- Digital games show promise for positively changing health behaviors and outcomes, but establishing evidence of their effectiveness faces major challenges of replicability and generalizability. - Key ingredients for sustainable success include multidisciplinary research to establish what works for different conditions and users, as well as iterative development working with stakeholders and users. - Gamification needs to go beyond just points and badges to drive long-term changes; social accountability and making health fun through games and narratives can help engage users.

1. Towards a successful implementation of
game mechanics (gamification) in e-
health interventions
Maged N. Kamel Boulos, MBBCh, MSc (Clin Dermatol), MSc (Med Inform), PhD, FHEA, FRGS, SMIEEE
UHI Professor and Chair of Digital Health, Scotland, UK
maged.kamelboulos@uhi.ac.uk / mnkboulos@ieee.org
t: @mnkboulos
Digital games and toys for health and healthcare:
how to make them work best

2. Agenda
• Why digital games for health? (with some examples)
• Ingredients for (sustainable) success
• Establishing and interpreting the evidence:
the great challenges of replicability
(reproducibility) and generalisability
Not part of the scope of the current
presentation:
The side effects of digital games,
including video game addiction/Internet
gaming disorder among others.
A prescription of Tetris!

3. Why games for health?
• Intended for health-related behaviour and lifestyle modifications, i.e., to help
positively change the way people think and behave in a manner that is
sustainable without relapse.
• Examples – digital games can be used to:
• Communicate important health messages, esp. to low-literacy populations.
• Motivate kids to roll up their sleeves to get a flu shot.
• Teach/educate midwives how to make births safer.
• Coach and facilitate behaviour change for people with chronic conditions, e.g., in obesity (to
encourage healthy diet and exercise).
• Convince men who have sex with men to take precautions against STIs.
• Encourage and support smoking cessation.
• Citizen science: engaging the wide masses of citizens in public and environmental health
initiatives and projects for the common good.
• Improve cognitive functions in certain disease conditions and age groups.

5. Screenshots of Monster Manor
game app aimed at helping kids with
diabetes better manage/control and
cope with their condition. Children
can input their blood glucose
measurements using an on-screen
numeric pad and earn virtual coins to
buy various in-game items that are
essential for progression through the
game.

7. Citizen science

8. Consoles

9. Kinect[All Fields] OR Wii[All Fields]
http://www.ncbi.nlm.nih.gov/pubmed/
?term=kinect+OR+wii
>800 records (Sept 2015)
Many uses; for example:
In physical therapy/rehabilitation, in dementia and
Alzheimer’s disease, etc.
https://vimeo.com/135560970 >
< https://youtu.be/nYnbL3MuqwQ

10. Games are also being developed and prescribed for brain (cognitive)
training, e.g., to improve episodic memory in people with schizophrenia.
Cognitive benefits for older adults can also be achieved with digital
exergames that have no explicit 'brain training' exercises attached to them,
according to a recent cluster randomised clinical trial that compared virtual
reality-enhanced interactive exercising or 'cybercycling' (Expresso Interactive
Exercise Bike) two to three times per week for 3 months with a similar dose
of traditional exercise.
The study found that "Cybercycling older adults achieved better cognitive
function than traditional exercisers, for the same effort, suggesting that
simultaneous cognitive and physical exercise has greater potential for
preventing cognitive decline.“
The authors of the study hypothesised that this result might be due to the
presence of unique mental stimulation and interactive combina-
tion of cognitive and physical challenges in graphical gaming
worlds (virtual reality).
____________
Anderson-Hanley C, Arciero PJ, Brickman AM, et al. Exergaming and
older adult cognition: a cluster randomized clinical trial. Am J Prev Med.
2012; 42:109–119.

11. Mini (companion/home) con-
nected robots and digital toys/
gadgets
Many uses: from
helping children with
autism and serving as
a personal weight loss
coach to providing
care and companion-
ship for older people

12. http://www.grushgamer.com/

13. 3D Virtual Worlds: The UOP Sexual Health SIM in Second Life® (2007-2009)
http://healthcybermap.org/slsexualhealth/
P.I. / Lead 3-D
experience architect
and developer:
MN Kamel Boulos
Co-Investigator:
S Toth-Cohen (Thomas
Jefferson University,
USA)
Funded by: SL
Education UK - a 1760
m2 Second Life® virtual
land was granted in
July 2007 until 2009.

14. The UOP Sexual Health SIM in Second
Life® (2007-2009)
http://www.nature.com/embor/journal/v9/n6/full/
embor200886.html
5-year Impact Factor (2012): 7.4

15. Google cardboard: Head
tracking using smartphone's
gyro sensor
Immersive virtual reality (VR)
The smartphone's
camera can be used for
augmented reality
experiences (AR)
Some applications:
• Virtual reality therapy for 'in
virtuo' systematic desensitisation
in treatment of phobias.
• Virtual reality exposure therapy
in treatment of post-traumatic
stress.
Oculus Rift
Control

16. An even more immersive future / augmented reality (AR)
http://microsoft.com/microsoft-hololens/en-us
VR -> AR
http://blogs.msdn.com/b/education/archive/2015/
07/14/hololens-case-study.aspx

17. Ingredients for success
• Success has to be sustainable (attitude and behaviour change without relapse).
• Multidisciplinary research is needed to establish the evidence base and best practices
concerning these different interventions and their (unique and overlapping) affordances
and various possible combinations in relation to the different health conditions we would
like to target: What works in each condition, what does not, and under which settings and
criteria/which types of users/user characteristics; cost/affordability; user acceptance; etc.
• Not all interventions will succeed in modifying a user's behaviour (the hardest of all, but
essential to prevent relapse). This needs to be studied and quantified with suitable
metrics/optimised for each intervention under investigation.

18. Ingredients for success
• The mere inclusion of conventional game features such as points, badges/
achievements and leaderboards in an e-health intervention cannot alone
guarantee that users will remain engaged, continue using the intervention
and reap all the benefits in terms of the desired positive (and sustainable)
health outcomes.
• Gamification must be designed and crafted into e-health interventions in
such a way that it can successfully effect the desired health outcomes and
long-term goals. This requires a full consideration of all the involved
human and personal factors, health status and psychological factors that,
combined, affect how players will engage with a given e-health game and
how they will (or will not) be persuaded via the game elements to
positively change their behaviour or lifestyle without relapse.

19. Ingredients for success
• Gamification should go beyond Points, Badges, and Leaderboards
(PBL) in order to effect the desired long-lasting health and behaviour-
changing outcomes.
Watch: Chou YK. TEDxLausanne.
Lausanne, Switzerland:
TEDxLausanne; 2014.
Gamification to improve
our world.
URL:
https://www.youtube.com/watch?v=v5Qjuegtiyc

20. "It takes more than (activity tracking) data to get
users motivated. If you bought a fitness tracker
but have since tossed it aside, you're not alone.
More than a third of people who buy wearables,
such as Fitbit or Nike Fuelband, abandon them
within a few months."
"Because wearables simply present a number, the
data alone is often not meaningful enough to
keep people devoted to their devices."
Solutions:
Making fitness fun, e.g., https://zombiesrungame.com/
Linking games to social media,
where strangers or friends/
family striving for the same
health objective can help make
the player feel accountable and become more
committed in the long run.

21. Quoting/paraphrasing the above article:
• Fortugno (Nick Fortugno, a game designer - http://playmatics.com/about/founders/) advises game
developers to "start with the endpoint — the scientific research results (evidence) — and work
back from there", rather than starting with the researchers' hypothesis (but see cautions on slide 23).
• Before any major work is done, team members need to answer the question, "Why would anyone
play this game?"
• Games for health development is multi-disciplinary: It helps to have a 'game producer' on board
who can facilitate communication between scientists/clinicians/psychologists, etc. and game
developers and keep both groups on schedule.
• Another important ingredient is 'iterative development' — working with stakeholders, including
a good representative sample of end users, to test (and refine) features of the game repeatedly
early in the process to help avoid late-stage failure.

22. Also worth noting…
• Computers + Persuasion = Captology: http://captology.stanford.edu/about/what-is-captology.html
• The 'Minecraft Phenomenon' (for gamified health education):
• Kids under the age of 12 are Minecraft's current core audience.
• Minecraft is a virtual '3D wiki' or sandbox in which children and teens (but also
interested adults) can learn and practice new skills in a socially contextualised way.
• Microsoft recently demoed a version of Minecraft for HoloLens (augmented reality).
• See: Microsoft launches 'Minecraft in Education' (June 2015): http://goo.gl/ispGes
• The 'Ikea Effect':
• (Games that) motivate and guide players to create/co-create their own personalised
health promotion and tracking e-solutions using suitable building blocks (cf. Lego
bricks).
• Albert Bandura's Social Learning/Cognitive Theory
and Self-efficacy:
• For a brief discussion of some of Bandura's concepts applied
to digital health games, please consult our recent paper at
http://doi.org/10.2196/games.3930
Logo source:
http://www.slideshare.net/
JuanJFValeraMariscal/gami
fication-psychology-inside-
gamification-world-
congress-2014

23. The great challenges of replicability and generalisability
• Published research/evaluation 'evidence' is not without (serious) limitations!

24. Thank you!