Nudged into Fitness: Insurers and Governments Use Gamification to Encourage Healthy Behaviors

In September 2018, the US insurance provider John Hancock announced that it was “transforming its 156-year old business model and will no longer sell traditional life insurance policies.” Instead, all of its policies “will come with John Hancock Vitality—a platform designed to help policyholders live longer, healthier lives by giving people incentives to make healthier choices linked to physical activity, nutrition and mindfulness.” As John Hancock’s President and CEO Marianne Harrison explained, John Hancock began its partnership with Vitality, “an engaging, tech-enabled wellness platform that rewards customers for the everyday things they do to live longer, healthier lives,” in 2015 and at that time offered the Vitality program to its policyholders as an option. John Hancock subsequently found that its policyholders who had joined the Vitality program “have taken nearly twice as many steps as the average American” and “logged more than 3 million healthy activities like walking, swimming and biking.” Furthermore, Vitality’s own statistics indicate that “its worldwide policyholders live 13 years to 21 years longer than the rest of the insured population and have 30 percent lower hospitalization costs.” Following this initial 3-year trial, John Hancock has hence decided to make Vitality mandatory for its policyholders.

John Hancock’s Vitality program is developed by Vitality, “a South African company that works with insurers around the world on similar programs.” (In Singapore, AIA has partnered with Vitality for a program similar to John Hancock’s.) For John Hancock’s policyholders, the Vitality program offers them recurring incentives to complete routine short-term fitness challenges such as taking a minimum of 10,000 daily steps as measured by a wearable fitness tracker. With the completion of fitness goals on the Vitality platform, policyholders can expect to be rewarded with reductions on their “annual premiums by as much as 15 percent.” They can also “accrue points for gift cards at various retailers” and stand to receive prizes such as Apple Watches. While such prizes may seem trivial to outsiders, for participants they can be very effective in nudging them to alter their behavior. I will return to this point later in this essay when I provide an autoethnography of my personal experience with the AIA Vitality program.

Some experts fear that insurance policies that are tied to programs such as Vitality could effectively exclude “a significant number of elderly and low-income users” since these programs are “contingent upon access to a relatively recent smartphone and a data plan,” leaving only those who have the means and knowhow to use smartphones to enjoy these programs’ benefits. Others have concerns about consumer privacy: “Of course, buying any life insurance policy requires customers to share detailed medical histories upfront. But consumers participating in the Vitality program must be comfortable providing enough information continuously to meet certain thresholds that will convert into worthwhile savings. That might include the frequency of workouts, reporting a physical exam or answering sensitive personal questions.”

While participants still have the choice of whether or not to disclose the requested information, their failure to disclose the information will prevent them from receiving the associated benefits. However, with the growing ubiquity of wearable fitness trackers like the Fitbit and the Apple Watch, consumers are increasingly less aware or even concerned about the consequences to their privacy arising from their use of such devices. Indeed, privacy experts warn that such programs are “creating norms of socially acceptable monitoring” which could enable companies to enact discriminatory practices. With continuous updates of their policyholders’ biodata, insurance companies could, for example, “raise costs for riskier clients.” Such privacy concerns will only intensify as wearable fitness trackers are installed with ever more sophisticated biosensors. The current generation of wearable fitness trackers are now able to track their users’ heart rates and blood pressure, and the new generation of the Apple Watch is even able to record electrocardiograms. The variety of health indicators that such devices can track is poised to increase in the future.

The National Steps Challenge

Apart from insurance companies like John Hancock, other organizations have embraced wearable fitness tracking technology and fitness tracking platforms like Vitality’s to nudge their members to embrace healthier behaviors. One good example is the Singapore government which recently launched the fourth season of the National Steps Challenge which will run from October 2018 to April 2019.

The National Steps Challenge was first launched in November 2015 and attracted more than 156,000 participants in that inaugural season. The second National Steps Challenge in 2016-17 attracted over 350,000 participants, while the third National Steps Challenge in 2017-18 attracted almost 696,000 participants. National Steps Challenge participants receive free wearable fitness trackers which are connected to the Healthy 365 smartphone application developed by the Singapore government’s Health Promotion Board. The Healthy 365 app records the participants’ daily physical activities and distributes the rewards.

Following the inaugural National Steps Challenge in 2015, “70% of previously inactive participants now average more than 7,000 steps per day, with 30% of participants clocking about 10,000 steps a day on average.” In addition, “63% of Challenge participants continued to use [their wearable fitness trackers and the Healthy 365 platform] well beyond the formal programme.” Following the close of the third season of the National Steps Challenge, the data collected showed that “the 41,000 people who have taken part in all three editions of the National Steps Challenge also walked more in the third season. Their average daily number of steps went up by 8 per cent to nearly 10,000 steps.” For the current fourth season of the National Steps Challenge, the free wearable fitness trackers have been upgraded to include heart rate monitoring. This greater depth of biodata will give the Health Promotion Board deeper insights into the state of the participants’ health.

As with the Vitality program for insurance companies, participants in the National Steps Challenge are nudged into completing their fitness goals with a selection of small rewards. In the current season of the National Steps Challenge, participants receive “Healthpoints” on the Healthy 365 app for the completion of a set number of steps per day as well as their completion each day of physically-demanding activities which result in an elevated heart rate. These Healthpoints can be redeemed for a variety of vouchers and other rewards. In essence, programs like Vitality and the National Steps Challenge have transformed fitness into a game. By formalizing fitness activities with sets of rules and offering rewards for the achievement of particular levels of activity, such gamification entices participants into completing the challenges and, in the process, improving their physical fitness. I shall now describe my personal experiences with AIA Vitality and the National Steps Challenge.

My Experience with Gamified Fitness

Earlier this year, following the recommendation of a friend whose parents had a good experience with AIA Singapore’s Vitality program, I signed up for AIA Vitality as well. I already had a Fitbit device, and I connected it to the two AIA Vitality smartphone applications: the main AIA Vitality app, and the AIA Vitality Weekly Challenge app. From the perspective of gamification, AIA Singapore’s Vitality program consists of two games: a short-term game and a long-term one. The short-term game is the AIA Vitality Weekly Challenge. Under the current rules of this game, you will earn points if you walk over 10,000 steps each day. If you accumulate a certain number of points, you will receive vouchers than can be redeemed at a selection of retailers. These rules are scheduled to change by the end of the year to nudge participants to upgrade to the newer-generation wearable fitness trackers that include heart rate monitors, which would then allow the platform to track a deeper level of its participants’ biodata.

The long-term game involves the participants not just accomplishing their weekly fitness goals, but also going for health and fitness assessments, receiving annual vaccinations, shopping for healthy groceries, and so on — all of which will be tracked using the main AIA Vitality app. With the accomplishment of these various goals, the participants will ascend from the default Bronze status to higher levels: Silver, Gold, and Platinum. Participants may receive varying discounts on their AIA insurance premiums depending on which Vitality tier they belong to at the period of their policy renewal. Those at the Platinum level will enjoy the largest premium discounts as well as annual cashback bonuses. Indeed, the complexity of this long-term game has prompted competitive AIA Vitality participants to form their own social media group for the exchange of detailed tips on how they can achieve Platinum status as quickly as possible.

While the Platinum rewards are rather enticing, the privacy concerns that have been identified with John Hancock’s Vitality program apply here as well, as the data tracked by the AIA Vitality platform includes not only the results of the health and fitness assessments but also information on the participants’ consumption habits. I hence have been primarily focusing on the Weekly Challenge, as the only data that I allow to be transmitted is the number of steps I take each day. While the AIA Vitality Weekly Challenge app now includes heart rate monitoring, the Fitbit device that I am using is a simple model that only has the pedometer function and does not include a heart rate monitor. I find this to be an acceptable compromise between addressing the privacy concerns of programs like AIA Vitality and productively using the AIA Vitality platform to motivate me towards increased physical activity.

This same Fitbit device is connected to my Healthy 365 app which tracks my participation in the National Steps Challenge. As my daily goal for the AIA Weekly Challenge is to achieve a minimum of 12,500 steps — as this will give me the maximum number of daily reward points — accomplishing this will simultaneously help me accomplish my daily goal of 10,000 steps for the National Steps Challenge. And just as the limited functionality of my Fitbit device prevents the recording and transmission of my heart rate data to the AIA Vitality platform, the Healthy 365 app likewise only receives my daily step count and not any data concerning my heart rate. As with the new rules for the AIA Vitality Weekly Challenge, the National Steps Challenge seeks to nudge participants to use the new generation of wearable fitness trackers with heart rate monitors by offering a separate category of challenges and rewards for the accomplishment of physical activities which result in elevated heart rates. By maintaining my medical privacy by using a wearable fitness tracker that is not equipped with a heart rate monitor, I am choosing to deprive myself of these potential rewards.

From my personal experiences with AIA Vitality and the National Steps Challenge, I have found myself surprised at the effectiveness of these programs to nudge me towards increased physical activity. This is especially given the token nature of the rewards — a S$5 weekly voucher from AIA Vitality and, in the case of the National Steps Challenge, S$35 in vouchers upon completion of the challenge. As it turns out, it is the gamified nature of these programs — not their rewards — which is the main source of the motivational nudges to accomplish the daily step goals. The decision to participate in a game motivates one to win the game. This is especially true if the game is simple to win — in the case of AIA Vitality and the National Steps Challenge, one just has to walk around more. Conversely, the sense of frustration arising from the failure to accomplish a daily goal — especially an easy one — has the effect of intensifying one’s desire and motivation to successfully complete the following day’s challenges.

Since joining AIA Vitality and now the National Steps Challenge, I find myself deliberately choosing longer routes to get to my destinations, just for the purpose of achieving my 12,500 daily steps goal. Where I would previously have taken a bus to get from my apartment to the subway station, or from the subway station to my workplace, nowadays I choose to walk both routes. Not only does this increased activity improve my physical fitness, I also find myself enjoying a sense of accomplishment when my AIA Vitality Weekly Challenge and Healthy 365 apps notify me that I have won my daily challenges. It is based on these direct experiences that I now appreciate the motivational efficacy of gamification and its power to nudge people into engaging in greater physical activity for their health.

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