App development for KOKU
KOKU is a fun, evidence-based app designed to reduce falls in older people and those with Dementia or Parkinson’s by improving strength and balance.
Falls are one of the biggest health risks for older adults, yet most prevention approaches feel clinical, laborious and uninspiring. This case study demonstrates how gamification and user-led design turned evidence-based exercises into an engaging app that improves lives worldwide. If you’re exploring digital health innovation, gamification or user-led design this is a powerful example of research meeting creativity.
The Challenge
Turn years of falls prevention research into an app older people actually want to use, build the evidence to convince clinicians and commissioners, and keep growing it to support more people, from better nutrition to dementia and Parkinson’s.
Our Approach
Co-Design with Users KOKU was made with older people, especially those in deprived communities who are more likely to fall. We worked alongside older adults and clinicians so it would be practical, enjoyable and easy for people who’ve never picked up a tablet. It’s still one of our best examples of co-production.
Gamification for Motivation Clinical exercise programmes became mini-games. An animated coach called Wilf demonstrates every move, explains the safety steps and keeps track of progress, so it feels a lot less like homework.
Inclusive, Accessible Design We tested with real users throughout. Swipes and scrolls that tech-savvy people take for granted are backed up by simpler, more obvious buttons, and the app meets NHS standards for health apps.
Exercise made engaging
We transformed complex clinical research into a simple, playful app that older adults love to use. The app combines OTAGO and FaME exercise programmes with interactive mini-games, making strength and balance training enjoyable and sustainable.
It’s split into levels that get harder as you go, and at the end of each one the app asks a few questions to check the exercises were done properly. If they weren’t, you go round again. It’s a simple safeguard that stops people racing to the finish.
Between exercises, games teach players about nutrition, hydration, wellbeing and staying safe at home. What started as 20 exercises and 2 games is now 30 exercises across a minimum 12-week programme, six games and new characters Edna and Hilda.
Designed for accessibility, it works on tablets and smartphones, even for users with limited tech experience. KOKU is now NHS-approved, widely adopted across multiple countries, and continuously evolving to support people with Dementia and Parkinson’s.
I found that the app has been beneficial in showing me a way of exercise that I wasn’t aware of before.
Adding nutrition
Exercise is only half the story. Protein and good nutrition help preserve muscle, yet the research team found hardly any digital tools linking nutrition to falls prevention. So we joined forces to add a nutrition game, starting the way we always do: by listening.
Five focus groups with 33 older adults aged 69 to 96, living in assisted housing across Greater Manchester, told us that appetite fades, sore teeth get in the way, and eating alone kills the motivation to cook (“Once you start cooking for one, it’s never the same”). Some of what they’d picked up came from the media rather than evidence. Most were keen to learn, and asked for three things: information, easy recipes and encouragement to stick with it.
We then ran a design sprint with the researchers, sketching eight game ideas in eight minutes before narrowing them to four. A matching-pairs card game won. It’s easy to grasp, it’s engaging, and it’s a natural way to slip in tips on protein, dairy, chewing difficulties and the signs of malnutrition.
Ten older adults tested the prototype in January 2024 and scored its usability 87.5 out of 100. Their feedback improved the app. “Phytochemical” became “vitamins”, “sarcopenia” became “to help maintain muscle mass and strength”, the cards now flip back one by one so you can see where they went, and bacon joined the list of ultra-processed foods. One tester said they’d rather play it than watch the soaps.
Put to the test
Good design is only half the story. Does it work? Researchers at the University of Manchester put KOKU through a randomised controlled trial across all ten localities of Greater Manchester, funded by NHS England and supported by the NIHR Applied Research Collaboration Greater Manchester.
202 people aged 60 to 98 took part. Half were given an iPad with KOKU and asked to use it for 20 to 30 minutes, three times a week, for 12 weeks. The rest got standard care: exercise advice and a falls prevention leaflet.
Read the full results of the Randomised Controlled Trial.
The impact
The researchers concluded that KOKU “could be considered as an effective self-management option to improve functional outcomes for older adults.”
- ORCHA score: 84% (highest for older adult wellbeing apps)
- Users include people aged up to 105 years old
- Rolled out in UK, US, Denmark, Norway, Latin America
- Clinical trials show improved balance after 4 weeks
Less fear of falling Concern about falling dropped by 3.11 points on the Short FES-I, and KOKU users reported less pain and a better quality of life.
+6.35 points better balance than standard care after 12 weeks on the Berg Balance Scale. The trial was designed to spot a 5-point difference, so KOKU cleared the bar.
6.85 seconds faster on the five-times sit-to-stand test, a good marker of leg strength and independence.
88.75 median usability score, comfortably above the industry average of 68 and the 80 mark for excellent.
£46.17 per person to deliver the 12-week programme, with lower falls-related healthcare costs and a quality-adjusted life year gain of 0.02.
£5.78 return on investment for every £1 spent, with a £12.81 societal return using the Public Health England ROI tool.
Reason Digital are fantastic to work with, they took on board all our stakeholders views, the evidence and specific design needs for older people – the results speak for themselves as we have positive research findings and great testimonials from clients and patients
In the real world: Swindon
When lockdown lifted, Swindon Borough Council’s public health team saw how much frailty, loneliness and inactivity had taken hold among their older residents. Many now needed walking aids. They tried KOKU, and residents gained better balance, posture and mobility, a first go at a tablet, a regular routine with a mentor’s support and a sense of being part of something. Some liked knowing they were helping the NHS by trialling an approved app. The council gained a clearer picture of clients’ digital skills and isolation, and a route to funding for devices that help people get online.
I think you have an amazing programme, we have been proud to be able to use it and recommend it.
Growing around the world
KOKU has travelled well. It’s been rolled out by the University of Texas and in Denmark and Norway, translated into Latin American Spanish, German, Danish, Norwegian, Chinese and Urdu, and piloted in the US with UnitedHealthcare. Along the way it picked up a dementia-friendly version, KOKU Lite, and KOKU4PD, co-designed with people with Parkinson’s. Funded by Parkinson’s UK and led by Dr Gill Barry at Northumbria University, that version scored 81.4 for usability and improved balance after just four weeks at home. Dr Barry described working with our team as excellent.
This is one of my favourite projects to work on at Reason Digital, it was one of the first projects I took over when I started nearly 8 years ago. We’ve evolved this so much that time and yet there’s still so much future potential for this app. I’m always excited for what comes next.
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