The gamification of everyday life, as lived on our smartphones, is near complete. The movement is no longer limited to just millenials and the Gen Z either, with over three quarters of the US population living increasingly on their smartphones. Whether it is through tracking our sleep patterns, swiping left and right for our love lives, learning a new language, or most recently, even trading on the stock market (thank you Robinhood!), there seems to be no aspect of life that cannot be improved upon by the addition of leaderboards, levels, points, badges, and competition.
The health and wellness industry in particular, with its infinite capacity for quantification of health metrics, has presented a plethora of opportunities for game-oriented developers. An informal survey of my classmates at business school, most of whom are likely adherents of the quantified self movement, revealed the sheer scope of activity: sleep patterns, calorie counting, diet management, period tracking, body mass index tabulating, sugar monitoring, and even keeping tabs on the quality and quantity of biological sex.
Of course there is a difference between gamification and passively tracking one’s health behaviors and metrics, the latter which uses self-review to influence behavior change by touching on feelings of empowerment and intrinsic motivation. Advocates of gamification seem to say that this is well and good, but probably not enough, and that the insertion of game-elements into these services can drive participation from the long tail of the distribution – in other words, grow the userbase overall, and drive more quality, meaningful, long-term engagement. What’s not to love?
The problem is that there is a dearth of objective data that proves any of these claims, particularly the last one. Dr. Joseph Kvedar of the Center for Connected Health at Partners Healthcare has noted in his blog that although one in ten US adults over the age of 18 owns an activity tracker, one-third stop using it within six months. Here’s another: more than 80% of health apps like Lose It! or MyFitnessPal that are downloaded are abandoned within two weeks. The answer here, per Dr Kvedar’s, is that health apps with traditional feedback loops are relatively weak motivators of change. His research team has repeatedly shown that the motivational messaging that puts these feedback loops in context is the true driver of change. To put it simply, patients need to feel like they have a connection with someone who cares about them to sustainably stay engaged.
A recent review on the topic out of Brigham Young University noted that the growth of gamified health and wellness apps has not been studied yet for metrics of effectiveness, appropriateness, and long-term sustainability, perhaps because the trend is relatively new. The authors did highlight a missed opportunity in the gamification of health to increase the motivation of users to change behavior, without adequately addressing capability or behavioral triggers. A research group out of UPenn iterated on this idea in JAMA: sustaining change may be relatively easy for the already motivated, quantified-self audience, but is likely to be difficult for the much larger group of persons with difficult-to-manage chronic health conditions. To be truly effective, these wellness programs need to leverage concepts from behavioral economics, and promote peer support and a sense of accountability to use the device/app and stay engaged in the new behavior.
The health tech community is slowly waking up and responding to the data. Boston-based chronic disease management start-up Wellframe is a great example. Wellframe has created a mobile app that generates automated daily checklists that encourages daily patient engagement through conversational messaging that implies a two-way communication portal and feedback loops that alert nursing staff if adherence falls off. Wellframe has conducted clinical trials at various hospital sites in and around the Boston area, and has demonstrated adherence rates of over 90% among its target populations, even six months into the trial. Vinnie Ramesh, CTO of Wellframe, believes that these results are driven by the patient’s awareness that there is someone on the caregiver side who is observing their results and adherence; in other words, a social connection again functioning as a powerful impetus.
One only needs to take a peek at the stock price performance of two breakout tech companies in recent years – Zynga and Facebook – to understand what drives long-term engagement, gamification or social connection. Zynga, which develops and markets online games debuted on the NASDAQ at over $9 a share, and is currently hovering at around $2.50. Meanwhile, Facebook, the now ubiquitous social networking site made its splash on the NASDAQ at $38 in 2012, and slowly but surely has climbed to its current stable asking price of $77. As much as spending a spare minute on Farmville can be diverting, it just cannot compare with the rush that comes from connecting with a vigorous and interactional community.
Social connections appear to be the common denominator that keeps patients coming back for more. Now it’s time for digital health companies to use these findings to advance care by making health addictive.