By Chris Powell, Solution Architect at Axian
However, our experience is that healthcare professionals (HCPs) may struggle to engage with digital materials, not least because they are very busy and have no incentive to participate beyond gaining knowledge. Here we explore what gamification is, how it works, and ask if it could potentially help HCPs to engage with digital materials.
Gamification is defined as “the use of game design elements in non-game contexts” (1). Any game must engage and retain its users, and several techniques have been used in other applications to elicit chemical responses that help with this. These include:
Triggering these responses helps to make users’ experiences more enjoyable and memorable so that they are more likely to return (2). Techniques widely used in gamified systems to achieve such responses include badges, points, and leaderboards (3). To understand these, let’s first look at an example of these design elements within a game context.
Candy Crush Saga
Candy Crush Saga, one of the most popular and highest grossing mobile games, with 273 million active players during Q1 2020 (4), employs these techniques very successfully. The game measures the points scored in individual levels and the number of levels completed, and each level has a leaderboard which compares a player’s scores to their friends’. The awarding of points, completing levels, and congratulating players for outperforming others all provide little hits of dopamine to encourage continued engagement. If a player is stuck on a level, they are offered convenient purchases to help them and so they keep the brightly coloured dopamine train rolling (Candy Crush generated revenue of $1.19 billion in 2020 alone (5))! Players also receive achievement badges which, along with the winding road level map, provide visual representations of their past accomplishments, triggering the release of serotonin.
Candy Crush Saga. Left: Points are scored during gameplay. Right: A player’s progress is displayed and compared to their friends for motivation.
Nike Run Club
The Nike Run Club app has an average rating of 4.8/5.0 from over 373,000 reviews on the Apple App Store. Elements of gamification keep users engaged and provide motivation for running. Users can take part in competitive challenges with friends (including point scores and leaderboards), receive badges to track their achievements, and the app often congratulates users to encourage continued engagement (6).
Nike Run Club. Left: Players can join or create challenges. Middle: Achievement badges give reminders of past activity. Right: The user is encouraged to continue their training.
This popular app for learning languages makes heavy use of gamification. Users are rated on their performance on particular topics (such as household items), gain experience points for completing lessons, are encouraged to meet daily goals, gain achievement badges, and can compare their progress with friends via leaderboards (7). Duolingo has 42 million active monthly users and was valued at $1.5 billion in 2019 (8).
Duolingo. Left: Users gain experience points and receive rewards for levelling up. Right: Achievement badges serve as long-term reminders of progress.
Plenty of anecdotal evidence suggests that gamification is associated with commercial success, but what about scientific evidence? Research focuses mainly on the effectiveness of gamification as a teaching and learning tool. Gamified systems vary hugely, with different combinations of experience points, score points, social features, badges, quality of content, user personalisation, external rewards, reminder notifications, competitive aspects, etc. This makes it difficult to carry out meaningful comparisons. Recent meta-analyses conclude that gamification has a positive effect on learning, but further research is required, which includes a need to establish well-defined processes and metrics (9, 10).
The success of gamification suggests it could help to improve the engagement of HCPs with digital drug safety and risk minimisation. So why is it not widely used? A few reasons spring to mind.
Commercial applications of gamification are much more prevalent than purely educational ones. There is perhaps an image problem to overcome: for example, it would not be appropriate to have a Duolingo-esque cartoon critter disseminating drug safety information. Of course, there is also some regulatory-induced resistance to trying new approaches to drug safety and risk minimisation, especially when working with many countries that have different regulations. Often a project can begin with the intent to implement some novel ideas but end up heavily diluted after multiple sets of restrictions.
However, some successes in gamified healthcare applications are emerging. For patients, apps such as Mango Health (4.4/5.0 on the Apple App Store after 9,400 ratings) allow users to track and manage their medicine routines (11). Users are provided with information about their medication, receive reminders to take it, and accumulate points for sticking to routines. Those points can be traded for external rewards such as gift cards.
Some patient-focused apps are also used to help HCPs with diagnosis or treatment, such as the recently launched LiverSync (12). Classed as a medical device, patients complete short games and changes in performance over time are used to detect possible early signs of brain function decline due to advanced liver disease. The patients can also connect with their HCP and HCPs can monitor their patients’ progress online.
Mango Health. Left: Users add actions to their medical care routines. Right: Sticking to routines is rewarded with experience points, level ups and real-world rewards.
LiverSync. Left: Patients complete simple games. Right: Patients can track their performance over time by patients and share results with their HCP.
Some applications specifically target HCPs, usually focusing on simulating treatment of virtual patients. For example, Stanford University’s Septris aims to train HCPs in diagnosis of sepsis with higher scores awarded for better performance. Septris was shown to improve the users’ knowledge and ability to recognise and manage sepsis (13). And the visually impressive Touch Surgery (16) (4.8/5.0 on the Apple App Store after 658 ratings) allows users to practise surgery on virtual patients and awards scores based on performance. The app also attempts to capitalise on the perceived competitive nature of HCPs by allowing the sharing of scores with peers.
A gamified system more closely aligned to risk minimisation was GSK’s Paper to Patient HCP education programme. This provided a set of training modules and asked HCPs to put their knowledge into practice on virtual patients with points awarded for success. Sadly it now appears to be defunct, but at one time it was very successful with over 18,000 HCPs having used the system by 2012 (14).
Touch Surgery. Allows users to practise surgery on virtual patients and awards scores based on performance
GSK’s Paper to Patient asked HCPs to put their knowledge into practice on virtual patients
Gamification has scientific approval and has been successful across a wide array of applications. Yet, whilst there are successful gamified applications in healthcare generally ((15) provides further examples), as far as we are aware, there is a distinct lack of applications targeting drug safety and risk minimisation (please do feel free to correct us with examples, we would love to see them).
We believe that gamification offers a fantastic opportunity to increase the value of digital distribution by improving HCP engagement. Gamification could overcome the barriers mentioned in the introduction (lack of time and incentive for participation), for example, by breaking content into concise pieces featuring short, undemanding questions (no 15-question monolithic knowledge tests!). We also believe gamification has the potential to improve the patient experience, but the engagement barriers are different and warrant a separate discussion.
The success of this innovative approach relies on the quality of content, careful/appropriate design choices, and robust implementation that considers local regulatory and cultural needs. Here at Axian we have deep expertise in implementing digital risk minimisation solutions in local markets, we love to innovate, and we excel at publishing high-quality content as part of well-designed, expertly built applications. So, if you’re interested in having a chat about how gamification could help to engage and educate HCPs (or patients) then do get in touch.
1. Deterding S, Dixon D, Khaled R, Nacke, L (2011) From game design elements to gamefulness: defining “gamification”. New York : ACM. In: Proceedings of the 15th International Academic Mindtrek Conference: Envisioning Future Media Environments. pp. 9-15
2. Growth Engineering Is gamification effective: the neuroscience of gamification in online learning. Growth Engineering. https://www.growthengineering.co.uk/the-neuroscience-of-gamification-in-online-learning/. Accessed 19 April 2021
3. Werbach K, Hunter D (2015) The Gamification Toolkit: Dynamics, Mechanics, and Components for the Win. Philadelphia : Wharton School Press
4. Reddix J Activision blizzard reaches new high with quarterly earnings. mxdwn.com.https://games.mxdwn.com/news/activision-blizzard-reaches-new-high-with-quarterly-earnings/. Accessed 17 February 2021
5. Curry D (2021) Candy crush revenue and usage statistics. Business of Apps.https://www.businessofapps.com/data/candy-crush-statistics/. Accessed 5 April 2021
6. Really Good UX Nike Run Club’s gamified approach to fitness training. Really Good UX.https://www.reallygoodux.io/blog/nike-run-club-gamification. Accessed 5 April 2021
7. Citrus Bits How Gamification Has Catapulted Duolingo and Strava to the Top. Citrus Bits.https://www.citrusbits.com/how-gamification-has-catapulted-duolingo-strava-and-forest-to-the-top-of-their-respective-app-categories/. Accessed 5 April 2021
8. Curry D (2021) Duolingo revenue and usage statistics. Business of Apps.https://www.businessofapps.com/data/duolingo-statistics/. Accessed 5 April 2021
9. Zainuddin Z, Chu SKW, Shujahat M, Perera CJ (2020) The impact of gamification on learning and instruction: A systematic review of empirical evidence. Educational Research Review 30: 100326
10. Sailer M, Homner L (2020), The gamification of learning: a meta-analysis. Educational Psychology Review 32: 77-112
11. Mango Health. https://www.mangohealth.com/. Accessed 5 April 2021
12. Norgine LiverSync. https://www.liversync.com/. Accessed 6 April 2021
13. Strehlow MC (2014) Septris: A novel, mobile, online, simulation game that improves sepsis recognition and management., Academic Medicine: Journal of the Association of American Medical Colleges
14. PMLiVE (2012) Paper to Patient – Communiqué Awards 2012. PMLiVE. http://www.pmlive.com/awards/communique/previous_winners/results_2012/healthcare_communications_awards/best_professional_education_initiative/paper_to_patient. Accessed 5 April 2021
15. Pesare E, Roselli T, Corriero N, Rossano V (2016) Game-based learning and gamification to promote engagement and motivation in medical learning contexts. Smart Learning Environments 3:5
16. Touch Surgery https://www.touchsurgery.com/. Accessed 5 April 2021