Gamification in Digital Health: Are we there yet?

⏩Introduction⏩

Understanding patient behaviors and using this understanding to develop and titrate an intervention has gained a lot of traction in the past few years. This has given rise to several new ways of reaching out to patients, keeping them engaged and ultimately showing impact on clinical outcomes.

With ubiquitous use of health trackers, apps and other such devices, there is a sense of competition amongst entrepreneurs to attract maximum user base and engage them for longer retention periods and due to this competition, gamification is considered to be an essential methodology for any digital health intervention.

As is the case with any such new trend, several such methodologies have gained a lot of hype, both in academic research, digital health entrepreneurial circles and in many cases, popular healthcare media.

📊 Number Game📊

According to Global Market Insights, the serious games segment in the healthcare gamification market accounted for USD 2.5 billion in 2020 and the market valuation of healthcare gamification will cross $65.1 billion by 2027.

In this mini-review, I have tried looking at some encouraging evidence, what is missing and what can be the future of gamification in digital health.

⏩What is Gamification and how is it being applied in Digital Health⏩

In its most simpler terms, gamification means using elements of a typical gaming set-up in a non-gaming context. Some of the most widely recognized game elements include reward points, sense of competitive community, and discovery.

There has been some interesting research work in this area trying to bring together the learnings from behavioral psychology and typical gaming environments. A recent review showcased several gaming elements and their connect to elements of Self-Determination Theory-

These gaming elements try to have some correlation with known factors from behavioral change theory. A BMJ article summarized these as below-

• Feedback and monitoring
• Comparison of behaviour
• Reward and threat
• Self-belief
• Repetition and substitution
• Social support
• Goals and planning
• Shaping knowledge
• Associations
• Antecedents
• Identity
• Natural consequences
• Comparison of outcomes
• Regulation
• Scheduled consequences
• Covert learning

✨ Did you know? ✨

Game design elements exist in about two-thirds of the most popular health and fitness mobile applications.

Due to the nature of digital health interventions, it has become easy for digital health researchers and entrepreneurs to apply these principles using game elements in the design of new interventions. Usually design elements are combined for trying to get the best possible engagement from users, as reviewed for a set of 64 apps.

Nikhil Krishnan wrote a fascinating overview of what video games can teach the gamification movement in healthcare. In his trademark, he gave several commonalities and examples from currently existing digital health interventions.

⏩Gamification and Digital Health Outcome⏩

While there seems to be a lot of work being done in applying this existing knowledge, collecting outcomes and evidence seems to be still catching up.

There are some common elements with the rest of the digital health interventions here-

• Poor Design decisions
• Lack of systematic evidence collection
• Undesired/adverse effects

Lets look at these in detail-

👉🏽Poorly designed interventions

Many interventions are being designed without thinking of the specific patient populations and needs. This leads to poorly designed products that use gaming elements that may or may not provide the desired benefit.

Poor design elements is a perpetual non-starter in digital health. Gamification as a strategy has been criticized from the field of game developers, as it only adopts selective or “convenient” components of functional games into nongame settings, as reported by Lister et al. They emphasize that the traditional games are already naturally reinforcing and motivating, while complex behaviors such as diet and physical activity may not be. Additionally, the push towards gamification assumes that the use of rewards, levels, leaderboards, and external incentives are enough to sustain (health) behavior responses without using other components of games like problem solving, storytelling, and fantasy.

👉🏽Limited evidence gathering

There are many interventions which may have beneficial effect/s however researchers and entrepreneurs have not studied the effects systematically, using sound research methodology and/or in sufficiently large user population over sufficient time period.

A study conducted by researchers from University of Washington studied systematic evidence gathering for such interventions. Their findings are fascinating, if depressing. Of the 172 study reports analysed by them-

• The majority had follow-up periods of 6 months or less.
• Over half of the interventions were delivered by a stand-alone app and Static/one-size-fits-all was the most common level of personalization.
• Most importantly, the effectiveness of gamification was higher compared to the other interventions but overall, the use of an app to modify behavior (either as a stand-alone or as part of a larger intervention) conferred only a slight/weak advantage over standard care in health interventions.

👉🏽Undesired effects

Finally, there might be undesired and adverse impact of poorly used gaming elements which is not being considered currently and can prove to be counter-productive for the desired health outcomes.

Researchers from the Karlsruhe Institute of Technology, Germany studied throw light on this phenomenon through this publication. Mindless approaches to gamification might not only lack effectiveness in increasing users’ motivation and engagement but additionally cause unintended side effects that could counteract the positive effects of gamified systems or even harm their users.

They summarize these side effects in 5 different classes as below

Let’s look at a couple of examples cited in this research

• Motivation Decreasing Over Time: As the novelty of the gaming element starts waning, user engagement may often drop.
• Trivializing the Health Context: Some health professionals shy away from participating in designing gamified interventions as they worry about their credibility and respect among patients.
• Privacy Infringements: Information about users’ health status and health behavior is often sensitive and subject to specific laws which limit the disclosure of healthcare information without explicit consent from the user.

While a lot is still being tried out, we also have some good news for gamification. US FDA approved First Game-Based Digital Therapeutic to Improve Attention Function in Children with ADHD, for the EndeavorRx to Akili Interactive. The FDA reviewed data from multiple studies in more than 600 children, including studies that evaluated, among other things, whether participants demonstrated improvements in attention function, as measured by the Test of Variables of Attention (TOVA), academic performance measures, and other assessment tools.

In conclusion, while a lot of exciting opportunities exist for gamification in digital health, a lot of work still needs to be done focusing on-

• Conceptualizing and designing the right gaming elements for the specified user population and use-case
• Focusing on the desired health outcomes (like meaningful clinical outcomes) and not restricting only intermediate ones(like user retention and engagement)
• Thinking about long-term intended and unintended consequences

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