NOTE: vacciNATION is currently running with data from the 2012 season.
This blog introduces an app BioMedware developed in response to CDC’s Flu App Challenge. This challenge calls for an innovative use of technology to raise awareness of influenza and educate consumers on ways to prevent and treat the flu. BioMedware’s submission is called vacciNATION.
At the time of this writing, the role small apps and games can or should play in health communication, promotion and intervention is not entirely clear. Last week, I attended the first half of the Games for Health conference in Boston, which took place near Logan airport in a patchy fog that afforded only occasional glimpses of Boston Harbor. I arrived in a skeptical frame of mind, ready to learn, but not seeing how gaming could possible lead to the long-term behavioral changes needed to improve the health of individuals. By the time I left I saw how the intersection of social networks and gaming could be a powerful force for encouraging, accomplishing, and sustaining salubrious health behaviors. From skeptic to cautious convert in 2 days? How is this possible?
Individual behavior and health: A host of studies have demonstrated the importance of individual behaviors in health. Exercise, a healthy diet, and a positive outlook on life are associated with positive health indicators such as appropriate body weight, lower blood pressure, good cholesterol, and improved immune system status, among others. In population studies, positive health indicators such as these are associated with decreased adverse outcomes such as heart disease, cancers and shorter life spans. What is not as clear is how we might accomplish durable – and by that I mean long-lasting – changes in individual health behaviors. Communicating health risks and giving access to instruction and programs is usually not sufficient. Dieting, for example, is notorious as an initially successful but often brittle (not durable) intervention, with many dieters who achieve their goal weight returning to their initial body weight within a year or so. What makes for durable change in health behaviors?
Durable behavior change and the social network: There is increasing evidence that social networks are part of the solution to durable behavior change. Consider, for example, the obesity epidemic, which is one of the most important health challenges in the U.S. today.
The CDC recently published a striking animation of the spread of obesity in the U.S. (Figure 1). Increasing body mass index when measured at the state level has been relentless, although some states have put on weight faster than others. Although high BMI clearly is spreading, what mediates its spread? One key factor appears to be social relationships, as illustrated by a study published in the New England Journal of Medicine (Figure 2). Light people tend to have other light people on their social network, as shown by the black ellipse in Figure 2, while obese people tend to have other obese people on their social networks, as shown by the red ellipse.
Each circle represents one person, there are 2200 persons in this social network. Circles with red borders denote women, and circles with blue borders denote men. The size of each circle is proportional to the person’s body-mass index, color indicates obesity status: yellow denotes body-mass index ≥30) and green denotes a nonobese person. The colors of the links between people indicates social relationship: purple denotes friendship or marriage and orange denotes a family. Adapted from Christakis NA et al. N Engl J Med 2007;357:370-79.
This illustrates that the spread of obesity is heterogeneous, both at macro-geographic (Figure 1) and individual-level scales (Figure 2). The “lumpiness” in Figure 2 has an important implication: health behaviors related to body weight are both spread and maintained by the social network, an aspect that is firmly reinforced when one views the animation in the web version of the paper by Christakis et al. (2007). Initially, the entire social network is relatively “light”, through time sub-portions of the network become heavier while other sub-portions maintain lower body weight (e.g. the social network in the black ellipse in Figure 2). That relationships on social networks are important in maintaining positive health behaviors makes sense when we think about the influence friends and family have on what we eat and the daily activities we engage in.
Gaming as an engine for changing personal health behaviors: What I learned at the Games for Health conference is that successful games require interaction on a social network, and often provide opportunities to expand the player’s social network to other gamers. In addition, the potential to accomplish durable behavioral change is high because of our natural competitiveness: improving our own scores becomes its own reward. At first blush it thus appears that games indeed might be part of the equation for improving our nation’s health, in that they may provide a venue for health communication that builds on social networks to accomplish goals associated with positive health behaviors.
So what characteristics must an effective health game have?
- The game must address a significant health problem (e.g influenza).
- It must communicate the current status of the health problem in a readily understood fashion (e.g. health maps and trends).
- It must seek to promote positive health behaviors (e.g. vaccination and the reduction of infection transmission)
- It must incorporate proven aspects of successful games including interactivity, rewards, and scoring.
- It must leverage social networks to promote awareness and foster adoption.
We had these characteristics in mind when we designed vacciNATION. The problem addressed is an important one – the surveillance and control of influenza. The app communicates influenza status and trends using maps and animations of the spread of flu and the penetration of vaccinations in different age groups. It seeks to promote positive health behaviors including vaccination and reducing infection transmission during an individual’s infectious periods. The flu game educates users regarding vaccination strategies and incorporates interactivity (vaccinating state populations), and scoring that rewards efficient allocation of resources. Finally, gamers may tweet their scores and the successful strategies for achieving them.