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Abstract
Stories in all of their many forms, including books, plays, skits, movies, poems, and songs, appeal to individuals of all ages but especially the young. Children are easily engaged in stories, and today's generation of children, the millennium generation, demands interactive, multimedia-rich environments. Story as a teaching and learning technique is pervasive in the classroom but is infrequently used to promote health. Because of advancing technology, it is possible to create interactive digital storytelling programs that teach children health topics. Using digital storytelling in an interactive environment to promote health has not been tested, but there is empirical support for using story in health education and interactive technology to promote health. This article briefly reviews the literature and discusses how technology and storytelling can be joined to promote positive health outcomes.
Mrs Hall, the school nurse, knew that Karen was embarrassed about having asthma because she always hid her inhaler and never disclosed information about her asthma to teachers or classmates. Mrs Hall realized that having asthma could be psychologically difficult. She recalled finding a digital story about asthma on the Internet, so she invited Karen to the clinic to review the digital story. As Karen began watching the screen, she heard fun music and saw dancing objects on the screen. Karen sat staring at the screen in anticipation. A story unfolded about a girl with asthma. Only this story was different. It had words like a book and cartoon characters that moved with music like a movie. Karen quickly discovered that the story was about living with asthma. Sometimes the story prompted Karen to click on objects to learn more. After the story, Karen made her own story about having asthma by adding text and filling in boxes. Karen played her story and printed it so that she could remember making her first computer story. Karen thanked Mrs Hall and said, "I am glad that I came to the clinic. I know it is important for me to take care of myself, and sometimes that means telling my teachers and friends about having asthma. Can I show this story to my friends?"
The above scenario depicts typical feelings of children with health problems, and it also presents a novel approach to health education for children. Digital stories, or living books, are a unique and creative teaching strategy to present information by using multiple media components such as text, images, and animation to engage the reader in a computerized vivid presentation of the content. Once a story is written, it is converted to a digital format using an assortment of software and stored on a personal computer or a CD or published on the Internet. Digital stories can be as simple as a page of words with images that correspond to text in a story or as sophisticated as animated movies that engage the reader with interactive buttons and icons.
Digital stories are being used by business organizations for marketing purposes, in primary schools to teach literature, and by individuals who are interested in telling their personal family stories in a creative format. Digital stories are an excellent medium for promoting health and teaching children about how to manage chronic illnesses because children become easily engaged in stories and interactive information. This article presents a brief review of literature that supports the use of story for health education and shows how stories can be combined with interactive technology to create digital stories that promote health.
USING STORIES FOR HEALTH
Story, in the form of storytelling or story writing, has long been used as a teaching tool in health education for children. Story has been used to teach children about food choices, first aid, alcohol, self-esteem, disease, and healthy lifestyles1-8 and integrated into coloring books9 and electronic media to create electronic books.10,11 Not until recently have researchers tested story methods to deliver health information. For example, Werle12 implemented a storytelling program to teach 13 middle school students in the eighth grade about violence. Over a 6-week period, students listened to four stories that were approximately 50 minutes in length. After each story, students were instructed to respond in writing to open-ended questions. The researcher concluded that using storytelling methods to present information about violence encouraged students to explore their own feelings about the topic.
Children in Australia are learning about nutrition through a Web-based storytelling interactive site.13 During 2003, the site was evaluated using an online survey to determine the children's satisfaction with the Web site. The 1349 participants of this study were fourth-grade students, of whom 51% were boys. Overwhelmingly, children "liked" the Web site (87%) and preferred the games on the site, followed by the stories, to all other activities on the site.
Bers et al14 developed and examined the effects of a three-dimensional (3D) multiuser computer program that allowed children to create health-related stories and role-play with other users through virtual characters. The 3D program, called Zora (Epistemology &Learning Group at the Massachusetts Institute of Technology Media Laboratory, Cambridge, MA), was accessible to seven adolescent children in a hospital dialysis unit for 5 months. Data from the interviews were analyzed using an ethnographic approach, and it was determined that the overall subjects were satisfied with Zora. Interestingly, none of the children discussed renal disease in the health-related stories that they created with Zora.
Stories are also used for therapeutic purposes to teach children appropriate social behavior and to engage children in moral lessons. Bibliotherapy is the use of stories that address problems or issues that parallel the reader's experiences.15 Using this technique to teach social and health-related behaviors is believed to be useful because children often possess rigid or concrete thinking styles and adhere to rules and routines, such as those presented in stories.16 Bibliotherapy has been tested in children with nonspecific developmental disorders, learning disabilities, and autism.16-23 In all instances, stories presented social situations and a desired behavior such as hand-washing. To reinforce the lessons in the story, Scattone et al23 had children read the story aloud before engaging in the desired behavior. Crozier and Ticani19 used a similar technique to reinforce desired behaviors, but instead of having children read the entire story, they created prompts and reminders. Collectively, using stories to teach developmentally disabled children learning and social behaviors yielded increased desirable behaviors.
Writing or telling one's own story may also promote health and well-being in children, but far less is documented on this technique as an intervention. Story writing has been used to collect data from children,24 but the act of composing a story, especially one that represents real-life experiences, may benefit the child. According to Bruner,25 individuals make sense of their lives through lived experiences that are organized in a story format. This is well demonstrated in children's personal stories. In early preschool age, children craft stories that are personal narratives with one or two characters that include familiar experiences or routines from daily life. By the time children are 5 or 6 years of age, they tell or draw make-believe stories, but often their stories include real-life situations.26 Telling or writing a story of one's personal experiences, known as narrative, has been combined with psychotherapy to help children with emotional needs.27-29 Often, children identify their own emotions through the process of telling, writing, or drawing their stories. These methods of intervention have not been examined in controlled-experimental trials, but reports of case studies indicate that a child's narrative may reveal facts and emotions pertinent to therapy.
Chandler30 used story writing to promote self-esteem and self-efficacy in adolescents. A creative writing program was organized that encouraged its 11 adolescent participants to write freely about events and circumstances based on health-related scenarios without regard to grammar or writing style. Overall, themes in stories included (1) recall of events, (2) exploration of feelings and emotions, and (3) new ideas. On the basis of a midpoint and postintervention survey, the participants liked writing about themselves and expressing their feelings, and they demonstrated self-efficacy behaviors through four sources: performance accomplishment, vicarious experience, verbal persuasion, and emotional arousal.
Story writing has also been used as an intervention in children with communication disorders resulting from emotional disturbances. Montgomery and Kahn31 reported several case studies of emotionally disturbed adolescents who wrote stories to improve oral and written communication. All four adolescents improved their language skills, and the authors speculate that by writing life stories, these adolescents became more capable of handling social complexities in their lives, including their contacts with peers and authority figures.
Stories have been used for centuries to share wisdom and knowledge from one generation to the next, but they have not been thoroughly explored as a delivery method for promoting health and well-being in children, especially story writing as an intervention. Furthermore, innovative ways to create and deliver stories have been minimally explored. With advancing interactive technology, it is possible to create multimedia books, or digital stories, that engage children in the story, arouse multiple senses, and allow children to write their own stories in a digital format.
COMBINING STORIES WITH TECHNOLOGY
Technology has the ability to deliver content using multiple modalities such as text, narration, motion picture, graphics, and sound. This is important because today's children, digital natives of the millennium generation (born during the information age), are accustomed to learning and access to information in rich audiovisual environments.32 Various interactive applications are used in health education, and the values in these environments, such as those in digital stories, are their potential to simulate activities that resemble direct experiences. Simulated environments potentially can personalize experience, emphasize individual responsibility, and promote knowledge and skill acquisition.6 By presenting material in multiple media, a learner constructs visual, verbal, and sometimes auditory representations of the material, which, according to Mayer,32 enhances learning.
Dana Atchley and Joe Lambert, founders of the Center for Digital Storytelling at the University of California, Berkeley, recognized the power of combining stories and technology as early as the 1990s. Although the goal of the center was simply to promote digital storytelling, it has profoundly influenced digital storytelling in multiple arenas, including industry and education, by teaching thousands of individuals how to create digital stories. The center is documented in just about every source on digital storytelling, including sources from Australia and the United Kingdom. For example, the Multimedia, Education and Narrative Organisation (MENO) research group at British Open University used the philosophy and teaching of Atchley and Lambert while evaluating storytelling and narrative in computer-based educational programs.33 Users of digital stories may choose to read the text, view an image of the character, or watch a movie of a character who is acting out the scene. When both visual and verbal modes of information are present, more effective learning can be expected.34 In some cases, readers may interact with the scene and determine the story line by selecting icons or buttons. This promotes active learning, information seeking, and problem solving.34
Several other centers are conducting research on the uses of digital storytelling. The Affective Computing Group in the media lab at Massachusetts Institute of Technology (MIT) has examined the ways technology-based narrative can assist with the development of human emotional intelligence. Daily,35 one of the researchers at MIT, developed software that allowed teenaged girls in the eighth grade to reflect on their emotions by creating pictorial narratives. In this computer program, teens selected images, words, and faces with emotions to build their own digital stories. Teens answered questions prompted by the program that in turn suggested words representing their emotions. The words describing various emotions were generated by ConceptNet (Massachusetts Institute of Technology, Cambridge, MA), a semantic network of commonsense knowledge bases with over 300,000 semistructured English phrases that represent spatial, physical, temporal, and social aspects of everyday life. Teens who used the system gained knowledge and understanding about themselves by writing their personal experiences enhanced with images. By reflecting on life events through expressive writing, individuals had an opportunity to examine thoughts, leading to an awareness of emotional reactions, which may have reduced their emotional distress.
Researchers at the University of Texas at El Paso and the Laboratory for Innovative Technology in Education (LITE) at the University of Houston are conducting research projects to evaluate the effectiveness of digital storytelling. The researchers anticipate findings similar to those of the MENO group at British Open University. More specifically, the LITE research team is collecting data about student learning, motivation, engagement, and teaching practices while using digital storytelling, whereas researchers at the University of Texas at El Paso are examining the use of digital storytelling in elementary and middle school education.36
Digital storytelling is gaining notable attention in K-12 education. Fourth and fifth graders in Lexington, MA, learned writing and technology skills by creating digital stories.37 In Boston, public schools are teaching high school students who are interested in becoming teachers how to develop digital stories for educational purposes.38 Scott County schools in Georgetown, KY, collaborated with Scott public libraries and volunteered in the community to develop a digital storytelling center to be used by any child enrolled in the public school system. Digital storytelling teaching strategies are incorporated into the curricula in multiple ways, and teachers claim the benefits of the center are immeasurable.39
Children who are not introduced to digital storytelling in schools have access to digital stories on the Internet. The Public Library of Charlotte & Mecklenburg County in North Carolina has offered digital stories through an online digital library at http://www.storyplace.org/storyplace.asp since 1999. On the site, children can view, listen, and read digital stories and they can create their own stories. The East of England Broadband Network in partnership with the London Grid for Learning and the South East Grid for Learning offers a comprehensive digital storytelling Web site (http://story.e2bn.org/ ) that allows users to view or submit stories and teaches users how to create digital stories.
Okay with Asthma, another digital story Web site (http://okay-with-asthma.org ), helps teach children about health issues.40 It uses digital story and story writing to present information about living with asthma to school-aged children. Children who visit the site learn ways to live with their asthma by recruiting help from parents, peers, teachers, and coaches and by reviewing the standard medical management of asthma. The digital story is a streamed animation that allows users to advance through scenes or click on various images in the scenes to learn more about asthma. The story includes feelings and emotions that may be associated with having asthma, and the story resolves the conflicts between living happily with asthma versus having negative feelings about asthma. The story also uses music in a familiar school setting with culturally diverse children so that it resonates with many children. The characters in the story are young teens because children emulate older children. After watching the animated story, users can build their own digital story by inserting texts into comic-strip-style scenes. After adding text into all scenes, users can preview and print their digital story. This digital story was pilot tested with 30 children between the ages of 8 and 11 years to determine the effects of the story on their knowledge about asthma and attitude toward having asthma. Children had improvements in asthma knowledge scores 1 week after watching the digital story and writing their own story and sustained their knowledge 2 weeks later. They also had improvements in attitude scores at 2 weeks after watching the digital story and writing their own digital asthma story.
The literature suggests that stories and story writing may be effective methods for teaching and revealing feelings and emotions in individuals. Because of the empirical evidence about story or story writing and advancing technology, digital storytelling should be explored as a method for teaching children health promotion and disease management. To do this, it is necessary to review basic steps for constructing stories suitable for health education and recommend procedures for converting a written story to digital format.
WRITING DIGITAL STORIES
Whether a story is oral, written, or in digital format, it must be well crafted and capture the attention of the audience while conveying a message. Egan,41-43 a leader in the uses of story for learning and education, proposes that readers learn the content of a story while relating to the characters and events. For this reason, well-written stories include characters that readers can relate to and sometimes even admire. In some stories written for a younger audience, animals or inanimate objects are personified. Other stories use characters that appear older than the reader because younger children often emulate and mimic the actions of older children. Regardless of the type of characters, it is through the story itself that the characters are developed while they are conveying the intended message.
In general, stories for children present a conflict or problem at the beginning of the story. In Egan's model for story, the importance of the topic or problem must be established, and this is typically accomplished by presenting binary or opposing concepts, such as a sunny day versus a rainy day. This is not only appealing to children but it also aids in their ability to comprehend the meaning of the concepts.41 Children often understand meanings by comparing a concept to what it is not. For example, cold is not hot and happy is not sad. As the story is revealed, it is organized around the opposing concepts so that the conflict is resolved to its binary opposite. In health-related stories, characters may exhibit unhealthy behaviors and lack knowledge at the beginning of the story but learn healthier behaviors during the story. By the end of the story, the conflict is resolved (ie, unhealthy) and the binary opposite of the concept exists (ie, healthy).
INTERACTIVITY AND MULTIMEDIA IN DIGITAL STORIES
Once a story is developed, it must be repurposed for a digital format. This may take many forms such as a text-based story with still digital images or pictures set to a narrated story stored on a DVD or CD, created as a computer application, or delivered via the Internet. Digital stories may be presented as passive or interactive entertainment, often referred to as "lean back" and "lean forward" experiences.44 A passive or "lean back" digital story presents a story line or movie that requires the user to simply observe or watch, similar to television programs. A "lean forward" story is interactive and requires actions of the reader beyond simply observing or watching. Because children are accustomed to multimedia, digital stories for children often include interactivity and animation. Interactivity, however, may affect the content of the story because by giving the reader a selection of choices, a story may no longer follow a prescribed sequence or fixed order.44 For example, in the most interactive environments, children may be able to create characters, select scenes and story lines, and write their own words in a digital story that reflects a personal story. In a more controlled interactive environment that includes a story with an intended message, children may select characters or click buttons and icons that allow the reader to move characters on a screen, turn pages of a storybook, and click images to learn more about a topic, but the story line remains the same.
A digital story is more engaging for children when it is interactive and multimedia rich with video or audio clips, text, and animation. The risk, however, with extensive interactivity and multimedia is that children become so consumed with manipulating objects and being entertained with the visual elements that the story and message becomes invisible. For this reason, digital story developers should consider a design method whereby elements of the story and interface are tested during its development, instead of testing the story at its completion. This method of evaluation may also save time and money. As a general rule of thumb, the more extensive the interactivity and multimedia, the more costly the digital story and the more time it takes to develop. To minimize the upfront time commitment and costs associated with digital stories, developers are advised to keep digital story interface and design simple initially. Once a digital story is developed and tested, it can be revised and modified adding more interactive and media elements.
Various applications may be used to develop digital stories, and selecting an application is dependent on the type of digital story being developed, the level of interactivity and multimedia, and the way that the digital story will be delivered to children. For example, a more simplistic digital story that uses text and still images may require only a word processing application with imported images. The images can be captured using a digital camera or by scanning photographs to create a digital image. This type of story can be printed or converted to a Web page document and viewed via the Internet. Electronic presentation applications, such as PowerPoint (Microsoft, Redmond, WA), support digital stories that use text, images, and audio clips, which can also be converted to a Web format and viewed on the Internet.
Many public schools teach children how to develop interactive presentations because technology is integrated into most school curricula. By using the software program Hyperstudio (Software MacKiev, Boston, MA), even children in primary schools are learning how to develop sophisticated programs. Hyperstudio, an easy-to-use program developed for K-12 education, allows users to create interactive and animated slide shows by adding text, pictures, sound, and drawings. Because children are learning to create interactive programs, they recognize elements, buttons, icons, or features in a digital story.
Digital stories may also incorporate videos, along with still images, text, and audio clips. A story that uses video requires capturing the scenes using digital video capture or converting analog video into a digital format. Once the video is captured, a video editing application such as iMovie or Final Cut Pro (Apple Computer, Cupertino, CA) allows digital story developers to edit video and add narration, background music and sounds, or still images to combine with video clips. Adding extensive animation and interactivity to a digital story requires more advanced computer skills using programs such as Macromedia Flash or Director (Adobe Systems, San Jose, CA), or using JavaScript coding. This level of complexity typically requires the skill of a graphics designer and/or programmer and, therefore, can become costly. Generally, 1 minute of an animated and interactive scene will cost between $1000 and $3000 to create. Graphic artists and programmers outside the United States often provide services at a cheaper rate. Because of the advancements in telecommunications such as instant messaging, e-mail, and VOIP, it is quite feasible to manage a project with an international team. The digital story developer, however, must consider the limitations of such communication tools and any variance in cultures, especially if the digital story is culture dependent or based on health practices unique to the United States.
EVALUATING DIGITAL STORIES
Methods of evaluation that incorporate testing during development can reduce time and costs, but developing the story in stages and testing it before moving to the next stage often delay the debut of a final product. One such evaluation method, known as rapid prototyping, may identify a poorly crafted story, overzealous interactivity and multimedia components, or problematic interface design before the digital story is completed. All testing and evaluation of the digital story should be based on heuristic methods of evaluation.45 A heuristic method of evaluation is a technique that uses small sets of evaluators to identify usability or design problems in a product. This method helps identify both easy- and difficult-to-fix usability problems on the basis of general principles of interface and design and provides a structure for ranking the importance of the identified problem. The evaluation principles include elements such as user control and freedom, consistency, error prevention, and an aesthetic and minimalist design.45
The following rapid prototyping stages are recommended for a digital story that incorporates more complex design elements and interactivity.
1. Develop the curriculum. Identify the important elements of the topic. Verify the elements of the topic with a content expert.
2. Write a story from curriculum. The story should have compelling characters; use binary opposites that are introduced at the beginning of the story and resolved by the end of the story.
3. Develop a storyboard. The storyboard should represent the entire story, including all scenes, characters, and activities. The storyboard may be a paper version or an electronic version of each scene.
4. Test the storyboard. With a group of children who represent the intended audience, test the storyboard version of the story to ensure that the story is compelling, interesting, and easy to understand, and that the readers learn the intended lessons from the story.
5. Develop mock-ups of the various scenes for the digital story. Develop the visual elements for each different scene of the story, including any modifications based on the storyboard testing, characters, and interactive elements and ensure that each feature functions properly. A health-related story may include scenes such as home, community or school settings, healthcare settings, or one with a group of characters. A more simplistic prototype version of the digital story may also be created.
6. Test the mock-up pages or prototype for usability and interface design. With a group of children who represent the intended audience, test the usability, design, and function of each mock-up page or prototype created. This method of testing should use heuristic methods of evaluation, as previously discussed.
7. Create all scenes and elements of the digital story. Incorporating feedback from the usability and interface testing of the mock-up pages, create all scenes, visual elements, and interactivity built into the digital story.
8. Test the final digital story product. With a group of children who represent the intended audience, test all elements of the digital story, requesting feedback regarding the story itself, usability, interface, and design.
9. Incorporate all feedback from the evaluation and testing sessions Finally, improve the design, function, and features of the completed digital story based on the feedback. Keep in mind, however, that because the digital story was evaluated while being developed, it is likely that the story will require minimal changes and modifications at this stage.
LIMITATIONS OF DIGITAL STORIES
Before embarking on an extensive health-promotion or disease-management program using a complex multimedia-rich and interactive digital story format, there are several issues to consider. First, developing a digital story may require advanced technology skills by the developers. Adequate technology and financial and human resources to develop and sustain the digital story program are essential. This often requires establishing contracts with developers who have not only expertise but also the hardware and software to develop the digital story. The initial expense of creating a digital story is justified if the program is effective and if the digital story is sustainable over time with limited expenses associated with modifications.
It is also important to consider that engaging in a digital story requires the user to possess computer skills, such as being able to use a keyboard and mouse comfortably and being familiar with traditional computer design interface. Today, nearly 100% of public schools in the United States have Internet access, and educational standards require children to be proficient in computer skills.46 Thus, most school-aged children have access to computers, are well versed in computer skills, and therefore can navigate freely through multimedia environments.
Despite limitations, digital stories for health-promotion and disease-management education are a viable option. For example, digital stories may be helpful in teaching children how to deal with feelings associated with grief and loss, being bullied, or ways to change nutritional habits and food choices. Digital stories have great potential for teaching health and management of chronic diseases because they grab children's attention, organize the content in a format that children are accustomed to, and develop a context in which ideas can be developed.
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