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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.
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.
A total of 72 (N=72) participants completed in-person, individual gaming sessions. Participants completed a survey before and after game play.
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);
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.
Serious games are designed to cultivate skills for a specific topic and do so by activating existing schema in the mind of a player to ultimately produce “new knowledge” and experiences [
There exists a variety of health-oriented serious games. In some cases, health-focused games allow players to explore risky or challenging situations without having to experience the direct effects they might encounter in the real world (eg, dying or harming someone, experiencing a negative health outcome, mismanaging a decision) [
A key benefit of serious games for health, specifically, is to stimulate or motivate patients for health efforts that may be perceived as unpleasant or uninteresting and thus avoided [
According to the Entertainment Software Association, 56% of Americans today play video games, and nearly half (48%) of frequent gamers are considered mobile and/or social gamers [
In this study, we developed a serious game that draws from principles of journalism, educational and video game design, and learning and literacy, in conceptualizing an online game experience [
Having health insurance has been linked to a number of advantageous health outcomes, including increased access to health monitoring, screening, information, and beneficial health decisions [
Understanding, selecting, and using a health insurance plan, however, is a complex process and requires a plethora of diverse literacy and numeracy skill sets [
Although the initiation of the Affordable Care Act increased the number of Americans who hold health insurance policies [
Historically, young adults have the lowest rates of health insurance plan enrollment among all nonelderly adult age groups [
Health insurance literacy is particularly low among young adults, including those who are highly educated. In one study, none of the participants felt “good” or “very good” about their understanding of a list of health insurance terms and at times transposed definitions or had questions about the information [
For this project, we created a Web-based newsgame, “Healthcare America,” to explore the possibilities for what games can offer the problem of engaging and informing young adults in concepts connected to health insurance literacy. Bogost and colleagues define “newsgames” as games that apply journalistic principles in their creation [
Specifically, newsgames infuse the concept of real-world
Newsgames are an emerging digital practice for today’s journalists, although games for journalism are not new. Historically, crossword puzzles and news quizzes have been found in newspapers and on broadcast radio as tools to engage audiences in interacting with news facts and information in engaging and fulfilling ways. As video games have evolved and the benefits of game design have grown out of commercial markets into serious and educational spaces, journalism has also begun taking the best practices of game design for nuanced storytelling, immersive learning and informing strategies, and engaging audiences in complex systems through play [
We selected a newsgame approach for Healthcare America to explore a mobile game execution for health journalism and to experiment with and contribute to the design models for engaging journalism. Games at the intersection of journalism and health provide new, strategic opportunities to create playful experiences around complex issues and offer real-world learning created from real data designed into hypothetical interactive narratives. These serious games provide a platform for audience engagement in ways that health communication and health journalism have only just begun to explore (conventional tools in health media communication include pamphlets and flyers, public service announcements, and radio ads) [
The purpose of this study was to develop an interactive-narrative newsgame that presents entry-level health insurance information and scenarios to young adults. To our knowledge, this study is the first to design and test an interactive game that encourages young adults’ interaction with health insurance concepts.
We hypothesized the following statements based on the notion that young adults often lack an understanding of many health insurance terms [
In addition to examining whether participants perceived themselves to have learned about health insurance terminology from the game, we sought to measure whether participants increased in their objective knowledge of health insurance terminology after game play.
Findings from this study will have important implications for many groups. Equipping young adults with a greater understanding and confidence in what health insurance is and how it works can lead to better overall health outcomes. Additionally, this study offers practical solutions for health practitioners, educators, and counselors who design programs to improve health literacy and access to health information. In the remainder of this paper, the development of a health insurance game created for young adults will be described and its effects tested. Implications for health practitioners, including health insurance counselors and other financial advisors, will be discussed.
We used the Playable Media Story Builder (Phoenix, Arizona) platform to develop the game, Healthcare America. The Story Builder is a visual engine that allows publishing of hosted, cross-platform responsive, interactive narrative games. The engine, designed to empower journalists to prototype narrative games, was funded by the Knight Foundation Knight Prototype Fund. The Playable Media team designed and developed the tool in collaboration with journalists and journalism students at Arizona State University through the News-Play Project, a partnership between Arizona State University’s New Media Entrepreneurship & Innovation Lab and Center for Games & Impact Innovation Lab.
Healthcare America positions the player as working for a health information advocacy organization with a series of client cases. The game interface includes simple graphics, narrative text, player choices, and two meters measuring community wellness and health care assistance funds (see
Using a newsgame design approach to develop game content, we gathered stories about personal struggles with health insurance from people in our community, undergraduate students, and national news stories. We collaborated with a news writing and reporting class to further investigate through personal narratives the ways in which people struggle with health insurance in the real world. Additionally, we pulled fact-based information from health insurance websites, the HealthCare.gov website, and our university’s health insurance Web page. We collaborated with stakeholders and knowledge experts at our university about how they typically administer information and guidance about health insurance to students.
Examples of the user interface and game play of the health insurance game.
As a result of this exploration, five scenarios or “client cases” were developed for the game based on real-world stories and information gathered from stakeholders and health insurance consumers. Characters included in the game were developed to consciously include a variety of different race/ethnicities, sex (white female, African American male, Hispanic female, white male, Asian female), age, and occupation.
Following these steps, we adapted the list of health insurance terms used by Wong and colleagues [
The game opened with a brief introduction and explanation of the game on screen. Game instructions, including the meaning of the game meters (Community Wellness, that is, how healthy the participant or player made the community, and Healthcare Assistance Fund, that is, the amount of money spent to assist the client), were then provided. With these meters in mind, the central goal of the game was to be a “successful intern” by assisting clients with troubling health insurance cases—aiming to maximize Community Wellness without spending all of the organization’s Healthcare Assistance Fund.
Participants read and experienced each of the aforementioned cases; key details about what happened and what went wrong for the client were presented. Then, health insurance terms were provided. Participants then selected one of three options for how to advise each client, which took into account how much each option would contribute to the overall Community Wellness (Did the participant help improve the health of the community through his or her advising decision?) and how much money would be spent from their Healthcare Assistance Fund, which was capped at US $5000.
To summarize and provide a specific example, the prototype narrative design of Healthcare America blends real-world experiences of stories from using, or struggling to use, health insurance. In the game, these stories are translated to “client cases.” The player is given a role within the narrative and the goal of “solving” or assisting a series of client cases while working as an intern (with the promise of being promoted to a full-time position for a job done well).
The player reads a client case file (eg, Vanessa who is a 42-year-old female, a project manager and mother of 2, annual income US $35,000, who regularly sees a therapist to manage her mental health and well-being. She fills a prescription for antidepressants on a monthly basis. “Vanessa sent us [Healthcare America] an email because she’s confused about what just happened at the pharmacy. After being diagnosed with depression, Vanessa has a regular prescription for antidepressants. Today the cost of her medication was much higher than usual.”) and is then provided with information about specific health insurance term (in the case of “Vanessa,” it is information about co-payments). The player is then able to advise the client using several options, each of which is linked to a corresponding increase or decrease in the Community Wellness meter, the Healthcare Assistance Fund, or both. The player advises the client presented and then learns the outcome of the corresponding meters.
There are obstacles to overcome (the main conflict is to balance solutions to clients’ health care and health insurance problems) and rewards for overall Community Wellness and the Healthcare America’s Healthcare Assistance Fund. The game ends if the player depletes the Community’s Wellness or Healthcare 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 (a win); see
We kept in mind the
Design of game meters: (1) Healthcare assistance fund and (2) community wellness.
An example of the community wellness meter options.
Demographic information of sample (N=72).
Characteristic | Sample | |
Male | 29 (40) | |
Female | 43 (60) | |
White | 27 (38) | |
Black, African American | 18 (25) | |
Hispanic, Latino/a | 17 (24) | |
Asian | 5 (7) | |
Mixed | 4 (6) | |
Other | 1 (1) | |
Yes | 19 (26) | |
Excellent | 8 (11) | |
Very good | 30 (42) | |
Good | 27 (38) | |
Fair | 5 (7) | |
Poor | 1 (1) | |
Don’t know | 0 (0) | |
Freshman | 19 (26) | |
Sophomore | 12 (17) | |
Junior | 26 (36) | |
Senior | 10 (14) | |
Super senior (+4 years) | 3 (4) | |
Other | 1 (1) | |
Yes | 17 (24) | |
Without health insurance, n (%) | 17 (24) | |
Age in years, mean (SD) | 21.15 (3.49) |
A 2-tailed power analysis calculated for paired data was performed with G-Power to calculate an estimated sample size of 67 participants (effect size=0.35, with 80% power, and alpha=.05) [
A call for participants was administered via email to classrooms, or a Web-based classroom boards through journalism and communications courses on campus. Participants indicated their interest by contacting the research team via email and scheduling an appointment. Each participant completed an individual, in-person data collection session. All study procedures were approved by the relevant institutional review board. Each session was scheduled for 1 hour and included an introductory phase in which participants read and signed a consent form, the completion of a pregame survey, game play on a computer, and a postgame survey.
Participants completed pre- and postgame surveys to determine their level of health insurance understanding before and after playing the health insurance game. In both surveys, participants were asked to indicate their understanding of “what health insurance is” and “how to use health insurance,” as well as rate their understanding of 9 health insurance terms using a 5-point scale (very good to very bad) [
Paired sample
The purpose of this study was to determine whether a health insurance game is a viable tool to communicate important information about health insurance terminology and how health insurance is used. The first hypothesis predicted that, following game play, participants would exhibit a greater self-reported, general understanding of what health insurance is and how it is used. Indeed, participants indicated a greater self-reported understanding of how to use health insurance from pregame play (mean=3.38, SD=0.98) to postgame play (mean=3.76, SD=0.76);
Hypothesis 2 surmised that participants will exhibit increased self-reported understanding of critical health insurance terminology. For all health insurance terms, participants felt they had a better understanding of the term following the game; see
Finally, in addition to examining whether participants felt that their understanding of a given health insurance term increased after playing a health insurance game, we wanted to determine whether participants objectively define more health insurance terms correctly following game play. The proportion of participants who correctly defined a given health insurance term was significantly different for the following terms: “monthly premium,” “referral,” “in-network provider,” “deductible,” and “HMO/PPO”; see
Among participants who provided a definition for every health insurance term for both pre- and postgame play (N=32), participants correctly defined more health insurance terms following game play (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68);
Self-reported understanding of health insurance terms, pre- and postgame play.
Health insurance term | Pregame self-reported |
Postgame self-reported |
Paired |
|
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 provider organization | 1.97 (1.04) | 3.26 (1.09) | −9.10 (68) | <.001 |
aDegrees of freedom differ across terms given that participants had missing data on either pre- or postgame items at different rates for each term.
Objective understanding of health insurance terms, pre- and postgame play.
Health insurance term | Correct pregame, |
Correct postgame, |
Cochran’s Q test statistic |
Asymptotic |
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 organization | 2 (4) | 18 (39) | 14.22 (1) | <.001 |
Findings from this study suggest that the implementation of a newsgame can facilitate health insurance knowledge among young adults, a population vulnerable to the negative impact of not having or understanding health insurance [
Young adults, even those who are well-educated, struggle with understanding health insurance and health insurance terminology [
In this study, significantly more participants provided correct definitions for the terms “monthly premium,” “referral,” “in-network provider,” “deductible,” and “HMO/PPO” following game play. The largest increase was seen for the term “referral,” where the frequency of correct definitions increased by 39%. It is possible that this is a term for which many students were already familiar with but needed to be reminded of the correct definition. Indeed, many of the top reasons why college students visit a health care provider are for health concerns that require a referral or prescription including respiratory infections, sexually transmitted diseases, birth control, and annual exams (mainly women’s health such as pap smears) [
In contrast, HMO and PPO are likely terms with which college students are not familiar with [
Although significant growth was not observed in the number of participants correctly defining the term “coinsurance” between pre and postgame play, it is worth noting that no participant provided a correct definition before playing the game. Following the game, 3 participants provided a correct definition. On the basis of the findings of this study, of the terms provided in the Healthcare America game, “coinsurance” requires the greatest exploration in future initiatives. This aligns with previous research, which suggests that patients often focus on the concept of paying premium every month but neglect other cost-sharing terms, including “coinsurance” [
Akin to Wong and colleagues, the correlation between the number of correctly defined health insurance terms and participants’ self-reported understanding of all terms was nonsignificant [
Additionally, in this study, participants indicated an increased self-reported understanding of how to use health insurance but not what health insurance is. In designing the game for this study, it became clear that there are a number of avenues to be tackled through games when it comes to health insurance. Future research should explore the needs of those who do not yet have health insurance and how gaming, immersion, and decision making can contribute to enrollment assistance. In conjunction with this initiative, those who currently have health insurance, yet struggle with using the health care system and insurance companies, would benefit from a game similar Healthcare America. Future gaming efforts could incorporate both suggestions into one game, having participants reach or unlock new levels as they successfully move from getting enrolled in health insurance initially, to making challenging decisions in a health care setting.
It should be noted that Healthcare America is just one example of how games can be used successfully to promote health knowledge and outcomes. There are a growing number of examples in which games and game projects are designed to engage audiences in health and wellness issues. Indeed, UnitedHealthcare offers a Health Insurance Matchmaking Game in which the player determines which type of health insurance is “right” for them based on a series of actions performed in the game [
The use of a Web-based platform, such as that used in this study, has far-reaching implications. This is especially clear in context of growing mobile “smartphones,” which are capable of accessing the Internet. Nearly all (92%) of Americans aged 18 to 29 own a smartphone [
In addition to these explicit advantages with a young, tech-savvy population, the majority of adults with potentially low health literacy indeed have smartphones including those who did not graduate from high school (54% have smartphones), make less than US $30,000 (64%), or are of minority race (72% of black adults and 75% of Hispanic adults). Future research initiatives should explore ways in which a newsgame would be a feasible method for connecting patients with low health literacy, general literacy, or experience difficulty with technology. One adjustment that could be made to Healthcare America is to offer audio cues and narration to facilitate engagement among these audiences. Additionally, game content could be further tailored to specific populations and include culturally relevant details, as well as specific health insurance scenarios encountered by patients who struggle with these skill sets.
This study presents important findings that can contribute to future intervention initiatives regarding health insurance, health, and newsgames, yet it is not without limitations. First, the study was limited by sample size. The purpose of this study was to explore an initial iteration of a newsgame in this area, and our study indeed exceeds the sample size included in other, comparable studies [
In this study, young adult participants indicated an increased level of self-reported and objective knowledge after playing an interactive, narrative-based newsgame about health insurance. This population is particularly susceptible to being at risk for not having or understanding health insurance [
Results from this study suggest that repeated play or multiple exposures to some concepts such as “coinsurance” may be needed to increase understanding of this more difficult term. In this study where only one example was implemented, few young adults increased in their understanding and confidence with this term. In contrast, terms that young adults encounter more often (and potentially have an increased immediate need for) such as “referral” need fewer examples or iterations to achieve understanding. Moreover, Healthcare America implemented client narratives based on real-world news stories, user experiences, and real-time information about health insurance to facilitate understanding. The strategy of asking young adults to help or assist others in need or with questions can be a fulfilling experience for the player and a beneficial game strategy.
Although the games for health field have grown considerably in recent years, this health insurance newsgame is the first of its kind. The design and pilot test phase shows promising results for game design strategy, health insurance content, and platform iterations, moving forward.
health maintenance organization
preferred provider organization
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).
None declared.
Full game design and possible game flow paths.