Paper presented at the 2013 World Marketing Congress (Melbourne), focusing on the use of mobile “app”-based interventions as tools to influence health-related behaviour. We use established design criteria to review a range of current apps developed by one public body, the UK NHS and commercial developers of health-related apps and compare these to commercial apps promoting unhealthy food items. We suggest that there are serious weaknesses evident in the apps provided by public bodies and that this sector could learn from an analysis of the development strategies used in the commercial sector. The full paper is available in the proceedings.

1. NOT QUITE PLAYING THE GAME?
MOBILE APPLICATIONS FOR
HEALTHIER LIFESTYLES

2. Electronic games & Apps
• Increase in popularity
2005 : $10 billion p.a. (Susi, Johannesson, & Backlund, 2007);
2012: $25 billion p.a. (Entertainment Software Association, 2012).
• Limited effectiveness of traditional channels,
=> “apps” becoming increasingly important as a
new channel
• phones are nearly always with their users
(Andrew, Borriello, & Fogarty, 2007)
• bridge between online and offline worlds
(Lathia, 2012).

3. Serious gaming
“… purpose in changing knowledge, beliefs,
attitudes and behaviours, solving problems or
building competencies” (de Wit-Zuurendonk & Oei, 2011; Göbel,
Hardy, Wendel, Mehm, & Steinmetz, 2010; Hummel et al., 2011)
“persuasive games” (Khaled, Barr, Noble, Fischer, & Biddle, 2007)
“gamification” (Groh, 2012)

4. Breadth of “Serious Gaming"
Serious Games overall
(Breuer & Bente, 2010)
Health-related serious
games (Susi, et al., 2007)
Military Exergames (physical activity and
exercise)
Governmental Health education
Educational Biofeedback
Corporate Therapy
Healthcare
Political
Religious
Art

5. • Evidence of success
Rehabilitation (de Wit-Zuurendonk & Oei, 2011)
Disease management (Thompson et al., 2010)
• But not automatic
simply presenting material in a game-like setting is insufficient (Breuer &
Bente, 2010)
enthusiasm for wanes in a short time period (Baranowski, Baranowski,
O'Connor, Lu, & Thompson, 2012)

6. Literature Criticisms
• fragmented, lacking in coherence regarding
theoretical underpinnings (Boyle, Connolly, & Hainey, 2011)
• small sample sizes, short time periods and
inconsistent success measures (Baranowski, et al., 2008;
Biddiss & Irwin, 2010; Woodruff, Hasbrouck, & Augustin, 2008)
• conclusions being presented that “cannot be
considered valid evidence to support or refute
efficacy” (Kato, 2012 : 74).

7. Purpose
1. reviewing the range of theoretical
frameworks claimed to be in use in the
serious games sector
2. contrasting the design principles used by
serious (health-related) and commercial
games delivered via mobile apps.

8. Theory Overview Author
Theory of Planned Behaviour Proposes that attitudes, perceived behavioural
control and social norms are important predictors
of behavioural intentions
(Boyle, et al., 2011; Kharrazi, Faiola, & Defazio,
2009; Lu, Baranowski, Thompson, & Buday, 2012)
Self- determination Theory Explains motives for playing games, including
needs for competence and autonomy, together
with the reduction of differences between the
ideal self and actual self. The theory also
acknowledges the impact of social environments
on behaviour.
(Deci & Ryan, 2008; Lu, et al., 2012; Lynch, La
Guardia, & Ryan, 2009; Przybylski, Weinstein,
Murayama, Lynch, & Ryan, 2012)
Uses and gratification theory Explains technology use in everyday life. (Kamal, Fels, Blackstock, & Ho, 2011)
Flow theory Immersion in tasks, together with channeling and
energising emotions and learning results in
enjoyment and fulfillment. In the serious games
context, the need for clear goals, direct feedback,
self-efficacy and control are acknowledged.
(Pavlas, Heyne, Bedwell, Lazzara, & Salas, 2010)
Multiple Identity Theory Players identify with games at affective, cognitive
and behavioural levels, resulting in positive
alternations to attitudes and thus behaviours.
(Christenson et al., 2012; Williams & Williams,
2011)
Health Belief Model Attempts to explain and predict behaviours by
focusing on attitudes and beliefs, assuming a
rational weighing up of perceived risk against
likelihood of alternative outcomes from behaviour
change. Accepts that knowledge alone is
insufficient to change behaviours.
(Brox, et al., 2011; Peng & Schoech, 2008)
Transtheoretical Model Explains behaviour change as a progression of
stages from lack of knowledge about a behaviour
and its impact, through to sustained behaviour
change.
(Lin, Mamykina, Lindtner, Delajoux, & Strub, 2006;
Ross & Tomlinson, 2011; Shegog, 2010) (Brox, et
al., 2011
Social Cognitive Theory Describes the reciprocal and interacting influences
of personal, environmental and behavioural
factors and includes learning from past and
current behaviours and from observing the
behaviour of others.
(Annetta & Bronack, 2011; Lu, et al., 2012)

9. • merely listing features rather than presenting coherent
predictive models (Boyle, et al., 2011)
Common also to wider behaviour change literature (Michie &
Prestwich, 2010)
• We were unable to locate
– any discussion of how the cited theories were used
– nor a systematic comparative analysis different theories across a
range of behavioural tasks and population segments.
• Further…
– several assume a direct link between attitudes and behavioural
intentions
> ignoring attitude-behaviour gap (Sniehotta, Scholz, & Schwarzer, 2005).
– focuses on games in isolation (Osorio, Moffat, & Sykes, 2012).

10. Design Principles
• Like the theoretical frameworks, design
principles are equally fragmented
Persuasive Strategy Description
Reduction Making a complex task simpler
Tunnelling Guided persuasion; giving control over to an
expert
Tailoring Customization; providing more relevant
information to individuals
Suggestion Intervene at the right time with a compelling
suggestion
Self-monitoring Automatically tracking desired behaviour
Surveillance Observing one’s behaviour publicly
Conditioning Reinforcing target behaviour
based on Andrew, Borriello, Fogarty, 2007

11. Methodologogy
1. five apps developed by the National Health
Service (NHS) in the UK
2. five top-selling, commercially available apps
for similar health behaviour outcomes,
3. five commercial apps not related to health
outcomes:
three apps for unhealthy food items (one each from
alcohol, soft-drinks and fast-food category respectively)
top two free games (all categories, UK iTunes store).

12. AppName
BMITracker
Smokefree
Moodometer
DrinksTracker
Fungenerator
5KRunner
Myplate
iFitness
Caloriecount
DrinkInMyHand
Stella9Step
FantaKingofthePark
McDonald'sMorning
FamilyFortune
TheSimpsons
Category
NHS
NHS
NHS
NHS
NHS
Commercial
Commercial
Commercial
Commercial
Commercial
Alcohol
SoftDrink
FastFood
Game
Game
Reduction × × × × × ✓ ✓ ✓ ✓ ✓ ✓ × × ✓ ✓
Tunnelling ✓ ✓ × ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ × ✓ × ×
Tailoring ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Suggestion × ✓ × × ✓ ✓ ✓ × ✓ × ✓ ✓ ✓ ✓ ✓
Self-
monitoring
✓ × ✓ ✓ × ✓ ✓ ✓ ✓ ✓ × ✓ ✓ ✓ ✓
Surveillance × × × × × ✓ ✓ × ✓ ✓ ✓ ✓ × ✓ ✓
Conditioning × × × × × ✓ ✓ × ✓ ✓ ✓ ✓ ✓ ✓ ✓
No of
Strategies
3 3 2 3 3 7 7 4 7 6 6 5 5 6 6

13. Livestrong vs NHS (Reduction)

14. iFitness vs NHS Drinks (Self-
Monitoring)

15. iFitness vs NHS Drinks (Self-
Monitoring)

16. Suggestion

17. Surveilance

18. Future directions
• identify health behaviour app providers and
investigate what theory or combinations of
theories used in planning the apps
• investigate whether, and in what way, age, gender
and cultural factors impact on the way games are
perceived
• evaluate apps as ‘stand-alone’ devices versus part
of multi-component interventions: This will
require transdisciplinary approaches to the
development of appropriate evaluation systems