KOKU (Keep On Keep Up)
A fun and friendly app that aims to reduce falls in older people and people with Dementia and Parkinson’s (PwP) by helping them to improve their strength and balance. KOKU was recently nominated for Product of the Year at the Bionow Awards.
The beginnings of KOKU
A small team from the Division of Nursing, Midwifery, and Social Work department at the University of Manchester (UoM), led by Professor Emma Stanmore, researched gamification, behaviour change, and how to empower older people to take control of their safety and health. In 2017, UoM came to us looking for a way to use digital technology to apply years of thorough research on how easy, low-effort exercises could improve mobility, health, and strength.
KOKU is also one of our first great examples of co-production and user involvement, developed with and for older people, particularly those in deprived communities who are more likely to experience falls. Led by user research, we first developed an iPad app that allowed users to follow a program of OTAGO-FaME exercises, all lead by an animated character called ‘Wilf’. These exercises are a combination of evidence-based strength and balance exercises developed from research that originated from the New Zealand Falls Prevention Research Group (OTAGO), and the Falls Management Exercise Programme (FaME) developed in the UK.
KOKU’s Founder, Professor Emma Stanmore, has since led research teams to demonstrate the usability and impact of the digital platform through a series of UK and internationally based feasibility and implementation studies, alongside an ongoing clinical trial. KOKU now also has a dementia-friendly version, ‘KOKU Lite,’ and has recently been co-designed with PwP to develop KOKU4PD, a project funded by Parkinson’s UK and led at Northumbria University by Dr Gill Barry and her team.
How does it work?
Split into levels, as the user progresses, the exercises become more and more challenging. At the end of each level of exercise, the app asks a series of questions to determine whether the user has completed the exercises to a satisfactory standard before moving on. If they haven’t, they will be asked to repeat that level. This aims to help ensure a level of safeguarding whilst also ensuring the user is getting the absolute most from the app rather than racing to the finish.
I found that the app has been beneficial in showing me a way of exercise that I wasn’t aware of before.
Designed in Figma, before developing into a native app for iOS, the UI interface had to be designed carefully to ensure accessibility for the target audience. Functionality such as swipe gestures and scrolling had to be combined with more straightforward or obvious interactions because many of the older users weren’t familiar with actions that the more tech-savvy generation takes for granted—this required trial and error and lots of testing with real end users.
The exercises are fun mini-games that aim to inform the users about nutrition, hydration, well-being and safety around the home. The user can replay these at any time, with the goal of improving their score, knowledge and as a result their quality of life.
We initially built 20 exercises and 2 games, but we have since increased this to 30 exercises that span a minimum 12-week programme. In addition, 4 new games have been added making 6 in total
The results:
The app has seen years of gradual, long-term development and this has contributed to its huge international success.:
- KOKU has been nominated for Product of the Year at the Bionow Awards.
- There is also a version for Android tablets.
- New Characters, Edna and Hilda, have been added to the app and feature in new games.
- KOKU is NHS Digital approved.
- The app is ORCHA approved, with a scoring of 84% which is the highest rating for a wellbeing application for older adults.
- The oldest person using KOKU is 105 years old.
- KOKU was rolled out by the University of Texas, Denmark, and Norway and has been translated into Latin American Spanish, German, Danish, Norwegian, Chinese, and Urdu.
- It was most recently piloted in the U.S. with UnitedHealthcare and adapted for studies with the University of Northumbria, which is investigating how it can help those with Parkinson’s improve their strength and balance.
- A Randomised Clinical Trial and implementation study, both funded by NHS England, are currently underway; understanding the many different groups and environments that KOKU can be successfully implemented in and comparing KOKU with ‘standard care’. Early results are due mid-2025
- A University of Texas study found that users were highly receptive to the KOKU platform, liking its convenience, structure and easy accessibility
- A University of Heidelberg study also found KOKU to be safe, gladly used and performed with increasing progression, with a further study planned using KOKU with individuals who have received a hip replacement and follow-on rehab
- KOKU has gained high acceptability and user friendly for PwP System Usability Scale rating “excellent” (81.4%) as well as significant improvements in balance after 4 weeks of using KOKU in the home.
More games and exercises are already planned for 2025
This one of my favourite projects to work on at Reason Digitial, 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
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
Working with David and the team as Reason Digital has been excellent, the team have provided a version of KOKU specifically co developed with people with Parkinson’s clinicians and the technical team as reason digital. The team have been fantastic in providing constant support throughout the process and we hope to continue our work in further development.