As we progress into the future, technology is becoming more entrenched in our everyday lives and implicitly shaping our minds. Only recently have we begun harnessing the power of technology to explicitly change behaviors through methods such as gamification. Gamification is the application of a “game system” in a non-game context (1). Frequently incorporated components include points, leadership, levels and achievements.

Gamification in Health 

Gamification has recently taken the health field by storm. From increasing prescription adherence to exercise-tracking apps, you can find a gamified version of almost any health practice. Within this field, there’s broad diversity to the level of gamification. At the most basic level, apps and technology provide feedback to make us more cognizant of our true behavior. While we may believe that we’ve exercised and eaten well, an unbiased device based on goals translated into points or badges (ex: Apple Health App) tells us otherwise. More advanced gamification apps engage the user to activate behavior change based on their input. For example, push notifications or prompts encourage users to record food intake or encourage movement (ex: Mango Health App, Nike Run Club). User data can be processed to create a personalized plan towards the individual’s specific habits. In digital health today, it is almost impossible to find a successful app without elements of gamification. 

How does it work? How well? 

To understand the success of gamification, we must understand self-determination theory coined by Richard Ryan and Edward Deci. They argued, and empirically supported, that motivation is either intrinsic or extrinsic. Intrinsic motivation is sourced in our own motivation to change and is fairly independent of others. Alternatively, extrinsic motivation is based on the people around us or artificial goals. In the long run, only intrinsic motivation has demonstrated a lasting effect. In the current digital health landscape, gamification largely targets extrinsic motivation through points, badges, levels and social leaderboards (2).

Gamification has been proven to work. (3) Now we need to understand why it works. Researchers have built a framework for what makes gamification interventions successful, known as the active ingredients. The most prominent categories of persuasive feedback involve goal setting, overcoming challenges, providing feedback on performance, reinforcement of positive behaviors, comparing progress, and social connectivity. With the exception of “fun,” all components of gamification should map back onto these techniques to properly target behavior change (4). Similar to any other health intervention, gamification must be rooted in evidenced and tested theory to produce efficacy. This requires interactions between the social sciences and engineering to drive future developments. While behavioral science lays the foundation for the theory, a team of designers and engineers must put the idea into practice. Gamification requires the coordination of both to create a fully functional behavioral health intervention.

Area for Future Development

Overall, gamification is proven to be an effective way to engage audiences and improve health behaviors in the short term. However, literature describes mixed results for long-term and intrinsic motivation. There are multitudes of different theories and ideas to what allows extrinsic motivation to become intrinsic. One article about gamification in education argues that the target’s characteristics (eg. age, sex, gender) dominate creating lasting change (5) while other researchers associate lasting change with specific active ingredients (eg. providing feedback) (4). Future gamification studies need to include more data and follow up for long-term impact. The large majority of research simply ends after the study period and offers little-to-no insight on efficacy in a year or longer. Further research is vital to constructing the future framework of gamification to improve efficacy for all participants across race, age, gender and sex.

While gamification seemingly provides countless benefits, there is a lack of literature on the possible negative attributes and downsides of gamification (eg. disinterest, burn-out). In mirroring the successes of behavioral health change and game active ingredients, if digital health researchers were able to map “Indifference, Loss of performance, Undesired behavior and Declining effects” (6), performance and user retention could improve. Furthermore, this research could mitigate the possible damage gamification of a health behavior could cause. Through expanding evidence in intervention design, the scientific community will have a better understanding of how to gamify for longer lasting impact. 

Conclusion

Gamification is not the solution to user engagement, but it’s certainly a powerful tool when applied correctly. It combines the aspects of technology that are “addictive” and channels that towards positive behavior change. As more technology and apps are developed, they must take into consideration the collaborations necessary across fields (eg. computer science, psychology, design) to produce a product that is evidence-based and truly engages the target audience. Like all fields, gamification requires more extensive research to create lasting, impactful approaches across all patient demographics. I look forward to seeing the copious amount of possibilities and research directions in this area of digital health innovation.

References

1. Fitz-Walter, Zachary. “What Is Gamification? Education, Business & Marketing (2021 Examples).” What Is Gamification? Education, Business & Marketing (2021 Examples), Gamify, https://www.gamify.com/what-is-gamification. 
2. Smith, Frank. “A Brief History of Gamification [#Infographic].” Technology Solutions That Drive Education, 15 June 2021, https://edtechmagazine.com/higher/article/2014/07/brief-history-gamification-infographic
3. Johnson, Daniel, et al. “Gamification for Health and Wellbeing: A Systematic Review of the Literature.” Internet Interventions, Elsevier, 2 Nov. 2016, https://www.sciencedirect.com/science/article/pii/S2214782916300380.
4. Cugelman, Brian, and AlterSpark Corp. “Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers.” JMIR Serious Games, JMIR Publications Inc., Toronto, Canada, 2013, https://games.jmir.org/2013/1/e3/. 
5. Smiderle, R., Rigo, S.J., Marques, L.B. et al. The impact of gamification on students’ learning, engagement and behavior based on their personality traits. Smart Learn. Environ. 7, 3 (2020). https://doi.org/10.1186/s40561-019-0098-x
6. Toda, Armando, et al. “(PDF) The Dark Side of Gamification: An Overview of Negative Effects of Gamification in Education.” ResearchGate, https://www.researchgate.net/publication/326876949_The_Dark_Side_of_Gamification_An_Overview_of_Negative_Effects_of_Gamification_in_Education.