Heroes vs. Villains: How Gamification Helped in the Fight Against COVID-19

Become a Hero!

Dealing with the pandemic required new approaches and thinking. Countries worldwide had devised creative campaigns to prevent the spread of the SARS-CoV-2 virus, and incentivize vaccination. During lockdown, many people tried to stay physically active using digital platforms, while people with chronic diseases heavily relied on self-monitoring and telemedicine.

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Such an unprecedented crisis forced the adoption – often through experimentation – of new measures. Among these measures were gamification and AI.

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Three scientists from the Aedimark R&D Group from the University of Extremadura in Spain – Prof. Dr. Luis R. Murillo-Zamorano, Prof. Dr. José Ángel López-Sánchez, and Dr. Carmen Bueno Muñoz  – studied whether these measures, never before used on such a scale were useful in curbing the spread of the virus.

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They draw upon academic research, and analyze selected initiatives to show the spectrum of possibilities that AI and gamification can provide.

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The authors found that gamification had been applied in many ways by national and regional authorities, consciously and unconsciously, to encourage the population’s participation in collaborative activities focused on the fight against COVID-19. The technique, which is rooted in behavioral psychology, is typically used to promote healthy habits, facilitate chronic patients’ use of telemedicine applications and adherence, and prevent health risks.

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Archetypes are one of the gamification design patterns practiced during pandemics. According to the authors, two main archetypes of games – heroes and villains – have been applied in the context of the pandemic. “The heroes are represented, among others, by the health professionals who fight against the coronavirus, and the villains could be those who deny the existence of the virus.”

This split into two competing roles can take different forms. For example, health professionals and vaccinated citizens were being promoted as heroes in public campaigns. UNICEF created a campaign called ‘Zero2Hero’, and New York City’s vaccination posters had the slogan ‘Be a Vaccine Hero’. There was one villain: the virus. With this narrative, social cohesion in the fight against the pandemic has been strengthened, resulting in better adherence to restrictions and recommendations.

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The authors of the Gamification and Artificial Intelligence During COVID-19: Case Studies in Health and Education investigate gamification use cases in contact tracing, patient management, training and education, and activation of necessary attitudes and actions.

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For example, apps with gamified design can help mitigate the increase in sedentary behavior caused by the pandemic. They can also improve user experience by contributing to achieving health-related goals. But there is also a societal aspect of apps and platforms applying gamification – establishing a gamified culture where spaces for exchange emerge and thus create an excellent opportunity for managing crises such as the pandemic.

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As the book points out “numerous empirical studies have been conducted before the pandemic about the application of gamification in the healthcare sector, and the results are positive.” This technique can be used to “promote healthy habits that prevent or stop the progression of disease or to increase the effectiveness of programs associated with health promotion”, according to Juho Hamari and Jonna Koivisto (Tampere University, Finland).

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AI Sees Patients and Tracks Misinformation

In late 2019, BlueDot, an AI-based software designed to locate, track, and predict the spread of infectious diseases, first warned about the possible spread of a new type of pneumonia. This was seven days before scientists in China identified the virus. Artificial intelligence was used for pandemic surveillance in many ways. In South Korea and China, authorities have used AI to monitor the spread of infectious diseases. AI-driven systems were used to monitor patients treated at home, and AI-based chatbots and platforms helped people manage anxiety and depression.

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The power of AI does not stop there. In the US, Mexico and Japan, users could ask Amazon’s home assistant, Alexa, what they could do if they thought they had coronavirus. In addition, AI systems reviewed X-rays and CT scans to diagnose COVID-19 to support overburdened healthcare professionals.

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It also identified thousands of new potentially effective compounds for drug development and has helped decode the new variants of concern. AI-based density maps were used to optimize vaccination in sparsely populated areas of the world. Facebook and Twitter turned to AI to review COVID-related content to fight misinformation.

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Even more exciting opportunities emerge when AI is combined with gamification, especially in learning, personalization, and behavioral change. Gamified AI-based apps offer individualized training, provide tailored treatment plans, improve adherence, and encourage continued use of digital tools and the acquisition of positive habits. As the book points out, “personalization refers to the use of Machine Learning (ML) to offer personalized gamified experience to each user and encourage long-term engagement through the modification of the activity.” The application in behavioral change “refers to the use of ML to vary the gamified design so that the user interacts in a certain way with the gamified system and realizes a change in their behavior.”

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In addition, techniques like scores, constant feedback, social exposure, habit loops and rewards motivated individuals to achieve their goals, whether it was to curb the spread of the virus or to manage a chronic disease. The authors point out that social exposure could be key in gamified health apps:

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Social interaction may positively affect user engagement in gamified health apps and make it easier for users to achieve their goals.

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Another mechanism in gamification is the habit loop. It takes place when an action is rewarded after carrying it out. “The reward encourages continued use of the app and the acquisition of positive habits. In addition, the results can be shared with loved ones or even a doctor […]”.

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High-quality gamified designs can lead to intended health results

Gamification and Artificial Intelligence During COVID-19: Case Studies in Health and Education offers a clear overview of how technologies have been of great importance in developing solutions to combat the pandemic. Gamification was applied in contact tracing apps, fitness and mental health apps, educational platforms and even vaccination campaigns. Some of these tools and approaches have proven their value, while others still require further research. For example, a study by Michail Kalogiannakis (University of Crete)  point out that gamification motivates students and improves their learning outcomes.

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In healthcare, gamification is booming. It can be used “to promote healthy habits and behaviors such as physical exercise and to encourage self-management of different aspects related to health statues”, according to the authors.

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Last but not least, Prof. Dr. José Ángel López-Sánchez, Dr. Carmen Bueno Muñoz and Prof. Dr. Luis R. Murillo-Zamorano concludes that technological innovations are of use only if they are accessible and of high quality. Therefore, health systems should implement strategies to minimize the digital divide – the disparity in the capabilities and resources to access and employ digital technology.

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Since March 2020, when the COVID-19 pandemic began, gamification has been used to encourage the adoption of behaviors that reduce the spread of COVID-19. In some cases, it has been of great help. In some, more research is still required. Nevertheless, its potential is just beginning to be discovered.

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Apps that Integrate Gamified Designs and Enhance Patient Experience

Interview with Prof. Dr. José Ángel López-Sánchez, Dr. Carmen Bueno Muñoz, and Prof. Dr. Luis R. Murillo-Zamorano, authors of the Gamification and Artificial Intelligence During COVID-19: Case Studies in Health and Education.

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How can patients benefit from gamification-based apps and platforms?

In general, health apps and platforms offer different functionalities for patients to manage and control their disease from their mobile devices. In the case of gamified apps, patients benefit from the engagement generated by the introduction of game-like elements, which encourages the use of the app. Therefore, their continued application is essential for achieving the objectives of these apps.

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Depending on the purpose of each app, it is possible to improve, for example, patients’ adherence to treatment and disease control through motivation and engagement as a result of gamification.

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Likewise, during the COVID-19 pandemic, chronic patient care has suffered as medical efforts have been directed toward caring for COVID-19 patients. Gamified platforms play a key role in this context as they promote monitoring of the disease by the patients themselves by involving them in its management.

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Finally, it should be noted that these applications often keep a record of disease-related parameters. The patient can show this to the physician during the subsequent visit, which helps the physician better understand how the disease affects each patient.

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What lessons did we learn regarding applying gamification during COVID-19 regarding patient management?

The COVID-19 pandemic has shown us that health apps are helpful in patient management and, in particular, that gamification can be used to motivate individuals to use these apps.

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One of the main challenges faced by health apps is getting patients to use them on an ongoing basis. Gamification is a simple option that can be integrated into these apps to incentivize their use in the long term so that patients can benefit from them. Gamification is a widely used technique to motivate individuals. When introduced in health apps, the aim is to encourage users and help them use them on an ongoing basis.

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You claim that social exposure could be critical in gamified health apps. Which other factors are also essential to increase patient engagement/adherence to achieve desired therapeutic impact?

Studies suggest that social exposure could be key in health apps as it promotes user engagement and, thus, adherence. However, this social exposure should be supported by other elements of gamification that allow the patient’s achievements to be appreciated. For example, points and badges can be used to measure and give visibility to each user’s progress, thus facilitating individual comparisons.

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The points and badges a user earns allow the rest of the app’s members to know their current status. This fosters the engagement of individuals as they are exposed to the community.

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In other words, for social exposure to be effective, it is necessary to use other elements that provide information about the actions performed by the user and make it possible to establish comparisons. This encourages and motivates patients influenced by the actions of others.

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You list some use cases of gamification in education, like tutoring or adaptive systems. However, in healthcare, patient education is essential to achieving therapeutic goals. So, what can healthcare learn from gamification in education?

Education represents the most significant area of application of gamification today. For this reason, even though the results obtained through gamification differ from the specific context in which it is applied, the findings discovered in the educational field suggest new avenues for research in the health sector.

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It should also be noted that in gamification in education, the teacher usually plays the role of guide. In healthcare, doctors and nurses should similarly guide patients and encourage the use of gamified health apps. In other words, healthcare staff should be encouraged to learn about these apps and be the ones to help patients with their management.

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Finally, patient education is another area of application of gamification in healthcare. In this case, gamification is used to involve the patient in the process of learning more about a disease.

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During the COVID-19 pandemic, gamification has been used to raise awareness about the new coronavirus, and gamified campaigns have been created for the general population and healthcare personnel.

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Learning, personalization and behavioral change are the main areas of application of machine learning in gamification. Could you please elaborate on what the potential of gamification is here?

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On the one hand, learning, personalization, and behavioral change are three areas where machine learning can be applied to improve gamification.

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By combining gamification with machine learning, more powerful designs can be created that deliver a personalized experience to each individual based on different parameters.

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As a result, behavioral change can be achieved more effectively.

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This combination is novel, and further research into its application possibilities remains to be done. In any case, it harbors excellent potential that can lead to major innovations in the field of gamification.

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On the other hand, machine learning needs a large volume of data to train the algorithm on which it bases its operation. This data can be obtained from different sources.

If it is desired that the user themself provides the data, a gamified design can be integrated into the system based on machine learning. This way, user participation is encouraged, and the more the app is used, the more data that is collected. This strategy improves the underlying algorithm’s performance and increases the app’s use.

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In the book, you describe the “habit loop”. What is it exactly?

The habit loop is a mechanism that seeks to promote a change in the behavior of individuals which is maintained in the long term by creating a habit. To do this, the app rewards the user when they perform a particular action by reinforcing a certain user behavior.

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This reward can take the form of points or badges and encourages the user to repeat the action and receive a reward again. In this way, a loop is created between action and reward, leading to behavioral change in the long term.

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The habit loop is a very useful mechanism in health apps. For example, it can be used to achieve adherence to treatments.

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The habit loop rewards the patient every time they take the medication, incentivizing them to retake it and receive the reward again.

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The ultimate goal is that the patient carries out this behavior in a sustained manner over time.

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One of the challenges in gamification in healthcare is transparency. What features should a health platform or app using gamification tools have? And how can these kinds of tools be integrated into routine care?

Transparency is essential for these applications. To this end, health apps must clearly state their objectives. The user must know the app’s purpose, and those responsible must provide this information. In addition, health apps require patients to provide sensitive data about their state of health.

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For this reason, they must establish [in their terms and conditions] how this data will be used, whether it will be shared with third parties and, if so, whether it will be shared in aggregate form or whether any processing of this data will be carried out to guarantee the privacy of the users.

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This information must be accessible to the user and kept up-to-date. Likewise, those responsible for apps should bear in mind that a lack of transparency acts as a barrier as it reduces the willingness of individuals to use them.

What’s the untapped potential of gamification in healthcare?

Today, new health apps that integrate gamified designs continue to emerge. However, one of the central claims of gamification experts in healthcare and general is that they tend to resort to simple designs that integrate few gamification elements.

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While points, badges and leaderboards are beneficial, other less recurrent elements such as storytelling, avatars and empowered users help achieve the objectives pursued through these apps.

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These latter elements give meaning to the experience and help users become immersed. Therefore, health app designers should consider their possible use.

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Also, the combination of gamification with new technologies such as AI offers new possibilities to personalize and enhance the experience for each user. To discover the full potential of gamification, further research is needed.

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