The Effectiveness of Online Health Intervention Programs

In recent posts on Web-based and mobile behavioral intervention programs, we reviewed evidence suggesting that social support, in one form or another, can improve participants’ adherence and engagement with the program. That didn’t always mean however, that participants achieved better outcomes as a result. In one study for example, an online community increased engagement with and utilization of a Web-based activity program, but it did not increase participants’ actual activity levels.

Another study, slightly older than the ones reviewed above, did show that a Web-based program improved outcomes. In this case, the intervention was an online videogame known as Re-Mission. Since I haven’t touched previously on outcome studies for automated lifestyle intervention tools or videogames as an example of such programs, I’ll do that here.

Re-Mission is intended improve medication compliance in teens and young adults with a history of cancer. In the game, players control a nanobot within a 3-dimensional body of a young person that has cancer. Play involves destroying cancer cells and managing chemotherapy-related adverse effects like vomiting and bacterial infections by using antiemetics and antibiotics. The game purports to help users understand their disease and its treatment and improve their sense of self-efficacy: they can take control of their disease.

In their randomized trial of Re-Mission, Pamela Kato and colleagues chose compliance with prescribed medications as the behavioral outcome. The Stanford scientists randomized 375 teens to play either Re-Mission or Indiana Jones and the Emperor’s Tomb, an entertainment game with a structure and controller interface similar to that in Re-Mission. They asked participants in both groups to play the assigned game for 1 hour each week during the 3-month study.

Kato’s group measured pre- and post-intervention adherence to the antibiotic trimethoprim-sulfamethoxazole using an electronic pill-monitoring device. They measured adherence to 6-mercaptopurine, chemotherapy drug used to treat many childhood cancers, using serum assays.

It turned out that participants who played Re-Mission exhibited better adherence to their prescriptions for both drugs. With respect to trimethoprim-sulfa, participants in the Re-Mission group took 62.3% of prescribed doses, whereas those in the control group took 52.5%, a 16% increase. For 6-MP the Re-Mission group had higher blood levels of a drug metabolite than their counterparts. Patients in the Re-Mission group also exhibited higher self-efficacy levels and more knowledge of their condition and its treatment.

These results were achieved despite the fact that only 33% of the participants in the Re-Mission group played the game for the requested hour per week. Interestingly, a similarly strong intervention effect was observed for both participants that played Re-Mission less than the requested one hour per week, and those who played it more frequently. This suggests that shorter play duration can be recommended as the game disseminates.

What Can We Make of This?

The findings are heartening since teens and young adults with cancer frequently do not adhere to prescribed, self-administered medications. Home nursing visits and other face-to-face programs can increase adherence in this group, but those approaches are expensive and not scalable.

Can the findings from this study be generalized into a larger statement about healthy videogames and their potential impact on outcomes? Well, the behavioral factors underlying improved medication compliance in Kato’s study are the same ones that adversely impact outcomes from other chronic diseases. So it’s fair to say that videogames hold promise as a tool for improving behavioral aspects associated with chronic disease management.

But I can’t go much further than that. It’s possible for example that medication adherence is simply more amenable to this sort of intervention than other behavioral aspects of chronic disease management. In the Kato study for example, broader measures of treatment adherence including keeping appointments for outpatient visits were not enhanced by Re-Mission (they were high in both groups).

In addition, Kato’s group gave computers to some study participants so they could play the videogame. That’s not going to happen in the real world.

Beyond this, African-American participants in Kato’s study used the games less frequently, suggesting that changes may be required to increase its appeal to certain subgroups. Similarly, many more male patients signed-up for the study, consistent with the greater appeal of games in that demographic. Clearly we have much more to learn about healthy videogames.

Still, this field is cool. It could get real big.

Glenn Laffel, MD, PhD, is a successful entrepreneur in health information technology. He blogs at Pizaazz.

Glenn Laffel, MD, PhD, is a successful entrepreneur in health information technology. He blogs at Pizaazz.