Effect of Gamification With and Without Financial Incentives to Increase Physical Activity Among Veterans Classified as Having Obesity or Overweight: A Randomized Clinical Trial

Abstract

Importance: Gamification is increasingly being used for health promotion but has not been well tested with financial incentives or among veterans.

Objective: To test the effectiveness of gamification with social support, with and without a loss-framed financial incentive, to increase physical activity among veterans classified as having overweight and obesity.

Design, setting, and participants: This 3-group randomized clinical trial had a 12-week intervention period and an 8-week follow-up period. Participants included veterans with a body mass index greater than or equal to 25 who were receiving care from a single site in Philadelphia, Pennsylvania. Participants underwent a remotely monitored intervention from March 19, 2019, to August 9, 2020. Data analyses were conducted between October 1, 2020, and November 14, 2020.

Interventions: All participants received a wearable device to track step counts and selected a step goal. The control group received feedback from their devices only. Participants in the 2 gamification groups were entered into a 12-week game with points and levels designed using behavioral economic principles and selected a support partner to receive weekly updates. Participants in the loss-framed financial incentive group had $120 allocated to a virtual account and lost $10 if weekly goals were not achieved.

Main outcomes and measures: The primary outcome was the change in mean daily steps from baseline during the intervention. Secondary outcomes include proportion of days goals were achieved and changes during follow-up.

Results: A total of 180 participants were randomized, 60 to the gamification with social support group, 60 to the gamification with social support and loss-framed financial incentives group, and 60 to the control group. The participants had a mean (SD) age of 56.5 (12.9) years and a mean (SD) body mass index of 33.0 (5.6); 71 participants (39.4%) were women, 90 (50.0%) were White, and 67 (37.2%) were Black. During the intervention period, compared with control group participants, participants in the gamification with financial incentives group had a significant increase in mean daily steps from baseline (adjusted difference, 1224 steps; 95% CI, 451 to 1996 steps; P = .005), but participants in the gamification without financial incentives group did not (adjusted difference, 433 steps; 95% CI, -337 to 1203 steps; P = .81). The increase for the gamification with financial incentives group was not sustained during the follow-up period, and the step count was not significantly different than that of the control group (adjusted difference, 564 steps; 95% CI, -261 to 1389 steps; P = .37). Compared with the control group, participants in the intervention groups had a significantly higher adjusted proportion of days meeting their step goal during the main intervention and follow-up period (gamification with social support group, adjusted difference from control, 0.21 participant-day; 95% CI, 0.18-0.24 participant-day; P < .001; gamification with social support and loss-framed financial incentive group, adjusted difference from control, 0.34 participant-day; 95% CI, 0.31-0.37 participant-day; P < .001).

Conclusions and relevance: Among veterans classified as having overweight and obesity, gamification with social support combined with loss-framed financial incentives was associated with a modest increase in physical activity during the intervention period, but the increase was not sustained during follow-up. Gamification without incentives did not significantly change physical activity.

Trial registration: ClinicalTrials.gov Identifier: NCT03563027.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Agarwal reported receiving contracts and grants from the US Food and Drug Administration, the Agency for Healthcare Research and Quality, and the Patient Centered Outcomes Research Institute (grant K12 HS026372) outside the submitted work. Dr Patel reported being a founder of Catalyst Health, a technology and behavior change consulting firm; serving on the medical advisory boards for Healthmine Services, Life.io, and Holistic Industries; and receiving research funding from Deloitte outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram

Participants in all groups received a wearable device and established baseline measures. Participants in the control group received regular feedback from the wearable device, but no other interventions. Participants in the gamification groups set goals for daily step counts and were entered into 1 of 2 gamification interventions that ran automatically for 20 weeks. Because of a technical issue with the platform, 2 participants in the gamification group with social support and loss-framed financial incentives were randomized but were not eligible and therefore did not receive the intervention.

Figure 2.. Unadjusted Outcomes

Depicted are outcome measures using imputed data as the unadjusted mean daily steps for each group by week (A) and mean proportion of participant-days meeting the step goal (B). The 4-week initial ramp-up period where daily step goal targets increased by 25% per week from baseline to full goal represents time when individuals in the intervention groups could not achieve full step goal until week 5.