Gamification 2.0 offers new ways for people with chronic conditions to stop feeling powerless and start adhering better

September 16, 2019

By Beverly Beaudoin

Research now shows that a key to the success of certain online games and game apps is that they give players a sense of competence and confidence.^[1] It’s a key part of their appeal and a reason why people play them over and over again. While these games pose challenges to players to keep things interesting, they never throw an obstacle in a player’s path at any level that they’re not ready to handle. That bolsters self-esteem, increasing desire to play more.

That is the opposite of what an illness typically does to a patient. Illness often feels immobilizing, driving patients into denial, non-adherence, and negative thoughts just when they most need to marshal their resources to fight back. It’s like an outside force that people feel they can’t control. These feelings set back not only their recovery, but also their motivation to use the medications and treatments their care providers prescribe or recommend.

In my professional life, for example, I often saw data that 60% of patients with high blood pressure weren’t adherent with their meds. But it really came home to me when I learned my husband wasn’t taking his pills.  The unacceptable thought that he could have a stroke because of non-adherence set me on a quest for ways to better understand how to change health behavior. I’d already encountered the breakthrough work of James Prochaska, PhD, whose smoking-cessation insights have created some of the most successful interventions in that highly treatment-resistant health habit. What if game science, too, could work to build adherence, and even build in some of Prochaska’s (and similar innovators’) approaches? The prospects were exciting. 

Since then, I’ve learned that new wave of second-generation health games can indeed be effective in re-mobilizing patients, promoting adherence, and re-building positive attitudes. One of the strongest assets of these health-related games is that they can restore a sense of control and empowerment to people who feel they have little of it, re-igniting their energy and optimism in the quest toward health and wellness. That’s especially important in early stages of behavior change, when patients in denial (or “pre-contemplation” in Prochaska’s schema) or just beginning to accept the fact of their illness often confront negative, self-limiting thoughts and feelings.

Let’s hear what Jane McGonigal, a PhD researcher, game designer, and bestselling author says:

“… when we’re in game worlds, I believe that many of us become the best version of ourselves — the most likely to help at a moment’s notice, the most likely to stick with a problem as long at it takes, to get up after failure and try again. And in real life, when we face failure, when we confront obstacles, we often don’t feel that way. We feel overcome, we feel overwhelmed, we feel anxious, maybe depressed, frustrated or cynical. We never have those feelings when we’re playing games, they just don’t exist in games.”

https://www.ted.com/talks/jane_mcgonigal_gaming_can_make_a_better_world]

Games, perhaps, could be just the ticket to bringing out the best in health behaviors.

Fighting the feeling of helplessness

The sense of helplessness that being diagnosed with an illness can induce in its victims is hard to over-estimate. What is it about disease that makes people feel powerless? Health behavior researchers say that some factors include: 

• Dependency on others, especially medical professionals—a sense that your fate is in everyone’s hands but your own, and that nothing you can do really matters.
• Preponderance of negative feedback… getting meds right and adjusting dosages typically involves “failing” on initial efforts.
• Lack of timely feedback on health-positive efforts. Think about cholesterol disorders, for example: the only way to know whether your diet and medication regimen helps or hurts is a lab test, available only two or three times a year in many insurance plans. Or consider what it’s like during treatment for cancer, where weeks are spent wondering what the next scan will show.
• Feeling isolated. The stigmatizing and alienating aspects of illness are well documented. Patients often feel they’ve been singled out and set apart from others, with a unique and unfair burden, and that few people truly understand what they’re going through.

Health games fight helplessness

Within these insights are clues to designing games that build confidence, supporting the adoption and maintenance of positive health habits such as medication adherence. Consider these ideas that are currently being built into online apps and health games:

• Put the patient/player on a quest. Adventure games never let you forget who’s responsible—you— for fighting opponents, forging alliances, or solving the puzzles that vex you along the path. That creates a sense of empowerment, what some health behaviorists call “self-efficacy”, while still allowing a role in games for helpful others —“mages” and “wizards” in fantasy games, doctors and nurses in health games— to advise, inform, and counsel. When patients feel in control, their confidence rises, and with it their sense that they can manage the demands of their illness.
• Celebrate the player doing things right. Effective games use bright colors, excited movements, and sounds to reward players for conquering a challenge or reaching a new level. Increase the frequency of that kind of feedback and link it to a desired health behavior (checking weight, taking meds, exercising) —to counter the negative voices in the patient’s head.
• Provide feedback fast. A mix of instant rewards (bells, whistles, points on a leaderboard) with long-term ones (prizes and other incentives) makes games exciting and fun. Structure games to reinforce positive patient behavior in real time. (Imagine how healthy your gums would be if your dentist popped up each time you flossed and said, “Hey, great job!”).
• Include a community. A key to many successful games is multiplayer involvement and inter-player dialogue. The game becomes a place to meet friends with similar concerns, feel understood, and find resources. For patients, a player community centered on their health issue can be an antidote to the loneliness and stigma that often surround it.

An informative example: Pfizer’s Hemocraft

Pfizer Rare Diseases worked with Drexel University’s Entrepreneurial Game Studio and the National Hemophilia Association to create a game for boys, 8 to 16 years old, who have hemophilia. Built on the wildly popular Minecraft platform, the Hemocraft^® game puts patients on a quest  to defeat a dangerous dragon. Along the way, they help their hero avatar deal with his hemophilia, by assembling infusion kits, monitoring coagulation factors, and accumulating resources. Staying prepared and sticking to the treatment plan enable the player to win while building confidence and optimism.

Each success gets kudos from avatars standing in for family, friend, and neighbors. Players interact with the game’s virtual doctor and nurses to gain the information they need to move to the next stage (and better manage their hemophilia). The game is fun to play with others, including children with normal coagulation factors, helping to de-stigmatize the condition and provide a supportive social environment.

Early reports show that kids with hemophilia enjoy playing the game over and over. Those playing the game in 2018 enjoyed it enough to return on average more 4 than  times, each spending over 3.5 hours playing and learning how to track coagulation factors, prepare injections, and reach goals.^[2]  They play both by themselves and with friends, particularly important for people with coagulation disorders, whose potential for bleeding often limits the games and sports they’re allowed to play with others. It’s too soon to tell what impact the game has on actual health outcomes, but it’s a great example that ticks many of the boxes of what makes for great second-generation gamification in health care, built on insights and a healthy dose of fun. We’re going to see more and more of these confidence-building health games emerge as game science makes inroads among health educators and marketers.

Next in this series: How to turn the science that makes online games so habit-forming into a force for good health.

^[1] Ryan, R.M., Rigby, C.S. & Przybylski, A. Motiv Emot (2006) 30: 344. https://doi.org/10.1007/s11031-006-9051-8

^[2] https://social.eyeforpharma.com/patients-and-medical/philadelphia-2019-patient-initiative-finalists-revealed.