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A pairing of exergaming and persuasive health messages for physical activity
by Wai Yen Tang on 06/27/14 09:53:00 am   Featured Blogs

The following blog post, unless otherwise noted, was written by a member of Gamasutraís community.
The thoughts and opinions expressed are those of the writer and not Gamasutra or its parent company.


I don't write much about health-related videogames studies as I am more familiar with psychological processes. However, my article count for this year tells me that are a lot of articles published in that area, more so than aggression research. This is telling that videogames are really taken seriously by other disciplines, unsure if the public are aware of that. Games for Health Journal is an academic journal that started in 2012, but I have not counted its articles into my library because citeulike can't enter its citation information and I can't be bothered to manually enter the info. Try going through 50+ emails of new academic articles every week.

May Lwin (Nanyang Technological University) and Shelly Malik have published an article on the effectiveness of exercise games (e.g. Wii fit) into physical education lessons for imparting health messages. It was published in the Journal of Health Communication which according to a Health Communication faculty member is a high-tiered journal in that area.


This study examines the effectiveness of incorporating exergaming into physical education lessons as a platform for imparting health education messages and influencing children's beliefs about and attitudes toward physical activity. The authors launched a 6-week intervention program using Nintendo Wii games coupled with protection motivation theory-based health messaging among 5th-grade school children in Singapore. Results indicated that when children who were exposed to threat-framed messages played Wii exergames during physical education lessons, they reported more positive physical activity attitude, self-efficacy, and perceived behavioral control than did those who underwent regular physical education lessons and were exposed to the same message. In addition, among children playing Wii, the threat and coping frames had similar effects on the degree of message influence on physical activity attitudes and beliefs. The implications for schools, parents, and health policy are discussed.

In health communication research, they use health campaigns to send messages about staying healthy. Their theoretical bases are social cognitive theory, theory of planned behavior and the elaboration likelihood model. These are theories about the processes of persuading people to do stuff or changing their attitudes or beliefs. One particular theory the authors focused on is the protection motivation theory which posited that a person's motivation to protect oneself from negative health conditions is determined by said individuals' assessment of health threats and their feelings of coping with it. Persuasive health messages can be constructed around individuals' level of threat and coping appraisals.

In exergaming research, it exploded at the seventh generation of consoles and focus on the Wii, Kinect, and much less on the Playstation Move as I recall. The gist of the research is they examined whether playing exergames exerted as much calories as traditional exercising, and it was, more or less depending on the individual studies, and exergames incorporated some extra features. For example, exergames could have the potential in encouraging more physical activity.

As the first attempt to combine these two research areas, they conducted a 6-week long experiment to see if elementary school children's attitudes and beliefs about exercise have changed. They do so through the theory of planned behaviour as their conceptual framework. I shall explain this in the measures section.


Participants: Elementary school children in Singapore because that's where they started with their idea and got funding from Singapore's Ministry of Education. Three elementary schools were picked. From each school, four classes were picked. Each class was assigned a condition (out of a possible four) for this 6-week long experiment. Total number of participants is 398, average age is 10.2 years.


This is a 2 X 2 experiment for a total of 4 conditions and we have four classes. Two of those classes get to play the Wiis, they get to play with three Wii consoles, during their physical education period every week. For the first two weeks, they get to play Dance Dance Revolution, after that it's Wii tennis for two weeks and then Wii boxing for the remaining weeks. The other two classes don't play the Wii during the physical education period. The classes get different health education brochures. Between the Wii and no-Wii classes, one class gets the coping appraisal brochure where it provided practical tips on developing physical activity habits, for example. The other class gets the threat appraisal brochure where it highlights the dangers associated with obesity. They read them during their first, third and sixth week.


The theory of planned behaviour is conceptualized around the individual's attitudes and beliefs that influence their motivation which in turn influence their behaviours.

Before the act, we have behavioural intentions reflecting a person's plans and motivations which is assessed with three items on a 5-point agreement scale. There are three factors that influence behavioural intentions.

1. Attitude towards the behaviour: it is one's positive or negative evaluation of the behaviour, in the study's case: exercise. Assessed on seven 5-point semantic differential scale for the following statement: "for me, exercising in my leisure time over the next 6 months would be..."

2. Subjective norms: it is one's perception/belief of the social pressures and/or opinions of others about the behaviour. There are several types of norms. 4 items to assess injunctive norms where beliefs about important persons' opinion (approval or disapproval) of the behaviour, like they approved of doing aerobic exercises. 2 items to assess descriptive norms where what would others commonly do in specific situations, like would they exercise regularly. 4 items to assess group norms where one's perception of one's group, specifically the class, does with the behaviour.

3. Perceived behavioural control: it is one's perception of how easy or hard in doing the behaviour. Assessed through one item on 5-point control scale. Another type is called self-efficacy which is about one's belief in their own ability in doing the behaviour assessed through 3 items on a 5-point agreement scale.


The analysis is carried through a two-way ANCOVA with pre-test attitudes and beliefs as the covariates. They found interaction effects for attitude, self-efficacy and perceived behavioural control. Further analyses found that the children who exercised with the wiis and read health brochures framed through threat appraisals expressed greater positive attitudes, self-efficacy and perceived behavioural control than their peers who did not exercise with the wiis.

The authors compared the data between the message framing (i.e. coping vs. threat) and found non-significant results in the wii classes. Interestingly, among the classes who exercised without the wiis, the coping appraisal brochures were more effective than the threat appraisal brochures.

Is it me or I don't see any cross condition analyses? I was looking over the figures in the article and it seems that the classes who exercised without the wii and read the threat appraisal brochure scored the lowest on attitudes, self-efficacy and perceived behavioural control whereas the other classes seemed to score closely to each other.


The authors' take-home message is that the pairing of exergames and health education messages have a potential future. Children who exercised with the wii during their gym periods over 6 weeks and read about the dangers of obesity from their teachers or some adults reported greater positive attitudes about exercise, self-efficacy and perceived behavioural control.

The authors discussed exergames' positive effects on children's attitude, self-efficacy and perceived behavioural control when given threat-appraised health messages. Threatening health messages are effective, if they are accompanied by proposed actions and solutions to overcome these threats. They argued the exergames provided these solutions and also may lead the children to feel empowered to overcome the health threats. My question is why these threat health messages did not work with regular PE classes as they offer a solution. IMO, it's probably the messages in those games that might provided encourage even with failure, it's honest feedback.

Regarding the unsurprising, as the authors noted, non-significant effects on subjective norms and behavioural intentions. There was no intervention that targeted subjective norms as the messages were directed to the children. They also argued that the 6-week long experiment may have been too short to see any effects.

Some limitations the authors have identified: more measures, more games, more time for the wii, and more research about the intervention.

My impression of the study is that it is retrospectively a bad study. But, this "bad" study would have pointed towards some good directions and ideas for future research. Frankly, I would have done the same thing as a beginner in health communication research. Here is what I offer as a videogames researcher.

We need a fifth group that serves as a control group, one that did not exercise with the wii nor received any health education messages.

We need media habits information from the children, how many children have a wii or kinect at their homes? What games do they play? How long do they play these games? It is possible that children were very excited at playing videogames during the physical education period and this could be an artifact of a novel stimuli rather than a true exergaming effect. Hence, the authors' need for a long experiment. If they are assessing norms about exercise, they should also examine norms around exergaming and Dance Dance Revolution, I heard that game is incredibly popular in Asian countries, like national competitions and stuff.

Regarding how to affect subjective norms would mean tapping into the online community of videogames. Perhaps an online leaderboard or online interactions with other players or e-sport athletes might serve as influence on children's subjective norms around exergaming.

A fusion of exergaming and health education messages is to embed health messages within the exergames rather than communicate it through a different medium. Perhaps a collaboration between Nintendo's Wii fit trainer and health communication scholars would be in order. What would be more encouraging than listening to a long-standing and perhaps loving exercise expert, even though she's just a videogame character that you interact with during your entire wii workout. Speaking of Wii fit trainer, a graduate colleague of mine gave up the wii because the game gave judgmental remarks about their weight and showed them a-not-so-pleasing player-character in the game. They can cheat by sitting on the couch and just wave the wii-mote around and the balance board that goes with the game isn't big enough. Needless to say, the colleague switched to the kinect.


Lwin, M. O., & Malik, S. (2014). Can exergames impart health messages? game play, framing, and drivers of physical activity among children. Journal of Health Communication, 19 (2), 136-151. DOI:10.1080/10810730.2013.798372

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Wai Yen Tang
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Cross-posted at my blog:

Larry Carney
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"My question is why these threat health messages did not work with regular PE classes as they offer a solution. IMO, it's probably the messages in those games that might provided encourage even with failure, it's honest feedback."

It could also be that the PE classes are structurally different from the Wii-exercises setting: with the PE class there is the whole hierarchy of who gets picked first for games, etc., which could be a factor that I don't think was mentioned in the study: to maybe mitigate this variable a future study might want to consider a "competitive" element to the games that are chosen for the study, perhaps?

Michael Joseph
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Larry makes a good point. In fact, intra school competition (teams or individual) probably detracts from instilling physical health consciousness across a wide variety of people because it shifts the attention away from well being to "achievement."

And treating physical education like a chore that one should take part in for a scheduled period each day is not a good way to instill health consciousness either. It may fit into a certain western worker life style from employers perspective who don't want to facilitate a healthy workforce on their own dime, but it doesn't lead to a healthy society.

Fitness is not something that can be compartmentalized. Physical health relates to mental health and when mental health is challenged (family issues, societal pressures, financial pressures, cultural messages), physical health gets challenged too. So much of the thinking around dealing with socio-economic problems (eg. growing obesity epidemics) start with acceptance of certain worker-centric realities and ultra liberal capitalistic philosophies (every man for himself individualism) that must be worked around because those realities are considered immutable. So we're not much interested in solving problems as we are in mitigating them within a set context (eg. shifting all responsibility to the individual). That is doomed to failure because it rules out (strips away support for) the type of education that would undermine that reality.

99 Problems But Obesity Aint One...

"Under Japanís health care coverage rules, employees who fail to meet waistline guidelines are forced to undergo counseling.

Indeed, if Japanese firms donít cut the number of overweight employees by 25 percent by the year 2015, they may be required to pay more money into health care programs for the elderly."

p.s. Not to say that mitigation techniques shouldn't be investigated... they may help some folks but I think it's a tiny fraction. Mostly I'm saying that we shouldn't be confused to think these are possible solutions.

Larry Carney
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Thanks. Speaking of healthier societies and video games, I was thinking that with the success the Wii had through Wii yoga and that board, and other software and hardware, that Nintendo would push for the Wii U to occupy a similar space as a socially acceptable form of exercise that people of all backgrounds could utilize (as the originally Wii was used this way from nursing homes to some public schools), and with Nintendo stating their research and development of Quality of Life initiatives it seemed like this is where the Wii U was going, so I am surprised that nothing has been revealed in this area. I would have thought at the very least Nintendo would have released something during the launch of the Wii U in this area as a way to capitalize on what it had established with branding the Wii as a fun and socially acceptable form of exercise.