The notion of gamification is gaining traction in healthcare as pharma looks for creative ways to engage and motivate patients to change behavior, especially as many current initiatives involve digital solutions. But do games really work to support long-term behavior change for patients who are managing their disease and treatment?
What is Gamification?
Gamification is defined as use of game design elements in non-game context.1 But it can mean many things and people typically think of a few central themes.
- Competition: Notions of challenge and “winning,” through the accumulation of points or rewards, is a commonly expressed theme.
- Social connections: There can be a strong social dimension of gamification, with potential to support social connectedness.
- Fun: Entertainment is at the very core of most gaming applications.
- On-trend and novel: Because gamification applications are frequently accessed digitally, either on a computer or a smartphone, they automatically take on an aura of being innovative and modern.
Evaluating the Effectiveness of Gamification Applications
Gamification applications in healthcare are increasingly common, however, not all are created equal. While many have an initial aesthetic appeal or “wow-factor,” it is important that pharma evaluate their effectiveness to promote sustained health behavior change. Before you launch the next exciting gamification application, be sure to think about the following three critical areas:
1. Consider the behavior to be changed
This sounds straightforward, but identifying the health behavior the application is attempting to change is not always immediately clear. Many of the more consumer-focused health-related gamification applications are aspirational in their broad objectives as they relate to behavior change. Wearable fitness tracking devices, for example, invite you to “live better,” and purport to make you “feel stronger, healthier, and better.” Enticing goals for sure! But if we are evaluating these applications in terms of their impact on behavior change, we need to understand what health behaviors these applications are designed to change. Broadly stated objectives such as “live better” need to be further translated into behaviors that can be readily measured so that the success of the application can be accurately assessed. So, for example, “live better” could be evaluated by looking at more measureable health behaviors such as physical activity, diet, and sleep.
2. Grounded in theory
Theories of behavior change provide an essential foundation for gamification development. They also provide a means of understanding the reasons why or why not a behavior occurs and, therefore, suggest appropriate intervention techniques. Many games involve rewards as the basis for driving behavior change. The application of rewards draws on the basic principles of operant conditioning, which asserts that behavior is changed by modifying its consequences. Many games also incorporate evidence-based behavior change techniques but do not explicitly draw on formal theory. For example, games may allow the user to set behavior goals, track their behavior in relation to this goal, and provide feedback about its effects. These techniques have all been demonstrated to be effective in supporting sustained behavior change.
However, without reference to a formal theoretical foundation, a gamification application will likely lack cohesiveness and its components may be experienced as piece-meal and disconnected, rather than as elements of an integrated structure. More than this, however, the application may fail to address proposed mechanisms of behavior change, and ultimately be less effective in changing behavior.
Related to this, it is also important to consider the actual application design process. A number of the more innovative gamification applications are being developed by startup companies who employ gaming or user-design specialists. These experts typically design iteratively, using bottom-up approaches. In other words, games can be somewhat rudimentary when first released, and are evolved and refined, sometimes over years, before they are demonstrated as even being somewhat effective in changing behavior. This approach to design is in contrast to the approach typically adopted by applied behavioral theorists and health psychology experts who work to draw on behavior theory to develop a more complete gamification application prior to design and release to the patient population.
3. Don’t assume rewards work
While rewards may appear to work in the beginning, they don’t necessarily work over the long term. There can be any number of reasons why someone may disengage with a game application. Common reasons relate to gaming fatigue, with people getting bored or the novelty simply wearing off. When this occurs, does the behavior fall away as well? For example, if someone stops using their wearable health tracking watch or wristband, are they still inclined to move more, or do they revert to the activity levels they had prior to the start of the gaming experience?
In addressing this question, it is necessary to understand the distinction between intrinsic and extrinsic motivators of behavior. Broadly speaking, intrinsic motivators are those that are intangible and internal to an individual, including their beliefs and values related to their health behaviors. Extrinsic motivators are those that are tangible and external to the individual. In this way, however, extrinsic motivators are also more vulnerable and have less permanence than intrinsic motivators. Gamification applications typically tap into extrinsic motivators (e.g., such as rewards, prizes, or social reinforcement) only, and could even be seen to undermine intrinsic motivators. When the gamification application is removed—e.g., the rewards stop—and if intrinsic motivators are not supported, the positive health behavior will likely cease.
Optimal self-management in chronic disease demands that a patient engages in sustained behavior change, including a wide range of health behaviors. Gamification applications can be successful in supporting patients to engage in sustained behavior change as it relates to optimal self-management. However, it is important to evaluate applications in terms of their ability to effect behavior change over the long term. At the very least, game applications in health behavior change should be designed to change a specific and measurable behavior, should be theoretically and structurally coherent, and should address the underlying mechanisms of change.
Without these key components, they are simply games and not effective healthcare solutions.