Towards a collective-adaptive system for self-organized, self-supervised exercise
Incorporating value-sensitive design in the development of an app that encourages exercise via the implementation of gamification and social theory could improve the health of patients suffering from vascular problems.
Vascular surgeons have recently demonstrated that, in many cases, the condition of patients presenting with intermittent claudication (cramping pain) and peripheral arterial disease are better treated by exercise than by endovascular or surgical intervention. However, many patients do not maintain regular exercise without supervision. This is because, in the short term, exercise causes them pain that is relieved by stopping. Supervised exercise, however, is a relatively costly and time-consuming use of medical resources.
There have been three relevant advances in ICT (information and communications technology) that could help encourage exercise in patients with these conditions without incurring the overheads inherent to one-on-one supervision. These advances have occurred in a number of fields, including: sensor and mobile device technology, which can be used to monitor activity and personal status (particularly health metrics); social computing, which enables people to self-organize solutions to collective problems; and gamification, i.e., the implementation of ideas originating from computer games in computer-supported applications.
We propose a convergence of these technological developments with recent advances in healthcare and treatment to provide patient exercise programmes that are both self-organized and self-supervised. Our proposal centres on the design and implementation of an app for which the value of healthcare is the primary operational requirement. Furthermore, we aim to promote and prioritize this value via self-organized collective action in the context of a game.
Our app requires the development of a collective and adaptive sociotechnical system. The system is based on two ideas: first, ongoing negotiated treatment between the patient and the clinician (`concordance’); and second, polycentrism. This latter idea is important, because the treatment of intermittent claudication relies on realizing multiple stakeholder values. For the patient and the clinician, these values are based on individual well-being whereas, for the healthcare organization and other policy makers, the values are based on effective health outcomes for the overall population with more efficient use of resources. Using a method called value-sensitive design (VSD), we place the focus on the values of the design rather than its usability or functionality. The first of these values is aimed at motivating and supporting those suffering from intermittent claudication to carry out exercise. Once the focus has been defined, it is necessary to examine its implications on the system design. Such study requires a deeper insight into the psychology of motivation to exercise, self-supervise and self-organize.
A theory often used to incite behavioural change with regards to exercise is Albert Bandura’s social cognitive theory, which posits that people learn by observing others. Part of his theory suggests that learning is most likely to occur when the person has a great amount of self-efficacy (i.e., “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations”). As a result, the amount of self-efficacy that a person possesses determines the way in which they will approach a goal or task. If someone has a high level of self-efficacy, they are more likely to believe that they will accomplish a task successfully and recover from setbacks easily. Someone with low self-efficacy, on the other hand, will be less confident in their abilities and therefore less likely to take on a challenge.
Our app aims to promote three aspects of self-efficacy: experience, modelling and social persuasion. Successful experiences (e.g., meeting a target) are the most effective at increasing self-efficacy. Modelling—the idea that if individuals see others carrying out a task, they will be able to do it themselves (particularly if the models are similar to them)—is another successful method for increasing self-efficacy. Finally, social persuasion describes direct encouragement or discouragement received from another person that works to promote the desired trait. The app, which applies some ideas from gamification with the intention of increasing self-efficacy, is shown in Figure 1. This app is based on an exploration game in which users are assigned an avatar that has crashed on an unknown world and is injured. To heal and survive in the game, they must explore the area and find items (such as food or medicinal plants) by tracking their real-life walks. Items are awarded at the end of the session depending on how far they have walked. Users are also able to connect to others via the app, enabling them to find peers to exercise with. Moreover, by tracking exercise in a group, they are able to pick up bonus items that are too ‘heavy’ to lift alone. This functionality enables self-supervision, progress monitoring and mutual verification. Additionally, an exercise plan can be created by the users of the app themselves, or prescribed by a qualified professional. Users are therefore appropriately incentivized to stick to the schedule and subsequently rewarded if they are successful.
Our design applies this idea in accordance with VSD, in which value is the central focus. The app first aims to increase self-efficacy. Experience is encouraged by gradually increasing the expected walking time of the user. As a result, users prove to themselves that they can complete the smaller task and avoid losing confidence (and possibly giving up) when their self-efficacy is low. Second, the app aims to support modelling. This, in turn, creates a self-supported system in which users are helped by one another instead of outside authorities. By encouraging users to meet up and exercise together, individuals see models similar to themselves exercising and their self-efficacy can thereby be increased. The community also cultivates social persuasion. Individuals encourage each other to exercise and discourage the quitting or missing of sessions, thereby further increasing self-efficacy. Autonomy represents another significant factor towards encouraging users to maintain their healthy habits. For this reason, users should be encouraged to set their own schedule. By taking this approach, they are used to organizing their own exercise and taking charge of their own health by the time the prescription is removed. The app will also provide the option for users to compete with one another. When a team gets together to exercise, they will be able to compare their workout statistics with another group. The aim is both to encourage the team to push themselves during training sessions and to improve over time compared to the other groups. We believe that this would also foster a nurturing environment in the group, whereby members pay attention to their collective progress.
We have used the VSD of a collective adaptive system to develop the concept of an app for self-supervised exercise. By combining a psychological approach with gamification techniques, the app should prove useful for those with exercise-treatable illnesses, particularly intermittent claudication. While there are many apps that combine health, activity and games, we believe that an approach based on self-governance, psychological theory and VSD is necessary in the development of a sociotechnical system that is capable of creating digital communities. In this specific case, the community can encourage its members (i.e., patients with vascular problems), particularly in groups, to begin and maintain a regular programme of activity with concomitant benefits for their own health. More generally, it offers a possible pathway for the grassroots empowerment of citizens that would encourage them to develop their own solutions to collective-action problems.
Helen Root and Jeremy Pitt
Department of Electrical & Electronic Engineering
Imperial College London
- D. Cheetham, L. Burgess, M. Ellis, A. Williams, R. Greenhalgh and A. Davies, Does supervised exercise offer adjuvant benefit over exercise advice alone for the treatment of intermittent claudication? A randomised trial, Eur. J. Vasc. Endovasc. Surg., pp. 17–23, 2004.
- B. Friedman, P. Kahn and A. Borning, Value Sensitive Design and Information Systems, Wiley, 2008.
- A. Bandura, Social Foundations of Thought and Action: A Social Cognitive Theory, Prentice-Hall, 1986.