Effect of a Game-Based Intervention Designed to Enhance Social Incentives to Increase Physical Activity Among Families: The BE FIT Randomized Clinical Trial

Abstract

Importance: Gamification, the application of game design elements such as points and levels in nongame contexts, is often used in digital health interventions, but evidence on its effectiveness is limited.

Objective: To test the effectiveness of a gamification intervention designed using insights from behavioral economics to enhance social incentives within families to increase physical activity.

Design, setting, and participants: The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial with a 12-week intervention period and a 12-week follow-up period. The investigation was a community-based study between December 7, 2015, and August 14, 2016. Participants in the modified intent-to-treat analysis were adults enrolled in the Framingham Heart Study, a long-standing cohort of families.

Interventions: All participants tracked daily step counts using a wearable device or a smartphone, established a baseline, selected a step goal increase, and received daily individual feedback on goal performance by text message or email for 24 weeks. Families in the gamification arm could earn points and progress through levels based on physical activity goal achievement during the 12-week intervention. The game design was meant to enhance collaboration, accountability, and peer support.

Main outcomes and measures: The primary outcome was the proportion of participant-days that step goals were achieved during the intervention period. Secondary outcomes included the proportion of participant-days that step goals were achieved during the follow-up period and the change in the mean daily steps during the intervention and follow-up periods.

Results: Among 200 adults comprising 94 families, the mean age was 55.4 years, and 56.0% (n = 112) were female. During the intervention period, participants in the gamification arm achieved step goals on a significantly greater proportion of participant-days (0.53 vs 0.32; adjusted difference, 0.27; 95% CI, 0.20-0.33; P < .001) and had a significantly greater increase in the mean daily steps compared with baseline (1661 vs 636; adjusted difference, 953; 95% CI, 505-1401; P < .001) than the control arm. During the follow-up period, physical activity in the gamification arm declined but remained significantly greater than that in the control arm for the proportion of participant-days achieving step goals (0.44 vs 0.33; adjusted difference, 0.12; 95% CI, 0.05-0.19; P < .001) and the mean daily steps compared with baseline (1385 vs 798; adjusted difference, 494; 95% CI, 170-818; P < .01).

Conclusions and relevance: Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community.

Trial registration: clinicaltrials.gov Identifier: NCT02531763.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Patel reported being supported by career development awards from the Department of Veterans Affairs Health Services Research and Development Service and the Doris Duke Charitable Foundation and reported being a principal at Catalyst Health, a technology and behavior change consulting firm. Dr Volpp reported being a principal at VAL Health, a behavioral economics consulting firm, and reported receiving consulting income from CVS Caremark and research funding from Humana, CVS Caremark, Discovery (South Africa), Hawaii Medical Services Association, and Merck, none of which are related to the work described in this article. Dr Fox reported becoming an employee of Merck Research Laboratories in December 2015. No other disclosures were reported.

Figures

Figure 1.. Study Flow CONSORT Diagram

The control arm received daily feedback for 24 weeks. The gamification arm received daily feedback for 24 weeks and a gamification intervention for the first 12 weeks. CONSORT indicates Consolidated Standards of Reporting Trials.

Figure 2.. Unadjusted Proportion of Participant-days That Step Goals Were Achieved by Study Arm and Week

Figure 3.. Unadjusted Mean Change in Daily Steps From Baseline by Study Arm and Week