Recommendations for Implementing Gamification for Mental Health and Wellbeing

Impact of family-oriented gamification on self-management of people with multiple sclerosis: a mixed-methods study protocol

INTRODUCTION

Multiple sclerosis (MS) is a chronic disease of the central nervous system that impacts millions worldwide, including individuals in Iran. It primarily affects young people, leading to biopsychosocial challenges with unpredictable symptoms. Self-management is crucial but challenging due to the lack of definitive treatment. New approaches, such as mHealth interventions, particularly gamification, aim to engage patients more effectively. Well-designed gamification may positively impact health behaviours and enhance collaborative care. However, its implementation in the field of MS in Iran is currently limited. So far, some mobile applications have been designed that do not incorporate gamification principles and only focus on one issue. These applications also fail to consider the family caregivers' understanding of the patient's condition. Therefore, this study aims to investigate the impact of family-oriented gamification on the self-management of Iranian patients with MS.

METHODS AND ANALYSIS

We propose a mixed-methods study with an exploratory sequential design consisting of a qualitative phase, gamification development and a dual-centre, prospective, single-blinded, parallel-group randomised controlled superiority trial. In the qualitative phase, data will be collected through purposive sampling via semistructured interviews with patients until data saturation is reached. Concurrently, the data will be analysed using conventional content analysis to provide insights into the patients' self-management challenges. Next, web-based and card gamification will be developed for patients and their families based on the findings of the qualitative phase. Ultimately, the effectiveness of these interventions will be evaluated through a randomised controlled trial. The preliminary literature suggests an initial sample size of 25-30 participants per group for this phase. After enrolling approximately 10 participants, the exact sample size will be recalibrated using G-Power software based on data analysis. Participants will then be randomly assigned to either the intervention or control group in a 1:1 ratio. Allocation concealment will be ensured using mixed block sizes of 2 and 4. The primary outcome, self-management, and the secondary outcome, self-efficacy, will be assessed both before and immediately after the intervention. Furthermore, the usability of the two gamification strategies will be evaluated following the intervention.

ETHICS AND DISSEMINATION

This study is part of a doctoral thesis approved by the Tehran University of Medical Sciences Research Ethics Board (IR.TUMS.FNM.REC.1401.185, 23 February 2023). Dissemination of findings will occur at the local, national and international levels.

TRIAL REGISTRATION NUMBER

IRCT20240116060708N1.

eMPower: An online Mind-body wellness Program for adults living with chronic health conditions: A three-armed randomized controlled trial protocol

BACKGROUND

Symptoms of depression and anxiety are prevalent among adults with chronic health conditions, contributing to reduced quality of life, morbidity, and mortality. Mind-body wellness interventions (i.e. psychology programming, mindful movement, breathwork, meditation) may impact mental health symptoms, with online delivery offering access and scalability. Whether online mind-body wellness interventions are effective in improving patient outcomes across a broad range of chronic conditions remains uncertain.

METHODS

This three-armed, pragmatic, randomized controlled trial will use a nested mixed methods approach to assess the effectiveness of an online mind-body wellness intervention (eMPower), offered at two levels of personnel support, on symptoms of anxiety and depression in adults with chronic health conditions. Inclusion criteria require a self-reported chronic condition and access to an internet-connected device. Eligible participants will be randomized 1:1:1 to [1] waitlist control; [2] eMPower; [3] eMPower + weekly 1-to-1 check-in. The primary analysis will compare the Hospital and Anxiety Depression Scale (HADS) total score between eMPower + weekly 1-to-1 check-in versus controls, with secondary and exploratory outcomes including HADS subscales, health-related quality of life, fatigue, program engagement, and frailty.

CONCLUSION

With online intervention delivery, a range of outcomes, mixed method evaluation, and automated intervention tracking, findings are anticipated to enhance our understanding of how individuals living with chronic health conditions engage with and are impacted by online mind-body wellness programming. Six hundred and fifty-six participants have been enrolled as of April 5, 2024, and 598 patients have completed 12-week follow-up.

Engagement challenges in digital mental health programs: hybrid approaches and user retention of an online self-knowledge journey in Brazil

Digital mental health interventions (DMHIs) have surged in popularity over the last few years. However, adherence to self-guided interventions remains a major hurdle to overcome. The current study utilized a phased implementation design, incorporating diverse samples and contexts to delve into the engagement challenges faced by a recently launched online mental health platform in Brazil with self-evaluation forms. Employing an iterative mixed-methods approach, including focus groups, online surveys, and think-aloud protocols, the research aims to evaluate user satisfaction, identify barriers to adherence, and explore potential hybrid solutions. Engagement in the platform was evaluated by descriptive statistics of the number of instruments completed, and qualitative interviews that were interpreted thematically. In the fully self-guided mode, 2,145 individuals registered, but a substantial majority (88.9%) engaged with the platform for only 1 day, and merely 3.3% completed all activities. In another sample of 50 participants were given a choice between online-only or a hybrid experience with face-to-face meetings. 40% of individuals from the hybrid group completed all activities, compared to 8% in the online-only format. Time constraints emerged as a significant barrier to engagement, with suggested improvements including app development, periodic reminders, and meetings with healthcare professionals. While the study identified weaknesses in the number and length of instruments, personalized results stood out as a major strength. Overall, the findings indicate high satisfaction with the mental health platform but underscore the need for improvements, emphasizing the promise of personalized mental health information and acknowledging persistent barriers in a digital-only setting.

Perceived Barriers and Facilitators Regarding the Implementation of Gamification to Promote Physical Activity in the Neighborhood: Interview Study Among Intermediaries

BACKGROUND

In the Netherlands, neighborhood sport coaches (NSCs) play an important role as intermediaries in promoting physical activity (PA) in the neighborhood. Gamification is the use of game elements in nongame contexts; it can be implemented with or without technology and holds promise for promoting PA. NSCs infrequently make use of this option.

OBJECTIVE

This study aims to understand barriers to, and facilitators of, using gamification to promote PA, as perceived by NSCs.

METHODS

A total of 25 semistructured interviews were conducted with NSCs in the Netherlands. The interviews were audiotaped, transcribed, and analyzed by means of thematic analysis using ATLAS.ti (version 22; ATLAS.ti Scientific Software Development GmbH) software. The deductive coding was informed by the capability, opportunity, motivation, behavior model and the theoretical domains framework, complemented by inductive coding.

RESULTS

Barriers and facilitators identified as factors influencing the implementation of gamification were related to 7 themes. NSCs required technical, creative, and promotion skills; knowledge about existing gamification tools; and social support from their employer and professional network. Financial costs were identified as a barrier to the successful implementation of gamification. Lack of clarity regarding stakeholders' responsibility to implement gamification could further hamper implementation. In general, NSCs were positive about investing time in implementing gamification and expected positive effects from implementing it.

CONCLUSIONS

To overcome identified barriers, a clear overview of tools, best practices, and available subsidies must be created, a gamification network must be established, the responsibility of NSCs must be clarified, and guidance must be offered on the promotion of gamification.

Gamification for Mental Health and Health Psychology: Insights at the First Quarter Mark of the 21st Century

The concept of gamification, originally rooted in digital media and game design, has increasingly emerged as a pivotal element in psychology and engagement strategies. Its application spans diverse domains within healthcare, offering innovative solutions to transform patient care through behavior modification and heightened engagement. This contemporary perspective explores theoretical frameworks and provides a critical interdisciplinary examination of current advancements in gamification for mental health and health psychology, identifying existing knowledge gaps and projecting future trends and research directions within these contexts. Based on this, concise criteria for designing, implementing, and evaluating gamification in healthcare, aligned with acknowledged best practices to promote ethical, fair, and trustworthy systems, are outlined, establishing a robust theoretical framework to design gamified interventions and scientifically evaluate their impact.

An Escape Game on University Students' Mental Health During the COVID-19 Pandemic: Cocreation Study

BACKGROUND

The COVID-19 pandemic has had a severe impact on students' mental health. Interventions are needed to promote their psychological well-being and prevent mental illnesses in the aftermath of this unprecedented situation. Digital escape games can be an effective tool to support students' mental health. A cocreation approach can improve the acceptability of these interventions by involving different stakeholders (eg, end users, game designers, and health professionals) to obtain audience-specific games.

OBJECTIVE

This study aims to describe the process of testing and optimizing the game "EscapeCovid" on students' mental health, to serve as a model for the cocreation of future similar interventions.

METHODS

The PRODUCES (Problem, Objective, Design, End Users, Cocreators, Evaluation, Scalability) framework was used. Cocreation steps (test and optimization) were detailed for replicability. A total of 45 students tested a pilot version of the game, with 10 undergoing a semistructured interview. Meetings with a group of stakeholders and brainwriting were organized to optimize the game.

RESULTS

We produced a new version of the game incorporating the suggestions provided by student testers and following the stakeholders' guidelines. Improvements were made to both the content and the form of the new version of the pilot game. The storyline, including the protagonist and the scenes, was adapted to the student population.

CONCLUSIONS

Our results suggested that cocreation can contribute to the design of more widely accepted interventions aimed at promoting mental health and preventing psychological disorders. Results also suggest that an end user-centered approach can facilitate intervention tailoring. When conceiving a health-related escape game for students, we recommend using the cocreation approach to enhance players' experience, thus positively influencing their learning process and overall well-being.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Motivation crowding effects on the intention for continued use of gamified fitness apps: a mixed-methods approach

It has become an emerging idea for fitness apps to be gamified to intrinsically and extrinsically motivate user's usage intention or behavior. For the long-term success of gamified fitness apps, understanding what and how various motivations affect continued use is critical. A combination of qualitative and quantitative methodologies was used to explore two research questions concerning gamified fitness applications. Specifically, the research questions focused on understanding the impacts of intrinsic and extrinsic motivations on continued usage. Additionally, the study aimed to investigate whether extrinsic motivations enhance or diminish the influence of intrinsic motivations. Results from qualitative study identified three intrinsic motivations (self-development, self-control and hedonic motivation) and two extrinsic motivations (social recognition and financial reward) in gamified fitness apps. Results from quantitative study indicated that intrinsic motivations (formed by self-development, self-control and hedonic motivation), financial reward and social recognition could significantly improve intention for continued use; and further, both financial reward and social recognition could crowd-in intrinsic motivations. This research offers insights into the phenomenon of motivation crowding effects on the intention to continue using gamified fitness apps.

The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review

BACKGROUND

Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients' participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases.

OBJECTIVE

This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population.

METHODS

We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis.

RESULTS

We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard.

CONCLUSIONS

This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification.

A systematic review on the efficacy of virtual reality and gamification interventions for managing anxiety and depression

This systematic review aims to assess the effectiveness of virtual reality (VR) and gamification interventions in addressing anxiety and depression. The review also seeks to identify gaps in the current VR treatment landscape and provide guidelines for future research and development. A systematic literature search was conducted using Scopus, Web of Science, and PubMed databases, focusing on studies that utilized VR and gamification technology to address anxiety and depression disorders. A total of 2,664 studies were initially identified, 15 of those studies fulfilled the inclusion criteria for this systematic review. The efficacy of VR in addressing anxiety and depression was evident across all included studies. However, the diversity among VR interventions highlights the need for further investigation. It is advised to incorporate more diverse participant samples and larger cohorts and explore a broader spectrum of therapeutic approaches within VR interventions for addressing anxiety and depression to enhance the credibility of future research. Additionally, conducting studies in varying socioeconomic contexts would contribute to a more comprehensive understanding of their real-world applicability.

Gamification: a Novel Approach to Mental Health Promotion

PURPOSE OF REVIEW

Gamification has emerged as a novel technique for improving mental health and enhancing treatment effectiveness. This paper provides an overview of gamification approaches to mental health intervention, identifies factors that may be related to variations in treatment effectiveness, and discusses possible strategies for tailoring gamified interventions to clients' needs.

RECENT FINDINGS

Recent research has documented the potential of gamified mental health interventions for bolstering mental wellness and mitigating psychological symptoms. However, their effectiveness may vary depending on study design-related factors and gender-specific considerations. Literature reviews have also identified yet-to-be resolved issues surrounding the possible strengths and weaknesses of the personalization versus standardization of gamification, as well as the potential benefits of gamification for increasing engagement versus the potential risks of over-engagement and behavioral addiction to gamified components. This review highlights the need for careful planning and execution of gamified mental health interventions to optimize their effectiveness and suitability for meeting clients' individual needs and preferences.

Improving mental well-being in psychocardiology-a feasibility trial for a non-blended web application as a brief metacognitive-based intervention in cardiovascular disease patients

Background

Many patients with cardiovascular disease also show a high comorbidity of mental disorders, especially such as anxiety and depression. This is, in turn, associated with a decrease in the quality of life. Psychocardiological treatment options are currently limited. Hence, there is a need for novel and accessible psychological help. Recently, we demonstrated that a brief face-to-face metacognitive therapy (MCT) based intervention is promising in treating anxiety and depression. Here, we aim to translate the face-to-face approach into digital application and explore the feasibility of this approach.

Methods

We translated a validated brief psychocardiological intervention into a novel non-blended web app. The data of 18 patients suffering from various cardiac conditions but without diagnosed mental illness were analyzed after using the web app over a two-week period in a feasibility trial. The aim was whether a non-blended web app based MCT approach is feasible in the group of cardiovascular patients with cardiovascular disease.

Results

Overall, patients were able to use the web app and rated it as satisfactory and beneficial. In addition, there was first indication that using the app improved the cardiac patients' subjectively perceived health and reduced their anxiety. Therefore, the approach seems feasible for a future randomized controlled trial.

Conclusion

Applying a metacognitive-based brief intervention via a non-blended web app seems to show good acceptance and feasibility in a small target group of patients with CVD. Future studies should further develop, improve and validate digital psychotherapy approaches, especially in patient groups with a lack of access to standard psychotherapeutic care.

Visuospatial working memory and attention control make the difference between experts, regulars and non-players of the videogame League of Legends

Video games have been postulated as an emerging field for studying the cognition-expertise relationship. Despite this, some methodological practices hinder scientific advance (e.g., heterogeneous samples, an ambiguous definition of expertise, etc.). League of Legends (LOL) is a massively played video game with a moderately defined structure that meets the requirements to overcome current study limitations. The aim of this study was to analyze cognitive differences among expert LOL players, regular LOL players, and non-videogame players. A sample of 80 participants was enrolled in three different groups of expertise. Participants were evaluated with behavioral tests of working memory, attention, cognitive flexibility, and inhibition. Kruskal-Wallis tests for group comparison showed that the experts performed significantly better than regular players and non-videogame players in the working memory test. Significant differences were also found between players and non-videogame players in the attention test. Methodological implications for future research in neuroscience and human-computer interaction are discussed.

A randomized pilot study of Rhythms And You (RAY): An internet-based program for bipolar disorder administered with and without clinical helper support in primary care

BACKGROUND

Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 min) calls from clinical helpers (CH).

METHODS

Participants (n = 47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks.

RESULTS

RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1 ± 5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d = 0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d = 1.3]. ARM also showed moderate effects (ISS-ACT d = 0.7; Quick Inventory of Depressive Symptoms, d = 0.8). SF-12 MHC scores showed a time*group interaction (F = 2.38, df = 6,32, p = 0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F = 4.09, df = 1, 17, p = 0.06).

LIMITATIONS

Sample size is small, limiting conclusions that can be drawn.

CONCLUSIONS

Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.

Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial

BACKGROUND

As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life.

OBJECTIVE

The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes.

METHODS

A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre- and post-psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data.

RESULTS

In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received.

CONCLUSIONS

Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life.

Ethics of Gamification in Health and Fitness-Tracking

The use of game-like elements is become increasingly popular in the context of fitness and health apps. While such “gamified” apps hold great potential in motivating people to improve their health, they also come with a “darker side”. Recent work suggests that these gamified health apps raise a number of ethical challenges that, if left unaddressed, are not only morally problematic but also have adverse effects on user health and engagement with the apps. However, studies highlighting the ethical challenges of gamification have also met with criticism, indicating that they fall short of providing guidance to practitioners. In avoiding this mistake, this paper seeks to advance the goal of facilitating a practice-relevant guide for designers of gamified health apps to address ethical issues raised by use of such apps. More specifically, the paper seeks to achieve two major aims: (a) to propose a revised practice-relevant theoretical framework that outlines the responsibilities of the designers of gamified health apps, and (b) to provide a landscape of the various ethical issues related to gamified health apps based on a systematic literature review of the empirical literature investigating adverse effects of such apps.