Is Reality Broken? App Life vs Real Life

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In 2011, Jane McGonigal, Director of Game Research at the Institute of the Future published “Reality is Broken“- a deep dive into the growing popularity of games and how players spend hours immersed in gaming platforms taking on challenging quests alone or as a team to win rewards. She also asked why? Would all these tasks not feel like work? The short answer is no, many of these games tap into our need as humans and adults to play, something we tend to abandon in adulthood.

Neuroscientists and psychologists point out the importance of play for children that is essential for brain development and social skill building. Is It any wonder teens and adults are flocking to gaming platforms to escape their day to day life? What can we learn from games that could be applied to improve health? The book goes deep into how games are actually different kinds of work, some scenarios being high pressured and faced paced and some being slower with predictable outcomes. Many apps also use elements of gamification to engage people, avatars, badges, and points are all part of a complex ecosystem to help people reach a goal or a health outcome. Since 77% of us own smartphones, we are also spending a lot of time on these phones in apps, how might we better understand app usage to drive behavior change? The science is emerging of how engagement in apps may support behavior change for weight management, smoking cessation, mental health, and physical activity.

One challenge digital health has is engagement, often the complex journey to build habits that lead to behavior change and positive changes can take time. That initial motivation to sustain a behavior change may wane as real-life issues emerge. Good apps understand this cadence and have tools to help you navigate the hard times. We are still early on our journey of translating theory into practice to optimize the balance of the time spent in-app learning new skills and time spent in real life applying these skills to enact positive change.

In 2016, Lucy Yardley and colleagues from the University of Southampton in the UK published a paper on promoting active engagement in digital health in the American Journal of Preventive Medicine. The article outlines a blueprint to measure engagement which includes conducting qualitative interviews with users to determine how and when they use the apps, the specific tools they use and find helpful but cautions this can be a victim of recall bias. Additional measures including surveys, in the moment app use, login in and usage data and any sensor data and app may be tracking are also recommended to obtain a complete picture of app use.

While app use is vital in supporting someone in their behavior change journey in digital health tools, this must also be balanced with helping someone in real life. Apps are not living in a vacuum they are used in many moments throughout our day. Good solutions are able to decant the science of behavior change and present it as a journey that builds competency over time that can also pace to preferences learning styles. To this end, an app company must focus first on the onboard experience to keep someone engaged then quickly layer on the tools to support someone making changes (e.g., goal setting, planning, tracking) without overwhelming them. It can be a hard balance to strike. The opportunity for digital health solutions is to define what bundle of metrics contributes to engagement as this is an essential metric for health care organizations as it relates to how it contributes to health outcomes.

What we don’t have today is a standard definition of engagement, nor do we have a sophisticated language or layering of different kinds of engagement. Digital companies live by adding new users to support monthly-recurring-revenue (MRR), and health care organizations are looking for health outcomes data and solutions that cater to people across the income and literacy spectrum. App companies will also have to balance app use with real-life application of skills and given behavior change is hard to sustain, create novel ways to re-engage people in their health journey if real-life has thrown their efforts off course. Much work needs to be done, but there are exciting advances weekly in the digital health space.

Thanks for reading – Trina
(Opinions are my own)


Yardley et al. paper on engagement in digital health

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