Effectiveness of Behaviorally Designed Gamification Interventions With Social Incentives for Increasing Physical Activity Among Overweight and Obese Adults Across the United States: The STEP UP Randomized Clinical Trial

Abstract

Importance: Gamification, the use of game design elements in nongame contexts, is increasingly being used in workplace wellness programs and digital health applications. However, the best way to design social incentives in gamification interventions has not been well examined.

Objective: To assess the effectiveness of support, collaboration, and competition within a behaviorally designed gamification intervention to increase physical activity among overweight and obese adults.

Design, setting, and participants: This 36-week randomized clinical trial with a 24-week intervention and 12-week follow-up assessed 602 adults from 40 states with body mass indexes (calculated as weight in kilograms divided by height in meters squared) of 25 or higher from February 12, 2018, to March 17, 2019.

Interventions: Participants used a wearable device to track daily steps, established a baseline, selected a step goal increase, were randomly assigned to a control (n = 151) or to 1 of 3 gamification interventions (support [n = 151], collaboration [n = 150], and competition [n = 150]), and were remotely monitored. The control group received feedback from the wearable device but no other interventions for 36 weeks. The gamification arms were entered into a 24-week game designed using insights from behavioral economics with points and levels for achieving step goals. No gamification interventions occurred during follow-up.

Main outcomes and measures: The primary outcome was change in mean daily steps from baseline through the 24-week intervention period.

Results: A total of 602 participants (mean [SD] age, 39 [10] years; mean [SD] body mass index, 30 [5]; 427 [70.9%] male) were included in the study. Compared with controls, participants had a significantly greater increase in mean daily steps from baseline during the intervention in the competition arm (adjusted difference, 920; 95% CI, 513-1328; P < .001), support arm (adjusted difference, 689; 95% CI, 267-977; P < .001), and collaboration arm (adjusted difference, 637; 95% CI, 258-1017; P = .001). During follow-up, physical activity remained significantly greater in the competition arm than in the control arm (adjusted difference, 569; 95% CI, 142-996; P = .009) but was not significantly greater in the support (adjusted difference, 428; 95% CI, 19-837; P = .04) and collaboration (adjusted difference, 126; 95% CI, -248 to 468; P = .49) arms than in the control arm.

Conclusions and relevance: All 3 gamification interventions significantly increased physical activity during the 24-week intervention, and competition was the most effective. Physical activity was lower in all arms during follow-up and only remained significantly greater in the competition arm than in the control arm.

Trial registration: ClinicalTrials.gov identifier: NCT03311230.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Patel reported receiving personal fees as the owner of Catalyst Health LLC, stock options from LifeVest Health, personal fees and stock options from HealthMine, Inc, personal fees from Holistic Industries, and personal fees from Deloitte Consulting LLP outside the submitted work. Dr Reh reported receiving personal fees from Deloitte Consulting LLP during the conduct of the study and outside the submitted work and having a patent planned outside the submitted work. Dr Szwartz reported being employed by Deloitte Consulting LLP. Dr Guszcza reported receiving personal fees from Deloitte Consulting LLP during the conduct of the study and outside the submitted work. Dr Steier reported receiving personal fees from Deloitte Consulting LLP during the conduct of the study and outside the submitted work and having a patent planned outside the submitted work. Dr Kalra reported receiving personal fees from Deloitte Consulting LLP during the conduct of the study and outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram

Participants in all arms used a wearable device to track daily step counts, established a baseline, and selected a step goal increase. Participants in the control arm received regular feedback from the wearable device and its smartphone application but no other interventions. Participants in the gamification arms were entered into the intervention that ran automatically during the first 24 weeks and then had no interventions during the 12-week follow-up period.

Figure 2.. Unadjusted Mean Daily Steps by Month and Study Arm

The mean daily steps for each arm by month using imputed data are shown. The vertical line separates the intervention period from the follow-up period.