The Importance of User Design in Games for Health

by Maisha Razzaque

Looking to regulate your sleeping habits? Searching for a way to teach sexual health? There’s an app for that. In today’s web-based world, games for health are rocketing in popularity. These “serious” games are specifically designed to encourage behavior changes to treat a health threat. Naturally, we are inclined to ask about the validity of the games: do they work the way they were designed to work? Can serious games be used to improve health outcomes? However, we may not consider the important role of user experience — how easy and pleasant the game is — factoring into the game’s influence. Paying attention to how a game is designed and what human interaction factors considered during its development may hold the key to the future of health-based games.

Gamification in a Nutshell

Using games to affect change in real life isn’t a new concept. Educational games have been a prominent feature in the integration of technology and grade school learning since the early days of and Mavis Beacon. These games use the theoretical approach of teaching and testing content in small quantities — having student pass a level before moving on to the next one. The late 90s birthed the exergaming (exercise + gaming) industry — utilizing movement tracking and virtual reality to turn movement into play. In 2013, we saw the integration of health metrics, heart rate and a pedometer, into these “exergames” with Nintendo’s Wii consoles. The most visible case of implementing health goals in game design today can be found in trending augmented reality apps like Zombies, Run! and Pokémon GO. One study assessed the walking and sedentary habits of young adults before and after downloading the game Pokémon GO. The GPS-based game requires players to use their phones to search for virtual Pokémon characters as they walk through real-world locations. They found that Pokémon Go was associated with increased walking and decreased sedentary behavior. Some unexpected negative side effects of a semi-virtual game that the experimenters found included the dangers in the environment as the user is walking right into it, too immersed in his/her phone to notice! This is an example of a real-life “bug” that needs to be addressed in these mobile exergames by the developers of the programs. Perhaps the lesson here is that the health benefits of resulting increased physical behavior can only be a priority if the safety of the user in any potential semi-virtual game is accounted for by the designer. After all, what good is an app that raises your heart rate and encourages exercise if the trade-off is mistakenly walking off a cliff?

Psychological Models in Games

Encouraging health-positive behavior and tracking metrics are a great start. However, to delve deeper, we need to start at the conceptual design stage of the game. The question of gamification pivots from “does the existing design work” to “how do we design it to make sure it works?” This is where experts toy with the idea of implementing psychological models of healing in health game design—specifically, the Health Belief Model.

According to the Health Belief model, an individual’s intention to “engage in health behavior” — this includes both positive and negative behavior — can be determined by their perception of their own vulnerability to health threats and consequences. In more technical terms, the user will behave based on self-perceived strengths and weaknesses. So how do you go about using the health belief model in conceptual design: in serious games that use role-playing and sci-fi/action themes to encourage diabetes management, users are rewarded when health landmarks are met.  This offers incentive for health record integration in the game — all to ensure that metric and therapeutic goals are accomplished in the process of playing the game.

Researchers at Johns Hopkins examined design principles of serious games (for patients with chronic illnesses) based on the Health Belief Model and their influence on the games’ effectiveness in health outcomes. Adolescent participants were recruited for user experience evaluation of the games, and they found that implementing the Health Belief Model in healthcare game design increases usability in games, improving the efficacy as a health tools. But that’s just one model. In the context of future experimental design for other chronic illnesses, it’s important to gauge the value of implementing appropriate models when designing games. However, if there’s one thing that can be taken away from this study, it’s that it sets an essential precedent. If our end goal is to improve health outcomes using games, then we need to use professionally developed tools for healing while designing them. The psychological model is an a necessary perspective during the design of health-motivated games.

One Dish, Many Cooks

The idea of different perspectives comes into play (no pun intended) in game design when we talk about the human factors behind health-based gaming. Recent studies have found evidence that may explain the convergences as well as conceptual differences between the different experts. Obviously, game design experts are most sensitive to the mechanics of the game, but they tend to prioritize the player’s autonomy during the experience. They view the integration of gameplay and health behavior in terms of two distinct concepts. On the other hand, health experts interpret player autonomy in the context of health. They are more likely to comment on the “fun” games in contrast to the “serious” games, and they are more likely to discuss game and health concepts less in the context of integration but rather in terms of a causal relationship — game mechanics were to model health behavior. In contrast with these single-discipline groups, games for health experts view content and interaction of the while emphasizing the outcomes and objectives of both the games and health behavior. According to games for health experts, the game mechanics — its own separate entity — are responsible for producing health outcomes. These findings can be applied as conceptual tools during the design process to make sure games are made with the intent to produce desirable health objectives.

Why Do I Care? Why Should You?

I’m nearing the end of my master’s program for applied cognition and neuroscience, and I’ve been spending its duration performing cognitive tests (testing memory and attention) on volunteer participants during a cognitive training regimen. What is the cognitive training in question? Any guesses?

If you thought “games,” you thought right. And since taking a special interest in human-computer interaction theory during my undergrad years, I can’t help but speculate on the relationship between the user experience of the games that we use for cognitive training and the behavioral and neurological effects that we investigate.

Are games the future of cognitive and physical health? I can’t definitively say that for sure, but I can be pretty confident that digitizing and gamifying health is and will continue to be an important tool in a holistic approach to manage health. The studies I mentioned earlier make it evident that the technological component of health games is not only important in terms of validity but also usability. If we plan to continue implementing games into behavioral health and cognitive training as aids in metrics, management, and even enhancement (in the terms of cognitive training), we have to pay attention to the multiple factors that go into designing the games themselves. At the risk of sounding corny, I feel like the conclusion I drew from this little investigation could be summed up in a little phrase: better game design allows for better user health.


There Is An App For That!

by Maisha Razzaque

“Noom isn’t just your average dieting app. It’s goal-oriented psychotherapy that helps you think critically about the food you’re eating.” I heard this pitch a few weeks ago during a radio ad, and I thought: wow, I like that way of looking at food tracking. I’d totally use this app.

Except I already have.

Here is a comprehensive list of apps I have used, am using, or have downloaded with the idea of future usage in order to regulate and maybe even improve my productivity, diet, and overall physical and emotional health: Noom (food and exercise tracking), Clue (period and ovulation tracker), (personalized health data), Calm (mood tracking), Sayana (mood tracking), 30 Day Fitness (exercise tracking), Lifesum (Macro Tracker), Flora (habit tracking), Reflectly (anxiety tracking), Focus Keeper (time management)— I’ll stop here. You get the point; there are a lot.

Reading a book, going for a run, eating a meal, and relaxing are all supposed to be pretty uncomplicated activities for most people. Yet, I — and I suspect an alarming number of others — have overcomplicated it to a point of chaos. The question remains: why did I convince myself that I need a billion apps to regulate my life?

Six years of being in school has taught me to look to the research. According to the Health and Wellness Foundation, 60 million people in the United States are using some sort of mobile health app. And, as studies indicate, a majority of those users are female millennials. The promise of these apps basically can be boiled down to something called the Health Belief Model. Developed in the 1950s, the Health Belief Model is a systemic method that identifies health behavior; the main gist of it is that an individual’s intention to “engage in health behavior” (positive or negative) is directly related to how vulnerable to health threats they believe themselves to be. The user will act according to his/her own perceived strengths and weaknesses. Health apps enable self-monitoring which, in theory, should lead to some positive effects. Mobile health apps are essentially a user-friendly tracking journal on your phone, and for the most part you don’t have to analyze your own data because the app does it for you. It can even be helpful to bring this sort of data to your healthcare provider if you’re trying to manage a chronic condition (e.g. blood sugar, blood pressure, heart rate, etc).

When it’s put that way, it doesn’t sound so bad, so what could go wrong? It turns out, a lot.

What starts out as helpful information from well-intentioned apps can turn into data overload. As a result, this can exacerbate health anxiety — a phenomenon in which a person has an irrational preoccupation with possible health threats. For people with certain proclivities to obsess over calorie/exercise tracking, these apps can actually be enablers of unhealthy behaviors. There is also the question of validity. Many mobile health products are self-report models. What if you don’t know the exact calorie count in a home-made meal or the “intensity level” — something a version of MyFitnessPal has asked users to report — of your cardio exercise? Without valid data, the analysis provided by these apps is not useful to managing health at all!

Last of all, we have to look at the money.

In 2019, the mobile health app industry made $3 billion in sales. A lot of this money is coming from advertising, but what the average user might not know about is the amount of personal data being harvested and sold to third party companies. In 2018, several period app companies including Glow and Flo got into hot water because they were selling personal data about people’s menstrual cycles to companies that were, in turn, using them to create targeted ads. Suddenly, aggressive online ads for baby clothes and cribs would coincide with a missed period. But is hot water the right way to describe the backlash? There were no legal consequences; In fact, most of these apps have tiny, tiny print stating that you’re allowing them to do whatever they want with your health data the moment you tap “install.”

But surely, you’re thinking, there are some legal standards to protect people from this kind of predatory data mining.

That’s just the thing. Mobile health apps have taken the market by storm and seemingly transforming how people are looking at health management overnight. The legislation has simply not had the time to catch up. The sheer vastness of the mobile health market makes it hard for the average user to judge quality. The FDA’s oversight of mobile health products has been met with a lot of handwringing. Pushback from the industry has been hanging on the argument that overregulation could hamper growth and innovation. Nathan Cortez, a law professor at the Southern Methodist University, has suggested broadening the FDA’s jurisdiction. In a 2014 article about FDA regulation of mobile health apps, he argues that the existing legislation that limits the FDA’s involvement is bad for doctors and dangerous for health app users. He proposes that Congress should consider allowing a professional third-party to evaluate the algorithm and quality safeguards outlined in an FDA regulatory guides. Since then, a 2017 redraft of the FDA’s regulatory guidelines has tightened regulations of diagnostic apps — ones that physicians use to aid with making clinical diagnoses. The wheels of government regulation turn slowly — so, so slowly — but surely.

What I’m piecing together from this crash course on mobile health products is that these too-good-to-be true apps might not work, may be using my personal data, and aren’t being closely regulated. But why did I convince myself I needed so many of them in the first place? The answer, as you may expect, isn’t quite so simple. It can be broken down into a few pieces. Maybe I may have not been the one doing the convincing. If everyone is touting the newest and best app that’s transforming their lives, it’s natural that I should want in. When my favorite disembodied nutrition podcast host voice tells me to take control of my life by downloading Noom, I just may do it. Perhaps, I — and the aforementioned millions of users — have fallen prey to the phenomenon of “too much data”; it’s very easy to rationalize that somehow having “more” apps is the same thing as having “better” apps. Then before you know it, you’ve used up all your phone storage on six different AI Mindfulness apps. Despite all this, I haven’t reached the conclusion that the apps are bad. After all, people just want to take an active role in their health. Understanding mobile health apps can help us critically think about which ones can better meet our needs and which ones are just unnecessary noise.