Digital Health for older adults through the lens of chess

I write this as I expect to shortly graduate with an MSc in Applied Digital Health.

As a context, I came to Oxford as a product manager with some prior design and implementation experience in digital health. My most compelling reasons were to explore how digital health could be designed for scalable population outcomes and the measurement of its success in clinical and economic terms.

My experience through the course was in equal parts, a journey of affirmative realisations and intense unlearning. The structure and flow of the curriculum ensured I could systematically connect dots from practical experience. While I unpacked potential answers, I discovered a lot more questions for the future! And through the process, I witnessed myself transition to a researcher, and develop an appetite for critical inquiry on whether digital health works for older adults, when the global narrative on digital health is largely ‘techno-optimistic’

My dissertation research included a systematic review of the effectiveness of digital technologies in the prevention of isolation and loneliness in older adults. The key learnings from this study were translated into public engagement as part of the Insights Festival at Reuben College, Oxford. I attempted to propose alternative approaches to digital health for older adults by inviting each participant to play a game of chess, through four stages, as follows:

 1.    Do we build trust?

As the first cue, the participants were blindfolded and requested to navigate the chess board, all by themselves. My audience was sceptical, but open to try this ‘strange’ idea. One could guess an obvious caution, and eventual mess on the chess board for each participant.

I equated this ‘blind navigation’ of the chess board to the asking for the adoption of digital health especially from older adults. If an intervention has not attempted a trust building exercise, has not considered user inputs actively and inclusively in design, and does not assist easy navigation in practice, it could potentially make users lose interest or demonstrate scepticism early on.  A critical requirement from ideation through design includes user participation and ethical considerations in consent, usability, data privacy and security.

 2.    Who are they playing with?

Do we expect older adults to navigate alone? In my engagement, I requested participants to follow a chess manual to play by themselves. “How is that even possible?” quipped many. A few were open to the idea, but “how boring!” or “I wish I didn’t have to read this”, were the responses, as I handed over the instruction manual. And yet many existing digital health interventions simulate a complex instruction manual for older users. They are often expected to learn in isolation for most part. What we might want to consider is the format, frequency, and delivery mode for adaptive training. Technology must be designed to be personalised and engage with the users, in a way that is most feasible and acceptable by them, and makes them feel they belong, and are not isolated.

3.    Do we consider emotions?

In the next stage, I agreed to sit down and play with the participant as a regular chess game. However, there was a pre-condition of no words, emotions, or expressions on either side. And it is safe to say that a few participants were okay with it. And in the end, it was really about their intention for playing chess. “I am playing it for cognitive reasons, so it doesn’t matter”, was a response. Another user felt it “might get a bit boring after a while”, especially if she “wasn’t being paid for playing chess”. And many felt they would ideally want to express or emote while in the game. And therein lies the case for personalisation with respect to emotional needs. Interventions should be able to adapt meaningfully to a wide range of user expectations. And a critical element is combining engineering with an understanding of emotional rewards for older adults. The intended health outcomes could be better achieved and sustained if principles of behaviour change and emotional intelligence found their place in the design framework.

4.    What is different from chess?

It was also important to understand how chess could be different from digital health. I asked each participant “Why do you play chess in the first place?” or “Is there an end goal?”, and “to enjoy”, “to compete” and/or “to win ultimately” were the responses. And that is where the goals of digital health engagement and chess begin to deviate. An intervention might promise to benefit patients, but its success entirely lies in their stickiness. The end goals of clinical and economic effectiveness in digital health can be potentially fraught with challenges and unintended outcomes. But we could tread more intelligently with an evidence informed approach and an iterative development process. In this sense, the methodology for patient involvement and technology trials needs to be contextualised for older adults. Metaphorically, it is always possible to re-think if we are designing for older adults, and make them win!

As I continue to research in healthy ageing and the role of digital technology, I thank the Nuffield Department of Primary Health Care. I am also grateful to Robert, my friend, who inspired the idea of using chess as a metaphor. Robert, aged seventy, suggested he continues to enjoy a game of chess with family or friends over his smartphone!