A Study on Wearables as a Health Care Device for Preeclampsia

Is there a market for an analog wearable technology in Africa ?

Bethlehem Seifu Belaineh(B.S.’17) Abhishek Kulkarni (B.S. ’18)

Jikun Zhou (B.A. ’18)

BUS 261A: Managing Technology & Innovation

Submitted to Professor Ben Gomes-Casseres Brandeis University

May 8, 2017

Contents I. Introduction

Background……………………………………………………………….. 2 Hypertension in Mothers…….……………………………………….…... 2 Ethiopia: Maternal and Perinatal Health Profile…………...….……....…. 3

II. Competitive Analysis……………………………………………….…… 4 III. Health Advocacy & Building Awareness………………………….……. 6

Improving Health Literacy in Ethiopia………………………….…6 Prevention & Care Preeclampsia……………………………..……6 Challenges Implementing Analog Wearable Devices………….….6

IV. Funding Analysis………………………………………………………….7 Gates Foundation Global Challenges Grant………………………7 Changing Pathways in Technology Applications……………...….9 Go to Market Strategy………………………………………...….10 Alternative Market: Arousal Games……………………….……..12

V. Conclusion……………………………………………………….13

Appendix………………………………………………………….……………..14 References ………………………………………………………...…………….16

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I. Introduction

Background

The wearable technology industry has been booming for the past decade; along with the rise of smart-phones and other interactive gadgets, wearables have shown the potential to change the way people engage with technology in their daily lives. In this paper, we will investigate analog wearable devices and their applications within a third world setting. Our sponsor Jocelyn Schneier has been working on an analog sensing device for the past 20 years. Our sponsor was aiming to secure funding through the Gates Foundation’s Grand Challenges grant to fund the development and distribution of an analog wearable device which reduces health complications amongst hypertensive pregnant women. We analyzed the target population to determine whether this is a viable endeavour to pursue.

This paper will provide a survey-study to understand the market for wearable technology that focuses on improving maternal health, and thereby decreasing maternal and infant mortality in Ethiopia. We will also explore challenges in implementing wearable analog device in rural settings in Ethiopia. Furthermore, our team did a competitive analysis on other wearable products in the market that cater to mother's’ health and wellness. In our analysis we also looked at digital wearable devices, and the competition they pose for analog wearables. We also investigated funding options for the wearable device starting with the Gates Foundation and moving on to alternative methods through collaboration with fabrication companies.

Hypertension in Mothers

According to the National Heart, Lung and Blood Institute, high blood pressure (HBP) is defined as “when the pressure readings are greater than 140 mmHg systolic or 90 mmHg diastolic (140-over-90)” while a normal blood pressure is between 120-over-80 and 1

140-over-90. Various studies have shown that high blood pressure is dangerous for both the mother and the fetus if untreated by a physician . Furthermore, women who have pre-existing 2

or chronic, high blood pressure are more likely to experience complications during pregnancy than women who have no history with high blood pressure. Women who develop high blood pressure while they are pregnant (also called gestational hypertension ) are more likely to go 3

on to develop preeclampsia during either pregnancy or labor, or right after giving birth. 4

Pre-eclampsia is a disorder of pregnancy which is characterized by abnormal high blood pressure in mothers.

High blood pressures cause hypertensive disorders in pregnancy that are fatal to the infant, and the mother. The effects of HBP include harm to the mother’s kidneys and other organs, low birth weight and early delivery . Pre-eclampsia is responsible for complicating 5

10% of pregnancies worldwide . According to the National Heart, Lung and Blood Institute, 6

1National Heart, Lung and Blood Institute, Website, https://www.nhlbi.nih.gov/health/resources/heart/hbp-pregnancy 2National Heart, Lung and Blood Institute 3 is blood pressure elevation after 20 weeks of gestation in the absence of previous case of hypertension. 4National Heart, Lung and Blood Institute, Website 5 National Heart, Lung and Blood Institute, Website. 6http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy

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there are 50,000-60,000 preeclampsia related deaths per year in the world . Furthermore, 7

studies confirm that hypertensive disorders of pregnancy contribute to prematurity . For the 8

past 10 years there have been significant advances in understanding preeclampsia pathophysiology, as well as to supplement further efforts to guide therapy. Although it is a challenge to identify patients with severe forms of preeclampsia, there is room for improvement to increase early detection in women with various degrees of health literacy as well.

Ethiopia: Maternal and Perinatal Health Profile

Based on the WHO (World Health Organization) Department of Maternal, Newborn, Child and Adolescent Health (MCA/WHO) Ethiopia has a high number of annual births, estimated from 2013 as 2,886,305 . Ethiopia has a high fertility rate of 4.5%, as estimated 9

from 2013 . The maternal mortality rate in Ethiopia is one of the highest in the world. 10

Accordingly the the maternal mortality ratio (MMR) in Ethiopia has slowly decreased with it’s lowest MMR being in 2013 . 11

The United Nations has stated improving maternal health as one of the eight Millennium Development Goals (MDGs). The goal is to reduce maternal mortality ratio by three quarters by 2015. UNICEF estimates that a woman dies from complications in childbirth every minute, and there are about 529,000 deaths each year, with a vast majority of them occurring in developing countries . According to UNICEF, Ethiopian women face 1 in 12

14 lifetime risk of maternal death, which is high number compared to other African countries such as South Africa, and Morocco where it is 1 in 120.

Since preeclampsia is a serious medical condition affecting maternal health and infant mortality, through using reasonable estimates one can calculate what percentage of the population is affected by high blood pressure, and estimate what percentage of Ethiopian women suffer from preeclampsia. According to a study conducted by researchers in 2015 it 13

was estimated that the prevalence of hypertension among Ethiopian population was estimated to be 19.6%, where the hypertension among males was more prevalent at 20.6% than females at 19.2% . Studies also show that the prevalence of hypertension is increasing, and that 14

attention should be given to primary prevention in the Ethiopian adult population. In another study on Ethiopian women suffering from hypertension revealed that 77% of women affected by preeclampsia lack knowledge about the condition, and are not able to protect themselves

7 Ibid. 8 Ibid. 9 Data from: http://www.who.int/maternal_child_adolescent/epidemiology/profiles/maternal/eth.pdf?ua=1 10 See Exhibit 1 for further details: 11 See Exhibit 2. 12 UNICEF: Millennium Development Goals, State of the World’s Children: Statistics on the situation of women: Also see Exhibit 3. 13 Kibret, Mesfin, Public Health Reviews: https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-015-0014-z 14 Kibret, Mesfin, Public Health Records, 2015.

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from the disorder . Studies have also shown that in Africa, “preeclampsia occurs in 10% of 15

pregnancies, which is significantly higher than the global average of approximately 2%” . 16

The maternal deaths related to preeclampsia were linked to external factors such as “lack of proper transportation (11-20%), lack of appropriately trained medical staff (up to 55%), and failure in recognizing patient’s problems (12%)” . Furthermore, there seems to be 17

a lack of awareness about the symptoms and signs of preeclampsia since 64% of the maternal mortalities in 1998 and 55.5% of mortalities in 2001 cases were mismanaged, which also contributes to the lack of studies about preeclampsia in Africa. Furthermore, through reasonable estimates from the statistics above, one can estimate that about 10% of the Ethiopian population that suffers from preeclampsia can benefit from wearable technology designed to treat the condition. This data establishes that there is a well documented need and a market for wearable technology as a preventative healthcare device to curb preeclampsia in Africa. Below we have identified some of the products that are currently in the market in the U.S, and abroad, and the to better maternal health.

II. Competitive Analysis Our team investigated established wearable devices that cater to the African maternal

health market and fulfill the requirements to enter the Bill & Melinda Gates foundation's Global Grand Challenges . Although each product we analyzed differs from our sponsor’s 18

product and from one another, it is important to note the competitive advantage each product offers if it were to apply for the Gates Foundation grant or other funding opportunities.

Ma Belly (see Exhibit 4) is a biodynamic maternity belt that can be optionally 19

outfitted with a smart sensor component. The belt itself helps wearers ease pregnancy related back and hip pressure to alleviate discomfort. By integrating biodynamic materials that sense the body and surrounding areas, Ma Belly allows the wearer’s body better adapt to a change in stimulus in the vicinity. For instance, the thermochromic pigment reacts to heat and the photochromic pigment reacts to sunset. Hence, if the wearer was a working female, the product ensures that her belly will not be influenced by outside environment. The wearable measures stretch, pressure, and movement in order to gauge maternity data including the mother’s pelvic width and more. If the mother chooses, the wearer can SMS the information from Ma Belly to her healthcare provider. Ma Belly intends to apply for the UNICEF Wearables For Good Challenge , so its primary target is expectant mothers in developing 20

countries, particularly Kenya, where the Ma Belly team is partially based. Since it is targeting women in third world countries, the product is predicted to be affordable.

15 Vata, Chauhan, Nallathambi, Hussein. US National Library of Medicine, National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4690301/ 16 Ibid. 17 Ibid. 18 https://gcgh.grandchallenges.org/grant-opportunities 19 http://arlduc.org/brogram/ma-belly-a-low-cost-smart-maternity-belt/ 20 http://wearablesforgood.com/

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Another competitor in the market we investigated is the PreVue Wearable (see 21

Exhibit 5). The main idea behind this wearable is that women in later stage of pregnancy can only sense up to a third of fetal activity. When their baby is especially quiet or inactive, mothers tend to feel anxious, releasing stress-induced chemicals which, as several studies have shown, harm babies. The wearable itself is an e-textile based apparatus that uses 4D ultrasound with cost-effective advantages in comparison to that of traditional transducers. The scan panel can help parents do a simple examination on the baby themselves simply by clicking a button, saving on high costs of baby ultrasounds and circumventing patients’ limited access to doctors in developing areas. It is designed to provide medical support for pregnant women living in distant areas, but not necessarily in third world countries. Considering this, pricing in underdeveloped countries could be an issue for such a product because it certainly requires expensive technology components for the wearable to work. Moreover, another challenge is accommodating the underdeveloped medical infrastructure and convincing local physicians of the device’s potential. Mishandling of ultrasonic technology, especially in African areas that have a shortage of trained medical personnel, could result in dire results such as shoulder pain and resonance damage in internal organs; this technology could help circumvent this hazard.

Comparing our sponsor’s wearable to MaBelly and PreVue, our competitors’ maternal wearable devices are far more sophisticated than basic arousal detection. Based on our sponsor's description and our analysis, we see possible competitive advantage for our sponsor’s product to be: lower production price and smaller chance of safety issue. Even though we could not find an exact price for our sponsor’s competitors,we do believe the price is within a reasonable range. This means “the lower price” of our sponsor’s product might not be a strong advantage after all. Moreover, we notice that our sponsor’s product lacks accuracy in distinguishing arousals from “strong emotions” versus hypertensive symptoms. In contrast, MaBelly and PreVue can accurately detect maternal information, and provide more useful information to patients and doctors in rural developing countries since they have features to collect digital data. This is an important aspect of wearable technologies that the Gates Foundation looked for from previous winners. It’s only from the raw data collected from these areas that distributors can better gather information about African women’s maternal health, as well as how the device works in reality.

Our client’s competitors’ products alleviate the burden of maternal complications by providing direct support to the user, while our client’s product does not. Ma Belly provides support for its users both by physically supporting the womb, as well as providing mental-comfort against discomfort during pregnancy. PreVue allows the user to be in control of pain detection, as well as providing the possibility of self-examination. Both of these products are critical to alleviating maternal health issues happening in third world countries and help to directly improve on maternal health. Nevertheless, it is challenging to make a direct connection between arousal levels and maternal health since there are several extenuating environmental factors that need to be taken into consideration. Hence, the link

21 https://competition.adesignaward.com/design.php?ID=23800

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between perceived stimuli by the device may not be directly associated with hypertensive symptoms in mothers. After all, we see our sponsor’s product lacks enough competitive advantage to compete with possible additional competitors. Further analysis of Gates Foundation requirements suggest our client’s product is unfit to compete in the African maternal-health market.

Our Sponsor Ma Belly PreVue Wearable

Device

Analog Wearable Ring Digital Wearable Belt Digital & Ultrasound Wearable Belt

Features Hypertension Back & Waist Support Movement Measurement Belly Protection through biodynamic materials

Fetal Activity Visualization Interact and record baby growth

Access to Data No Yes Yes

Price Cheap Cheap Slightly more expensive

Electricity Requirement Lifelong Battery Built-in Battery No Information

Connection with Doctors No Yes Yes

Table A: Comparison of Our sponsor’s product, Ma Belly and PreVue Wearable

III. Health Advocacy & Building Awareness Improving Health Literacy in Ethiopia

Improving health Literacy is an important aspect of identifying and treating preeclampsia, as well as in spreading awareness about its negative health effects. The analog wearable device can be used in monitoring the arousal of mothers who are expecting, to diagnose, and warn mothers who are at high risk of developing preeclampsia. Prevention & Care Preeclampsia

For mothers who are at high risk of developing preeclampsia, or mothers who are conceiving with health issues of hypertension, prevention and care should be consulted with a doctor, or a primary health caretaker familiar with hypertensive disorders during pregnancy. Wearable technologies can be implemented as part of the care-routine for a pregnant mother to diagnose pregnancy-induced preeclampsia early on, to reduce complications the mother experiences during pregnancy. Challenges Implementing Analog Wearable Devices: Incorporating Midwives

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There have been significant efforts made by the Ministry of Health to increase health care for pregnant women in rural areas. One of the efforts is the “Senior Midwife Mentoring”, which is a mentorship approach that recruits trained midwives to rural areas In 22

March 2014, the Ministry of Health piloted this program to populations that have the disadvantage of inaccessible health centers. Additional challenges faced by the midwives include transportation costs, high workload, and also lack of technology in these areas that prevented their access to printers and copy machines 23

The use of an analog device in these areas can be introduced through health care workers such as midwives, and nurses who have access to rural population. Moreover, since midwives know the region’s culture well, they are better suited to introduce these analog devices into the rural areas.

IV. Evaluation of Gates Foundation Opportunity The Bill & Melinda Gates Foundation Global Grand Challenge for “Wearables and

Technology for Maternal, Neonatal, and Child Health Behavior Change” has specific requirements and expectations for proposals, described under the “What we are looking for”, “We seek proposals that”, “What we will consider for funding”, and “What we will not consider for funding” headings. We examined this to determine how well our sponsor’s proposal fit with the requirements and what may be done to improve this fit.

“What we are looking for” The “What we are looking for” section asks for a “clear theory of change for

catalyzing healthy maternal/newborn behaviors”. We believe our sponsor’s theory to be “allowing users, primarily pregnant women in poor countries, to monitor their arousal on an instantaneous basis will allow them to better control their arousal, leading to a long-term reduction of hypertension in the target population”. We recommend that an explanation for the relationship between arousal and hypertension be included in the report along with data that emotional monitoring and self-control lead to a significant decline in hypertension, especially maternal hypertension. This section further requires that the proposal “facilitate data collection for maternal-newborn health research with consideration of data privacy mechanisms”. Our sponsor’s device, being analogue in nature, may not be suitable for data collection; we recommend that a clear data collection method be proposed in the application. Conversely, that inability of the device to collect data limits potential data privacy concerns. The light-based output of the device may pose a small privacy concern as others may see the light as well and know the user’s arousal state — replacing the light with a vibration-based output may alleviate this concern. Proposals are required to consider the technical and social restrictions founding within target countries. The section asks submissions to be “feasible within limited infrastructure environments”, “consider projections and trends in technology in low-income settings”, and “consider the societal norms of target communities in low income countries”. The device, being an analogue, low power, battery based sensor, does not rely on local infrastructure such as electricity of internet access. However, it may depend on local medical infrastructure and

22 Senior Midwife Mentoring, from the Federal Democratic Republic of Ethiopia, Ministry of Health. (https://ciff.org/grant-portfolio/ethiopia-perinatal/) 23Ibid.

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its willingness to adopt new technology and techniques. Research demonstrating that such medical facilities are available or at least may be circumvented should be included within the application. The device does not depend on technology trends within target countries as it is entirely self-contained. We recommend the social norms, especially those relating to medicine and to new and foreign technology should be studied and included. The section furthermore wants proposals to consider safety, comfort, and usability for the target population. Specifically, the “comfort and safety of the proposed user”, the “sustainability and maintenance of the technology”, ease of use, and “human-centered design” must be considered. As per safety, the device is not expected to place its users in any direct danger, though this should also be studied. Potential dangers arising from device malfunction, overreaction to or misinterpretation of output, and violation of societal norms should be investigated. The device should be designed with the user’s comfort in mind and this should be put in consideration as well. As per the sustainability and maintenance requirements, the device should be durable to avoid complex and expensive maintenance. If the battery is replaceable, then a type commonly found in target countries should be chosen. We do not believe the device will raise concerns about “ease of use”— all the user must do is wear it correctly and interpret its simple output. Strategies for ensuring that users understand the device and how to use it should be investigated for future study.

“We seek proposals that ...” The second section, “We seek proposals that”, requires that the submissions be “rooted in authentic understanding of and experience in local contexts”, “bridge the gaps between user need and demand with technology”, and be “forward-thinking, leveraging upcoming and future technological trends”. Due to the target population’s lack of financial resources and of pertinent information, there is a great user need to mitigate maternal hypertension in poor countries that the market is unable to meet; our proposal can bridge this gap by providing the necessary technology and information free of charge to those who need it to survive. Our proposal leverages the future technological trend of using biosensors to detect, monitor, and solve medical problems. Specifically, it leverages 25 years of research on galvactivators and electrodermal response.

Dos & Don’ts The final two sections dealt with what the foundation was and was not willing to fund. Of the listed categories of proposals the organization was willing to fund, only the “wearable on an expectant mother that could measure and transmit data on blood pressure, heart rate, temperature, activity, sleep state and fetal heart rate” is appropriate to our sponsor’s proposal. The final section states what the organization will not fund. First, it will not fund “basic research without clear relevance to the goals of this topic”. We do not believe this will be a problem as our proposal focuses on an explicitly stated goal — “prevention and treatment of hypertensive disorders for mothers”. It rejects “ideas that do not specifically address causes of neonatal or maternal death”; Our proposal addressed a key cause of maternal health. The foundation will not fund “ideas without a clearly articulated and testable hypothesis and metrics” — these must be determined and developed before filing the application to avoid automatic rejection. It finally rejects “ideas for which the described indicator of success cannot be demonstrated within the scope of the GCE Phase 1 award” or “Proposals involving clinical trials in human volunteers or patients or large-scale field trials at this time, unless those studies can reasonably be expected to be completed within the timeline and budget of the GCE Phase I award”. The pilot test for the proposal should be

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determined according to these requirements. Furthermore, since our device requires clinical trials, these must be done beforehand or in such a way as to fit within the constraints.

Recent Winners Having examined the requirements, we proceeded to look at recent winners. We examined the 10 most recent recipients and looked for trends. One of these lacked a summary, so it was excluded from our analysis. We found that 8 of the 9 recipients had university affiliations while the remainder had a laboratory affiliation. We believe this is advantageous for our sponsor, a Brandeis professor. We learned that 6 of the 9 recipients were American, which is also advantageous to our sponsor. Further, a good sum, 4 of the 9, summaries explicitly mentioned field work in the target countries. Since our sponsor’s proposal is almost entirely conducted in the field, it is ambiguous whether this is advantageous; 7 of the 9 involved disease, whereas the remaining 2 involved contraception. This is very favorable for our sponsor. However, almost all the winning proposals involving disease involved pathogenic disease, which may be unfavorable for our sponsor, who is attempting to fight a nonpathogenic condition. All the proposals were oriented toward the collection of data or the development of new technologies or techniques. This may be very unfavorable for our sponsor, whose proposal involves the testing and deployment of an existing technology.

Unfortunately, the Global Grand Challenges appear to change every six months, meaning that the grant may no longer be available when our sponsor is ready to apply. Therefore, we recommend exploring other sources of funding and other potential markets as well.

Changing Pathways in Technology Applications Lifestyle Wearable

Although we see a large gap between our sponsor’s product and those of her competitors, we are proposing a new market for our sponsor to consider pivoting to. According to Exhibit 12, we notice that younger people, especially ages from 18 to 34 show the highest interest in using fitness tracker. There is a larger market potential for fitness wearables in the younger generation, and they are easier to sell to. However, compared to people in their 40s, they generally have less income. This means younger customers are also more price-sensitive than other generations.

Furthermore, younger people are healthier; their needs revolve around fitness and athletics rather than health. This means that they have different uses and expectations of the device than pregnant women. We find that our sponsor’s product would be applicable to this fitness wearable market as well.

Therefore, we started to look into the market. We divided the large fitness wearable market into two categories. The first is the sports market. We identify some problems in this market. Our sponsor’s product is an analog device, which detects human emotion arousal changes based on palm sweat excrete from hands . However, based on reports our sponsor 24

provided us previously, sweat from athletic activity could be affecting the analog result

24 https://www.media.mit.edu/galvactivator/faq.html

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dramatically and continuous. Considering the nature of sponsor’s product, we do not think the sports market would be a good fit. A sports wearable device also require extra accuracy and more features such as calculating calories burned, floors climbed. These are all features would require much more further research investment, that our sponsor does not have. Moreover, we noticed that the sports wearables market have been packed with strong competitors established in the market, such as Fitbit which already captures 30% market share. Therefore we would suggest her to solely target at the second category: the daily life related wearable. First we start from looking at some competitors in the market. Bellabeat Leaf

Bellabeat Leaf (see Exhibit 6) is a form of “smart jewelry” which can be worn as a 25

bracelet or necklace and features similar functions as a Fitbit. It is available at $139. The device works on the premise that shallow breathing reveals stress level, so it monitors your breathing and teaches you how to re-focus and calm your mind through a series of breathing exercises that you can easily visualize with the Leaf's application. Leaf runs 24/7 and lasts up to 8 months without charge. It is water resistant, and secures backup data for 14 days. Wearers have to sync data manually from the wearable device to their phone and can only see their data from the associated application. Feel Wristband

Another competitor in the market is the Feel wristband (see Exhibit 7), which is sold 26

at $149. It is able to detect Electrodermal Response EDR, which is regarded as a great indicator of emotional state. That's also combined with a movement and skin temperature sensors to deliver the data to your phone. Data logged can give an indication of your emotional state and help identify the factors that could be having an impact on it. Whether that's an environment you've been in or people you've met. It'll also offer breathing and meditation exercises to get you feeling good again.

After doing in-depth research on Bellabeat Leaf, Feel Wristband, and more products in the market, we notice that, although all of them use different methods to do the actual measurement, most daily-life use wearables available in the market are used to measure emotion, movement, and several basic data on human body. Compared to these products, our sponsor’s product shows a smaller distance to commercialization. According to Table B, we think the key differentiation is pricing. For young people who show interest in fitness wearable as a daily-life product, we can predict that they see the wearable device as a signature of lifestyle more than an actual measuring device. Therefore, a cheaper price providing similar functions can be attractive for this group of customers.

Our Sponsor Bellabeat Leaf Feel Wristed

25https://webshop.bellabeat.com/pages/leaf-nature?gclid=Cj0KEQjwxbDIBRCL99Wls-nLicoBEiQAWroh6oDw_kjtrzULx49Aa_3etsmL1rQkxllnfH6ATrYpclAaArwV8P8HAQ 26 http://www.businessinsider.com/feel-wristband-can-track-your-emotions-features-photos-2017-1

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Device Analog Wearable Digital Wearable based on Breath

Digital Wearable based on EDR & minor sensors

Features Arousal Reminder Stress Level Monitor Stress & Movement Sensor

Price Cheap $139 $149

Access to Data No Yes Yes

Solution Provided No Application with suggestion for stress control

Application for stress factor indicator, and suggestion for stress control

Table B: Competitive Advantage of Bellabeat Leaf and Fell Wristed, along with our sponsor’s product

Go to Market Strategy After looking closely into the market and competitor analysis, one possible market for

our sponsor is to target a younger generation, which uses wearable device as a lifestyle device. Therefore, the key competitive advantage our sponsor should pursue is price, product design, and promotion. We believe our sponsor has already achieved competitive pricing in her current stage. In the long run, we believe she will be able to generate profits from achieving economies of scale rather than higher profit margins.

Regarding product design, according to Table B, we think our sponsor should try to make the product digital; digitization is a major trend in the market. Therefore in order to compete with other established products, making her product digital is an optimal strategy. Moreover, to attract younger generation customers who want to show off their taste and lifestyle, she should put more effort on the actual product aesthetic. For instance, a sleek design similar to the Apple Watch would be more attractive to customers then her current design with minimal fabrication.

Promotion is also an important strategy. Currently, younger generations spend more than 1 hour on social networking applications such as Facebook everyday, and they are curious about what others, especially celebrities, are using. In the early stage, in order to target university students, we suggest our sponsor hire student representatives to post advertisements on social networking applications. By encouraging students to write reviews and post selfies while wearing the product, the product could become a major fashion trend. After generating enough capital, we would then suggest hiring internet celebrities to post pictures tagging the product. This move will drive the trend of using the lifestyle wearable product from university settings to society at large.

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Alternative Market: Arousal Games Another key market for this technology may be in biofeedback based games. These games

would ask the player to wear a biosensor, such as our sponsor's product, and incorporate the data into gameplay. We discovered various games which do this, some of which have even been commercialized.

Nevermind

Nevermind is a game that incorporates biosensors to measure its player’s reaction and adapt accordingly. As "you explore surreal labyrinths and solve the puzzles of the mind, Nevermind’s biofeedback algorithm will monitor how scared or stressed you may be feeling moment-to-moment. If you let your fears get the best of you, the game will become harder. If you’re able to calm yourself in the face of terror, the game will be more forgiving. Nevermind strives to create a haunting gameplay experience that also teaches you how to be more aware of your internal responses to stressful situations. If you can learn to control your feelings of anxiety within the disturbing realm of Nevermind, just imagine what you can do when it comes to those inevitable stressful moments in the real world…" The game allows the user to incorporate a wide variety of biosensors to detect 27

physiological emotional biofeedback and eye tracking. It is available on Stream for $19.99, excluding any hardware the user may wish to incorporate.

Pip

Pip is a relaxation technology. According to the website, the “skin pores on your fingertips are extremely sensitive to changing levels of stress. Pip accurately captures these changes and through biofeedback, allows you to visualize them. It achieves this by detecting variations in your electrodermal activity (EDA)." Furthermore, "Pip communicates these variations with our companion apps ( iOS & Android ), which use audio and visual feedback to externalize your body’s changing stress levels. Being aware of your stress is the first step towards learning to managing it." The device 28

costs $179; associated apps must be bought separately.

Hyde

Hyde is a physical game produced by Slingshot Effect. It was originally released as a beta under the name The Black Maze. According to Johnson from Slingshot Effect, "We will measure your heart rate. We will start the game by giving you the time it takes for your heart to beat 1000 times. We will then send you into the maze, into the darkness. How far you get is up to you. With each beat of your heart your time diminishes. The more your heart races the faster your time goes down. If we are going to make Hyde a maze that responds to your fear , we will need to spend some time learning 29

what you're afraid of the most." 30

27 See Exhibit 8. (http://nevermindgame.com/about/) 28 See Exhibit 9 (https://thepip.com/en-us/) 29 Information on access or pricing could not be found about this specific product. 30 See Exhibit 10 (http://www.wired.co.uk/article/hyde-wearable-biosensor-experience)

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Game by Texas A&M's Perception Sensing Instrumentation Lab

This is a car game developed by Texas A&M primarily for research purposes; it does not appear to have a name and does not appear to be available to the general public. The game uses biosensors to determine its user’s arousal in real time and adjust gameplay accordingly. For instance, if the arousal level appears to be dropping, perhaps indicating boredom, then the gameplay would intensify; if the arousal level rose too high, perhaps indicating frustration, gameplay become calmer and slow down. 31

Arousal Party Game

This was an idea our team thought of with the help of our class. A player would wear an arousal ring. Other players would then try to arouse this player within a prespecified timespan. This game could be targeted for middle and high school audiences and college audiences if it were marketed as a drinking game.

Our sponsors technology appears ripe to compete in this relatively new market. We would recommend that she digitalize her product and pair it with a game similar to the above examples. We feel that the Texas A&M model of adjusting difficulty based on the player’s arousal level may be a good way to appeal to game makers with a following in the market and raise the technology’s profile in the gaming community.

Most of the existing players in this market appear to be relatively small. The Texas A&M project does not even appear to have been marketed yet. We feel that if our sponsor were to enter the market now and gain brand recognition and market share, her product may become successful in the long run as the gaming industry moves toward automation.

V. Conclusion We identified possible competitors in the market if our sponsor is firm about of applying for

the Gates Foundation grant, such as Ma Belly and PreVue Wearables. However, we want to point out that it would be difficult for our sponsor’s product to compete with them at the current stage of our sponsor’s product inventory. Moreover, the grant may no longer be available when our sponsor is ready to apply. We provide details about the grant requirements and make suggestions about how they should to be met. We find that much improvement to the device would be needed if our sponsor wishes to keep targeting at third-world medical market. However, we recommend that our sponsor look for alternative opportunities. One possible path forward is transiting into a lifestyle digital wearable. Comparing our sponsor’s product to existing competitors in the market, we find most of them are simple digital wearables featuring basic health and movement measurement features. Our strategy for our sponsor’s product is to attract younger audience awareness through affordability, modern product design, and unconventional marketing strategy. Another possible option may be to enter the gaming industry. We find that wearable biosensors are in their infancy in this market, and our sponsor may have a real opportunity of conquer it and ride the wave as biosensor gaming grows in the future.

31 See Exhibit 11 (http://psi.cse.tamu.edu/portfolio_item/biofeedback-games-2/)

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Exhibit 1: WHO Health Statistics 2014.

Exhibit 2: Maternal Mortality ratio (MMR): maternal mortality per 100 000 live births

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Exhibit 3: Maternal Mortality ratio (MMR): maternal mortality per 100 000 live births UNICEF: Millennium Development Goals, State of the World’s Children: Statistics on the situation of women:

https://www.unicef.org/mdg/maternal.html Exhibit 4 Ma Belly Product Design

Exhibit 5 PreVue Wearable

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Exhibit 6

16

Exhibit 7

Exhibit 8

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Trailer: https://player.vimeo.com/video/187755518 Exhibit 9

Video: https://www.youtube.com/watch?v=ZxNoGaIJwmU&feature=youtu.be Exhibit 10

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Video: https://www.youtube.com/watch?v=Az6l5HKS9UU Exhibit 11

Video: https://www.youtube.com/watch?v=QXdknlwwT_8

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Exhibit 12

Bibliography “About Nevermind.” Nevermind, Flying Mollusk, nevermindgame.com/about/. "Analytical Summary." Ethiopia:Analytical Summary - Health Status and Trends - AHO. World Health

Organization, 2014. Web. 01 May 2017. Arlduc. "Ma Belly: A Low-Cost, Smart Maternity Belt." ARLDUC The Exotic Brother. ARLDUC: The

Exotic Other, 15 Sept. 2015. Web. 01 May 2017. Berhan, Yifru, and Asres Berhan. "Review of Maternal Mortality in Ethiopia: A Story of the Past 30

Years." Ethiopian Journal of Health Sciences. Research and Publications Office of Jimma University, Sept. 2014. Web. 01 May 2017.

“Awarded Grants.” Global Grand Challenges, Bill & Melinda Gates Foundation, 30 Nov. 2016,

gcgh.grandchallenges.org/grants?items_per_page. Bonsa, Feyie, Esayas Kebede Gudina, and Kifle Woldemichael Hajito. "Prevalence of Hypertension and

Associated Factors in Bedele Town, Southwest Ethiopia." Ethiopian Journal of Health Sciences. Research and Publications Office of Jimma University, Jan. 2014. Web. 01 May 2017.

"Ethiopia." World Health Organization, n.d. Web.

<http://www.who.int/maternal_child_adolescent/epidemiology/profiles/maternal/eth.pdf?ua=1>. "Frequently Asked Questions." — MIT Media Lab. MIT Media Lab, n.d. Web. 08 May 2017.

<https://www.media.mit.edu/galvactivator/faq.html>. Kamen, Matt. “Escape Game 'Hyde' Uses Biosensors to Test Survival Instincts.” WIRED UK, WIRED

UK, 23 May 2016, www.wired.co.uk/article/hyde-wearable-biosensor-experience. Accessed 1 May 2017.

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Kibret, Kelemu Tilahun, and Yonatan Moges Mesfin. "Prevalence of Hypertension in Ethiopia: A Systematic Meta-analysis." Public Health Reviews. BioMed Central, 09 Dec. 2015. Web. 01 May 2017.

“Home.” Pip, thepip.com/en-us/. Nakimuli, Annettee, Olympe Chazara, Josaphat Byamugisha, and Alison M. Elliott. "Pregnancy,

Parturition and Preeclampsia in Women of African Ancestry." Science Direct. Wellcome Trust, 2014. Web. May 2017.

“Portfolio.” Perception, Sensing & Instrumentation Lab,

psi.cse.tamu.edu/portfolio_item/biofeedback-games-2/. Accessed 1 May 2017. Shiue, Melody Yi-Yun Shiue. "PreVue Wearable Pregnancy Ultrasound by Melody Yi-Yun Shiue." PreVue Wearable Pregnancy Ultrasound. A' Design Award, 2012. Web. 01 May 2017. TechnologyAdvice Research, and Google Consumer Insights. "WEARABLE TECHNOLOGY &

PREVENTATIVE HEALTHCARE." Wearable Technology & Preventative Healthcare (n.d.): n. pag. Technology Advice, 2014. Web. May 2017.

Tessema, Gizachew Assefa, Abebe Tekeste, and Tadesse Awoke Ayele. "Preeclampsia and Associated

Factors among Pregnant Women Attending Antenatal Care in Dessie Referral Hospital, Northeast Ethiopia: A Hospital-based Study." BMC Pregnancy and Childbirth. BioMed Central, 29 Mar. 2015. Web. 01 May 2017.

Vata, Prabhanjan Kumar, Nitin M. Chauhan, Arasumani Nallathambi, and Fentaw Hussein. "Assessment

of Prevalence of Preeclampsia from Dilla Region of Ethiopia." BMC Research Notes. BioMed Central, 2015. Web. 01 May 2017.

“Wearables and Technology for Maternal, Neonatal and Child Health Behavior Change (Round 19).”

Global Grand Challenges, Bill & Melinda Gates Foundation, gcgh.grandchallenges.org/challenge/wearables-and-technology-maternal-neonatal-and-child-health-behavior-change-round-19.

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