The goal of game mechanics and game dynamics is to drive a user-desired behavior predictably. The same ideas apply to human health behavior and the application of behavioral models and frameworks in health intervention design. This requires an understanding of how humans behave. This is where all those behavior models come into play.

There are many such models and frameworks, each useful in specific contexts. A model/framework is chosen based on whether it can give us the understanding we need to address the particular problem.  Specifically to game dynamics and game mechanics, we can use the multi-factor model behavior model by J. Fogg of Stanford University known as Fogg’s behavior model (FBM). FBM asserts that there are three required factors that underlie any human behavior:

• Motivation (the want or desire to do something )
• Ability (the necessary resources)
• Trigger (the ‘spark,’ ‘signal,’ or ‘facilitator’)

According to FBM, these factors must converge at the same time to successfully drive a behavior. Any temporal misalignment in these three factors will degrade effectiveness. FBM also asserts that for the target behavior to happen, users usually require a minimum level of ability and motivation called the activation threshold for the behavior. When the trigger (something that prompts or tells the users to carry out the target behavior now) is introduced at the right time (above the activation threshold), the user is lead to the inception of the predictable behavior.

Of course, more than one behavior model or framework can be applied to a health intervention. For example, we can leverage the Power Law of Practice into a task-based intervention. The Power Law of Practice states that people make fewer errors and are faster with the more time they spend doing the task. About 80% of improvement along the power function comes from figuring out a good strategy for getting the task done, while about 20% of improvement comes from getting better at the same strategy.

There is good evidence that the steep part of the power function is actually composed of a combination of step functions where each step is a learning event – where one acquires new knowledge or develops a better model for how the system works. An intervention designer needs to understand what learning events occur so that individuals don’t get stuck and stop using the technology or some of its features.

From a motivation perspective, we can utilize a model by Daniel Pink. Pink hypothesizes that in the modern society where the lower levels of the Maslow’s hierarchy are more or less satisfied, people become more and more motivated by other intrinsic motivators, specifically: autonomy, mastery and purpose. From a game dynamics perspective, purpose is satisfied by quests, discovery, epic meaning; mastery is satisfied by points, progression and levels.

As you can see, when the appropriate behavior models and frameworks are applied a health intervention, behavior change can occur in a more effective and predictable manner.

Millions of people across the world are constantly looking for the answer to a longer and healthier life. Resolutions are made to go to the gym more often and eat healthier foods, and to spend more time with family and have a better work life balance. But at the end of the day, it’s tough to make all of these changes. We’re constantly stressed by family and work commitments and the daily struggle to make time for competing demands. So how do the people living in Blue Zones, those areas of the world where people have been found to live the longest and happiest lives, make this happen amidst the normal stress of daily life?

Dan Buettner, the author of The Blue Zones: Lessons for Living Longer From the People Who’ve Lived the Longest, outlines nine commonalities found among those people living in the five Blue Zones that have been identified as those areas of the world where people live the longest. And a January 9, 2013 article on this topic provides a nice summary of these nine “secrets” to living a long life. I’ve included them below for consideration. For more details, you can visit Dan Beuttner’s Blue Zones website.

1. Move naturally: The world’s healthiest and longest-living people don’t run marathons, nor do they go to the gym. Their body is the gym, and life is a workout.

2. Purpose: Know and live your life with purpose.

3. Downshift: Stress leads to chronic inflammation, which is associated with every major disease. Cultivate daily rituals and strategies for managing stress. Prayer, mediation and naps are among “Blue Zone” techniques.

4. The 80 Percent Rule: Stop eating when you’re 80 percent full. Don’t snack all day. Eat your smallest meal in the evening.

5. Plant slant: Eat a more plant-based diet with lots of beans. Have just 3 ounces of meat about five times a month.

6. Drink a little vino: That’s one to two glasses – 3-ounce glasses, that is!

7. Belong: Faith-based communities play a big part of Blue Zone lifestyles. According to the research, participating in a faith-based community four times a month adds 4 to 14 years to your life.

8. Loved ones first: Put family first. Blue Zoners have committed relationships, investing time and love with their children and their aging parents. Sorry, no nannies and no nursing homes.

9. It takes a tribe: Blue Zone communities share and support healthy lifestyle behaviors, and these values are passed on to subsequent generations.

These don’t seem so difficult upon first reading them, but really if they were that easy, we’d all live to 100!

Dr. Charlene Quinn, from the NIH’s Office of Behavioral and Social Sciences Research, put it this way in her recent spotlight video (you can watch below) concerning mHealth in diabetes management: “There are thousands of applications calling themselves mobile health, but very few of those applications actually have science behind them…”, which includes the clinical data, the evidence, they actually work.  She concludes by saying: “We really need to think through not only data and numbers, but what behaviors, using mobile health or mobile technologies, most encourages people to change their behavior, improve their health, and ideally improve the health of a population.”

That got me to thinking about what fundamental characteristics that an mHealth intervention needs to have to be successful in changing a patient’s behavior.  Many of these characteristics are simply good design principles: understanding the patient, knowing the socio-ecological system and sub-systems, iterative design and implementation. In general, simple messages delivered at the right time in the right place that are tailored, non-disruptive and repetitive and consistent is a sound way to think of how to build an mHealth intervention. The nature of portable computing with mHealth gives us the right place (where the patient is). Characteristics for a behaviorally-based mHealth intervention also require the ability to detect points of decision, behavior, and consequence and mobile devices require attention to interface design.

One important thing to consider is that sensors sometimes lose contact or run out of power or the wireless network is interrupted. Additionally, patients may willfully disable senor devices or not log the data or be as truthful as they should.  What then? Statistics can play a big role with imputation techniques (procedures are designed to fill in the missing data gaps), but there can be legal, privacy and medical issues and is a topic for another day.

So as we think about both the advantages of mHealth (ability to observe multiple and repeated levels of behavior as it happens in naturalistic settings) we must also consider some of the issues (missing data, good user experiences, privacy, etc.) as well.

It’s December. That means in just one month it will be a new year. And with a new year comes the ever popular New Year’s resolution. Whether it’s to stop biting your nails, exercise more, eat healthier food, or spend less money on clothes and shoes you don’t really need, it’s a commitment you’re making. And as we all know, just because you make a commitment doesn’t mean you’ll keep it. In fact, Dr. John Norcross, a psychology professor at the University of Scranton, indicates that only 40% to 46% of “New Year’s resolvers” will actually be successful after six months. That means more than 50% of those who desire to make changes won’t achieve success.

If you do plan to participate in this popular New Year’s activity, try to make an effort to set achievable and realistic goals for yourself. You can do this by setting SMART goals. These are goals that are specific, measurable, attainable, relevant, and timely.

For example, If you’re interested in exercising more, your goal shouldn’t just be, “In 2013, my goal is to exercise more.” Instead, include additional details that are not only realistic for you given your schedule and desire, but also measurable. An example of a SMART goal is, “In 2013, I will go to the gym 4 days a week for 45 minutes each day.” And don’t be afraid to adjust your goal if you find it’s too lofty. Sometimes schedules can get in the way. This doesn’t mean you should give up. It just means you need to make some changes so that you’re working towards something more feasible.

This year, in addition to breaking that nail biting habit, make a commitment to fall into that select group of 46% that is successful.

Take Two Apps and Call Me in the Morning

It may not be too long in our future when part of a prescription from our physicians may include and app (or two). This is the exciting idea of medically prescribed apps. Some futurists predict that doctors will prescribe FDA-approved apps to treat patients. So far, the FDA has maintained that it will only vet apps that perform device-like functions, such as making diagnostic determinations or treating ailments. The FDA has yet to release its full guidance on the regulation of mobile apps and will not go after the many available downloads that make untested medicinal claims until its rules are in place.

WellDoc is one of the pioneers in the prescription-app field. Its DiabetesManager system collects biometrics about a patient’s diet, blood sugar levels and medication regimen through manual input or from wireless devices. It then gives advice to a patient and sends clinical recommendations to the doctor. The Food and Drug Administration gave the system 510(k) clearance to operate as a medical device in 2010.

Happtique (health app boutique) is a company that operates a mobile app prescribing solution for healthcare called mRx. Happtique has recently launched a pilot that will test whether the company’s solution will encourage doctors to prescribe mobile software for patient use. mRx consists of Apple and Android smartphone and tablet compatible apps that focus on cardiology, rheumatology, endocrinology, orthopaedics, physical therapy and fitness training. The mRX system gives patients more structured guidance when it comes to selecting and using health apps and empowers them with tools to help them take a more active role in their care. And similar to traditional prescription, mRx will track how many times an app is prescribed as well as how many times patients click the “fill” button once the prescription is sent.

If the mRx trial is successful, it will help demonstrate that mHealth technology will be viewed as legitimate, powerful healthcare tools, not just fun programs to install on a phone or tablet.

From a behavioral point of view, the WellDoc and mRx systems can help encourage a dialogue between physicians and patients about available healthcare technology tools. These conversations will not only give patients additional resources, but will also encourage them to consider incorporating apps and other healthcare technology into their health management. In addition to increased health care provider connectedness, these systems also help achieve behavioral change and continued adherence through sustained influence over the patient’s multiple chronic states and enhanced patient self-determination.

When you think about it, these apps are no different from physicians prescribing a diet, a support group or any other resource. In fact, these apps will enable physicians to be more creative with the ways they engage their patients and provide the best care to them.

Last week I had the privilege of spending two days with diabetes experts in Washington, DC at the American Diabetes Association’s 5^th Disparities Partnership Forum.

The goal of the conference was to provide a forum for discussion around the onset of type 2 diabetes in high-risk populations. One of the many populations discussed was women. Brandy Barnes, the Founder and CEO of DiabetesSisters, and I submitted an abstract to the ADA highlighting the unique needs of women living with diabetes and it was selected as one of two Promising Practices to be presented at the conference.

I was so excited about being able to share the work of MicroMass and DiabetesSisters with an audience of experts who are all genuinely interested in understanding how to positively influence women with diabetes. Creating sustainable behavior change is critical, and I know together our organizations are already making great strides.

Andi Weiss presents at The 5th Disparities Partnership Forum from MicroMass on Vimeo.

More than one-third of US adults are obese, and this number is only predicted to increase over time. And with obesity, there’s often an increase in the number of preventable health problems, like diabetes, heart disease, and stroke, to name just a few. According to a recent article, online weight loss programs have proven results to help combat this public health problem in the United States.

It comes as no surprise to me that the online, interactive programs that offer chat rooms and individualized capabilities are showing more success with weight loss than pamphlets and other hard copy materials often provided to patients by doctors and counselors. While this study does indicate that in-person weight loss programs are also highly effective, the fact of the matter is that patients may not have the time or money to invest in these kinds of in-person programs. Additionally, healthcare professionals often have limited time with their patients, making it difficult to have a real impact on weight loss in the short time they spend together.

Online weight loss programs pay attention to the drivers and barriers of behavior change – support, motivation, and goal setting, among others – that are specific to weight loss. They allow patients to personalize their experience to ensure it meets the individual goals each person has for him or herself, and help patients overcome the inevitable road blocks along the way. And, online programs are available day and night for patients to access and interact with, providing a constant, long term resource.

As a behaviorist at MicroMass, understanding what patients need to motivate positive change is near and dear to my heart. The science is out there proving that static materials are just not cutting it when it comes to sustainable behavior change. It takes more than a pamphlet; but rather, a true understanding of what is holding patients back, what will drive them to action, and a personalized plan to create the desired change.

Healthcare Gamification

Gamification is the infusion of game design techniques, game mechanics, and/or game style into anything, and it has proven popular in the medical world as well. While gamification can help liven up health-related tasks and make them more enjoyable, it can also provide health benefits – take the Pain Squad  for young people with cancer, T-Haler for asthma sufferers, the depression-tackling SPARX game and Limbs Alive for hemiplegia patients as good examples.

From my perspective, these solutions are best as part of a well-considered behavior change program for patients.

Pain Squad

The Pain Squad app was developed by the Canada-based Hospital for Sick Children, also known as SickKids. Pain Squad gamifies the process of tracking the physical and emotional wellbeing of young people with cancer. Pain Squad uses the narrative of a police force hunting down pain. Patients are inducted as recruits in Pain Squad – a special police force dedicated to hunting down pain. Their pain reporting mission is to fill out a daily survey – which asks questions relating to whether they felt pain that day, how intense it was and its location. Patients move up through the ranks of the force when they keep their records updated. Stars from Rookie Blue and Flashpoint appear in videos that are unlocked when patients do well and progress the narrative. By gamifying the process, the app gives patients an incentive to keep a daily journal of their pain. The app is still in the testing phase, but SickKids hopes to release it later this year. Watch the following video to see how the app works:

T-Haler

T-Haler, developed by Cambridge Consultants, uses wireless technology to gamify inhaler use and help those with asthma get the optimum dose of medication. Interactive software, linked to a wireless training inhaler, monitors how a patient uses their device and provides real-time feedback via an interactive video ‘game’. T-Haler provides visual feedback to the user on their performance and the areas that need improvement. Feedback is highly visual which allows asthma sufferers to see what is wrong with their technique and monitor their progress as they improve. The interface offers visual instructions on how to correctly use the inhaler, such as shaking the device before use. Check out the video and see how it works:

SPARX

SPARX, which stands for Smart, Positive, Active, Realistic, X-factor thoughts, is a 3D fantasy roleplaying game that teaches young people with mental health issues the skills they need to boost their confidence. SPARX was developed by a team of specialists in treating adolescent depression from the University of Auckand. SPARX leads players through seven realms (each about 30 minutes long) that teach mental behavioral skills for battling depression. For example, in one level, gamers battle their way through a swamp where they’re attacked by black, smoldering balls called GNATS (Gloomy Negative Automatic Thoughts). SPARX doesn’t require supervision and could help fill treatment gaps, especially in underserved areas. It’s also a private way for kids to get help when they may not want to talk to an adult. The SPARX trial results are in the British Medical Journal (20/04/2012). Watch the SPARX trailer:

Limbs Alive

Limbs Alive is a therapy service for hemiplegia patients that uses games to improve motor skills in a fun way. Using Limbs Alive’s first game, “Circus Challenge,” patients can do much of their physical therapy at home – in conjunction with consultations from experts. This is the first action video game designed specifically to be played at home that provide an expert therapy program. Using wireless controllers, players participate in activities such as lion taming, juggling, plate spinning, high diving, and flying the trapeze. The games are meant to encourage patients to work their way through increasingly difficult levels of movement designed to gradually build up the strength and skills of the patient. Limbs Alive plans to create a whole library of games that help make therapy fun and effective for patients suffering from other conditions such as Cerebral Palsy, Chronic Lung Disease, Type 2 Diabetes and Dementia. Take a look at this video for more background:

Most of my doctors are pretty great. They give me the time I need to get my questions answered, they help allay any fears or concerns that I have, and they are just all around good people. It got me thinking about all of the healthcare reform research that we’ve been doing the last several months and what it truly means for a provider to be “patient centric.” There are so many definitions floating around for this term, but what does it truly mean?

We learned that patients and providers often have different views of what it really means to be patient centric. Patients often determine whether a doctor is patient centric by evaluating their bedside manner while providers see it as a balance between good clinical outcomes, patient satisfaction/customer service, and being able to successfully run their practice. This lack of consensus can be confusing for those who interact regularly with the healthcare system.

In general, patient centricity is a buzzword that’s being used a lot these days, and it clearly needs some additional attention. At MicroMass, we understand what needs to happen to create lasting relationships between patients and providers, between providers and managed care, and between the pharmaceutical industry and its clients. Patients, providers, payers, and administrators all have varying needs in this evolving healthcare environment, and our most recent research study has shed additional light on this topic. Using our behavioral science lens, we’re focused on the relationships that matter most and how to sustain them. 

Bottom line: at MicroMass, patient centricity isn’t just a buzzword.

We are biologically wired to react to stimuli in the world around us because of the evolutionary importance of rapidly detecting dangers and potential rewards. How we react to stimuli has been shown to be influenced by distance. In other words, the type of stimulus and its distance from us impacts its relevance to us. For example, a close threat is something to which we all react emotionally because we sense danger. We react in a similar way to images of larger sizes, meaning we interpret a picture’s size to be the proximity of the object in reality.

However, words are another matter…

Words are abstract and symbolic – not an image of reality. Rationally, we would not expect the size of a word to make a difference to us emotionally because a word is not a depiction of reality and requires higher order processing for us to interpret its meaning.

But even for words, size does matter…

A recent study, led by Mareike Bayer of the Humboldt University of Berlin in Germany, shows that both positive and negative words that are printed in larger fonts promotes a stronger emotional brain response than the same words in smaller fonts. What the researchers found was that the bigger the text, the faster someone responded emotionally to the word. Also, their emotional response lasted longer.  The researchers proved this by monitoring the brain activity with electroencephalograph (EEG) recordings in volunteers as they looked at different positive, negative and neutral words in a variety of font sizes. The net-net is that emotional meaning is boosted when emotionally charged words are presented in large fonts.

Large fonts are used in headlines all the time, suggesting that we intuitively understand that words presented in bigger type captures our readers’ attention. Through this study, we now know that words in larger sizes also trigger a stronger emotional response. This means in the broad sense that behavior pursues emotion (people learn to anticipate what actions lead to what emotions), we can influence our readers’ behavior (decision and action control processes) not only by our choice of words but their size as well.