Understanding persuasion contexts in health gamification: A systematic analysis of gamified health behavior change support systems literature

Smartwatch-Based Tailored Gamification and User Modeling for Motivating Physical Exercise: Experimental Study With the Maximum Difference Scaling Segmentation Method

BACKGROUND

Smartwatch-based gamification holds great promise for enhancing fitness apps and promoting physical exercise; however, empirical evidence on its effectiveness remains inconclusive, partly due to "one-size-fits-all" design approaches that overlook individual differences. While the emerging research area of tailored gamification calls for more accurate user modeling and better customization of game elements, existing studies have relied primarily on rating scale-based measures and correlational analyses with methodological limitations.

OBJECTIVE

This study aimed to improve smartwatch-based gamification through an innovative user modeling approach to better motivate physical exercise among different user groups with tailored solutions. It incorporated both individual preferences and needs for game elements into the user segmentation process and used the maximum difference scaling (MaxDiff) technique, which can overcome the limitations of traditional methods.

METHODS

With data collected from 2 MaxDiff experiments involving 378 smartwatch users and latent class statistical models, the relative power of each of the 16 popular game elements was examined in terms of what users liked and what motivated them to exercise based on which distinct user segments were identified. Prediction models were also proposed for quickly classifying future users into the right segments to provide them with tailored gamification solutions on smartwatch fitness apps.

RESULTS

We identified 3 segments of smartwatch users based on their preferences for gamification. More importantly, we uncovered 4 segments motivated by goals, immersive experiences, rewards, or social comparison. Such user heterogeneity confirmed the susceptibility of the effects of gamification and indicated the necessity of accurately matching gamified solutions with user characteristics to better change health behaviors through different mechanisms for different targets. Important differences were also observed between the 2 sets of user segments (ie, those based on preferences for game elements vs those based on the motivational effects of the elements), indicating the gap between what people enjoy using on smartwatches and what can motivate them for physical exercise engagement.

CONCLUSIONS

To our knowledge, this study is the first to investigate MaxDiff-based user segmentation for tailored gamification on smartwatches promoting physical exercise and contributes to a detailed understanding of preferences for, and the effectiveness of, different game elements among different groups of smartwatch users. As existing tailored gamification studies continue to explore ways of user modeling with mostly surveys and questionnaires, this study supported the adoption of MaxDiff experiments as an alternative method to better capture user heterogeneity in the health domain and inform the design of tailored solutions for more application types beyond smartphones.

Gamified Mobile Health Strategies for Promoting Physical Activity in Autistic Adults

Physical inactivity and sedentarism among autistic adults are a growing public health concern. By integrating behavior change theories and emphasizing unique preferences for visuospatial learning and gaming technology, we hypothesize that gamified mobile health (mHealth) applications can be effective at increasing free-living physical activity and reducing sedentary behavior in autistic adults.

Gamify to persuade: A systematic review of gamified sustainable mobility

The increasing need to address climate change has intensified efforts to promote green transportation options, such as cycling and public transit. Over the past few decades, gamification-the integration of game-like elements into non-game contexts to motivate and engage people in adopting new behaviors-has emerged as a strategy to encourage the use of sustainable transportation. This literature review examines how gamification has been used to drive the adoption of green transportation. Following the PRISMA methodology, 49 documents were initially screened, leading to a final selection of 14 papers. We analyze the stakeholders involved, the game elements, the external rewards (e.g., financial incentives), and persuasive strategies employed, and the overall effectiveness of these initiatives both in the short and in the long term. We also explore the relationship between game elements and persuasive approaches, offering insights into how they are related. Finally, we propose a research agenda that emphasizes the exploration of different game elements and the need for a multidisciplinary approach to designing gameful systems that promote sustainable behaviors.

Facilitating Thought Progression to Reduce Depressive Symptoms: Randomized Controlled Trial

BACKGROUND

The constant rise in the prevalence of major depressive disorder calls for new, effective, and accessible interventions that can rapidly and effectively reach a wide range of audiences. Recent developments in the digital health domain suggest that dedicated online platforms may potentially address this gap. Focusing on targeting ruminative thought, a major symptomatic hallmark of depression, in this study we hypothesized that delivering a digital health-based intervention designed to systematically facilitate thought progression would substantially alleviate depression.

OBJECTIVE

The study aims to investigate the efficacy of a novel digital intervention on the reduction of depressive symptoms. This intervention was designed as an easy-to-use gamified app specifically aimed to facilitate thought progression through intense practicing of associative, semantically broad, fast, and creative thought patterns.

METHODS

A randomized clinical trial was conducted, comparing changes in depression symptoms between participants who used the app in the intervention group (n=74) and waitlist control group (n=27) over the course of 8 weeks. All participants filled out a battery of clinical questionnaires to assess the severity of depression at baseline and 4 and 8 weeks after starting the study. These primarily included the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 as well as the Positive Affect Negative Affect Scale-Negative Affect Score, Ruminative Response Scale, and Symptoms of Depression Questionnaire. Additional questionnaires were implemented to assess anxiety, positive affect, anhedonia, and quality of life.

RESULTS

The results indicate that across multiple clinical measurements, participants in the intervention group who played the gamified app showed greater and faster improvement in depressive symptoms compared with their waitlist control counterparts. The difference between the groups in MADRS improvement was -7.01 points (95% CI -10.72 to -3.29; P<.001; Cohen d=0.67). Furthermore, the difference in improvement between groups persisted up to 4 weeks posttrial (MADRS differences at week 12: F49,2=6.62; P=.003; ηp2=0.21). At the end of the trial, participants who played the app showed high interest in continuing using the app.

CONCLUSIONS

The results demonstrate that a gamified app designed to facilitate thought progression is associated with improvement in depressive symptoms. Given its innovative and accessibility features, this gamified method aiming to facilitate thought progression may successfully complement traditional treatments for depression in the future, providing a safe and impactful way to enhance the lives of individuals experiencing depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05685758; https://clinicaltrials.gov/study/NCT05685758.

A Virtual Reality Serious Game for the Rehabilitation of Hand and Finger Function: Iterative Development and Suitability Study

BACKGROUND

Restoring hand and finger function after a traumatic hand injury necessitates a regimen of consistent and conscientious exercise. However, motivation frequently wanes due to unchallenging repetitive tasks or discomfort, causing exercises to be performed carelessly or avoided completely. Introducing gamification to these repetitive tasks can make them more appealing to patients, ultimately increasing their motivation to exercise consistently.

OBJECTIVE

This study aims to iteratively develop a serious virtual reality game for hand and finger rehabilitation within an appealing and engaging digital environment, encouraging patient motivation for at least 2 weeks of continuous therapy.

METHODS

The development process comprised 3 distinct stages, each of which was subject to evaluation. Initially, a prototype was created to encompass the game's core functionalities, which was assessed by 18 healthy participants and 7 patients with impaired hand function. Subsequently, version 1 of the game was developed and evaluated with 20 patients who were divided into an investigation group and a control group. On the basis of these findings, version 2 was developed and evaluated with 20 patients who were divided into an investigation group and a control group. Motivation was assessed using the Intrinsic Motivation Inventory (IMI), while the application's quality was rated using the Mobile Application Rating Scale and the System Usability Scale. User feedback was gathered using semistructured interviews.

RESULTS

The prototype evaluation confirmed the acceptance and feasibility of the game design. Version 1 significantly increased motivation in 2 IMI subscales, effort (P<.001) and usefulness (P=.02). In version 2, a significant increase in daily performed exercises was achieved (P=.008) compared to version 1, with significantly higher motivation in the IMI subscale effort (P=.02). High Mobile Application Rating Scale scores were obtained for both versions 1 and 2, with version 2 scoring 86.9 on the System Usability Scale, indicating excellent acceptability. User feedback provided by the semistructured interviews was instrumental in the iterative development regarding improvements and the expansion of the playable content.

CONCLUSIONS

This study presented a virtual reality serious game designed for hand and finger rehabilitation. The game was well received and provided an environment that effectively motivated the users. The iterative development process incorporated user feedback, confirming the game's ease of use and feasibility even for patients with severely limited hand function.

N-of-1 health optimization: Digital monitoring of biomarker dynamics to gamify adherence to metabolic switching

The digital health field is experiencing substantial growth due to its potential for sustained and longitudinal deployment. In turn, this may drive improved monitoring and intervention as catalysts for behavioral change compared to traditional point-of-care practices. In particular, the increase in incidence of population health challenges such as diabetes, heart disease, fatty liver disease, and other disorders coupled with rising healthcare costs have emphasized the importance of exploring technical, economics, and implementation considerations, among others in the decentralization of health and healthcare innovations. Both healthy individuals and patients stand to benefit from continued technical advances and studies in these domains. To address these points, this study reports a N-of-1 study comprised of sustained regimens of intermittent fasting, fitness (strength and cardiovascular training), and high protein, low carbohydrate diet and parallel monitoring. These regimens were paired with serial blood ketone, blood glucose (wearable and finger stick) and blood pressure readings, as well as body weight measurements using a collection of devices. Collectively this suite of platforms and approaches were used to monitor metabolic switching from glucose to ketones as energy sources-a process associated with potential cardio- and neuroprotective functions. In addition to longitudinal biomarker dynamics, this work discusses user perspectives on the potential role of harnessing digital devices to these dynamics as potential gamification factors, as well as considerations for the role of biomarker monitoring in health regimen development, user stratification, and potentially informing downstream population-scale studies to address metabolic disease, healthy aging and longevity, among other indications.

Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study

BACKGROUND

Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission.

OBJECTIVE

In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change.

METHODS

As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot's optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants' water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day.

RESULTS

A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P≥.17 in all cases).

CONCLUSIONS

Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective.

TRIAL REGISTRATION

Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8.

Review on Emerging Therapeutic Strategies for Managing Cardiovascular Disease

Cardiovascular disease (CVD) remains a foremost global health concern, necessitating ongoing exploration of innovative therapeutic strategies. This review surveys the latest developments in cardiovascular therapeutics, offering a comprehensive overview of emerging approaches poised to transform disease management. The examination begins by elucidating the current epidemiological landscape of CVD and the economic challenges it poses to healthcare systems. It proceeds to scrutinize the limitations of traditional therapies, emphasizing the need for progressive interventions. The core focus is on novel pharmacological interventions, including advancements in drug development, targeted therapies, and repurposing existing medications. The burgeoning field of gene therapy and its potential in addressing genetic predispositions to cardiovascular disorders are explored, alongside the integration of artificial intelligence and machine learning in risk assessment and treatment optimization. Non-pharmacological interventions take center stage, with an exploration of digital health technologies, wearable devices, and telemedicine as transformative tools in CVD management. Regenerative medicine and stem cell therapies, offering promises of tissue repair and functional recovery, are investigated for their potential impact on cardiac health. This review also delves into the interplay of lifestyle modifications, diet, exercise, and behavioral changes, emphasizing their pivotal role in cardiovascular health and disease prevention. As precision medicine gains prominence, this synthesis of emerging therapeutic modalities aims to guide clinicians and researchers in navigating the dynamic landscape of cardiovascular disease management, fostering a collective effort to alleviate the global burden of CVD and promote a healthier future.

Diabetes and hypertension MobileHealth systems: a review of general challenges and advancements

Mobile health (mHealth) systems are sipping into more and more healthcare functions with self-management being the foremost modus operandi. However, there has been challenges. This study explores challenges with mHealth self-management of diabetes and hypertension, two of the most comorbid chronic diseases. Existing literature present the challenges in fragments, certain subsets of the challenges at a time. Nevertheless, feedback from patient/users in extant literature depict very variegated concerns that are also interdependent. This work pursues provision of an encyclopedic, but not redundant, view of the challenges with mHealth systems for self-management of diabetes and hypertension.

Furthermore, the work identifies machine learning (ML) and self-management approaches as potential drivers of potency of diabetes and hypertension mobile health systems. The nexus between ML and diabetes and hypertension mHealth systems was found to be under-explored. For ML contributions to management of diabetes, we found that machine learning has been applied most to diabetes prediction followed by diagnosis, with therapy in distant third. For diabetes therapy research, only physical and dietary therapy were emphasized in reviewed literature. The four most considered performance metrics were accuracy, ROC-AUC, sensitivity, and specificity. Random forest was the best performing algorithm across all metrics, for all purposes covered in the literature. For hypertension, in descending order, hypertension prediction, prediction of risk factors, and prediction of prehypertension were most considered areas of hypertension management witnessing application of machine learning. SVM averaged best ML algorithm in accuracy and sensitivity, while random forest averaged best performing in specificity and ROC-AUC.

Effects of a Gamified Agent-Based System for Personalized Elderly Care: Pilot Usability Study

BACKGROUND

The global percentage of older people has increased significantly over the last decades. Information and communication technologies have become essential to develop and motivate them to pursue healthier ways of living. This paper examines a personalized coaching health care service designed to maintain living conditions and active aging among older people. Among the technologies the service includes, we highlight the use of both gamification and cognitive assistant technologies designed to support older people and an application combining a cognitive virtual assistant to directly interact with the older person and provide feedback on their current health condition and several gamification techniques to motivate the older person to stay engaged with the application and pursuit of healthier daily habits.

OBJECTIVE

This pilot study aimed to investigate the feasibility and usability of a gamified agent-based system for older people and obtain preliminary results on the effectiveness of the intervention regarding physical activity health outcomes.

METHODS

The study was designed as an intervention study comparing pre- and posttest results. The proposed gamified agent-based system was used by 12 participants over 7 days (1 week), and step count data were collected with access to the Google Fit application programming interface. Step count data after the intervention were compared with average step count data before the intervention (average daily values over a period of 4 weeks before the intervention). A　1-tailed Student t test was used to determine the relationship between the dependent and independent variables. Usability was measured using the System Usability Scale questionnaire, which was answered by 8 of the 12 participants in the study.

RESULTS

The posttest results showed significant pre- to posttest changes (P=.30; 1-tailed Student t test) with a moderate effect size (Cohen d=0.65). The application obtained an average usability score of 78.

CONCLUSIONS

The presented pilot was validated, showing the positive health effects of using gamification techniques and a virtual cognitive assistant. Additionally, usability metrics considered for this study confirmed high adherence and interest from most participants in the pilot.

A Systematic Review of Evidence-Based High School Melanoma Prevention Curricula

Incorporation of melanoma prevention behaviors into daily lifestyles is difficult. Data suggest that high school educational programs on skin cancer prevention can be successful and should incorporate evidence-based teaching and learning strategies to achieve greatest impact. The goal of this systematic review is to describe evidence-based educational practices for a high-school melanoma curriculum through a comprehensive review of the literature. Ovid MEDLINE, Embase, CINAHL, and PyscINFO were searched in June 2020 for all original articles published between June 18, 1946 and June 17, 2020. All studies that used an educational curriculum to promote sun safety, skin exams, and early detection to high school students were included. A total of 25 studies with 22,683 adolescent participants were analyzed. Sixteen studies showed a significant increase in knowledge, twenty-one studies showed changes in behavior, and fifteen studies showed significant changes in attitudes. Limitations of this review include the heterogeneity of implementation and outcome reporting of educational curricula. These findings support incorporating active learning strategies as key aspects of creating an effective curriculum aimed at the prevention and early detection of melanoma.

A Software Engineering Framework for Reusable Design of Personalized Serious Games for Health: Development Study

BACKGROUND

The use of serious games in health care is on the rise, as these games motivate treatment adherence, reduce treatment costs, and educate patients and families. However, current serious games fail to offer personalized interventions, ignoring the need to abandon the one-size-fits-all approach. Moreover, these games, with a primary objective other than pure entertainment, are costly and complex to develop and require the constant involvement of a multidisciplinary team. No standardized approach exists on how serious games can be personalized, as existing literature focuses on specific use cases and scenarios. The serious game development domain fails to consider any transfer of domain knowledge, which means this labor-intensive process must be repeated for each serious game.

OBJECTIVE

We proposed a software engineering framework that aims to streamline the multidisciplinary design process of personalized serious games in health care and facilitates the reuse of domain knowledge and personalization algorithms. By focusing on the transfer of knowledge to new serious games by reusing components and personalization algorithms, the comparison and evaluation of different personalization strategies can be simplified and expedited. In doing so, the first steps are taken in advancing the state of the art of knowledge regarding personalized serious games in health care.

METHODS

The proposed framework aimed to answer 3 questions that need to be asked when designing personalized serious games: Why is the game personalized? What parameters can be used for personalization? and How is the personalization achieved? The 3 involved stakeholders, namely, the domain expert, the (game) developer, and the software engineer, were each assigned a question and then assigned responsibilities regarding the design of the personalized serious game. The (game) developer was responsible for all the game-related components; the domain expert was in charge of the modeling of the domain knowledge using simple or complex concepts (eg, ontologies); and the software engineer managed the personalization algorithms or models integrated into the system. The framework acted as an intermediate step between game conceptualization and implementation; it was illustrated by developing and evaluating a proof of concept.

RESULTS

The proof of concept, a serious game for shoulder rehabilitation, was evaluated using simulations of heart rate and game scores to assess how personalization was achieved and whether the framework responded as expected. The simulations indicated the value of both real-time and offline personalization. The proof of concept illustrated how the interaction between different components worked and how the framework was used to simplify the design process.

CONCLUSIONS

The proposed framework for personalized serious games in health care identifies the responsibilities of the involved stakeholders in the design process, using 3 key questions for personalization. The framework focuses on the transferability of knowledge and reusability of personalization algorithms to simplify the design process of personalized serious games.

Dynamic assessment of the upper extremity: a review of available and emerging technologies

The purpose of this review article is to provide an update on the realm of emerging technology available for the assessment of dynamic functional movement of the hand and upper limb. A critical overview of the literature and a conceptual framework for use of such technologies is proposed. The framework explores three broad purpose categories including customization of care, functional surveillance and interventions through biofeedback strategies. State-of-the-art technologies are described, from basic activity monitors to feedback-enabled robotic gloves, along with exemplar trials and clinical applications. The future of technologies innovation in hand pathology is proposed in the context of the current obstacles and opportunities for hand surgeons and therapists.

Development of an mHealth Platform for Adolescent Obesity Prevention: User-Centered Design Approach

Obesity is a chronic condition that influences the quality of life of patients and families while increasing the economic burden for the world population. Multidisciplinary prevention programs are crucial to address it, allowing an early introduction of healthy behaviors into daily habits. Mobile health interventions provide adequate support for these programs, especially considering the gamification techniques used to promote users' engagement. TeenPower is a multidisciplinary mHealth intervention program conducted in Portugal during 2018 to empower adolescents, promoting healthy behaviors while preventing obesity. An agile software development process was applied to the development of the digital platform that holds a web-based application and a mobile application. We also propose a model for future developments based on the user-centered design approach adopted for this development and the assessment conducted in each phase. The user-centered design approach model proposed has three distinct phases: (1) design study; (2) pre-production usability tests; and (3) post-production data. Phase 1 allowed us to obtain the high-fidelity version of the graphical user interfaces (n = 5). Phase 2 showed a task completion success rate of 100% (n = 5). Phase 3 was derived from statistical analysis of the usage of the platform by real end users (n = 90). We achieved an average retention rate of 35% (31 out of 90 participants). Each technique has provided input for the continuous design and improvement of the platform. This allowed the creation of a tailored platform that could meet users' expectations. Nevertheless, the retention rate decreased significantly over a short period of time, revealing the need for further work in the improvement of the gamification experience.

The Effects of Sensory Cues on Immersive Experiences for Fostering Technology-Assisted Sustainable Behavior: A Systematic Review

Games are consistently acknowledged as a powerful approach that can significantly impact people’s behavior towards living in a sustainable way. Sensory cues are regarded as influential factors in facilitating immersive experiences in gamified applications to foster sustainable behavior. As our perception of an environment is influenced not only by what we can see but also by additional sensory input such as sound and touch, additional sensory information can be part of the participant’s experience. This study systematically scrutinized game-based applications containing sensory cues to interpret current technology-assisted sustainable behavior development. This study provides a review of the impact of the sensory signals offered by video games, virtual reality, and augmented reality on pro-environmental behavioral intention. This research found that human senses can change the perception of immersion in multiple ways: visual (dimensions, angles, color), auditory (music, dialogue), and haptic, and these can affect sustainable behavior. Thus, we argue that multiple sensory modalities provide more opportunities to influence users to act sustainably. Based on the results, the theoretical contribution of this paper emphasizes the level of immersion, which is closely related to various sensory perceptions, and explains the correlation between them. In terms of industrial applications, it provides game designers, developers of VR and AR applications, and planners of sustainable education guidelines for the adoption of immersive scenarios.

Effects of a Gamified, Behavior Change Technique-Based Mobile App on Increasing Physical Activity and Reducing Anxiety in Adults With Autism Spectrum Disorder: Feasibility Randomized Controlled Trial

BACKGROUND

Physical activity (PA) has an impact on physical and mental health in neurotypical populations, and addressing these variables may improve the prevalent burden of anxiety in adults with autism spectrum disorder (ASD). Gamified mobile apps using behavior change techniques present a promising way of increasing PA and reducing sedentary time, thus reducing anxiety in adults with ASD.

OBJECTIVE

This study aimed to compare the effectiveness of a gamified and behavior change technique-based mobile app, PuzzleWalk, versus a commercially available app, Google Fit, on increasing PA and reducing sedentary time as an adjunct anxiety treatment for this population.

METHODS

A total of 24 adults with ASD were assigned to either the PuzzleWalk or Google Fit group for 5 weeks using a covariate-adaptive randomization design. PA and anxiety were assessed over 7 days at 3 different data collection periods (ie, baseline, intervention start, and intervention end) using triaxial accelerometers and the Beck Anxiety Inventory. Group differences in outcome variables were assessed using repeated-measures analysis of covariance, adjusting for age, sex, and BMI.

RESULTS

The findings indicated that the PuzzleWalk group spent a significantly longer amount of time on app use compared with the Google Fit group (F2,38=5.07; P=.01; partial η2=0.21), whereas anxiety was unfavorably associated with increases in light PA and decreases in sedentary time after intervention (all P<.05).

CONCLUSIONS

Further research is needed to clarify the determinants of physical and mental health and their interrelationship in adults with ASD to identify the factors that facilitate the use and adoption of mobile health technologies in these individuals. Despite these mixed results, the small changes in PA or anxiety may be clinically significant for adults with ASD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05466617; https://clinicaltrials.gov/show/NCT05466617.

Big data analyses and individual health profiling in the arena of rheumatic and musculoskeletal diseases (RMDs)

Health care processes are under constant development and will need to embrace advances in technology and health science aiming to provide optimal care. Considering the perspective of increasing treatment options for people with rheumatic and musculoskeletal diseases, but in many cases not reaching all treatment targets that matter to patients, care systems bare potential to improve on a holistic level. This review provides an overview of systems and technologies under evaluation over the past years that show potential to impact diagnosis and treatment of rheumatic diseases in about 10 years from now. We summarize initiatives and studies from the field of electronic health records, biobanking, remote monitoring, and artificial intelligence. The combination and implementation of these opportunities in daily clinical care will be key for a new era in care of our patients. This aims to inform rheumatologists and healthcare providers concerned with chronic inflammatory musculoskeletal conditions about current important and promising developments in science that might substantially impact the management processes of rheumatic diseases in the 2030s.

An overview of literature on COVID-19, MERS and SARS: Using text mining and latent Dirichlet allocation

The unprecedented outbreak of COVID-19 is one of the most serious global threats to public health in this century. During this crisis, specialists in information science could play key roles to support the efforts of scientists in the health and medical community for combatting COVID-19. In this article, we demonstrate that information specialists can support health and medical community by applying text mining technique with latent Dirichlet allocation procedure to perform an overview of a mass of coronavirus literature. This overview presents the generic research themes of the coronavirus diseases: COVID-19, MERS and SARS, reveals the representative literature per main research theme and displays a network visualisation to explore the overlapping, similarity and difference among these themes. The overview can help the health and medical communities to extract useful information and interrelationships from coronavirus-related studies.

APLICAÇÕES DA PERSUASÃO PARA OTIMIZAÇÃO DE CAMPANHAS NA SAÚDE: UMA REVISÃO

Apesar da persuasão estar presente de forma natural na comunicação humana, o seu uso adequado parece estar ausente nas campanhas de conscientização na saúde, como é evidenciado pela disparidade entre a frequência de certas campanhas e a diminuição dos comportamentos associados a ela. Nesse sentido, o objetivo do estudo foi realizar uma revisão de literatura acerca dos tipos de persuasão empregados na saúde, sua eficácia, e contextos de aplicação mais adequados. Foram considerados trabalhos em português ou inglês, publicados nos últimos cinco anos nas plataformas BVS, PubMed e Scielo, sendo selecionado o total de 38 artigos que foram divididos por estratégia de persuasão ou o tipo de questão abordada (alimentação, doenças, drogas, exercício, vacinação e outros). Os resultados indicaram que no geral, as estratégias persuasivas obtiveram eficácia em alcançar seus objetivos, sendo o maior desafio a adequação na escolha das estratégias ao tipo de questão abordada pela campanha. Portanto, é concluído que pensar na forma de persuadir o público-alvo é um tema pertinente para otimizar as campanhas de saúde, devendo ser um aspecto considerado no futuro.

The role of informational feedback as a game mechanic on user perceptions, attitudes and the intention to continue using a gamified Health Behaviour Change Support System

Gamification's widespread application across industries has demonstrated its usefulness as a user engagement strategy. In the healthcare sector, the impact of lifestyle diseases has seen the need for modifying health-related behaviours. Health Behaviour Change Support Systems (HBCSS) enhanced with gamification features seek to help users achieve their health related goals. Adapting the Technology Acceptance Model, the role of informational feedback as a game mechanic in influencing perceptions, attitudes and continued usage intentions towards the gamified HBCSS is assessed. The results show a strong influence of attitude towards informational feedback afforded on the continued use intentions of the user.

A Rationale for a Gamified E-Coach Application to Decrease the Consumption of Sugar Sweetened Beverages

The design and implementation of applications for behavior change should be preceded by careful analysis of the behavior change process and the target population. We, therefore, present on the basis of a blended research approach a rationale, opportunities and basic requirements for an application that offers a program for reducing intake of sugar sweetened beverages (SSB) by adolescents. This paper discusses the role of e-coaching and gamification as two high-touch design patterns in the behavior change process. Both design patterns aim at supporting the individual in a transformational journey from a current state toward a desired state where the detrimental behavior should be replaced by healthy alternative behavior. First, an elementary behavior scheme is introduced that frames three empirical studies. In the first study (plenary focus groups; n = 13), participants advised to include system recommendations for alternative healthy behavior, stressed the need for personalization of the e-coach and showed strong appreciation for the inclusion of gamification elements. The second study (online survey; n = 249) showed that SSB-intake is highly contextual and that reasons for (limiting) consumption SSB varies greatly between individuals, which the e-coach application should take into account. In a final small-scale pilot study (n = 27), we observed the potential of the inclusion of gamification elements, such as challenges and rewards, to increase compliance to the self-monitoring process of SSB consumption. Building upon these insights and prior studies, we argue that an e-coach mimics the collaborative practice of the program; its main task is to enrich the interaction with cooperative conversational experiences, in particular with respect to the alignment between user and system, motivational encouragement, personalized advice, and feedback about the activities. In addition, we outline that gamification not only has the potential to increase self-monitoring of the target behavior, user engagement, and commitment with the intervention program, but also enables a designer to shift long-term negative outcome of excessive intake in real life to short-term consequences in a virtual environment. In future larger follow-up studies, we advise to integrate the two design patterns within a social network of virtual and human agents that play a variety of competitive, normative and supportive roles.

Investigating the Influence of Personalised Gamification on Mobile Survey User Experience

Gamification in healthcare has shown to increase user motivation and treatment adherence. Personalisation strategies have the potential to create sustainable health change and user motivation. In striving for personalisation, surveys are often used as an easy tool to collect information about the user. But lengthy surveys are often tedious and demotivating, provoking bad respondent behaviour which results in a loss of data quality. Gamified surveys can enhance respondent behaviour but are labour-intensive to develop. This study explores the effect of a re-usable mobile survey application, using personalised gamification, on user experience. In an A/B study setting with 28 participants, The Hexad Player Type Framework is used to determine the player type of the user and personalise the survey accordingly. Results have shown that the overall user experience of the gamified application is higher than the traditional survey and 37.5% of gamified users perceived the duration of the survey as shorter than the actual time, compared to 20% of the respondents of the traditional survey. No significant difference in data quality has been detected, as loss in data quality remained limited in both versions. Future work should explore the influence of more elaborate game elements in a larger population.

Short and Long-Term Innovations on Dietary Behavior Assessment and Coaching: Present Efforts and Vision of the Pride and Prejudice Consortium

Overweight, obesity and cardiometabolic diseases are major global health concerns. Lifestyle factors, including diet, have been acknowledged to play a key role in the solution of these health risks. However, as shown by numerous studies, and in clinical practice, it is extremely challenging to quantify dietary behaviors as well as influencing them via dietary interventions. As shown by the limited success of 'one-size-fits-all' nutritional campaigns catered to an entire population or subpopulation, the need for more personalized coaching approaches is evident. New technology-based innovations provide opportunities to further improve the accuracy of dietary assessment and develop approaches to coach individuals towards healthier dietary behaviors. Pride & Prejudice (P&P) is a unique multi-disciplinary consortium consisting of researchers in life, nutrition, ICT, design, behavioral and social sciences from all four Dutch Universities of Technology. P&P focuses on the development and integration of innovative technological techniques such as artificial intelligence (AI), machine learning, conversational agents, behavior change theory and personalized coaching to improve current practices and establish lasting dietary behavior change.

Removable retention: enhancing adherence and the remit of shared decision-making

Patient adherence to removable retainer wear is integral to the long-term success of retention regimes. We discuss the factors influencing removable retainer wear, the methods of gauging wear levels, approaches to enhance adherence and the quality of online available information concerning retention. The potential value of patient involvement in approaches to retention within a shared decision-making framework and motivational interviewing are also highlighted.

Knowledge Gaps in Mobile Health Research for Promoting Physical Activity in Adults With Autism Spectrum Disorder

A growing body of research highlights that adults with autism spectrum disorder (ASD) have poor health outcomes, yet effective health interventions are lacking for this population. While mobile health applications demonstrate potential for promoting physical activity (PA) in adults with ASD, scientific evidence for supporting this tool’s long-term effectiveness on PA behavior change remains inconclusive. This study aimed to provide the latest information on PA research and the prospective role of mobile health applications for promoting PA in adults with ASD. A literature review demonstrated that a few available studies show contradictory results regarding PA levels in adults with ASD, and behavior change techniques and gamification-guided mobile health applications can be promising tactics to leverage autism’s strengths and increase PA in these individuals. Optimizing design decisions based on needs analysis and user feedback is crucial to identifying and developing a sustainable mobile health intervention for PA promotion in adults with ASD.

Game Experience and Learning Effects of a Scoring-Based Mechanic for Logistical Aspects of Pediatric Emergency Medicine: Development and Feasibility Study

Background

Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals.

Objective

This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure.

Methods

First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment.

Results

A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR² of 0.796 (F1_4,31=2725.49, P<.001) for the board version and 0.702 (F2_4,31=2635.31, P<.001) for the multiplayer online version after the learning engagement attributes.

Conclusions

The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used.

Promoting Occupational Health through Gamification and E-Coaching: A 5-Month User Engagement Study

Social gamification systems have shown potential for promoting healthy lifestyles, but applying them to occupational settings faces unique design challenges. While occupational settings offer natural communities for social interaction, fairness issues due to heterogeneous personal goals and privacy concerns increase the difficulty of designing engaging games. We explored a two-level game-design, where the first level related to achieving personal goals and the second level was a privacy-protected social competition to maximize goal compliance among colleagues. The solution was strengthened by employing occupational physicians who personalized users' goals and coached them remotely. The design was evaluated in a 5-month study with 53 employees from a Dutch university. Results suggested that the application helped half of the participants to improve their lifestyles, and most appreciated the role of the physician in goal-setting. However, long-term user engagement was undermined by the scalability-motivated design choice of one-way communication between employees and their physician. Implications for social gamification design in occupational health are discussed.

Gamifying quantitative face-to-face interviews in rural India: An empirical evaluation based on the basic psychological needs theory

Objective

Standardized face-to-face interviews are widely used in low and middle-income countries to collect data for social science and health research. Such interviews can be long and tedious. In an attempt to improve the respondents’ experience of interviews, we developed a concept of gamified interview format by including a game element. Gamification is reported to increase engagement in tasks, but results from rigorously developed research are equivocal, and a theory of gamification is still needed.

Materials & methods

We evaluated the proposed gamification with a randomized controlled trial based on self-determination theory, specifically on the basic psychological needs theory. In total, 1266 respondents were interviewed. Single and multiple mediation analyses were used to understand the effects of the gamified interview format.

Results

Our evaluation showed that the gamification we had developed did not improve the outcome, the experience of the interview reported by respondent. The effect of the gamified interview format depended on the ability of respondents: gamification can be counterproductive if it overburdens the respondents. However, the basic psychological needs theory explained the mechanisms of action of gamification well: feeling competent and related to others improved the reported experience of the interview.

Conclusion

We emphasize the need to develop context-specific gamification and invite researchers to conduct equivalently rigorous evaluations of gamification in future studies.

Archetypes of Gamification: Analysis of mHealth Apps

BACKGROUND

Nowadays, numerous health-related mobile apps implement gamification in an attempt to draw on the motivational potential of video games and thereby increase user engagement or foster certain health behaviors. However, research on effective gamification is still in its infancy and researchers increasingly recognize methodological shortcomings of existing studies. What we actually know about the phenomenon today stems from fragmented pieces of knowledge, and a variety of different perspectives. Existing research primarily draws on conceptual knowledge that is gained from research prototypes, and isolated from industry best practices. We still lack knowledge on how gamification has been successfully designed and implemented within the industry and whether certain gamification approaches have shown to be particularly suitable for certain health behaviors.

OBJECTIVE

We address this lack of knowledge concerning best practices in the design and implementation of gamification for health-related mobile apps by identifying archetypes of gamification approaches that have emerged in pertinent health-related mobile apps and analyzing to what extent those gamification approaches are influenced by the underlying desired health-related outcomes.

METHODS

A 3-step research approach is employed. As a first step, a database of 143 pertinent gamified health-related mobile apps from the Apple App Store and Google Play Store is set up. Second, the gamification approach of each app within the database is classified based on an established taxonomy for gamification in health-related apps. Finally, a 2-step cluster analysis is conducted in order to identify archetypes of the most dominant gamification approaches in pertinent gamified health-related mobile apps.

RESULTS

Eight archetypes of gamification emerged from the analysis of health-related mobile apps: (1) competition and collaboration, (2) pursuing self-set goals without rewards, (3) episodical compliance tracking, (4) inherent gamification for external goals, (5) internal rewards for self-set goals, (6) continuous assistance through positive reinforcement, (7) positive and negative reinforcement without rewards, and (8) progressive gamification for health professionals. The results indicate a close relationship between the identified archetypes and the actual health behavior that is being targeted.

CONCLUSIONS

By unveiling salient best practices and discussing their relationship to targeted health behaviors, this study contributes to a more profound understanding of gamification in mobile health. The results can serve as a foundation for future research that advances the knowledge on how gamification may positively influence health behavior change and guide practitioners in the design and development of highly motivating and effective health-related mobile health apps.

PuzzleWalk: A theory-driven iterative design inquiry of a mobile game for promoting physical activity in adults with autism spectrum disorder

Primary symptoms of adults with autism spectrum disorder (ASD), such as pervasive social deficits in social interaction and communication, cause adults with ASD to adopt a sedentary lifestyle. Meanwhile, gamified and behavioral theory-based interventions have been shown to improve physical activity in a fun and unobtrusive way. In this paper, we describe the iterative design inquiry process of PuzzleWalk, a gamified, physical activity-promoting mobile app designed for adults with ASD. We report the design rationales and lessons learned across four user-centered design phases with ASD experts and adults with ASD, including user requirement gathering, iterative participatory design, usability evaluation, and field deployment. The design insights generated from this work could inform future research focusing on designing sociotechnical systems, games, and interventions for people with ASD.

Personality Traits, Gamification and Features to Develop an App to Reduce Physical Inactivity

Background: Health benefits from physical activity (PA) can be achieved by following the WHO recommendation for PA. To increase PA in inactive individuals, digital interventions can provide cost-effective and low-threshold access. Moreover, gamification elements can raise the motivation for PA. This study analyzed which factors (personality traits, app features, gamification) are relevant to increasing PA within this target group. Methods: N = 808 inactive participants (f = 480; m = 321; age = 48 ± 6) were integrated into the analysis of the desire for PA, the appearance of personality traits and resulting interest in app features and gamification. The statistical analysis included chi-squared tests, one-way ANOVA and regression analysis. Results: The main interests in PA were fitness (97%) and outdoor activities (75%). No significant interaction between personality traits, interest in PA goals, app features and gamification were found. The interest in gamification was determined by the PA goal. Participants’ requirements for features included feedback and suggestions for activities. Monetary incentives were reported as relevant gamification aspects. Conclusion: Inactive people can be reached by outdoor activities, interventions to increase an active lifestyle, fitness and health sports. The study highlighted the interest in specific app features and gamification to increase PA in inactive people through an app.

Exploring Features of the Pervasive Game Pokémon GO That Enable Behavior Change: Qualitative Study

Background

Digital gaming is one of the most popular forms of entertainment in the world. While prior literature concluded that digital games can enable changes in players’ behaviors, there is limited knowledge about different types of behavior changes and the game features driving them. Understanding behavior changes and the game features behind them is important because digital games can motivate players to change their behavior for the better (or worse).

Objective

This study investigates the types of behavior changes and their underlying game features within the context of the popular pervasive game Pokémon GO.

Methods

We collected data from 262 respondents with a critical incident technique (CIT) questionnaire. We analyzed the responses with applied thematic analysis with ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software.

Results

We discovered 8 types of behavior changes and 13 game features relevant to those behavior changes. The behavior changes included added activity in life, enhancing routines, exploration, increased physical activity, strengthening social bonds, lowering social barriers, increased positive emotional expression and self-treatment. The game features included reaching a higher level, catching new Pokémon, evolving new Pokémon, visiting PokéStops, exploring PokéStops, hatching eggs, fighting in gyms, collaborative fighting, exploiting special events, finding specific Pokémon, using items, Pokémon theme, and game location tied to physical location. The behavior changes were connected to specific game features, with game location tied to physical location and catching new Pokémon being the most common and connected to all behavior changes.

Conclusions

Our findings indicate that the surveyed players changed their behaviors while or after playing Pokémon GO. The respondents reported being more social, expressed more positive emotions, found more meaningfulness in their routines, and had increased motivation to explore their surroundings.

Incorporating Behavioral Trigger Messages Into a Mobile Health App for Chronic Disease Management: Randomized Clinical Feasibility Trial in Diabetes

Background

Although there is a rise in the use of mobile health (mHealth) tools to support chronic disease management, evidence derived from theory-driven design is lacking.

Objective

The objective of this study was to determine the impact of an mHealth app that incorporated theory-driven trigger messages. These messages took different forms following the Fogg behavior model (FBM) and targeted self-efficacy, knowledge, and self-care. We assess the feasibility of our app in modifying these behaviors in a pilot study involving individuals with diabetes.

Methods

The pilot randomized unblinded study comprised two cohorts recruited as employees from within a health care system. In total, 20 patients with type 2 diabetes were recruited for the study and a within-subjects design was utilized. Each participant interacted with an app called capABILITY. capABILITY and its affiliated trigger (text) messages integrate components from social cognitive theory (SCT), FBM, and persuasive technology into the interactive health communications framework. In this within-subjects design, participants interacted with the capABILITY app and received (or did not receive) text messages in alternative blocks. The capABILITY app alone was the control condition along with trigger messages including spark and facilitator messages. A repeated-measures analysis of variance (ANOVA) was used to compare adherence with behavioral measures and engagement with the mobile app across conditions. A paired sample t test was utilized on each health outcome to determine changes related to capABILITY intervention, as well as participants’ classified usage of capABILITY.

Results

Pre- and postintervention results indicated statistical significance on 3 of the 7 health survey measures (general diet: P=.03; exercise: P=.005; and blood glucose: P=.02). When only analyzing the high and midusers (n=14) of capABILITY, we found a statistically significant difference in both self-efficacy (P=.008) and exercise (P=.01). Although the ANOVA did not reveal any statistically significant differences across groups, there is a trend among spark conditions to respond more quickly (ie, shorter log-in lag) following the receipt of the message.

Conclusions

Our theory-driven mHealth app appears to be a feasible means of improving self-efficacy and health-related behaviors. Although our sample size is too small to draw conclusions about the differential impact of specific forms of trigger messages, our findings suggest that spark triggers may have the ability to cue engagement in mobile tools. This was demonstrated with the increased use of capABILITY at the beginning and conclusion of the study depending on spark timing. Our results suggest that theory-driven personalization of mobile tools is a viable form of intervention.

Trial Registration

ClinicalTrials.gov NCT04132089; http://clinicaltrials.gov/ct2/show/NCT004122089

A Gamification-Based Intervention Program that Encourages Physical Activity Improves Cardiorespiratory Fitness of College Students: 'The Matrix rEFvolution Program'

The aim of the present study was to examine the effects of a gamification-based program on cardiorespiratory fitness (CRF) levels of college students. We divided 112 college students into an intervention group (IG) and a control group (CG). IG college students followed a 15-week gamification-based program, whereas CG followed traditional lectures. CRF was assessed using the 20-meter shuttle-run test. CRF significantly improved after the program in the IG compared to CG (d ≤ 0.94, p < 0.001). Only participants of IG had significant CRF improvements (d ≤ 0.87, p < 0.001) between pre- and post-assessments. In the IG, from the students who attended 100% of lectures, 87.8% met physical activity recommendations for 100% of weeks, whereas from those who attended <100%, only 26.7% met them them for 100% of weeks (p < 0.001). Participants who met recommendations 100% of weeks had a significant CRF improvement (p < 0.001). Motivating college students throughout innovative teaching methods (e.g., gamification) can lead to health improvements.

Feasibility of an Interactive Patient Portal for Monitoring Physical Activity, Remote Symptom Reporting, and Patient Education in Oncology: Qualitative Study

Background

Digital health interventions, such as the use of patient portals, have been shown to offer benefits to a range of patients including those with a diagnosis of cancer.

Objective

This study aimed to explore the participant experience and perception of using an interactive Web-based portal for monitoring physical activity, remote symptom reporting, and delivering educational components.

Methods

Participants who were currently under treatment or had recently completed intensive treatment for cancer were recruited to three cohorts and invited to join a Web-based portal to enhance their physical activity. Cohort 1 received Web portal access and an activity monitor; cohort 2 had additional summative messaging; and cohort 3 had additional personalized health coaching messaging. Following the 10-week intervention, participants were invited to participate in a semistructured interview. Interview recordings were transcribed and evaluated using qualitative thematic analysis.

Results

A total of 17 semistructured interviews were carried out. Participants indicated that using the Web portal was feasible. Personalized messaging improved participant perceptions of the value of the intervention. There was a contrast between cohorts and levels of engagement with increasing health professional contact leading to an increase in engagement. Educational material needs to be tailored to the participants’ cancer treatment status, health literacy, and background.

Conclusions

Participants reported an overall positive experience using the Web portal and that personalized messaging positively impacted on their health behaviors. Future studies should focus more on design of interventions, ensuring appropriate tailoring of information and personalization of behavioral support messaging.

International Registered Report Identifier (IRRID)

RR2-10.2196/9586

Main gamification concepts: A systematic mapping study

Gamification involves incorporating elements of online games, such as points, leaderboards, and badges into non-game contexts, in order to improve engagement with both employees and consumers. The main point of this paper is, to sum up, what previous authors investigated in the field of Gamification. An analysis of the literature covering 50 papers from 2011 to 2016 was conducted, using Leximancer software, to determine and shape the main themes and concepts proposed in gamification papers. Answering our research question, "What guidelines may provide to future research, the key themes and concepts found in published scientific papers on gamification?", we conclude that the researchers identified eight themes (gamification; game; use; users; business; points; engagement; learning) and twenty-eight related concepts. The present systematic review contributes to establishing possible guidelines for prospective studies, based on the analyzed papers, considering particularly their 'Conclusions' and on the 'Future research' sections, integrating game design contents in business, learning and education. Further, highlights the usefulness of Leximancer for qualitative content analysis, in this field of research.

Data Mining in the Development of Mobile Health Apps: Assessing In-App Navigation Through Markov Chain Analysis

Background

Mobile apps generate vast amounts of user data. In the mobile health (mHealth) domain, researchers are increasingly discovering the opportunities of log data to assess the usage of their mobile apps. To date, however, the analysis of these data are often limited to descriptive statistics. Using data mining techniques, log data can offer significantly deeper insights.

Objective

The purpose of this study was to assess how Markov Chain and sequence clustering analysis can be used to find meaningful usage patterns of mHealth apps.

Methods

Using the data of a 25-day field trial (n=22) of the Start2Cycle app, an app developed to encourage recreational cycling in adults, a transition matrix between the different pages of the app was composed. From this matrix, a Markov Chain was constructed, enabling intuitive user behavior analysis.

Results

Through visual inspection of the transitions, 3 types of app use could be distinguished (route tracking, gamification, and bug reporting). Markov Chain–based sequence clustering was subsequently used to demonstrate how clusters of session types can otherwise be obtained.

Conclusions

Using Markov Chains to assess in-app navigation presents a sound method to evaluate use of mHealth interventions. The insights can be used to evaluate app use and improve user experience.

3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study

Background

Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider.

Objective

The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification.

Methods

This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions.

Results

The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process.

Conclusions

This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.

A systematic literature review of simulation models for non-technical skill training in healthcare logistics

Background

Resource allocation in patient care relies heavily on individual judgements of healthcare professionals. Such professionals perform coordinating functions by managing the timing and execution of a multitude of care processes for multiple patients. Based on advances in simulation, new technologies that could be used for establishing realistic representations have been developed. These simulations can be used to facilitate understanding of various situations, coordination training and education in logistics, decision-making processes, and design aspects of the healthcare system. However, no study in the literature has synthesized the types of simulations models available for non-technical skills training and coordination of care.

Methods

A systematic literature review, following the PRISMA guidelines, was performed to identify simulation models that could be used for training individuals in operative logistical coordination that occurs on a daily basis. This article reviewed papers of simulation in healthcare logistics presented in the Web of Science Core Collections, ACM digital library, and JSTOR databases. We conducted a screening process to gather relevant papers as the knowledge foundation of our literature study. The screening process involved a query-based identification of papers and an assessment of relevance and quality.

Results

Two hundred ninety-four papers met the inclusion criteria. The review showed that different types of simulation models can be used for constructing scenarios for addressing different types of problems, primarily for training and education sessions. The papers identified were classified according to their utilized paradigm and focus areas. (1) Discrete-event simulation in single-category and single-unit scenarios formed the most dominant approach to developing healthcare simulations and dominated all other categories by a large margin. (2) As we approached a systems perspective (cross-departmental and cross-institutional), discrete-event simulation became less popular and is complemented by system dynamics or hybrid modeling. (3) Agent-based simulations and participatory simulations have increased in absolute terms, but the share of these modeling techniques among all simulations in this field remains low.

Conclusions

An extensive study analyzing the literature on simulation in healthcare logistics indicates a growth in the number of examples demonstrating how simulation can be used in healthcare settings. Results show that the majority of studies create situations in which non-technical skills of managers, coordinators, and decision makers can be trained. However, more system-level and complex system-based approaches are limited and use methods other than discrete-event simulation.

Increasing Health Care Adherence Through Gamification, Video Feedback, and Real-World Rewards

Treatment non-adherence poses a sizeable and persistent challenge to health professionals. In the US alone, it is estimated that at least $100 billion per year is spent on avoidable health care costs with an additional $230 billion per year forfeited due to lost productivity. Efforts to increase adherence have yielded mixed results. We present an adaptable, theoretical framework that uses established gamification methods coupled with a means of motivating patients using real-world rewards. The framework presented herein is implemented via user interface modifications to a clinically validated health tracking app, as well as a means of delivering video feedback for viewing a variety of potential reward outcomes.

Feasibility of mobile health game "Fume" in supporting tobacco-related health literacy among early adolescents: A three-armed cluster randomized design

OBJECTIVE

New interventions supporting health literacy and a tobacco-free lifestyle in adolescence are needed to narrow the widening gap in existing health inequalities. Health games offer potential and could be utilized for example in school healthcare, but more research is needed to increase the understanding of the effects of game elements in health interventions. The aim of this feasibility study is to determine the short-term effectiveness of the tobacco-related mobile health game Fume and a non-gamified website in comparison with a no-intervention control group, regarding tobacco-related health literacy among 10-13-year-old early adolescents. In addition, we compare the demand for and acceptability of Fume to that of the website.

METHODS

In total, 151 early adolescents participated in this single-blinded, three-armed cluster randomized trial. The participants from three municipalities in southwest Finland were randomly allocated between a group with access to the health game Fume (n = 61), a group with access to the website (n = 47), and a group with no intervention (n = 43). The intervention groups first participated in a 20-min training session with Fume/the website, and then had two weeks to use Fume/the website based on their own interest. Short-term effectiveness was measured by primary (anti-smoking self-efficacy) and secondary (smoking outcome expectations, attitudes towards tobacco use, tobacco-use motives, motivation to decline tobacco use in the future, and knowledge about tobacco) outcomes derived from the theory-based determinants of tobacco-related health literacy and evaluated with self-assessment questionnaires at baseline and post-intervention (after a two-week follow-up). For evaluating the demand, the actual use of Fume/the website was tracked during the two-week period. Regarding acceptability, the raised interest towards Fume/the website and opinions about the interventions were evaluated post-intervention. Differences were tested with the McNemar, Fisher exact, and non-parametric tests.

RESULTS

Statistically significant favorable changes during the study period were found for positive (P = 0.002) and negative (P = 0.02) smoking outcome expectations and attitudes towards cigarette smoking (P = 0.01) within the group using Fume. No statistically significant changes were detected within the website or control groups. Statistically significant differences were not found for the change in outcome variables among the three groups. The number of visits (P < 0.001), number of separate visit days (P < 0.001) and total duration of use (P < 0.001) were larger for the group using Fume than for that using the website. Fume sparked more interest in early adolescents than the website did (P <  0.001). There were no statistically significant differences in opinions about Fume and those regarding the website.

CONCLUSIONS

The intervention with embedded game elements, the health game Fume, was found to be more feasible as a tobacco-related health education intervention than the non-gamified website among early adolescents in light of demand and acceptability (raised interest). Even though no change in anti-smoking self-efficacy was found, the results of this feasibility study demonstrated favorable short-term changes with Fume in some other theory-based determinants of tobacco-related health literacy.

A systematic review of gamification in e-Health

Gamification is a relatively new trend that focuses on applying game mechanics to non-game contexts in order to engage audiences and to inject a little fun into mundane activities besides generating motivational and cognitive benefits. While many fields such as Business, Marketing and e-Learning have taken advantage of the potential of gamification, the digital healthcare domain has also started to exploit this emerging trend. This paper aims to summarize the current knowledge regarding gamified e-Health applications. A systematic literature review was therefore conducted to explore the various gamification strategies employed in e-Health and to address the benefits and the pitfalls of this emerging discipline. A total of 46 studies from multiple sources were then considered and thoroughly investigated. The results show that the majority of the papers selected reported gamification and serious gaming in health and wellness contexts related specifically to chronic disease rehabilitation, physical activity and mental health. Although gamification in e-Health has attracted a great deal of attention during the last few years, there is still a dearth of valid empirical evidence in this field. Moreover, most of the e-Health applications and serious games investigated have been proven to yield solely short-term engagement through extrinsic rewards. For gamification to reach its full potential, it is therefore necessary to build e-Health solutions on well-founded theories that exploit the core experience and psychological effects of game mechanics.