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Breaking Health Insurance Knowledge Barriers Through Games: Pilot Test of Health Care America

Breaking Health Insurance Knowledge Barriers Through Games: Pilot Test of Health Care America Background: Having health insurance is associated with a number of beneficial health outcomes. However, previous research suggests that patients tend to avoid health insurance information and often misunderstand or lack knowledge about many health insurance terms. Health insurance knowledge is particularly low among young adults. Objective: The purpose of this study was to design and test an interactive newsgame (newsgames are games that apply journalistic principles in their creation, for example, gathering stories to immerse the player in narratives) about health insurance. This game included entry-level information through scenarios and was designed through the collation of national news stories, local personal accounts, and health insurance company information. Methods: A total of 72 (N=72) participants completed in-person, individual gaming sessions. Participants completed a survey before and after game play. Results: Participants indicated a greater self-reported understanding of how to use health insurance from pre- (mean=3.38, SD=0.98) to postgame play (mean=3.76, SD=0.76); t =−3.56, P=.001. For all health insurance terms, participants self-reported a greater understanding following game play. Finally, participants provided a greater number of correct definitions for terms after playing the game, (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t =−3.61, P=.001. Significant differences from pre- to postgame play differed by health insurance term. Conclusions: A game is a practical solution to a difficult health issue—the game can be played anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its execution. (JMIR Serious Games 2017;5(4):e22) doi: 10.2196/games.7818 KEYWORDS health insurance; games, experimental; young adult; information literacy concepts in an enjoyable way. In turn, players often exhibit Introduction increased conceptualization of specific challenges, even for stigmatized health issues such as sexual risk [3]. In addition to Serious games are designed to cultivate skills for a specific topic building skill sets, games can increase self-efficacy and result and do so by activating existing schema in the mind of a player in behavior change [4]. Given these benefits, serious games are to ultimately produce “new knowledge” and experiences [1]. a growing, effective medium for current and future generations In contrast to reading a pamphlet or searching online, players of young adult audiences [5]. engage with serious games, given their inherent fulfillment of a need to have fun or be satisfied, as suggested by There exists a variety of health-oriented serious games. In some self-determination theory [2]. As such, serious games are cases, health-focused games allow players to explore risky or increasingly implemented to train or immerse players in novel challenging situations without having to experience the direct experiences so that they may encounter and test structures and effects they might encounter in the real world (eg, dying or http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James harming someone, experiencing a negative health outcome, Understanding, selecting, and using a health insurance plan, mismanaging a decision) [6]. This includes training and allowing however, is a complex process and requires a plethora of diverse players to practice specific skills such as attention and reaction literacy and numeracy skill sets [17]. Politi and colleagues argue time while driving [7] or learning and experiencing how to that health insurance plan comprehension and decision making prepare surgical instruments [8]. Other games emphasize are “essential” for the consumer [18]. Thus, determining ways education and promoting an increased understanding of to discuss and facilitate health insurance information with the action-oriented knowledge. For example, after playing a game public is an important avenue for health-based research. titled Mommio, mothers indicated that they acquired knowledge Simultaneously, patients are increasingly encouraged to take by experiencing interactions between a mother and a child who ownership of their own health information and participate in does not enjoy eating vegetables [9]. Other games depict their own health care [19-21]. As a result, patients are given a topic-specific knowledge increases, such as increased growing amount of health insurance information and details to information about nutrition as a result of playing a diet- and interpret and consider [22]. exercise-oriented game titled SpaPlay [10]. Although the initiation of the Affordable Care Act increased A key benefit of serious games for health, specifically, is to the number of Americans who hold health insurance policies stimulate or motivate patients for health efforts that may be [23], it is not yet known whether health insurance consumers perceived as unpleasant or uninteresting and thus avoided [6]. indeed have knowledge and confidence in how to use their Games can also help players understand specific positions or benefits [24]. Previous research suggests that insured adults roles in one’s life, akin to imagining what it would be like to lack an understanding of terminology and how to use this try on a specific identity [6]. Games of every kind allow players important entity. Many states have implemented the use of to take on roles outside of their everyday lives, which can have health insurance counselors to aid consumers in their positive impact [11,12]. understanding and selection of a health insurance plan. Interviews with counselors point to critical health insurance According to the Entertainment Software Association, 56% of literacy concerns; patients tend to avoid reading information Americans today play video games, and nearly half (48%) of about specific plans and, as a result, misunderstand how much frequent gamers are considered mobile and/or social gamers coverage they have or how much they owe as the result of a [5]. Moreover, 77% of college-aged men and 57% of medical procedure (eg, if the patient pays a premium, the patient college-aged women report playing video games [13]. As such, might think he or she does not owe any additional medical costs) digital and Web-based games are a reasonable and strategic [25]. Counselors also note that patients rely on word-of-mouth platform to engage with these audiences. Games present an information about plans; often misunderstand terms such as additional opportunity to connect audiences with news and with “co-pay,” “deductible,” and “co-insurance”; and lack knowledge health. The overlapping, growing trends in gaming and media about provider restrictions such as being in network/out of speak to the opportunity for using a mobile-ready Web-based network [25]. game to engage new demographics in meaningful health information in innovative ways, reach existing audiences with Historically, young adults have the lowest rates of health alternative, interactive journalism, and speak to a new generation insurance plan enrollment among all nonelderly adult age groups of media users on the devices and in the media with which they [26,27]. Young adults remain the age demographic with the are already interacting. fewest insured individuals; 14.4% of young adults aged between 18 and 24 years did not have health insurance in 2015 and 17.9% In this study, we developed a serious game that draws from of those aged between 25 and 34 years [28]. Limited research principles of journalism, educational and video game design, has specifically tackled strategies for best communicating health and learning and literacy, in conceptualizing an online game insurance information to this vulnerable population. It is experience [14,15]. Given that young adults may currently avoid worrisome that young adults may not be equipped with the or misunderstand health insurance information, a game is a knowledge or skills to appropriately select and enroll in a plan. practical solution to this difficult health issue. A Web-based Furthermore, young adults with plans may struggle when health game may be particularly appropriate for young adults, navigating the health care system and amass high health care almost all of whom use the Internet. The game can be played bills. anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its Health insurance literacy is particularly low among young adults, execution. including those who are highly educated. In one study, none of the participants felt “good” or “very good” about their Health Insurance Literacy understanding of a list of health insurance terms and at times Having health insurance has been linked to a number of transposed definitions or had questions about the information advantageous health outcomes, including increased access to [29]. The need for increased understanding about health health monitoring, screening, information, and beneficial health insurance among young people is a long-standing health decisions [16]. As a result, those who do not have health challenge. Robertson and Middleman called for greater health insurance are at a greater risk for serious and exacerbated health insurance education for young people based on their findings consequences related to cancer, cardiovascular issues, that almost half of the adolescents in their study were unaware hypertension, diabetes, kidney disease, human of “how their medical bills [were] paid” [30]. Young adults immunodeficiency virus infection, and injury [16]. should be equipped with the information necessary for them to http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James make informed decisions when it comes to getting and using insurance terms [29] and exposure to an interactive game about health insurance. health insurance will improve this knowledge; given this, after game play: Newsgames Hypothesis 1: Participants will exhibit a greater For this project, we created a Web-based newsgame, “Healthcare self-reported, general understanding of what health America,” to explore the possibilities for what games can offer insurance is and how to use health insurance. the problem of engaging and informing young adults in concepts Hypothesis 2: Participants will exhibit increased connected to health insurance literacy. Bogost and colleagues self-reported understanding of critical health insurance define “newsgames” as games that apply journalistic principles terminology. in their creation [14]. For example, a newsgame might implement stories from various first-person sources or illustrate In addition to examining whether participants perceived the complexities of a real-world issue. themselves to have learned about health insurance terminology from the game, we sought to measure whether participants Specifically, newsgames infuse the concept of real-world increased in their objective knowledge of health insurance narrative into game play. Narrative communication and terminology after game play. storytelling are promising methods to increase engagement of an audience with content, yet are not frequently utilized in Hypothesis 3: Participants will be able to correctly health-related research and interventions [31]. Thompson and define a greater number of health insurance terms Kreuter note that “vivid, engaging writing can help audiences following game play. identify with storytellers and understand health messages” [32]. Findings from this study will have important implications for A growing interest in research is the narrative work written by many groups. Equipping young adults with a greater medical professionals, which can promote improved on-the-job understanding and confidence in what health insurance is and skills when read and considered by other professionals working how it works can lead to better overall health outcomes. in this industry (ie, learning from someone else through their Additionally, this study offers practical solutions for health stories) [33]. It was the hope of this study that playing a game practitioners, educators, and counselors who design programs with client-based narratives generated from news and real-world to improve health literacy and access to health information. In encounters and interviews would contribute to increased the remainder of this paper, the development of a health understanding of health insurance information. insurance game created for young adults will be described and its effects tested. Implications for health practitioners, including Newsgames are an emerging digital practice for today’s health insurance counselors and other financial advisors, will journalists, although games for journalism are not new. be discussed. Historically, crossword puzzles and news quizzes have been found in newspapers and on broadcast radio as tools to engage Methods audiences in interacting with news facts and information in engaging and fulfilling ways. As video games have evolved and Game Development Tool the benefits of game design have grown out of commercial markets into serious and educational spaces, journalism has also We used the Playable Media Story Builder (Phoenix, Arizona) begun taking the best practices of game design for nuanced platform to develop the game, Healthcare America. The Story storytelling, immersive learning and informing strategies, and Builder is a visual engine that allows publishing of hosted, engaging audiences in complex systems through play [34]. cross-platform responsive, interactive narrative games. The engine, designed to empower journalists to prototype narrative We selected a newsgame approach for Healthcare America to games, was funded by the Knight Foundation Knight Prototype explore a mobile game execution for health journalism and to Fund. The Playable Media team designed and developed the experiment with and contribute to the design models for tool in collaboration with journalists and journalism students engaging journalism. Games at the intersection of journalism at Arizona State University through the News-Play Project, a and health provide new, strategic opportunities to create playful partnership between Arizona State University’s New Media experiences around complex issues and offer real-world learning Entrepreneurship & Innovation Lab and Center for Games & created from real data designed into hypothetical interactive Impact Innovation Lab. narratives. These serious games provide a platform for audience engagement in ways that health communication and health Game Design and Development journalism have only just begun to explore (conventional tools Healthcare America positions the player as working for a health in health media communication include pamphlets and flyers, information advocacy organization with a series of client cases. public service announcements, and radio ads) [11]. The game interface includes simple graphics, narrative text, player choices, and two meters measuring community wellness The purpose of this study was to develop an interactive-narrative and health care assistance funds (see Figure 1). newsgame that presents entry-level health insurance information and scenarios to young adults. To our knowledge, this study is Using a newsgame design approach to develop game content, the first to design and test an interactive game that encourages we gathered stories about personal struggles with health young adults’ interaction with health insurance concepts. insurance from people in our community, undergraduate students, and national news stories. We collaborated with a We hypothesized the following statements based on the notion news writing and reporting class to further investigate through that young adults often lack an understanding of many health http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James personal narratives the ways in which people struggle with Web page. We collaborated with stakeholders and knowledge health insurance in the real world. Additionally, we pulled experts at our university about how they typically administer fact-based information from health insurance websites, the information and guidance about health insurance to students. HealthCare.gov website, and our university’s health insurance Figure 1. Examples of the user interface and game play of the health insurance game. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James As a result of this exploration, five scenarios or “client cases” experiences of stories from using, or struggling to use, health were developed for the game based on real-world stories and insurance. In the game, these stories are translated to “client information gathered from stakeholders and health insurance cases.” The player is given a role within the narrative and the consumers. Characters included in the game were developed to goal of “solving” or assisting a series of client cases while consciously include a variety of different race/ethnicities, sex working as an intern (with the promise of being promoted to a (white female, African American male, Hispanic female, white full-time position for a job done well). male, Asian female), age, and occupation. The player reads a client case file (eg, Vanessa who is a Following these steps, we adapted the list of health insurance 42-year-old female, a project manager and mother of 2, annual terms used by Wong and colleagues [29] to include the income US $35,000, who regularly sees a therapist to manage following: “the Affordable Care Act,” “deductible,” “monthly her mental health and well-being. She fills a prescription for premium,” “referral,” “in-network provider,” “co-payment,” antidepressants on a monthly basis. “Vanessa sent us [Healthcare “out-of-pocket maximum,” “coinsurance,” and “health America] an email because she’s confused about what just maintenance organization (HMO) and preferred provider happened at the pharmacy. After being diagnosed with organization (PPO).” Within the game, each term and a depression, Vanessa has a regular prescription for corresponding definition was provided to the participant for antidepressants. Today the cost of her medication was much their review. See Figure 1 for a screenshot of two definitions, higher than usual.”) and is then provided with information about which were both relevant for a case in which a consumer in the specific health insurance term (in the case of “Vanessa,” it is game had recently encountered unexpected health insurance information about co-payments). The player is then able to charges. advise the client using several options, each of which is linked to a corresponding increase or decrease in the Community The game opened with a brief introduction and explanation of Wellness meter, the Healthcare Assistance Fund, or both. The the game on screen. Game instructions, including the meaning player advises the client presented and then learns the outcome of the game meters (Community Wellness, that is, how healthy of the corresponding meters. the participant or player made the community, and Healthcare Assistance Fund, that is, the amount of money spent to assist There are obstacles to overcome (the main conflict is to balance the client), were then provided. With these meters in mind, the solutions to clients’ health care and health insurance problems) central goal of the game was to be a “successful intern” by and rewards for overall Community Wellness and the Healthcare assisting clients with troubling health insurance cases—aiming America’s Healthcare Assistance Fund. The game ends if the to maximize Community Wellness without spending all of the player depletes the Community’s Wellness or Healthcare organization’s Healthcare Assistance Fund. Assistance Funds as a result of his or her decision to assist a client (a loss) or if the player successfully assists all 5 clients Participants read and experienced each of the aforementioned (a win); see Figures 2, 3 and Multimedia Appendix 1. cases; key details about what happened and what went wrong for the client were presented. Then, health insurance terms were We kept in mind the body of information as is needed both for provided. Participants then selected one of three options for a narrative driven game and for narrative-driven journalism, how to advise each client, which took into account how much and situated the information a player would need to use [35,36]. each option would contribute to the overall Community As game designers, we designed each level of Healthcare Wellness (Did the participant help improve the health of the America based on a health insurance problem and distributed community through his or her advising decision?) and how the essential information the player would need across the game much money would be spent from their Healthcare Assistance to overcome obstacles and work toward the goal at the start of Fund, which was capped at US $5000. each level to gauge how much health insurance term information the player would need and could use—just enough information To summarize and provide a specific example, the prototype and just in time [36]. narrative design of Healthcare America blends real-world http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Figure 2. Design of game meters: (1) Healthcare assistance fund and (2) community wellness. Figure 3. An example of the community wellness meter options. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Table 1. Demographic information of sample (N=72). Characteristic Sample Sex, n (%) Male 29 (40) Female 43 (60) Race/Ethnicity, n (%) White 27 (38) Black, African American 18 (25) Hispanic, Latino/a 17 (24) Asian 5 (7) Mixed 4 (6) Other 1 (1) First-generation college, n (%) Yes 19 (26) General health, n (%) Excellent 8 (11) Very good 30 (42) Good 27 (38) Fair 5 (7) Poor 1 (1) Don’t know 0 (0) Academic year, n (%) Freshman 19 (26) Sophomore 12 (17) Junior 26 (36) Senior 10 (14) Super senior (+4 years) 3 (4) Other 1 (1) Non-English household, n (%) Yes 17 (24) Without health insurance, n (%) 17 (24) Age in years, mean (SD) 21.15 (3.49) an appointment. Each participant completed an individual, Participants in-person data collection session. All study procedures were A 2-tailed power analysis calculated for paired data was approved by the relevant institutional review board. Each session performed with G-Power to calculate an estimated sample size was scheduled for 1 hour and included an introductory phase of 67 participants (effect size=0.35, with 80% power, and in which participants read and signed a consent form, the alpha=.05) [37]. In total, 75 (N=75) students were included in completion of a pregame survey, game play on a computer, and this study. Due to a computer error, three of these participants a postgame survey. were unable to play the game and were thus removed from the Measures dataset, resulting in 72 (N=72) valid participants. The demographic information of the sample is included in Table 1. Participants completed pre- and postgame surveys to determine their level of health insurance understanding before and after Procedures playing the health insurance game. In both surveys, participants A call for participants was administered via email to classrooms, were asked to indicate their understanding of “what health or a Web-based classroom boards through journalism and insurance is” and “how to use health insurance,” as well as rate communications courses on campus. Participants indicated their their understanding of 9 health insurance terms using a 5-point interest by contacting the research team via email and scheduling scale (very good to very bad) [29]. Additionally, to measure http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James objective understanding of a given health insurance term, insurance is used. The first hypothesis predicted that, following participants were asked to write a definition for each of the 9 game play, participants would exhibit a greater self-reported, health insurance terms. These items were adapted from previous general understanding of what health insurance is and how it is research [29]. Similar to Wong and colleagues, a team of 4 used. Indeed, participants indicated a greater self-reported investigators determined whether each health insurance term understanding of how to use health insurance from pregame was defined correctly or incorrectly based on the content play (mean=3.38, SD=0.98) to postgame play (mean=3.76, provided in the game and the definitions provided by health SD=0.76); t =−3.56, P=.001. There was no significant insurance companies and Healthcare.gov. Participants also difference between pre- and postgame play for participants’ completed demographic items, including sex, race/ethnicity, self-reported understanding of what health insurance is. Given age, whether they were a first-generation college student (the this, hypothesis one was partially supported. first in their family to attend college), self-reported rating of Hypothesis 2 surmised that participants will exhibit increased their general health, year in school, whether they currently have self-reported understanding of critical health insurance health insurance, and whether they grew up in a household that terminology. For all health insurance terms, participants felt primarily spoke a language other than English. In cases where they had a better understanding of the term following the game; multiple numerical responses were selected (eg, both 3 and 4 see Table 2 for complete results. to indicate understanding of a health insurance term), the average of the 2 numbers (eg, 3.5) was used. Finally, in addition to examining whether participants felt that their understanding of a given health insurance term increased Analyses after playing a health insurance game, we wanted to determine Paired sample t tests were used to determine whether whether participants objectively define more health insurance participants’ self-reported understanding of what health terms correctly following game play. The proportion of insurance is, how to use health insurance, and the 9 health participants who correctly defined a given health insurance term insurance terms were different between pre- and postgame play. was significantly different for the following terms: “monthly A paired sample t test was also used to determine whether the premium,” “referral,” “in-network provider,” “deductible,” and total number of correctly defined health insurance terms differed “HMO/PPO”; see Table 3 for complete results. from pre- to postgame play. A Cochran’s Q test was used to Among participants who provided a definition for every health examine differences in correctly defined health insurance insurance term for both pre- and postgame play (N=32), terminology (paired nominal data) between pre- and postgame participants correctly defined more health insurance terms play. following game play (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t =−3.61, P=.001. However, Results the number of correct definitions provided following game play The purpose of this study was to determine whether a health did not correlate with participants’ overall self-reported insurance game is a viable tool to communicate important understanding of all terms following game play (self-reported information about health insurance terminology and how health scores for all terms were summed together), r=.18, N=42, P>.05. Table 2. Self-reported understanding of health insurance terms, pre- and postgame play. Health insurance term Pregame self-reported Postgame self-reported Paired t statistic (degrees P value understanding, mean (SD) understanding, mean (SD) of freedom) Affordable Care Act 2.75 (1.12) 3.73 (0.81) −6.92 (70) <.001 Premium 2.70 (1.20) 3.87 (0.81) −8.89 (70) <.001 Referral 3.11 (1.37) 4.13 (0.81) −6.25 (70) <.001 In-network provider 2.35 (1.37) 3.71 (0.97) −8.58 (71) <.001 Co-pay 3.24 (1.32) 3.72 (1.03) −3.10 (68) .003 Deductible 2.97 (1.17) 3.77 (0.80) −5.06 (70) <.001 Out-of-pocket maximum 2.23 (1.18) 3.39 (1.09) −7.62 (69) <.001 Coinsurance 1.91 (1.00) 2.39 (1.03) −3.88 (68) <.001 Health maintenance organization and preferred 1.97 (1.04) 3.26 (1.09) −9.10 (68) <.001 provider organization Degrees of freedom differ across terms given that participants had missing data on either pre- or postgame items at different rates for each term. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Table 3. Objective understanding of health insurance terms, pre- and postgame play. Health insurance term Correct pregame, Correct postgame, Cochran’s Q test statistic Asymptotic n (%) n (%) (degrees of freedom) P value Affordable Care Act 15 (25) 17 (29) 0.33 (1) .56 Monthly premium 27 (46) 39 (66) 5.54 (1) .02 Referral 19 (31) 43 (70) 18.00 (1) <.001 In-network provider 19 (40) 34 (71) 13.24 (1) <.001 Co-payment 25 (41) 23 (38) 0.15 (1) .70 Deductible 7 (12) 23 (40) 12.80 (1) <.001 Out-of-pocket maximum 13 (25) 11 (22) 0.25 (1) .62 Co-insurance 0 (0) 3 (7) 3.00 (1) .08 Health maintenance organization and preferred provider 2 (4) 18 (39) 14.22 (1) <.001 organization (mainly women’s health such as pap smears) [38], which could Discussion explain why referral garnered the largest increase from pre- to postgame play. Principal Findings In contrast, HMO and PPO are likely terms with which college Findings from this study suggest that the implementation of a students are not familiar with [29], yet a significant improvement newsgame can facilitate health insurance knowledge among was observed in this study. Indeed, before game play, only 2 young adults, a population vulnerable to the negative impact of participants in this study correctly defined this concept. A total not having or understanding health insurance [27-29]. In this of 18 participants (39%, 18/46) demonstrated an objective study, a Web-based newsgame about health insurance was understanding of “HMO” and “PPO” after playing the game. developed by exploring health insurance challenges experienced In addition to this being the last term presented (and thus closest by everyday consumers and re-creating these scenarios in the to the administration of the post-game survey), this effect could context of an interactive game. be due, in part, to the relatability of the client profile to the Young adults, even those who are well-educated, struggle with student participants. The client featured in the game regarding understanding health insurance and health insurance terminology the “HMO/PPO” term admitted to being “new to having health [29]. On the basis of the findings from this study, a game insurance,” was relatively young (33 years old) and worked as appears to be a viable option for presenting this audience with a communications professional at a start-up company. Although information about this challenging topic. This aligns with the the focus of this study was not on the relationship or relatability existing research on the beneficial impact of narrative on health, of the client/profile with the participant, perceptions of decisions, and skills [31-33]. Following game play, participants homophily would be a fruitful focus for future research when self-reported a significantly greater understanding for all terms. it comes to increasing engagement with health insurance It is encouraging that participants felt that they understood more information. of this difficult content, as previous research notes that evading Although significant growth was not observed in the number health insurance information is common [25]. It may be that of participants correctly defining the term “coinsurance” the medium, a gaming platform, combined with a narrative between pre and postgame play, it is worth noting that no newsgame approach creates a context in which emerging adults participant provided a correct definition before playing the feel comfortable, in contrast to pamphlets or static websites. game. Following the game, 3 participants provided a correct Upon examining objective knowledge assessment through definition. On the basis of the findings of this study, of the terms correctly/incorrectly defined health insurance terms, however, provided in the Healthcare America game, “coinsurance” it is important to note that participants made significant requires the greatest exploration in future initiatives. This aligns improvements for some, but not all, health insurance terms. with previous research, which suggests that patients often focus In this study, significantly more participants provided correct on the concept of paying premium every month but neglect definitions for the terms “monthly premium,” “referral,” other cost-sharing terms, including “coinsurance” [25]. “in-network provider,” “deductible,” and “HMO/PPO” following “Coinsurance” may be commonly complicated with game play. The largest increase was seen for the term “referral,” “co-payment” and perhaps “cost-sharing” and thus should be where the frequency of correct definitions increased by 39%. teased apart further in future initiatives. In this study, all terms It is possible that this is a term for which many students were were given equal attention (ie, presented an equal number of already familiar with but needed to be reminded of the correct times, one opportunity to make a decision related to the term definition. Indeed, many of the top reasons why college students rather than repeated practice), yet findings suggest that future visit a health care provider are for health concerns that require initiatives attribute greater explanation and additional examples a referral or prescription including respiratory infections, for some terms. sexually transmitted diseases, birth control, and annual exams http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Akin to Wong and colleagues, the correlation between the The use of a Web-based platform, such as that used in this study, number of correctly defined health insurance terms and has far-reaching implications. This is especially clear in context participants’ self-reported understanding of all terms was of growing mobile “smartphones,” which are capable of nonsignificant [29]. One explanation for this discrepancy is that, accessing the Internet. Nearly all (92%) of Americans aged 18 although participants may feel that they understand health to 29 own a smartphone [42]. As such, dissemination of our insurance content (self-report knowledge), providing a definition health insurance newsgame could be simple and extensive. The (objective knowledge) is notably more challenging. Although game could be texted to a phone number or the link sent through writing a correct definition served as a valuable method for email, and shared via social platforms such as Facebook, assessing participant knowledge for the purpose of a research Twitter, Instagram, or Snapchat, without the need for in-person study and has been used in previous research [29], this is not game administration assistance. One avenue for future research how health insurance knowledge would be captured in everyday would be the implementation of this game in college campus activities. Rather, individuals must make decisions using the health and wellness center waiting rooms, where students may given information, including completing calculations. It could actively desire something to fill their time while waiting. Using be that participants would have been more successful in a Web-based, mobile-ready game also provides the potential demonstrating their knowledge through applied scenarios and for reaching populations underserved in health insurance questions, comparable with what they did within the game. This understanding; younger adult audiences may not get their news is just one of many avenues for future research initiatives. and information from traditional outlets, but this is a large population of the people who are online, on mobile technologies, Additionally, in this study, participants indicated an increased and are playing games. There are also possibilities for self-reported understanding of how to use health insurance but game-infused programs for health insurance literacy that begin not what health insurance is. In designing the game for this with the Healthcare America mobile game as part of a suite of study, it became clear that there are a number of avenues to be health insurance literacy games that deploy automatically to tackled through games when it comes to health insurance. Future participants at particular times during their university experience research should explore the needs of those who do not yet have and incorporate participant follow-up surveys along the way health insurance and how gaming, immersion, and decision possibly between 3 and 6 months, at 1 year, and at university making can contribute to enrollment assistance. In conjunction exit/graduation. This strategy addresses the issue of building with this initiative, those who currently have health insurance, real literacy in this complex system, realizing it is not a problem yet struggle with using the health care system and insurance that can be solved with one game, one time. companies, would benefit from a game similar Healthcare America. Future gaming efforts could incorporate both In addition to these explicit advantages with a young, tech-savvy suggestions into one game, having participants reach or unlock population, the majority of adults with potentially low health new levels as they successfully move from getting enrolled in literacy indeed have smartphones including those who did not health insurance initially, to making challenging decisions in a graduate from high school (54% have smartphones), make less health care setting. than US $30,000 (64%), or are of minority race (72% of black adults and 75% of Hispanic adults). Future research initiatives It should be noted that Healthcare America is just one example should explore ways in which a newsgame would be a feasible of how games can be used successfully to promote health method for connecting patients with low health literacy, general knowledge and outcomes. There are a growing number of literacy, or experience difficulty with technology. One examples in which games and game projects are designed to adjustment that could be made to Healthcare America is to offer engage audiences in health and wellness issues. Indeed, audio cues and narration to facilitate engagement among these UnitedHealthcare offers a Health Insurance Matchmaking Game audiences. Additionally, game content could be further tailored in which the player determines which type of health insurance to specific populations and include culturally relevant details, is “right” for them based on a series of actions performed in the as well as specific health insurance scenarios encountered by game [39]. Future iterations of this study could compare the patients who struggle with these skill sets. effectiveness of Healthcare America with other games and strategies for increased interaction with and understanding of Limitations health insurance. In contrast, at the specific intersection of health This study presents important findings that can contribute to games and health journalism, in which stories and scenarios future intervention initiatives regarding health insurance, health, from the real world are directly incorporated into the design of and newsgames, yet it is not without limitations. First, the study the game, there are only limited projects despite the possibilities was limited by sample size. The purpose of this study was to for increased awareness, engagement, and education. Seven explore an initial iteration of a newsgame in this area, and our Ways to Defy Death from the Washington Post [40] does provide study indeed exceeds the sample size included in other, one example, as well as Propublica’s experimental game, comparable studies [18,29]. In Healthcare America, players are Heartsaver [41]. Journalists cite time, design and technical provided with information about and definitions of health resources, and budget as pain points for developing games to insurance terms. Information is not sufficient to change behavior engage audiences in game-infused storytelling. Free engines [43,44]. However, in conjunction with an interactive game in such as the Story Builder used for this project offer journalists which young adults were asked to note, evaluate, and assist the ability to create mobile games quickly and experiment with clients with health insurance issues, it is the hope that players audience engagement in this space. experience and learn about health insurance through modeling and applying information they acquire. An additional limitation http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James was the confines of the lab setting as well as participant This population is particularly susceptible to being at risk for self-selection (and convenience sampling) in choosing to play not having or understanding health insurance [27,29]; yet, based the game and participate in the study. It may be that participants on the findings of this study, a game such as Healthcare America felt they needed to respond to questions or act a specific way is an appropriate initial step to decreasing these health-related when playing the game. Participants could have felt pressured challenges. to take on the role of an “intern” for a health care position. With Results from this study suggest that repeated play or multiple this in mind, within the game, the player is provided with the exposures to some concepts such as “coinsurance” may be “pages from the intern manual” (the health insurance needed to increase understanding of this more difficult term. In terminology explanations and examples) and thus must act and this study where only one example was implemented, few young provide suggestions based on the information they have—a adults increased in their understanding and confidence with this learning and growing process akin to working at an internship. term. In contrast, terms that young adults encounter more often In this study, we implemented previously used survey items (and potentially have an increased immediate need for) such as [29]; however, other types of measures, including “referral” need fewer examples or iterations to achieve multiple-choice questions or selecting a “correct” answer from understanding. Moreover, Healthcare America implemented a list could have produced different results. Moreover, the client narratives based on real-world news stories, user findings rely on a single group pre- and postgame play design experiences, and real-time information about health insurance and did not measure subsequent behavior change or retained to facilitate understanding. The strategy of asking young adults knowledge long term. In an effort to minimize these limitations to help or assist others in need or with questions can be a in future studies, we are currently collaborating with the fulfilling experience for the player and a beneficial game on-campus health and wellness center to make the Web-based strategy. game available on its website and thus extend access and data collection. Although the games for health field have grown considerably in recent years, this health insurance newsgame is the first of Conclusions its kind. The design and pilot test phase shows promising results In this study, young adult participants indicated an increased for game design strategy, health insurance content, and platform level of self-reported and objective knowledge after playing an iterations, moving forward. interactive, narrative-based newsgame about health insurance. Acknowledgments Funding for this study was provided in the form of a research microgrant from the dean of the Mayborn School of Journalism at the University of North Texas. Also, we would like to thank the graduate and undergraduate research assistants who assisted in this project (Rita Unogwu, Hailey Sutton, Beatriz Martinez, and Sonia Gomez). Conflicts of Interest None declared. Multimedia Appendix 1 Full game design and possible game flow paths. [PNG File, 450KB-Multimedia Appendix 1] References 1. Anetta L. The Is have it: a framework for serious educational game design. Rev Gen Psychol 2010;14(2):105-112. [doi: 10.1037/a0018985] 2. Ryan RM, Rigby CS, Przybylski A. The motivational pull of video games: a self-determination theory approach. Motiv Emot 2006;30(4):344-360. [doi: 10.1007/s11031-006-9051-8] 3. Eleftheriou A, Bullock S, Graham CA, Ingham R. Using computer simulations for investigating a sex education intervention: an exploratory study. 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Coverage matters: insurance and health care URL: http://www. nationalacademies.org/hmd/~/media/Files/Report%20Files/2003/Coverage-Matters-Insurance-and-Health-Care/ Uninsurance8pagerFinal.pdf [accessed 2017-10-24] [WebCite Cache ID 6uRidSqdI] 27. Collins SR, Nicholson JL. Commonwealthfund. 2010. Rite of passage: young adults and the Affordable Care Act of 2010 URL: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/May/ 1404_Collins_rite_of_passage_2010_v3.pdf [accessed 2017-10-24] [WebCite Cache ID 6uRiytGyF] 28. Ward BW, Clarke TC, Nugent CN, Schiller JS. CDC. Early release of selected estimates based on data from the 2015 National Health Interview Survey URL: https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201605.pdf [accessed 2017-10-24] [WebCite Cache ID 6uRjKWPwD] 29. Wong CA, Asch DA, Vinoya CM, Ford CA, Baker T, Town R, et al. Seeing health insurance and HealthCare.gov through the eyes of young adults. 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Hawkins SC. Emergency medicine narratives: a systematic discussion of definition and utility. Acad Emerg Med 2004 Jul;11(7):761-765 [FREE Full text] [Medline: 15231467] 34. Niemanstoryboard. 2016. Harnessing the power of video games for journalism URL: http://niemanstoryboard.org/stories/ harnessing-the-power-of-video-games-for-journalism/ [accessed 2017-06-15] [WebCite Cache ID 6rF6x18BB] 35. Salen K, Zimmerman E. The Game Design Reader: A Rules of Play Anthology. Cambridge: The MIT Press; 2009. 36. Gee JP. Academiccolab. 2005. Good video games and good learning URL: http://www.academiccolab.org/resources/ documents/Good_Learning.pdf [accessed 2017-10-24] [WebCite Cache ID 6uRkyLZKl] 37. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007 May;39(2):175-191. [Medline: 17695343] 38. Healthcenter.ucsc. 2017. 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Contento I, Balch GI, Bronner YL, Lytle LA, Maloney SK, Olson CM, et al. The effectiveness of nutrition education and implications for nutrition education policy, programs, and research: A review of research. Nutr Educ Behav 1995;27(6):277-418 [FREE Full text] 44. Kasturi Rangan V, Karim S, Sandberg SK. Do better at doing good. Harvard Bus Rev 1996(May-June):4-11. Abbreviations HMO: health maintenance organization PPO: preferred provider organization Edited by A McDougall; submitted 03.04.17; peer-reviewed by A Antoniades, R Buday, D Daylamani-Zad, L Fernandez-Luque, S Flynn, M Jordan-Marsh, E Lyons, L Fernandez-Luque; comments to author 12.05.17; revised version received 16.06.17; accepted 26.08.17; published 16.11.17 Please cite as: Champlin S, James J JMIR Serious Games 2017;5(4):e22 URL: http://games.jmir.org/2017/4/e22/ doi: 10.2196/games.7818 PMID: 29146564 ©Sara Champlin, Juli James. Originally published in JMIR Serious Games (http://games.jmir.org), 16.11.2017. 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Breaking Health Insurance Knowledge Barriers Through Games: Pilot Test of Health Care America

Champlin, Sara; James, Juli
JMIR Serious Games , Volume 5 (4) – Nov 16, 2017
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Abstract

Background: Having health insurance is associated with a number of beneficial health outcomes. However, previous research suggests that patients tend to avoid health insurance information and often misunderstand or lack knowledge about many health insurance terms. Health insurance knowledge is particularly low among young adults. Objective: The purpose of this study was to design and test an interactive newsgame (newsgames are games that apply journalistic principles in their creation, for example, gathering stories to immerse the player in narratives) about health insurance. This game included entry-level information through scenarios and was designed through the collation of national news stories, local personal accounts, and health insurance company information. Methods: A total of 72 (N=72) participants completed in-person, individual gaming sessions. Participants completed a survey before and after game play. Results: Participants indicated a greater self-reported understanding of how to use health insurance from pre- (mean=3.38, SD=0.98) to postgame play (mean=3.76, SD=0.76); t =−3.56, P=.001. For all health insurance terms, participants self-reported a greater understanding following game play. Finally, participants provided a greater number of correct definitions for terms after playing the game, (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t =−3.61, P=.001. Significant differences from pre- to postgame play differed by health insurance term. Conclusions: A game is a practical solution to a difficult health issue—the game can be played anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its execution. (JMIR Serious Games 2017;5(4):e22) doi: 10.2196/games.7818 KEYWORDS health insurance; games, experimental; young adult; information literacy concepts in an enjoyable way. In turn, players often exhibit Introduction increased conceptualization of specific challenges, even for stigmatized health issues such as sexual risk [3]. In addition to Serious games are designed to cultivate skills for a specific topic building skill sets, games can increase self-efficacy and result and do so by activating existing schema in the mind of a player in behavior change [4]. Given these benefits, serious games are to ultimately produce “new knowledge” and experiences [1]. a growing, effective medium for current and future generations In contrast to reading a pamphlet or searching online, players of young adult audiences [5]. engage with serious games, given their inherent fulfillment of a need to have fun or be satisfied, as suggested by There exists a variety of health-oriented serious games. In some self-determination theory [2]. As such, serious games are cases, health-focused games allow players to explore risky or increasingly implemented to train or immerse players in novel challenging situations without having to experience the direct experiences so that they may encounter and test structures and effects they might encounter in the real world (eg, dying or http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James harming someone, experiencing a negative health outcome, Understanding, selecting, and using a health insurance plan, mismanaging a decision) [6]. This includes training and allowing however, is a complex process and requires a plethora of diverse players to practice specific skills such as attention and reaction literacy and numeracy skill sets [17]. Politi and colleagues argue time while driving [7] or learning and experiencing how to that health insurance plan comprehension and decision making prepare surgical instruments [8]. Other games emphasize are “essential” for the consumer [18]. Thus, determining ways education and promoting an increased understanding of to discuss and facilitate health insurance information with the action-oriented knowledge. For example, after playing a game public is an important avenue for health-based research. titled Mommio, mothers indicated that they acquired knowledge Simultaneously, patients are increasingly encouraged to take by experiencing interactions between a mother and a child who ownership of their own health information and participate in does not enjoy eating vegetables [9]. Other games depict their own health care [19-21]. As a result, patients are given a topic-specific knowledge increases, such as increased growing amount of health insurance information and details to information about nutrition as a result of playing a diet- and interpret and consider [22]. exercise-oriented game titled SpaPlay [10]. Although the initiation of the Affordable Care Act increased A key benefit of serious games for health, specifically, is to the number of Americans who hold health insurance policies stimulate or motivate patients for health efforts that may be [23], it is not yet known whether health insurance consumers perceived as unpleasant or uninteresting and thus avoided [6]. indeed have knowledge and confidence in how to use their Games can also help players understand specific positions or benefits [24]. Previous research suggests that insured adults roles in one’s life, akin to imagining what it would be like to lack an understanding of terminology and how to use this try on a specific identity [6]. Games of every kind allow players important entity. Many states have implemented the use of to take on roles outside of their everyday lives, which can have health insurance counselors to aid consumers in their positive impact [11,12]. understanding and selection of a health insurance plan. Interviews with counselors point to critical health insurance According to the Entertainment Software Association, 56% of literacy concerns; patients tend to avoid reading information Americans today play video games, and nearly half (48%) of about specific plans and, as a result, misunderstand how much frequent gamers are considered mobile and/or social gamers coverage they have or how much they owe as the result of a [5]. Moreover, 77% of college-aged men and 57% of medical procedure (eg, if the patient pays a premium, the patient college-aged women report playing video games [13]. As such, might think he or she does not owe any additional medical costs) digital and Web-based games are a reasonable and strategic [25]. Counselors also note that patients rely on word-of-mouth platform to engage with these audiences. Games present an information about plans; often misunderstand terms such as additional opportunity to connect audiences with news and with “co-pay,” “deductible,” and “co-insurance”; and lack knowledge health. The overlapping, growing trends in gaming and media about provider restrictions such as being in network/out of speak to the opportunity for using a mobile-ready Web-based network [25]. game to engage new demographics in meaningful health information in innovative ways, reach existing audiences with Historically, young adults have the lowest rates of health alternative, interactive journalism, and speak to a new generation insurance plan enrollment among all nonelderly adult age groups of media users on the devices and in the media with which they [26,27]. Young adults remain the age demographic with the are already interacting. fewest insured individuals; 14.4% of young adults aged between 18 and 24 years did not have health insurance in 2015 and 17.9% In this study, we developed a serious game that draws from of those aged between 25 and 34 years [28]. Limited research principles of journalism, educational and video game design, has specifically tackled strategies for best communicating health and learning and literacy, in conceptualizing an online game insurance information to this vulnerable population. It is experience [14,15]. Given that young adults may currently avoid worrisome that young adults may not be equipped with the or misunderstand health insurance information, a game is a knowledge or skills to appropriately select and enroll in a plan. practical solution to this difficult health issue. A Web-based Furthermore, young adults with plans may struggle when health game may be particularly appropriate for young adults, navigating the health care system and amass high health care almost all of whom use the Internet. The game can be played bills. anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its Health insurance literacy is particularly low among young adults, execution. including those who are highly educated. In one study, none of the participants felt “good” or “very good” about their Health Insurance Literacy understanding of a list of health insurance terms and at times Having health insurance has been linked to a number of transposed definitions or had questions about the information advantageous health outcomes, including increased access to [29]. The need for increased understanding about health health monitoring, screening, information, and beneficial health insurance among young people is a long-standing health decisions [16]. As a result, those who do not have health challenge. Robertson and Middleman called for greater health insurance are at a greater risk for serious and exacerbated health insurance education for young people based on their findings consequences related to cancer, cardiovascular issues, that almost half of the adolescents in their study were unaware hypertension, diabetes, kidney disease, human of “how their medical bills [were] paid” [30]. Young adults immunodeficiency virus infection, and injury [16]. should be equipped with the information necessary for them to http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James make informed decisions when it comes to getting and using insurance terms [29] and exposure to an interactive game about health insurance. health insurance will improve this knowledge; given this, after game play: Newsgames Hypothesis 1: Participants will exhibit a greater For this project, we created a Web-based newsgame, “Healthcare self-reported, general understanding of what health America,” to explore the possibilities for what games can offer insurance is and how to use health insurance. the problem of engaging and informing young adults in concepts Hypothesis 2: Participants will exhibit increased connected to health insurance literacy. Bogost and colleagues self-reported understanding of critical health insurance define “newsgames” as games that apply journalistic principles terminology. in their creation [14]. For example, a newsgame might implement stories from various first-person sources or illustrate In addition to examining whether participants perceived the complexities of a real-world issue. themselves to have learned about health insurance terminology from the game, we sought to measure whether participants Specifically, newsgames infuse the concept of real-world increased in their objective knowledge of health insurance narrative into game play. Narrative communication and terminology after game play. storytelling are promising methods to increase engagement of an audience with content, yet are not frequently utilized in Hypothesis 3: Participants will be able to correctly health-related research and interventions [31]. Thompson and define a greater number of health insurance terms Kreuter note that “vivid, engaging writing can help audiences following game play. identify with storytellers and understand health messages” [32]. Findings from this study will have important implications for A growing interest in research is the narrative work written by many groups. Equipping young adults with a greater medical professionals, which can promote improved on-the-job understanding and confidence in what health insurance is and skills when read and considered by other professionals working how it works can lead to better overall health outcomes. in this industry (ie, learning from someone else through their Additionally, this study offers practical solutions for health stories) [33]. It was the hope of this study that playing a game practitioners, educators, and counselors who design programs with client-based narratives generated from news and real-world to improve health literacy and access to health information. In encounters and interviews would contribute to increased the remainder of this paper, the development of a health understanding of health insurance information. insurance game created for young adults will be described and its effects tested. Implications for health practitioners, including Newsgames are an emerging digital practice for today’s health insurance counselors and other financial advisors, will journalists, although games for journalism are not new. be discussed. Historically, crossword puzzles and news quizzes have been found in newspapers and on broadcast radio as tools to engage Methods audiences in interacting with news facts and information in engaging and fulfilling ways. As video games have evolved and Game Development Tool the benefits of game design have grown out of commercial markets into serious and educational spaces, journalism has also We used the Playable Media Story Builder (Phoenix, Arizona) begun taking the best practices of game design for nuanced platform to develop the game, Healthcare America. The Story storytelling, immersive learning and informing strategies, and Builder is a visual engine that allows publishing of hosted, engaging audiences in complex systems through play [34]. cross-platform responsive, interactive narrative games. The engine, designed to empower journalists to prototype narrative We selected a newsgame approach for Healthcare America to games, was funded by the Knight Foundation Knight Prototype explore a mobile game execution for health journalism and to Fund. The Playable Media team designed and developed the experiment with and contribute to the design models for tool in collaboration with journalists and journalism students engaging journalism. Games at the intersection of journalism at Arizona State University through the News-Play Project, a and health provide new, strategic opportunities to create playful partnership between Arizona State University’s New Media experiences around complex issues and offer real-world learning Entrepreneurship & Innovation Lab and Center for Games & created from real data designed into hypothetical interactive Impact Innovation Lab. narratives. These serious games provide a platform for audience engagement in ways that health communication and health Game Design and Development journalism have only just begun to explore (conventional tools Healthcare America positions the player as working for a health in health media communication include pamphlets and flyers, information advocacy organization with a series of client cases. public service announcements, and radio ads) [11]. The game interface includes simple graphics, narrative text, player choices, and two meters measuring community wellness The purpose of this study was to develop an interactive-narrative and health care assistance funds (see Figure 1). newsgame that presents entry-level health insurance information and scenarios to young adults. To our knowledge, this study is Using a newsgame design approach to develop game content, the first to design and test an interactive game that encourages we gathered stories about personal struggles with health young adults’ interaction with health insurance concepts. insurance from people in our community, undergraduate students, and national news stories. We collaborated with a We hypothesized the following statements based on the notion news writing and reporting class to further investigate through that young adults often lack an understanding of many health http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James personal narratives the ways in which people struggle with Web page. We collaborated with stakeholders and knowledge health insurance in the real world. Additionally, we pulled experts at our university about how they typically administer fact-based information from health insurance websites, the information and guidance about health insurance to students. HealthCare.gov website, and our university’s health insurance Figure 1. Examples of the user interface and game play of the health insurance game. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James As a result of this exploration, five scenarios or “client cases” experiences of stories from using, or struggling to use, health were developed for the game based on real-world stories and insurance. In the game, these stories are translated to “client information gathered from stakeholders and health insurance cases.” The player is given a role within the narrative and the consumers. Characters included in the game were developed to goal of “solving” or assisting a series of client cases while consciously include a variety of different race/ethnicities, sex working as an intern (with the promise of being promoted to a (white female, African American male, Hispanic female, white full-time position for a job done well). male, Asian female), age, and occupation. The player reads a client case file (eg, Vanessa who is a Following these steps, we adapted the list of health insurance 42-year-old female, a project manager and mother of 2, annual terms used by Wong and colleagues [29] to include the income US $35,000, who regularly sees a therapist to manage following: “the Affordable Care Act,” “deductible,” “monthly her mental health and well-being. She fills a prescription for premium,” “referral,” “in-network provider,” “co-payment,” antidepressants on a monthly basis. “Vanessa sent us [Healthcare “out-of-pocket maximum,” “coinsurance,” and “health America] an email because she’s confused about what just maintenance organization (HMO) and preferred provider happened at the pharmacy. After being diagnosed with organization (PPO).” Within the game, each term and a depression, Vanessa has a regular prescription for corresponding definition was provided to the participant for antidepressants. Today the cost of her medication was much their review. See Figure 1 for a screenshot of two definitions, higher than usual.”) and is then provided with information about which were both relevant for a case in which a consumer in the specific health insurance term (in the case of “Vanessa,” it is game had recently encountered unexpected health insurance information about co-payments). The player is then able to charges. advise the client using several options, each of which is linked to a corresponding increase or decrease in the Community The game opened with a brief introduction and explanation of Wellness meter, the Healthcare Assistance Fund, or both. The the game on screen. Game instructions, including the meaning player advises the client presented and then learns the outcome of the game meters (Community Wellness, that is, how healthy of the corresponding meters. the participant or player made the community, and Healthcare Assistance Fund, that is, the amount of money spent to assist There are obstacles to overcome (the main conflict is to balance the client), were then provided. With these meters in mind, the solutions to clients’ health care and health insurance problems) central goal of the game was to be a “successful intern” by and rewards for overall Community Wellness and the Healthcare assisting clients with troubling health insurance cases—aiming America’s Healthcare Assistance Fund. The game ends if the to maximize Community Wellness without spending all of the player depletes the Community’s Wellness or Healthcare organization’s Healthcare Assistance Fund. Assistance Funds as a result of his or her decision to assist a client (a loss) or if the player successfully assists all 5 clients Participants read and experienced each of the aforementioned (a win); see Figures 2, 3 and Multimedia Appendix 1. cases; key details about what happened and what went wrong for the client were presented. Then, health insurance terms were We kept in mind the body of information as is needed both for provided. Participants then selected one of three options for a narrative driven game and for narrative-driven journalism, how to advise each client, which took into account how much and situated the information a player would need to use [35,36]. each option would contribute to the overall Community As game designers, we designed each level of Healthcare Wellness (Did the participant help improve the health of the America based on a health insurance problem and distributed community through his or her advising decision?) and how the essential information the player would need across the game much money would be spent from their Healthcare Assistance to overcome obstacles and work toward the goal at the start of Fund, which was capped at US $5000. each level to gauge how much health insurance term information the player would need and could use—just enough information To summarize and provide a specific example, the prototype and just in time [36]. narrative design of Healthcare America blends real-world http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Figure 2. Design of game meters: (1) Healthcare assistance fund and (2) community wellness. Figure 3. An example of the community wellness meter options. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Table 1. Demographic information of sample (N=72). Characteristic Sample Sex, n (%) Male 29 (40) Female 43 (60) Race/Ethnicity, n (%) White 27 (38) Black, African American 18 (25) Hispanic, Latino/a 17 (24) Asian 5 (7) Mixed 4 (6) Other 1 (1) First-generation college, n (%) Yes 19 (26) General health, n (%) Excellent 8 (11) Very good 30 (42) Good 27 (38) Fair 5 (7) Poor 1 (1) Don’t know 0 (0) Academic year, n (%) Freshman 19 (26) Sophomore 12 (17) Junior 26 (36) Senior 10 (14) Super senior (+4 years) 3 (4) Other 1 (1) Non-English household, n (%) Yes 17 (24) Without health insurance, n (%) 17 (24) Age in years, mean (SD) 21.15 (3.49) an appointment. Each participant completed an individual, Participants in-person data collection session. All study procedures were A 2-tailed power analysis calculated for paired data was approved by the relevant institutional review board. Each session performed with G-Power to calculate an estimated sample size was scheduled for 1 hour and included an introductory phase of 67 participants (effect size=0.35, with 80% power, and in which participants read and signed a consent form, the alpha=.05) [37]. In total, 75 (N=75) students were included in completion of a pregame survey, game play on a computer, and this study. Due to a computer error, three of these participants a postgame survey. were unable to play the game and were thus removed from the Measures dataset, resulting in 72 (N=72) valid participants. The demographic information of the sample is included in Table 1. Participants completed pre- and postgame surveys to determine their level of health insurance understanding before and after Procedures playing the health insurance game. In both surveys, participants A call for participants was administered via email to classrooms, were asked to indicate their understanding of “what health or a Web-based classroom boards through journalism and insurance is” and “how to use health insurance,” as well as rate communications courses on campus. Participants indicated their their understanding of 9 health insurance terms using a 5-point interest by contacting the research team via email and scheduling scale (very good to very bad) [29]. Additionally, to measure http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James objective understanding of a given health insurance term, insurance is used. The first hypothesis predicted that, following participants were asked to write a definition for each of the 9 game play, participants would exhibit a greater self-reported, health insurance terms. These items were adapted from previous general understanding of what health insurance is and how it is research [29]. Similar to Wong and colleagues, a team of 4 used. Indeed, participants indicated a greater self-reported investigators determined whether each health insurance term understanding of how to use health insurance from pregame was defined correctly or incorrectly based on the content play (mean=3.38, SD=0.98) to postgame play (mean=3.76, provided in the game and the definitions provided by health SD=0.76); t =−3.56, P=.001. There was no significant insurance companies and Healthcare.gov. Participants also difference between pre- and postgame play for participants’ completed demographic items, including sex, race/ethnicity, self-reported understanding of what health insurance is. Given age, whether they were a first-generation college student (the this, hypothesis one was partially supported. first in their family to attend college), self-reported rating of Hypothesis 2 surmised that participants will exhibit increased their general health, year in school, whether they currently have self-reported understanding of critical health insurance health insurance, and whether they grew up in a household that terminology. For all health insurance terms, participants felt primarily spoke a language other than English. In cases where they had a better understanding of the term following the game; multiple numerical responses were selected (eg, both 3 and 4 see Table 2 for complete results. to indicate understanding of a health insurance term), the average of the 2 numbers (eg, 3.5) was used. Finally, in addition to examining whether participants felt that their understanding of a given health insurance term increased Analyses after playing a health insurance game, we wanted to determine Paired sample t tests were used to determine whether whether participants objectively define more health insurance participants’ self-reported understanding of what health terms correctly following game play. The proportion of insurance is, how to use health insurance, and the 9 health participants who correctly defined a given health insurance term insurance terms were different between pre- and postgame play. was significantly different for the following terms: “monthly A paired sample t test was also used to determine whether the premium,” “referral,” “in-network provider,” “deductible,” and total number of correctly defined health insurance terms differed “HMO/PPO”; see Table 3 for complete results. from pre- to postgame play. A Cochran’s Q test was used to Among participants who provided a definition for every health examine differences in correctly defined health insurance insurance term for both pre- and postgame play (N=32), terminology (paired nominal data) between pre- and postgame participants correctly defined more health insurance terms play. following game play (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t =−3.61, P=.001. However, Results the number of correct definitions provided following game play The purpose of this study was to determine whether a health did not correlate with participants’ overall self-reported insurance game is a viable tool to communicate important understanding of all terms following game play (self-reported information about health insurance terminology and how health scores for all terms were summed together), r=.18, N=42, P>.05. Table 2. Self-reported understanding of health insurance terms, pre- and postgame play. Health insurance term Pregame self-reported Postgame self-reported Paired t statistic (degrees P value understanding, mean (SD) understanding, mean (SD) of freedom) Affordable Care Act 2.75 (1.12) 3.73 (0.81) −6.92 (70) <.001 Premium 2.70 (1.20) 3.87 (0.81) −8.89 (70) <.001 Referral 3.11 (1.37) 4.13 (0.81) −6.25 (70) <.001 In-network provider 2.35 (1.37) 3.71 (0.97) −8.58 (71) <.001 Co-pay 3.24 (1.32) 3.72 (1.03) −3.10 (68) .003 Deductible 2.97 (1.17) 3.77 (0.80) −5.06 (70) <.001 Out-of-pocket maximum 2.23 (1.18) 3.39 (1.09) −7.62 (69) <.001 Coinsurance 1.91 (1.00) 2.39 (1.03) −3.88 (68) <.001 Health maintenance organization and preferred 1.97 (1.04) 3.26 (1.09) −9.10 (68) <.001 provider organization Degrees of freedom differ across terms given that participants had missing data on either pre- or postgame items at different rates for each term. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Table 3. Objective understanding of health insurance terms, pre- and postgame play. Health insurance term Correct pregame, Correct postgame, Cochran’s Q test statistic Asymptotic n (%) n (%) (degrees of freedom) P value Affordable Care Act 15 (25) 17 (29) 0.33 (1) .56 Monthly premium 27 (46) 39 (66) 5.54 (1) .02 Referral 19 (31) 43 (70) 18.00 (1) <.001 In-network provider 19 (40) 34 (71) 13.24 (1) <.001 Co-payment 25 (41) 23 (38) 0.15 (1) .70 Deductible 7 (12) 23 (40) 12.80 (1) <.001 Out-of-pocket maximum 13 (25) 11 (22) 0.25 (1) .62 Co-insurance 0 (0) 3 (7) 3.00 (1) .08 Health maintenance organization and preferred provider 2 (4) 18 (39) 14.22 (1) <.001 organization (mainly women’s health such as pap smears) [38], which could Discussion explain why referral garnered the largest increase from pre- to postgame play. Principal Findings In contrast, HMO and PPO are likely terms with which college Findings from this study suggest that the implementation of a students are not familiar with [29], yet a significant improvement newsgame can facilitate health insurance knowledge among was observed in this study. Indeed, before game play, only 2 young adults, a population vulnerable to the negative impact of participants in this study correctly defined this concept. A total not having or understanding health insurance [27-29]. In this of 18 participants (39%, 18/46) demonstrated an objective study, a Web-based newsgame about health insurance was understanding of “HMO” and “PPO” after playing the game. developed by exploring health insurance challenges experienced In addition to this being the last term presented (and thus closest by everyday consumers and re-creating these scenarios in the to the administration of the post-game survey), this effect could context of an interactive game. be due, in part, to the relatability of the client profile to the Young adults, even those who are well-educated, struggle with student participants. The client featured in the game regarding understanding health insurance and health insurance terminology the “HMO/PPO” term admitted to being “new to having health [29]. On the basis of the findings from this study, a game insurance,” was relatively young (33 years old) and worked as appears to be a viable option for presenting this audience with a communications professional at a start-up company. Although information about this challenging topic. This aligns with the the focus of this study was not on the relationship or relatability existing research on the beneficial impact of narrative on health, of the client/profile with the participant, perceptions of decisions, and skills [31-33]. Following game play, participants homophily would be a fruitful focus for future research when self-reported a significantly greater understanding for all terms. it comes to increasing engagement with health insurance It is encouraging that participants felt that they understood more information. of this difficult content, as previous research notes that evading Although significant growth was not observed in the number health insurance information is common [25]. It may be that of participants correctly defining the term “coinsurance” the medium, a gaming platform, combined with a narrative between pre and postgame play, it is worth noting that no newsgame approach creates a context in which emerging adults participant provided a correct definition before playing the feel comfortable, in contrast to pamphlets or static websites. game. Following the game, 3 participants provided a correct Upon examining objective knowledge assessment through definition. On the basis of the findings of this study, of the terms correctly/incorrectly defined health insurance terms, however, provided in the Healthcare America game, “coinsurance” it is important to note that participants made significant requires the greatest exploration in future initiatives. This aligns improvements for some, but not all, health insurance terms. with previous research, which suggests that patients often focus In this study, significantly more participants provided correct on the concept of paying premium every month but neglect definitions for the terms “monthly premium,” “referral,” other cost-sharing terms, including “coinsurance” [25]. “in-network provider,” “deductible,” and “HMO/PPO” following “Coinsurance” may be commonly complicated with game play. The largest increase was seen for the term “referral,” “co-payment” and perhaps “cost-sharing” and thus should be where the frequency of correct definitions increased by 39%. teased apart further in future initiatives. In this study, all terms It is possible that this is a term for which many students were were given equal attention (ie, presented an equal number of already familiar with but needed to be reminded of the correct times, one opportunity to make a decision related to the term definition. Indeed, many of the top reasons why college students rather than repeated practice), yet findings suggest that future visit a health care provider are for health concerns that require initiatives attribute greater explanation and additional examples a referral or prescription including respiratory infections, for some terms. sexually transmitted diseases, birth control, and annual exams http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James Akin to Wong and colleagues, the correlation between the The use of a Web-based platform, such as that used in this study, number of correctly defined health insurance terms and has far-reaching implications. This is especially clear in context participants’ self-reported understanding of all terms was of growing mobile “smartphones,” which are capable of nonsignificant [29]. One explanation for this discrepancy is that, accessing the Internet. Nearly all (92%) of Americans aged 18 although participants may feel that they understand health to 29 own a smartphone [42]. As such, dissemination of our insurance content (self-report knowledge), providing a definition health insurance newsgame could be simple and extensive. The (objective knowledge) is notably more challenging. Although game could be texted to a phone number or the link sent through writing a correct definition served as a valuable method for email, and shared via social platforms such as Facebook, assessing participant knowledge for the purpose of a research Twitter, Instagram, or Snapchat, without the need for in-person study and has been used in previous research [29], this is not game administration assistance. One avenue for future research how health insurance knowledge would be captured in everyday would be the implementation of this game in college campus activities. Rather, individuals must make decisions using the health and wellness center waiting rooms, where students may given information, including completing calculations. It could actively desire something to fill their time while waiting. Using be that participants would have been more successful in a Web-based, mobile-ready game also provides the potential demonstrating their knowledge through applied scenarios and for reaching populations underserved in health insurance questions, comparable with what they did within the game. This understanding; younger adult audiences may not get their news is just one of many avenues for future research initiatives. and information from traditional outlets, but this is a large population of the people who are online, on mobile technologies, Additionally, in this study, participants indicated an increased and are playing games. There are also possibilities for self-reported understanding of how to use health insurance but game-infused programs for health insurance literacy that begin not what health insurance is. In designing the game for this with the Healthcare America mobile game as part of a suite of study, it became clear that there are a number of avenues to be health insurance literacy games that deploy automatically to tackled through games when it comes to health insurance. Future participants at particular times during their university experience research should explore the needs of those who do not yet have and incorporate participant follow-up surveys along the way health insurance and how gaming, immersion, and decision possibly between 3 and 6 months, at 1 year, and at university making can contribute to enrollment assistance. In conjunction exit/graduation. This strategy addresses the issue of building with this initiative, those who currently have health insurance, real literacy in this complex system, realizing it is not a problem yet struggle with using the health care system and insurance that can be solved with one game, one time. companies, would benefit from a game similar Healthcare America. Future gaming efforts could incorporate both In addition to these explicit advantages with a young, tech-savvy suggestions into one game, having participants reach or unlock population, the majority of adults with potentially low health new levels as they successfully move from getting enrolled in literacy indeed have smartphones including those who did not health insurance initially, to making challenging decisions in a graduate from high school (54% have smartphones), make less health care setting. than US $30,000 (64%), or are of minority race (72% of black adults and 75% of Hispanic adults). Future research initiatives It should be noted that Healthcare America is just one example should explore ways in which a newsgame would be a feasible of how games can be used successfully to promote health method for connecting patients with low health literacy, general knowledge and outcomes. There are a growing number of literacy, or experience difficulty with technology. One examples in which games and game projects are designed to adjustment that could be made to Healthcare America is to offer engage audiences in health and wellness issues. Indeed, audio cues and narration to facilitate engagement among these UnitedHealthcare offers a Health Insurance Matchmaking Game audiences. Additionally, game content could be further tailored in which the player determines which type of health insurance to specific populations and include culturally relevant details, is “right” for them based on a series of actions performed in the as well as specific health insurance scenarios encountered by game [39]. Future iterations of this study could compare the patients who struggle with these skill sets. effectiveness of Healthcare America with other games and strategies for increased interaction with and understanding of Limitations health insurance. In contrast, at the specific intersection of health This study presents important findings that can contribute to games and health journalism, in which stories and scenarios future intervention initiatives regarding health insurance, health, from the real world are directly incorporated into the design of and newsgames, yet it is not without limitations. First, the study the game, there are only limited projects despite the possibilities was limited by sample size. The purpose of this study was to for increased awareness, engagement, and education. Seven explore an initial iteration of a newsgame in this area, and our Ways to Defy Death from the Washington Post [40] does provide study indeed exceeds the sample size included in other, one example, as well as Propublica’s experimental game, comparable studies [18,29]. In Healthcare America, players are Heartsaver [41]. Journalists cite time, design and technical provided with information about and definitions of health resources, and budget as pain points for developing games to insurance terms. Information is not sufficient to change behavior engage audiences in game-infused storytelling. Free engines [43,44]. However, in conjunction with an interactive game in such as the Story Builder used for this project offer journalists which young adults were asked to note, evaluate, and assist the ability to create mobile games quickly and experiment with clients with health insurance issues, it is the hope that players audience engagement in this space. experience and learn about health insurance through modeling and applying information they acquire. An additional limitation http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Champlin & James was the confines of the lab setting as well as participant This population is particularly susceptible to being at risk for self-selection (and convenience sampling) in choosing to play not having or understanding health insurance [27,29]; yet, based the game and participate in the study. It may be that participants on the findings of this study, a game such as Healthcare America felt they needed to respond to questions or act a specific way is an appropriate initial step to decreasing these health-related when playing the game. Participants could have felt pressured challenges. to take on the role of an “intern” for a health care position. With Results from this study suggest that repeated play or multiple this in mind, within the game, the player is provided with the exposures to some concepts such as “coinsurance” may be “pages from the intern manual” (the health insurance needed to increase understanding of this more difficult term. In terminology explanations and examples) and thus must act and this study where only one example was implemented, few young provide suggestions based on the information they have—a adults increased in their understanding and confidence with this learning and growing process akin to working at an internship. term. In contrast, terms that young adults encounter more often In this study, we implemented previously used survey items (and potentially have an increased immediate need for) such as [29]; however, other types of measures, including “referral” need fewer examples or iterations to achieve multiple-choice questions or selecting a “correct” answer from understanding. Moreover, Healthcare America implemented a list could have produced different results. Moreover, the client narratives based on real-world news stories, user findings rely on a single group pre- and postgame play design experiences, and real-time information about health insurance and did not measure subsequent behavior change or retained to facilitate understanding. The strategy of asking young adults knowledge long term. In an effort to minimize these limitations to help or assist others in need or with questions can be a in future studies, we are currently collaborating with the fulfilling experience for the player and a beneficial game on-campus health and wellness center to make the Web-based strategy. game available on its website and thus extend access and data collection. Although the games for health field have grown considerably in recent years, this health insurance newsgame is the first of Conclusions its kind. The design and pilot test phase shows promising results In this study, young adult participants indicated an increased for game design strategy, health insurance content, and platform level of self-reported and objective knowledge after playing an iterations, moving forward. interactive, narrative-based newsgame about health insurance. Acknowledgments Funding for this study was provided in the form of a research microgrant from the dean of the Mayborn School of Journalism at the University of North Texas. Also, we would like to thank the graduate and undergraduate research assistants who assisted in this project (Rita Unogwu, Hailey Sutton, Beatriz Martinez, and Sonia Gomez). Conflicts of Interest None declared. Multimedia Appendix 1 Full game design and possible game flow paths. [PNG File, 450KB-Multimedia Appendix 1] References 1. Anetta L. The Is have it: a framework for serious educational game design. Rev Gen Psychol 2010;14(2):105-112. [doi: 10.1037/a0018985] 2. Ryan RM, Rigby CS, Przybylski A. The motivational pull of video games: a self-determination theory approach. Motiv Emot 2006;30(4):344-360. [doi: 10.1007/s11031-006-9051-8] 3. Eleftheriou A, Bullock S, Graham CA, Ingham R. Using computer simulations for investigating a sex education intervention: an exploratory study. 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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. http://games.jmir.org/2017/4/e22/ JMIR Serious Games 2017 | vol. 5 | iss. 4 | e22 | p. 13 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Nov 16, 2017

Keywords: health insurance; games, experimental; young adult; information literacy

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