Rodriguez DM, Teesson M, Newton NC. A systematic review of computerised serious educational games about alcohol and other drugs for adolescents. Drug Alcohol Rev 2014 Mar;33(2):129-135. [doi: 10.1111/dar.12102] [Medline: 24329810] 17. Boendermaker WJ, Maceiras SS, Boffo M, Wiers RW. Attentional bias modification with serious game elements: evaluating the shots game. J Med Internet Res Serious Games 2016 Dec 6;4(2):e20 [FREE Full text] [doi: 10.2196/games.6464] [Medline: 27923780] 18. MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias. J Abnorm Psychol 2002 Feb;111(1):107-123. [doi: 10.1037/0021-843X.111.1.107] [Medline: 11866165] 19. Schoenmakers TM, de Bruin M, Lux IF, Goertz AG, van Kerkhof DH, Wiers RW. Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients. Drug Alcohol Depend 2010 Jun 1;109(1-3):30-36. [doi: 10.1016/j.drugalcdep.2009.11.022] [Medline: 20064698] 20. Boendermaker WJ, Veltkamp RC, Peeters M. Training behavioral control in adolescents using a serious game. Games Health J 2017 Dec;6(6):351-357. [doi: 10.1089/g4h.2017.0071] [Medline: 28926286] Abbreviations AUDIT: Alcohol Use Disorders Identification Test CBM-A: cognitive bias modification of attention GEQ: Game Experience Questionnaire WHO: World Health Organization https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Edited by G Eysenbach; submitted 28.05.18; peer-reviewed by W Boendermaker, J Salisbury; comments to author 03.08.18; revised version received 31.12.18; accepted 10.02.19; published 15.10.19 Please cite as: Carvalho DBF, Domingueti DB, Almeida Santos SMD, Dias DRC JMIR Serious Games 2019;7(4):e11151 URL: https://games.jmir.org/2019/4/e11151 doi: 10.2196/11151 PMID: 31617849 ©Darlinton Barbosa Feres Carvalho, Daniel Bueno Domingueti, Sandro Martins De Almeida Santos, Diego Roberto Colombo Dias. Originally published in JMIR Serious Games (http://games.jmir.org), 15.10.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 13 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

A Game to Deal With Alcohol Abuse (Jib): Development and Game Experience Evaluation

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Abstract

Background: Alcohol abuse is the primary cause of (public) health problems in most parts of the world. However, it is undeniable that alcohol consumption is a practice that is widely accepted socially in many places, even being protected by law as a cultural and historical heritage. The issue of alcohol abuse is complex and urgent, and consequently, it is necessary to create innovative approaches such as the proposal explored in this study. Objective: This study aimed to explore the development and evaluation of a serious game for smartphones to present a novel approach to address the issue of alcohol abuse. Methods: A serious game was developed to instill the consequences of alcohol abuse into the player through experimentation in the game. In the game, the consequences of alcohol use are demonstrated by increasing the game speed that gives an illusion of fun but also leads to a premature death. The evaluation employed an assessment based on the Alcohol Use Disorders Identification Test (AUDIT) and the Game Experience Questionnaire (GEQ). The participants belonged to the university student’s house. Results: The game development process has been presented, including its mechanics and gameplay. The game has the style of action and adventure games in which the player controls an indigenous avatar that can deflect or attack opponents coming his or her way. The game evaluation comprised an assessment based on 23 participants, aged 20 to 29 years. According to the AUDIT assessment, 18 participants reported having a low or nonexistent degree of alcohol dependence and 5 declared average dependence. Regarding their habit of playing games on smartphones, 9 participants declared they have this habit of playing (habitual players), and among the 14 that did not have this habit of playing (nonhabitual players), 3 participants declared not having a smartphone at all. The GEQ core assessment showed a higher positive affect among the participants with a habit of playing games, scoring 2.80 (habitual players) on a scale of 4.0 versus 1.61 (nonhabitual players), and higher tension as an opposite relationship of 0.81 (nonhabitual players) versus 0.37 (habitual players). The overall GEQ evaluation showed that the game presents a more positive than negative affect on all users, besides showing the other desirable characteristics of serious games. Conclusions: We present a new way of dealing with the issue of alcohol abuse through a game designed for smartphones. It promotes an overall positive user experience, having a greater impact on users accustomed to games. The proposed approach has its niche, though it is still a minority in the evaluated population. Further research should explore new game features, such as new styles, to make the game more attractive to a wider audience, in addition to performing an in-depth study on the effects of playing it. (JMIR Serious Games 2019;7(4):e11151) doi: 10.2196/11151 https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al KEYWORDS alcohol abuse; serious game; software design; proof of concept evaluation of some factor over another. Thus, it is feasible to relate a game Introduction to other human activities, as all have rules (of society or a particular environment), participants, successes, and failures Background (of tasks or procedures involved). Alcohol abuse is the primary cause of (public) health problems An indigenous hero is considered for the setting of the game. in Brazil. According to the World Health Organization (WHO), It is worth noting that alcohol abuse also extends in Brazil to in 2012, about 3.3 million deaths or 5.9% of all deaths recorded the indigenous sphere of society. Langdon [5] points out that on the planet were attributable to alcohol consumption [1]. The because of the process of inclusion of the indigenous people in abusive consumption of alcoholic beverages is the component the broader society, they have begun to substitute or add the cause of more than 200 types of diseases and injuries. distilled beverage into their everyday life. The consequences Alcoholism represents harm to private health, public health, of this change have also been addressed by Viertler [6] and and the economy as a whole. The estimated annual cost of Guimarães and Grubits [7], demonstrating that alcohol abuse alcoholism is £20 billion in the United Kingdom and more than is the main cause of addiction diagnoses, accidents, and cases US $200 billion in the United States. Brazil loses around 7% of violence against other members of the community, including of its gross domestic product per year because of excessive the use of various weapons and incidence of fatal victims. The consumption of alcoholic beverages. The cost estimated in 2014 indigenous theme also brings out the problem in these societies reached R$372 billion [2]. to a wider audience as intervention in this area is also not an However, it is undeniable that alcohol consumption is a part of easy task and lacks attention in a broader sense. many cultures, being a practice that is widely accepted socially As Ingold [8] points out, the learning process is about the in most parts of the world. In Brazil, the spirit cachaça (a type education of attention. Thus, as a child, learning is consolidated of distilled spirit made from fermented sugarcane, the most through games and toys. Through them, the study by Ritterfeld popular distilled alcoholic beverage in Brazil) is even protected et al explains [9], “children exploit and accumulate the world, by law for its distinguished characteristics (Brazilian Presidential improving their skills and abilities” because they are extremely decree n.6871/2009) and is considered a part of national cultural motivating activities. However, later in elementary school, there and historical heritage. The issue of alcohol abuse is complex is a clear separation between learning and fun, making learning and urgent, and consequently, it is necessary to create innovative somewhat unmotivating and unpleasant. This is because approaches such as the proposal explored in this study. motivation dictates the learning flow—when motivation ends, Objectives learning and the act of playing also end [10]. The main aim of this study was to explore the possibilities Electronic games have been proposed to make learning offered by new technologies to address this relevant issue. motivational as they have the ability to communicate concepts Numerous successful cases have been found in the literature and facts of many subjects effectively and allow people to employing serious games in dealing with relevant health care recreate themselves in new worlds and achieve recreation and issues [3]. Considering the growing use of smartphones, the deep learning at the same time. That is, they are capable of creation of a serious game for smartphones takes advantage of creating a dramatic representation of the studied situation this important channel of communication to innovate an [4,10,11]. intervention for such issues. Such games are called educational games. However, they do Our proposal was to employ new technologies to raise awareness not always achieve their goal as many prioritize the educational about the consequences of alcohol abuse, promoting or entertainment components separately. A methodology is used empowerment of the individual, traditional cultures, and social specifically for the development of serious games that are games responsibility. The authors believe that a suitable means for this that use the artistic medium of the game to deliver a lesson or is a playful educational tool, that is, a serious game. In this teach about some subject so that both components are balanced sense, the user is allowed to experience the option of drinking [9]. and modifying the gameplay, eventually increasing the fun factor, but also showing the consequences, such as the premature According to Michael and Chen [11], a serious game should termination of the game (player’s death in the game). contain some elements related to design and development itself, including the following: (1) simple (intuitive)—usable by people who have little or no experience with digital games, (2) adequate Methods simulation—both in terms of realism and difficulty, and (3) Design Rationale progress analysis—it allows the player to formulate strategies, in case he or she learns what the game wants to pass to achieve Game development is based on the premise that games are greater progress in the game. strongly linked to reality. According to Abt [4], a game has some core elements such as rules, participants, information, To achieve these desirable characteristics, the development was gains, and losses. It is also possible to assimilate factors such divided into 3 stages: (1) planning, (2) prototyping, and (3) app as competition, opposition, and maximization or minimization consolidation. The whole process was documented in the Game https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Development Document, which contains all the necessary of all the alternatives, determines the level of alcohol information for game development, such as an execution dependence of the interviewee. The risk degree of dependency, flowchart, the definition of gameplay, and references and potential consequences, and intervention recommendation for inspiration. This paper has presented a consolidated version of the interviewee are classified according to 4 levels. The the Game Development Document, highlighting the main correspondence among scores and the meaning of their risk concepts employed in the game with regard to mechanics, level is shown in Table 1. gameplay, and implementation. The Game Experience Questionnaire (GEQ) [13] was used for the postintervention evaluation. It consists of a questionnaire Field Evaluation composed of 3 modules: the core, the postgame, and the social The game evaluation was carried out with students from the modules. The questionnaire has simple and direct questions student residence of the Federal University of São João del-Rei. about the player’s thoughts and feelings, such as “I felt happy” This residence is the student housing provided by the university and “I felt angry.” The core module has questions regarding for low-income students under the university’s official assistance feelings and beliefs that the interviewee had while playing. In program. All participants were volunteers and had to sign a the postgame module, the questions are focused on when the participant consent form, which described the general purpose player stopped playing. In this way, the participant demarcates of the study and stated the research procedures according to the level of agreement with the corresponding sentence on a international and Brazilian ethical research laws and principles. scale from 0 to 4, where 0 means no agreement and 4 means a The results are opinions declared by the participants and were lot of agreement. disclosed anonymously. The proposed evaluation consisted of 3 stages: 2 questionnaires (pre- and postintervention) and a Only the core and postgame modules were used as the proposed 20-min intervention phase of user interaction with the game. game does not have social interactions. The participants No further explanation about the game was provided, leaving answered them after the intervention stage. In each module, a the exploration process up to the participants. When the group of questions defined a component to be analyzed, and participants asked about a specific game element, the feedback the final calculation of it was given by the simple average of was an incentive for them to explore and test the interface to the questions. The total average of the components was given figure out the answer. by the simple average of all the individual components of the interviewees—with results ranging from 0 to 4. In this case, 0 The preintervention interview was performed to characterize means that there is no presence of that component and 4 means the participant by collecting information such as age, sex, and there is a lot of it. their level of alcohol dependence. To identify the level of alcohol dependence of the users, the Alcohol Use Disorders Finally, the postintervention evaluation consisted of 3 questions Identification Test (AUDIT) was employed. The WHO to evaluate the design of the app concerning the visual and sound recommends the use of AUDIT [12] as a simple, brief method resources and the available information about the game (such of screening for excessive drinking. Its questionnaire contains as tutorials and information about the project) and about the 10 multiple-choice questions with 5 choices each. The controls. A scale from 0 to 4 was also used at concordance assessment works as a sum of points acquired by each levels, where 0 meant weak and 4 meant optimal. alternative—from 0 to 4—and the final result, that is, the sum Table 1. Risk level scores with regard to alcohol consumption behavior according to the Alcohol Use Disorders Identification Test assessment. Score Risk level 0-7 Inexistent: low-level drinking or abstinence 8-15 Low: alcohol use in excess of low-risk guidelines 16-19 Medium: harmful and hazardous drinking Over 20 High: alcohol dependence first one but using the Unity Graphic Engine (ie, Unity3D) for Results its implementation. Development The game was deployed on the Android operating system because of its popularity. The development of an app through The Game Development Document details the proposed native language is the development of an Android app modeling and the definition of the rules, basic interface, and exclusively using the Android Software Development Kit or other details. The details of the graphics and sound features Android Native Development Kit. This allows for efficient were being defined along with the game development. In total, development as the developer has direct access to all the tools 2 versions were developed. The first prototype was made in the of the device. Access to all tools allows you to design the app Massachusetts Institute of Technology (MIT) AppInventor in the best possible way for the operating system, maximizing platform, but its development was discontinued because of the user experience. However, this environment requires mastery performance issues. The last prototype is the evolution of the of the platform’s native language and its tools. All physical modeling involved in the app must be developed. For easy game https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al development, many platforms can be found in the Android The proposed game follows the style of action and adventure ecosystem that assist developers in creating new games. games, in which the player controls an indigenous avatar who can deflect or attack opponents coming his or her way. It has 3 A study was carried out on game development platforms screens: the initial menu screen, an information display screen available for the Android system. The most promising ones about game rules and the project, and the screen that contains were MIT AppInventor and Unity Graphic Engine. the game. The initial menu screen, described in Figure 1 (left), The MIT AppInventor platform is an Android app development allows you to move to any other screen within the app and to platform supported by Google and maintained by the MIT exit the app. The about screen, shown in Figure 1 (right), allows (United States). It has a drag-and-drop system where users the user to return to the initial menu screen (using the return select, drag, and fit blocks that determine a line or method of button in the upper left corner). Information regarding the game execution in an interaction area. It is an open-source license screen (and the game itself) is described in the following environment that is easy to learn, with the freedom to run the subsections. It is important to note that all graphics and sounds program for any legal purpose. are available on the internet under the Creative Commons license. At first, the authors chose the MIT AppInventor platform for prototyping because of the small learning curve and the need The instructions presented in the about screen (Figure 1 [right]) to set implementation details. It was a straightforward can be translated as follows: About the Game – “JIB is a game implementation of what was designed. However, because of created to address the issue of alcoholism, allowing the player performance issues when the game had to perform fast updates to experience the consequences of alcohol abuse through the of the graphic elements on the screen (ie, the game starts game. The indigenous theme has been explored to compose the experiencing unexpected screen update errors), a more robust hero of this game, creating a narrative contextualized in the platform was needed. Therefore, the game’s final version was forest. The effects of using alcohol can be perceived by fully implemented using the Unity Graphic Engine. It took a increasing the game speed and giving an illusion of more fun while to learn this new platform, but the process of prototyping but also by showing that alcohol abuse might lead to premature in AppInventor to achieve better implementation later in Unity death.”; and How to Play “Move the Indian by touching the was shown to be effective to enable fast prototyping, especially lower half left and right of the screen and shoot by touching the considering programmers without much experience in game center of the screen. Opponents will appear at the top of the development, and produce a better game in terms of quality on screen, and you must act. Be careful with the drinks, it can be a more robust platform. tasty, but the alcohol level will rise, and it will change you.” https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 1. Two screens of the proposed game: (left) first screen; (right) about the game screen (in Portuguese). The user interaction consists of using a touch screen, where his or her way. Opponents appear on the upper edge of the areas are defined for interaction and arrangement of the elements device screen, and when they reach the lower end, they of the game. Figure 2 (right) presents a schematic of these areas disappear. Some defined opponents are the snake, the jaguar, in comparison with the game screen (Figure 2 [left]: (1) move and the drink. Once the Indian comes in direct contact with the character to the left, (2) shoot the arrow, (3) move character to snake or the jaguar, the game ends. If the arrow hits an opponent, the right, (4) restart the game, (5) enable or disable the sound the player gets a score that is added and displayed on the screen. in the game, (6) enable or disable the display of indicative signs When the player consumes the drink, it increases the points and of the action buttons, (7) display the player’s current score, (8) speed of the game, which in a way also increases the fun. The return to the home screen, and (9) indicate current alcohol idea is that drinking causes the player to slow down compared consumption level). with the world, that is, the other elements get faster. The player, as already mentioned, controls an indigenous avatar who can deflect or shoot arrows at the opponents that appear in https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 2. User interface with interaction elements positioning: (left) game play screen; (right) sensible areas of the interface for user interaction. The opponents use a system for continuous displacement, launch of an opponent, the counter of the chosen and adjacent explained in Figure 3, to avoid the overlap and improper lane is incremented. Counters are decreased when an opponent collision of opponents on the screen. The lanes have counters passes a safety range (represented by the horizontal blue dashed associated with them to notify their availability (or not). At the line closer to the top in Figure 3). https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Figure 3. Enemy movement lanes in the game screen. degree of dependence, and 5 declared an average dependence. Evaluation No participant declared a high degree of dependency. Data were collected from a total of 23 participants, 12 of whom Of the 23 participants, only 3 did not have a smartphone. Among were male and 11 were female. The participants’ ages ranged those who owned a smartphone, 11 did not use it for games. from 20 to 29 years, although 2 participants preferred not to declare their age. Regarding the degree of dependency identified Game Experience Questionnaire by the AUDIT questionnaire [12], 5 claimed not having any The GEQ [13] was used to gain an understanding of user alcoholic dependence, 13 reported having a low or nonexistent experience with the game. Overall, 2 GEQ modules were used: core and postgame. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al First, the elements of the questionnaire should be understood. during the game. All core elements of the GEQ are presented According to Johnson et al [14], the components—competence, in Table 2. stress, negative affect, and positive affect—are self-explanatory. The GEQ postgame questionnaire was used to identify how the Negative affect and positive affect refer to the user experience. player felt after playing. This questionnaire is composed of 4 For example, a user may feel good or unmotivated about the variables: positive affect, negative affect, tiredness, and return game. Challenge aims to present data regarding the amount of to reality. Positive affect is related to the satisfaction, victory, effort, difficulty, and pressure felt by the user during the game. and power of the user after playing. In contrast, the negative Tension is related to the player’s frustration while playing the affect addresses the user’s bad experiences after playing. game. Flow aims to identify how interested the user was during Tiredness is related to the user’s exhaustion during the game. the game. Immersion shows how immersed the user was with Finally, the returning to reality component addresses the user’s the story and elements of the game. Finally, competence is disorientation after a gaming period. Table 3 presents the related to the player’s ability and how well he or she performed postgame elements and related questions. Table 2. Core Game Experience Questionnaire components and response options. Core Game Experience Questionnaire components Response options Immersion I was interested in the game’s story It was aesthetically pleasing I felt imaginative I felt that I could explore things I found it impressive It felt like a rich experience Flow I was fully occupied with the game I forgot everything around me I lost track of time I was deeply concentrated on the game I lost connection with the outside world Competence I felt skillful I felt competent I was good at it I felt successful I enjoyed it Negative affect It gave me a bad mood I thought about other things I found it tiresome I felt bored Tesnion I felt annoyed I felt irritable I felt frustrated Challenge I thought it was hard I felt pressured I felt challenged I felt time pressure I had to put a lot of effort into it https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Table 3. Postgame Game Experience Questionnaire components and response options. Postgame Game Experience Questionnaire components Response options Positive affect I felt revived It felt like a victory I felt energized I felt satisfied I felt powerful I felt proud Negative affect I felt bad I felt guilty I found it a waste of time I felt that I could have done more useful things I felt regret I felt ashamed Tiredness I felt exhausted I felt weary Returning to reality I found it hard to get back to reality I felt disoriented I had a sense that I had returned from a journey (total=1.64), challenge (total=1.26), negative affect (total=1.03), Analysis and, finally, tension (total=0.64). In the combination of the 2 Analyses of the results from the core and postgame GEQ classes, it can be noted that the positive affect component had questionnaire (Tables 2 and 3, respectively) are presented as a relatively higher score than the negative affect component. follows. The mean score was calculated for each component in Only the components, challenge, negative affect, and tension, both questionnaires. The average score was calculated for 3 reached scores below the mean (mean 1.44). different classes of users: nonhabitual players, habitual players, With regard to the results obtained through the GEQ postgame and total. Table 4 presents the results of the core questionnaire questionnaire for nonhabitual players, the positive affect for the 3 distinct classes. component reached the highest score (nonhabitual players=0.75). As shown in Table 4, the highest score found among users who Negative affect was lower than the positive affect (nonhabitual declared themselves to be nongamers was the positive affect players=0.5). The lowest value found was related to the return component (nonhabitual players=1.61), followed by flow and to reality component (nonhabitual players=0.43). The tiredness competence components (nonhabitual players=1.54). However, component obtained a relatively high value in comparison with although the positive affect component obtained a higher score, the other components (nonhabitual players=0.68). The results it was similar to the negative affect component (nonhabitual referring to the GEQ postgame questionnaire for the 3 distinct players=1.25). Tension component was the one with the lowest classes are presented in Table 5. score (nonhabitual players=0.81). The scores of the components, For the habitual players class, the component with the highest competence (nonhabitual players=1.54), immersion (nonhabitual score was the positive affect (habitual players=1.17), followed players=1.44), and challenge (nonhabitual players=1.33), were by the components return to reality (habitual players=0.48), higher than the general mean (mean 1.25). negative affect (habitual players=0.2) and, finally, tiredness The highest score was of the positive affect component (habitual (habitual players=0). Positive affect reached a score considerably players=2.8), followed by competence (habitual players=2.18), higher than negative affect. The components below the immersion (habitual players=1.96), flow (habitual players=1.89), arithmetic mean (mean 0.46) were negative affect and tiredness. challenge (habitual players=1.16), negative affect (habitual The following scores were obtained for the 2 combined classes players=0.69) and, finally, tension (habitual players=0.37). It (nonhabitual players and habitual players): positive affect should be noted that in this evaluated class, the positive affect (total=0.95), return to reality (total=0.47), tiredness (total=0.43), component scored considerably higher than the negative affect and negative affect (total=0.40). Only the positive affect component. The scores obtained in the components, tension, component had a score above the arithmetic mean (mean 0.56). negative affect, and challenge, were below the arithmetic mean However, this score was responsible for an increase in the mean. (mean 1.57). The users also evaluated the proposed game interface in 3 A combination of the 2 classes (nonhabitual players and habitual aspects: (1) defined controls for the game, (2) quality of the players) was also performed. The positive affect component graphics and sound, and (3) game information about the project had the highest score (total=2.08), followed by the components, and how to play. The simple arithmetic mean of these aspects competence (total=1.79), flow (total=1.68), immersion was calculated and is presented in Table 6. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Table 4. Core Game Experience Questionnaire average scores for the 3 classes. Core Game Experience Questionnaire Nonhabitual players, mean Habitual players, mean Total, mean Negative affect 1.25 0.69 1.03 Positive affect 1.61 2.80 2.08 Challenge 1.33 1.16 1.26 Tension 0.81 0.37 0.64 Flow 1.54 1.89 1.68 Immersion 1.44 1.96 1.64 Competence 1.54 2.18 1.79 Table 5. Postgame Game Experience Questionnaire average scores for the 3 classes. Core Game Experience Questionnaire Nonhabitual players, mean Habitual players, mean Total, mean Positive affect 0.75 1.17 0.95 Negative affect 0.50 0.20 0.40 Returning to reality 0.68 0.68 0.43 Tiredness 0.43 0.48 0.47 Table 6. The average of usability aspects based on evaluation. Aspect Values (mean) Game control 2.86 Graphics and audio resources 3.09 Available information 2.05 An important feature of this experiment was the division of Participant 22 had the highest negative affect score among all participants into those who are habitual players and those who the participants. Participant 11, on the contrary, obtained a score are not (nonhabitual players). It should be taken into account for positive affect within the average, which was not expected, that the analyses performed by players tend to produce less given his or her level of tension. variation as these participants have a basis for comparison with previous experiences. Discussion During analysis of the results, it was verified that the participants Related Studies more accustomed to playing games did not feel challenged by Although there is a vast body of literature available regarding the Jib game. This can be explained by the difficulty of the game serious games applied to health care, this is a recent topic, and as the game does not have an increasing level of difficulty and therefore, there are only a few pieces in the literature related to can be saturated very quickly, using few iterations. Another serious games that deal with alcohol abuse. factor that potentially influenced the perceived level of challenge in the game was self-declared competence. Gaibler et al [15] presented a study that addresses the effect of alcohol on safe driving activity, especially in the young age The score of the immersion component was significant, even group (between 14 and 27years). The app, a serious game, is a though the game was simple. Participants used to play games racing game in the third person, where the intention is to reach reported a good experience in this component. The returning to the final goal safely, avoiding alcoholic beverages in the process. reality component scored 0 among participants who are habitual Our proposal shares the principle of alcohol consumption players. The authors believe that the habit of playing more affecting the gameplay. In this game, the players are challenged complex games had a great influence on this component as the by lowering their game vision according to the level of sense of reality of these people may be less influenced by Jib, intoxication. In our proposal, varying the game speed offers a and they could easily discern their virtual experience from the more dramatic consequence to the user experience, leading to real one (returning to reality). In such cases, serious games with a premature end of the game. Nonetheless, this paper is limited low complexity can possibly generate more significant results to a discussion of some preliminary and promising results. in people who are nonhabitual players. Rodriguez et al [16] conducted a systematic review related to In total, 2 participants were identified as outliers (participant serious educational games aimed at the consumption of alcohol 11 and 22). Both of them had much higher stress levels (tension) and other drugs by adolescents. The search for papers was than the other participants. This component possibly had an carried out in research portals. According to the authors, 8 influence on the negative and positive affect components. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al papers related to the consumption of alcohol, cannabis, tobacco, Although the current results are not yet conclusive as to whether methamphetamine, ecstasy, and other drugs were found. In their game is effective regarding its purpose, the study shows addition, 6 other papers addressed the use of other drugs. exciting findings of the suitability of serious games. Serious However, only one of the papers showed a decrease in the games seem to be suitable to exercise new skills, but the frequency of drug use. The authors highlight the need for further evaluation of its effectiveness is still a major challenge. investigation and development of serious educational games, Nevertheless, their results, and our results, suggest that this is such as the one presented in this paper. a promising way, and further research is required to disclose and assess its potential. Boendermaker et al [17] applied gamification techniques similar to a cognitive bias modification of attention (CBM-A) training Conclusions task to draw attention away from images of alcoholic beverages. The paper presented the development of a serious game for The applied training task is called a visual probe task [18,19] smartphones aimed at addressing the issue of alcohol abuse. that consists of the use of pairs of images, where one presents The main purpose was to call the player’s attention to the an important stimulus to the alcoholic beverage and another consequences of alcohol abuse through experimentation in the one a neutral stimulus (something nonalcoholic). The activity game. The authors do not have the illusion that people would consisted of 4 sessions, with at least a 1-day difference between cease drinking immediately but do intend to contribute to the sessions, for 2 weeks. The study was aimed at undergraduate awareness of this social problem. students (96 students, mean age 21.2 years). The authors To evaluate the proposed approach, an assessment based on identified the problems of excessive alcohol consumption of AUDIT and GEQ was carried out with residents of a student’s the candidates by using questionnaires. The authors concluded house. The proposed evaluation consisted of 3 stages: 2 that the innovation proposed in their study was insufficient to questionnaires (pre- and postintervention) and 1 intervention the task of motivating adolescents in training when compared stage, which consisted of 20 min of exposure to the game. The with conventional CBM-A training. They believe that one of users were divided into groups based on their habit of gaming the motivations for such an outcome is related to the expectation in the data analysis. that a game should be fun, a feature that was not the focus of their study. In this study, the focus is on building a game that The quantitative analysis presents a high degree of positive is fun and fosters educational drive, but no analysis regarding affect concerning the participants who declared themselves to user motivation to play the game or gameplay consequences have the habit of playing, although they did not have a high has been performed. level of challenge because of the low difficulty and small learning curve. Overall (among all participants), the positive More recently, Boendermaker et al [20] developed and evaluated affect score was twice that of the negative affect. In this way, a serious game aimed at increasing behavioral control in the authors believe that the Jib game obtained a proper adolescents and thereby helping them to improve control over evaluation in the 2 different groups of participants, considering their alcohol use. The studied compared the game training to a the limitations of this first version of the game. game placebo and a nongame training version in a randomized controlled trial. The study sample was 185 adolescents (mean In the future, the authors expect to continue to develop Jib and age 14.9 years) assessed for 4 weeks. As a result, the game to increase the level of difficulty and application of the game. variants were shown to motivate adolescents beyond the level New experiments should also be conducted using different of the nongame version. The exercised skill, behavioral control, groups of users, such as indigenous people in urban contexts, improved significantly over time, but this effect was also present and exploring the variations between gender, age, and family in the game placebo. Yet, as baseline drinking levels were low, background related to the issue of alcohol abuse. The net effect no significant training effects on drinking behavior were found. of the gaming experience, with the implied alcohol use and fun, Our study also employs a sample that has been characterized needs to be better studied and its suitability verified especially by having a low baseline on drinking. The authors believe the regarding addicts. Further research should also explore new game activities alone may have had a beneficial impact on the game features, such as new styles, to make it more attractive to measures of behavioral control. a wider audience, in addition to performing an in-depth study on the effects of playing the game. Acknowledgments The authors would like to thank Caroline Vaczy, for conducting proofreading, the reviewers, for the valuable feedback, and the Federal University of São João del-Rei, for the support partially funding the publication fees. Conflicts of Interest None declared. References 1. World Health Organization. Global Status Report on Alcohol and Health. Geneva, Switzerland: World Health Organization; https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al 2. Correio Braziliense. 2015. Brazil Loses 7.3% of PIB With Excessive Alcohol Consumption URL: http://www. correiobraziliense.com.br/app/noticia/economia/2015/01/18/internas_economia,466870/ brasil-perde-7-3-do-pib-com-consumo-excessivo-de-bebidas-alcoolicas.shtml [accessed 2018-02-05] [WebCite Cache ID 6x06jpO9Y] 3. Arnab S. In: Dunwell I, Debattista K, editors. Serious Games For Healthcare: Applications And Implications. Hershey, Pennsylvania, USA: IGI Global; 2012. 4. Abt CC. Serious Games. Lanham, Maryland: University Press Of America; 1987. 5. Langdon EJ. What to Drink, How to Drink, and When to Drink: The Sociocultural Context of Alcoholism Among Indigenous Populations. 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New York: Routledge; 2009. 10. Gee JP. What Video Games Have to Teach Us About Learning and Literacy. Basingstoke, United Kingdom: Palgrave Macmillan; 2003. 11. Michael D, Chen S. Serious Games: Games That Educate, Train, and Inform. Boston, MA, USA: Course Technology PTR; 12. Babor F, Higgins-Biddle JC, Saunders JB, Monteiro MG. World Health Organization. 2001. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care URL: https://www.who.int/substance_abuse/publications/audit/en/ [accessed 2018-02-01] [WebCite Cache ID 6wuXNWsa1] 13. Ijsselsteijn WA, de Kort YA, Poels K. Eindhoven University of Technology. 2013. The Game Experience Questionnaire URL: https://research.tue.nl/en/publications/the-game-experience-questionnaire [accessed 2019-09-11] 14. Johnson D, Wyeth P, Sweetser P, Gardner J. Personality, Genre and Videogame Play Experience. In: Proceedings of the 4th International Conference on Fun and Games. 2012 Presented at: FnG'12; September 4-6, 2012; Toulouse, France p. 117-120. [doi: 10.1145/2367616.2367633] 15. Gaibler F, Faber S, Edenhofer S, von Mammen S. Drink & Drive: A Serious but Fun Game on Alcohol-Induced Impairments in Road Traffic. In: 7th International Conference on Games and Virtual Worlds for Serious Applications. 2015 Presented at: VS-Games'15; September 16-18, 2015; Skovde, Sweden p. 1-5. [doi: 10.1109/VS-GAMES.2015.7295771] 16. Rodriguez DM, Teesson M, Newton NC. A systematic review of computerised serious educational games about alcohol and other drugs for adolescents. Drug Alcohol Rev 2014 Mar;33(2):129-135. [doi: 10.1111/dar.12102] [Medline: 24329810] 17. Boendermaker WJ, Maceiras SS, Boffo M, Wiers RW. Attentional bias modification with serious game elements: evaluating the shots game. J Med Internet Res Serious Games 2016 Dec 6;4(2):e20 [FREE Full text] [doi: 10.2196/games.6464] [Medline: 27923780] 18. MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias. J Abnorm Psychol 2002 Feb;111(1):107-123. [doi: 10.1037/0021-843X.111.1.107] [Medline: 11866165] 19. Schoenmakers TM, de Bruin M, Lux IF, Goertz AG, van Kerkhof DH, Wiers RW. Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients. Drug Alcohol Depend 2010 Jun 1;109(1-3):30-36. [doi: 10.1016/j.drugalcdep.2009.11.022] [Medline: 20064698] 20. Boendermaker WJ, Veltkamp RC, Peeters M. Training behavioral control in adolescents using a serious game. Games Health J 2017 Dec;6(6):351-357. [doi: 10.1089/g4h.2017.0071] [Medline: 28926286] Abbreviations AUDIT: Alcohol Use Disorders Identification Test CBM-A: cognitive bias modification of attention GEQ: Game Experience Questionnaire WHO: World Health Organization https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Carvalho et al Edited by G Eysenbach; submitted 28.05.18; peer-reviewed by W Boendermaker, J Salisbury; comments to author 03.08.18; revised version received 31.12.18; accepted 10.02.19; published 15.10.19 Please cite as: Carvalho DBF, Domingueti DB, Almeida Santos SMD, Dias DRC JMIR Serious Games 2019;7(4):e11151 URL: https://games.jmir.org/2019/4/e11151 doi: 10.2196/11151 PMID: 31617849 ©Darlinton Barbosa Feres Carvalho, Daniel Bueno Domingueti, Sandro Martins De Almeida Santos, Diego Roberto Colombo Dias. Originally published in JMIR Serious Games (http://games.jmir.org), 15.10.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2019/4/e11151 JMIR Serious Games 2019 | vol. 7 | iss. 4 | e11151 | p. 13 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Oct 15, 2019

Keywords: alcohol abuse; serious game; software design; proof of concept evaluation

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