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Groundhog Day
Seeking Progress in
Gaming for Health
Prof Sebastian Deterding
Dyson School of Design Engineering
Imperial College London
@codingconduct.cc @[email protected]
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Almost every new applied gaming paper I read
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Retrofuturist Longing
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1997
1977
1970
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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, …
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The great 2020 success story?
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2024: Taken private at 4% of valuation, after letting go
46% of staff and sustained massive losses
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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
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NICE: Play COTS games to distract from restless leg or
smoking cravings, counter mild dementia, improve mood
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We are stuck in
promise land
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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+!
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“Soon”
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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
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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
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Single custom-built breakout successes …
… do not make applied games a commodity
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10 reasons,
3 calls to action
Why are we
stuck?
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Unclogging the
translation pipeline
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Health games are stuck in the translation pipeline
Most work today
Where we should extend to
10.1016/j.mayocp.2023.02.005
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#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?
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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?
• …
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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?
• …
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Service design can help us address these questions for
b2b and b2c game services
https://grantbook.com/service-blueprints-grantmaking
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! We have an open PhD studentship on service design for
undergrad science education game, apply by Aug 17:
" https://bit.ly/games-phd-25 #
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Even more questions when implemented in healthcare
institutions – addressed in implementation research
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#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
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Games and gamification promise retention and adherence
motivation from the outset …
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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
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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
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#3 Cost-effectiveness sells non-functional qualities
– a lesson learned in IT and UX design
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Cost-effectiveness of adherence could sell health games
– especially to insurers and public funders
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But again, cost-effectiveness studies of health games like
this one are the absolute exception
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Let’s study adoption,
retention, adherence*;
cost-effectiveness; service
design and implementation
* ITT RCTs with treatment-as-usual controls and treatment-typical duration
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Bridging the
Valley of Death
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Health games hit the Valley of Death
– and face some additional funding barriers
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#4 Games have a less clear IP “moat” than traditional
pharmaceuticals or medical devices
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#5 Digital therapeutics regulation is only emerging
– and can be geared toward/captured by incumbents
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#6 Games have less clear customers and business
models
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#7 Games need to cross the chasm among clinicians
– who would recommend/prescribe them
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#8 Health games lack a commoditisation flywheel:
a multi-sided market platform that attracts/generates $
Cables,
power plants
Appliances
Electricity usage
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A Roblox for health games?
A tool/market platform for produsers
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#9 Health games face consumerisation pressure
– possibly much more strongly than other health tech
Syndicate (1993)
<£2.5m (inflation-adjusted)
Cyberpunk 2077 (2020)
≅$436m
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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
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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
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Resolving
Genre Troubles
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#10 Health game researchers are all “from elsewhere”
– creating fuzzy, parallel, limited contribution genres
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“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
???
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Convergence research around health impacts could create
a clearer agenda
https://www.nsf.gov/funding/learn/research-types/learn-about-convergence-research
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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
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A funder-supported
convergence science
agenda for health games
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Summary
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55 years on, commoditised health games are still sci-fi
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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
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Health games are stuck in the translation pipeline
Most work today
Where we should extend to
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Health games are stuck in the Funding Valley of Death
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To get unstuck …
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We need new kinds of studies
Adoption, retention, adherence;
cost-effectiveness;
service design & implementation
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We need new colleagues
Business and legal scholars,
implementation researchers,
health economists, …
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We need to convince funders of
a new agenda
Convergence science of real-life
health impacts with games
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Then, health games may actually be … closer than we think
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Thank you.
@codingconduct.cc @[email protected]
PhD studentship:
" bit.ly/games-phd-25 #