‘Gamification’: Influencing health behaviours with games

Every month at Google Campus in London, dozens of software developers, clinicians, behavioural scientists and investors get together to discuss new strategies to influence health behaviours. The collective aim of these networking events is to develop digital ‘games with purpose’ that can improve health by integrating software design and game mechanics with public health theory and behavioural insights. Gamification is a purposely-broad umbrella term used to encompass the process of using ‘gaming’ elements to motivate and engage people in non-game contexts.¹ Enhanced opportunities now exist to deliver behaviour change interventions through game platforms on new smartphone devices.

Defying traditional stereotypes, people across demographic boundaries now play video games on a wide range of digital devices.² Whilst such games continue to be primarily used for entertainment purposes, there is increasing interest in their potential to influence positive changes in health behaviours.³ This has been encouraged by the finding that rather than spending hours being sedentary and chasing intangible outcomes, players of active video games (e.g. Nintendo Wii Fit) are motivated to exert themselves to achieve activity goals through game mechanics.^4,5

Whilst still in its infancy, we predict that gamification will become an increasingly familiar concept in healthcare as a consequence of two trends. The first builds on the consumer's appetite for new smartphone devices that provide games designers with a wider audience to target and more attractive tools to use in designing interactive health interventions. The second factor is the enthusiasm and willingness of developers to incorporate the latest behavioural insights into electronic interventions.

Mobile phones as a conduit to behaviour change

Mobile phones have been shown to be effective platforms for delivering health interventions (including for smoking cessation and encouraging medication adherence).^6,7 In the near future the majority of phones in use will be smartphones (e.g. iPhones or Samsung Galaxy), which are handsets that incorporate more advanced hardware and software capabilities that provide enhanced functionality. Features of smartphone handsets that make them a useful delivery vehicle for gamification in healthcare include GPS services, inbuilt accelerometers (that measure movement) and external sensors (that can measure heart rate and blood pressure).⁸

Incorporating lessons from behavioural economics in game design

Behavioural economics applies insights from psychology to understand how people make real life economic decisions. In doing so, behavioural economists have identified numerous strategies to counter sub-optimal decision-making.^9,10 Video games are designed to motivate users behaviour and whether knowingly or not, insights from behavioural economics are related to many of these features. For example, many games provide conditional rewards (e.g. points and prizes) that risk being lost if gamers do not return frequently to play. This plays on the well-known tendencies of people to avoid losses (loss aversion) and to irrationally value things they hold over things they do not have (endowment effect). The gamer's refrain is often ‘Just one more level’. The question is can this be turned into a health advantage?

Current ‘state of play’ and next steps

Empirical evidence to support gamification in health is starting to emerge.³ Some of the best examples of gamification are exergames that encourage exercise by turning physical activity into a game.¹¹ The use of mobile phones for these games has obvious advantages as handsets can be used to support and monitor outdoor activities. Exergames supported by GPS services on mobile phones include Nike + Fuelband and RunKeeper. These platforms are widely in the UK, with activity and achievements often tracked on social networks like Facebook and Twitter. Games have also been created for specific health conditions. An example is Bant, a mobile app targeted at adolescents with diabetes that has successfully used incentives to improve the frequency of glucose monitoring.¹² Other available game platforms are seen in Table 1.

Table 1.

Examples of gamification platforms targeting health behaviours

www.zamzee.com	A zamzee device is carried on a belt or in a pocket and measures intensity of activity. Data is converted to points that can be redeemed for virtual goods and real life rewards.
www.keas.com	Work based platform that encourages colleagues to compete in online games to improve their lifestyle
www.ayogo.com	Children are rewarded for entering information into this diabetes tracking app
www.slimkicker.com	This calorie tracker turns diet and fitness goals into a winnable level-up game, where prizes can be won when milestones are reached

Alongside more commercial software developers, multidisciplinary games design labs have been established at a number of universities. One such centre is the tiltfactor studio at Dartmouth College in the USA. Funding bodies are also willing to support the development and evaluation of gamification in healthcare, with our department at Imperial College London recently receiving funding to support work in this area.

Going forward, there are a number of issues that need to be addressed for gamification platforms to be successful in influencing ingrained health behaviours. ‘Games with purpose’ will need to hook people in the same way that games for fun entertainment currently do. The success of platforms will be related to the motivation and engagement of the players and this will often depend on experienced game developers building good games. The input of clinicians and behavioural scientists will also be essential to delivering effective interventions that are grounded in a theoretical framework that allows testing of hypotheses. RCTs with appropriate rigour will be needed to demonstrate effectiveness. Given the requirement for games to look and feel good, there may be value in academics and clinicians designing interventions around existing commercial platforms (such as Nike + Fuelband) rather than going to the expense of developing bespoke applications that are likely to be less engaging. It may be necessary that some form of light regulation, or accreditation will be required which must not stifle development or the market but provide consumers with assurance regarding quality.

Although much of the language in this field is new and occasionally ugly, we are hopeful, given the enthusiasm in which new ideas are being generated, that gamification will become a more familiar term when thinking about influencing health behaviours.

DECLARATIONS

Competing interests

None declared

Funding

This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Ethical approval

Not applicable

Contributorship

All authors contributed to the design and writing of the editorial and Dominic King acts as guarantor

Acknowledgements

None