Gamification of Healthcare

Effectiveness of Gamification in Healthcare domain: Review on its Impact, Applications and Benefits

1. Introduction

A game takes place in a well defined "game space" and provides an abstraction of reality. This game space involves elements like players for interacting with the game, rules that define the game and challenges which the players overcome in order to achieve the goals. Gamification is the application of these game-design elements and various gaming principles in a non-game context to solve a real-world problem (Huotari & Himari, 2012).

Gamification can be used in different fields like in education to improve learning, as an online marketing technique to encourageengagement with a product, in business to encourage innovationand alsoto improve user engagement.

The Gamification and the Future of Education (2016) published by the World Government Summit, identified 3 functional advantages of gamification: The first is the freedom to experiment: games allow players to explore and discover new strategies and pieces of information. The second is the freedom to assume different identities which encourages players to see problems from a different perspective. Lastly, gamification alleviates the burden of effort to learn the information.

While traditional methods might be effective, new innovative ways are being continually researched and developed. Engagement is a key factor for learning as compared to mere observation. The value of intrinsic motivation as a driver to complete an action is being increasingly recognized. When people are intrinsically motivated they have a genuine desire to complete a task in hand and enjoy it. This concept is being effectively utilized in gamification.

2. Background

Technology is being continuously evolving and has changed a lot since early 80's.

As earlier the only way to get a medical aid was by visiting a doctor for even basic problems which was costly and time consuming. Nowadays because of new technology getting medical aid is available easily at our finger tips and is also less expensive and faster. From ordering medicines from online stores, booking appointment to getting assistance virtually, technology has changed the lives and the way we carry out our routine. In today's world there is a massive need for technology as the problems are getting complicated and technological innovation is speeding up at a fast pace. With the advent of smart phones, many applications have been developed for maintaining, aiding and monitoring health well being. For example from using apps to help us take medicines on time, manage weight and nutrition to smart watches that check our BP , heart beat rates and can track our steps and calories burnt. Technology has now introduced the concept of "gamification" to promote development of games with a "purpose". This concept supports the fact that healthcare can be monitored without stress and using some user friendly technologies, in this paper, readers will find numerous ways in which technology has been gamified to provide better healthcare and what's the latest in the domain as what are the future prospects.

3. Gamification in Healthcare domain

The concept of gamification is not new and had been formerly used in several military applications as well as in airline industries ("Gamification of the Healthcare Industry and its implications | Orthogonal", 2018). As the importance towards creating awareness and maintaining a healthy life style has been increasing, various techniques are being investigated to promote and maintain healthy living. While traditional methods might be effective, new innovative ways are being continually researched and developed.

Every month at Google campus in London many software engineers, scientists, clinicians and investors gather to discuss new strategies to influence health behavior, the main aim being to develop a "game with a purpose" (King et al., 2013).

In healthcare it is used to provide motivation and education for health awareness and wellness. The main goal is to change the behavior of people by making them take actions beneficial to their health and with the help of gamification, it is now possible to experience fun and joy in developing a healthy lifestyle.

4. Literature synthesis

The American Heritage Dictionary defines games as "An electronic or computerized game that can be played by manipulating imagine on video display" and in order for this game to be successful some intervention is needed: The game must provide rewards and incentives to provide the necessary motivation, the game should be competitive in a healthy way and also should be have a good user experience (engaging and fun) (Primack et al., 2012).

Juual observation states that games are "half real" as there is an intertwining between the fantasies and rules. Juual further defines games as made up of 6 parts:

1. A game is a rule-based: This means that every game has certain rules to be followed while playing
2. Different outcomes could be possible in a game
3. Different outcomes have been assigned a different value: either a win state or a loose
4. Challenges are part of the game that motivate users to take efforts to reach an outcome
5. The player also must feel emotionally attached to the outcome
6. The consequences of the game are optional.

The concept of "serious games" was introduced. Wilson (1970) gave the initial definition of serious games and used simulation and games to improve education. Chen and Michael (2005) finally defined the serious games as "Games that do not have their primary purpose as providing fun and entrainment". Initially the concept of serious game was used in learning and advertisements.

In 2006, hope lab introduced the Re-mission, to help teenagers who were diagnosed with cancer. In this game the players Roxxi and Nanobot through bodies of teenage cancer patients fight cancer and destroy the cells (Tate, Haritatos, & Cole, 2009). Their study showed positive results in medication adherence even in the patients who played less than an hour per week.

King, Greaves, Exeter, & Darzi (2013) in their study suggest that as there is an increase in use of digital devices, mobile phone is now the conduit for causing change in behavior. They suggest that mobile phones are the most effective way for achieving alteration in health behavior. As mobile devices are getting more advanced and their hardware and software capabilities are enhancing the use of mobile devices are most suitable for these games. The can also provide range of features one of which is GPS that are used by Exergames like Nike+ (King et al., 2013).

The success of these games lies in the level of motivation and user engagement these games can provide so as to make the "game with purpose" equally entertaining as any other video game(King et al., 2013).

Nowadays gamification is being applied in improving mental health. These games are developed to help patients suffering from disorders like depression and post traumatic stress disorder (PTSD)(Lau, Smit, Fleming, & Riper, 2017). Even though the benefits of using gamification in improving mental health have been recognized, designing effective games in this field is challenging. While designing games for mental wellness a lot of factors should be considered as different users exhibit different characteristics and may require different level of motivation (Siriaraya, Visch, Dooren, &Spijkerman, 2018). Therapeutic objectives must be clearly defined and games must be designed to achieve them.

5. Applications & their Benefits:

Lack of physical activity can be a major cause for health issues. The World health organization promotes the importance of physical activity and specifies certain recommended levels of physical activity for different age group. Various digital gadgets like fitness band and apps have been introduced with the idea of promoting physical activity. In the term paper we have tried to study and analyze the various popular sources available in the market that justify the theme like apps, gadgets, etc. and how they impact the healthcare and how their impact can be improved for the betterment of mankind healthcare in general.

5.1 Pokémon-Go

Newer techniques using gamification was then introduced that incorporated real-life physical activity into games and one such was the digital game "Pokémon Go" which was introduced in 2016 and was one of the most successful game. It is an augmented reality game that consisted of frictional characters called Pokémon. A screenshot of the game can be seen in figure 1. The users have to hunt the creatures and collect different types of Pokémon. One of the interesting aspects of this game was the "look and feel" of the game which augmented a two-dimensional image of the characters onto the real world which was captured by the mobile camera. The game awarded points on collecting the various characters that was needed to reach a higher level. Rasche, Schlomann and Mertens in their study investigated the various factors that motivated its users. In their web-based survey, a total of 199 participants were selected which included 81 active users, 56 former users, and 62 nonusers of Pokémon Go game. This study focused on 3 aspects: the motivation that is needed to start playing a game, continue to play the game and quitting the game. The 2 factors that contributed to the motivation to start playing the game was the curiosity and also the liking the users had towards the Pokémon character (Rasche, Schlomann, & Mertens, 2017) The study also revealed the factors that helped the users keep motivated to continue playing the game which included aim to achieve higher levels, while the factors that made users quit the game was related to poor AR and some users found it boring and disappointing and lacking social interaction(Rasche, Schlomann, & Mertens, 2017).

Some of the major benefits recognized using this game are ("Five Ways Pokémon GO Is Actually Good for You", 2018):

As the game demanded moving around while tracking a nearby Pokémon it was successive in achieving its actual intend that is a motivating its users to walk around. At the Pokestop, an egg can be placed at the incubator and wait to let it hatch. The first egg usually required its users to walk up to 2 to 5 km. This not only motivated the users to walk but also making their walk more fun and exciting.

A lot of studies suggest that vitamin D is vital and breathing in fresh air can have positive effects on body as well as mind. While this game was able to motivate,it also was able to make its users to get some outdoor activity.

Another benefit recognized was its ability to provide short breaks during routine activities. The game when used just as a break can help improve a person's productivity by preventing boredom.

Figure 1: Screenshot of Pokémon-Go

While the game looks promising and is effectively providing motivation for physical activity, it eventually came to an end due to the bugs that remained unfixed. Also new ways like incorporating an immersion or sense of emotional connectivity should be incorporated. New ways to keep the users motivated to continue playing must be researched and the games must be modified to enhance the user experience and prevent users from getting bored.

5.2 Mango Health

Another application is in the use of medication management. Mango health is a Smartphone application developed with an aim to effectively manage ""prescription adherence"" by making use of game elements to motivate its users to take medicines on time (Cutler, 2013).The app allows users to set notifications and also provides important information on drugs that could be harmful. Mango health app reminds its users to take the medicines on time and also awards an in game currency that the users can save and also level u to unlock some real world rewards ("mobilehealthnews", 2018).

5.3 Fitness Trackers

Another device commonly being used are the fitness trackers. These devices come in the form of wearable like smart watches accompanied by their relevant mobile app and these trackers make use of different sensors, algorithms and are capable of providing the steps count, calories burnt and also heartbeat/ pulse rate.These devices are small sized and are capable of logging a range of data about activities like steps taken, distance travelled, and calories burnt. The device has sensors can even distinguish a slow stroll from a run. A study on the availability of wrist worn fitness watches from the year 2011 to 2017 was made. The results are interesting where in them found out 423 unique devices from 132 brands(Henriksen, et al., 2018). A study published by journal BMC Publish health in 2009 showed that having a goal set up and being able to see the results of the activity helped obese and overweight women and encouraged them to move more often. There was an increase noticed in daily step count by 36% in the users of pedometers ("Making the Most of Your Fitbit", 2018).

5.4 Fitbit

The Fitbit devices provide various benefits:

1. The fitness tracker can help you get a set count and also can provide with information on calories burnt. This allows users to constantly keep a track of their physical activity and also setting a goal motivates them to achieve it. A screenshot of the application can be seen in figure 2.
2. The device can also monitor sleep, disturbances and duration of inactivity and alert the user. Fitbit Ionic, is one of the fit bit's first smartwatch consisted of a blood oxygen sensor and could detect sleep apnea
3. The device can also track the heart beat rate to determine if the rate is higher than normal.

Figure 2: Fitbit Application

5.5 Zombies Run

A smartphone application called "Zombies Run!" an immersive running game was introduced in 2012 with the idea to motivate the users to run. This application uses GPS to track speed and distance and the game must be played with headphones as it comes with special sound effects. One of the unique features is that the player will have to increase their speed of run by 20% in order to survive being attacked by a zombie. The app allows listening to music and instructions are provided as audio from headphones. When the users are being chased by zombies they have to speed up. The app was not only a motivator to run but also make running more fun.

5.6 Super Better

An application called super better helps users achieve their health goals, personal growth and tackle real life problems. This application allows users cope up with mental disorders like depression, anxiety or for overall personal growth to develop a talent or new habits or achieving short/long term goals or to overcome a challenge faced like finding a job, or loss of a loved one. The strategy that this game uses is trying to evoke psychological strengths such as optimism, determination which is naturally experienced when we play a game (""About SuperBetter – SuperBetter"", 2018)

Figure 3: Super Better Application's Screenshot

5.7 Bayer's Didget

Bayer's Didget blood glucose meter, has been created for young children between an age group of 4 to 14 to help them cope and manage diabetes. This meter connects with Nintendo DS gaming platform. The game converts the test results into rewards to help children level up.

Figure 4: Fitness Device- Bayer's Didget

A virtual physical therapy app called relaxation health assists in physical therapy-based exercises by using animated figures. Technology incorporated compares the patient's movements with those of the models and provides a video-based feedback and correction suggestion ("Reflexion Health", 2018).

6. Benefits of gamification in healthcare

The popularity of smartphone technology has been increasing and it's easy and less expensive these days to download games that can help them achieve the health goals. There are applications that range from aiding in weight and diet management adhering to exercise scheduleand curing chronic diseases. Gamification in healthcare is not only for medical wellness but is also used for various other purposes:

1. It can be educating Physicians: A study states that online video games are shown to be effective in imparting education to physicians and are more effective than traditional methods of reading the educational books and materials (Patten, 2018). These games are designed such that the physicians can compete with each other. These games were more effective and less time consuming.

2. One of the challenges that physical therapists are facing are patients who take up unsupervised exercise programs (Patten, 2018). Gamification has provided a tool that is cost effective and helps motivate patients to do their exercises even when they are not being supervised by their physical therapist (Patten, 2018). The games are designed to be both fun and also the patients can also get an immediate feedback, also any problems can be quickly detected by the physical therapist. The results have shown a significant increase in usageof home-based exercise routines (Patten, 2018).

3. A study that was conducted at Beth Israel Hospital in New York revealed that surgeons who were regular video game players had better surgical skills (Patten, 2018). Another study performed at VA Boston health care system in Massachusetts, introduced surgical procedures to residents using a gamification simulator, this training had duration of 14 weeks and the residents participated in 28 training exercises (Patten, 2018). An increased level of success was shown in the participants with the surgical training when compared to other residents who were not part of the study (Patten, 2018).

4. Another application is to aid in weight loss. These games allow its user to set goals and motivate them to achieve by providing incentives and feedback. They can also be used in conjunction with other users to compare progress or to have a healthy competition.

7. Support for novelty

In the term paper we have tried to analyze the current technologies offered in the market that benefit healthcare in a unique way itself i.e. via gamification. We have not only studied but also used the various applications and fitness devices to try to figure out how useful they are and in tried to suggest ways so that they can be made more useful to the general public in a broader sense thus improving the healthcare for mankind in general. Gamification in Healthcare is a relatively new approach but is on the rise in the market as big prospect not only to help increase awareness regarding some serious health problems but also because people have actually started finding it useful and user friendly and innovative. Use of fitness trackers for monitoring sleep, walking, running, heart rate, etc., smart watches, healthcare applications for smartphones, etc. have been able to create a successful and lasting impact on the users. It has open options for new business and technology innovations which can earn huge revenues and good ROI as well.

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