Groundhog Day: Seeking Process in Gaming for Health

Keynote for IEEE SeGAH 2025, the 13th International Conference on Serious Games and Applications for Health, August 6, 2025 in Manchester, UK.

These days, reading through the abstracts of any given conference proceedings or journal on serious games or gamification fills me with a profound sense of déjà vu: all (or most of it) is good and solid work, and yet – pilot after pilot, trial after trial, framework and review after framework and review, what have we really learned? In this keynote, I will draw on my experience as designer, researcher, and editor to speculate on some of the barriers to cumulative scientific progress in gaming for health, and chart some possible solutions.

Transcript

1. Groundhog Day Seeking Progress in Gaming for Health Prof Sebastian Deterding Dyson School of Design Engineering Imperial College London @codingconduct.cc @codingconduct@hci.social
2. Almost every new applied gaming paper I read
3. Retrofuturist Longing
4. 1997 1977 1970
5. It’s 55 years later! Where are my flying cars?!? •Training games in every medical and nursing school? •Prescription games for every behavioural intervention? •Public health campaign games on every social media channel? •Health game industries with strong GVA, employees, valuations, revenues, profits, serviced markets, …
6. The great 2020 success story?
7. 2024: Taken private at 4% of valuation, after letting go 46% of staff and sustained massive losses
8. Prescription Digital Therapeutics and Digital Health keep growing, but “games” are not on the map* * Of 13 FDA-cleared PDTx, only EndeavoRx self- labels as game
9. NICE: Play COTS games to distract from restless leg or smoking cravings, counter mild dementia, improve mood
10. We are stuck in promise land
11. The New Black* Serious games! 1970 2010 Gamification! * Rekindles public debate and R&D funding 2001 2017 2021 Serious games! 1990 Edutainment! XR! Metaverse! 2023 AI+!
12. “Soon”
13. Ubiquity Certainty Genesis Custom-built Product Service/commodity Wonder Imagine what it could do! Building & awareness How to make your own & why that matters Difference & operation Which one to buy & how to maintain it Use How to use it efficiently Wardley: New tech follows a curve of commoditisation
14. Ubiquity Certainty Genesis Custom-built Product Service/commodity Wonder Imagine what it could do! Building & awareness How to make your own & why that matters Difference & operation Which one to buy & how to maintain it Use How to use it efficiently Health games are stuck at custom-built
15. Single custom-built breakout successes … … do not make applied games a commodity
16. 10 reasons, 3 calls to action Why are we stuck?
17. Unclogging the translation pipeline
18. Health games are stuck in the translation pipeline Most work today Where we should extend to 10.1016/j.mayocp.2023.02.005
19. #1 Health games lack service design and implementation Nice idea that works in the lab … but how do you get it to work in real world constraints?
20. Lab studies leave a vast range of customer journey questions unanswered that make or break success • How do people learn about it & decide to use? • How do they find it? • What touch points do they go through? • How do they resolve errors, queries, …? • How do they share the word? • …
21. There’s an equal amount of unanswered staff-side questions that make or break success • Who delivers and installs? • Who instructs how? • Who maintains how? • Who supports in case of issues? • Who upgrades how? • …
22. Service design can help us address these questions for b2b and b2c game services https://grantbook.com/service-blueprints-grantmaking
23. ! We have an open PhD studentship on service design for undergrad science education game, apply by Aug 17: " https://bit.ly/games-phd-25 #
24. Even more questions when implemented in healthcare institutions – addressed in implementation research
25. #2 Adherence and retention are big real-world efficacy issues – especially for digital interventions • 35% longer-term (>8wks) attrition • 8-41% non-users (don’t even download app) • Only 34-64% fully adhere to programme • 75% of health app users stop using after 10 uses • Only 2% of an asthma tracking app still used at 6m follow-up
26. Games and gamification promise retention and adherence motivation from the outset …
27. Longitudinal (6m) RCT, n=69, with major app Fitocracy No significant differences in physical activity, body fat %, intrinsic motivation between gamification and control group Main issue: Non-use/quick disengagement Gummelt, 2017 … and yet they can fail to deliver just that
28. The evidence that games drive adoption, adherence, retention is just not there (yet?) • Few high-quality adoption, adherence, retention studies • Few intention-to-treat studies, existing find games work less well (14% in Primack et al. 2012) • Few active/treatment as usual comparators (34% in Primack et al. 2012) • Few studies reporting and measuring over typical/target treatment duration
29. #3 Cost-effectiveness sells non-functional qualities – a lesson learned in IT and UX design
30. Cost-effectiveness of adherence could sell health games – especially to insurers and public funders
31. But again, cost-effectiveness studies of health games like this one are the absolute exception
32. Let’s study adoption, retention, adherence*; cost-effectiveness; service design and implementation * ITT RCTs with treatment-as-usual controls and treatment-typical duration
33. Bridging the Valley of Death
34. Health games hit the Valley of Death – and face some additional funding barriers
35. #4 Games have a less clear IP “moat” than traditional pharmaceuticals or medical devices
36. #5 Digital therapeutics regulation is only emerging – and can be geared toward/captured by incumbents
37. #6 Games have less clear customers and business models
38. #7 Games need to cross the chasm among clinicians – who would recommend/prescribe them
39. #8 Health games lack a commoditisation flywheel: a multi-sided market platform that attracts/generates $ Cables, power plants Appliances Electricity usage
40. A Roblox for health games? A tool/market platform for produsers
41. #9 Health games face consumerisation pressure – possibly much more strongly than other health tech Syndicate (1993) <£2.5m (inflation-adjusted) Cyberpunk 2077 (2020) ≅$436m
42. incumbents regulation buyers users Consequence: Growth happens in gamified wellness apps with … • Low regulation • Buyer = consumer (b2c) • Low prior incumbent capture • Game-literate buyers • Established business and monetisation models • Lower consumerisation pressures production Health games hit the funding valley of death – also due to an under-developed/unclear market fit
43. Health game team science with health economics, business, law, etc. •Developing new business models •Identifying regulatory hurdles, developing regulation guidance •Identifying clinician adoption hurdles and marketing strategies •Identifying new public, 3rd sector financing strategies to address market failures
44. Resolving Genre Troubles
45. #10 Health game researchers are all “from elsewhere” – creating fuzzy, parallel, limited contribution genres
46. “We made a thing” is a common denominator for disciplinary contributions – but unclear for health games Computer Science New algorithm/system Design New design methods Health science New treatment mechanism HCI New user insights/interface Default case study “We made and tested a new serious game” Contribution to health games ???
47. Convergence research around health impacts could create a clearer agenda https://www.nsf.gov/funding/learn/research-types/learn-about-convergence-research
48. Convergence research around health impacts could create a clearer agenda – if embraced by funders https://www.nsf.gov/funding/learn/research-types/learn-about-convergence-research
49. A funder-supported convergence science agenda for health games
50. Summary
51. 55 years on, commoditised health games are still sci-fi
52. Ubiquity Certainty Genesis Custom-built Product Service/commodity Wonder Imagine what it could do! Building & awareness How to make your own & why that matters Difference & operation Which one to buy & how to maintain it Use How to use it efficiently Health games are stuck in custom built
53. Health games are stuck in the translation pipeline Most work today Where we should extend to
54. Health games are stuck in the Funding Valley of Death
55. To get unstuck …
56. We need new kinds of studies Adoption, retention, adherence; cost-effectiveness; service design & implementation
57. We need new colleagues Business and legal scholars, implementation researchers, health economists, …
58. We need to convince funders of a new agenda Convergence science of real-life health impacts with games
59. Then, health games may actually be … closer than we think
60. Thank you. @codingconduct.cc @codingconduct@hci.social PhD studentship: " bit.ly/games-phd-25 #