Games for improved gynecological health

The burden of poor gynecological health affecting women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality, sexually transmitted diseases and cervical cancer. 

The project leverages the power of video games to educate, engage and empower women in low-income countries and disadvantaged populations in the US, around enhanced gynecological health. Games offer a safe environment to simulate the different aspects of gynecological health and show long-term impacts of reproductive decisions.  The games facilitate an alternative direct-to-consumer approach bypassing many of the challenges associated with traditional interventions for adolescents. 

This proposal builds on our on-going work around our reproductive health games including MoHiM, Nari Paila and SurrEndo. 

The potential impact of these games is immense. Think Pokemon Go for improving gynecological health, a game that had people around the world chasing a shared goal.

About 830 women die from pregnancy- or childbirth-related complications every day — 99% of these deaths occur in developing countries, with more than half of them in sub-Saharan Africa, according to the World Health Organization (WHO).

The burden of disease and public health issues affecting girls and women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality and morbidity, sexually transmitted diseases, and cervical cancer are major problems. These health challenges curtail educational and vocational opportunities, lead to poor reproductive health outcomes, and contribute to the intergenerational cycle of poverty.

Discussing reproductive health remains taboo and pervasive myths about menstruation and family planning reinforce normative behaviors restricting women’s and girls’ movement.

Traditional facilitator- and provider-based programming is expensive, requiring multiple interactions, significant training, and extensive coordination. It often fails to reach young mothers at scale.

Reviews of sexual and reproductive health programs found that mobile technologies are underutilized, and in the few instances when they were used, focus primarily on SMS for health promotion. 

At GRID we create digital games offer a platform to educate, engage and empower our players in an effective manner. We believe in the saying “Tell me, & I will forget, show me, & I may remember, involve me, & I will understand” Confucius. 

The solution aims to leverage mobile games to raise awareness about antenatal and postnatal health among women. The current solutions expands on our suite of reproductive health games MoHiM (menstrual health game), Nari Paila (reproductive health awareness) & SurrEndo (empathy for Endometriosis patients). 

In order to ensure inclusive international access and sustainable impact, GRID games are developed to be compatible with low-end smartphones phones and do not require internet connectivity to run. The solution will leverage four windows of opportunities:

(i) the widespread penetration of low-end smartphones in developing countries,

(ii) the private nature of mobile phones to provide information around culturally sensitive topics such as gynecological health,

(iii) the interactive nature of games to keep the player coming back for more and finally

(iv) the ease with which games can be scaled-up across different countries.

Every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth.

Lower levels of maternal education were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum care. Reducing risks for maternal, neonatal, and fetal mortality frequently involves behavioral changes for women. While such changes are often difficult to achieve, they can be facilitated with information about pregnancy, risks, and healthy behaviors .

Games are a fun way to engage young women and provide information that may otherwise be perceived as embarrassing or sensitive. The solution will focus on designing and deploying games that provide useful reproductive health information, leveraging high penetration rates of smartphones. the maternal health module will provide tips including, but not limited to the following:

• Eating healthy for mom and baby
• WHO recommendations on antenatal care for a positive pregnancy experience
• stopping smoking; 
• using a bednet to protect against malaria; 
• arranging for a skilled birth attendant at labor and delivery; 
• and recognizing and acting promptly on signs of a complicated delivery.

The solution falls within the focus are of "Improve gynecological health for all women" of the Challenge. 

Given the rapid growth in smartphone penetration and the recognition of games as behavioral change tools, the stage is set for expanding the use of games to enhance gynecological health. 

Nari Paila (meaning Women First in Nepalese) is a suite of mobile games that aim to raise reproductive health awareness in a fun and engaging way. The solution aims to expand the reach and scope of the Nari Paila games. 

Nari Paila (meaning Women First in Nepalese) is a suite of mobile games that aim to raise reproductive health awareness in a fun and engaging way.  Available for free download on the Google Play Store and Apple store,  the games walk their players through a Nepalese family's journey of learning about reproductive health decision making. 

Given their interactive, iterative, and inspiring nature, digital games appeal to human psychology in a way most other communication tools don’t and their impact on our brains far transcends the boundaries of the virtual world. 

Globally, there is no modality similar to the Nari Paila app. Other projects have developed digital experiences tied to computers, limiting the experience and reach of the interventions. The pilot experience for Nari Pail suggests an entirely new domain for public health promotion, the potential of which has yet to be realized.

Traditional interventions are facilitator dependent, limited in reach to those who are nearby, occur in busy areas at the time of group learning activities, and lack privacy for participants when discussing sensitive topics. Nari Paila transcends these issues by providing the same factual information in a fun and engaging way that provides anonymity and personal exploration. There is no waiting while facilitators take attendance, organize a large group of people, or linger on a specific topic. Nari Paila reflects the next generation of social and behavior change interventions. Additionally, as a free download, Nari Paila has no cost to users other than internet connectivity for download.

Available for free download on the Google Play Store and Apple store,  the Nari Paila games walk their players through a Nepalese family's journey of learning about reproductive health decision making (including menstrual health, fertility awareness, family planning, and son preference) .

The games facilitate an alternative direct-to-consumer approach bypassing many of the challenges associated with traditional interventions for adolescents. Designed for smartphones and connectivity in places like Nepal, the app engages adolescents through a dynamic and culturally relevant back story. In-app questions capture and track user knowledge acquisition and social normative responses. Additionally, analytic data that captures real-time interactions of players, answers to in-app questions, and game success allowed for rapid refinement at scale.

The games built on two existing initiatives; IRH’s Pragati community games and (ii) GRID’s menstrual health game MoHiM. Both teams were able to reuse the content of Pragrati games and the technical design of MoHiM, enhancing the final product in scope and outreach. 

Designed for low-end smartphones and minimal connectivity, the Nari Paila games engage players through a dynamic and culturally relevant back story. In-app questions capture and track user knowledge acquisition and social normative responses. To ensure inclusive access and sustainable impact, the games have been developed to be compatible with low-end smartphones. The games are small in size and do not require internet connectivity for gameplay.

In the last decade, research has identified games as an effective and engaging way for adolescents to explore topics they are otherwise too nervous to discuss and enables critical thinking around sensitive topics (e.g. menstruation, puberty, relationships) in a safe space. 

Results from the initial launch of Nari Paila indicate that adolescents are interested in the apps and in learning about reproductive health via mobile game, providing our proof-of-concept. Naria Paila had more than 10,000 downloads in its first 2 months of launch. 32% of downloads were attributed to females of whom 71% are under 24 years old. These results suggest high rates of acceptability and interest among adolescents in Nepal. Nari Paila overcomes the challenges of traditional interventions in places like Nepal, where connectivity and smartphone access is high.

There is extensive empirical evidence of the impact of games on behavioral change, specifically in the health sector. Some key evaluations are provided below:

• “A Randomized Controlled Trial: The Effects of SuperBetter on Depression.” University of Pennsylvania in collaboration with SuperBetter Labs. (2013, PDF) A six-week trial of the mobile game SuperBetter yielded positive results: for the typical player, the game eliminates six symptoms of depression in six weeks.

• 9 Minutes for Maternal Health in Kenya by USAID and Games for Change: “9-Minutes” simulates the experience of nine months of pregnancy in nine minutes. The game presents players with a series of physical, medical and social choices in a race against the clock.

Communication is essential when educating women on gynecological health and attention should not only be given to ensuring that the information being provided is evidence-based, accurate and consistent but also that it is delivered in a fashion that is actionable, easily digestible and retainable.  

The Nari Paila (Her Journey) mobile games facilitate an alternative direct-to-consumer approach bypassing many of the challenges associated with traditional interventions for adolescents. 

 Designed for smartphones and connectivity in places like Nepal, the app engages adolescents through a dynamic and culturally relevant back story. In-app questions capture and track user knowledge acquisition and social normative responses. Additionally, analytic data that captures real-time interactions of players, answers to in-app questions, and game success provides facilitates rapid refinement at scale.

Appealing to players’ intrinsic and extrinsic motivation through game design, Nari Paila sparks curiosity, establishes agency, personalizes contextual decision-making, and motivates players to act.  Utilizing a storyline of one extended multigenerational family and their decisions that affect reproductive health, the games build players’ knowledge, skill, and confidence in the subject. Dynamic characters and avatars allow players to personalize their challenges, while varied difficulty levels and game features facilitate engagement and encourage mastery of topic matter.

The theory of change can be broken down as below: 

Assumptions:

• A large share of women have access to low-end smartphones and 
• Enhanced awareness will translate into better gynecological health outcomes (barring other factors such as limited access to health facilities)

Inputs: 

• Expanding Nari Paila game design to include content on basic prenatal and post natal care in a fun and engaging way. 
• Outreach measures to ensure the games reach target beneficiaries. 

Outputs:

• Number of women that access the games measured through app downloads/game plays

Outcomes:

• Enhanced gynecological health awareness: Increased awareness among women on the basics of prenatal and post natal care. Knowledge gains will be measured through surveys embedded in the game design to track learning progression.
• Games mainstreamed as communication and behavior change tools for reproductive health awareness. 

Longterm Impact: 

• Improved reproductive health outcomes among women

Results from the initial launch of Nari Paila indicate that adolescents are interested in the apps and in learning about reproductive health via mobile game, providing our proof-of-concept.

Naria Paila has had 11,000 downloads so far. Digital marketing of Nari Paila began on March 19th, 2019. In the first 5 weeks, social media advertisements reached approximately 50,000 individuals across Nepal and resulted in over 7,000 game downloads. This 14% conversion rate exceeds US and global estimates of 4.5%. 32% of downloads were attributed to females of whom 71% are under 24 years old. These results suggest high rates of acceptability and interest among adolescents in Nepal. Nari Paila overcomes the challenges of traditional interventions in places like Nepal, where connectivity and smartphone access is high.

Initial responses to in-app knowledge and attitude questions embedded within the fertility cycle mini-game reflect learning about topic matter. 

In five years: 

• Grow to impact at least 100,000 women in low-income, minority, immigrant populations in the US and in developing countries;

The potential outreach for gynecological health games is immense. Think Pokemon Go for improving prenatal and postnatal health among women; a game that had youth around the world chasing a shared goal. Our suite of reproductive health games have the potential to mobilize women on a large scale and have them playing together to improve their gynecological health. 

Our goal in the first year is to build on the Nari Paila game design to include a focused module on basic prenatal and postnatal health. This module will:

• Highlight tips for pregnancies including do's and dont's. 
• Simulate key pregnancy decisions such as having a birth plan, gaining family support, nutrition, getting antenatal care, and going to a health facility for delivery. 
• Provide information on healthy nutrition during pregnancy

Five year goal: 

Product and technology: Create a suite of games in 5 different languages that leverage the current template to create awareness around gynecological health. 

We foresee the following barriers:

Concerns around inclusion: There are concerns around the reach of mobile games since there are areas with smartphone penetration. While we fully acknowledge this concern and encourage hybrid (digital + face to face) approaches of raising awareness in this case, we do know that smartphone penetration will continue to rise and it will be a lost opportunity to not act until there is 100% coverage. 

Conversion of apps to new countries: We are committed to scaling up our game to new regions. With expansion comes risks associated with investments in research, development, and testing of the games. We will proceed cautiously, but continuously learning from our experiences.

Access issue: In order to ensure inclusive international access and sustainable impact, GRID games are developed to be compatible with low-end Android phones, are free to play and do not require consistent internet connectivity to run. The games are also developed at one-fifth the cost of comparable commercial games and are available for free downloads, hence providing a long-term scalable solution for meaningful behavior change. Given that the upfront costs of game development are already incurred, the games can be scaled up across different regions and adapted to different contexts in a cost effective manner. 

Context-vigilance: GRID games have a focus on user-centered design and we ensure that all aspects of our games (scripts, character depiction, art, language) are context-vigilant. 

GRID is a social impact gaming studio that tackles global problems with a global team. With a core team of 7 members and an extended team of 5 others, our group of 12 is diverse in gender, ethnicities and experience. More than 65% of our team is female (8 women, 4 in core team and 4 in extended team), we are spread across 4 different countries (USA, Pakistan, Australia and Greece) and we come from different professional backgrounds including graphic designers and software development professionals with extensive experience in app development, international development practitioners and marketing experts. 

At GRID, we aim to leverage the universal language of video games to inspire social change. We have created games on reproductive health (MoHiM, Nari Paila & SurrEndo) on compassion for animals (KritterKneads), climate change (EarthFenders), Math learning (Gumbers & Calculasia) and Covid19 (Coronacombat) and are currently working on games on financial literacy, opioid crisis and entrepreneurship. 

We created the very first menstrual health game with a global reach. MoHiM, the period game, tackles the stigma around menstrual health and inspires behavior change towards improved menstrual hygiene practices. 

Based on MoHiM's success, we expanded our suite of games aimed at women's health with two new games, the first aimed at increasing awareness on endometriosis (SurrEndo) in the US and the other, Nari Paila, on reproductive health in Nepal. Nari Paila was developed in partnership with Georgetown University’s Institute of Reproductive Health (IRH).  The game was launched in Nepal in collaboration with the Nepali Ministry of Health and Population. 

Nari Paila had more than 10k downloads within the first ten weeks of its launch. 32% of Nari Paila players are females of whom 71% are under the age of 24. Initial results from the Nari Paila launch suggest high rates of acceptability and interest among the adolescents in Nepal.

The GRID team has extensive experience in dealing with technical and contextual issues involved with the design of serious games. 

We have several partnerships focused on funding, content development and implementation of our games.Key partners include: 

Georgetown University Institute of Reproductive Health (IRH): Content and implementation partners for Nari Paila, a game that raises awareness on reproductive health. Nari Paila was launched in Nepal in collaboration with the National Health Education, Information and Communication Center (NHEICC) within the Nepali Ministry of Health and Population. The game was funded by IRH as part of a USAID project. 

George Mason University: Development of "SurrEndo" - a game that build empathy for Endometriosis patients. The partnership with GMU was aimed at funding and evaluating this game through the Public Health school. 

UNICEF Pakistan: With UNICEF Pakistan, we have an MoU around our menstrual health game MoHiM. MoHiM is being integrated into UNICEF’s activities to promote positive hygiene practices around MHM in Pakistan.

American Pakistani Foundation: Our COVID19 awareness game CoronaCombat was translated into Urdu through a grant provided by American Pakistani Foundation. 

FLOC DC: GRID has an on-going partnership with FLOC DC where FLOC students are involved in the development of GRID’s game StereoWiped, a game that aims to wipe racial, gender and cultural stereotypes to promote tolerance and diversity.

Value Proposition: Making behavior change interactive, scalable and fun through digital games, on a global scale. 

Key GRID activities:

• Serious games development, with a focus on behavior change among the bottom billion
• Thought leadership in the serious games space 

Customers & Beneficiaries:

GRID's beneficiaries are often people around the world that are aspiring for positive behavior change, while our customers are social impact organizations and donors who are implementing programs to support behavior change in social sectors. E.g: Our game Nari Paila's consumers/beneficiaries are young adolescents in Nepal while our customer was Georgetown University's Institute for Reproductive Health who had an on-going reproductive health awareness project in Nepal. 

Revenue Generation:

• Fee for development of games
• grant funding, 
• innovation competitions, 
• potentially in-app purchases and advertisements (to be explored in the future)

GRID will employ three strategies to expand financial growth:

(i) Continue partnerships with organizations working in the social sectors to generate revenue by providing game development services.  

(iii) Partnerships with private sector: GRID games are tackling behavior change among the bottom billion and hence creating a niche market for the private sector. For instance, through our menstrual health game MoHiM, we are not only raising awareness and mainstreaming the conversation around menstruation but also tapping a new niche of customers for feminine care products. Through private sector partnerships, we will pursue a model where the game can be used to boost sales of pads using real-life game mechanics. As the player progresses along the game, she will be able to gather game rewards that can be traded for discount coupons on the sales of Always pads. Conversely, codes found on products (pads and soaps) can be used to "unlock" different game features.  

(iii) Explore revenue generation options through game features such as in-app purchases, advertisements and donation buttons. 

As a female-owned tech start-up, collaboration is critical to our growth. 

1. Validation: Being recognized as one of the Solvers for Solve's 2020 Global Challenges provides us with the validation that is critical when we are forging new partnerships. The visibility and prestige attached to the Award will benefit us in our next stage of growth. Our key means for growth is through collaborations with partners. We identify organizations that are working on the same issues and are interested in using our games to enhance the impact of their programs. We then explore opportunities to either have them directly fund game development or co-apply for grants that align with our joint priorities. Being a Solver will allow us to forge new partnerships. 

2. Opportunity to collaborate with other game-changers: Given that we are creating games that enhance the work of organizations in our focus areas, we see collaboration opportunities with most fellow Solvers. In particular, we would like partnerships that enable us to embed with real-life linkages to information and action in our games. 

3. The Solve prize will allow us to develop our reproductive health games. We are able to develop games in a phased-in manner and therefore align them with the availability of resources. We will define the scope of our reproductive health games based on the funding available through Solve and external partners. 

Nari Paila is innovative and engaging. It also reflects the first step toward the next phase of global social and behavior change interventions. Harnessing the capacity of smartphones for behavior change provides a low cost alternative to the heavy and expensive community level interventions.

We are seeking partnerships and funding to develop the games at a level where it is poised for scale in a second country and with the capacity to rapidly integrate it into multiple new locations around the globe.

If funded, completion of the following activities will poise the innovation for global scale:

1) Identify private sector support for the continued development and marketing of the Nari Paila games. Refine marketing approaches to maximize advertisement investments.

2) Test different revenue models such as coupons, advertisements.

3) Expand the number of games and functionality of the existing game platform to increase the number and types of users exposed to the messages.embed a dedicated module to basic prenatal and post natal care. 

4) Improve the existing game play experience for users.

6) Market Nari Paila in the US to determine acceptability and feasibility of fee-based download.

At the end of this project, we will have a roadmap for Nari Paila integration in a new country that includes clear steps for the translation, game coding and an experienced team ready to market the games ondigital platforms.

Refugees are often faced with difficult situations and being a woman compounds these challenges exponentially. Conflict affected women & girls face a number of challenges, including poor access to reproductive health services and education, poor menstrual health management facilities, unwanted pregnancies and sexually transmitted diseases. Our innovation addresses the gaps in knowledge and information that prevent refugees from managing their reproductive health with dignity, hygiene and security.

If we receive the Andan Prize for Innovation, we propose the development of a mobile game that will provide reproductive health education & information on availability of health and sanitation resources in refugee camps. The game will also include a digital map of relevant health & sanitation service locations and a fertility tracker. The game will be contextualized for specific refugee camps and is designed for smartphones used in low-resource settings & will leverage lessons from similar games that were developed for and tested in Nepal.

The game will be designed to focus on key sanitation and health needs of refugees. If the game is successful, women and girls will:

1. Develop agency to lower unwanted pregnancies, manage menstruation, and avoid STDs;

2. Have improved access to MHM products, safe sanitation facilities and reproductive health services,

3. Provide a medium to communicate with health care providers

Our reproductive health games at their core improve quality of life for women and girls.  

GRID has been most active in the women empowerment and reproductive health space, where behavior change can be relatively sticky and are deeply rooted in social norms. We created the very first menstrual health game with a global reach. MoHiM, the period game, tackles the stigma around menstrual health and inspires behavior change towards improved menstrual hygiene practices. 

Dialogue around serious social issues such as racial stereotyping, birth control or women empowerment can be tricky to initiate and sustain amongst young people. These issues are so deeply inscribed in our social constructs that few people question them and even the ones that do, find it difficult to engage in a dialogue around them. Video games can target these social constructs and prompt our youth to challenge them in a fun way. Games can bring the dialogue to the comfort zone of people, specifically young women, and leverage the convenience of technology and interactive nature of video games to promote behavioral change.

If we were to receive the Innovation for Women Prize, we would utilize that funding to create a suite of games that focus on the women's health and socioeconomic challenges. 

If we were to receive the Health Workforce Innovation Prize, we will develop a dedicated module to train community health workers that work on maternal and newborn health. 

Our solution is fully aligned with the priorities of the Bill & Melinda Gates Foundation Funded Award. At GRID, Gaming Revolution for Inspiring Development, we are working towards creating context-vigilant games (in local languages) for low-end smartphones that can educate, engage and empower people in all aspects of their lives, irrespective of where they live. GRID has been most active in the women empowerment and reproductive health space, where behavior change can be relatively sticky and are deeply rooted in social norms.

Our game Nari Paila was launched in Nepal (in English and Nepalese) in 2019 to build awareness on reproductive health. Initial results from the Nari Paila launch suggest high rates of acceptability and interest among the adolescents in Nepal. In the first ten weeks of Nari Paila’s launch, we had more than 10000 downloads. 32% of downloads were attributed to females of whom 71% are under 24 years old. 

Appealing to players’ intrinsic and extrinsic motivation, ShaKeti will aim to establish agency, personalize contextual decision-making and motivate players to act positively to identify and eliminate different forms of gender-based violence. ShaKeti will leverage four windows of opportunities (i) games are a universal language and appeal to the human psychology in a truly global way (ii) the widespread penetration of low-end smartphones in South Asia and Sub-Saharan Africa, (iii) the private nature of mobile phones to provide information around culturally sensitive topics such as gender-based violence and finally (iv) the ease with which games can be scaled-up across different countries.

As a free download, the commercial viability of Nari Paila will be determined by four different, but related factors: 1) the feasibility of utilizing in-app advertisements and/or product vouchers, 2) establishing private sector revenue streams, 3) winning new grant proposals, and 4) securing funds or structural support from ministries of health and/or education in new countries. We propose to test the feasibility and market value of a voucher (coupon) system for purchasing feminine hygiene products, family planning methods, and related goods. Working with private sector partners and point of sale agents, we will establish a secure system that creates unique vouchers, a retrieval system, and digital transfer of funds for point of sale distributors. The team has already begun identifying a list of private sector partners for potential sponsorship and/or advertising within the games.