Designing and play testing falls prevention games for older adults

In Series 2 Episode 5 of the Health Points podcast Ben Wilkins and Pete introduce Jaime Garcia, a senior lecturer in game development at the University of Technology Sydney. Jaime discusses how he got into gamification and health through a happy accident and his experience working with researchers to develop games for the senior community. He also explains Australia’s culture around health gamification, mentioning that universities now offer courses on it. The conversation then shifts to Jaime’s projects on falls prevention and ankle sprains, specifically focusing on Step Connection, a game designed to improve balance and reflexes using Microsoft Kinect technology. The game involves stepping in response to stimuli while exploring different countries. Play testing was crucial in refining the game for older adults’ understanding and enjoyment.

The game was designed to collect reaction time parameters and assess improvement in players. Each level of the game took about 3 minutes to complete, and exertion was considered when determining the length of each level. The game used royalty-free songs related to different countries, and fruits were included based on research on which fruits are produced by each country. Players needed to play each level three times in order to unlock the next one and earn money by collecting fruits. There was a rewarding screen after achieving this goal. Players were recommended to play for 20 minutes, three times a week, but they could play more or less if desired. The game design was influenced by focus groups with seniors who expressed interest in traveling and visiting other countries due to various limitations. The game successfully achieved positive results in terms of adherence, enjoyment, and improvement for players. Some participants became emotionally attached to the game as part of their daily routine.

We also discussed the importance of observing nonverbal cues during co-design projects and suggests that more support is needed for new designers entering this field. In terms of evaluation, people adhered well to playing the game more than expected, enjoyed it, and showed improvements in motor skills such as reaction time but not significant cognitive improvements.

Overall, the game had a meaningful impact on reducing fall risk through improving reaction time abilities. However, despite its success, there are questions raised about why similar interactive computer vision games have not become widely accessible despite being available for over a decade

You can listen to this episode below:

Episode summary:

Jaime discusses the challenges of adopting games for health purposes on a global scale. The main obstacles include the perception that games are not taken seriously, the high cost of technology, and the lack of tech-savviness among older adults. He also talks about his project involving gamification for pregnant women’s health and exercise, using devices they already have in their homes like webcams and laptops. The aim is to provide safe exercises during pregnancy and promote overall well-being. Co-designing with experts such as midwives and expectant mothers has been an important part of the process.The concept for the game came from code design sessions and conversations with women. The idea was to have players manage a village where a massive egg represented their baby. As players performed activities in the village, such as gardening and picking fruits, the egg would grow along with the village. The women found this concept appealing because it emphasized providing care. However, incorporating exercises like gardening into the game proved challenging but interesting. The game is still being developed, but so far, the women seem happy with what has been built.One challenge in health gamification is regulation and research due to ongoing iteration and improvement of game mechanics. The existing format of regulation may not account for changes made after initial research projects are completed. Taking games seriously is crucial for progress in health gamification, and if big game makers like Nintendo and Microsoft develop games targeting specific health outcomes for older audiences, it could lead to a perception shift.Health gamification apps on accessible platforms are popular, but targeting specific games through mass gaming platforms could be beneficial. Prototyping, iteration, and understanding subtle feedback signs during participant co-design are essential aspects of developing these games.

Outline:

Chapter Outline: Health Points – Exploring Gamification in Health Introduction to Health Points (00:06-00:42).
Welcome to another episode of Health Points. Ben and Pete are the hosts. Jaime is working on health games and research projects Jaime’s Journey and PhD Scholarship (02:54-09:24).
Jaime met researchers at UTS during his PhD application process. The focus is on using games for a real purpose in life. Started with a literature review to identify gaps in the academic literature. Identified the need to improve usability and game objectives Creation of the Board Game (06:40-07:48).
As part of the assignment, they had to create a board game. Exploring gameplay for individuals and usability issues Developing the Health Game (09:46-13:49).
Presenting the game idea to the researchers. Translating body movements into gameplay. Creating a story where players are explorers visiting different countries. Pilot study results showed players finished 16 countries in less than a week Points-based Game and Narrative Elements (16:39-18:53).
Decision to make the game points-based with a narrative. Conducting focus groups and gathering feedback from the target audience. Engaging players with the concept of visiting other countries Evaluation and Results (18:53-25:29).
Assessing the project from different angles. Conducting tests and follow-up interviews. Noticing improvements in reaction time and engagement Challenges and Future Directions (27:00-30:31).
Discussing the challenge of global adoption. The importance of recognizing nonverbal cues in engagement. Need for more support and training in co-design and co-production Current Project and Technology (32:09-39:41).
Overview of the current project in the faculty of engineering. Incorporating lessons learned from the previous game. Creating a customized program based on prescribed exercises. Challenge of conducting focus groups during COVID-19 Collaboration and Prototyping (41:31-43:56).
Collaboration with Deborah Fox and finding participants. Brainstorming sessions with game designers and prototyping. Incorporating suggestions and feedback from participants Future Considerations and Wrap-up (45:11-47:49).
Discussing the challenges of regulation and research in gaming. Importance of evidence-based approaches. Potential campaigns and future discussions on health gamification

Episode Transcript:

Ben
Hey everyone, welcome to another episode of Health Points where we talk about anything and everything, gamification, health. And I’m Ben and here with me is my co host, Pete.

Pete
Hi everyone.

Ben
And today we have with us Jaime Garcia, who is a senior lecturer in games development at the University of Technology, Sydney, with a background in software engineering at neuroscience Research Australia, primarily designing and developing, maintaining fools prevention video games and mobile apps for the Fools Balance Injury research Centre. He’s working on multiple health games and research projects evaluating these games and we’re looking forward to exploring them on today’s episode of Health Points. Jamie, it’s fantastic to have you here.

Jaime
Well, thank you guys for giving me the chance to join the podcast and really excited to have a chat with you guys.

Ben
Wonderful stuff. Right, so we kick off. You are doing a hell of a lot in terms of health, gamification and research. How did you get here? What was the passion that led you to where you are now?

Jaime
That’s a really interesting question because there isn’t a clear answer for it. It was a bit of a happy accident, I want to say. So as a kid I used to play the Nintendo all the time and I spent quite a bit of time in it and mom and dad weren’t quite happy about it. But yeah, I always saw a bit of an interest in technology, games doing things that were interesting and people wanted to use in terms of engagement, technology, all of that. And when I came to Australia, I just met the right people at the right time and I think I was probably the right person to join the team at the moment as well.

Jaime
So I met a couple of researchers in the University of Technology, Sydney who wanted to explore the Nintendo Wi as a means to exercise and help the senior community stay active, but they didn’t even know how to plug it in, how to set it up. And I was like, I know how to those things. So I volunteered to help the research lab and that’s why I call it a happy accident, because I just started working with these guys and it was really exciting, really cool stuff. And I got the chance to participate in a whole bunch of experiments with health experts and the senior community. And I got excited to see how tech was helping them to stay active and I was excited to see how a game that was not meant to be an exercise program was actually getting these people to move.

Jaime
So that’s when I had the Eureka moment and I said, I want to do this stuff.

Ben
Brilliant. So the desire and drive to go and learn coding and software development, would that go in parallel or was that a separate interest?

Jaime
It was a bit of a sequential set of things. So when I met all these researchers at UTS, I was going through the application process for a PhD scholarship. So I started working with them before I actually got admitted to the PhD and I did my PhD in that specific topic, which was I initially was designing games specifically for the senior community because the games in the Nintendo WI at the time were designed for kids. So when you put one of those games in front of someone over 65 years old, they might not know how to play it. And all these fussy things you see on the screen, like sounds and animations and flashy buttons, it’s just confusing. So initially the project was about building one of those games, but at a much simplified version.

Jaime
And that kind of led to us meeting that people in neuroscience research Australia, because were working similar project and they had a really strong clinical background and we had good coding skills. So we started collaborating on my PhD and there was another PhD candidate at Neura, short for Neuroscience Research Australia. And yeah, we just started collaborating. Collaboration went really smooth, really organic, we got a couple papers out and when I finished my PhD studies, there was an opportunity for me to join the Neura team as a software engineering and specifically building false prevention games. So I was know I tick all the boxes, I want to join this team and I was able to contribute making cool games for them.

Ben
It seems like Australia is a bit of a hotbed for health gamification. We’ve had a fair few Australians come on the show before, and I know quite a lot of Australians working health gamification. Why is there such a culture around health Gamification Australia happening?

Jaime
I’m not entirely sure. That’s a good question. I’m not entirely sure I’m going to say Melbourne is a hub for gaming in general. There’s a whole bunch of indie game development companies and universities started creating courses for this stuff, which is relatively new. So if you think about this stuff, 20 years ago, there was no games degrees at unis. There were computer science degrees with, you can specialize in computer graphics or I guess related fields like that, animation, all those things, but there was no degrees in it. And all of a sudden the uni started offering we actually have one at uts, which I get the chance to coordinate, and that attracted people and that attracted really brilliant students that saw the potential of using games for doing all this stuff.

Jaime
We actually have a new subject now in the games degree, which starts this year, and it’s called serious games and gamification studio. And it’s all about this stuff, how you can use games for a real purpose in life. I mean, aside from entertainment and all that. So I believe that might have a bit of an impact, having proper courses that are recognized. And I guess it’s just the nature of gaming.

Pete
That’s great news. And also it’s fantastic to have the courses because it makes it easier to get buy in for the apps, the games that we design, because there’s a profession behind it.

Jaime
Absolutely.

Pete
It’s a big support for making this go forward.

Ben
That’s great.

Jaime
Yeah, absolutely. And I think that’s one of the main differences. For example, back in 15 years ago, you could learn how to make games, but they were not fantastic games. Whereas the students in our classes now, they learn to code games since day one and they study for three years. So you get really good at not only coding, but designing. And funnily enough, one of the first assignments they have to complete is making a board game. It’s a physical game, no coding. It’s more about the game mechanics and what makes a game. How you make sure that people have fun and engage with your game.

Ben
Fantastic to mean, Pete, I know you lecture as well in the UK, as well as running kind of education globally, but what’s exciting for me is that it still feels like quite a pioneering field. I know that we live it and breathe it all the time, but when we speak to other people, it still feels quite novel. But the idea that universities are starting to bring out the future gamifiers and the future people working in this industry, yeah, that’s what’s going to transform it in the coming decades. Really exciting. So, Jamie, you work on some really interesting projects around kind of ankle sprains, falls prevention. I’ve seen the one around pregnancy as well. Let’s start with falls prevention because that was kind of where you flagged up with me and Pete.

Ben
So let’s talk about step connection, kind of where did the concept come from? Why does it exist? What does a gameplay look like for an individual?

Jaime
Yep, absolutely. As I mentioned, that was probably the beginning of my PhD studies. So initially we started doing interviews with health experts, looking at the Nintendo Wi and how the WI was a tool that can be used for senior people to stay active. And in doing that initial study, we found that the WI wasn’t really a fantastic game. There was a whole bunch of issues related to usability, people being able to understand the instructions, understand the game objectives. And I don’t know if you guys probably know the balance board that came with the Wi fit, that was a bit of a hazard for older people. And some of the movements you needed to on that thing didn’t really correlate with what you see on the screen.

Jaime
Like, for example, there was a game where you’re supposed to walk, but you’re standing on that thing all the time. So what you do and what you see on the screen, there’s no connection. And that was confusing for the senior community. So that’s when we started thinking about, how can we make a game that do help or does actually help people? And what’s the most important issue for the senior community right now. So we started a really boring process called the literature review, which most PhD students have to, or anyone doing research have to. And effectively that means going through a whole bunch of academic papers and then finding the gaps in the academic literature. And that’s when we found that faults is the main cause of fatality and the main cause of injury in the senior community.

Jaime
And it affects one in three people every year. So we thought that’s when we said, this is what we need to fix, this is what we need to focus on. Let’s make a game that makes people better, improves balance, reflexes, all of those things. So we tackled that issue, and that’s how we started collaborating with neuroscience Research Australia, because they’re quite active in that space. So that’s when we came to them and said, we have this game idea, and what do you guys think? They said, yeah, we love it. And at the time, the connect, the Microsoft Connect, was brand new. It was just released by Microsoft. That was mid 2011. And it was just, again, perfect timing because the connect allowed us to do a whole bunch of things that no one could do before.

Jaime
So I don’t know if you guys have seen the connect, how it works. It’s effectively a camera with a whole bunch of sensors in it. And that camera can see your whole body, and you can effectively track every part of your body at a really relatively high accuracy level. And all those movements can be translated into the game. So what that allowed us to do is to create a game where you don’t have to attach sensors to people, you don’t have to press buttons, you don’t have to step on tricky platforms, you just move your body point on the tv, and that’s how you navigate the menus, and that’s how you also play the game, because you step in space.

Jaime
That’s a bit of the tech in terms of the game itself, in doing the research and talking to experts, we realized, or we learned that training, the ability to take quick steps, it’s all you need to do. And the best way to do that is to have a bit of an activity where people have to react to a stimuli on the screen or set of stimuli in the screen. So that’s when we thought, what if we make a stepping game, but we make it a bit more fun because if we get people to simply step in space, reacting to a light, there’s no fun in that. And that’s when we came up with the whole game concept of you’re an explorer, sort of like Indiana Jones, because they recognize the character from back in the day. These are the movies.

Jaime
And we told them, in this game you have to take steps and those steps will help you collect fruits and those fruits will give you money. And if you make money, you can travel to different countries. So that’s how we came up with the story. So it’s a story where you’re an explorer, you go to different countries, but you have to make the money to visit them. And that’s how we kind of created a bit of a progression system, and that is what kept them going and playing with the game, because there was always a goal to achieve and the goal was always to unlock a new level, unlock a new game. In that new country that you visited, there was new music, new fruits, new rewards. So that’s how the whole concept was developed.

Pete
I’m interested, how many countries are there to visit?

Jaime
We initially had 16, and we thought that was going to be enough. And then after doing the pilot study, in less than a week, most people finished 16 countries. So we took the game back and developed more and gave it back to them. So I think right now it’s probably 60 something countries in the game just to make sure they had something to play with for three months. That was the duration of the study.

Pete
That’s why play testing is so important.

Jaime
Yeah, of course, 100%.

Pete
Sometimes the game is more successful than you think in terms of getting the activity you want.

Jaime
It’s fantastic. Yeah, I mean, play testing is super important because the first version of the game was super confusing. We thought it was great and we played it and it was all based the literature, and we played it in the lab and everyone’s like, yeah, this is great. And we took it to a retirement village and people got really confused. They couldn’t navigate the menus, they didn’t understand how to switch levels, they didn’t get the whole progression system, and we had to oversimplify the whole interface so they could actually understand and play the game.

Ben
Oh, Jamie, I’m so in. This is like exactly my domain. Fantastic. My mind is worrying. So one is they finished the 16. How much gameplay was it to get to the end of 16 countries? Duration of gameplay?

Jaime
Let me do the math. So the game was based on a clinical test that is used to assess the risk falling. So effectively, what we did is a game that collects those same reaction time parameters which allow us to not only keep this person playing, but also to assess if they’re getting better, which is one of the key things in series games, evaluation as people play. So the game, every level took about 3 minutes because we didn’t want each level to be too much. Exertion was a big deal. So we didn’t want people to get exhausted from playing one level. And songs don’t last that long, so that kind of limited how long the level could be. So we found a whole bunch of royalty free songs and we put them together and we found songs that sort of related to the countries.

Jaime
And the same goes for the fruits. We did a bit of research on what country produces which fruit. So that’s how the whole game was created in terms of how long it took. The progression system needed each person to play at least three times each level. So that’s why you needed to unlock the next one. And as you collect the fruits, you get money. So effectively, what we said is, hypothetically, we know one person will take between one and 2 seconds to get one fruit or react to one of the stimulus on the screen. So if we put 30, that equals a couple of minutes. So realistically, what we needed people to achieve is, say, get $100 so you can move to the next level.

Jaime
That means if you play the same level three times and in each play you get the 30 objects that you’re supposed to collect, you get the money that you need for the next one. And there was a bit of a rewarding screen that every time you achieved that and there was like a passport and a stamp that goes, good job, you can go to the next level. So, yeah, people could play as long as they wanted. We’d recommended 20 minutes, three times a week, and they could just play 3 minutes if that was the minimum, or they could play a bit more if they wanted to.

Ben
Michael, so many questions coming through, right? So the nostalgia, the Indiana Jones, I completely agree. We found that in a research project I’m on right now in that we’re doing very basic laptop webcam games and what came through in the types of games that people were interested were the 1970s, 80s Atari style games. And that was because an element of nostalgia. But the benefit of it is that there’s minimal onboarding time, because actually, it’s a well known game mechanic in how you play the game. So I completely get why you went to Indiana Jones as a basis and concept. Why did you decide on a points based game and the narrative elements to it? Where was the idea for the game mechanics that underpin it? Where do they come from?

Jaime
It was a mix of meeting with actual people, like part of the target audience. So for making that game, we did a whole bunch of focus groups, and we had initial prototypes, the basic white screen with some character, and we had them play with that and got feedback and something we learned from looking at what they said, because sometimes we gave them surveys and questionnaires, and they filled it up. And often they don’t say paper what they actually mean, because it’s the first time they see tech like this, and they go and they say things like, this is Fantastic, Jamie. This is the best thing I’ve seen my life.

Jaime
But when you look at them play, you can see a frustration in the faces, or you can see that they’re not engaged, or sometimes they don’t show up to the neck, the following, the follow up meeting. So you need to read those signs. And in doing that, we learned that the senior community really enjoyed the concept of traveling and going places. And in some cases, some of them were not allowed to travel anymore, or some of them just the health conditions they had at the time prevented them from going places. So the concept of being able to visit other countries was quite appealing to the focus groups that we had. This is the interesting thing with serious games. It was a mix of making something appealing for the audience, but also making something that achieves health outcomes.

Jaime
So the second part of the game design was what helps these people reduce faults and the quick step training, that’s how we sort of combine the two ideas. We need something that makes them engage or keeps them engaged, and the whole concept of traveling is one of those. But also we need these people take quick steps in phase, and that’s how those two ideas were combined.

Ben
Okay, I want to go into the stats and results in just a second. One of the things around co design is what you’ve just said. The acknowledgment and recognition about someone not showing its next focus group, or these kind of subtle, nonverbal cues when someone’s engaging with it, no matter what they told you, there’s no book on this. So over years of code and coproduction, like kind of picked up these kind of things as I go along. I really think for new people coming in to co design coproduction iteration, there needs to be more support and training with these little things you’re picking up that I’ve picked up with so many researchers and designers out there have done. I think there is a code design manual that’s needed. But like the real world codesign manual, not kind of step by step theory.

Ben
But it’s so good to hear you say that. Right. Let’s get into it. What did the results show you? What that came out in the evaluation?

Jaime
So we look at the project from different angles we’re interested in. Did people use it? Did people adhere to, I don’t want to say therapy because that’s when it kills the fun, but did people adhere to therapy? Did people use the thing the way we expected them to use? That was one of the angles. Second angle was, did people have fun because one thing is compliant because the doctor says you have to do the thing. The second thing is, did you actually enjoy it, and did you play it because it was fun? And the third angle is, did these people get better? Did they get faster? Did they achieve the improvement that were expecting? And it was a huge analysis, and I’m happy to say that we got positive results in all of them.

Jaime
So people did adhere to the thing actually more than what we expected. And as I mentioned earlier, they were meant to play those 16 levels for like a month, and a lot of them completed it in a couple of weeks. And we actually had to rush and develop more content and give it back to them just to keep them play engaged with the whole three months. There was a couple of participants that actually got emotional when we took the games away because they said, this became part of my routine. I get up in the morning, I make a cup of tea, I play the game. I feel energized. I go and talk to my friends. This game kind of gives me the energy to get out, and you guys are taking it away from me. Why are you doing that?

Jaime
I mean, it was just the end of the study and we needed to get the equipment back anyway.

Pete
That makes a lot of sense, though.

Jaime
Some of them that start the day.

Pete
With a game routine, I know tons of. What are we calling them in this oldies? I’ve heard you say who start the day with a wordle, and that’s part of their routine before they go off and do something else. And isn’t it great that it could be an exercise based one? That’s what I like about what you said.

Jaime
Yeah, absolutely. And I was surprised to see that they saw a game. It’s a thing. They saw the game as a companion, as, I don’t want to say someone that was with them, but they saw it as part of their life and that was quite an interesting outcome. Also, I mentioned that just to give you guys a bit of context, we did it in every time and village, so they know everyone and not everyone put the hand up for the project, but those that did kind of created a separate group organically. So I started chatting about the game and all the residents in the village started to get a bit jealous that they were not part of the vip club that plays games in the mornings. That was an interesting social sort of dynamic happening there.

Jaime
So from the adherence point of view, people did play the game a bit more than what we expected. We actually had a couple playing the game because most of the people were independent living seniors. There was a couple and they actually competed against each other a little bit. And they used to ask me questions like, jamie, who’s doing better? Can’t tell you. Jamie, is it me? I know it’s me. Can’t tell you, but yeah, it’s you. So I guess from the usability point of view, people didn’t have issues using the game because we actually built a sort of system to collect data, not to invade their privacy, but to see what buttons they press in the game, how they did with each level, all the actions they did inside the game. So were able to monitor that without having to look at them.

Jaime
And we noticed that the progression system was used the right way. They went through all the levels in the right way. We actually noticed that some people started playing level one just to warm up, which is the easiest one, and then they moved back to the one they left off last day before. And then from the clinical perspective, we also did a whole bunch of tests in the village. So we gave them the game for three months. Every four weeks I will visit them and run a whole bunch of tests. Every session will take about hour and a bit. So it was a combination of motor skills and cognitive skills that were assessed. So we wanted to see if the game made the brain faster, if they were able to solve more complex problems.

Jaime
Aside from all the physical benefits, from the physical point of view, we noticed improvements, like huge improvements in the first month. Everyone got really fast. They improved reaction time quite a lot in the first month. From the first month up to the final one, there was tiny improvements, but nothing too significant. So I guess that’s one of the things we learned from the game. It makes you better, but it’s not like the improvement is linear or exponential. You get really good at the beginning. Once you finish the first month, there is only so much the body can do, and we can expect people to react, to take a quick step in less than a second. Physiologically, we just can’t. The body doesn’t do it. So we actually pushed people to the best they could and they stayed in that level.

Jaime
When they finished the study, we took the equipment away, we let them live the life again for a month. We visited them at the end. That was the follow up interview, and we noticed that the improvements were still there, they were still stepping faster, they were still reacting to all the stimuli in the screen. From the cognitive perspective, we didn’t really see huge improvements, or at least we didn’t get improvements that were statistically significant. So we couldn’t say, yes, the game works, it makes your mind better. We notice tendencies for improvement, but nothing we can claim as this fixes that.

Ben
So with that, really interesting. In terms of the speed of improvement and the plateau of it, does it matter if it plateaus that point, was it still a meaningful or significant improvement that as long as it was maintained, that was sufficient to reduce the risk of falls?

Jaime
Yeah, absolutely. And it’s funny because false prevention, or if you look at false prevention from the reaction time perspective, which is how fast people can react to a hazard, a tiny difference, or a tiny difference in your reaction time, it’s a huge difference in the impact of the fall. So if you’re able to improve 200 milliseconds, that will prevent you from falling. And those were the kind of improvements we noticed. People, instead of taking second and a half to react, they do what they were doing in 1.1 second. That tiny difference is what separates folders from non folders. So being able to react to the thing really quickly is what stops the fault from happening. And the game was able to achieve that in all the participants.

Ben
So playing a bit of DevOps advocate now, the Kinect system has been around for over a decade, and interactive computer vision games has been around, kind of communally accessible, with affordable technology for a decade as well. Clearly you’ve been able to develop games which have been really well taken on great usability, great satisfaction levels. Why isn’t it everywhere? What are we missing? Where is the silver bullet of adoption at a global scale?

Jaime
Yes, I’m with you on this one. That’s always been the question I ask myself every day in the morning. What I think the problem is people don’t take game seriously. And this has happened to us when we apply for grants every time we say we’re making a game for as soon as they see a game now, they don’t take you seriously. That’s 1 second one, the cost of technology. So all these interactive games, they are expensive. And that was a bit of background. When I finished my PhD, I tried to turn my game into a product and I actually had a chat with the Ministry of Health and I spoke to a institution that ran a program across Australia which is all about faults, prevention. And we saw the opportunity for that program to take the game as part of the program.

Jaime
But when we did the math, we realized that it was too expensive. And just to give you guys some numbers from ten years ago, having the connect with a computer and a game cost $1,000. And if you need a business behind it, like if you want to establish a business that is sustainable and can operate and can develop more games and keep updating the thing, you still have to make money on top of that $1,000. So the cost of getting a client, and I’m using quotation here, was higher than the income you can get or the profit you can get from that client. So creating a business out of that was challenging. The tech was too expensive.

Jaime
And if you go to a retirement house and you tell old residents, you’re going to have to spend $1,000 for a game, that will keep you active, but it’s $1,000, they’ll be like, nah, thank you. Not interested. So that’s one of the issues, tech, it’s expensive. I guess the stigma of games not being a serious thing. And my third point was going to be the senior community. They’re not that tech savvy. That’s changing because the people I met in my phd days, almost 15 years ago, they didn’t have a lot of computer literacy. Like they didn’t grow with computers. And when they finished, when they retired, when they left the workforce, computers were. It wasn’t a thing for them. Whereas the people finishing, like retiring now, and my mom, my dad, they’re almost 65, 70 now. It’s a whole different generation.

Jaime
They actually use computers at work. They both have devices, they have iPads, tablets, mobile phones, they have a Chromecast, they know how to put Netflix on the tv. It’s a bit of a shift in the audience. So, going back to your question, why isn’t that being used? The generation from ten years ago, they were scared of technology. The generation of today, that might be a bit of a change.

Ben
I hope your mum doesn’t mind you outing her age in public. I’ve also.

Jaime
No, that’s fine.

Ben
I’m not letting Pete get a word in Ed’s ray on this episode. So, in that case, what is next for older adult gamification in terms of health management and rehab? I want to go into the other games you’re doing. I want to go into the other research, but I want to kind of close off this part of step connected. Where do you think older adult gamification is going in rehab and health and well being?

Jaime
I think for this to be successful, it has to use things that people have in the house. Most adults or older adults have mobile phones. I think that’s an opportunity. The challenge is developing a game that can track your body and can take a lot of measurements to do the whole evaluation, the background accurately. And the challenge with phones is that the screen is too small, so if you put it away, they can see it. Probably. Smart tvs might be an opportunity. Smart tvs were not a thing back in 2010, 2011, when I started my phd. That’s an opportunity these days because a lot of people have smart tvs. So those tvs are effectively computers. So if you can develop apps for those tvs that can do a bit of a tracking or can deliver exercises, that’s an opportunity. Yeah.

Jaime
I think what needs to change is the tech has to get a bit cheaper and it has to get to the point where anyone can just get it and using existing devices, it’s probably the way to go.

Ben
Okay, thank you very much for that kind of nice end to step connection. Right, I want to move on now into the current project. You’re working with pregnant women in terms of being active in early stage of pregnancy. Again, opposite end of the life spectrum. Where did that come from? The idea, the concept, the project you’re working on now.

Jaime
Yeah, that one I can claim as one idea of my own, to actually have colleagues in the faculty of health. I’m in the faculty of engineering, and it. And given that series games can be applied to a whole bunch of things, I have collaborations with different faculties and health is one of the strongest collaborations we have. And it was just a coffee chat with one colleague who said, jamie, what are you guys working on right now? And I said, well, we’re making these games for faults prevention. So she’s like, cool. I’m actually working in all these pregnant women exercise programs and all that. Do you think we can use games for that? Yeah, I think we can. So the whole concept sort of came up from that coffee chat.

Jaime
So again, I’m not the lead investigator on this project, but I guess my role is to provide advice on game tech. And we’re actually developing a game as well. So the project has two components. The first one is, let’s see what the Nintendo Switch can offer to pregnant women as an exercise tool. And we have a PhD student doing all the heavy lifting for that. And a spin off from that project was, okay, we’ve seen what the Switch can do. We know what the Switch cannot do. What if we make our own game? And that’s also happening at the same time?

Pete
So by your own game, do you mean you’re doing the tech as well?

Jaime
Yes. So we’re trying to get all the lessons we learned in the faults prevention game step connection. And I was a big fan of the Connect, but Microsoft stopped building the connect in 2017. So it’s seven or six years ago or a bit more. And, yeah, one of the lessons we learned is that if you want to use the connect, you need a powerful computer next to it, and all of that is just going to add costs. So let’s go with an approach that is, as I said a few minutes ago, let’s use tech that people have in the house. How can we get these pregnant women to exercise using devices they do have in the house already?

Jaime
That’s when we came up with the idea of using webcams and laptops and building a game that does the whole body or skeletal tracking using a simple webcam. So that’s when we asked our new friend AI to help us with that. So we found AI. It wasn’t a plugin, really, but let’s say it was a plugin or it was a component that was able to get the full body picture and get joined locations from there and turn that into things we can plug into the game. So we found a way to track bodies without using a connect. We kind of built our own connect. Problem with that is you have to have an okay ish computer because a lot of the processing uses a lot of cpu power or gpu power to be more precise.

Jaime
But if you put that aside, were able to make a game that does full body tracking and works on a laptop and delivers safe exercises for pregnant women.

Ben
So, like I say, what’s the objective of it? What’s the ambition? What’s the aim of the project and technology.

Jaime
So, project started with. I guess the main aim at the beginning was weight management in the early stages of pregnancy, because that’s an issue. And there is a whole bunch of complications that can come from being overweight in the first weeks of pregnancy. Like, even the child can have issues with that. I’m not an expert in that thing, so I probably won’t get into the details, but that was one of the main motivations, helping these people stay active, helping these women stay active, and helping them with the weight management. We sort of moved away from that because there was ethical complications there. So we just did it as just a way for you to stay active and healthy and exercise in a safe manner while you’re pregnant, because, again, that’s a bit of an issue.

Jaime
You can just go and do the things that you did before, because now you have a baby inside you, and there’s exercises that you can’t do, like you shouldn’t do it. It will compromise the whole thing. So that’s when step one was let’s get a Nintendo Switch, let’s get the rim feed game, which is the exercise thing that comes with the switch these days. And we started looking at all the exercises, at all the minigames in that game, and we had experts in exercise physiologists, maternal care, and the midwives. And we started looking at kind of like, mapping what exercises were doable and what benefits were in each of those exercises and what exercises were a no. And we kind of went through that list and kind of created a customized program based on that.

Jaime
And then again, we had the eureka moment of, now we can do body tracking without the connect. We have all these exercises. What this tech will let us achieve. What can we achieve with that body recognition? And that’s when we make a list of new exercises that became game mechanics. And again, we created a story, and we did focus groups that was in the middle of COVID that made a bit challenging. So we made focus groups with pregnant women, or women that had been pregnant recently, or women that were about to get pregnant. And we created a game concept that, again, was appealing to them, but also incorporated the exercises that were prescribed by the experts.

Pete
Now, I’m intrigued. How many exercises are you able to work with on this?

Jaime
Quite a few, actually. And most of the exercises are upper body, lower body, but not so much of the core, because you don’t want to mess with that. And some of the exercises we couldn’t include require people to get on the ground and have a position that we just couldn’t track. But most of the exercise are doing things with your upper body, but no heavy lifting. You can use a bit of thera bands.

Ben
Yeah, resistance bands or something.

Jaime
Yeah, those. Just to put a bit of resistance. But we avoided things. Anything above your head increases your blood pressure. We don’t want that, so we avoided all of those. But it was mostly exercises that you can just do yourself.

Ben
Yeah. So, again, not an expert in this area, I know gestational diabetes and things around kind of weight management early is a challenge and needs to be something to be. There needs to be more support around it. But maintaining physical activity during pregnancy and importantly, hopefully to promote that post pregnancy is really important within my role in good boost. We’re working on an aquinatal program at the moment in swimming pools for what we do, but again, it’s a real shift from where we normally work with as older adults. So what I’m really curious about, Jamie is there’s such a similar journey. So where has this been led by and how is it?

Ben
Because we’ve done a lot of work with midwives and natal specific physios and importantly, expectant and recent mums, how has it been through that process of you, in terms of the co design with the end user?

Jaime
It was interesting because we didn’t want to make assumptions about women, and that’s a gender these days, a bit of a tricky one. So we work closely with the midwife, who’s actually. I mean, she’s a senior lecturer. My colleague, Deborah Fox, she’s the person leading the project and she actually found the participants. So when we came up with the initial design idea, we didn’t want to go with the whole, let’s put rainbows and unicorns and make it all pink, because that’s what women do. We avoided all of those assumptions and all those misconceptions and stereotypes. Funny enough, when we put the game in front of them, they wanted the rainbows, they wanted the pink thing, they wanted the unicorns. That got a little funny anyways.

Jaime
But I guess the final concept that came from doing the code design sessions and talking to these women is that they wanted something they can care for or care about. So we came up with the concept of you actually manage a village, you live in a village, there is a massive egg, and the egg was a bit of a representation of your baby. So as you do things for the village, like picking fruits or doing gardening or doing simple activities that were appealing to them and they actually suggested those activities as you do those things. The egg gets bigger, the village gets bigger. And that was the concept that they found appealing, or that was the concept.

Jaime
They started making suggestions and we had a bit of a brainstorming session with the game designers and kind of prototyped things and had a second session and showed them what we created. And they started to get really excited about the idea of the egg and the idea of doing all these things, that it’s about providing care. That was the concept that was appealing to them. And that’s why gardening wasn’t a game component or cooking was a game component. So the challenge was, how do we get gardening? A thing where you move your arms this way, like, how do we incorporate the exercises in something like that? So that’s when it got a little tricky. Not tricky, but that’s when it got challenging or interesting. I mean, challenge equals interesting. And again, the game is not fully finished.

Jaime
We’re still working on it, but so far they seem quite happy with what’s been built.

Ben
Gone for hours. Jamie, there is one thing I want to go into before we kind of close out the episode today, is we speak to a lot of people. That’s the whole point of health points. But one of the thing that keeps coming up is around regulation and research and the challenges and nuances of health gamification. Compared to a drug or a traditional medical device, which is usually relatively static, like the biochemical formula of a pill, or the actual kind of medical device of a rehabilitation device, whatever it is, within gamification, like with all games and with all apps, there is ongoing iteration, improvement to improve engagement and outcomes and statistics.

Ben
The challenge being is the existing format of regulation and research means that what is submitted five years ago, three years ago, a year ago may be completely different in terms of the gameplay, but that was not involved in the research project a year ago. What needs to happen in terms of regulation? In thinking about how fast paced the development and improvement of game mechanics within what you’ve explained narrative, hugely within both the games that you described today, where do you think the future lies within health gamification and regulation?

Jaime
That’s a tricky one. I’m not entirely sure. I guess the challenge is what I mentioned before. People don’t take games seriously, and there has to be a shift in that mentality, because games can be powerful and there is evidence that they do work and help you achieve a whole bunch of things aside from entertainment, what needs to happen? This is me. A bit of dreaming, but what needs to happen is that they take it seriously.

Ben
In that case, then I think within kind of rehab and physiotherapy, I’ve seen a real shift in paradigm and thinking in the past few years. The view was that quantitative is king and kind of RCT is king. What actually is the recognition? These are complex innovations with complex human beings which are multifactorial problems. And as a result, qualitative research is actually incredibly valuable, if not maybe more valuable in some cases. Do you think that perception shift needs to change as well? With health gamification?

Jaime
And I think something that can make a difference is the big game makers, once they start incorporating games for health, that will change things. And I mean, Nintendo, Sony with the PlayStation, Microsoft with the Xbox, once they start putting serious games in it. I mean, they do have games like these games like the biggest loser for the Xbox or know Ringfeed for the Nintendo Switch, but they’re not games targeting an older audience and they’re not games targeting a specific health outcome. It’s just exercise games in general. Once they start developing games where the main goal is to help, say, an older person, reduce their risk of falling, that might make the shift, because if you see that the big players are going that way, people will follow.

Jaime
Whereas if an indie game development studio does it’s like, yeah, keep going, guys, that’s fun, that looks cool, but no one takes you seriously. And I think that’s been one of the biggest challenges for us as well. We’ve spoken to Microsoft, we’ve spoken not to Nintendo, we’ve spoken to Microsoft and we had a team in Singapore who look at the game and they were like, yeah, looks good, but no thanks. That’s probably what needs to change, because the evidence is there. The evidence is there. Sorry again.

Pete
I think it makes a lot of sense because health gamification apps are pretty popular and getting quite a lot of coverage and use. And I guess that’s because they’re on a platform that is accessible to everyone, whereas what we’re talking about here is specific games through the mass gaming platforms. I think that’s something worth targeting.

Ben
I think that is something worth targeting. Pete, maybe there’s a campaign we need to pull together on somewhere over the next health gamification conference. Jamie, it’s been so good to have you on. We could have gone for absolute hours. I know I’m going to follow up with you, but talk about things like nostalgia as a shortcut to onboarding with older adults and the role of games that can improve and maintain old adults’reaction time, which can be the difference between a fool and staying upright. And importantly, the value of play. Testing, prototyping, iteration, and reading the less subtle feedback signs when you’re working with participant co design. Jamie, it’s fantastic to have you on the show today.

Jaime
Thank you, guys. I really appreciate the opportunity to chat with you, and it’s been refreshing to have this discussion and all the questions are very interesting, and they actually got me thinking. And, yeah, I think there is really cool stuff coming from this. Thank you, guys. Appreciate it.

Pete
It’s been great. Jamie, and it’s been fun to see Ben swept away with his enthusiasm for it.

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