Augmented reality games to reduce stress and anxiety for any child in hospital

In Series 2 Episode 9 of the Health Points podcast Ben and Pete welcome Dom Raban, the co-founder of Xploro, a digital therapeutics platform that uses gamification to deliver health information to young patients. Dom shares his background as a designer and explains how his daughter’s experience with cancer led him to create an app that provides information and reduces anxiety for children going through hospital treatment. He discusses the impact of reducing patient anxiety on clinical outcomes and shares research findings that demonstrate the effectiveness of Xploro in reducing procedural anxiety and increasing knowledge about procedures. The team also talks about multiplayer interaction in Xploro, its potential benefits for siblings and families, and future plans for expanding content development and creating an adult version of the platform. Dom expresses his view that gamification will become more embedded in engagement strategies rather than being talked about as a separate concept.

You can listen to this episode below:

Outline:

I. Introduction   A. Welcome to Health Points podcast (00:07)   B. Introduction of hosts and guest, Dom (00:12-00:56)II. Background and Founding of Xploro   A. Dom’s background and reflection on his child’s medical experience (01:02-02:42)   B. The idea of creating an app for children in hospitals (02:42-03:42)   C. Research study on Xploro’s impact (03:42-04:28)III. Engaging with Xploro   A. Creating and customizing avatars (04:34-04:57)   B. Introduction to augmented reality models and complex treatments (04:57-05:21)   C. Games and learning outcomes (05:21-05:54)   D. Calendar and mood diary feature (05:54-06:07)IV. Design Process and User Involvement   A. Involving school kids in game idea generation (06:23-07:30)   B. Co-developing content with patients, parents, and clinicians (07:30-08:28)   C. Challenges in human-centered design (08:28-09:24)V. Expansion and Localization   A. Working in different countries and cultures (09:26-10:45)   B. Adapting content based on user feedback and context (10:45-11:17)VI. Decision-making and Roadmap   A. Balancing long-term goals and opportunistic projects (11:17-12:58)   B. Content development and collaborations for future growth (12:58-14:33)VII. Impact and Behavior Change   A. Quantitative and qualitative outcomes of Xploro (14:44-15:24)   B. Empowering children to self-manage their healthcare (15:24-16:33)   C. Anecdotal feedback from parents (16:33-17:28)VIII. Safety and Security   A. Secure communication and interaction within Xploro (18:21-19:28)   B. Age-specific experiences and ongoing studies (19:28-21:13)IX. Future Plans and Expansion   A. Long-term goal of becoming a health education platform (21:13-21:29)   B. Opening up Xploro to incorporate other content (31:23-32:07)   C. Adult version and ongoing development (32:24-33:57)X. Role of Gamification in Healthcare   A. Importance of gamification in health education (33:03-35:34)   B. Co-design approach and humanistic design process (35:34-36:03)XI. Conclusion and Well Wishes   A. Appreciation for Dom’s work and future success (36:03-36:17)

Episode Transcript:

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

Ben
And joining us today, we have Dom. Dom is the co founder of Explore, a unique digital therapeutics platform that delivers health information to young patients. Using augmented reality, artificial intelligence and games, explore aims to reduce their stress and anxiety and improve children’s clinical outcomes. He’s also chair of the corporation Pop, a creative digital agency that specializes in mobile app development and immersion technologies. Dom, it’s great to have you on the show today.

Dom
Great to be here. Thanks for inviting me.

Ben
In that case, let’s start. Can you tell us about your background and what led you to founding Explorer?

Dom
Yeah, sure. So I’ll tell you about my background first. So, I’m a designer. By background, I’ve spent God, too many years, probably 40 years as a designer. 40 years. Wow. And for most of those years, I’ve owned and managed digital and creative agencies. But Explorer comes about through personal experience. So, back in 2011, my daughter, who was 13 at the time, was diagnosed with a rare bone cancer called Ewing sarcoma. I have to say, she’s fit and well. She’s eleven years cancer free, doing great, so I’m just getting that out there really quickly. But she went through, as I’m sure you can imagine, she went through a horrendous year of treatment. She was treated at six different hospitals in total, including two in the United States. She had 15 rounds of chemotherapy, numerous operations, the works, basically.

Dom
And part of the reason why she’s fit and well today is because she had great clinical care. But what was missing from her treatment was information. So she had no information about any of the people she would meet, no information about any of the technologies that would be used to treat her, and no information about any of the environments she was going into. So when she came out of treatment, I did what many parents I’ve subsequently met do, which is kind of reflect on that experience and think what was missing? It was information, what was missing, and what can I do to improve that experience for other children? So, given my background in digital agencies, in design, I started thinking about what an app might look like that would provide information to not just child cancer patients, but to any child going through hospital.

Dom
So that’s kind of how explorer came about.

Pete
So I’ve got to ask, what sort of impact does it have on the child not having this information?

Dom
Yeah. So there’s lots and lots of evidence that says, and this isn’t just based on children. This is for any patient going into hospital, that if you provide patients with information prior to an intervention, they experience reduced anxiety, and that can lead to better clinical outcomes. So the whole premise of explore is that by providing patients with age appropriate and playful information, we’re able to reduce their anxiety. And we actually did a research study, I say we did it. Our research partners did a research study about two years ago now at the biggest children’s hospital in the UK, where they had 80 children, 40 with access to standard healthcare information and 40 with access to explore.

Dom
And what the research has found was that those kids with access to explore demonstrated a statistically significant reduction in procedural anxiety, as well as statistically significant increases in both knowledge about procedures and patient satisfaction. So absolute gold dust to have that research evidence. But essentially that’s what explorer is trying to do, is reduce that anxiety around coming into a hospital.

Ben
In that case, can you talk us through what it’s like to engage with Explorer from one of your players point of view?

Dom
Yeah, sure. So the first thing a child does is create and customize an avatar, and that avatar becomes their guide through their healthcare journey. And the guide introduces the child to 3d augmented reality models of hospital environments. And they can play with those models in much the same way as they might interact with the Sims. The guide also introduces them to complex treatments and procedures. So things like MRI scans, cannulation, there’s a series of games, and each game has a learning outcome. So, for instance, we’ve got games about blood cancers. We’re working on a game at the moment around sedation, we’ve got games about surgery, so a whole range of stuff. And then there’s a calendar and mood diary that allows the child to take control of their day.

Dom
And we can actually, when the child records a mood against a calendar event, so let’s say they’ve got a scan coming up and they’re feeling anxious about it. We can send that data to the medical record. And if a clinician sees that a child’s feeling anxious about an upcoming event, they can then get someone from the play team or someone else or psychology or wherever to go and talk to that child about their anxiety around that upcoming event.

Ben
The gameplay that you’re experiencing, explorer, how did you get to that? Was it because the Sims is just a popular game title and that seemed like an obvious way to start, or what was your journey to get to the gameplay in Explorer now?

Dom
So I talked about my background in design and human centered design, user centered design, whatever you want to call it has always been central. Why I say always, probably since the turn of the second millennium, has been central to the way I design. And so the very first thing that we did, once we had the idea that we wanted to create an intervention to provide children with information, the very first thing we did was we got some school kids in on work experience placements and we set them a project. And the project was, you’ve got to go to a hospital. What’s going to make you feel better about that experience? And to a t, they all came up with game ideas.

Dom
And some of those game ideas have actually been, you can trace through from that intervention six years ago to now, where those games are in a slightly more advanced state, a part of the explorer package, and so involving patients, parents and clinicians in the design process is absolutely central. We’ve actually got an expert advisory board, and I would argue that our expert advisory board is the best group of experts you could ever hope to find. The youngest is eight, the oldest is 16. They come from a range of backgrounds and experiences. We’ve got kids who are absolute hospital experts. They’ve been through treatment, some of them have been through treatment all of their lives, and the other half of the group have never had any experience of coming to hospital. So we’ve got a really wide range of experiences, neurodiversities, well represented.

Dom
So we’ve got a great cross section of kids who give us not only feedback on the things we do, but we co develop content with them. So I mentioned earlier the mood diary that we’ve got. So that was co developed with our expert advisory board. And so by doing that, we can be confident that all of the content we create is age appropriate.

Ben
So I want to dive a bit deeper into that then. So within my work as well, a huge amount is focused around human centered design. Some of the biggest challenges within human centered design is, first of all, having a representative sample of the people you’re trying to support or stakeholders. Second of all, even if it’s representative, some people shout louder than others, some people are more opinionated than others. How do you balance that off within your process to ensure that what you’re designing and developing and deploying truly represents the actual population you’re trying to support, rather than representing the sample that you’re working with in that design process?

Dom
Yeah, really great question. So test, and test again with as wider group as possible. So our expert advisory board give us great feedback. But although it’s a diverse group of children, it’s a limited group of children. And so we test widely with bigger sample sizes when we have special requirements. So for example, I’ll list a couple. So when were doing our spanish translation, we asked our translation agency to provide four sample translations from four different translators who all had the brief to the translation agency was we want translators who have experience in writing for children and in the clinical domain. So we got these four sample translations. We then got a group of twelve spanish kids and said which one is the best? And we chose the translator based on that translation when went live in Ghana.

Dom
In the app you give your avatar a name, and because we use the avatar in multiplayer gaming, and we’ll talk about that a bit later, but because we use the avatar in multiplayer gaming, there’s no opportunity for free text entry. So we have kind of funny first names and funny second names. Now, those names weren’t very funny in Acan, which is the language spoken in Ghana. And so we asked ghanaian kids to come up with funny first names and funny second names. So getting that input from users in context, the right users in the right place, is really important.

Ben
I completely agree. There are so many specific perspectives, which is so much beyond language and translation. I’m working in the same area right now, even within colloquialisms within the UK, it’s amazing how much you need to shift and adapt to make sure it reflects even the same nationality, let alone different ones. Absolutely remarkable. So how do you keep working on different features and functions in Explorer? Because explorer’s been around for a while now. So how do you make a decision process as to where you’re going to put your time and energy into what you’re going to work on next?

Dom
We obviously have a roadmap of features that we want to develop and that roadmap is based around strategy. So, for example, if I talk about our long term goal is to be a health education platform for any patient, any age, any condition, anywhere in the world, which is an enormous content development task. So to get to that endpoint, we need to work with subject matter experts to build out content for new disease areas. And some of the big areas that we have on our roadmap are some of the big chronic diseases like asthma and diabetes.

Dom
However, what happens is that opportunity comes along and hospital will say, let’s say, I’ll give an example, we’ve got a real need for some specialist content around transplants and so we’ll work with that hospital to develop that specialist content because there’s an opportunity of a live deployment and usually a budget attached to that. And so planning new features is a combination of strategic direction and following the roadmap, but also allowing opportunity to disrupt that roadmap when it comes along.

Ben
Even when opportunity shows up to disrupt the roadmap, trying to convince your team of designers, developers and engineers that they have to shift and pivot can still be a challenge. I know from experience.

Dom
Tell me about it.

Ben
So how many people have engaged with explore to date?

Dom
Well, so probably easiest if I talk about the areas we’re working in. So I’ve mentioned Africa. We’re live in Ghana, Malawi and Cameroon. What we’re doing in Africa is we’re working with a charity called World Child Cancer, and we basically give them unlimited licenses. They work with another of their donors to give hardware to the children. So we’re providing the software the other donor is providing the hardware numbers in Africa are relatively small because we’re in the cancer domain. Unfortunately, there aren’t that many kids with cancer in the United States. We’re working across all sorts of domains. We’re probably more active in the United States than we are in the UK. In fact, we’re working with Boston Children’s Hospital, arguably one of the best children’s hospitals in the world. They’ve currently got several hundred active users.

Dom
At the moment, we’re working with a number of other hospitals across the United States. We’ve got a couple of customers coming on board in Canada, and we’ve got a number of NHS customers as well. So active in the UK, USA, Africa, and a research study going on in Spain at the moment.

Ben
So one of the elements you have around explorer is multiplayer interaction. So a couple of questions around this one. Kind of where is the leap in the product development journey you went? Multiplayer is a thing and what does it look like? Because I can conceptualize what this individual solar interaction with this Sim stars game with, kind of seeing, exploring how a procedure goes forward. How does that shift when suddenly there are multiple players in?

Dom
I mean, one of the big challenges with multiplayer is, particularly in the health domain, is ensuring that it’s a safe space in which to interact with other players. So we obfuscate identity behind the avatar. And the avatar has a predetermined name? Well, not predetermined. A user can choose a name, but they choose from a predetermined list of first and second names. So you can only identify other players in the multiplayer environment by their avatar name. So you’ve no idea who the real person is behind that. Obviously, you can make an offline appointment to play a multiplayer game with a friend, but there is no way that in that multiplayer environment you can determine who anyone is. So we handle safety in that way. We use multiplayer in different levels of sophistication.

Dom
So our first multiplayer game was very much a kind of term based game, so very simple. We’re getting slightly more sophisticated with some of our multiplayer activities now, but multiplayer has actually been core to all of our game development from day one. It wasn’t something that we tagged on afterwards.

Pete
And why is that?

Dom
Why is it, why has it been core? It’s been core because it seemed important that in a very lonely experience, you should be able to share that experience with other children who are on a similar journey. And so it felt like regardless of the networking difficulties and the security difficulties and all of those kind of things, it felt like multiplayer had to be central to Explorer.

Pete
That’s cool. I thought it might be something like that.

Dom
Yeah. So actually I’m going to share something related to multiplayer, which is in development, and it’s not a game, it’s what we’re calling our mini metaverse for families and it enables. I’ll step back from that a second and just explain how it came about. So if I refer back to my daughter’s experience when she was 13, going through cancer treatment, her brother was eleven and her brother had a pretty tough time because our focus was on our daughter and he didn’t get the attention that an eleven year old boy needs for the course of a year. And so I’ve become really interested in the psychosocial needs of siblings when there’s a sick child going through treatment, and that’s kind of developed into the psychosocial needs of the whole family.

Dom
So what we’re doing, because a family member has authorized access to explorer, we can unlock some of those communication elements that you wouldn’t be able to do in a freely accessible multiplayer game. So by doing that, by knowing it’s a secure, family based environment, we’re allowing avatars to exchange short messages, exchange virtual hugs, exchange emojis, and also share calendars so that you always know what your other family members are doing. So imagine that you’ve got an MRI scan coming up tomorrow. Other family members might get notification saying you’ve got an MRI scan tomorrow, or your brother’s got an MRI scan tomorrow. Do you want to find out what’s involved in that? And also, when it comes to the pure games within Explorer, you will be able to choose family based games to play with your other family members.

Dom
It won’t be obfuscated behind an avatar name.

Pete
So that’s a bigger range of collaboration and team play. Part with anonymous, part with family, depending on your mood. To a certain extent, yeah, absolutely. Sort of person.

Ben
I like that. What’s the youngest players that you have, Dom? Part of the reason I ask is what you’ve flagged around safety and security and what does it look like for you as an organization? And is there a lower age limit that you can support because of that too?

Dom
So we usually talk about Explorer being appropriate for seven to 15 year olds, and the reason we have such a wide age range, because developmentally there’s a massive difference between a seven year old and a 15 year old is because we use a very similar approach to the one that Nintendo use, which is Nintendo have developed a language style that is neither patronizing to older children and adults, but simple to understand for younger children. So we do a very similar thing with Explore. However, we’ve got a study going on in Spain at the moment where they’re looking at three age cohorts of children, so three to six year olds, where it’s primarily a facilitated experience with a parent or a healthcare professional, seven to twelve year olds and then 13 to 18 year olds.

Dom
And we haven’t got any data back from that study yet, but what we’re hoping to show is the applicability of explore across an even wider age range than our core of seven to 15. We’re actually doing a discovery exercise as well, with a hospital in the UK where we’re looking for the first time at a version of explorer for late teenagers and young adults. And the discovery exercise is really just to find out how much the Explorer platform would need to change to be appropriate for people of that age group.

Ben
Now, one of the things you mentioned earlier in the research project you completed was this change in statistically significant change in things like anxiety pre and post procedure. Now, we’ve had a lot of speakers on health points talk about the limitations of gamification. A lot of what Explorer is doing is around a more effective way for health literacy and health education. Now, you see that result in emotional changes. Can it result in things like behavioral changes, do you believe? Are you seeing that happen in terms of how your players start to manage their health condition, not just in the way they go into understanding the treatment that they’re there to receive?

Dom
Yeah, so there’s so many points I want touch on there, and I’ll try and answer this with not too long answer, but I’ll start by talking about that behavior change and health literacy. So there’s good evidence that says that if you have a health literate population, then that population are better able to self manage their health care. And self management of health care is really important for the long term future of any health service. So we’re building a generation, potentially, of patients better able to self manage their health care in future, but because they become used to learning about their own health pathway, their own health journey. So that’s the first thing I wanted to say.

Dom
The second thing I wanted to kind of relay is a message, actually, that we had from a parent recently, which I think beautifully encapsulates how the power of gamification in enabling a child to deal with their treatment. So this is a message that we had from a parent of a twelve year old boy who’s being treated for osteosarcoma. He played one of the games within Explorer, which is a game where essentially you’re flying a rocket through the bloodstream and you have to destroy cancer cells and avoid white blood cells, and then you get power ups through capturing bags of chemotherapy and that sort of thing.

Dom
So he played this game, and the message from the parents said that he went in for his fourth round of chemotherapy the following day, and he said to the nurse that he finally got why he was having chemotherapy. And she said that there was a lightness about him that she hadn’t seen before during the course of his treatment. And I find it incredible that getting 300 points for a bag of chemotherapy in a game can actually change perception about treatment. And for me that was, well, I certainly shed a tear when we got that email, but I think the whole team did. It’s just so powerful.

Ben
Unbelievable having those little bits of feedback. And this is the interesting thing about research as well, I think, is that the quantitative outcomes that we gather through research may show some sort of statistical change, but it really is that anecdotal and qualitative feedback which really highlights the depth of change that these interventions and gamified services can, having people, which annoyingly in the hierarchy of evidence, often isn’t taken in the same level of quality, but is so important to receive it.

Dom
Yeah, absolutely. And just to talk tangentially about that evidence as well. So we’ve talked a lot about reduction in anxiety and the benefits for the patient. What we haven’t talked about so far is the benefits for the provider. And actually we’ve got some studies going on at the moment around that, which I’ll talk about in a second, but less anxious patients are easier to treat patients. They result in shorter appointment times, less need for sedation, reduction in repeat procedures in things like MRI. So there are a whole load of procedural efficiencies that result from reducing anxiety in patients. And we’ve actually got a study going on at Boston Children’s Hospital at the moment, which is looking at reduction in repeat procedures and procedural efficiency in the radiology department.

Dom
So I think it’s important to make that point that this isn’t just about, it is about reducing anxiety in patients. But the ancillary benefit is that creates procedural efficiencies for providers.

Ben
Double bottom line instinct, which I’m sure is then the triple bottom line, because actually it’s for the children, it’s the parents and the clinicians and clinics that are delivering the procedures to. I want to go a bit deeper into behavior change because one of our guests previously talked about how education components within a gamified setting around dietary literacy and understanding lifestyle change. One of those things was, oh, it’s so much better to have fruit and vegetables in your diet, as opposed to things like pizza and ice cream. And then the understanding in the adolescent players was that, oh, yes, of course, fruit and vegetables are the most important thing into the diet compared to these other fast food. But then the researcher asked the subjects, what do you want to do? Do you want to go for pizza now?

Ben
And they go, yeah, let’s go for pizza. And so I agree that a huge challenge facing the 21st century health systems is a need for lifestyle change. Do you think we can really create those inherent lifestyle changes that are going to be essential for avoiding mass obesity, diabetes, cardiovascular disease, which is so much around lifestyle? Or do you think, as humans, we are so hardwired to be seeking out high calorie, high sugar, sedentary lifestyles that the education component only has a limited effect for behavior change.

Dom
You frame that very much in terms of the patient changing and adapting, and I think you need societal change for those changes to take place. I think all too often we place responsibility for those choices on the patient when the opportunity to make those choices is removed from them. Because the kind of food stuffs that are available to them, the food stuffs that are marketed to them, presented to them in the supermarket, are unhealthy. And for that kind of real step change, you need governments to lead that, you need legislation to lead that, and you need a change in mindset that is way beyond, way out of the remit of the individual.

Ben
I guess, on that, the idea of five minutes of gameplay versus being bombarded for half an hour to an hour a day of adverts, billboards, flashy packaging, toys that come with certain sung with meals. Trying to combat that with five minutes of gameplay a day is a challenge. Yeah, very good point.

Pete
I think it’s interesting, and from an explorer point of view, what are you up against in terms of.

Ben
The actual.

Pete
Institutions that the kids are going into? How scary are they? How much difference can you make? And as an extra, are you able to spot, shall we say, the more anxiety inducing procedures or institutions you could offer help to something like that?

Dom
So, I mean, I think, you know, I talked earlier about our kind of long term goal of any patient, any age, any condition, anywhere. And I think we’re not kind of pinpointing specific procedures or places or processes and saying, hey, that’s really scary. Let’s create some content that makes it less scary. What we’re thinking about is that overall experience for everyone, which is anxiety inducing experience. I really hate going to see the doctor. I’m really anxious about it. I wouldn’t be surprised if you’re the same. Certainly feel that way about the dentist. And it’s not because there’s any one thing that is going to trigger that anxiety, it’s because I have a general fear of doctors and dentists. I think that’s what we’re trying to do.

Dom
We’re not kind of trying to be laser focused and think this is the next big thing that we’re going to reduce anxiety for. We’re trying to shift attitudes generally about how you interact with.

Pete
Okay, so more meta level. Yeah, good answer.

Ben
What’s next for Explorer then? Where do you see your roadmap over the next two, three years?

Dom
Mean, I talked about our kind of long term goal, any patient, any age, any condition, anywhere. And I talked about that being an enormous content development task. Now, we don’t plan to do all of that content ourselves. So one of the next things that we’re doing is thinking about how Explorer can become a platform that uses other people’s content. So we’re thinking about building an SDK for our games so that other games developers can contribute games to the platform. We’ve already built a new feature which allows us to incorporate video content in Explorer from other video providers. So linear content, so that will be key, is opening up the platform to other content developers. What is at the moment code name mini metaverse for families, but we’ll probably change. Name is very much part of our roadmap.

Dom
So that will be a development that will happen over the next year or so. And really, I suppose the next four or five years is all about working towards that long term goal. So by 2024, we are planning to have an adult version available. And I mentioned earlier the first steps we’re taking to that with our discovery ex.

Pete
I was going to ask, how big is the team and what’s the funding look like for making this happen?

Dom
So the team is not very big. We’re just over a dozen people now. We fortunately have some flex, because I mentioned earlier that I’ve spent the last 40 years owning and managing digital and creative agencies. So explorer started its life within the agency of which I’m chair, which is corporation pop. And so when we run out of Explorer team members, we borrow or we buy time from corporation pop, and in terms of what funding looks like, so we’re equity backed. We went through a really painful process last year called a Delaware flip, where we flipped our corporate structure from UK limited to us incorporated, and that has enabled us to get us investment. So we have a couple of hospital systems as investors, as well as more conventional vcs over in the states.

Ben
My final question for you, Tom, is not just explorer, but where do you see the role of gamification, health generally? Where do you see the next decade going?

Dom
So I’m always a little hesitant to use the word gamification because it’s something that I think will start distinguishing less and less as it becomes more embedded in the way we do things. You can trace gamification back to Baden Powell and getting scout badges in the early part of the 20th century. So 100 and 2130 years into gamification, at some point we need to stop talking about gamification and just thinking about engagement and tools for engagement and things like reward systems and all the other things that we think of as gamification will become central to that driving of engagement.

Ben
I think that sentiment shared by a lot of our guests, that gamification has become a term that doesn’t necessarily represent the views and thoughts of a lot of people working in the space. And actually it’s just that these are elements of usually a digital service and rather than calling it a gamified service, because actually the wider perception from healthcare professionals, academic institutions, is that games aren’t health. And rather than talking about these as codesign solutions, following a humanistic design process, which we believe are more effective than just a piece of paper with information about a condition, a procedure or anything else, is the way we should be representing them, rather than saying, this is a game led service because it often devalues it from the perception of the wider audience.

Dom
I wish I’d put it like that.

Ben
Dob, it’s been absolutely fantastic having you on the show today. I wish you all the success in the future of Explorer as well and the things to come and achieving your world domination plans for Explorer two.

Dom
It’s been a pleasure. Thanks very much.

Pete
I think we should have him back on in a couple of years and see how much more has changed and expanded.

Ben
I completely agree. Who knows, maybe you won’t even be called health points then. Maybe we’ll remove all the terms of gamification by that point. Too close.

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