1. Application for the Robert Wood Johnson
Foundation: Games to Generate Data Challenge
Zoofit

2. Abstract
Social networking and casual gaming have broadened acceptance and the
market for smartphone games. Engaging, socially fun experiences can
improve people’s behaviours dramatically. Poor diet and physical inactivity
are major factors contributing to poor health and pre-mature deaths. The
core design of this game is a virtual zoo, and the purpose of the game is to
maximize the size of zoo and variety of animals. This is achieved through
adopting healthy lifestyles by encouraging regular walking, recording of
biometric data and visiting parks and recreational areas. This game provides
a novel method of capturing accurate public health data prospectively in real
time; this has not been achieved before. Using a multi-pronged approached combining a smartphone game - to
achieve personal lifestyle change; and social networking - to maintain behavioural change in a social circle; this game
is unique and potentially more effective in driving behaviour change and compliance. Data generated from this game
can be used to inform public health policy to focus resources on target areas leading to lasting improvement in the
population health.
Problem
In the United States (US), it was estimated that nearly 1/5 of all deaths [1] is attributable to poor diet and lack of
physical activity. Whilst we all know better diet and more regular exercise is beneficial, very few of us actually have
sufficient exercise and consume the recommended daily amount of fruit and vegetables. In the US 1 in 4 people has
no exercise at all in the past month [2] while 3 in 4 adults in the US do not consume at least five portions of fruits and
vegetables a day [3]. Moreover when it comes to treatment, adherence is an issue. In some disease conditions, more
than 40% of patients incur significant risks by forgetting, or ignoring healthcare advice [4].
Game overview
The aim of the game is for the players to maintain and
expand a virtual zoo by engaging in healthy habits such as
exercising regularly, eating healthily and encouraging
engagement with recreational areas. Players and teams
compete with each other to build the biggest/most successful
zoo with the happiest animals.
Players start with a small zoo with a small repertoire of
animals. As players achieve certain missions (e.g. recording
distance travelled everyday for a week) they will receive
bonus upgrades in terms of enlarging the zoo, increasing number of habitat type, and types of animals. With larger
parks and happier animals; they will be able to draw in the most visitors; thus generating the most money which can
be reinvested into the zoo to buying new enclosures or other bonuses. Upkeep costs (care of animals, and building
upkeep) are deducted from ticket sales to result in a profit/loss.
In addition, players are encouraged to enter their body weight consistently which will triggers exotic food bonuses to
keep animals happy and healthy. This not only creates continuous engagement with the game but also ensures
players engage in real physical exercise and a healthy eating habit. Teams of players (i.e. families or workplace
based) can personalize their zoos with “community only” items as they compete against other teams to clinch top
place in the public leaderboard.

3. The key ideas that underlie our proposed solution
Increasing exercise and improving diet require a fundamental change in personal choice and environmental factors.
The game helps to promote this via the use of social networking and peer support.
1) Power of social networking
Social norms can dramatically encourage or discourage the adoption of healthy behaviours [5]. Points, social media
status updates about reaching new levels/bonuses gained from the game, or public leaderboards can normalize
behaviours such as walking for longer, exercising more, and eating healthily. Team based activities (such as
competitions in workplace or family) can foster engagement from people that would not otherwise be reached by the
game.
2) The Hawthorn Effect
Inputting and tracking biometric data (weight/distance walked/calories consumed etc.) can lead to improved outcomes.
This is due to the Hawthorne Effect in psychology whereby the mere act of monitoring something regularly can lead to
positive change [6], examples include:
 People who wear a pedometer tend to walk a mile a day more, on average than those who don’t.
 Dieters who weigh themselves every day lose more weight than those who weigh themselves less frequently.
3) Community and business engagement
Data collected by this game such as supply and demand of
recreational facilities and healthy food will be valuable to
local councils, government and public health doctors. In
addition, this game can be expanded further through
collaboration with local business where discounted healthy
food products could be offered as rewards to players. This
not only ensure engagement with the game but ensure
changes in the wider society, moreover, businesses are
encouraged to sell and promote healthy food leading to
sustained improvements in lifestyles.

4. Design and features in Zoofit
1) Smartphone acts as pedometer - the recording of distance walked will be rewarded by enlargement of the zoo in-
game.
2) Body Mass Index (BMI) - players are asked to input their weight at regular intervals - and consistently inputting such
data will unlock special bonus treasure chests which can contain hidden power-ups and treats for animals. In addition
measuring the body weight will unlock the vet which will look after your animals to make sure that they are healthy
(unhealthy animals are unhappy animals and put off visitors).
3) GPS location check in - players are asked in the game to check in
regularly at recreational facilities such as parks, swimming pools and gyms -
players will then receive building speed upgrades so that enclosures and
pens are built faster, which will then be able to host more animals.
4) Healthy recipes – a collection of low cost healthy recipes, new recipes
are downloaded automatically weekly but users are encouraged to unlock
new recipes by completing missions in the game.
5) Health Factoids - at certain points in the game, the in-game
advisor will pop up with health facts to educate the gamer and
hopefully raise awareness of the wider health issue (as well as
throwing in some interesting animals facts in too!)

5. 6) Public ranking of players/teams according to various criterias (happiest animals, greatest wealth, size of zoo
etc.) to reinforce social collaboration and competitive spirit.
7) Consistent behavioural feedback (rewards and achievements) to reinforce compliance and engagement of
using the app and reward healthy behaviour.
Generating Health Data
Data generated in this game is relevant to the following aspects of theses national database:
1) County health rankings, by the Robert Wood Johnson Foundation and the University of Wisconsin Population
Health Institute – limited access to healthy food, access to recreational facilities, physical inactivity and obesity.
2) Centre for Disease Control (CDC) Behavioral Risk Factor Surveillance System (BRFSS) is the largest telephone
based annual health questionnaire, data generated in this questionnaire is used in many national health statistics –
exercise (During the past month, did you participate in any physical activities?), fruit and vegetable consumption (% of
adult consumed fruit and vegetables more than 5 times a day), exercise (% of Adults with 30+ minutes of moderate
physical activity five or more days per week, or vigorous physical activity for 20+ minutes three or more days per
week), weight (BMI measurement).
Generating public health data with players' informed consent, this game is able to generate and collect accurate data
highly relevant to the above two database. In addition, using existing smartphone technology, data that could not be
otherwise generated or captured is now a possibility. The data captured in this game is sufficiently accurate for
publication in medical and public health journals. Data can also be used in clinical trial to verify the clinical
effectiveness of the game.

6. (a) Access to recreational facilities - using GPS technology as above. Timing and frequency of visit to recreational
facilities can be accurately recorded. Analysis of this data again allows local council and town planner to analyse
the relative demand and supply of recreational facilities. Certain recreational locations such as open park, forest
trail or harbour traditionally cannot be easily monitored is now possible with this game.
(b) Physical inactivity - smartphone can be used as pedometer to measure the number of steps, for outdoor
activities such as running or cycling GPS technology can be used to trace distance travelled and duration of
exercise. This quantification of exercise has not been possible with traditional forms of public health research such
as questionnaires.
(c) Obesity - players can record and monitor their weight and feedback given to them. BMI of the whole player
population can be monitored over time. If BMI reduces with time compared to a control population who did not use
the game then this game will be one of the most effective cost effective public health intervention invented. This
also makes use of the Hawthorne effect where players are more likely to improve their behaviour or performance
when they are aware that they are being monitored.
Why does this game and data collected achieve the
objective of improving public health?
1) Helps public to improve health by encouraging positive behaviour change.
2) It provides a platform to distribute public health messages (health factoids) to the general population.
3) Provides fine grained public health data collection facility to governmental health organisations so that public
health in a more local community fashion.
4) Creating competition and social networking – competitions are organized at local, national and international
levels, this encourages healthy peer-to-peer competition to create a social movement towards better diet and
healthier lifestyles.

7. Technical details, challenges and solutions
Backend Technology
This game necessitates three separate datastores in the backend infrastructure, these are: (a) the game database
that stores the game data (zoo size, number of animals, teams, etc.) for each player; (b) a geographical database to
store locations of recreational facilities to be used for player check in; and (c) the health database that stores the
health related data (pedometer readings, weight readings, etc.) that do not have a direct effect on the state of the
game.
In addition to the databases, a game logic server is required to provide an interface between the databases and the
game app on the players’ smartphones.
Since this app is intended to be distributed to a large number of players, this infrastructure will be required to scale up
very quickly. For this reason we would initially deploy these servers using a cloud platform such as Amazon Web
Services [7]. The health database will have a relatively low utilisation since the game is designed not to need the data
once it has been recorded. Therefore, if necessary due to data privacy concerns around personal health data, it could
be relocated outside the cloud infrastructure with very little disruption.
Smartphone Technology
The game itself requires three key pieces of technology from the smartphone, these are: (a) the ability to act as a
pedometer - this is achieved by using the smartphone accelerometer to count the steps [8], (b) the ability to detect the
player’s current location - by using the smartphone GPS; and (c) the ability to connect to the internet - either
through wifi or using mobile data. Any modern smartphone is likely to capable of this.
In order to support the widest range of players as quickly as possible, this game has been designed so that it can be
built using Cordova [9]. This enables us to target multiple smartphone platforms simultaneously. In particular we will
be able to support both iPhone and Android phones from the start.

8. The Team
Clearstream Health LLC is a team of frontline clinicians, academics, graphic designers and computer programmers
working with members of public at all stage of development to ensure this game is produced to a high standard
relevant to the needs of target audience. In addition, our collective experience and skills in international research,
presentation and publications ensures any data generated and published will be valid with sufficient rigor to influence
public health practice globally.
Dr Philip Xiu, Dr Ivan Wong, Mr Alex Fargus, Dr Alain Vuylsteke, Mr Richard Heatley.
References
1. McGinnis, J.M & Foege, W.H. (1993). Actual causes of death in the United States. JAMA., 270(18), 2207-2212
2. http://apps.nccd.cdc.gov/brfss/list.asp?cat=EX&yr=2011&qkey=8041&state=All. BRFSS, CDC, 2011.
3. http://apps.nccd.cdc.gov/brfss/list.asp?cat=FV&yr=2009&qkey=4415&state=All. BRFSS, CDC, 2009.
4. Martin, LR et al (2005). The challenge of patient adherence. Ther Clin Risk Manag 1(3) 189-199
5. Lin RJ and Zhu X. (2012). Leveraging social media for preventative care - A gamification system and insights. Stud Health Technol Inform
180:838-42
6. Parsons, HM (1974). What happened at Hawthorne?: New evidence suggests the Hawthorne effect resulted from operant reinforcement
contingencies. Science 183(4128): 922-932
7. Amazon Web Services - http://aws.amazon.com/
8. Mladenov, Martin, and Michael Mock. "A step counter service for Java-enabled devices using a built-in accelerometer." Proceedings of the 1st
international workshop on context-aware middleware and services: affiliated with the 4th international conference on communication system
software and middleware (COMSWARE 2009). ACM, 2009.
9. Apache Cordova - http://cordova.apache.org/