Co-Designing Culturally Grounded Mobile Health Games for Hypertension Management in Indigenous Communities
Alison Graham, Tochukwu Arinze Ikwunne, Jared Duval · 2025 · ASSETS 2025: 27th International ACM SIGACCESS Conference on Computers and Accessibility · doi:10.1145/3663547.3746321
Summary
This paper presents a co-design study conducted with 14 Indigenous community members from Northern Arizona, representing seven tribal nations including Hopi, Navajo, Diné, Chickasaw, Hidatsa, Oneida, and native Hawaiian backgrounds. The research addresses the disproportionate burden of hypertension in Indigenous communities, where cardiovascular disease is a leading cause of death and prevalence rates significantly exceed those of other populations. The authors argue that existing mobile health interventions fail Indigenous users because they are designed from Western-centric perspectives that overlook Indigenous epistemologies, cultural practices, and communal values. Using participatory design and Research through Design methodologies, the team facilitated a two-hour workshop where participants split into five groups, each tackling a different factor of hypertension care: medication adherence, nutrition, exercise, education, and blood pressure monitoring. Each group produced a medium-fidelity game prototype. The research follows Indigenous data sovereignty principles and positions community members as expert designers rather than passive subjects. The study builds on prior work in culturally grounded computing and extends it into the mobile health gaming space, demonstrating how Indigenous knowledge systems—including relational connections with non-human kin, distributed cognition, collective responsibility, and embodied storytelling—can fundamentally reshape how health technology is conceptualized and designed.
Key findings
Five distinct game prototypes emerged from the co-design sessions, each reflecting Indigenous cultural values in unexpected ways. A Jeopardy-style hypertension education game incorporated selectable categories for personalized learning. A diet game featured an animal companion named Chef who guides cooking tasks with culturally inclusive food options. A medication adherence game used leaderboards and point systems tied to real medication-taking behaviors. A blood pressure monitoring game combined playful visual elements with BP logging and cognitive mini-games like Sudoku and crosswords. An exercise game offered avatar selection between human and zombie characters with gamified physical activity tracking. Thematic analysis revealed six intermediate design knowledge contributions: gamification elements that connect health behaviors to meaningful rewards, reappropriation of familiar Western game formats infused with Indigenous meaning, situated play design rooted in local contexts and landscapes, integration of cultural narratives and storytelling traditions, incentivized progression systems that reinforce sustained engagement, and playification that makes health management feel less clinical and more communal. Crucially, participants consistently incorporated relational and collective elements rather than individual competition, reflecting Indigenous values of community wellbeing over personal achievement.
Relevance
This research challenges the accessibility community to think beyond disability-focused design and consider how cultural accessibility shapes health technology engagement. For practitioners working on health apps or gamified interventions, the study provides concrete design patterns for culturally grounded approaches that could improve adoption and sustained use among underserved populations. The participatory methodology offers a model for respectful community engagement that centers Indigenous expertise and data sovereignty. The findings highlight that accessibility barriers are not solely technical—they can be deeply cultural, and designing inclusive technology requires understanding the epistemological frameworks of target communities. The six intermediate design knowledge contributions are transferable to other contexts where culturally responsive design is needed. A limitation is the small sample size and single workshop format, though the depth of cultural insight generated suggests this approach warrants scaling.
Tags: Indigenous health · co-design · mobile health games · hypertension · culturally grounded design · participatory design · gamification · health equity