Introducing Health Protocol: enhancing health literacy and patient empowerment through e-learning and gamification

Virginia Helena Quadrado, DPT, PhD, CEO of Health Protocol 

Correspondence: [email protected]

Overview

The use of technology is part of nearly everyone’s daily life. The Health protocol team is composed of healthcare practitioners and technologists, aiming at developing solutions that use technology to cope with the detriments that modern society and technology may cause in one’s health. Our mission is to assess the physical and physiological body of a person, providing them with analysis and reports, followed by interventions that combine education for health literacy, as well as life habit changes that will increase quality of life in fun ways of e-learning and gamified strategies. Our journey starts with addressing posture. Ordinary people, namely non-medical individuals, understand posture. In modern days, postural distortion patterns have become an epidemic in our society, and the constant use of technology such as smartphones and spending daily hours sitting in front of a computer plays an important role in our posture. In the past years, someone came up with the expression that sitting is considered the “new smoking”, and nowadays, we can extend that analogy to the frequent usage of smartphones across all ages, understanding that postural distortion patterns increase at the speed of technology.

Good posture is essential for physical and mental well-being. Proper alignment of the body optimizes physiological function, enhances psychological state, and prevents numerous health issues such as chronic diseases and neurological impairments. The scientific literature outlines the profound impact of posture on various aspects of health, from neurological functions to emotional well-being. Understanding, educating, and promoting good posture is vital for enhancing quality of life across all age groups.

Poor posture and musculoskeletal disorders are not merely physical health issues; they represent a significant financial burden on society. The total cost of treating low back pain only in the United States has exceeded $100 billion per year, with two-thirds attributable to lost wages and reduced productivity (Crow and Willis, 2009). This economic burden surpasses the annual cost of chronic diseases like diabetes, cancer, and heart disease. Gaskin and Richard in 2011 estimated the incremental annual cost of healthcare due to musculoskeletal pain to be approximately $300 billion. When considering lost productivity, the total annual financial cost to society ranges from $560 to $635 billion. This staggering expense shows the critical need for educational initiatives and health literacy amongst the general population, aimed at improving posture and reducing the incidence of musculoskeletal disorders.

Recent neurological studies have significantly deepened our understanding of how posture directly impacts brain function and overall health. The research performed by Pettorossi and Schieppati in 2014 was a landmark in this field, showing that tonic cervical proprioceptive input is paramount in shaping a person’s mental representation of space, motion patterns, motor responsiveness, and head position. This finding shows a strong neurological basis for posture, emphasizing its importance beyond mere physical alignment. Furthermore, the work of Katz and colleagues in 2019 contributes to this understanding by showing that correcting cervical lordosis, or the inward curvature of the neck, can lead to an immediate increase in the parameters of cerebral arteries. This suggests that proper posture can enhance blood flow to the brain, potentially improving cognitive functions and overall neurological health. Further emphasizing the neurological impact of posture, a study by Ha and Sung in 2020 showed the negative effects of forward head posture (FHP), a common issue in modern society. This posture was found to disrupt muscle spindle activity crucial for proprioception, leading to errors in cervical repositioning and deficits in dynamic balance ability. Such findings are important in understanding how everyday postural habits can have far-reaching effects on our neurological health. Moreover, a study amongst office workers showed that excessive smartphone use significantly increases the risk of neck pain, potentially exacerbating psychological distress, including anxiety, stress, and depression (Derakhshanrad et al. 2021​). In a similar line of research, a recent systematic review performed by Lin and colleagues in 2022, provides compelling evidence suggesting that FHP significantly impacts limits of stability, balance performance, and cervical proprioception, highlighting the need for specific clinical evaluations and interventions for individuals with FHP, correlating the serious implications of posture on both brain function and overall health, in order to increase awareness and proactive measures to improve posture for better neurological outcomes. 

The epidemic of postural distortion patterns

The increasing concern over the posture of children, particularly in the context of more sedentary lifestyles, is shown by recent research as well. Ludwig and colleagues in 2016 stressed the importance of age-specific posture assessments in children and adolescents to detect incorrect posture early, using photometric analysis as a cost-efficient method. Early intervention is important as postural issues can rapidly progress if left unaddressed. Additionally, in 2020, Moustafa and colleagues discovered that children exhibiting FHP showed abnormal sensorimotor control and dysfunction in the autonomic nervous system compared to those with normal head alignment. It suggests that poor posture can significantly affect children’s neurological and physical development. Moreover, in 2018,  Inagaki and colleagues found that maintaining an upright posture not only boosts vitality and pleasure in children but also enhances their performance in cognitive tasks, including calculations and listening comprehension. These studies collectively underline the important effect of posture on both the physical and cognitive development of children. 

Furthermore, the relationship between posture and the use of screen-based media in children has become a critical point of discussion. A study by Hutton and colleagues (2020) has demonstrated a correlation between increased screen time and a decline in cognitive function in children. This correlation is particularly alarming given the prevalent use of digital devices in modern childhood. The study of MacDonald and colleagues in 2017 showed the prevalence and nature of low back pain amongst school-aged children and adolescents, as a largely nonspecific and self-resolving condition. Their analysis outlines the importance of a thorough clinical evaluation based on detailed history and physical examination to effectively manage this common yet benign condition, emphasizing that the approach to pediatric back pain significantly differs from adult cases due to its unique etiological factors and clinical presentation.

 The physical implications of poor posture are evident, with magnetic resonance image studies performed by Kjaer and colleagues in 2005 showing lumbar disc degeneration in one-third of the examined 13 year olds. These worrying statistics show the urgent need for early and effective interventions. They emphasize the importance of educating both children and caregivers about the consequences of poor posture and encouraging healthier lifestyle habits that promote proper physical development. 

Older adults have also been catching attention in the research field, showing the significant impact of posture on the health and well-being of this population, emphasizing its importance beyond mere physical alignment. A pivotal study by Cohen and colleagues in 2016 showed a notable association between mobility, upright posture, and various aspects of cognition, including memory and attention span. This groundbreaking research provided the first evidence of a direct link between postural alignment and cognitive functioning in this age group, suggesting that maintaining a good posture could be key to preserving cognitive abilities as we age. 

Research performed by Kado and colleagues (2007) showed that hyperkyphosis, an exaggerated forward curving of the thoracic spine, is associated with increased mortality and reduced physical functionality in older adults. This correlation between poor posture and health outcomes outlines the need for interventions aimed at improving posture to enhance longevity and physical capabilities. Moreover, the psychological aspects of posture have been increasingly recognized. In a study by Veenstra and colleagues in 2016, the authors showed that posture significantly influences mood regulation and the ability to recover from negative emotional states in older adults. These findings show the serious impact of posture not only on physical health but also on psychological well-being. The cumulative evidence from these studies outlines the vital role of posture in the neurological health and overall well-being of older adults. It emphasizes the necessity for ongoing research and educational initiatives that focus on promoting proper posture across all age groups. With an aging population, addressing the issue of posture in older adults is becoming increasingly crucial. Ensuring good postural habits can play a significant role in maintaining quality of life, optimizing cognitive functions, and potentially reducing healthcare costs associated with age-related postural disorders. This body of research provides a compelling argument for the integration of posture-focused health strategies into the care and lifestyle of older adults.

This white paper aims to address the important issue of poor posture and musculoskeletal disorders by enhancing health literacy, empowering patients, and providing posture education through innovative e-learning solutions and gamification. Our goal is to leverage technology to engage and retain users, ultimately reducing the substantial healthcare costs and personal impact associated with these disorders.

Digital health and gamification strategy

In the world of healthcare applications (apps) and platforms, where user commitment can be a significant challenge, gamification adds an element of fun and motivation, making it more likely for individuals to return regularly and consistently engage with the platform. In recent years, gamification has emerged as a powerful strategy in the realm of digital health, offering a compelling solution to boost user traction, retention, and engagement. 

A systematic review performed by Johnson and colleagues in 2016 showed how gamification principles, such as rewards, challenges, and progress tracking, can transform routine health tasks into engaging experiences, thus increasing user interest. Incorporating game-like elements into health-related platforms has been shown to be effective in motivating users to engage regularly and consistently with the provided services, transforming mundane health routines into exciting and interactive experiences. It fosters a sense of achievement and progress, as users can see their efforts translating into tangible results, being rewarded for their consistency, and reinforcing positive behavior to stick with their health and wellness goals in a long-term engagement. This has been validated by studies like that of Cugelman in 2013, which found that users exposed to gamified health interventions demonstrated improved adherence to health routines compared to non-gamified counterparts. Gamification not only promotes a sense of accomplishment and progress but also simplifies complex health information into easily digestible formats, as demonstrated in a systematic review by Sardi and colleagues in 2017, making it more accessible and engaging for users seeking health improvement.

Our strategy involves the development of an e-learning, digital health platform that uses gamification techniques to educate and engage users in improving their posture. By integrating interactive learning, real-time feedback, and reward systems in the format of apps, we aim to make posture assessment and education accessible, enjoyable, and effective. 

Health Literacy and Patient Empowerment

Low health literacy in society has profound and multifaceted impacts on individual and public health, as well as on healthcare systems. A significant consequence is poor health outcomes. Individuals with limited health literacy often struggle to understand and adhere to medical instructions, which can result in poorer management of chronic diseases, increased hospitalization rates, and overall worse health outcomes. In a systematic review performed by Berkman and colleagues in 2011, the authors concluded that low health literacy is a more crucial predictor of health than race, socioeconomic status, or educational attainment, emphasizing its impact on health disparities.

The economic burden of low health literacy is substantial. According to the research performed by Palumbo in 2017, low health literacy skills lead to an estimated $73 billion in additional annual healthcare costs only in the United States. This increase is primarily due to longer hospital stays and the ineffective use of prescriptions or misunderstandings about treatment plans. Such excessive healthcare utilization strains both public health budgets and individual expenses, highlighting the need for effective health literacy interventions.

Preventive health services are less utilized by individuals with low health literacy, leading to delayed diagnoses and treatments of health conditions. This includes lower utilization of important screenings such as mammograms and Papanicolaou smears, and vaccinations. Consequently, diseases like cancer, which are more treatable when detected early, are often diagnosed at later stages in populations with low health literacy (Scott et al. 2002).

Educating individuals about the importance of good posture and providing them with tools to manage their health can significantly reduce the prevalence and impact of posture-related disorders, as well as to preserve neurological functions and prevent cognitive decline across lifespan. As we previously stated, ordinary people (non-medical individuals) understand posture. By approaching this topic as a potential solution to increase health literacy is a viable solution that the user could engage. Our digital platform will offer user-friendly information and guidance, enabling users to understand and take control of their posture-related health.

Implementation and impact through interactive digital platforms

We will develop an interactive digital platform that uses gamification to make learning about posture engaging. This platform includes features like posture tracking, personalized goals, and reward systems to motivate users.

Posture tracking via computer vision (CV) has been in the market for over a decade (Aroeira et al. 2016). This technology enables the user to use a cellphone camera to capture photos of their posture, and is a valuable tool for clinicians to enhance their physical assessments, as well as a powerful way to engage the user in their diagnosis and plan of treatment. However, those solutions in the market only analyze static posture, which can mislead the findings of postural distortion patterns due to the consciousness of the user that knows they are being observed. Our technology aims to use CV to track dynamic posture, assessing anatomical landmarks both statically and dynamically through specific instructions for specific movements that will feed the machine learning (ML) algorithm to analyze and interpret the data. Therefore, it is possible to report to the user whether or not there is a present postural distortion pattern. As we do not intend to become a medical device in the beginning of the Health Protocol journey, we will not infer any sort of diagnostic or suggestion of potential spinal disease. Our algorithm simply identifies whether or not there is a postural distortion pattern after the exposure to the CV step. 

After postural analysis, the user is guided through the e-learning module, which is personalized based on the type of postural distortion patterns previously identified. The educational module aims to provide health literacy about posture, and it is designed in a gamified way that contains tasks, games, and information that is fun to engage. Microlearning modules are designed with the intention of continuous learning journeys and incentives such as points, badges, and rewards to engage the user in the app and promote knowledge sharing with other users in the platform. 

A general path of learning is also available in the app, in the case that the user does not want to use the CV for postural analysis. However, the lessons are designed to motivate the user to go through the personalized path, sending reminders and tips of how important it is to identify the user’s own postural distortion patterns. Ultimately, if the user opts to go through the general learning path, there will be questionnaires along the way that enable the user to choose a multiple choice answer that ends up personalizing the educational path even from a subjective point of view.

Conclusion

The evidence from various studies highlights the critical role of posture in overall health and well-being. This proposal seeks funding to develop digital health solutions that combine health literacy, patient empowerment, and posture education with gamification for maximum engagement and effectiveness. Our approach encompasses neurological, developmental, and gerontological perspectives, providing a comprehensive strategy to address this modern-day epidemic, aiming to reduce its substantial financial burden and health impacts on individuals and society. 

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