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A Step in the Right Direction: Using Games to Improve Heart Health for New Moms

A headshot of Jennifer Lewey

Hypertension (high blood pressure) occurs in up to 10 percent of all pregnancies in the United States. While the condition generally resolves after giving birth, the impact on the new parent’s cardiovascular system can be far-reaching. “Ongoing vascular damage or toxicity even after delivery can predispose these women to increased cardiovascular risk,” said Jennifer Lewey, MD, MPH, director of Penn Women’s Cardiovascular Health Program.

Adopting a healthier lifestyle — including physical activity — can help lower high blood pressure and improve cardiovascular health. But for many new parents, post-pregnancy challenges, such as caring for the newborn, postpartum depression, and sleep deprivation, can derail even the best of intentions.

Fortunately, new research led by Lewey shows that patients who just gave birth can gain encouragement to increase their activity through gamification (the use of game elements, such as point scoring and competition with others). A recently published study in JAMA Cardiology shows that a digital health intervention, which includes gamification strategies from behavioral economics — such as nudges and incentives — can be an effective and feasible way to improve physical activity among this post-partum population.

The study marked a first for using gamification techniques with postpartum and younger patients. At the end of the 12-week program, the group who participated in the game took more daily steps than the control arm — and they achieved step goals on a greater proportion of days.

Here’s a closer look at what participants in the study’s gamification groups experienced, with some lessons that any new parent who’s looking to become more active could take away from what worked.

How Postpartum Patients Ramped Up Their Steps

A woman walking and pushing a stroller

The new parents who were invited to enroll in the 12-week study were postpartum patients who were already sending and receiving text messages with their care team through Penn’s Heart Safe Motherhood, a program that remotely monitors their blood pressure if they had a hypertensive disorder during pregnancy. Participants who enrolled received a wearable activity tracker and established a baseline step count. Then each participant set a daily step goal greater than their typical daily step total.

“We encouraged them to set a goal at least 1,000 steps above baseline,” explained Lewey, who collaborated with Lisa Levine, MD, director of the Pregnancy and Heart Disease Program, and other members of Maternal Fetal Medicine on the project. All participants received daily feedback. If they met their step goal, they received a text message, such as “Keep up the good work.” If they didn’t, they were encouraged to meet the goal the next day.

About half of the participants were selected to be in an intervention arm of the study and they were further divided into virtual teams of three. They were introduced to one another through texts but could not speak to each other during the trial.

Each of the three-person team started each week with a clean slate of 70 points, which could increase — or decrease — depending on whether a team member (randomly chosen each day) met their targeted step count. If the member achieved her daily step goal on the prior day, the team kept their points. If not, they lost 10 points.

There are a few principles at work for these teams that were meant to help them keep up with their goals.

One principle is known as loss aversion. Lewey explained that people respond more strongly to losing something than gaining something of similar value. “If I give you 70 points, and take some, you’d get upset. But if you start with zero points and I gave you 10, you wouldn’t care as much.”

Competitive elements created an accountability factor as well. Although there was no communication among members of a team, they knew if one of their members did not make their step count goal that day. Lewey explained that they used Way to Health, an online platform developed at Penn Medicine designed to provide automated tech infrastructure and allows for one-way text messaging.

To motivate team members further, the trial included step goal levels: bronze, silver, gold and platinum. All teams started at the silver level each week. Teams with a weekly total of at least 50 points advanced to the next level. If below 50, the team went down one level. Those at the top two levels at the completion of the study received a baby onesie and water bottle.

The intervention also incorporated something called the “fresh start” phenomenon. “People tend to change behavior at milestones, like when everyone joins a gym at the beginning of the year,” Lewey said. “At the beginning of each week, each team received 70 ‘fresh’ points, regardless of how they did the previous week.”

Other Lessons Learned

What’s more, although the study population was racially and socioeconomically diverse, “many were from lower socioeconomic status who were less likely to be enrolled in healthy lifestyle interventions and less likely to stay engaged — but they are also at greater risk for cardiovascular disease,” Lewey said. “The fact that we were able to target this population — and engage them for 12 weeks — was an important first step.”

Lewey said the majority of participants were happy with the program, although the most common feedback was “a request for more interaction with other postpartum women. In the intervention group, some wanted to reach out to encourage their teammates,” she said. “Moving forward, we’re thinking about ways to connect postpartum women to each other to facilitate social support, which might help them achieve their goals.”

Both the American Heart Association and American College of Obstetricians and Gynecologists stress the importance of women adopting healthier lifestyle changes earlier in life. Although a new mom usually has very little time for self-care, Lewey said that staying active in any way is a positive first step.

“It doesn’t have to be large chunks of time. Walk instead of taking an escalator or spend five to 10 minutes on a brisk walk. It adds up.” Lewey said. And making healthy food choices — such as minimizing processed food or eating out — will set a person up for success. “Just start small. Substitute sparkling water for soda, for example.”

Equally important is keeping appointments with an obstetrician or primary care physician after delivery. This is true for all postpartum patients, she said, but especially those who experience high blood pressure, both during the pregnancy and after giving birth.

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