More than half of American adults do not obtain the recommended amount of physical activity and are at a higher risk for cardiovascular disease. To help increase physical activity, some physicians are trying the technique of “gamification,” which is the application of game design elements into non-game contexts such as the use of wearable devices and counting steps.

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The availability of mobile technologies such as wearable devices and smartphone apps continue to expand, providing a platform for monitoring daily health behaviors. Through game-based interventions, the researchers behind a JAMA Internal Medicine study used wearable devices and step counting to get families involved. The study examined the effectiveness of a game-based intervention that uses collaboration, peer support and accountability to increase physical activity.

“Social incentives, or the influences that motivate individuals to adjust their behaviors based on social ties or connections, are ubiquitous and could be leveraged within gamification interventions to provide a scalable, low-cost approach to increase engagement,” says the study.

The year-long Behavioral Economics Framingham Incentive Trial (BE FIT) looked at adults enrolled in the Framingham Heart Study, which is a long-standing group of families. Eligible participants downloaded an app to their phone or were sent a wrist-worn wearable device, such as a Fitbit, to track steps taken.

When designing gamification, three psychological principles were used. The principles stated that individuals are motivated by losses more than gains, behavior is better sustained by variable than constant reinforcement and individuals are motivated more by aspirational behavior at the beginning of the week as a fresh start.

“Injunctions to exercise regularly, eat a healthy diet and shed weight tend to be viewed by many patients as an obligation, a chore or a duty,” Ichiro Kawachi, Phd, wrote in a commentary for JAMA Internal Medicine. He is the John L. Loeb and Frances Lehman Loeb professor of social epidemiology, and chair of the department of social and behavioral sciences at the Harvard T.H. Chan School of Public Health.

“Reframing the same behaviors as fun and challenging might be more motivating. That is, we might boost success by turning a behavior into a game,” he wrote. “It is reverse engineering the process by which Pokémon Go accidentally ended up becoming the best exercise app on the market.”

Friendly competition breeds success

In the BE FIT trial, families started with points they might lose if their goals were not met. Through this, the behavioral principle of loss aversion was leveraged and families were motivated to meet their daily goals. As part of gamification, each family pledged to try their best because “precommitment has been demonstrated to motivate behavior change,” says the study.

To keep their points, families had to meet their step goal for the day or 10 points would be deducted from their initial 70 points. If a family member was sick or if activity was not possible, five lifelines per member were available to use. This allowed for some forgiveness and for members to ask for help.

At the end of each week, teams with a minimum of 50 points advanced up a level. Families in gold or platinum levels at the end of the intervention period received a coffee mug as a reward.

Teams took an average of 1,661 steps per day, which was significantly higher than the baseline of 636 steps. However, physical activity declined during the follow-up period. With the decline, activity remained significantly greater than in the control arm, with 1,385 steps per day compared to 738.

This level of decline in activity was also seen in a 2016 BMJ study of new Pokémon Go users. Over several weeks, the number of extra steps walked by players dropped as the novelty wore off. But some players did remain active, which was a “win for public health,” according to Kawachi.

“The future of gamification—beyond providing more rigorous evaluation of effectiveness—will be in interfacing with emerging technology,” Kawachi wrote. “With the advent of augmented reality gaming and “exergaming” in virtual reality, the line between entertainment and public health is becoming progressively blurred. There is an opportunity for clinicians to turn health promotion into an engaging, fulfilling and fun activity.”