Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review

Menna Brown, Noelle O'Neill, Hugo van Woerden, Parisa Eslambolchilar, Matt Jones, Ann John, Menna Brown, Noelle O'Neill, Hugo van Woerden, Parisa Eslambolchilar, Matt Jones, Ann John

Abstract

Background: Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of "active" technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being.

Objective: This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being.

Methods: A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched.

Results: A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration.

Conclusions: Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data.

Keywords: Web-based mental health interventions; adherence; dropout; engagement; gamification; patient compliance; patient nonadherence; well-being.

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Risk of bias assessment of included articles (N=61).
Figure 2
Figure 2
Forest plot showing the adherence rate of interventions using goal setting as a gamification feature.
Figure 3
Figure 3
Forest plot showing the adherence rate of interventions using progress as a gamification feature.
Figure 4
Figure 4
Forest plot showing adherence of interventions employing feedback as a gamification feature.
Figure 5
Figure 5
Forest plot showing adherence of interventions employing rewards as a gamification feature.
Figure 6
Figure 6
Forest plot showing adherence of interventions employing story/theme as a gamification feature.

References

    1. Mohr DC, Duffecy J, Ho J, Kwasny M, Cai X, Burns MN, Begale M. A randomized controlled trial evaluating a manualized TeleCoaching protocol for improving adherence to a web-based intervention for the treatment of depression. PLoS One. 2013 Aug;8(8):e70086. doi: 10.1371/journal.pone.0070086.
    1. Wells KB, Miranda J, Bauer MS, Bruce ML, Durham M, Escobar J, Ford D, Gonzalez J, Hoagwood K, Horwitz SM, Lawson W, Lewis L, McGuire T, Pincus H, Scheffler R, Smith WA, Unützer J. Overcoming barriers to reducing the burden of affective disorders. Biol Psychiatry. 2002 Sep 15;52(6):655–675.
    1. Newport F, editor. The Gallup Poll: Public Opinion 2010. Lanham, MD: Rowman & Littlefield Publishers; 2010.
    1. European Pact for Mental Health and Well-being EU High-Level Conference Together for Mental Health and Wellbeing Brussels, 12-13 June 2008. 2008. [2016-03-01]. .
    1. Andersson GP, Cuijpers P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther. 2009;38(4):196–205. doi: 10.1080/16506070903318960.
    1. Amstadter AB, Broman-Fulks J, Zinzow H, Ruggiero KJ, Cercone J. Internet-based interventions for traumatic stress-related mental health problems: a review and suggestion for future research. Clin Psychol Rev. 2009 Jul;29(5):410–420. doi: 10.1016/j.cpr.2009.04.001.
    1. Barak A, Hen L, Boniel-Nissim M, Shapira N. A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. J Technol Hum Serv. 2008 Jul 03;26(2-4):109–160. doi: 10.1080/15228830802094429.
    1. Morrell CJ, Sutcliffe P, Booth A, Stevens J, Scope A, Stevenson M, Harvey R, Bessey A, Cantrell A, Dennis C, Ren S, Ragonesi M, Barkham M, Churchill D, Henshaw C, Newstead J, Slade P, Spiby H, Stewart-Brown S. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technol Assess. 2016 May;20(37):1–414. doi: 10.3310/hta20370.
    1. Reynolds J, Griffiths KM, Cunningham JA, Bennett K, Bennett A. Clinical practice models for the use of e-mental health resources in primary health care by health professionals and peer workers: a conceptual framework. JMIR Ment Health. 2015;2(1):e6. doi: 10.2196/mental.4200.
    1. Griffiths F, Lindenmeyer A, Powell J, Lowe P, Thorogood M. Why are health care interventions delivered over the internet? A systematic review of the published literature. J Med Internet Res. 2006;8(2):e10. doi: 10.2196/jmir.8.2.e10.
    1. Bennett GG, Glasgow RE. The delivery of public health interventions via the Internet: actualizing their potential. Annu Rev Public Health. 2009;30:273–292. doi: 10.1146/annurev.publhealth.031308.100235.
    1. Finkelstein J, Lapshin O. Reducing depression stigma using a web-based program. Int J Med Inform. 2007 Oct;76(10):726–734. doi: 10.1016/j.ijmedinf.2006.07.004.
    1. Finkelstein J, Lapshin O. Reducing depression stigma using a web-based program. Int J Med Inform. 2007 Oct;76(10):726–734. doi: 10.1016/j.ijmedinf.2006.07.004.
    1. Klein B, Meyer D, Austin DW, Kyrios M. Anxiety online: a virtual clinic: preliminary outcomes following completion of five fully automated treatment programs for anxiety disorders and symptoms. J Med Internet Res. 2011;13(4):e89. doi: 10.2196/jmir.1918.
    1. van den Berg S, Shapiro DA, Bickerstaffe D, Cavanagh K. Computerized cognitive-behaviour therapy for anxiety and depression: a practical solution to the shortage of trained therapists. J Psychiatr Ment Health Nurs. 2004 Oct;11(5):508–513. doi: 10.1111/j.1365-2850.2004.00745.x.
    1. Rothert K, Strecher VJ, Doyle LA, Caplan WM, Joyce JS, Jimison HB, Karm LM, Mims AD, Roth MA. Web-based weight management programs in an integrated health care setting: a randomized, controlled trial. Obesity (Silver Spring) 2006 Feb;14(2):266–272. doi: 10.1038/oby.2006.34.
    1. Eysenbach G. The law of attrition. J Med Internet Res. 2005 Mar;7(1):e11. doi: 10.2196/jmir.7.1.e11.
    1. Melville KM, Casey LM, Kavanagh DJ. Dropout from Internet-based treatment for psychological disorders. Br J Clin Psychol. 2010 Nov;49(Pt 4):455–471. doi: 10.1348/014466509X472138.
    1. Kelders SM, Kok RN, Ossebaard HC, Van Gemert-Pijnen JE. Persuasive system design does matter: a systematic review of adherence to web-based interventions. J Med Internet Res. 2012;14(6):e152. doi: 10.2196/jmir.2104.
    1. Cuijpers P, van Straten A, Warmerdam L, Andersson G. Psychological treatment of depression: a meta-analytic database of randomized studies. BMC Psychiatry. 2008;8:36. doi: 10.1186/1471-244X-8-36.
    1. Donkin L, Christensen H, Naismith SL, Neal B, Hickie IB, Glozier N. A systematic review of the impact of adherence on the effectiveness of e-therapies. J Med Internet Res. 2011;13(3):e52. doi: 10.2196/jmir.1772.
    1. Manwaring JL, Bryson SW, Goldschmidt AB, Winzelberg AJ, Luce KH, Cunning D, Wilfley DE, Taylor CB. Do adherence variables predict outcome in an online program for the prevention of eating disorders? J Consult Clin Psychol. 2008 Apr;76(2):341–346. doi: 10.1037/0022-006X.76.2.341.
    1. Hilvert-Bruce Z, Rossouw PJ, Wong N, Sunderland M, Andrews G. Adherence as a determinant of effectiveness of internet cognitive behavioural therapy for anxiety and depressive disorders. Behav Res Ther. 2012 Aug;50(7-8):463–468. doi: 10.1016/j.brat.2012.04.001.
    1. Morrison D, Wyke S, Thomson NC, McConnachie A, Agur K, Saunderson K, Chaudhuri R, Mair FS. A Randomized trial of an Asthma Internet Self-management Intervention (RAISIN): study protocol for a randomized controlled trial. Trials. 2014;15:185. doi: 10.1186/1745-6215-15-185.
    1. Sharry J, Davidson R, McLoughlin O, Doherty G. A service-based evaluation of a therapist-supported online cognitive behavioral therapy program for depression. J Med Internet Res. 2013;15(6):e121. doi: 10.2196/jmir.2248.
    1. Kelders SM, Bohlmeijer ET, Van Gemert-Pijnen JE. Participants, usage, and use patterns of a web-based intervention for the prevention of depression within a randomized controlled trial. J Med Internet Res. 2013;15(8):e172. doi: 10.2196/jmir.2258.
    1. Clarke G, Eubanks D, Reid E, Kelleher C, O'Connor E, DeBar LL, Lynch F, Nunley S, Gullion C. Overcoming Depression on the Internet (ODIN) (2): a randomized trial of a self-help depression skills program with reminders. J Med Internet Res. 2005;7(2):e16. doi: 10.2196/jmir.7.2.e16.
    1. Vervloet M, Linn AJ, van Weert JC, de Bakker DH, Bouvy ML, van Dijk L. The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature. J Am Med Inform Assoc. 2012;19(5):696–704. doi: 10.1136/amiajnl-2011-000748.
    1. Christensen H, Griffiths KM, Korten AE, Brittliffe K, Groves C. A comparison of changes in anxiety and depression symptoms of spontaneous users and trial participants of a cognitive behavior therapy website. J Med Internet Res. 2004 Dec 22;6(4):e46. doi: 10.2196/jmir.6.4.e46.
    1. Khadjesari Z, Murray E, Kalaitzaki E, White IR, McCambridge J, Thompson SG, Wallace P, Godfrey C. Impact and costs of incentives to reduce attrition in online trials: two randomized controlled trials. J Med Internet Res. 2011;13(1):e26. doi: 10.2196/jmir.1523.
    1. Alexander GL, Divine GW, Couper MP, McClure JB, Stopponi MA, Fortman KK, Tolsma DD, Strecher VJ, Johnson CC. Effect of incentives and mailing features on online health program enrollment. Am J Prev Med. 2008 May;34(5):382–388. doi: 10.1016/j.amepre.2008.01.028.
    1. Gliddon E, Lauder S, Berk L, Cosgrove V, Grimm D, Dodd S, Suppes T, Berk M. Evaluating discussion board engagement in the MoodSwings online self-help program for bipolar disorder: protocol for an observational prospective cohort study. BMC Psychiatry. 2015;15:243. doi: 10.1186/s12888-015-0630-7.
    1. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuji BI, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res. 2014;16(2):e40. doi: 10.2196/jmir.2952.
    1. Primack BA, Carroll MV, McNamara M, Klem ML, King B, Rich M, Chan CW, Nayak S. Role of video games in improving health-related outcomes: a systematic review. Am J Prev Med. 2012 Jun;42(6):630–638. doi: 10.1016/j.amepre.2012.02.023.
    1. McGonigal J. Reality Is Broken: Why Games Make Us Better and How They Can Change the World. New York: The Penguin Press; 2011.
    1. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games. 2013;1(1):e3. doi: 10.2196/games.3139.
    1. Hamari J, Koivisto J, Pakkanen T. Persuasive Technologies. Cham, Switzerland: Springer International Publishing; 2014. Do persuasive technologies persuade?-A review of empirical studies; pp. 118–136.
    1. Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: video games and stories for health-related behavior change. Am J Prev Med. 2008 Jan;34(1):74–82. doi: 10.1016/j.amepre.2007.09.027.
    1. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: defining gamification. Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments 2011 ACM; 15th International Academic MindTrek Conferencenvisioning Future Media Environments; Sep 28-30, 2011; Tampere, Finland. 2011. pp. 9–15.
    1. Seaborn K, Fels DI. Gamification in theory and action: a survey. Int J Hum-Comput St. 2015 Feb;74:14–31. doi: 10.1016/j.ijhcs.2014.09.006.
    1. Werbach K, Hunter D. For the Win: How Game Thinking Can Revolutionize Your Business. Philadelphia, PA: Wharton Digital Press; 2012.
    1. Kapp KM. The Gamification of Learning and Instruction: Game-based Methods and Strategies for Training and Education. San Francisco, CA: John Wiley & Sons; 2012.
    1. Silva F, Analide C, Rosa L, Felgueiras G, Pimento C. Distributed Computing and Artificial Intelligence. Berlin: Springer; 2013. Social networks gamification for sustainability recommendation systems; pp. 307–315.
    1. van Ballegooijen W, Cuijpers P, van Straten A, Karyotaki E, Andersson G, Smit JH, Riper H. Adherence to Internet-based and face-to-face cognitive behavioural therapy for depression: a meta-analysis. PLoS One. 2014;9(7):e100674. doi: 10.1371/journal.pone.0100674.
    1. Brouwer W, Kroeze W, Crutzen R, de Nooijer J, de Vries NK, Brug J, Oenema A. Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review. J Med Internet Res. 2011;13(1):e2. doi: 10.2196/jmir.1639.
    1. Schubart JR, Stuckey HL, Ganeshamoorthy A, Sciamanna CN. Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement. Comput Inform Nurs. 2011 Feb;29(2 Suppl):TC9–TC20. doi: 10.1097/NCN.0b013e3182155274.
    1. Christensen H, Griffiths KM, Farrer L. Adherence in internet interventions for anxiety and depression. J Med Internet Res. 2009;11(2):e13. doi: 10.2196/jmir.1194.
    1. Hamari K, Koivisto J, Sarsa H. Does gamification work? A literature review of empirical studies on gamification. Proceedings of the 2014 47th Hawaii International Conference on System Sciences; 47th Hawaii International Conference on System Sciences; Jan 6-9, 2014; Waikoloa, HI. 2014. pp. 6–9.
    1. Pallant J. SPSS Survival Manual, 5th edition. Berkshire, UK: McGraw-Hill Education; 2013.
    1. The Cochrane Collaboration . In: Cochrane Handbook for Systematic Reviews of Interventions. Higgins JP, Green S, editors. Chichester, UK: Wiley-Blackwell; 2008.
    1. Imamura K, Kawakami N, Furukawa TA, Matsuyama Y, Shimazu A, Umanodan R, Kawakami S, Kasai K. Effects of an Internet-based cognitive behavioral therapy (iCBT) program in Manga format on improving subthreshold depressive symptoms among healthy workers: a randomized controlled trial. PLoS One. 2014;9(5):e97167. doi: 10.1371/journal.pone.0097167.
    1. Ritterband LM, Bailey ET, Thorndike FP, Lord HR, Farrell-Carnahan L, Baum LD. Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. Psychooncology. 2012 Jul;21(7):695–705. doi: 10.1002/pon.1969.
    1. Schover LR, Yuan Y, Fellman BM, Odensky E, Lewis PE, Martinetti P. Efficacy trial of an Internet-based intervention for cancer-related female sexual dysfunction. J Natl Compr Canc Netw. 2013 Nov;11(11):1389–1397.
    1. Sanders MR, Baker S, Turner KM. A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems. Behav Res Ther. 2012 Nov;50(11):675–684. doi: 10.1016/j.brat.2012.07.004.
    1. Irvine AB, Gelatt VA, Seeley JR, Macfarlane P, Gau JM. Web-based intervention to promote physical activity by sedentary older adults: randomized controlled trial. J Med Internet Res. 2013;15(2):e19. doi: 10.2196/jmir.2158.
    1. Christensen H, Griffiths KM, Mackinnon AJ, Brittliffe K. Online randomized controlled trial of brief and full cognitive behaviour therapy for depression. Psychol Med. 2006 Dec;36(12):1737–1746. doi: 10.1017/S0033291706008695.
    1. Kajiyama B, Thompson LW, Eto-Iwase T, Yamashita M, Di Marioa J, Marian TY, Gallagher-Thompson D. Exploring the effectiveness of an internet-based program for reducing caregiver distress using the iCare Stress Management e-Training Program. Aging Ment Health. 2013;17(5):544–554. doi: 10.1080/13607863.2013.775641.
    1. Santucci LC, McHugh RK, Elkins RM, Schechter B, Ross MS, Landa CE, Eisen S, Barlow DH. Pilot implementation of computerized cognitive behavioral therapy in a university health setting. Adm Policy Ment Health. 2014 Jul;41(4):514–521. doi: 10.1007/s10488-013-0488-2.
    1. Moritz S, Schilling L, Hauschildt M, Schröder J, Treszl A. A randomized controlled trial of internet-based therapy in depression. Behav Res Ther. 2012 Aug;50(7-8):513–521. doi: 10.1016/j.brat.2012.04.006.
    1. Phillips R, Schneider J, Molosankwe I, Leese M, Foroushani PS, Grime P, McCrone P, Morriss R, Thornicroft G. Randomized controlled trial of computerized cognitive behavioural therapy for depressive symptoms: effectiveness and costs of a workplace intervention. Psychol Med. 2014 Mar;44(4):741–752. doi: 10.1017/S0033291713001323.
    1. Titov N, Andrews G, Schwencke G, Robinson E, Peters L, Spence J. Randomized controlled trial of Internet cognitive behavioural treatment for social phobia with and without motivational enhancement strategies. Aust N Z J Psychiatry. 2010 Oct;44(10):938–945. doi: 10.3109/00048674.2010.493859.
    1. Whitton AE, Proudfoot J, Clarke J, Birch M, Parker G, Manicavasagar V, Hadzi-Pavlovic D. Breaking open the black box: isolating the most potent features of a web and mobile phone-based intervention for depression, anxiety, and stress. JMIR Ment Health. 2015;2(1):e3. doi: 10.2196/mental.3573.
    1. Dear BF, Zou JB, Ali S, Lorian CN, Johnston L, Sheehan J, Staples LG, Gandy M, Fogliati VJ, Klein B, Titov N. Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive behavior therapy for older adults with symptoms of anxiety: a randomized controlled trial. Behav Ther. 2015 Mar;46(2):206–217. doi: 10.1016/j.beth.2014.09.007.
    1. Knaevelsrud C, Maercker A. Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry. 2007;7:13. doi: 10.1186/1471-244X-7-13.
    1. Twomey C, O'Reilly G, Byrne M, Bury M, White A, Kissane S, McMahon A, Clancy N. A randomized controlled trial of the computerized CBT programme, MoodGYM, for public mental health service users waiting for interventions. Br J Clin Psychol. 2014 Nov;53(4):433–450. doi: 10.1111/bjc.12055.
    1. Seaborn K, Fels DI. Gamification in theory and action: a survey. Int J Hum-Comput St. 2015 Feb;74:14–31. doi: 10.1016/j.ijhcs.2014.09.006.
    1. Tech Trends 2012: Elevate IT for Digital Business. Sydney, Australia: Deloitte Australia; 2012. [2016-08-18]. .
    1. Bogost I. Gamasutra. 2011. [2016-08-17]. Persuasive games: exploitationware
    1. Antin J, Churchill E. Badges in social media: a social psychological perspective. ACM CHI Conference on Human Factors in Computing Systems; May 7-12, 2011; Vancouver, BC. 2011.
    1. Cobb NK, Poirier J. Effectiveness of a multimodal online well-being intervention: a randomized controlled trial. Am J Prev Med. 2014 Jan;46(1):41–48. doi: 10.1016/j.amepre.2013.08.018.
    1. Sheeber LB, Seeley JR, Feil EG, Davis B, Sorensen E, Kosty DB, Lewinsohn PM. Development and pilot evaluation of an Internet-facilitated cognitive-behavioral intervention for maternal depression. J Consult Clin Psychol. 2012 Oct;80(5):739–749. doi: 10.1037/a0028820.
    1. Wangberg SC, Bergmo TS, Johnsen JK. Adherence in Internet-based interventions. Patient Prefer Adherence. 2008;2:57–65.
    1. Litz BT, Engel CC, Bryant RA, Papa A. A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. Am J Psychiatry. 2007 Nov;164(11):1676–1683. doi: 10.1176/appi.ajp.2007.06122057.
    1. Morrison C, Doherty G. Analyzing engagement in a web-based intervention platform through visualizing log-data. J Med Internet Res. 2014;16(11):e252. doi: 10.2196/jmir.3575.
    1. Akobeng AK. Understanding randomised controlled trials. Arch Dis Child. 2005 Aug;90(8):840–844. doi: 10.1136/adc.2004.058222.
    1. Powell J, Hamborg T, Stallard N, Burls A, McSorley J, Bennett K, Griffiths KM, Christensen H. Effectiveness of a web-based cognitive-behavioral tool to improve mental well-being in the general population: randomized controlled trial. J Med Internet Res. 2013;15(1):e2. doi: 10.2196/jmir.2240.
    1. Høifødt RS, Lillevoll KR, Griffiths KM, Wilsgaard T, Eisemann M, Waterloo K, Kolstrup N. The clinical effectiveness of web-based cognitive behavioral therapy with face-to-face therapist support for depressed primary care patients: randomized controlled trial. J Med Internet Res. 2013;15(8):e153. doi: 10.2196/jmir.2714.
    1. Watts S, Mackenzie A, Thomas C, Griskaitis A, Mewton L, Williams A, Andrews G. CBT for depression: a pilot RCT comparing mobile phone vs computer. BMC Psychiatry. 2013;13:49. doi: 10.1186/1471-244X-13-49.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する