If digital games can be habit-forming, could the powerful techniques used to glue people to their screens, known as “ludic loops”, be put to use to break bad health habits or create good ones? They’re a potential force for good, and health marketers are now looking at them closely as health gamification 2.0 becomes more widespread and sophisticated.

For those who haven’t been following this series of posts, gamification is the application of games and game principles — score-keeping, competition, leaderboards, badges, rewards — to non-game contexts, and health care has been quick to adopt it. Many smartphone and online games of varying quality now exist for helping to manage medication, control weight, reduce substance abuse, and educate about disease self-management. And as gaming grows, so does the science underpinning its ability to engage users.

Health promoters are excited about gamification in part because changing health behaviors has historically proven difficult. Short-lived bursts of enthusiasm for a change for the better (remember those New Years’ resolutions?) tend to peter out quickly, and bad health habits often rapidly return as novelty turns to drudgery. People often have the best intentions but lack a reliable means for turning those intentions into lasting improvements. So making behavior change fun—by making it a game— holds promise as a way around this challenge. Imagine if people got as deeply into diet improvements, exercise regimens, or medication adherence as they have with Minecraft or Pokemon Go. As I noted in a previous blog, I’ve seen subway riders miss their stops, so engrossed in smartphone games that they lose awareness of where they are.  There’s no denying how “sticky” (in the digital argot) Internet and smartphone games can be. Studies show that of the 150 million Americans who use the games, 60% now use them at least daily.

What makes people return again and again to games? It’s no accident. Today’s games are programmed with the intent to hook us. They deliberately apply psychological and neuroscience insights from the world of compulsive gambling, among others. Game designers systematically apply what MIT anthropologist and author Natasha Dow Schüll has dubbed “ludic loops”, a moniker derived from the Latin word ludos meaning “games”.

Ludic loops are patterns of sensory feedback that activate neural pathways of reward in our brains, stimulating repetitive game-playing. Schull discovered ludic loops when she studied slot machine users, seeking clues to why people return again and again to these aptly named one-armed bandits. She discovered that semi-predictable and multisensory feedback rewards —flashing lights, jangling sounds, and bright colors that unexpectedly congratulate desired user actions (and mildly punish undesired ones)—create in users a relaxed, focused feeling that they start to crave—an otherworldly calm not unlike that gained via meditation.

Schull and others have found that it isn’t a big jackpot win that gamers typically are after; rather, they find playing and getting these rewards puts them in a trance-like state they experience as soothing and pleasurable. A neurochemical phenomenon,  this zone isn’t the result of deep thought. It’s more the outcome of continual attention and activity. It’s rewarding essence is escape from the stressors of the real world. Further research suggests that the cognitive component of constant cycling from uncertainty to certainty and back again that gamers experience additionally triggers dopamine, a brain neurotransmitter associated with reward and motivation.

It’s been known since the days of behaviorist pioneer B.F. Skinner that random rewards reinforce behavior more powerfully than predictable ones. Schull’s findings and similar research, however, go way beyond Skinner’s work. Today’s game science has become what a New Scientist article called “a recipe for obsession”—a way to engineer games to make playing them more compulsive. Ludic loops have become a central tenet of game design.

As an example, a friend of mine trying to learn French has developed a quasi-addiction to the app Duolingo and the ludic loops built into it. He finds it hard to stop “playing” after reaching his daily goal, often spending an hour or more interacting with the game. He gets into a pleasant and energizing reverie (is that French?) while playing. He worries that if he misses a day, he’ll lose a wager (of imaginary points) that the game offers him, or drop down a notch on the leaderboard of other learners. He claims he was never so diligent when taking classes or studying on his own. And he says he’s having a lot of fun.

For someone looking for help in overcoming bad health habits, this is precisely what the doctor ordered. We know that people often try again and again to change their health behaviors, only to slip back under stress or when caught off guard. There’s a statistic from a 2016 study, for example, that people who quit smoking on average do so only after trying – and failing – 30 times.[1] People, it seems, want to have better, more effective choices they can rely on to give their efforts staying power. When willpower flags, ludic loops provide staying power in abundance.

The stakes in health care are often a lot higher than in other areas where gamification works. A patient who succeeds in taking blood pressure medications could prevent a deadly stroke, for example; changes in diet and lifestyle can reduce risk of some cancers. That’s a strong argument in favor of offering patients the power of ludic loops.

Some critics of the game industry say that the “addictiveness” of games raises ethical questions, but  simple common sense suggests that the potential health benefits of, say, reducing tobacco use, decreasing obesity, or preventing a stroke as in my husband’s case, far outweigh any harm associated with obsessively playing a smartphone game.

Can there be too much of a good thing when it comes to healthy behavior? I don’t think so. That’s why I’m eager to see more health challenges addressed by games and their ludic loops… and to see good health become habit-forming.

As a marketer, I’d like to see us continue to explore methodical, scientifically sound approaches to designing and testing games that use a combination of digital best practices, behavior change theory and gamification 2.0 to help patients realize healthy behaviors.  It’s not only fun, it’s the right thing to do.

In upcoming posts I’ll venture into how games can address specific stages along the route to better health behavior—from denial to determination to relapse prevention. Stay tuned!

[1]  Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.  BMJ Open 2016;6:e011045. doi: 10.1136/bmjopen-2016-011045

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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.

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I can’t tell you how many times my marketing clients, especially those in pharma and health care, have asked me that question about using digital technology in creative ways to change consumer behavior. They’ve had good reason to ask. Until now, there’s been little solid evidence or clear guidelines to turn to, and more hype than actual help.

Thankfully, that’s changing. In fact, great strides are being made through applying new insights from digital technology through the use of apps with strategies and tactics from behavioral and game science—a phenomenon I’m calling Gamification 2.0. These insights are turning what some considered a fad into possibly the most powerful tool in the behavior-change arsenal, applicable to enhancing patient education, prescription adherence, managing chronic diseases, and much more.

As a digital and integrated marketing communications strategic consultant, I’ve been closely following the gamification phenomenon almost since the beginning. That wasn’t so long ago: The term was first coined in 2008 but only gained widespread usage beginning in 2010. That was around the time when two clients of mine, one in financial services and one very forward-thinking maker of OTC children’s meds, piloted a couple of the first in-market programs I know of. Gamification has since been defined in many ways, but the definition most people use is “the application of game-design elements and game principles in non-game contexts.” (Wikipedia).

The idea first caught on as observers started to realize how many hours people were spending playing games like Candy Crush on their smartphones. I was amazed that subway riders would miss their stops over such absorbing play. Games on this platform clearly had the power not only to command engagement and attention, but also to sustain it over not only hours, but days and weeks. Indeed, the video/mobile game industry now dwarfs Hollywood in annual sales ($138 billion to $38 billion), according to some analysts. What if that power could be turned on stubborn problems like medication adherence and lifestyle changes?

Early enthusiasm led to some stumbles. Just as early Web sites were often lackluster “brochure-ware”—repurposed text and art served up without understanding how people really use the Internet—early health behavior apps for smartphones were neither games at all nor a lot of fun. A 2014 review of leading health and fitness apps found that fewer than 50% of them integrated gamification components or true game elements. The authors also found that few apps employed recognized health behavior theory constructs, “thus showing a lack of following any clear industry standard of effective gaming, gamification, or behavioral theory in health and fitness apps.”

Well-intentioned though these beginning steps were, results were scattershot. My own OTC client was able to show increased brand reach and awareness, but metrics in those days had not yet evolved sufficiently to link sales increases with the digital initiative or to measure ROI. Some in the industry considered giving up on smartphone apps as a marketing channel.

Then the industry got serious.

2012 saw the first peer-reviewed scientific publication, Games for Health Journal, debut with well-controlled studies on health gamification. A second journal, JMIR Serious Games, began publishing the year after. Global conferences brought together experts to bring discipline and rigor to the subject (the 7th International Conference on Serious Games and Applications for Health, IEEE SeGAH 2019, was held in Kyoto, Japan in August.)

From these and other sources have finally come the guardrails, guidelines, insights, and best practices we’ve searched for. Today we are applying success factors derived from Minecraft, Pokémon Go, and other blockbuster games with behavioral science and (of course) digital best practices to drive journeys to lasting health improvements. Badges, leaderboards, points and levels, challenges and quests—these are some of the elements found in the most effective behavior-changing apps such as Boehringer Ingelheim’s RespiPoints and in offerings like Pfizer’s HemoCraft.

The good news is gamification testing is now more mainstream, with major players creating and developing serious in market programs. In my next post, I’ll dive deeper into how second-generation gamification is aiming to build patient confidence and motivation, particularly in stigmatizing illnesses.

Meanwhile, I’m off to play Minecraft.

Games for Health Journal Editor-in-Chief: Tom Baranowski, PhD ISSN: 2161-783X
JMIR Serious Games JMIR Serious Games (JSG, ISSN 2291-9279

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Learn how digital technology can be used to help patients modify or change behavior to manage chronic diseases and other health issues.

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As a result, patients often aren’t taking the medicines they should, or taking them the way they should. That leads to ineffective treatment and side effects, both of which inflate health care costs.

Why is medicine full of such disconnects? Here are several reasons—and, with them, potential solutions.

1.  Many Americans are poor readers. Many, if not most patient education materials are written at the 10th grade level, yet 1 in 5 US adults reads at the 5th grade level (age 10/11) or below. One solution: picture-rich infographics that deliver needed information in a cartoon-like form even low-literacy audiences can take in.
2. Medical jargon is off-putting. Many patients find medical language confusing, but they’re too intimidated by health professionals to ask for clarification. Doctors and nurses who make the effort to choose simpler language get better results. A key strategy: Asking the patient to repeat back the doctor’s instructions in his or her own words.
3. English is a second language for more than 61 million Americans. Consider that the language spoken at home is Spanish for 38.4 million, Chinese for 3 million, Tagalog for 1.6 million, Vietnamese for 1.4 million, French for 1.3 million, and Korean and Arabic for 1.1 million each.³ Children often end up being the translators. If you’re preparing education materials, ensure they’re available in a variety of languages.
4. Doctors aren’t listening. On average, the physician interrupts the patient 18 seconds into the office visit.⁴ Only 9% of patient care decisions are made with patient involvement. We’ve got to replace a condescending “doctor-knows-best” approach with a genuine appreciation for the patient’s experience, even as clinical teams experience relentless time pressure.

When medical communication falters, patient adherence drops. Adherence is the extent to which a patient’s behavior follows medical advice in terms of taking medication and adopting new health behaviors. The most frequent reasons cited by patients for poor adherence are:

• Forgetting to use or renew a prescription (24%)
• Avoiding side effects (20%)
• Drug costs (17%)
• The patient believes he or she no longer needs the drug (11%)⁶

Technological aids such pillbox organizers, smartphone-based reminders, and pharmacy driven refill automation can help patients remember and renew. Answers to the other issues listed above depend, however, on changing patient understanding of what’s involved. Patient education and better patient-physician dialogue are needed.

To communicate better in medicine, one size doesn’t fit all and individualization pays off in better outcomes. Clinical teams can and should look beyond the symptoms and assess the context of the individual patient’s attitudes and behaviors. Patient-centered encounters can then be individually adjusted so as to increase comprehension, adherence, and patient satisfaction.

Importantly, the focus of the visit can change from diagnosing the problem to implementing a realistic care plan. This includes involving patients in assessing how successful their therapy is in relation to predetermined and agreed goals. When reasonable expectations are articulated well, understood, and agreed, it is far more likely that the desired result will be achieved. These expectations must include discussion of potential benefits and risks of treatment (in language relevant and understandable to the patient), as well as costs of both treatment and poor adherence.

As part of patient communications and education programs, key performance indicators should be assessed at various points along the patient’s journey; it’s not just that the symptoms improve, but that they do so in a sustainable and self-reinforcing way. When patients believe the action to be taken is attainable and they see tangible progress, they’re more likely to stay on course.

We’re not going to see overnight changes in how medical consumers understand their bodies and the interventions that can help them. With some of these insights, however, we can substantially improve the status quo—with health and economic benefits for us all.

References:
1. Danny Hakim. Ask your doctor; until then, here’s a word from our sitcom. https:// www.nytimes. com/2018/03/09/business/drug-commercials-product-placementblackish. html. Accessed March 12, 2018.
2. Kaplan SH, Greenfield S, Ware Jr JE. Assessing the effects of physician patient interactions on the outcomes of chronic disease. Med Care, 1989, 27 (supplement 3), S110-S127. 3. Data are derived from the 2013 American Community Survey of the Census Bureau. Cited in Camarota SA, Ziegler K. One in Five U.S. Residents Speaks Foreign Language at Home. Center for Immigration Studies. https://cis.org/One-Five-US-Residents-Speaks-Foreign-Language-Home-Record-618-million. Accessed March 12, 2018.
4. Beckman HB, Frankel RM. The Effect of Physician Behavior on the Collection of Data. Ann Intern Med. 1984;101(5):692-696. DOI: 10.7326/0003-4819-101-5-692.
5. Boston Consulting Group. The Hidden Epidemic: Finding a cure for unfilled prescriptions and missed doses. http://www.bcg.com/publications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf.
6. Marcum ZA, Sevick MA, Handler SM. Medication Nonadherence: A Diagnosable and Treatable Medical Condition. JAMA. 2013;309(20):2105-2106. doi:10.1001/ jama.2013.4638

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Based on the revolution in technology, companies need to reimagine the way they sell and communicate with customers and prospects. Based on a company’s growth objectives or barriers to success, business and brand managers need to take a deep look into the analytics to derive actionable insights to determine whether a company needs to refine, retool, redefine or reinvent itself or the way and how it communicates with its customers.

Do you want to expand your customer base or entice customers buy more? Make e-commerce work profitably for your business? Do you want to convert business customers into leisure customers or generate more repeat stays? Do you want to help patients adhere to drug regimens to improve their health? Do you want to know how the new CX paradigm can positively affect ROI?

There’s a simple approach we at Beverly Beaudoin and Associates follow. Some of you may say the steps are standard operating procedure at your company, but in the digital economy, we’ve seen many a company short circuit process to the point of not having critical data needed to make the right decisions for their company’s future.

The 4R’s Process: Roadmap To Success

The process has 7 steps. Based on the stage of product, service or company life cycle, some steps may be accelerated or some may be streamlined or combined with others. The roadmap steps:

1. Audit & Consumer Listening: We listen to what customers and prospects are saying about your brand on social media. We assess what has or has not been successful in communicating the brand.
2. Competition: We analyze how your competitors and their value propositions differ from your brand and how they fulfill unmet or unique consumer needs vs. your product or service.
3. SWOT Analysis: Your company/brand Strengths, Weaknesses, Opportunities and Threats. This analysis helps us find quadrants of opportunity, gaps or overlaps in the market. We determine what market space your company can own.
4. Target Audience Identification and/or Profiling: We gain deeper knowledge into customers’ buying habits, motivations, rational and emotional needs to determine the ability of your business to reach more customers who are like your best customers or find new pockets of customers you may be missing.
5. The Positioning Statement(s): We create statements that articulate your brand’s key competitive difference and/or what unmet consumer or business need it fulfills. All future communications drive off this critical point of differentiation.
6. The Value Message Architecture: We develop your company/brand promise to the consumer and its key distinguishing value claims. It also articulates key message support with emotional and rational reasons to believe.
7. Program Definition & Deliverable: From the above, Beverly Beaudoin and Associates creates the recommendations to achieve the stated business or brand objective(s). Based on insights from the analysis, Beverly will identify business solutions or opportunities, communications programs, advertising improvements or business efficiencies needed, making specific recommendations in an in-person presentation.

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