Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Dr. Nick Bowman, who is Associate Professor in the College of Media and Communication at Texas Tech University.

He has published over 80 peer-reviewed manuscripts on the uses and effects of video games and other interactive media.

Nick is the incoming editor of the Journal of Media Psychology and completed a Fulbright program in Taiwan studying persuasive applications of virtual reality.

I was introduced to Nick from Sandi Smith, who is a colleague of mine and on a panel at PCORI, or Patient-Centered Outcomes Research. At a recent meeting, Sandi spoke about the power of online games and how they’re increasingly being used to communicate about health. I was really intrigued and wanted to learn more. Happily, Sandi introduced me to Nick.

Nick, welcome to Health Literacy Out Loud.

Dr. Nick Bowman: Hey. Thanks for having me this morning.

Helen Osborne: Online games as a tool for health communication. I want to go into this with my set of biases and assumptions. When I think of online games, I think of that shoot-‘em-up stuff where you get the right target and it explodes. That’s all I think of. I’m thinking, “This is not my demographic.”

Tell us more. Is that what online games are, or is there more to it than that?

Dr. Nick Bowman: This is a really interesting conversation to have because it’s one that I have often. When we think of a video game in society, we think of exactly what you just said: kids with guns shooting other kids. And then we have to deal with the fallout and consequences of that.

What we see when we think about video games, as somebody who studies interactive media, is yes, of course, that is a type of video game. But gaming is so much more broad than that.

In many ways, to have a game, what you need are a set of rules and some kind of goal or outcome.

Helen Osborne: Rules and goals. Okay.

Dr. Nick Bowman: Rules and goals, yes. When you think about that activity, certainly the shooter has rules and goals. You have to stay within a certain arena, you have to have a gun and that person has to get hit by your gun.

But then you think about things like chess, poker or bridge.

Helen Osborne: Really?

Dr. Nick Bowman: Absolutely.

Helen Osborne: You just got my sweet spot here. You mentioned bridge. I just have to tell you I spend enormous amounts of time playing online bridge. How is online bridge, poker, chess or any of those kinds of things I can relate to similar to that shoot-‘em-up game? They seem very disparate. I know you said they both have rules and goals, but tell us more.

Dr. Nick Bowman: Absolutely. When you’re playing these games, you’re solving a puzzle. Whether it’s figuring out or trying to intuit or realize your opponent’s hand, or whether it’s trying to figure out or intuit how your opponent is going to move around a battlefield so you can get the cleanest shot, they’re a very similar activity. The brain in many ways processes them very similarly.

Helen Osborne: Really?

Dr. Nick Bowman: Absolutely. Not to mention your emotional reactions and the conversations you have around those things.

There’s an old film term called a McGuffin. From “The Maltese Falcon,” the Maltese Falcon isn’t important. It’s just that it has to exist for the movie to exist. Without the Falcon, there’s no movie.

The Falcon could be anything. It could be a dog bone. In many ways, the video game is a McGuffin. It’s the thing that gets you to act, think, feel or talk to other people. In that way, they’re weirdly common.

I actually bet that if you were to talk to a gamer, at some level, you could discuss mechanics, controllers and social interactions. You may be doing different things, but that’s where they’re remarkably similar.

Helen Osborne: Wow. You got me at the word puzzle, too. I am an indeed a puzzle person. In ways, I think health literacy is a puzzle. We have this whole mish-mosh of very complicated health information and the puzzle is “How do we do it clearly and simply?” That’s probably one reason that it has intrigued me for as long as it has. I indeed am a puzzle person.

Thanks for making clearer what games are and the broad scope of what they include. What are the benefits? How do they help people to do these things?

Dr. Nick Bowman: In talking about the benefits, I always acknowledge that with any type of media content, there can always be content-based consequences, like aggression and things that are associated with seeing certain images and things of that nature. But that’s not all these games are.

Once we make that connection between not all games are war-like battle games, then we start to think, “Why do folks do this? Why do folks play these games?” From a functional perspective, we would argue it’s because they do something for us.

I can point to three areas of research where games seem to be very beneficial. One of them is stress management and emotional regulation, one of them is cognitive abilities and then one of them would be socializing. These are the three areas across different kinds of games.

Helen Osborne: I’m taking notes as you’re talking about it. I want to go through each of them. That’s why I noted them there.

Stress management and our emotional regulation, our cognitive skills and socialization. Curious how we can do that through using this interactive technology.

Take it from the top. Tell us about stress management.

Dr. Nick Bowman: The stress management part is an interesting set of studies where we look at what people do when they’re experiencing noxious mood states, mood states that are damaging their ability to be mentally healthy, to perform or to be comfortable.

Stress, of course, is one of the most commonly occurring noxious mood states, those things that prevent us from being who we want to be.

Video games can help us deal with stress because they have a property that very few other media do. They’re remarkably absorbing.

To play a video game, whether you’re going through bridge hands or going across the beaches of Normandy, you’ve got to pay attention. You’ve got to process the information and think about your opponents, do strategy and basically take a bunch of mental notes. Frankly, it’s hard to do that and then also be stressed at the same time.

Helen Osborne: Nick, as you’re describing this, I’m realizing when I am doing these games that I am so focused on it, I don’t think my body moves. I often end up with a crick in my neck because I’ve probably been in the same position for a while, more than I realize. It’s kind of like I’m in another bubble. That’s what you’re talking about, that experience?

Dr. Nick Bowman: Absolutely. In fact, in my dissertation work, that’s how I met Sandi Smith, at Michigan State. I studied the use of video games as a mood management tool. The idea being you’re in a bad mood, and for mine, it was either being frustrated or bored. Video games require so many of our physical, mental and even emotional resources.

Unlike other forms of media, with a video game, you have to actually do things, and you have to do things constantly. If you don’t, the game doesn’t work. If you just sit there and watch the screen, nothing will happen.

The argument from the stress management area is it’s not so much escapism. It’s not just you’re distracting yourself. It’s more than that. It’s you’re actually having to work your mind through different puzzles.

My colleague, Leonard Reinecke, talks about this in terms of recovery experiences. You’re sort of giving yourself energy, essentially. You’re pulling all these resources, you’re working through these problems, you end up being maybe successful and then by the time the game is over, the stressor is gone.

Helen Osborne: Nick, I am coming up with all these stories of my experience and people I hang around with online that relates to all this. I am 100% in agreement. I am living that experience.

Let’s move on to the cognition part.

Dr. Nick Bowman: One of the things about video games, if we continue on that vein of thinking that they’re incredibly absorbing and intentionally heavy experiences, the way our brains and cognitive faculties work is they’re trying to constantly make sense of all of that information.

It turns out, as many people know, and I’m sure your listeners are aware of this, the brain’s mental networks are very much like the muscles in your legs and arms. As you work them, they get stronger, and as you don’t work them, they get weaker. The brain “rewires” itself depending on what you’re using it for.

Video games require visual attention and mental rotation. You’re looking at a screen that’s two-dimensional, and often the things you’re thinking about are three-dimensional.

They require working memory. How do I remember the thing I saw five minutes ago and store that in my working memory so I can have it five minutes later?

When you start engaging all those systems and processes, we find that overall the effects are relatively strong. We’ve seen this in study after study.

I think in 2018 there was a piece published in Frontiers in Psychology where they had done a meta analysis of all the past research on gaming and cognition. They found overall positive effects, and not only for custom-made games that are designed to work your memory, but even for just games you would buy off the shelf at Walmart.

Again, they all have that element in common. Most games require your attention, working memory and visual acuity. Whether you realize it or not, you’re practicing those muscles. You may not sweat after doing it, but you do find that your attention increases.

Helen Osborne: That’s interesting. Until talking with you, I didn’t realize that we actually had anything in common. With all the hours I spend doing this stuff, and thinking you do something else and that’s nice and I’ll do a podcast on it, I didn’t realize we were talking about the same thing.

You talked about it’s two-dimensional. Yes, it is on a screen. The ones I’m involved with also have a sound. I don’t want to bore people. I keep going back to the same thing. But for my bridge, you can hear the shuffling of cards. It has timing in it. If you wait too long, you get kicked off.

There are many other elements. It’s visual. There are different pieces you can be doing. Yes, it’s multi-layered in there.

Let’s move on to the socialization. I know how I do it. It’s just me in front of a computer and I’m alone while I’m doing that. What’s the socialization piece?

Dr. Nick Bowman: This is the one I get excited about, because I think the stereotype of the gamer in a way is what you talked about. It’s the kid in their basement all by themselves with the curtains closed playing video games and they’re not talking to anybody.

Except there are two problems with that. One of them is if you look at the history of video games, they’ve been social from the beginning. The very first games had more than one player.

The reason was very simple: There wasn’t enough computing memory to actually have a computer component. You had to have two people or you wouldn’t have a video game, so early games had two players.

Then the public arcades and finding games in bars and arcades. Those are very social spaces. Those are places where kids socialize while playing games. Home consoles have controllers that have multiple players.

But the big one for us, I think, is online play. When the ’90s hit and communication technology accelerates to allow us to communicate through our desktop computers, all of a sudden video gaming changed.

I plug in my copy of a video game and I plug my phone line into the back of my computer, and I go to this DOS prompt and type in the address I want to go play at. All of a sudden, I’m playing with a human. That person is talking back to me and we’re having a conversation, and I’ve never met this person.

Helen Osborne: Through typing or something? Like Words with Friends, you can communicate.

Dr. Nick Bowman: Yes. Then going further, we have games like World of Warcraft where the entire game takes place online. You log in to a server, and then there’s a world of planets. Your character is on that planet with thousands of other people doing the exact same thing at the same time.

You’re walking around, playing this game and talking to each other. You’re talking about both the world, like, “Hey, where do I find this weapon or this quest?” or whatever the game language is, but then you’re saying, “Also, how is the weather in Myanmar?” or, “Hey, I heard your sister got married.”

The games became these intensely social places, because funny enough, humans are social critters.

Helen Osborne: That’s interesting.

Dr. Nick Bowman: We can’t help but have conversations. As we leak information about ourselves, other people pick it up. Before you know it, you have these things called guilds where people go online and the game is the world that they play in, but they spend as much time talking to each other about life as they do playing the video game itself.

Helen Osborne: That’s really interesting. I’m envisioning what those circles are that overlap in there. Then I’m seeing that overlapping part.

I’ve got a bunch of questions. My first question really was in the beginning, and I realize it’s happening to me, too. You talk about all the many benefits. I’m there. I got it. Yay. But what about the downside?

For me, I’m finding it actually feels addictive. I keep saying, “One more game. One more this and that,” and my whole evening has been gonzo and I’m not reading my book like I meant to do. What about the addictive property?

Dr. Nick Bowman: There’s an interesting double-edged sword here. A lot of psychologists refer to what you’re talking about as a flow state, where you’re engaging in an intrinsically motivating activity to where the challenges that the activity provides you are equally matched to your skill. The result of that is this self-perpetuating situation to where the benefit you’re getting is the experience itself.

Of course, the drawback to that could be all of a sudden five hours have passed. You think, “What just happened to my evening? I sat down to play this video game and now it’s 1:00 in the morning.”

Those happen a lot, frankly. It’s a weird scenario because there’s a psychological benefit of actually experiencing the flow state. But then there’s a psychological detriment of feeling guilty that you just spent all this time doing this thing, or you didn’t get to consume something else.

The work on addiction is a bit rough because there are a lot of fights in the field over “What does it even mean to say we’re addicted to a game in the first place?”

Part of that is because all those things I mentioned earlier, socializing, cognitive skills and stress management, we don’t know which ones are causing people to play too much.

Are they going to a game because their friends are there and, of course, they just can’t get enough of that? Or are they going to the game because the game is programmed in a way to kind of trick them into keep playing over and over again?

That being said, there is literature on this. The way it’s commonly understood is that gaming addiction takes place when video games take the place of other activities to your own detriment.

It’s a concern. I think what many people do at the extreme level is they will put actual timers and locks on their games themselves. On some video game consoles, you can literally set a timer, and after two hours it shuts off.

Helen Osborne: Interesting. I say to myself, “I’m just going to do one more thing. One more and I’m done.”

Dr. Nick Bowman: “I’m going to play until noon and then I’m out of here.”

Helen Osborne: What I really want to get to is who does this include and exclude? As you know, the focus of this podcast and the focus of much of the work and the reason I am in touch with Sandi Smith has to do with communicating about health. I wonder who this includes and excludes.

Thinking about people who we’re more concerned about health literacy, they are disproportionately affected. They may not have strong reading skills or equal access to technology. They might be way skewed at a different end of this spectrum for age or come from other cultures. How inclusive are these games and how much do they exclude?

Dr. Nick Bowman: This has been a fascinating conversation to watch unfold in the gaming industry. If you look at just the industry numbers as to who’s playing and how often, you see that about 70% of Americans play video games. You see that the average age of a gamer is about 33 years old, and it’s pretty evenly split between male and female.

On the surface, that seems to imply that a lot of people are gaming across the demographic spectrums.

When we go into minority communities, you can find that gaming rates can even be a little higher. One reason that’s been given for that is they are a relatively affordable mode of entertainment. If you think about the “bang for your buck,” if you will, a gaming console can provide hundreds of hours of entertainment.

The good news is if you look at who’s playing, it seems to spread pretty fairly across different demographics. I think the bad news is that’s not how we socially construe video games. We tend to think of games as for kids. That somewhat limits how we think about inclusivity and other elements.

For example, if all the content in the video game is designed to make 21-year-olds scream and holler, it’s probably going to cut off people who are older who don’t want to see that content.

My grandfathers do not want to play Call of Duty. They don’t want to play a war game. They experienced war. They’re not going back to that.

Over the last couple years, you’ve seen the development of games to start to recognize how diverse the gaming populations are. The growth of puzzle games, casual games, the match three colors games. Board games and card games are very popular.

Systems like the Nintendo Switch, which is both a system you can put into your TV at home but you can also hold it in your hand, and you can have it all online but you don’t have to have it online, tend to overcome all the technical barriers.

Helen Osborne: When you talk about the puzzles there, I think of jigsaw puzzles. People who are probably uncomfortable with online a little bit, but sometimes that’s all we have to be working with, I think they’re going from a place of familiarity and branching out from that.

Nick, I’m wowed I’m on your side. Please keep going and doing your research. Can we just address a little bit about how games are being used as a tool of health communication?

Dr. Nick Bowman: Definitely. There are a couple areas there that are very interesting. I think the most common one is going to be what’s called the exercise game. It’s the game that requires you to physically move. You stand up, grab a controller and exercise with it, whether it’s a golf swing, tennis swing, bowling ball, stretching your arms or things like that.

These became immensely popular in the early 2000s with the Nintendo Wii. One of the things that we saw was that system was placed in a lot of retirement communities to keep people active and keep them moving. It was a very simple game. You hold a wand with two buttons on it, and then you move your arms.

You may have heard the stories of a game called Dance Dance Revolution where kids would go to the mall and dance on a pad for hours drenched in sweat.

Helen Osborne: I did see that at our mall, kids fooling around.

Dr. Nick Bowman: It’s amazing.

Helen Osborne: Bring us up to today. How are games being used? We’ve got a world of health information we want to communicate and get it to a broad population.

Dr. Nick Bowman: Now where we’re going is using games to message health campaigns, so the anti-smoking video game, the anti-drinking video game and the fitness video game.

There was a game in the ’90s where people would learn about juvenile diabetes on their Nintendo because the character had diabetes and you had to treat him as you played the game.

The newest one, though, and the most exciting one, I think it was earlier this month . . .

Helen Osborne: We’re recording this in 2020 and in the middle of the COVID epidemic. Just putting this into context.

Dr. Nick Bowman: Sure. The Food and Drug Administration, the FDA, approved the first digital prescription, which is a video game designed to treat ADHD.

Helen Osborne: Attention deficit hyperactive disorder.

Dr. Nick Bowman: That’s right. It’s fantastic. It’s a recognition that there is a lot of discussion in, I think, Western medicine about the extent of which we rely on medications and treating symptoms versus underlying conditions and problems. There’s a recognition that activity and action, whether it’s moving the brain or moving the body, those things matter.

The ADHD game takes all the things we said in the beginning of the podcast, like absorption potential and cognitive attention, and draws those things into an experience to where a child who suffers from an inability to focus has to focus on the video game to treat their ADHD. It brings it all together.

Helen Osborne: Wow. That went farther even than I expected. Hearing about diabetes and what to do and going down the journey, that kind of stuff is what I expected. I did not expect that games would actually be an intervention and a treatment.

Nick, this is so exciting. I am learning so much from talking with you. I hope our listeners are, too.

I hope what listeners will take away from this is an enthusiasm and an appreciation, like I have, that there are new and exciting tools out there for health communication. Move beyond our bias of what we think they are to really what they are doing.

Thank you so much for doing your research and your publications and all you’re doing to broaden this world for all of us. And of course, for being a guest on Health Literacy Out Loud.

Dr. Nick Bowman: It was a real pleasure to be on today. This was a fantastic conversation. Next time you see that game section at the store, just take five minutes and walk through it.

Helen Osborne: I will. I’ll think of you. Thanks, Nick.

As we just heard from Professor Nick Bowman, it’s important to communicate in a wide variety of ways and appreciate the potential of tools that we didn’t even think were about us or our audience.

Communicating health information clearly is not always easy. For some help, take a look at my book Health Literacy from A to Z. You might be especially interested in Chapter 36, “Technology: Interactive Media.”

Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

Health Literacy Out Loud podcasts come out every few weeks. You can get all the episodes automatically, for free, by subscribing at www.HealthLiteracyOutLoud.com. You can also find us in Apple Podcasts, Google Play, Spotify, iHeartRadio, RadioPublic, Stitcher and probably all the other places you get podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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