We4Fit: A Game with a Purpose for Behavior Change - IEEE Xplore

Proceedings of the 2014 IEEE 18th International Conference on Computer Supported Cooperative Work in Design

:H)LW: A Game with a Purpose for Behavior Change Carla V. Pereira, Gustavo Figueiredo, Maria Gilda P. Esteves, Jano Moreira de Souza PESC/COPPE/UFRJ, Graduate School of Engineering, Federal University of Rio de Janeiro Rio de Janeiro, Brazil {cvpereira,gustavodsf,gilda,jano}@cos.ufrj.br encourage the adoption of healthy behaviors by consumers to engage in disease prevention, health promotion, and early detection [13].

Abstract—Smartphones are increasingly present in our daily lives. Since the launch of the Apple store, more than 500,000 applications were built and some 25 billion downloads were made. We are facing an era where the traditional medical paradigm is leaving the traditional physician-centred model and evolving towards a new de-centralized model where patients are given more responsibility for their health. In this new health care context, the premise whereby many people are eager to contribute by sharing health information, anytime and anywhere, should be included in the design of new technologies to support collaborative work in healthcare. This article presents We4Fit, a mobile phone app intended to change the behavior of the users through participation in a collaborative game. The game was developed to show how gamification can be used as a motivational trigger and the value of persuasive technology in changing the eating habits of the users and in promoting a healthy life.

Key behavioral factors (such as problematic lifestyle choices concerning diet, exercise, drug use (i.e., alcohol and tobacco), sexual practices, and exposure to environmental risks are key contributors to many worldwide health problems that directly influence the “global burden of disease” [14]. Changing a lifestyle habit often means trying something new and different, and this has proven difficult for most people [5] and promoting a behavioral change can be a challenge. We can find many of health, fitness and medical apps available in the main mobile app stores intended to change specific behaviors using persuasive technology. B.J. Fogg, a pioneer in the use of technology to change human behavior, says that what prevents change in a target behavior is a combination of three categories: lack of motivation, lack of ability, and a lack of a well-timed trigger to perform the behavior [18].

Keywords— health; behavior change; persuasive technology; serious games, mobile games; medicine 2.0; collaborative games

I.

INTRODUCTION

Games are rapidly becoming an important tool for improving health behaviors such as healthy lifestyle habits and behavior modification, self-management of illness and chronic conditions, and in promoting a healthy physical activity [15]. When we use game design elements in a non-game context – e.g., to promote behavior change – we are entering a new field of research called gamification [16] [17]. Turning an experience into a game – including some reward for achievement – can produce unprecedented behavior change [9] and can be important in improving health.

The advance of Information Technology and the evolution of the Web are promoting changes in processes and relationships even in the most traditional areas such as Medicine, which has kept a clear definition of the roles of physicians and patients. However, the doctor-patient relationship has been affected by this new wave and is moving to a model where the patient becomes more participatory and responsible for one’s health [10]. New research communities and conferences were created and new terms appeared such as Medicine 2.0, Health 2.0, Social Health, e-Health, e-Patient, to investigate what is changing in this new way of practicing medicine. G. Eysenbach, creator of the Medicine 2.0 congress, defined Medicine 2.0 applications, services and tools as Web-based services for health care consumers, caregivers, patients, health professionals, and biomedical researchers who use Web 2.0 technologies and/or semantic web and virtual-reality tools, to specifically enable and facilitate social networking, participation, apomediation, collaboration, and openness within and between these user groups [13]. Nowadays, there is a broad range of Web-based applications such as health information websites, online social support networks, interactive electronic health records, health decision support systems, tailored health education programs, health care system Web portals, mobile health communication devices, and advanced telehealth applications. These new tools have tremendous potential to

This paper presents We4Fit, a mobile phone game designed to promote behavior change in bad eating habits of users through the participation in an amusing and collaborative game using persuasive technology. II.

The first review of a weight-loss mobile apps was done by [6] in 2009. In this article, 204 apps directly related to weight loss and weight management were selected and evaluated. The mobile apps were reviewed and classified, taking into account their level of adherence to 13 evidence-informed practices common to governmental agencies [6]. Results showed that

83 978-1-4799-3776-9/14/$31.00 ©2014 IEEE

BACKGROUNG

Although our work was not directly related to weight loss, we started our study by doing an investigation on the available app related to diet and weight control as they deal with important issues such as eating habits and behavior change.

The background acquired in the evaluation of existing initiatives was a key step to give insight to our group. We learned how apps automated behavior change, got inspired by some approaches, and identified lacks and needs to map our next steps.

43% of the apps recommended or provided a tool for keeping a food diary and just 3% provided social support. Keeping a food diary is very important to infer what is going wrong with our meal choices, but this activity is not part of our daily routine and is not a pleasant task to be performed, being just the opposite. Making notes about everything one eats can be extremely annoying. Research has shown that electronic self-monitoring is more effective at changing weight outcomes than the more cumbersome paper diaries [6]. The Eatery is an app that asks the user to take a photo of everything one eats. This approach is more flexible than asking the user to inform the calories of the food. Although this process sacrifices accuracy, it is much easier and friendlier to the user.

TABLE I.

PERCENT OF EACH STRATEGY FOR THE 43 APPS REVIEWED

Ongoing social support from family and friends as well as other sources may help to sustain weight loss efforts and group-based treatment approaches improve the efficacy over individual treatment approaches [6]. By using social media we can connect geographically distributed people who are going through the same treatment or have the same interests. A recent study under the current scenario was conducted by [20] in 2012. This study is complementary to [6] in identifying the apps that include the highest proportion of behavioral strategies, identify which behavioral strategies have yet to be adapted into a mobile format, identify technology-enhanced features of apps that reduce user burden and compare free to paid apps in terms of evidence-based strategies and technology-enhanced features [20]. Understand the technologyassisted strategies present in the apps was very important to our work, as it may enhance adherence, help prevent relapse, improve outcomes and make the process of eating healthy more enjoyable.

III.

PERSUASIVE TECHNOLOGY

Persuasive computing technology is a computing system, device, or application intentionally designed to change a person’s attitudes or behavior in a predetermined way. Persuasive computing technologies can bring about constructive changes in many domains, including health. In the process, computers can help us improve ourselves, our communities, and our society, and function in three basic ways – as tools, as media, or as social actors – each affording different pathways to persuasion [19].

Armed with this background acquired in previous studies, we started in December 2013 an informal review of 43 apps available for iTunes. These apps were investigated under the “Health and Fitness” category using the expressions “weight loss” and “diet” to identify features to enhance change behavior as presented in these apps. We downloaded each of the 43 apps and investigated the app’s features and tools, searching for persuasive strategies and taking three factors into account: trigger, ability, and motivation. Results are presented in TABLE I.

B.J. Fogg proposed eight steps to outline a path to follow in designing persuasive technologies [18]: Step 1: Choose a simple behavior to target for change Step 2: Choose a receptive audience

Our findings were consistent with those of the two previous works, which found that most of the apps use weight-loss goals and found that the apps still lack an use of social media to provide more interaction between users. We also saw that few apps use challenges and game mechanics in the weight-loss context and just three apps users were able to collaborate in groups.

Step 3: Find what is preventing the audience from performing the target behavior Step 4: Choose a familiar technology channel Step 5: Find relevant examples of persuasive technology Step 6: Imitate successful examples

In order to evaluate the benefit of using competition strategies, we chose the most popular apps for tracking physical activities. They were Strava, Run Keeper, Sports Tracker, and Endomondo. Strava is an app to tracks rides with a GPS like many other apps; what makes it different from others is the elements of competition this application has. One can see what one’s relative position against friends and other users is. The app shows leaderboards and other status items such as medals and trophies for the best results.

Step 7: Test and iterate quickly Step 8: Expand on success In our work we chose the eating habit as our behavior target. Our initial selected audience has people over 18 who demonstrate a desire to improve their diet and who enjoy using mobile phone apps, which is our chosen technology channel. Our goal is to motivate the users to eat better through the participation in a collaborative game, using elements of

84

competition and social factors. The results shown in Table I helped us select the group of strategies we should consider in the first stage of the app. As our project expands, we plan to add more features to increase engagement. IV.

To change eating habits is neither an easy nor pleasant task, but one can make it more fun by turning the experience into a game. Games have begun to influence our lives every day. As our society becomes more and more game-obsessed, much of the conventional wisdom about how to design products and market them to consumers is no longer enough. To further engage our audiences, we need to consider reward structures, positive reinforcement, and subtle feedback loops alongside mechanics such as points, badges, levels, challenges, and leaderboards [9].

GAMIFICATION

Games have begun to influence our lives on an every-day basis. They affect everything from how we vacation to how we train for marathons, learn a new language, and manage our finances [9]. Gamification can be defined as “the use of game design elements in non-game contexts” [16]. What makes a game attractive is not its theme but rather its mechanics. Even games that intend to make users eat healthy can be an enjoyable experience if one uses the right elements [4].

V. SERIOUS GAMES AND MOBILE DEVICES Serious Games can be applied to a broad spectrum of application areas including healthcare. They are used for purposes other than mere entertainment, such as education and training [3]. Serious games applications related to health and healthcare are becoming more common, one category of them is called “exergaming”. Exergames aim to promote healthy habits by adding engaging elements to physical activities.

A. Games McGonigal defined four key elements for games [15]: 1.

A specific goal that people are willing to work for.

2.

Rules that stimulate creativity within specified boundaries.

3.

A feedback system that lets individuals know how they are going as regards the goal.

4.

Voluntary acceptance of the goal, rules, and feedback information.

The recent emergence of smartphones opens up new ways to reach a crowd of people, users of these devices, and to apply them to health and behavior-related issues. Smartphones offer their users app stores where external developers gain space to advertise and sell their products. The applications available to users are categorized by subject. Various features, from ubiquitous and pervasive computing, as found in smartphones, make them good candidates for the delivery of behavioral interventions. Because they are portable devices, highly valued by individuals, they tend to be switched on and remain with the owner throughout the day. In addition, smartphone apps offer solutions that are cheaper, more attractive and less stigmatized than other ones available [1].

Below we describe a system of rewards proposed by the authors [4]. • Status: Status is the relative position of an individual in relation to others, especially in a social group. Some examples or status items include badges and leaderboards.

The technical aspects of smartphones also help: they usually stay connected to the Web, furthering the exchange of information between healthcare professionals and users; the increasing ability of smartphones that can use the internal sensors found in these devices to infer information such as geolocation, movement and emotions, enable the monitoring of health-related behaviors; mobile devices have storage space to store data that can be saved in various formats such as text, image, video and audio; and we can find measurement devices, such as blood pressure meters and glucose monitors that have interfaces to communicate with mobile devices.

o Badges – Badges are a known status item. They can be given virtually or physically. However, they must be visible to other players; otherwise their meaning and valuation is limited. o Leaderboards – Leaderboards are another way to indicate that a player has some more or less status in a given game; they can be a powerful tool in the quest for engagement. • Access: To provide access reward to a player can give early access to some features.

Promoting behavioral change can follow three basic ways: to encourage an individual to slow down on a particular negative habit, part of one’s routine, such as quitting smoking or drinking; encouraging one to assume a new positive behavior, e.g., starting a physical activity routine, or reinforcing a positive behavior the individual already has, such as encouraging healthy eating [11].

• Power: Power reward is to offer a bit of control over the players in the game. For example, a good player might be asked to serve as a moderator in a forum. •

Stuff: Stuff rewards are items given away to players.

B. Games for Health Games are rapidly becoming an important tool to improve health behaviors, ranging from healthy lifestyle habits and behavior modification, self-management of illnesses and chronic conditions, to motivating and supporting physical activity [15].

By combining serious games strategies and mobile devices we can benefit from mobile phone features to engage users to perform tasks in a fun experience.

85

VI.

WE4FIT

To apply the concepts described in the previous sessions and design an application that at the same time makes weight control, promotes social interaction and behavioral change, we envisioned the design of a collaborative application for mobile phones called We4Fit. The purpose of the application is causing a change in user behavior, promoting an improvement in eating habits through the use of game engines, blending elements of social integration and competition. The user may participate alone or as part of a group, and each user has to post pictures of the food consumed during the day. The photos go through a collaborative process of voting, their grade ranging from 0-100, indicating how healthy the food photographed is. Each round of the competition lasts seven days, and at the end of the interval the sum of the notes is computed and the group that receives the highest score is the winner. According to psychologists, joining a slimming group is the best way to lose weight. Researchers found that the support received at such groups led to dieters losing three times as much as those attending groups supervised by medical professionals [12]. We expect that being a part of a group can be an extra motivating factor for the users, as members can share their results and encourage others to eat healthy.

Fig. 1. User Profile

2) Forming Groups In this section, the user can create a group or simply join an existing one. The group has a name, a description and the user has to choose a type to classify his/her group, choosing the option that best fits from a list.

To verify the effectiveness of the game and allow the users to follow up on their progress, the application asks them to provide some personal information and body measurements such as height, weight, waist and hip measures, and also asks users if they suffer from some chronic disease influenced by the diet. By monitoring measures and symptoms associated with diseases one can assess whether the use of the application improved the health of the users.

The user that creates the group becomes its moderator and is the person responsible for inviting other members and also removing users from the group whenever necessary. Users that are invited to the group are notified and have to accept or decline the invitation.

The principle is very simple, as the healthier the food one eats is, the better is the grade one gets. Group members should work together, persuading others to eat better food to obtain the best results for the group, each member being an important element in the game. Therefore, the idea of the application is causing a shift in eating habits of the users and, as a result, an improvement in the quality of their lives through the participation in a collaborative game. The following section describes the elements of the game. 1) Creating a Profile In the profile section, the user must enter some required information such as name, email, gender, birth date and password. It is really desirable but not obligatory that the user fills one’s metrics such as weight, height, waist, and hip measurements. The app also asks the user if one suffers from any selected chronic diseases such as insomnia and headaches.

Fig. 2. Group

3) The Posting Mode In this mode the user can post as many pictures of all the food one eats as desired as there is no limit for the number of pictures.

When users do not enter their personal metrics they will not be able to access a feature of the app where one can see one’s history data in a graphic format.

86

The user should take a picture of the food and inform the portion size. Optionally the user can inform the name of the place where he/she had his/her meal, and the app helps the user by showing the name of the places near where he/she is.

5) Ranking In this mode an user can see his/her relative position in relation to other users as well as the relative position of his/her group in relation to the others. A group can also challenge another group, and the app presents the challenges in a separate view.

Fig. 3. The Posting Mode

4) The Votting Mode In this mode the user should give a grade to the picture presented to him/her. A low grade means he/she thinks this food is not healthy and a high grade means the food is very healthy. Each user has a daily quota of pictures to evaluate and when one does not reach the required number, there is a penalty for that.

Fig. 5. Ranking

6) Feed In this mode of the application, users will be able to view news, results, messages and other alerts. They will be notified of invitations to groups, the notes of his/her pictures posted as well as the grades for the group's members. The app also displays data on the penalties the group receives when any member fails to meet the daily goals. We use this mode to report changes in the group ranking. We believe the social interaction will promote user engagement.

The user does not know who posted the picture, and this is a very important rule for the game mechanics as it prevents malicious groups.

Fig. 4. The Votting Mode

Fig. 6. Feed

87

VII. TECHNICAL ASPECTS

The application is now in its implementation stage and we hope to deliver our first version in the next months. We intend to start testing the application with a restricted controlled group and then open it to more users.

The goal of our work is to investigate mobile applications as tools for behavioral change. We want to reach as many users as possible, and to achieve this, our application should not be restricted to a single mobile platform. There are currently two main platforms in the mobile market, IOS and Android, although the efforts from Microsoft and Mozilla to gain market share should not be discarded. We do not intend to develop native applications for each platform as this approach would be costly, in its relying on a multidisciplinary team or larger number of developers.

As future work, we plan to adjust the game mechanics and algorithm according to the first results, to include new elements and rewards to leverage user engagement and bring more fun to the game and feedback to the users.

REFERENCES [1]

When searching for an alternative to this scenario we found PhoneGap. It is a free and open-source framework that allows creating mobile apps using standardized Web technologies such as HTML, CSS, and JavaScript. We are planning to use this framework because we could develop the application using technologies that are familiar to us, which would make our job easier and allow the application to be developed faster. Other advantage in using this framework is that the application can be deployed to the most used mobile platforms in an easy way, so we could have our app running for multiple mobile platforms. The framework also provides APIs for communication and controls, for phone features such as GPS and camera, extremely useful elements in our work.

[2]

[3] [4] [5] [6]

Using the framework we could build a hybrid application that is neither purely HTML/JavaScript based, nor in a specific OS language. Parts of the application, mainly the UI, application logics, and communications with the server is based on HTML/JavaScript and the other part of the app, that communicates and controls the device, is based on the native language of the platform.

[7]

[8]

[9] [10]

However, some limitations had to be overcome during the design of our app interface. We had to use the smartphones’ webviews to render the screens of our application and had to deal with some inconsistencies in Android’s webview that change the shape of rendering of some components from one version to another.

[11] [12]

VIII. CONCLUSION This work presented We4Fit, a smartphone app intended to change the behavior of users through their participation in a collaborative game. The main purpose of the game is to turn a hard task that is changing one’s eating habits into an exciting experience through the use of collaborative game elements.

[13]

[14]

As we know, healthy food can reduce the risk of many chronic diseases. Better eating habits and the regular practice of a physical activity can improve life quality.

[15] [16]

We made an evaluation of existing initiatives available at the iTunes app store, designed to control the user’s diet and weight-loss, got inspired by some approaches, identified gaps and needs and got the inspiration to our work.

[17] [18]

Gamification can be explained as picking and ordinary activity and making it more fun by adding gaming elements. Our experiment chose to promote healthy eating habits in the domain of a contest and social game to engage and affect the behavior of the users.

[19] [20]

88

L. Dennison, L. Morrison, G. Conway, and L. Yardley “Opportunities and Challenges for Smartphone Applications in Supporting Health Behavior Change: Qualitative Study”, Journal of Medical Internet Research, April 2013. J. H.West, P. C. Hall, C. L. Hanson, M.D. Barnes, C. Giraud-Carrier and J. Barrett, “There’s an App for That: Content Analysis of Paid Health and Fitness Apps”, Journal of Medical Internet Research, May 2012. T. Susi, M. Johannesson and P. Backlund, “Serious Games – An Overview”, 2007. L. Von Ahn and L. Dabbish, “Designing Games With a Purpose”, Communications of the ACM, vol. 51, no. 8, pp. 58–67, 2008. V. Katch, “Why is Behavior Change so Hard?” , Michigan Today, available at: http://michigantoday.umich.edu/a8589/, April, 2013. E. R. Breton, B. F. Fuemmeler and L. C. Abroms, “Weight loss-there is an app for that! But does it adhere to evidence-informed practices?”, TBM 2011;1-523-529, 2011. N. Eyal, “Why Behavior Change Apps Fail to Change Behavior”, Tech Crunch, available at: http://techcrunch.com/2013/07/13/why-behaviorchange-apps-fail-to-change-behavior, June, 2013. M. Healy, “Study says: Financial Reward + Competition = More Weight Loss”, Los Angeles Times, available at: http://articles.latimes.com/2013/apr/01/news/la-heb-weight-loss-groupmoney-20130401, April, 2013. G. Zichermann and C. Cunningham, “Gamification by Design”. C. V. Pereira, M. G. P. Esteves, S. P. J. Medeiros, J. M. de Souza and M. Antelio, “How the Crowd can Change Collaborative Work in Patient Care, CSCWD, June, 2013. S. J. Salend, “Creating Inclusive Classrooms: Effective and Reflective Practices”, cap.7, p.278-320, August, 2011. L. Osborne, “Don’t diet on your own: If you want to lose weight, it’s best to join a slimming group, say the experts”, Mail Online, available at: http://www.dailymail.co.uk/femail/article-2215062/MembersWeight-Watchers-groups-lose-times-diet-study-reveals.html, October, 2012. G. Eysenbach, Medicine 2.0 Congress Website launched (and: Definition of Medicine 2.0 /Health 2.0) Gunther Eysenbach Random Research Rants Blog. 2008. Mar 06, at: http://gunthereysenbach.blogspot.com/2008/03/medicine-20-congress-websitelaunched.html. World Health Organization. The global burden of disease. Update ed. Geneva: WHO; 2008. B. Ferguson, “The Emergence of Games for Health”, Games for Health Journal, 2012. S. Deterding, D. Dixon, R. Khaled, and L. Nacke, “Gamification: Towarda definition,” CHI 2011 gamification workshop, 2011. S. Deterding, D. Dixon, R. Khaled, and L. Nacke, “From game design elements to gamefulness: Defining gamification,” Mindtrek 2011, 2011. BJ Fogg, “Creating Persuasive Technologies: An eight-step Design Process”, Proceedings of the 4th International Conference on Persuasive Technology, Claremont, California, April 2009. BJ Fogg, “Persuasive Technology: Using Computers to Change What We Think and Do”, Science & Technology Books, 2002. S. Pagoto, et al. “Evidence-based Strategies in Weight Loss Mobile Apps”, Am J Prev Med. In press.