Concepts, Assessments, Subversions
Edited By Matteo Stocchetti
Social Health Education Programs at School: Investigating the integration of serious games in the curriculum
Social Health Education Programs at School: Investigating the Integration of Serious Games in the Curriculum
To date, studies conducted on the effectiveness of games as learning tools often show mixed results, making it difficult to generalize about their overall impact on learning. Therefore, this study investigates the relationship between technology and education, more specifically the potential of educational games as a tool to enhance the effectiveness of traditional health education programs in school. First, we investigate whether including a serious game into a traditional school health education program can potentially increase the effectiveness of this program, increasing children’s awareness of the health issue and improving their behavior. Second, we consider how these games should be integrated into health education programs to maximize their potential. We investigate the impact of two integration strategies (a game as pre-instructional versus post-instructional strategy) to maximize the learning (and persuasive) process of the health education program. The results show that integrating a serious game into a traditional classroom lesson appears to be an effective tool to increase children’s classroom attention, although it does not directly lead to behaviour change. Second, the results reveal that games are better played before the lesson than afterwards. In sum, this study shows that digital games can provide an additional value to the educational program but in domains like health education where actual behavioural changes are pursued, the transfer from game to behaviour change is neither automatic nor guaranteed.
Every year, new public health campaigns are launched in an attempt to shape people’s attitudes, increase awareness, and improve changes in personal or collective behavior. In general, these campaigns can be labeled as social marketing campaigns, as they use marketing principles and techniques to advance a social cause, idea or behavior (Kotler & Zaltman, 1971). When it comes to social marketing campaigns targeting children, a large portion of the education is provided through the school system. Schools are important outlets to reach millions of children, and school-based education programs allow social marketers to educate children on key topics like health problems (e.g. unhealthy nutrition) and promote lifelong healthy behaviors (e.g. physical activity). Today, however, traditional school health education programs and other behavior-change interventions targeted at children are facing a big challenge as they seem to be limited in their effectiveness (Baranowski et al., 2002; Summerbell et al., 2005; Waters et al., 2011). Although ← 167 | 168 → the specific reason behind this decline is unknown, various authors attribute these findings to changes that the current generation is facing (e.g. Baranowski et al., 2008), basing themselves mainly on Prensky’s (2001) ‘digital natives’ theory.
According to Prensky (2001), people born in the last two decades are substantially different from earlier generations because they are always surrounded by, and interacting with, new technologies such as computers, videogames, cell phones, and so on. For this reason, this generation is often labeled as ‘digital natives’ (Prensky, 2001) or the ‘net generation’ (Tapscott, 1998). While previous generations may learn to use new technologies along the way, digital natives are supposed to be ‘native speakers’ of the digital language as they have been immersed in this technology all their life (Helsper & Enyon, 2009). As a result, it is argued that pupils from the net generation process information in a fundamentally different way. Digital natives are said to be so used to technology and active, collaborative learning that the way they think and learn has changed (Prensky, 2001; Tapscott, 2008). If this is the case, however, there are some profound implications for education as our current educational system is unprepared for these ‘new ways of learning’ (Oblinger & Oblinger, 2005; Rainie, 2006; Underwood, 2007; Gibbons, 2007; Bennett, Maton & Kervin, 2008). This is echoed by Prensky’s (2001: 1) claim that: ‘our students have changed radically. Today’s students are no longer the people our educational system was designed to teach’. A powerful new teaching method, according to Prensky and other advocates of game-based learning, would be to use computer games to teach the digital natives. As games combine learning with fun, challenge and interactivity, they are expected to appeal more strongly to youngsters of the net generation than traditional education (Clarke & Dede, 2007; Dede, 2009). Baranowski and colleagues (2008: 74) also confirm the potential of games for traditional school health education, arguing that ‘new channels are needed to reach children that offer promise of promoting substantial health-related behavior changes. One such new channel is the video game.’
Although the concept of the net generation has been widely adopted in literature, recent work argues that Prensky’s theory is overly simplified and lacks empirical support, as most knowledge has been derived from anecdotal accounts or based on untested assumptions (see Bennett, Maton & Kervin (2008) or Bennett & Maton (2010) for a review). For example, recent empirical research has questioned the validity of the generational interpretation of the digital native concept (Helsper & Eynon, 2009). While some support the natives / immigrants dichotomy proposed by Prensky, reporting significant differences between their use of (and preferences for) technologies (e.g., Facer & Furlong, 2001; Dutton & Helsper, 2007; Livingstone & Helsper, 2007; Cheong, 2008; Hargittai & Hinnart, 2008), other studies fail to find results predicted by the digital native rhetoric (e.g., Conole et al., 2006; ← 168 | 169 → Kennedy et al., 2008, 2009; Czerniewicz & Brown 2010; Jones & Healing, 2010; Jones et al., 2010). Also, while traditional studies assume that the digital natives are a homogenous group characterized by a wide experience and advanced skills in using information and communication technologies (Prensky 200;1 Oblinger & Oblinger 2005; Tapscott, 2008; Bekebrede, Warmelink & Mayer, 2011), recent studies indicate that the Net Generation is actually a diverse group when it comes to technology use and experience (van Dijk 2005; Barzilai-Nahon 2006; Helsper & Enyon, 2009; Kennedy et al., 2010; Hargittai, 2010). In sum, we can conclude that more and more authors are questioning Prensky’s concept of digital natives, which in turn relates to a broader and possibly critical debate on the educational role of digital games. If the notion of a new, digital generation is exaggerated, should we also question the potential of digital games as a means to teach this new generation? Today, although various authors support the potential of games as learning tools (Squire & Steinkuehler, 2005; Garcia-Barcena, & Garcia-Crespo, 2006; Vasiliou, & Economides, 2007; Tuzun et al., 2008; Echeverria et al., 2011; Yang, Chien, & Liu, 2012), others appear far less enthusiastic about this new approach to learning. Ferneding (2003), for example, argues that there is a need for a more critical attitude toward the adoption of technological innovations in education. Other authors even label Prensky’s work as ‘misplaced technological determinism’, arguing he attributes too great a role to technology, and thereby questioning the importance of digital technology for younger generations, as well as its value in educational practices (Selwyn, 2009; Koutroloulos, 2011).
In order to contribute to this debate, the first and main goal of this study is to investigate the relationship between technology and education, more specifically the potential of educational games (also referred to as serious games) as a tool to enhance the effectiveness of traditional health education programs in school. As mentioned above, studies conducted on the effectiveness of games as learning tools often show mixed results, making it difficult to generalize about their overall impact in improving learning. Also, most research is focused on the effectiveness of games as learning tools, but games are rarely studied as a part of an overall health education program. As a consequence, empirical research on the explicit integration of games into the pedagogical process of the class is lacking (Echeverria et al., 2011). In this study, we investigate whether including a serious game on dental hygiene into a traditional school health education program can potentially increase the effectiveness of this program, increasing children’s awareness of the health issue and improving their behavior.
Second, next to research explaining whether serious games can be effective learning tools, it is also essential to consider how these games should be integrated into health education programs to maximize their potential (Van Eck, 2006). ← 169 | 170 → Games can be integrated in various ways and previous research shows that different ways of implementation may lead to different learning outcomes, but their effects on behavioral outcome are unknown. Today, however, an important factor inhibiting the use of serious games in health education programs at school is the teacher’s lack of knowledge about how to implement these games in traditional teaching (Baek, 2008). Therefore, the second aim of this study is to investigate the impact of two strategies to integrate games into the traditional lesson to maximize the learning (and persuasive) process of the health education program. The impact of a game as pre-instructional versus post-instructional strategy in relation to a traditional lesson is examined.
Theoretical framework and hypotheses development
Games as learning tools
One of the main aspects of social marketing is to increase and improve children’s health-related knowledge and behavior and avoid or reduce health risks. Although today, health information is mainly communicated to children through traditional media, the substantial growth of new interactive game technology raises new opportunities for health education. Indeed, an increasing amount of research suggests that computer games can also be powerful learning tools (Klopfer & Squire, 2008; Mitchell, Dede, & Dunleavy, 2009). When used for purposes other than mere entertainment, these games are referred to as serious games, defined as:
a mental contest, played with a computer in accordance with specific rules, that uses entertainment to further government or corporate training, education, health, public policy, and strategic communication objectives (Zyda, 2005 p. 26).
Besides being a fun activity, serious games also involve pedagogy, thereby offering a new and interactive learning experience based on learning by doing (Schaffer et al., 2005). The benefits of video games as learning tools have been extensively documented in various studies. Among others, due to their fun and engaging nature, games are said to attract and maintain attention, increase player engagement and interest in the subject, promote a more positive attitude towards learning and enhance behavior change through enhanced motivation (Ryan, Rigby & Przybylski, 2006; Bourgonjon et al., 2009). Therefore, digital games could potentially be interesting new communication tools to integrate in health education programs at schools, making the educational activities more enjoyable and increase engagement while fostering better behavioral outcomes (Baranowski et al., 2003). ← 170 | 171 →
To date, however, most games used in a classroom context focus on traditional disciplines such as mathematics, science or language (Papastergiou, 2009), aiming to increase children’s knowledge rather than change children’s behavior. Although there are games which have proven to be effective in changing children’s behavior, these are often advergames designed to change children’s behavior in a commercial sense (e.g. Mallinckrodt & Mizerski, 2007). Nevertheless, a few games have been found to change children’s health-related behavior, but these are rarely suited for general health education programs at school, as these games often focus on specific health issues such as teaching children with type 1 diabetes to use insulin (Brown et al., 1997) or enhancing self-management skills for children with asthma (McPherson et al., 2006). To our knowledge, only a few general health education games can be found (e.g. for improving dietary outcome), but these are investigated in simple effect studies (play versus no play), rather than evaluated as a part of a health education program (see Baranowski et al., 2003; Pempek & Calvert, 2009). As educational games should be integrated in the school curriculum, rather than being an add-on (Mitchell & Savill-Smith, 2004), the main goal of this study is to investigate whether integrating serious games into the traditional lessons could potentially bring added value to health education programs at school.
Learning in a state of flow
Integrating educational games in traditional lessons has the advantage that teachers can combine education with entertainment and playfulness. This playfulness, supplemented by high challenge, clear goals, multimodal representation and continuous feedback triggers an experience of flow during game play (Csikszentmihalyi, 1990). Flow is an optimal state of enjoyment where people are completely absorbed in the game, feeling as if they were actually part of the game, also referred to as immersion, forgetting their surroundings (Gentile, 2009). As argued by Adachi and Willoughby (2012), a positive outcome of video game play is that it may induce flow since the player may experience extreme focus, lose track of time, and find the activity intrinsically rewarding. The combination of the flow experience and the active participation allows games to encompass and capture a player’s full attention (Baranowski et al., 2012). In addition, research in the domain of integrated marketing communication shows that a multiple-source condition engenders higher attention compared to a single-source condition (Peltier, Schibrowsky & Schultz, 2003). Therefore, we expect that integrating games into the traditional lesson may lead to increased attention and concentration with children, increasing their attention to the game, but also to the traditional lesson in which the game is integrated. ← 171 | 172 →
H1: Compared to a traditional teacher-centered lesson, a combined teaching method (where an educational game is included in the lesson) will result in a higher attention to the traditional lesson.
Next to increasing children’s attention, a feeling of flow (evoked by the game) is believed to be a component of intrinsic motivation. This claim is supported by the findings of Baranowski et al. (2008), proving that games may be intrinsically motivating, which may in turn promote a more positive attitude towards learning and enhance behavior change. Indeed, Finneran and Zhang (2005) state that during flow, people are so absorbed in an activity that they show high performance without being aware of their environment. In addition, research shows that interactivity raises the comprehension and retention rate of players, which may enhance learning as well (Lindstrom, 1994).
Furthermore, feelings of flow have been proven to support a positive user experience (Inal & Cagiltay, 2007). Therefore, it can be expected that integrating serious games into the educational programs at school may lead to a ‘transfer’ of positive feelings, leading to a more enjoyable, more interesting and thus more effective learning environment than traditional learning modes. This means that children do not only like these games, but their increased attention during game play may also boost the educational impact of games. This is confirmed by Dowey (1987), who found that a combination of traditional teaching and game-based learning is the best way to transfer health-related knowledge to children. Based on these findings, we expect that a combined teaching method of a traditional lesson with a game will be an effective way to increase children’s awareness and thus improve their health related behavior:
H2: Compared to a traditional teacher-centered lesson, a combined teaching method (where an educational game is included in the lesson) will result in more favorable behavioral intention (improve dental hygiene).
Integrating games in the classroom – comparing different integration strategies
Although a lot of attention has been devoted to the effectiveness of games as learning tools, research has overlooked the practical aspect of integrating computer games in a classroom setting. However, additional investigation is necessary to determine how games should be integrated into the education program at school (Read & Shortell, 2011). The fact is that developing effective games is not enough. Educators or schools should also know what to do with them. And while the majority of students play video games, this is, however, not the case for teachers (Schaffer et al., 2004). Therefore, the next challenge for game designers and educators is to understand how to integrate games into the predominant ← 172 | 173 → arena for learning: schools. If we are to bring computers into the classroom, it is essential to know how these games can be integrated most effectively to improve student learning. Therefore, we try to find an answer to this question by testing to what extent different lesson/game sequences can influence the desired outcomes. In sum, two different types of strategies can be distinguished, based on when the game is integrated into the traditional lesson. In the pre-instructional strategy, the game is played before the lesson in order to evoke interest in the topic. In the post-instructional strategy, however, games are played after the lesson for synthesis and to enhance memory (Van Eck, 2006).
To date, however, only one study has examined the effect of integration strategies on learning outcome, but this study dates from 1985 and uses a game designed to teach children mathematics, rather than improve their health behavior (Bright, Harvey & Wheele, 1985). According to the ‘bin model’ theory (Wyer & Srull, 1986), children are only able to process a limited amount of information, which is why the order in which information is presented affects children’s processing. According to this model, information encountered last will have a higher probability of recall, following the last-in-first-out principle. Also relevant here are the mechanisms of the primacy and recency effects, two types of order effects identified by researchers in risk communication, marketing and psychology (Hogarth & Einhorn, 1992; Buda & Zhang, 2000; Petty, Tormala, Hawkins & Wegener, 2001; Murphy, Hofacker & Mizerski, 2006; Chiou, Wan & Lee, 2008). A primacy effect occurs when learning is more heavily influenced by early experience than by later experience or by the first presented information. The recency effect, on the other hand, occurs when the last presented information generates a stronger effect than earlier presented information (Luhmann, 2011). Impression formation research showed that low motivation to process is linked with primacy effects and high motivation to process information is associated with recency effects (Ein-gar et al., 2012; Petty et al., 2001). The reasoning behind this is that it asks more motivation to withhold judgment until all information has been processed (Ein-gar et al., 2012). As playing a game is a typical situation which evokes high motivation to process information among players (Papastergiou, 2009), we expect recency effects to occur.
As the aim of this study is to increase children’s attention to – and enhance the effectiveness of – traditional education programs at school, the main goal is to enhance the learning outcome of the traditional lesson. Taking both the bin model theory and the primacy and recency theory into account, the best way to obtain this effect is to precede the traditional lesson with the game. This is in line with an advertising study on message sequence by Loda and Coleman (2005), who found that preceding traditional advertising with multimedia publicity leads to ← 173 | 174 → more message acceptance and more message response, increasing advertising effectiveness. Therefore, we expect that playing an educational game before attending the lesson will raise curiosity and interest, resulting in more attention paid to the subsequent traditional lesson:
H3: When the educational game precedes the lesson, children’s attention to the lesson will be higher compared to the condition where the game is played after the lesson.
In addition, we expect that playing an educational game before attending the lesson will raise curiosity and interest, leading to a deeper processing of the subsequent traditional lesson and hence more impact on attention and behavioral outcome.
H4: When the educational game precedes the lesson, children’s behavioral intention will be higher compared to the condition where the game is played after the lesson.
Materials and methods
To test the hypotheses, 3 different experimental conditions were set up in which children 1) played the game before the traditional lesson, 2) played the game after attending this lesson or 3) only attended the lesson but did not play the serious game (control group). In total, 5 classes from different primary schools across Belgium were examined and pupils were randomly divided across conditions. In total, 136 children from the third grade (mean age = 8 years, 53% boys) participated. Children between the age of seven and nine are chosen because at this age children are capable of reading information and they also have the skills to play the computer game properly. Prior to data collection, institutional approval and parental and child informed consent were obtained.
At the start of the experiment (expect for the control condition), the pupils were informed that they were about to attend a lesson and play a computer game, and that they would be asked a few questions afterwards. The educational topic was dental care since this is a part of the third-grade curriculum and a current health problem among young children. In the lesson, the importance of dental hygiene, healthy food and frequent visits to the dentist were discussed.
In the first two conditions, each child individually played the serious game either before or after attending the same collective lesson. The game was especially developed to teach third grade children the importance of dental hygiene. Throughout the game, children are challenged to brush teeth correctly using the mouse, visit the dentist and distinguish between healthy and unhealthy food (see appendix 1). In the third (control) group, the children did not play the educational game, but only attended a traditional teacher-centered lesson. As there is no game ← 174 | 175 → play, this lesson lasts approximately 10 minutes longer than the lesson in the first and second experimental conditions in order to keep the ‘total learning time’ equal between all groups. This is important because the total time the children are exposed to the topic can have an important effect on the learning process. Further, we made sure that all the children received the same amount of information (whether they played a game or not), only presented in a different way (through the game or via the teacher).
Afterwards, all participants were asked to complete the same standardized questionnaire measuring self-reported attention to the lesson (Hart & Staveland, 1988) and behavioral intention to brush teeth better and more frequently (based on the scale by Marin, Lee & Yang, 2004). Given the young age and limited reading skills of the target audience, existing scales were simplified into one item, 4 point Likert scales. A few days after the experiment, the parents of each participant received a survey asking them to indicate on a 5-point scale (never – very often) whether they have noticed any increased engagement concerning dental hygiene with their child (‘Since the study, is your child more consciously engaged with his or her dental care?’), or any improvement in their dental care (‘Since the study, does the child ask to brush his or her teeth more often than before?’).
To test the first two hypotheses, the results of the children who played the game before attending the lesson are compared to those of the children who did not play the game (control group). Independent t-tests show that children from the combined condition (game + lesson) pay significantly more attention to the lesson (M= 3.73) than children who only attend the (longer version of the) lesson (M = 3.34, t(60)= 2.750, p = .008). This shows that integrating a game into the lesson can increase the amount of attention children pay to this lesson, supporting H1. However, the results show no difference in children’s intention to improve their dental hygiene between the combined condition (M = 2.73) and children who only attended a lesson (M= 2.60, t(58)= 1.344, p = .185). H2 is not supported. A follow-up survey conducted among the parents reveals that children from the combined condition showed more conscious engagement with their dental hygiene (M= 3.33) than children from the control group (M= 2.47; p = .034). However, there appears to be no difference in the amount of behavioral change parents had noticed between these two groups (p = .138).
To test the third and fourth hypotheses, the results of the children who played the game before the lesson were compared to those of the children who played the ← 175 | 176 → game after attending the lesson. The results show that when the game is played before the lesson, children paid more attention to this lesson (M = 3.73) than when it is not preceded by game-play (M= 3.48, t(67)= 1.945, p = .056). This supports H3. Further, children’s intention to improve their dental care is significantly higher when the educational game is played before the lesson (M= 2.73), than when it is played afterwards (M= 2.48 t(66)= 2.579, p = .012). H4 is supported. Furthermore, the results of the follow-up survey show that parents noticed a higher increase in both children’s engagement (p= .003) and their dental care (p= .029) in the game-lesson compared to the lesson-game condition.
Conclusion: what is the use of games in traditional education?
When it comes to the debate of the educational role of digital games, both ardent proponents and techno-cynics can be found. While some argue that shifting our current educational system towards a more digital approach is necessary, others describe this notion of digital natives or “new millennium learners” who need to be approached with renewed educational formats as overrated and unrealistic (Bennett, Maton & Kervin, 2008). As to date, empirical research on the explicit integration of games into the in-class pedagogical process is lacking, the goal of the present study was to shed light on whether games should be used and how they can be implemented in traditional school-based health education, in order to increase children’s motivation to adjust their behavior and reconnect them with traditional health education programs at school.
The present study contributes to the literature on game-based learning in several ways. First, the results show that integrating a serious game into a traditional classroom lesson does not improve children’s intention to adjust their behavior in a favorable way. However, implementing computer games in the classroom does appear to be an effective tool to increase children’s classroom attention. This suggests that although games could potentially be an effective way to reconnect today’s children with the educational system, it does not directly lead to behavior change. This is in line with previous research which suggests that games may be very appealing to children, but may also distract children from learning (Jaruratanasirikul, Wongwaitaweewong & Sangsupawanich, 2009).
Second, when educational games are integrated in traditional education, this study provides a first step towards a practical guideline for educators on how to best implement computer games in the classroom. The results reveal that games are better played before the lesson than afterwards. This way, through recency effects, the last presented information generates a strong learning effect, generating ← 176 | 177 → interest in the topic and making children pay better attention to the subsequent lesson, which even results in a higher behavioral intention. Consequently, these results provide a guideline for those digital immigrants (teachers) who wish to integrate serious games into their traditional teaching methods.
In sum, this study provides some evidence in support of a more nuanced interpretation of the popular assumption that games are indispensable tools in the current educational system. The results show that digital games can provide an additional value, but they are not essential or omnipotent as educational tools. Although children seem to be attracted by the game, and integrating a game in the educational program has the power to increase children’s classroom attention, the results show that in domains like health education where actual behavioral changes are pursued, the transfer from game to behavior change is neither automatic nor guaranteed.
Finally, we end this chapter with some directions and suggestions for further research. First, it would be interesting to investigate the effect of these games after repeated exposure, since repetition could affect both learning and attention once the players get more confident with the game. Secondly, further research could, for example, use recall methods to measure attention in addition to the self-reported measures used in this study. Finally, as not all games will be equally effective at all levels of learning, further research should look into different types of serious games discussing different educational topics.
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