How do you a tackle an often unspoken problem, with technology that's not viewed as widely used by your target audience? With a collaborative team of experts from a variety of fields and a guy called Wilf.
The ‘F’ word
Leonard Cohen, singer-songwriter, Grammy winner, Rock and Roll Hall of Fame inductee, died November 2016 following a fall at home. He had been fighting leukemia but it was the fall that resulted in his death. We have an odd habit that starts with deifying our stars, our heroes, and then when bad things happen to them we seem to think, “If it can happen to them it could happen to anyone”. It is as though, before that point there existed an element of doubt that there was ever any risk to us.
Slips, trips and falls are terrifying for a variety of reasons:
- They cost the NHS £2.3 billion each year either directly or indirectly.
- 30-50% of people over 65 fall at least once per year, there is a 20% range because your likelihood increases with age, starting at 30% at 65 and onwards.
- Falls are the new ‘F-word’. Research shows that if you asked an older person if they’re at risk of falling, in most cases, they’d say no.
This isn’t a topic the public seem to be discussing, but our experience in the sector over the last two years shows it is certainly a hot topic for care professionals, researchers and the tech industry.
A lot of work has gone into detection of falls using a whole range of solutions from mesh wifi signal detection, to wearables and even repurposing the Microsoft Kinect camera. However, there is good evidence that exercises which improve balance, muscular strength and power; if intensive, progressive and continued; can reduce falls. Unsurprisingly, there is evidence that without support from therapists, there is low uptake and adherence to exercises in the home, a factor that is unique to the older section of society. This poses a barrier to change as it requires regular availability of a trained therapist in order to maintain a routine that will have lasting impact.
Fall prevention, but don’t mention falls
This project started in 2015, off the back of a phone conversation between Dr. Paul Dewick, economist and lecturer at the University of Manchester, and Dr. David Hoyle Business Impact and Innovation Lead at what was New Charter Group (and is now part of Jigsaw Homes Group). They spoke about the need for some way to educate and encourage older people to not only be more active, but to take control over their own safety and reduce their risk of falling.
Before all this, Dr Emma Stanmore had been working on falls projects for many years as a senior lecturer at the School of Nursing, Midwifery and Social Work and as a Healthy Ageing researcher. Along with colleagues in the Healthy Ageing research group she worked on projects such as MS Kinect Falls prevention Exergames and RehabMat (which uses iiMagiMat technology to measure balance). This work was done as part of the huge EU network in falls prevention led by Prof. Chris Todd which has the fantastic name – ProFaNE.
Emma first met David when he went to see a demonstration of the Exergames project as a potential falls prevention method. Many of the learnings taken from that project have helped inspire the decisions on this project and have supported us by providing a strong platform for us to progress from. When discussing the Exergames project Paul references a metaphor often used in academic work – “standing on the shoulders of giants”.
The solution came when David introduced Emma and Paul – leading to research into the viability of using an app that would encourage behaviour change and access a wider audience. The barrier for achieving this was a prototype that could be used to test the viability of the approach.
This is the point that Reason Digital joins the team.
I was the strategist on this project and on the morning of the day we are set to meet Emma and Paul, I sit down with Chris (the project manager) to discuss the project and he says those two words.
App and gamification.
My heart sank.
Let me bring in some context. This was around the time there was growing evidence that people rarely download apps and no one uses them when they do download them. There had been so much push from less ethical sectors of the digital industry to promote the ‘wonder’ of apps but explain none of the realities. It was a buzzword that created more problems than it solved and desire for that particular solution approach has dwindled since then. Now it’s chatbots and AI, but we’ll leave that for another day.
And that other word, ‘gamification’… gamification is a widely misused concept, certainly in relation to socially focused goals. The application of game principles to drive engagement and retention has huge potential in health related apps and explains why the use of gamification is so popular however, the lack of adherence to principles or theory has resulted in questionable efficacy.
However, this project wasn’t based on ‘just an idea’. Emma and Paul came at this from an academic background and this was based on a theory; a theory developed off the back of their initial research and Emma’s own experience of gamification using VR to drive similar behaviour change. Our role was to help them test that theory, using our knowledge and experience of developing apps for market, and to provide a prototype that would not only complete this portion of research but form the foundation of a scalable platform.
The primary focus of this platform was to reduce the occurrence of falls in older people, but as mentioned the ‘F-word’ causes a disconnect and would result in users not seeing themselves as being a part of the target audience. So from the start of the project we began exploring names for the app that didn’t involve the word ‘fall’. This took a while as we needed the name to be relevant to the audience whilst also being short and unpretentious. It was through the course of user testing that Paul picked up on two terms regularly used, ‘keep on…’ and ‘keep up’ or ‘keep your head up’, and so we named the app ‘Keep On, Keep Up’.
Start with collaboration
To deliver this we pulled together a multidisciplinary team including myself, a designer (David), a developer and of course, Emma, Paul and David. We used a method based on the Google Ventures Design Sprint in combination with a workshop tool I had just started to implement called Assumption Mapping. I came across this during an NUX meet-up from the team at Valtech and we now use it whenever possible to establish what we know on a project. Thanks to the research we found that most of the key assumptions around the overall concept had already been well accepted. The remaining assumptions were mainly focused around the design of the app and choices on the functional aspects.
“The process has provided spaces where collaborators can 'be the best that they can be’ – an embodiment of Aristotle’s three activities of what makes us human : theoria (thinking), poiesis (making), and praxis (doing).”
Having this cross-spectrum of skills in this decision-making phase, backed up by clear research with in-depth sector knowledge from Emma and Paul, allowed us to quickly make decisions for how the app would look and work. These decisions, although agreed collectively, were made based on assumptions at this point. Testing these assumptions formed the basis of our user testing approach.
Co-designing with the developer also allowed us to have upfront, functional discussions with Emma and Paul whilst also establishing a shared understanding between the designer and developer. Besides being good practice, collaboration on innovation related to health and social care is essential.
“Collaborative design attention is most needed where the probability of harm is increased by poor design decisions. Nobody dies from a bad website, but patients can and do die from information display errors and counterintuitive device interfaces. Thoughtless design is magnified greatly when it shows up in healthcare process or medical device.”
One of the earliest design decisions was to use an animated character to engage the user who we named, Wilf. He’s not only the face of ‘Keep On, Keep Up’ and the instructor for the physical activities but also a real source of enjoyment for all of us working on the project and those who tested the app. Our in-house illustrator and animator, Alex, has really given life to the character of Wilf. His tiniest movement, expressions and actions all act to engage users. The only negative feedback we had in the start was that Wilf was a little fat.
We wanted someone to guide users but we didn’t want to use an avatar who was too formally a ‘physical instructor’. The guide needed to be approachable. ‘He’ also needed to be a ‘he’ – sorry everyone but the generation we are targeting generally view authority figures as male, don’t worry though, this choice was very much questioned later as the app developed.
Instilling that element of fun was essential for us. The gamification just would not work unless the app was fun and that isn’t solely down to the game mechanics. To make something fun you need to consider the whole experience and if you are structuring your app around a character then they need to embody fun.
“…if you start with the education and put fun second, learning doesn’t seem to work the same way – or as effectively.”
P3, Gamification by Design, G. Zichermann & C. Cunningham
That first prototype had a menu screen, one exercise, further reading and an awful game that was supposed to raise awareness about trip hazards. The hazard room game was included at this point, just to give testers the sense that there was a bigger game behind the one activity we were testing. Owing to the early involvement of the design and developer, this was one of the easiest prototypes to build as our shared understanding of the output meant quite simply, that everyone was on the same page.
My favourite moment was the first time Emma, Paul and David saw the prototype – they navigated through the exercise together and there appeared an animation of Wilf blowing his whistle – their faces lit up and they all smiled together. That visual sign of success was something we saw again as we began testing the prototype with real users as we observed those same smiles. Thanks to our collaborative team (in particular David and New Charter Homes) we had access to the kind of older people who would benefit from use of the app. This meant that we could test the prototype in their homes, providing an environment more comparable to one they would use the app in normally.
That initial round of testing was a success and further user testing and feedback ensured that the initial research question of viability had been answered.
This was never the end though.
The project started as a way of taking research into practice but everyone involved has always had the vision of making this product available to as many people as possible. There has been various funding and support from The University of Manchester Alliance Business School, Manchester Academic Health Science Centre, Health Innovation Manchester and Greater Manchester Academic Health Science Network, to name just a few. This funding enabled Emma and Paul to continue to understand user needs and further develop the app, introducing new features and refining the existing ones.
An example is the original hazard room game which was scrapped for a clear, visual approach alongside the introduction of multiple choice questions to provide an additional layer of challenge in order to maintain the gamification approach.
In developing the new rooms for the hazard game, Wilf found his cat Mr Wigglesworth, who has a habit of getting underfoot and later featured as one of the hazards in the improved game. He also remembered he had a wife, Hilda, who was introduced to help users to think more about their diet and raise awareness about the impact of things like salt that can cause your body to lose calcium and can lead to bone loss – a fact I did not know until working on this project.
This brings us to this year, when new funding is being provided by the Innovation Fund Denmark that will allow the app to be tested with 200 older people in Denmark. We will also introduce new games focused on hydration and continence. I for one am looking forward to the animations from Alex as he takes on those issues.
With the next phase coming up, the team met to plan and we took the opportunity to review and recap what we had done so far. There was a unanimous sentiment that, although the work we have produced and the results of the testing was a success, things hadn’t moved as fast as we would all have liked. We don’t yet have a product that could be released to the public.
We also had to face some hard truths about the scope of the product and whether delivery of a scalable app would be possible. When we started the project, developing the character of Wilf and animating the exercises was labour intensive, scaling that would have been impossible without a large budget at our disposal. So, we have gone back to basics, refreshed our purpose, our vision and goals for ‘Keep On, Keep Up’ and planned how we will achieve this using an iterative and scalable approach.
We also noted the ‘game’ aspect has got to be significantly strengthened – the inherent motivations within a game psychology are the means to keep users coming back time and again to the app; which is the critical purpose – someone using ‘Keep On, Keep Up’ once won’t reduce their risk of a fall; engaging someone to come back twice a week and have a reason to try to improve their score will reduce their risk of a fall.
End with collaboration
Reason Digital turned 10 years old this year and to mark the occasion we had a team ‘away day’. Besides some bowling and jollity, we took some time to reflect. We reflected on what we’ve done well and for everyone who has worked on this project, ‘Keep On, Keep Up’ was one of their examples. For some it was the animation aspect, for others it was the overall concept. For me it was the collaboration that occurred at every level. The sharing of knowledge, experience and expertise combined with a truly open and honest relationship ensured we all worked together to keep the project on track.
“… it is a project that could not have happened without the core team’s involvement. We bring different skills and knowledge sets and access to resources. We have had tremendous support from a wide range of stakeholders. It has been a Magical Mystery Tour, and I’m excited about what comes next.”
As funding continues to grow and the line between public and private in the health sector becomes more blurred, we believe that collaboration is required to develop safe and effective health products. As the tech industry struggles to balance ethics with its hunger for innovation we must be cautious about the way we approach our public health from both a safety aspect but also societal, preventing further divisions and side stepping into a tiered system that makes the American health service look like a socialist dream.
The tech industry alone cannot answer those ethical questions, we must work with colleagues in health, social care and education. Only through that collaboration can we hope to develop sustainable solutions to our growing health and social care issues. The health sector has been exploring the need for collaboration for over a decade – the Greater Manchester Academic Health Science Network was itself the result of research into collaboration and co-production by the National Institute of Health Research.
My hope is that our work not only helps our target audience but acts as an example to others on how this approach can not only give you great results but also be a lot bloody fun along the way.