Note: In 2013, Health Games Research completed its work. This web site is now an archive and will not be updated. Please visit the web site of the Center for Digital Games Research at UC Santa Barbara to find current information about health games and the broader field of digital games, and to use the Health Games Research online searchable database.

Steve Cole

By Kate Metropolis

Steve Cole conducted a clinical trial to see whether playing a video game improved the likelihood that adolescent cancer patients would take their medicine. Now he’s trying to understand why the game succeeded in motivating the players when their doctors didn’t. The reason appears to be radically different from what the game’s designers expected.

Fifty years ago, if you were a teenager diagnosed with acute lymphocytic leukemia, the most common form of cancer in adolescents, your chance of survival was bleak. Fewer than three out of a hundred patients lived longer than five years. However, years of research and clinical studies have led to treatments that have increased the five-year survival rate to 87 percent.

But, so far, this remarkable medical advance has not saved as many adolescent’s lives as it could, and the reason it hasn’t reveals something about the intricate machinery of the mind that shapes these patients’ behavior. Acute lymphocytic leukemia is treated first in the hospital for an intensive month or so, until no leukemia cells show up in the patient’s blood and bone marrow. Then the patient, now in remission, goes home with instructions to take maintenance chemotherapy in the form of a pill every day for the next two-and-a-half to three-and-a-half years, to destroy any residual cancer cells and prevent the disease from recurring. For teenagers who follow this protocol, there’s a greater than 80 percent chance that they will live as long as someone the same age who never had the disease. But if they skip the maintenance chemo just a fifth of the time, the odds of recurrence and death shoot up by 200 percent. Yet, despite hearing these statistics from their doctors, some twenty to thirty out of every one hundred adolescent patients skip enough pills to double their risk of avoidable death.

The key to understanding the behavior of the teenagers who don’t take their meds lies in their thinking, according to Dr. Steve Cole, who is an associate professor of hematology-oncology at the UCLA School of Medicine. Cole says the adolescent patients generally understand their doctors’ lectures about the importance of taking the pills. They are not being willfully defiant. They’re in remission, they have a sense of well-being, their hair is growing back. Thinking about their future as if the disease were behind them is appealing--a daily reminder that they are still cancer patients becomes, literally, a hard pill to swallow. It’s a “viscerally miserable experience,” he says.

Modern medicine is full of such challenges, Cole notes. “We have great tools for making changes at the biochemical level, but for many major health problems—obesity, type II diabetes, heart disease—physicians also need strategies to change behavior.”

Cole, who has a Ph.D. in psychology, has been investigating the connection between our minds and our physical health for more than fifteen years. He’s a pioneer in the quest to understand how stress, loneliness, and misery reach deep into the immune system and re-shape the body’s biochemical responses, making people not only more susceptible to illnesses like heart disease, HIV, and cancer, but sometimes even reducing the effectiveness of the drugs used to treat them.

A few years ago, Cole got a call from psychologist Pam Kato, who offered him the chance to assess one new approach to changing behavior: video games. She recruited him to help with a project for HopeLab, a non-profit foundation dedicated to motivating young people to improve their health-related behavior. HopeLab, where Cole now serves as Vice President of Research and Product Development, wanted to develop a computer-based video game to help adolescent cancer patients become better at adhering to their chemotherapy and then to conduct a rigorous clinical trial to assess the game’s impact. (A cancer-fighting video game was the idea of Pam Omidyar, the founder of HopeLab, who is married to the founder of the online auction site eBay.)

Players of the HopeLab game pilot a smart, attractive nanobot through the bodies of teenagers with cancer. “In the game, just as in real life, patients in remission feel fine,” says Cole, “but your nanobot hunts around and discovers some bad-guy cells still lurking around, so you lay waste to them with your chemoblaster and your radiation gun and your antibiotic rockets. Symbolically, chemo becomes a sidearm in your battle.”

Kato and Cole designed a rigorous protocol to test the game’s effectiveness: 374 cancer patients between the ages of thirteen and twenty-nine were randomly assigned either to the intervention group, which played the HopeLab game, “Re-Mission,” or to the control group, which played a commercial game with a similar play structure but no medical content (The researchers controlled for factors they thought might affect the results of the study—race, gender, age, diagnosis, game-playing habits).  Blood samples from each patient were drawn and analyzed regularly over a three-month period. In the control group, eighteen percent of the patients showed dangerously low levels of medication in their blood, which suggests that they weren’t taking all of their chemotherapy; in the group that played “Re-Mission,” that number dropped to eight percent. That is, playing “Re-Mission” roughly halved the number of people who were at greatest risk for suffering a relapse. “That’s not a bad outcome for such an easily disseminated intervention,” Cole observes.

What really surprised the scientists was what the study, reported in the journal Pediatrics, suggested about how the game affected the patients’ behavior. “Originally, we based the game on cognitive-behavioral theory. We really tried to jam a lot of information in,” Cole explains. “There were something like twenty levels—twenty-five hours of total game play.” The assumption was that the longer patients played the game, the more knowledgeable they’d become about their treatment regimens, so the more likely they’d be to take their pills. The data revealed, however, that “kids who played only a couple of hours showed the same positive outcome as kids who made it through all the levels. In fact, when we pulled out all the preachy lectures, the game intervention did even better.

“At that point,” says Cole, “I started thinking, ‘This must be working like a commercial, where a gripping thirty-second message unleashes persistent psychological and behavioral changes.’”

Marketing, Cole explains, succeeds by linking a product to someone’s identity. Describing what a cola tastes like is less likely to motivate you to buy it than showing you someone happy and attractive—someone you’d like to be—drinking the soda. Playing the game “re-branded chemo,” Cole thought, by transforming mundane medication into bullets to kill the enemy cells, and by changing the humdrum routine of swallowing pills into a heroic act. It converted lingering cancer cells from an abstract concept into concrete, visible bad guys, and it gave the players a sense of power and control, which adolescents—particularly adolescent cancer patients—often lack. In short, it took the behavior that patients had an aversion to and reshaped it into an action that excited them.

Functional MRI scans of young adults’ brains as they played the game seem to bear out Cole’s hypothesis. They show activity in three key areas of the brain: the thalamus, which indicates general excitement; the ventral striatum, which is associated with the anticipation of attaining something that’s desired; and the hippocampus, where transitory experience is transformed into long-term memory. “If you want a brief experience to stay with a person,” says Cole, “you want to activate this area.”

Cole believes games have the potential to help people get over other major hurdles related to health behavior. Two aspects of games can offer particularly powerful boosts, in his view.

First, as “Re-Mission” does with lingering cancer cells, good health games make visible the invisible: they enable players to viscerally experience the seriousness of things they cannot see or events they have not undergone. “If you’ve maintained a healthy weight, stayed active, and never smoked, you may not sense that you’ve succeeded: you don’t feel the heart attack you didn’t have. But, if you could feel what it’s like to live with a heart muscle that’s half dead, you could use that as a motivator to sustain healthy choices,” Cole says. “Games can be a way of showing you what you’ve bought with your good behavior that you can’t see any other way.”

However, a successful health game doesn’t work the way a persuasive movie does, in Cole’s view: “It’s not that you just shove the right piece of information into the brain and people spontaneously behave the way they should.” A game will connect what people know, with how they feel, with what they do, if it “gets the motivational alignment right.” It has to put the player in control and link the healthy behavior to the power, glory, and drama of winning the game. Ultimately, he says, it has to show the players that the behavior “is going to get them to be the ideal self they really want to be.”


Photo of Steve Cole courtesy of HopeLab.