Can lives be saved by stories, games and apps?

* This article originally appeared in the Winter 2013 edition of the "USC Annenberg Agenda" magazine, which is available online . *

By Andrea Richards

In the late 1980s when USC Annenberg Professor Lynn Miller began researching ways to reduce the risk-taking behaviors that lead to HIV infection among men who had sex with men (MSM), she had a revelation while reviewing interviews: “I listened to the tapes and it became obvious to me that we weren’t factoring in the heavily contextualized factors―smells, tastes, sights—that were automatically activating decisions for people and leading them down a road to risk. Sensory perceptions played a huge role in decision making.” At the time, most interventions into at-risk behaviors were based on cognitive learning, teaching skill components such as condom use. From her studies, Miller saw the need for a different approach―one that took into account the emotionally charged context and the fact that “it wasn’t a single decision, but a sequence.” “That’s where I came up with the interactive video,” she says, “I wanted to get inside the head of the person making the decisions.”

Miller’s idea was to develop an interactive video game that would serve as a narrative-based intervention, simulating the actual choice scenarios people faced and showing them the points where risky decisions are made. In this virtual environment, users choose how the narrative proceeds, and when a risky choice is made there’s an interruption―a virtual future self that shows the possible repercussions of the choice.

Technologically, it was an idea ahead of its time; the interactive video game itself was an innovative concept, much less the use of one for a major public health concern. But thanks to almost two decades of research and development and many grants, including a five-year, $3.475 million dollar grant from the National Institute of Mental Health (NIMH) that Miller received in 2008, the fully realized 3D animated computer game called SOLVE IT is being studied in national testing. Improvements in digital technology not only permit the game’s intelligent agents to be more complex within the game, it also permits more rapid dissemination of the game via the Internet.

Investigating the Role of Narrative

The effectiveness of the game relies on its ability to immerse the user and relay a simulacrum of the situations and choices they encounter in life. “A huge amount of formative science goes into designing the game environment,” says Miller. “Just because it’s a game doesn’t mean it’s going to be successful—you’ve got to get it right. You have to leverage the capability of the game to create an intervention effective for the target population.”

Quick! Help App

That capability is at least partially reliant on the strength of its narrative―a take as innovative as its medium in health communications. “Narrative scenarios and choices have not been the predominate paradigm,” says Miller. Her USC Annenberg colleague, Professor Sheila Murphy, whose NIH-funded grant “Transforming Cancer Knowledge, Attitudes and Behavior through Narrative” highlights the power of narrative in health-related communications, concurs: “When it comes time to craft health messages designed to convey crucial, potentially life saving health information, Western medicine all but ignores the use of narrative.”

Awarded a prestigious five-year Transformative RO1 grant from the National Cancer Institute, Murphy and Co-Principal Investigator (PI) Lourdes-Baezconde Garbanati (USC Keck School of Medicine) test whether using a narrative format to convey health information produces a stronger and more sustained impact. To do so, their team produced two short films containing the same key facts about cervical cancer. Results show the narrative film, “The Tamale Lesson” more effective than the non-narrative (titled “It’s Time”) in increasing knowledge about cervical cancer–and an increase in the cervical cancer screening rates. The data also revealed that among The Tamale Lesson’s audience the usual ethnic disparity in cervical cancer screening rates was erased.

Murphy’s films, like Miller’s video game, were carefully created to address key demographic factors of her audience so as to foster identification with the characters and engagement with the story. The Tamale Lesson uses a Mexican American family’s preparations for their daughter’s quinceañera as the narrative vehicle. Murphy writes that the positive results “call for a re-examination of the prevailing ‘one-size-fits-all’ assumption that guides most health messages…Although this research focuses on cervical cancer, our results have clear implications for virtually all health communication.” The American Public Health Association awarded The Tamale Lesson its 2013 Public Health Education and Health Promotion Contest Award.

Using Technology to Reach Underserved Communities

Murphy is also currently working (with Co-PI, USC Annenberg’s Sandra Ball-Rokeach) on a second NIH-funded grant that looks at health-related storytelling and the factors that inhibit or facilitate health communication in the social networks of Hispanic women in Los Angeles. By identifying and mapping the assets within specific communities, Murphy hopes to identify individual, interpersonal and community level factors both in isolation and as a system, so that practitioners and researchers can explore a multilevel approach to cervical cancer prevention and health communication in general. “We are looking for hot spots―and asking why do some communities have better communication about health-related information?” Murphy explains.

According to Margaret McLaughlin, Professor of Communication and Associate Dean for Faculty Affairs and Research at Annenberg, Murphy and Millers’ projects are “typical of the type of grant-funded research projects Annenberg professors do here, that investigate health promotion and literacy among underserved communities,” and “use technology to reach multi-ethnic communities.”

"SOLVE IT" game screenshot

Yet another example that combines the use of new technology with an underserved community is a smartphone app designed to help low-income families utilize fresh produce from food banks and food-assistance programs. Called “Quick! Help for Meals,” the app’s development is the result of research USC Annenberg Professor Peter Clarke and Research Scientist Susan Evans.

Their work, supported by a grant from the National Institute of Food and Agriculture, is entitled “Fighting Obesity among Low-Income 9-14 Year Olds: A Home-Based Intervention Using Mobile Phones to Deliver Customized Nutrition Outreach.” Clarke and Evans have collaborated for more than two decades with food assistance programs, work that has proved instrumental in helping food banks distribute fresh produce alongside the carbo-heavy pantry staples like breakfast cereal and cookies (thanks largely to their efforts nearly one billion pounds of produce is distributed a year).

Pleased that healthier fare has become available, the researchers noticed a new concern: “The rub though is that so many people don’t know what to do with some of the produce they are receiving either due to lack of time or cooking skills or both,” Evans explains. “So here you have a group of very determined people who are grateful to have received this food and don’t want to waste it. Plus, they are really interested in feeding their children the most nutritious way possible. But, often, they simply don’t know how.”

Ergo, their idea for an app that can create customized recipe selections and tips (nearly three hundred recipes and seventy “Secrets to Better Eating” are included in the app’s current incarnation) for each client, allowing the user to enter relevant data about food preferences, cooking methods, and available cooking equipment in their home. Tests thus far prove that the app makes a difference―the amount of fresh vegetables consumed in low-income households increases dramatically. With more than a third of food assistance recipients owning smartphones (and that number is expected to grow), Quick! Help for Meals could change users’ eating habits. Along with being able to select recipes and learn tips for food preparation, storage, and presentation, the app allows users to order print copies that can be picked up at the community food bank―or email recipes to friends. Not only does such social messaging help spread healthy eating habits, studies also show the user is more likely to prepare a recipe he or she has given someone else.

While new technology makes this practical tool to combat obesity easier to disseminate and use, Clarke cautions, “It’s a mistake to be beguiled by the technology. If you don’t follow through by implementing it with content people can really use, what is to gain?” Clarke, Evans and their research team spent time developing the content so that it is responsive to low-income people’s needs. Recipes forgo items like expensive spices and keep ingredient demands simple, incorporate time saving techniques and convey innovative uses of old standbys (tortilla broccoli pizzas, sweet potato smoothies). Perhaps it is the carefully calculated balance and precision between the project’s medium and its message that allows the app to work as an effective health intervention―and a profound example of the possibilities new technologies offer, provided they are grounded in narratives, stories, and even foods, relevant to real communities.

* See the digital version of the "USC Annenberg Agenda" magazine here . Stay tuned for more Agenda articles being released online this month. *