Effectiveness of a Behavior Change Technique-Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Christoph Höchsmann, Denis Infanger, Christopher Klenk, Karsten Königstein, Steffen P Walz, Arno Schmidt-Trucksäss, Christoph Höchsmann, Denis Infanger, Christopher Klenk, Karsten Königstein, Steffen P Walz, Arno Schmidt-Trucksäss

Abstract

Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients.

Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation.

Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data.

Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales "interest/enjoyment" (+2.0 (SD 1.9) points, P<.001) and "perceived competence" (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01).

Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks.

Trial registration: ClinicalTrials.gov NCT02657018; https://ichgcp.net/clinical-trials-registry/NCT02657018.

Keywords: behavior change; exercise adherence; gamification; intrinsic motivation; mhealth; mobile phone game; physical activity; type 2 diabetes.

Conflict of interest statement

Conflicts of Interest: None declared.

©Christoph Höchsmann, Denis Infanger, Christopher Klenk, Karsten Königstein, Steffen P Walz, Arno Schmidt-Trucksäss. Originally published in JMIR Serious Games (http://games.jmir.org), 13.02.2019.

Figures

Figure 1
Figure 1
Flow diagram of study participants.
Figure 2
Figure 2
Illustration of the group-dependent change in total Intrinsic Motivation Inventory score and for the subscales "interest/enjoyment", "perceived competence", "perceived choice", and "value/usefulness". Pre: value at baseline; Post: value after the 24-week intervention period; n.s., not significant. *P<.05>

Figure 3

Illustration of phone-recorded physical activity…

Figure 3

Illustration of phone-recorded physical activity data during the intervention period. A: weekly average…

Figure 3
Illustration of phone-recorded physical activity data during the intervention period. A: weekly average of total steps per day, B: weekly average of steps per day during in-game training, C: average duration (minutes) of in-game strength training per week, D: total duration (minutes) of in-game training per week.

Figure 4

Linear regression model illustrating the…

Figure 4

Linear regression model illustrating the relationship between total in-game training (minutes) and change…

Figure 4
Linear regression model illustrating the relationship between total in-game training (minutes) and change in the Intrinsic Motivation Inventory total score. IMI: Intrinsic Motivation Inventory.
Figure 3
Figure 3
Illustration of phone-recorded physical activity data during the intervention period. A: weekly average of total steps per day, B: weekly average of steps per day during in-game training, C: average duration (minutes) of in-game strength training per week, D: total duration (minutes) of in-game training per week.
Figure 4
Figure 4
Linear regression model illustrating the relationship between total in-game training (minutes) and change in the Intrinsic Motivation Inventory total score. IMI: Intrinsic Motivation Inventory.

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