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I suffer from multiple interests, too, including human behavior change and emerging markets. Behavior change has been an interest dating back to my first career as a practicing dentist. For nearly as long a time, I have also been curious about emerging markets, first as an equity researcher on Wall Street, and now as an independent analyst and digital health consultant. Beginning in 2011, my curiosity led me to interview over 50 experts in diverse disciplines; from academics such as Debra Lieberman and BJ Fogg, to Paul Tarini of the Robert Wood Johnson Foundation and Diego Miralles of J & J, as well as hardware and software engineers, behavioral and cognitive psychologists, plus gaming and entertainment experts.
This slide summarizes my original research, a first-of-its-kind view of an emerging ecosystem – Mobile Social Games for Health - published by Mobihealthnews.
This table shows an evolving ecosystem of experimenters trying to produce behavior change in people across the disease spectrum, from health and wellness to chronic disease. Starting at your left at the Wellness side, I found an expanding definition of health to include life balance and self-improvement. Moving on to Brain Games An exciting application of game technology takes advantage of a new understanding of brain plasticity leveraged with fun. Looking at Employee Wellness The societal shift in attitudes toward health and wellness, with consumers leading the way, is exemplified in the rise of employer-sponsored employee wellness games. Social networking can bring people together within a trusted environment to share information and work toward common goals. Social games encourage three positive behaviors - teamwork, friendly competition and accountability. At the far right of this diagram is Disease Management Interesting to us provider types is whether these principles will work in chronic disease management. Early signs are positive: Mobile games are finding a place in disease management, making mundane tasks more fun: glucose monitoring, insulin and other drug management, as well as diet and exercise, often through developing a support network of like people.
A few quick definitions of Game Mechanics Motivate Behaviors Game mechanics are elements that gamify an activity. These include points, levels, challenges, virtual goods, leaderboards, and donations, which act as rewards, playing to a natural human desire. Game elements trigger other natural human motivators, such as status, achievement, self-expression, competition and altruism. As a practicing dentist who spent much time trying to get my patients to take care of their oral health, using game techniques is appealing.
For the mobile health research, my initial hypothesis centered around gaming elements as motivators, providing additional impact to online support.
Today’s presentation, asking the question of what is working in mobile games, will update my initial research. 3
Everyone engaged in health care is finding themselves in the behavior change business. So, what is behavior change?
We can think of Behavior Change as a series of cumulative small feedback loops composed of small baby steps- for example: start flossing one tooth and then add a second tooth and another tooth, etc. A simple feedback loop can be illustrated like this: as the user engages with the mobile tool, it captures data, and sends feedback to the user- this could be a simple reward system for flossing every tooth one time per day. More complex loops involve multiple iterations that build upon themselves, such as flossing your entire mouth twice a day, changing your sleeping routine or improving eating and exercise patterns. The ultimate goal is to foster healthy behavior, but as we know, changing patterns of behavior or routines that have become comfortable is not easy. The question of behavior change has recently become interesting to many more designers, so much so that there is a meet-up with over 650 members called Habit Design, meeting in SF, NY
When I asked “What is working?” three themes or trends emerged Engage, Personalize and Iterate - EPI
Engage is to capture people’s interest and involvement- using game elements to trigger motivators such as reward, status, achievement, self-expression, competition and altruism. Personalize or customize is important. There is no one-size-fits-all in behavior change; giving people what they need at the time they need it is crucial to keeping their limited attention. We see many examples of this type of personalization outside of healthcare, where Amazon and Zappos understand what we search for and buy, and use that data to suggest new items that might interest us. Iterate is the third theme of what is working: experiment, using feedback, to better engage or more closely personalize, see what works and do more like that. This concept is well known in consumer product marketing, but not yet much recognized in healthcare circles.
I will discuss 4 case studies, across the disease spectrum, that shed light on how these themes are playing into contributing to behavior change and propelling successful company models. I’ll start with Zamzee- a health and wellness company, Lumosity, Healthrageous, and ending with OneHealth, a chronic disease management company.
Case Study 1Zamzee is a mobile game that gets kids moving, doing more exercise and increasing activity through positive feedback. Here is how the game works: 1. Upload chosen activity 2. Track progress through an avatar- a self-chosen picture 3. Level up and earn badges as the user progresses 4. Earn rewards To earn badges, pass levels, take challenges or personalize an avatar, kids have to move. In a recent clinical trial of 448 kids over a 24-week time period, those who had access to the accelerometer and the website engaged in 59% more physical activity than those with just access to the meter. How does Zamzee motivate users? It combines extrinsic rewards, which include small prizes, to stir physical activity One example is challenges: timed, story-based adventures that inspire activity. If you move around enough in a certain time period, you can earn double, triple or quadruple Pointz, or even free Zamz to spend in the Zamzee rewards shops. The personalized dashboard is iteratively designed to create positive experiences related to physical activity over time, giving kids a feeling of mastery and competence. Themes - Zamzee exemplifies all 3 themes: engagement with motivation through extrinsic rewards, personalization via dashboard, and iteration - they have been experimenting over 5 years, with some surprising results Initially focused on kids, they have found that moms want to join in the fun, too - so Zamzee is including more adult and family-friendly offerings. Case Study 2 -Lumosity is the closest to what we think of as a real “game”- where you play for fun and get rewards. Their brain games come in different “flavors,” depending upon which area of the brain you want to train - speed, attention, flexibility, memory and problem solving. Initially launched in 2007, Lumosity now has more than 35 brain games, with 20 million members, and paying subscribers from 180 countries. The mobile app has been downloaded 10 M times since 2010. What is working along our three themesengage, personalize and iterate- in Lumosity Engage- the user interface is particularly inviting, simple and straightforward Personalize- More interesting is the use of adaptive algorithms that personalize the questions offered to the user. If you answer several questions wrong in a row, it gives you easier ones so that you can have a feeling of mastery. If you get several hard questions in a row right, it will increase the difficulty of the next question, giving you an ongoing sense of accomplishment. Iterate- doing extensive research based on user data, producing the largest database of behavior and cognitive performance indicators A recent survey of 750,000 users and uncovered some interesting findings, on how life style can affect cognitive performance- based upon the performance on their games. (one drink a day may give your brain a boost) To summarize: Lumosity has an engaging user interface, giving the user a personalized mix of questions at customized difficulty while collecting both user and behaviorial data to iterate the product and gain new insights into behavior and cognition.
The next two case studies have contrasting focus on different themes Case Study 3- Healthrageous Healthrageous was built on feedback loops using timely and dynamic information as the center post. Alongside this information, they incorporate gaming mechanics and social interaction- creating iterative feedback loops using social interaction and fun as supporting pillars. They are experimenting with education, automated coaching, feedback loops, different incentives and game mechanics as an automated coach providing quantitative and qualitative monitoring and guidance. The core of their solution is dynamic personalization and expert knowledge built upon: Evidence-based understanding of people Vast scientific experience and effective treatment plan knowledge Commitment to using sophisticated quantitative analysis, enabled by machine learning Coming back to our three themes: Engage-integrate evidence-based protocols with gaming dynamics- make it simple, fun and convenient, using positive reinforcement through rewards and competition Personalize- use analytics, to present timely and high-impact information Iterate- Healthrageous is in a perpetual process of experimenting; right now they are exploring how to bundle their services for institutional needs Case Study 4- OneHealth In contrast to Healthrageous, whose roots put data at the center of the platform, OneHealth was built from the ground up with the patient’s needs at the center. OneHealth launched as OneRecovery for addiction relapse, and it has many of the elements of AA brought to an online digital world. OneHealth is an interesting example of combining gaming mechanics with multiple online support networks. First applied to addiction-related disorders and then to other behavioral health conditions such as depression, anxiety, stress, and smoking. They are now applying this approach to chronic medical conditions such as heart disease and weight loss. For engagement, just like a good game developer who puts the player in the center of the experience, OneHealth has created a user-centered experience that cleverly hides a series of game mechanics alongside clinical protocols. Rewards include badges to mark achievement levels, such as going to meetings, getting a sponsor, sharing a story, journaling. To further personalize the experience on the emotional side, there are emoticons- a series of happy/sad faces - to show how you are feeling and to express empathy to your online support network. For social support, you can build your own support group with varying levels of privacy, customized to personal needs that can change over time. With iteration of the platform features, they discovered that it is not just the inbound support that helps us feel better; we feel better when we help others. Building upon this understanding of how we use technology, OneHealth is developing a program where you can participate and become acknowledged as a “certified” peer counselor, trusted by the members of the community.
Coming back to our three themesFor engagement and personalization, at the front end, OneHealth uses a combination of multiple support networks alongside gaming elements delivered to the right person at the right time to get people involved in helping themselves. Giving them an opportunity to help others keeps them coming back. For iteration, on the back end, data collection allows OneHealth to iterate the product and gather real time behavioral health pattern data that may help us better understand how to use this technology in patients who struggle with multiple diseases, such as obesity, depression and addiction.
What’s next? Moving forward depends on funding support and successful business models Funding support ranges from non-profit to vc funded Zamzee is a non-profit and Healthrageous, Lumosity and OneHealth are VC-funded with Lumosity- $67 M Healthrageous- $8.5 M OneHealth- $7 M Business models range from direct-to-consumer to corporate wellness and chronic disease management. Lumosity is direct-to-consumer Zamzee started direct-to-consumer, catering to kids, is now aiming at the whole family and is thinking about expanding into corporate. Healthrageous and OneHealth are already focused on corporate wellness Along the themes of personalization and customization, we are starting to see the use of big data analytics underneath the gaming platform in Lumosity, Healthrageous and OneHealth. Lumosity’s adaptive algorithms get you the right difficulty question at the right time. Healthrageous is using data analytics as a support pillar to personalize the experience OneHealth is building a real-time behavior health platform with a 2 sided api that combines social data- user generated content about they use the communities and other platform features- with clinical data. So what is working? In conclusion, we have seen 3 themes of engage, personalize and iterate in our 4 case studies including Zamzee, Lumosity, Healthreagous and OneHealth. As a practicing dentist, who deeply understood the human frailties associated with behavior change, I know there is no one size fits all. We each need different types of help at different times. And so we have seen a variety of approaches that seem to work… Zamzee has tweaked their dashboard based on a better understanding of what motivates the user Lumosity customizes the questions, based on user responses. Healthrageous began using data as the center pillar, augmented with gaming mechanics and online support. In contrast, OneHealth started with the patient at the center using the power of social networks, then added the data-driven personalization. While Healthrageous and OneHealth began from opposite emphasis, they are converging on approaches that seem to work better. As we have seen, these 4 pioneering companies- Zamzee, Lumosity, Healthrageous and OneHealth, using a 3 pronged approach, engagement, personalization and iteration, are starting to show positive momentum in the quest to influence behavior change. Also, iteration seems to be key- with data analytics, game mechanics, and online support powering new approaches to personalization and influencing behavior. Iteration also means experimenting with business models, aiming at disease management and selling to groups, such as employers or plans, rather than retailing to individuals.
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