Gamification of behavior change:
Using game mechanics and behavior
change techniques in ehealth/mhealth
interventions
Elizabeth J. Lyons, PhD, MPH
Maria Swartz, PhD, MPH, RD
February 19, 2015
Department of Nutrition and Metabolism
Gamification & behavior change
What gamification is (theoretically)
What gamification is (in practice)
But what should gamification be?
Game mechanic or behavior change technique?
Using theory to guide BCT implementation
Department of Nutrition and Metabolism
What is gamification?
Using game mechanics to increase motivation
In practice, though…
• Using badges, leaderboards, and leveling up to trick people into
doing something they don’t like
• Often added to something required to make it more appealing
Those sound kind of like extrinsic rewards to me…
• You’re right!
• That’s bad, isn’t it?
• You’re right!
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What should gamification be?
Using game mechanics to increase motivation
What is a game?
• “Gratuitous introduction of unnecessary obstacles to the
achievement of an end” (Suits)
What is required for a game to be a game?
• Lusory goals
• Pre-lusory goals
• Rules
• Pure, complete autonomy
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Gamification = autonomy support
Magic circle
• The state of mind that defines play as safe, separated from the real
world but still connected to it
Intrinsic motivation
• Play IS intrinsic motivation
Practice and failure
• Games require failure (arguably)
• Games reframe failure as well as success
• Games are practice
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So you want to use video games…
…to increase physical activity in a program
• There are some really important things to consider
• Recall that the vast majority of studies have found null results
• You need to be super clear about how EXACTLY the desired
behavior change is supposed to occur
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Game mechanics have meaning
Just throwing a game mechanic on an app is unlikely to work
Context is extremely important
You are working to encourage and support feelings of
• Autonomy
• Competence
• Relatedness
Game characteristics of particular import are
• Feedback
• Rewards
• Challenge
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Feedback
Social cognitive theory:
• Specific
• Clear
• Compare to past accomplishments, similar groups, goals
Self-determination theory
• Richly informational
• Empowering mastery
• Multiple levels (moment to moment, sustained, cumulative)
Rigby, 2012; Rovniak et al., 2005
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Not-so-good feedback
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A breakdown of good feedback
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Rewards
Why are extrinsic rewards so bad?
• They seem to work short-term
• But once you have the achievement, there’s no point to
continuing
• They dictate how you are supposed to play, which can be good or
bad
• Large literature on extrinsic rewards reducing intrinsic motivation
• Controversial
• Likely due to the presence of many moderating variables
• In other words: implementation and context matter
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Autonomy vs. control & rewards
Four types of rewards
• Verbal, intangible
• “The grateful masses” in RPGs
• Unexpected, task non-contingent
• Task-contingent
• Engaging in task
• Completing task
• Performance-contingent
Rigby, 2009
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Not great rewards: an example
Beauty Idol (iOS) boyfriends
• Acquire boyfriend
• Sequester him in your home
• Tap on him to receive rewards
• Discard boyfriend
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Highly reinforcing rewards
Fire Emblem: Awakening (3DS) supports
• Your mating strategy impacts both the story and your success
• Example: Gerome, or “If Batman were also Morrissey”
• Strategy 1: give him the strongest dad, mate
• Rewards: super strong kid, declarations of love, sparkles
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Highly reinforcing rewards
Fire Emblem: Awakening (3DS) supports
• Your mating strategy impacts both the story and your success
• Example: Gerome, or “If Batman were also Morrissey”
• Strategy 2: mate with his mom
• Rewards: torture him with dad jokes, team up as angsty
father/son duo, witness significantly less smooth romancing
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Why autonomy in rewards matters
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http://www.xboxachievements.com/game/your-shape-fitnessevolved/achievement/45480-Calorie-Score-10-000.html
Challenge
Repens (exploration, discovery, learning from surprise)
Repositio (replaying, returning, learning from re-trying)
Falstein, 2005 cited in Juul, 2009; Lauwaert et al 2007
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Failure isn’t the end of the world
Failure is necessary for autonomy support
Games should frame failure as
• Unstable vs. stable
• Specific vs. global
• Internal vs. external
• Less pleasurable, but must take responsibility
Games induce failure, then teach us how to overcome it
• Reframing failure from trait to state
• The right kind of failure should actually support competence
Juul, 2013
Department of Nutrition and Metabolism
What gamification should be
It’s not just “make exercise more fun”
It’s “make exercise more fun by…”
• Providing a solid rationale and choices
• Increasing feelings of competence (which involves
deliberately inducing failure)
• Encouraging relationships with others (including fake
others)
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Behavioral Change Techniques and
Wearable Activity Trackers
•
<50% of U.S. adults meet the 2008 Physical activity
(PA) guidelines.
•
Behavioral PA interventions have shown success in
increasing activity levels, but may be costly to
implement on a larger scale. (Archer et al., 2012)
•
Traditional health behavior change interventions are
limited (Pagoto & Bennett, 2013):
o Ability to measure and intervene on behavior in
real time
o Adherence varied widely (e.g. physical activity
log)
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Wearable Activity Trackers:
Promising Medium
• 1 in 10 U.S. adults now own a fitness tracker. (NDP
Connected Intelligence Report, 12/2014)
Table 1 — Worldwide Wearable Electronic
Fitness Devices Shipments Forecast,
2013-2016 (Millions of Units)
Device Category 2013 2014 2015 2016
Smart Wristband
30
20
17
19
Sports Watch
14
18
21
24
Other Fitness
Monitor
Chest Strap
Smart Garment
Total Market
18
20
12
15
11 12.1
8 7.3
0.01 0.1 10.1
26
73.01 70.2 68.1 91.3
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• Wearable activity
trackers and their
apps show promise
as a medium to
deliver a more
personalized PA
intervention.
Which one to choose?
• Cost vs. Function
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Behavioral Change Techniques and
Wearable Activity Trackers
• A mix of behavioral and cognitive strategies are
needed in order to change PA behavior. (Pagoto &
Bennett, 2013)
o
Which one is most effective to impact change?
• Purpose of the study by Lyons et al. (2014)
1. Characterize behavior change techniques used in
trackers
2. Determine the extent to which they include
techniques associated with successful outcomes
3. Compare implementation of several critical
techniques to theory-based and evidence-based
recommendation
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What is a behavior change technique?
Higher category
Technique
Description
Goals &
planning
Goal-setting (behavior)
Set or agree on a goal defined in
terms of the behavior to be achieved
Action planning
Prompt detailed planning of
performance of the behavior
Commitment
Ask the person to affirm or reaffirm
statements indicating commitment
to change the behavior
Feedback on behavior
Monitor and provide informative or
evaluative feedback on performance
of the behavior
Feedback &
monitoring
Self-monitoring of behavior Establish a method for the person to
monitor and record their behavior(s)
as part of a behavior change strategy
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Michie et al., 2013 (http://www.ucl.ac.uk/healthpsychology/bcttaxonomy)
Lyons et al. (2014)—Methods
•
•
Evaluated 13 wearable activity trackers.
o
Sources: CNET reviews, “Health and Fitness” section of the Apple
Store, “Activity Monitor” search on Amazon, and suggestion from
expert colleagues.
o
Monitors: Basis B1, BodyMedia Fit, Fitbit Force, Fitbug Orb,
Gruve, Ibitz Unity, Jawbone Up24, Lumo Back, Misfit Shine, Nike
FuelbandSE, POLAR Loop, Striiv Play, and Withings Pulse.
Inclusion criteria:
1. Continuous monitoring of some kind of physical activity
outcome
2. Recent iteration of similar series of products by the same
company
3. Provide feedback through mobile device or personal computer
Department of Nutrition and Metabolism
Lyons et al. (2014)—Methods
(Cont.)
•
Coding procedure done based on the taxonomies of behavior
change techniques by Michie et al (2013).
o
Tentative list of 16 behavioral change techniques impactful
behavior change techniques on changing PA behavior was
developed.
•
Meta-analyses
•
Meta-regressions
•
Systematic reviews
•
U.S. Preventive Services Task Force
•
2 Coders wore each of the monitors and used the apps for at least 1
week between 11/2013 and 2/2014.
•
Coding was based on full access to all behavioral tools (including the
paid options)
Department of Nutrition and Metabolism
List of BCT associated with PA (Part
1)
BCT #
Behavior Change Techniques (BCT)
8.1
Prompt practice
2.3
Prompt self-monitoring of behavior
1.1
Goal-setting/intention formation
1.2
Barrier identification/problem solving
2.2
Provide feedback on performance
1.5
Prompt review of behavior goals
5.1
Provide information on consequences of behavior in
general
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Lyons et al. 2014
List of BCT associated with PA (Part
2)
BCT #
Behavior Change Techniques
1.4
Action planning
10.3
Prompt rewards contingent on effort or progress
towards behavior
6.2
Facilitate social comparison
4.1
Provide instruction
15.4
Self-talk
10.9
Self-rewards
3
Social support
7.1
Teach to use prompts/cues
Department of Nutrition and Metabolism
Lyons et al. 2014
Lyons et al. (2014)—Results
•
6 behavior change techniques in >76% (10/13 to
13/13) of the wearable activity trackers’ apps.
BCT category
BCT
# of Monitors
Goals & Planning
Goal setting (behavior)
13
Review behavior goal(s)
10
Discrepancy between current
behavior and goal
13
Feedback on behavior
13
Self-monitoring of behavior
13
Adding objects to the environment
13
Feedback & Monitoring
Antecedents
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Goal-setting (behavior) & Feedback
Institute for Translational Sciences
Self-monitoring of PA behavior
Lyons et al. (2014)—Results (Cont.)
•
6 additional behavior change techniques in >60%
(8/13) of the wearable activity trackers’ apps:
BCT category
BCT
# of Monitors
Goals & Planning
Goal setting (outcome)
8
Feedback & Monitoring
Self-monitoring of outcome(s) of
behavior
8
Feedback on outcome(s) of behavior
8
Social support
Social support (unspecified)
8
Comparison of behavior
Social comparison
8
Reward and threat
Social reward
8
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Lyons et al. 2014
Goal-setting (outcome) & Social Support
Institute for Translational Sciences
Lyons et al. (2014)—Results (Cont.)
• Rare/Missing behavior change
techniques/alternative presentation:
o Rare: Information about consequences of the
behavior, action planning, and problem solving
o Missing: Prompting practice, self-rewards,
and self-talk
Department of Nutrition and Metabolism
Lyons et al. 2014
Action planning & problem-solving
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Theory-based recommendations
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Top 3 monitors’ apps with the most
techniques coded (Appendix 2)
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Lyons et al. 2014
Top 3 monitors’ apps with the most
techniques coded (Cont.)
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Lyons et al. 2014
Conclusion
•
Apps interfaced with the wearable activity trackers
incorporated into this review included a variety of evidencebased behavior change techniques. Many also conform to
theory-based recommendations.
•
Most commonly found techniques are:
o Self-monitoring
o Feedback provision
o Adding objects to the environment
o Goal-setting
•
Be aware of missing techniques such as prompting practice,
self-reward, and self-talk.
Department of Nutrition and Metabolism
Recommendations
•
Conduct a mini trial prior to full-scale implementation.
o Apps are being updated constantly.
•
Example: Contents within several apps were
changed within 6 months of manuscript submission.
Lyons et al. had to re-code and update the results.
•
Familiarize yourselves with the location and the display of
various options within the apps.
•
Familiarize yourselves with how the apps and the monitors
interact.
•
Keep track of what behavior change techniques participants
are using during the intervention.
Department of Nutrition and Metabolism
Acknowledgements and thanks
Mentors & collaborators
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Tom Baranowski (BCM)
Karen Basen-Engquist (MDA)
Abbey Berenson
Jim Goodwin
Koyya Lewis-Powell
Eloisa Martinez
Sara Nowakowski
Ken Ottenbacher
Jennifer Rowland
Maria Swartz
Elena Volpi
Department of Nutrition and Metabolism
Funding
• ACS (MRSG-14-165-01-CPPB)
• AHA (13BGIA17110021)
• NIH CTSA (UL1RR029876)
• NIH Pepper OAIC (P30AG024832)
Happy Chinese New Year!