Digital Health through the lens of chess!

I write this as I expect to shortly graduate along with the first cohort of the MSc in Applied Digital Health (ADH). As we announced the conclusion of our academic curriculum, I received some common queries about our course that I now know took a few years of careful design process in the making.  Why did I choose this course? How did it help me? How best can I summarise it?

As a context, I came to Oxford as a product manager with prior work in digital health design and implementation. My most compelling questions were to explore how digital health could achieve scalable health outcomes, what could be done differently, especially in the approaches to product design and if there was a way to assess economic effectiveness in digital health.

To say the least, my course was in equal parts a journey of affirmative realisations and intense unlearning. The structure and flow of the curriculum ensured I systematically connected dots from practical experience. While I unpacked potential answers to my initial questions, I opened a lot more! And through the process I witnessed myself transition to a researcher, and develop a balanced appetite for innovation and critical inquiry.

Some of my learnings found their medium in a public engagement event as part of the “Insights Festival” at my college: Reuben College, Oxford. This is an annual event for Reuben members to present their research to the wider public through creative ways. I attempted to rethink digital health, specifically in the context of older adults, by inviting participants to play a game of chess, albeit a bit differently! For the purpose of this article, I define ‘users’ as the end users of a digital health technology, including but not limited to patients, doctors, and beneficiaries on a healthcare plan.

 1. The ground rules.

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 expect an obvious caution, and eventual mess on the chess board. I equate this ‘blind navigation’ to the early stages of user adoption of digital health. If an intervention has not shared its intent in a fair and trust building exercise, has not considered user inputs actively and inclusively in design, and does not assist easy navigation, it could potentially make a user lose interest early on.  A bare minimum through all stages of design includes user participation and ethical considerations in data privacy and security.

 2. Who are they playing with?

Do we expect digital health users to play alone? In my engagement, I requested participants to follow a chess manual to play by themselves. “How is that even possible?” quipped many. I was surprised that a few were open to the idea, but “how boring” or “I wish I didn’t have to read this” or “thank God I know how to play already;” were the responses as I handed over the instruction manual. And yet, many digital health interventions around us are almost monologues in engagement. A user might be expected to learn in isolation for most part. What we might want to consider is the format, frequency, and delivery mode for adaptive training in digital health. How do we personalise and engage with the user, in this case an older adult, in a way that is most feasible and acceptable by them, and makes them feel they belong, and not feel isolated?

3. There is no place for emotions!

In the next stage, I agreed to sit down and play with the participant. 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 doesn’t matter”, was a response. Another user felt it “might get a bit boring after a while”, especially if he “wasn’t being paid for it”. And there many who felt they would ideally want to express or emote a little while in the game. And here is what I learnt. 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 behaviour change. The intended health outcomes could be better achieved and sustained if emotional intelligence found its place in the design framework.

4. What is different?

It was also important to understand how chess could be different from digital health. I asked each participant “Why do you play 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 I found the goals of digital health engagement and chess to deviate. An intervention might strive to begin the game with the end user, but its success entirely lies in their success.

To conclude, the journey of the design to clinical and economic effectiveness is often unpredictable and fraught with challenges. But we could tread more intelligently with an evidence-informed approach at every stage and an understanding of fair practices. Metaphorically, it is always possible to re-think if we are playing for the users, and making them win!

Big thanks to the Nuffield Department of Primary Health Care, our course directors, supervisors, the Reuben community and the ADH Class of 2023. I am also grateful to Robert, my friend, who inspired the idea of using chess as a metaphor. Robert, aged seventy, suggested he enjoys playing chess with his wife over spending time on a smartphone!