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Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic... Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales “interest/enjoyment” (+2.0 (SD 1.9) points, P<.001) and “perceived competence” (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 (JMIR Serious Games 2019;7(1):e11444) doi: 10.2196/11444 KEYWORDS behavior change; exercise adherence; gamification; intrinsic motivation; mhealth; mobile phone game; physical activity; type 2 diabetes interdisciplinary team featuring sports scientists, gamification Introduction researchers, professional game developers, and clinical professionals, we developed a novel smartphone game that Diabetes mellitus affects over 400 million adults worldwide incorporates established motivational elements [15] and behavior [1], and 90%-95% of all cases are attributed to type 2 diabetes change techniques [16] to encourage inactive patients with type [2]. The disease is associated with numerous complications and 2 diabetes to adopt a healthier, more active lifestyle. comorbidities that drastically increase direct and indirect medical costs and considerably contribute to the disease’s enormous The purpose of this study was to investigate if the behavior financial strain worldwide [3]. change technique–based smartphone game can motivate inactive individuals with type 2 diabetes for regular use and thereby Regular physical activity (PA), with its proven positive effects increase their intrinsic PA motivation. We hypothesized that on glucose and lipid metabolism, blood pressure, cardiovascular use of the game would lead to greater improvements in intrinsic complications, and quality of life, is a key component of PA motivation than a control intervention consisting of a successful diabetes treatment [4]. Despite these health benefits one-time lifestyle counseling and thereby increase PA and the fact that patients with diabetes are usually encouraged adherence. to increase PA by their physicians, long-term adherence to PA-promoting programs is generally poor, and the level of Methods regular PA remains low [2,5]. PA has been estimated to be responsible for 6%-10% of the world’s type 2 diabetes Study Design prevalence [6] and increase the risk of all-cause mortality by This 24-week randomized controlled trial was conducted in an estimated 60% [7]. Lack of infrastructure, missing social accordance with the Declaration of Helsinki [17] between support, health concerns, and especially low motivation and August 2016 and April 2018 at the Department of Sport, lack of PA enjoyment are the main deterrents that keep patients Exercise and Health of the University of Basel, Switzerland with type 2 diabetes from effectively changing their PA (trial registration: NCT02657018) and was approved by the behaviors [8,9]. As intrinsically motivated individuals have local ethics committee (EKNZ 2015-424). Written informed been shown to have higher PA engagement and better PA consent was obtained from all study participants prior to adherence than those who are primarily motivated by external inclusion in the study. The primary aim of this study was to factors [10], PA-promoting programs should aim at particularly investigate the effect of a novel PA-promoting smartphone game helping patients increase their PA enjoyment, and consequently, on daily PA in inactive patients with type 2 diabetes, measured intrinsic motivation for regular PA [11]. as steps per day with the previously validated Garmin Vivofit A promising approach that has increasingly been examined in 2 activity wristband [18] for 1 week before and after the recent years to promote regular PA in unmotivated, inactive intervention period. A significant increase in daily PA was found target groups is exergames. Through the enjoyable game in the intervention group with average postintervention step experience, console-based exergames have been shown to counts corresponding to established PA recommendations [19]. motivate inactive patients with type 2 diabetes to voluntarily The increases in daily PA were accompanied by significant engage in more regular PA and thereby improve their glycemic improvements in aerobic capacity and stabilization of the control and overall health status [12]. Very recently, glycemic control, measured as hemoglobin A1c (C. Höchsmann, PA-promoting game apps such as Pokémon GO (Niantic Labs, personal communication, June 2018). Additional aims were to San Francisco, CA) have entered the market and likewise aim assess the effect of the game on the predefined [20] further at sustaining PA habits through gamified incentives. Although outcomes “intrinsic PA motivation” and “PA adherence.” Pokémon GO certainly has the potential to increase daily PA, Participants were allocated at random to either the intervention it should be noted that the game-related initial increases of daily or the control group using R version 3.2.3 (R Foundation for PA of 25% in the first week have been shown to gradually Statistical Computing, Vienna, Austria) and the R add-on diminish in subsequent weeks and return to baseline after only package “blockrand” version 1.3 to apply permuted block 6 weeks [13]. It is possible that the game design does not include randomization with randomly varying block sizes. The a sufficient degree of narrative, gameplay, or storytelling, which randomization list was generated in advance and transmitted are required to sustainably motivate the player to play the game by a person not involved in the study by using serially and consequently make a PA-promoting game effective in the numbered, sealed, opaque envelopes. All outcome assessors long term [14]. To address these design challenges, with an http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al were blinded with respect to the group allocation. It has been comprehensible to a wide range of players because of their shown that after the initial 6 weeks, adherence to an exercise straightforward mechanics [28,29]. In the game, regular PA is program in patients with type 2 diabetes decreases steadily, with rewarded with water or building materials that are needed to a dropout of almost 80% after 6 months but is relatively stable restore the garden and proceed in the storyline. When designing beyond the 6-month timeframe [21]. Therefore, we chose an the game, close attention was paid to the inclusion of established intervention duration of 24 weeks, which matches this critical motivational elements [15] and behavior change techniques 6-month timeframe and would consequently allow assessment [16]. In addition to the rewards for successful PA behavior, goal of the longer-term PA adherence. The detailed study protocol setting, action planning, feedback on performance, and prompts can be found in a previous publication [20]. and cues were incorporated into the game mechanics to support sustained changes in PA behavior. During the development Recruitment phase of the game, all design choices, behavioral/motivational Physically inactive overweight (body mass index ≥ 25 kg/m ) elements, and game mechanics were tested extensively with the patients with type 2 diabetes (noninsulin-dependent) between target group regarding usability and motivational efficacy. the ages of 45 and 70 years were recruited in cooperation with Overall, four user studies (unpublished data) with a total of 44 various hospitals, doctor’s offices, and diabetes care centers in participants and various thematic foci (eg, motivational efficacy the Basel metropolitan area and via online and newspaper of game concept and storyline, suitability of in-game workout advertising. Eligible participants were required to have used a regimen and baseline tests, usability of sensor tracking, and smartphone regularly during the year before the study to ensure suitability of motivational elements) were conducted during the that they were technologically proficient enough to represent a 26-month development phase. realistic target audience for a PA-promoting smartphone game. The game’s PA content includes in-game workouts as well as During the eligibility screening, participants underwent a the promotion of daily PA that follow the American College of medical examination including height, body mass, body fat Sports Medicine and European Association for Cardiovascular content (by bioelectrical impedance analysis), and resting blood Prevention & Rehabilitation principles of exercise training pressure measurements as well as resting electrocardiography. [30,31]. In-game workouts consist of 130 variations of strength, To verify insufficient levels of PA before the study (<150 endurance, balance, and flexibility exercises whose execution, minutes of moderate-intensity PA per week), participants filled as well as daily PA, is tracked via the phone’s sensors (camera, out the Freiburg Questionnaire of PA [22] as part of the accelerometer, and gyroscope). To allow individualization of eligibility screening. Present health risks that contraindicate the PA-related content of the game, exercise tests such as the exercise testing [23] as well as an impaired physical mobility, 1-minute Sit-to-Stand Test [32] and the 6-Minute Walk Test acute infections, or injuries excluded participants from enrolling [33] assess the player’s fitness level at baseline and periodically and continuing their participation in the study. during play. Based on the results, an algorithm selects appropriate entry levels and tailored rates of intensity Intervention progression for the exercise regimens and the daily PA goals, After the baseline assessment, the self-developed and which could also be manually adjusted by the player to fit commercially released smartphone game “Mission: personal preferences and potential physical limitations. An Schweinehund” was installed on the phones of participants in individualization of the exercise regimen is crucial because the intervention group. The game was designed to be unrealistic, overwhelming targets often reduce patients’ self-explanatory and motivate for regular use through its game motivation and thereby directly affect adherence [34]. Regularity mechanics. Therefore, participants only received basic of PA and relative improvements rather than high absolute instructions regarding the game controls, which were not related values determine the progression in the game and thereby make to an intended frequency or duration of use during the game success independent of the individual fitness level. intervention period. The game uses the self-determination theory Participants in the control group received a one-time lifestyle as the theoretical framework [24]. The self-determination theory counseling to promote baseline activities of daily life [35]. is a widely researched theory of motivation that addresses both Further, control group participants were provided with a intrinsic and extrinsic motives for acting and has shown its structured exercise plan consisting of strength and endurance utility in explaining processes that underpin exercise behavior exercises with moderately increasing intensity and duration, [25] as well as motivation to play video games [26]. The goal comparable to the content of the game that was to be of the game is to restore a decayed garden by planting trees and implemented autonomously during the intervention period. A flowers. In doing so, the player attracts animals that used to live detailed description of the game including screenshots can be in the garden to come back and help with the restoration process. found in a previous publication [20]. At the same time, the Schweinehund, the game’s adversary, is kept in check. In German, “innerer Schweinehund” (inner swine Outcome Measures hound) refers to the weak or lazy part of one’s nature, often Intrinsic Physical Activity Motivation regarding PA, that has to be overcome to get one’s self going. The garden setting was deliberately chosen, as its restoration Intrinsic PA motivation was measured using an abridged 12-item stands metaphorically for the restoration of the player’s body version of the Intrinsic Motivation Inventory (IMI) at baseline through regular PA. In addition, it has been shown that and after the 24-week intervention. The IMI has gained gardening is among the target group’s preferred forms of PA widespread acceptance as a multidimensional measure of [27] and that gardening-themed games are quite popular and intrinsic motivation in the context of sports and physical activity http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al [36-41]. The questionnaire included four subscales: Sample Size “interest/enjoyment,” “perceived competence,” “perceived An a priori sample size calculation based on the primary choice,” and “value/usefulness.” These subscales have been outcome was conducted for this study. Since intrinsic PA previously used to assess participants’ subjective experience motivation and PA adherence are secondary outcomes, the regarding participation in a television exercise program [36] corresponding analyses presented in this report should be and to examine the motivational pull of video games [26]. The considered explorative, and we reported the evidence in the data “interest/enjoyment” subscale is considered the true self-report for the hypothesized effect of the game use on intrinsic PA measure of intrinsic motivation, whereas “perceived motivation and PA adherence. competence,” “perceived choice,” and “value/usefulness” are viewed as positive predictors of intrinsic motivation [36]. The Results items of each subscale were modified to fit the content of this study and rated on a 7-point Likert scale ranging from 1 (not at Participant Flow and Characteristics all true) to 7 (very true). This yielded total scores between 3 Figure 1 illustrates the participants’ flow through the study. A and 21 for each subscale and between 12 and 84 for the entire total of 68 subjects were assessed for eligibility, of which 19 questionnaire. Higher scores indicated more internally did not meet the inclusion criteria and 13 declined to participate, motivated, self-regulated PA behavior. leading to the exclusion of 32 subjects. All the remaining participants (n=36) were randomly assigned to either the Physical Activity Adherence intervention group (n=18) or the control group (n=18) (Figure In the intervention group, adherence to the game-proposed PA 1). Baseline characteristics of study participants were balanced recommendations was assessed during the intervention period between the two groups (Table 1). One participant dropped out via the recorded usage data from the participants’ phones. Usage of the study before follow-up due to medical reasons not related data included daily PA (steps per day), completed and canceled to the study. No study-related or other adverse events were in-game workouts, and patterns and total duration of game use. reported during the intervention period. Further, 35 participants The accuracy of iPhones and Android phones to detect steps completed the study and were included in the analyses. during various walking conditions independent of the placement on the body has been confirmed in our previous study [18]. For Changes in Intrinsic Physical Activity Motivation in-game walking, stride cadence was measured to assess periods Figure 2 shows the pre- and postintervention data as mean and of moderate-to-vigorous-intensity walking defined as ≥100 IQR for the IMI total score and all four subscales. Intrinsic PA steps/minute [19]. motivation (IMI total score) increased significantly by an average of 6.39 (SD 4.19; P<.001) points in the intervention Statistical Analysis group and decreased by an average of 1.94 (SD 16.46; P=.62) Summary statistics were calculated to characterize the study points in the control group with an adjusted difference of 8.15 sample and for pre- and postintervention data, as appropriate. points (95% CI 0.90-15.39; P=.03) between the two groups. Continuous data were summarized using mean (SD) and median Similarly, we observed significant increases in scores for the (interquartile range [IQR]). Intrinsic PA motivation (IMI total subscales “interest/enjoyment” (by 2.00 [SD 1.94] points, score and scores for all four subscales) after the intervention P<.001) and “perceived competence” (by 2.44 [SD 2.36] points, was analyzed by analysis of covariance [42]. Results are P<.001) in the intervention group but no significant change in presented as differences in outcome (with 95% CI) between the control group. The adjusted difference between the two participants in the intervention group and those in the control groups was 2.03 points (95% CI 0.04-4.09; P=.049) for group, adjusted for the corresponding values at baseline. PA “interest/enjoyment” and 2.88 points (95% CI 0.59-5.17, P=.02) adherence was analyzed descriptively using the median, IQR, for “perceived competence.” The value/usefulness subscale and range to illustrate game-related and overall-recorded daily showed a significant adjusted difference of 2.72 points (95% PA per week during the 24-week intervention period. A linear CI 0.28-5.16; P=.03) in favor of the intervention group despite regression model was used to assess the relationship between nonsignificant changes in either group. The score for the total in-game training (minutes) and change in IMI total score. “perceived choice” subscale increased significantly by 1.22 (SD Assumptions of the analysis of covariance were checked visually 2.44) points in the intervention group, but with a nonsignificant using residual plots. All statistical methods used to compare the adjusted difference of 0.67 points (95% CI –1.27 to 2.61; P=.91) groups for intrinsic PA motivation in the present report were between the two groups. prespecified and registered. R 3.4.0 (R Foundation for Statistical Computing) was used for statistical analyses and graphics with the significance level set to .05 (two-sided). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 1. Flow diagram of study participants. Table 1. Baseline characteristics of study participants. Characteristic Intervention (n=18) Control (n=18) n Mean (SD) n Mean (SD) Sex Female 8 9 — Male 10 — 9 — Age (years) 18 56 (5) 18 58 (6) Height (m) 18 171 (7) 18 172 (8) Weight (kg) 18 93 (12) 18 100 (16) 18 32 (4) 18 34 (5) Body mass index (kg/m ) Fat mass (%) 18 38 (7) 18 38 (7) Moderate-to-vigorous physical activity 18 39 (34) 18 37 (31) (min/week) Diabetes duration (years) 18 4 (4) 18 5 (4) Not applicable. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 2. Illustration of the group-dependent change in total Intrinsic Motivation Inventory score and for the subscales "interest/enjoyment", "perceived competence", "perceived choice", and "value/usefulness". Pre: value at baseline; Post: value after the 24-week intervention period; n.s., not significant. *P<.05, **P<.001. of 1893 (SD 723) daily steps. Participants performed an average Physical Activity Adherence of 4.9 (SD 1.3) in-game walking trainings per week (average Figure 3 illustrates the usage data regarding daily PA as well duration of 26.8 [SD 8.2] minutes per training), leading to a as patterns and total duration of in-game training as median, total average duration of 131.1 (SD 48.7) minutes of in-game IQR, and range. On an average, the participants’ phones walking per week. The analysis of the stride cadence revealed recorded 6559 (SD 1182) steps per day during the 24-week that on an average, 83.7% (SD 3.5%) of all in-game walking intervention period. The weekly steps during in-game walking, was done at a cadence of ≥100 steps/minute, indicating an averaged per day, are also shown in Figure 3, with an average http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al average weekly amount of 109.8 (SD 43.4) minutes of of strength workouts and 96.5% of walking workouts were moderate-to-vigorous-intensity in-game walking. One participant completed, and 82.6% of all in-game workout reminders led to stopped playing the game after the third week and consequently a completed work out on the same day. did not produce any usage data beyond that time. We did not The linear regression model (Figure 4) showed a significant exclude this participant from the analyses because we consider positive association between total in-game training (minutes) nonuse as important of an outcome as regular use. Participants and change in IMI total score (beta=0.0028; 95% CI engaged in an average of 6.8 (SD 6.4) strength workouts per 0.0007-0.0049; P=.01; R =0.34). This indicates that for every week with a total average duration of 15.3 (SD 24.6) minutes additional 30 minutes of in-game training per week during the per week. In total, participants used the game for an average of 24-week intervention period, the total IMI score increased by 143.1 (SD 59.1) minutes of training per week. Overall 70.4% 2.03 points (95% CI 0.54-3.51). Figure 3. Illustration of phone-recorded physical activity data during the intervention period. A: weekly average of total steps per day, B: weekly average of steps per day during in-game training, C: average duration (minutes) of in-game strength training per week, D: total duration (minutes) of in-game training per week. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 4. Linear regression model illustrating the relationship between total in-game training (minutes) and change in the Intrinsic Motivation Inventory total score. IMI: Intrinsic Motivation Inventory. PA. However, a cross-sectional study [36] showed that Discussion enjoyment and perceived competence of performing a television exercise program (ie, higher intrinsic motivation) are the most Principal Findings predictive factors of more frequent participation in the program. The results of this randomized controlled trial show that a novel The recorded in-game training data in our study support this smartphone game, whose storyline is based on established finding. By illustrating the direct impact of the game-induced motivational elements and behavior change techniques, can increase in intrinsic PA motivation on the weekly PA behavior, significantly improve intrinsic PA motivation and lead to stable the usage data provide a more tangible meaning to the shown increases in PA in inactive patients with type 2 diabetes over a increase in the relatively abstract IMI scores, extending beyond 24-week period. Participants in the intervention group showed the primarily predictive value of the IMI. significant increases in the IMI total score and the subscales Analysis of the recorded usage data further shows that “interest/enjoyment,”“perceived competence,” and “perceived participants walked an average of 1893 steps per day during choice,” indicating improvements in true PA-related intrinsic in-game training. This is distinctly higher than the amount motivation and factors that predict intrinsic motivation. There reported for other PA-promoting smartphone games such as was no significant change in the “value/usefulness” subscale in Pokémon GO, even when assuming that the reported maximal the intervention group; however, it is noteworthy that the increase of 955 steps per day was entirely attributable to baseline value of this intrinsic motivation-predicting subscale Pokémon GO-related walking [13]. Further, in contrast to was relatively high (18.7 points) and thus did not leave a lot of Pokémon GO, which showed a gradual decline in daily steps room for improvement in a scale with a maximum score of 21 back to baseline values after only 6 weeks of the points. The average recorded time of 143 minutes of total abovementioned initial increase in daily PA, the amount of both in-game training per week during the intervention phase in-game steps and overall recorded daily steps in our study was underlines the game’s strong potential in motivating formerly considerably more consistent. Average daily in-game steps inactive patients with type 2 diabetes (39 minutes of between 1619 and 2206 throughout the intervention period moderate-to-vigorous PA per week at baseline) to meet and indicate a substantially better PA adherence that is especially sustainably adhere to established PA recommendations [4]; this meaningful when considering the distinctly longer timeframe level also confirmed our hypothesis that the game-induced of 24 weeks. The stable, objectively measured increases in increases in intrinsic PA motivation would lead to an improved weekly PA during the intervention period, along with the PA adherence. positive association between total in-game training (minutes) Interpretation of Results and change in IMI score, further confirm the previously indicated [25,36] importance of pursuing improvements in Intrinsic PA motivation increased significantly in the intrinsic motivation through increased PA enjoyment especially intervention group during the 24-week intervention period. A in behavioral interventions targeting inactive and unmotivated comparison of the magnitude of these improvements with other individuals. As this smartphone game is a motivating and studies is difficult, since no studies used IMI to assess changes enjoyable experience, the subjectively perceived cost of PA is in intrinsic motivation in game-based interventions that promote http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al reduced and people are encouraged to engage in regular PA Limitations and Implications for Future Research based on their personal intrinsic motivation [14,43]. Thus, our A limitation of this study is that we have no objectively game’s narrative and gameplay may be more elaborate and the measured record of any additional PA beyond the motivational elements incorporated into our storyline may be phone-recorded PA. Although participants used the game more successful in motivating players for long-term use as extensively as a training tool and accrued close to the compared to Pokémon GO. It is further possible that our guideline-recommended amount of 150 minutes of approach of tailoring the in-game PA recommendations and moderate-intensity PA per week during in-game training alone, exercises to the fitness level of each player prevented feelings it would have been interesting to see if participants engaged in of incapability and failure that result from overwhelming PA any additional structured, moderate-intensity PA outside of the volumes and intensities and instead enabled players to game. Further, although the phones recorded daily steps with experience PA-related competence by allowing them to complete a likely high accuracy when they were placed on the body [18], suitable workouts and meet appropriate and realistic PA goals. we have no record of the number of steps that were taken when The effectiveness of our game is highlighted by the fact that the phones were not placed on the body. Although participants 83.7% of all in-game walking (110 minutes/week) was of were encouraged to carry their phones with them as much as moderate-to-vigorous intensity (≥100 steps/minute) and possible (ie, reminder function of the game), and based on the therefore most likely suitable to improve aerobic fitness [44] average daily step counts, it is likely that they did most of the and prevent morbidity and premature mortality [45]. This weekly time, it is quite conceivable that especially when participants amount of moderate-to-vigorous-intensity walking is equal to were at home or work, they did not always carry their phones an average duration of 15.6 minutes per day, which has been on them. These periods without phone wear likely led to an shown to be associated with a 14% reduction in all-cause underestimation of unknown magnitude of the true number of mortality and has therefore been proposed as the minimum daily steps. Therefore, future smartphone-based studies should amount of PA required to extend life expectancy [46]. consider measuring daily steps additionally with an accurate accelerometer that has the high potential for good wear-time The average amount of time spent in in-game strength exercises compliance such as an activity wristband [18]. A further was distinctly lower than that spent in in-game walking limitation is that we are not certain of which conceptual ideas throughout the intervention period. Although the completion and motivational elements incorporated into the game have rate of strength workouts was considerably lower than that of indeed caused the increased intrinsic PA motivation and led to walking workouts (70.4% vs 96.5%), the shorter average the improved PA behavior. Although it is justifiable to argue engagement in strength workouts was a factor of how these that the ensemble of all behavior change mechanics was crucial workouts were designed. In contrast to walking workouts, which for the success of the game, a more detailed analysis would were designed to be of sufficient intensity and duration to have provided important knowledge for future game designs. improve aerobic fitness [4,44] while avoiding a demotivating Finally, a follow-up assessment after an appropriate interim physical overload, strength workouts were designed as brief period should be considered to evaluate the effectiveness of the bouts of activity to interrupt prolonged times of sedentary game regarding the sustainability of the improvements in PA behavior that could be easily integrated into the daily routine adherence beyond the 24-week intervention period. and performed anywhere without extensive equipment. This design choice is supported by recent findings, showing that Conclusions interrupting prolonged sitting by brief bouts (2-5 minutes) of In summary, our randomized controlled trial shows that a novel PA every 20-30 minutes can yield improvements in glycemic smartphone exergame that incorporates established motivational control in inactive individuals with an impaired glucose elements and personalized PA recommendations in the storyline regulation for up to 22 hours [47,48]. On an average, participants can generate significant increases in intrinsic PA motivation in made use of this design feature approximately seven times per inactive individuals with type 2 diabetes. The clinical relevance week, with an average duration of approximately 2.5 minutes of the game-induced increases in intrinsic PA motivation is per workout, and thereby made clinically relevant changes to highlighted by the associated de facto and stable improvements their sedentary daily routine. in PA adherence during the 24-week intervention period that Overall, the game encouraged an average of 143 minutes of demonstrate the game’s suitability for successfully encouraging in-game activity per week and supported patients with type 2 persistently sedentary individuals to meet and adhere to diabetes who were physically inactive for many years, in established PA guidelines. The combination of playful elements adopting and adhering to a physically active lifestyle that and an individualized PA promotion has high potential for corresponds to established PA guidelines [4]. success in other inactive, unmotivated target groups with and without chronic diseases. Acknowledgments We thank Promotion Software GmbH for providing technical support in programming the game application “Mission: Schweinehund” and during the intervention period. We are grateful to Novartis Pharma GmbH for the financial support during the development of the game application and RMIT University for providing support. We also thank all the participants for their time and effort, which was critical to the successful completion of this research. This research was funded by the Swiss National Science Foundation (SNSF grant no. 166214). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Authors' Contributions CH, AST, and SPW specified the research plan for the development and evaluation of the game concept. CH and AST initiated, planned, and conceptualized the present study and applied for the research grant. CH, CK, and KK were involved in the recruitment of participants and data collection and contributed to the discussion. CH and DI performed statistical analyses and created the tables and figures. CH, AST, and SPW wrote the manuscript. All authors reviewed and edited the manuscript and approved the final version to be submitted for publication. Conflicts of Interest None declared. Multimedia Appendix 1 CONSORT‐EHEALTH checklist (V 1.6.1). [PDF File (Adobe PDF File), 149KB-Multimedia Appendix 1] References 1. World Health Organization. 2017. Diabetes URL: https://www.who.int/news-room/fact-sheets/detail/diabetes [accessed 2018-12-19] [WebCite Cache ID 74mgXAAxk] 2. Centers for Disease Control and Prevention. 2017. National Diabetes Statistics Report Internet URL: https://www.cdc.gov/ diabetes/data/statistics/statistics-report.html [accessed 2018-12-19] [WebCite Cache ID 74mgbJUTK] 3. Li R, Bilik D, Brown MB, Zhang P, Ettner SL, Ackermann RT, et al. 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Understanding physical activity facilitators and barriers during and following a supervised exercise programme in Type 2 diabetes: a qualitative study. Diabet Med 2010 Jan;27(1):79-84. [doi: 10.1111/j.1464-5491.2009.02873.x] [Medline: 20121893] 35. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. 2018. URL: https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf [accessed 2018-12-19] [WebCite Cache ID 74mj0Qgwc] 36. Meis JJ, Kremers SP, Bouman MP. Television Viewing Does Not Have to Be Sedentary: Motivation to Participate in a TV Exercise Program. Journal of Obesity 2012. [doi: 10.1155/2012/752820] [Medline: 22187637] 37. Buckworth J, Lee RE, Regan G, Schneider LK, DiClemente CC. Decomposing intrinsic and extrinsic motivation for exercise: Application to stages of motivational readiness. Psychology of Sport and Exercise 2007 Jul;8(4):441-461. 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Physical activity and risk of all-cause and cardiovascular disease mortality in diabetic adults from Great Britain: pooled analysis of 10 population-based cohorts. Diabetes Care 2014 Apr;37(4):1016-1023. [doi: 10.2337/dc13-1816] [Medline: 24652727] 46. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. The Lancet 2011 Oct 1;378(9798):1244-1253. [doi: 10.1016/S0140-6736(11)60749-6] [Medline: 21846575] 47. Henson J, Davies MJ, Bodicoat DH, Edwardson CL, Gill JMR, Stensel DJ, et al. Breaking Up Prolonged Sitting With Standing or Walking Attenuates the Postprandial Metabolic Response in Postmenopausal Women: A Randomized Acute Study. Diabetes Care 2016 Jan;39(1):130-138. [doi: 10.2337/dc15-1240] [Medline: 26628415] 48. Dempsey PC, Blankenship JM, Larsen RN, Sacre JW, Sethi P, Straznicky NE, et al. Interrupting prolonged sitting in type 2 diabetes: nocturnal persistence of improved glycaemic control. Diabetologia 2017 Dec;60(3):499-507. [doi: 10.1007/s00125-016-4169-z] [Medline: 27942799] Abbreviations IMI: Intrinsic Motivation Inventory IQR: interquartile range PA: physical activity Edited by G Eysenbach; submitted 10.07.18; peer-reviewed by A Staiano, M Kelley; comments to author 07.10.18; revised version received 19.11.18; accepted 09.12.18; published 13.02.19 Please cite as: Höchsmann C, Infanger D, Klenk C, Königstein K, Walz SP, Schmidt-Trucksäss A Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial JMIR Serious Games 2019;7(1):e11444 URL: http://games.jmir.org/2019/1/e11444/ doi: 10.2196/11444 PMID: 30758293 ©Christoph Höchsmann, Denis Infanger, Christopher Klenk, Karsten Königstein, Steffen P Walz, Arno Schmidt-Trucksäss. Originally published in JMIR Serious Games (http://games.jmir.org), 13.02.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 12 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

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Abstract

Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales “interest/enjoyment” (+2.0 (SD 1.9) points, P<.001) and “perceived competence” (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 (JMIR Serious Games 2019;7(1):e11444) doi: 10.2196/11444 KEYWORDS behavior change; exercise adherence; gamification; intrinsic motivation; mhealth; mobile phone game; physical activity; type 2 diabetes interdisciplinary team featuring sports scientists, gamification Introduction researchers, professional game developers, and clinical professionals, we developed a novel smartphone game that Diabetes mellitus affects over 400 million adults worldwide incorporates established motivational elements [15] and behavior [1], and 90%-95% of all cases are attributed to type 2 diabetes change techniques [16] to encourage inactive patients with type [2]. The disease is associated with numerous complications and 2 diabetes to adopt a healthier, more active lifestyle. comorbidities that drastically increase direct and indirect medical costs and considerably contribute to the disease’s enormous The purpose of this study was to investigate if the behavior financial strain worldwide [3]. change technique–based smartphone game can motivate inactive individuals with type 2 diabetes for regular use and thereby Regular physical activity (PA), with its proven positive effects increase their intrinsic PA motivation. We hypothesized that on glucose and lipid metabolism, blood pressure, cardiovascular use of the game would lead to greater improvements in intrinsic complications, and quality of life, is a key component of PA motivation than a control intervention consisting of a successful diabetes treatment [4]. Despite these health benefits one-time lifestyle counseling and thereby increase PA and the fact that patients with diabetes are usually encouraged adherence. to increase PA by their physicians, long-term adherence to PA-promoting programs is generally poor, and the level of Methods regular PA remains low [2,5]. PA has been estimated to be responsible for 6%-10% of the world’s type 2 diabetes Study Design prevalence [6] and increase the risk of all-cause mortality by This 24-week randomized controlled trial was conducted in an estimated 60% [7]. Lack of infrastructure, missing social accordance with the Declaration of Helsinki [17] between support, health concerns, and especially low motivation and August 2016 and April 2018 at the Department of Sport, lack of PA enjoyment are the main deterrents that keep patients Exercise and Health of the University of Basel, Switzerland with type 2 diabetes from effectively changing their PA (trial registration: NCT02657018) and was approved by the behaviors [8,9]. As intrinsically motivated individuals have local ethics committee (EKNZ 2015-424). Written informed been shown to have higher PA engagement and better PA consent was obtained from all study participants prior to adherence than those who are primarily motivated by external inclusion in the study. The primary aim of this study was to factors [10], PA-promoting programs should aim at particularly investigate the effect of a novel PA-promoting smartphone game helping patients increase their PA enjoyment, and consequently, on daily PA in inactive patients with type 2 diabetes, measured intrinsic motivation for regular PA [11]. as steps per day with the previously validated Garmin Vivofit A promising approach that has increasingly been examined in 2 activity wristband [18] for 1 week before and after the recent years to promote regular PA in unmotivated, inactive intervention period. A significant increase in daily PA was found target groups is exergames. Through the enjoyable game in the intervention group with average postintervention step experience, console-based exergames have been shown to counts corresponding to established PA recommendations [19]. motivate inactive patients with type 2 diabetes to voluntarily The increases in daily PA were accompanied by significant engage in more regular PA and thereby improve their glycemic improvements in aerobic capacity and stabilization of the control and overall health status [12]. Very recently, glycemic control, measured as hemoglobin A1c (C. Höchsmann, PA-promoting game apps such as Pokémon GO (Niantic Labs, personal communication, June 2018). Additional aims were to San Francisco, CA) have entered the market and likewise aim assess the effect of the game on the predefined [20] further at sustaining PA habits through gamified incentives. Although outcomes “intrinsic PA motivation” and “PA adherence.” Pokémon GO certainly has the potential to increase daily PA, Participants were allocated at random to either the intervention it should be noted that the game-related initial increases of daily or the control group using R version 3.2.3 (R Foundation for PA of 25% in the first week have been shown to gradually Statistical Computing, Vienna, Austria) and the R add-on diminish in subsequent weeks and return to baseline after only package “blockrand” version 1.3 to apply permuted block 6 weeks [13]. It is possible that the game design does not include randomization with randomly varying block sizes. The a sufficient degree of narrative, gameplay, or storytelling, which randomization list was generated in advance and transmitted are required to sustainably motivate the player to play the game by a person not involved in the study by using serially and consequently make a PA-promoting game effective in the numbered, sealed, opaque envelopes. All outcome assessors long term [14]. To address these design challenges, with an http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al were blinded with respect to the group allocation. It has been comprehensible to a wide range of players because of their shown that after the initial 6 weeks, adherence to an exercise straightforward mechanics [28,29]. In the game, regular PA is program in patients with type 2 diabetes decreases steadily, with rewarded with water or building materials that are needed to a dropout of almost 80% after 6 months but is relatively stable restore the garden and proceed in the storyline. When designing beyond the 6-month timeframe [21]. Therefore, we chose an the game, close attention was paid to the inclusion of established intervention duration of 24 weeks, which matches this critical motivational elements [15] and behavior change techniques 6-month timeframe and would consequently allow assessment [16]. In addition to the rewards for successful PA behavior, goal of the longer-term PA adherence. The detailed study protocol setting, action planning, feedback on performance, and prompts can be found in a previous publication [20]. and cues were incorporated into the game mechanics to support sustained changes in PA behavior. During the development Recruitment phase of the game, all design choices, behavioral/motivational Physically inactive overweight (body mass index ≥ 25 kg/m ) elements, and game mechanics were tested extensively with the patients with type 2 diabetes (noninsulin-dependent) between target group regarding usability and motivational efficacy. the ages of 45 and 70 years were recruited in cooperation with Overall, four user studies (unpublished data) with a total of 44 various hospitals, doctor’s offices, and diabetes care centers in participants and various thematic foci (eg, motivational efficacy the Basel metropolitan area and via online and newspaper of game concept and storyline, suitability of in-game workout advertising. Eligible participants were required to have used a regimen and baseline tests, usability of sensor tracking, and smartphone regularly during the year before the study to ensure suitability of motivational elements) were conducted during the that they were technologically proficient enough to represent a 26-month development phase. realistic target audience for a PA-promoting smartphone game. The game’s PA content includes in-game workouts as well as During the eligibility screening, participants underwent a the promotion of daily PA that follow the American College of medical examination including height, body mass, body fat Sports Medicine and European Association for Cardiovascular content (by bioelectrical impedance analysis), and resting blood Prevention & Rehabilitation principles of exercise training pressure measurements as well as resting electrocardiography. [30,31]. In-game workouts consist of 130 variations of strength, To verify insufficient levels of PA before the study (<150 endurance, balance, and flexibility exercises whose execution, minutes of moderate-intensity PA per week), participants filled as well as daily PA, is tracked via the phone’s sensors (camera, out the Freiburg Questionnaire of PA [22] as part of the accelerometer, and gyroscope). To allow individualization of eligibility screening. Present health risks that contraindicate the PA-related content of the game, exercise tests such as the exercise testing [23] as well as an impaired physical mobility, 1-minute Sit-to-Stand Test [32] and the 6-Minute Walk Test acute infections, or injuries excluded participants from enrolling [33] assess the player’s fitness level at baseline and periodically and continuing their participation in the study. during play. Based on the results, an algorithm selects appropriate entry levels and tailored rates of intensity Intervention progression for the exercise regimens and the daily PA goals, After the baseline assessment, the self-developed and which could also be manually adjusted by the player to fit commercially released smartphone game “Mission: personal preferences and potential physical limitations. An Schweinehund” was installed on the phones of participants in individualization of the exercise regimen is crucial because the intervention group. The game was designed to be unrealistic, overwhelming targets often reduce patients’ self-explanatory and motivate for regular use through its game motivation and thereby directly affect adherence [34]. Regularity mechanics. Therefore, participants only received basic of PA and relative improvements rather than high absolute instructions regarding the game controls, which were not related values determine the progression in the game and thereby make to an intended frequency or duration of use during the game success independent of the individual fitness level. intervention period. The game uses the self-determination theory Participants in the control group received a one-time lifestyle as the theoretical framework [24]. The self-determination theory counseling to promote baseline activities of daily life [35]. is a widely researched theory of motivation that addresses both Further, control group participants were provided with a intrinsic and extrinsic motives for acting and has shown its structured exercise plan consisting of strength and endurance utility in explaining processes that underpin exercise behavior exercises with moderately increasing intensity and duration, [25] as well as motivation to play video games [26]. The goal comparable to the content of the game that was to be of the game is to restore a decayed garden by planting trees and implemented autonomously during the intervention period. A flowers. In doing so, the player attracts animals that used to live detailed description of the game including screenshots can be in the garden to come back and help with the restoration process. found in a previous publication [20]. At the same time, the Schweinehund, the game’s adversary, is kept in check. In German, “innerer Schweinehund” (inner swine Outcome Measures hound) refers to the weak or lazy part of one’s nature, often Intrinsic Physical Activity Motivation regarding PA, that has to be overcome to get one’s self going. The garden setting was deliberately chosen, as its restoration Intrinsic PA motivation was measured using an abridged 12-item stands metaphorically for the restoration of the player’s body version of the Intrinsic Motivation Inventory (IMI) at baseline through regular PA. In addition, it has been shown that and after the 24-week intervention. The IMI has gained gardening is among the target group’s preferred forms of PA widespread acceptance as a multidimensional measure of [27] and that gardening-themed games are quite popular and intrinsic motivation in the context of sports and physical activity http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al [36-41]. The questionnaire included four subscales: Sample Size “interest/enjoyment,” “perceived competence,” “perceived An a priori sample size calculation based on the primary choice,” and “value/usefulness.” These subscales have been outcome was conducted for this study. Since intrinsic PA previously used to assess participants’ subjective experience motivation and PA adherence are secondary outcomes, the regarding participation in a television exercise program [36] corresponding analyses presented in this report should be and to examine the motivational pull of video games [26]. The considered explorative, and we reported the evidence in the data “interest/enjoyment” subscale is considered the true self-report for the hypothesized effect of the game use on intrinsic PA measure of intrinsic motivation, whereas “perceived motivation and PA adherence. competence,” “perceived choice,” and “value/usefulness” are viewed as positive predictors of intrinsic motivation [36]. The Results items of each subscale were modified to fit the content of this study and rated on a 7-point Likert scale ranging from 1 (not at Participant Flow and Characteristics all true) to 7 (very true). This yielded total scores between 3 Figure 1 illustrates the participants’ flow through the study. A and 21 for each subscale and between 12 and 84 for the entire total of 68 subjects were assessed for eligibility, of which 19 questionnaire. Higher scores indicated more internally did not meet the inclusion criteria and 13 declined to participate, motivated, self-regulated PA behavior. leading to the exclusion of 32 subjects. All the remaining participants (n=36) were randomly assigned to either the Physical Activity Adherence intervention group (n=18) or the control group (n=18) (Figure In the intervention group, adherence to the game-proposed PA 1). Baseline characteristics of study participants were balanced recommendations was assessed during the intervention period between the two groups (Table 1). One participant dropped out via the recorded usage data from the participants’ phones. Usage of the study before follow-up due to medical reasons not related data included daily PA (steps per day), completed and canceled to the study. No study-related or other adverse events were in-game workouts, and patterns and total duration of game use. reported during the intervention period. Further, 35 participants The accuracy of iPhones and Android phones to detect steps completed the study and were included in the analyses. during various walking conditions independent of the placement on the body has been confirmed in our previous study [18]. For Changes in Intrinsic Physical Activity Motivation in-game walking, stride cadence was measured to assess periods Figure 2 shows the pre- and postintervention data as mean and of moderate-to-vigorous-intensity walking defined as ≥100 IQR for the IMI total score and all four subscales. Intrinsic PA steps/minute [19]. motivation (IMI total score) increased significantly by an average of 6.39 (SD 4.19; P<.001) points in the intervention Statistical Analysis group and decreased by an average of 1.94 (SD 16.46; P=.62) Summary statistics were calculated to characterize the study points in the control group with an adjusted difference of 8.15 sample and for pre- and postintervention data, as appropriate. points (95% CI 0.90-15.39; P=.03) between the two groups. Continuous data were summarized using mean (SD) and median Similarly, we observed significant increases in scores for the (interquartile range [IQR]). Intrinsic PA motivation (IMI total subscales “interest/enjoyment” (by 2.00 [SD 1.94] points, score and scores for all four subscales) after the intervention P<.001) and “perceived competence” (by 2.44 [SD 2.36] points, was analyzed by analysis of covariance [42]. Results are P<.001) in the intervention group but no significant change in presented as differences in outcome (with 95% CI) between the control group. The adjusted difference between the two participants in the intervention group and those in the control groups was 2.03 points (95% CI 0.04-4.09; P=.049) for group, adjusted for the corresponding values at baseline. PA “interest/enjoyment” and 2.88 points (95% CI 0.59-5.17, P=.02) adherence was analyzed descriptively using the median, IQR, for “perceived competence.” The value/usefulness subscale and range to illustrate game-related and overall-recorded daily showed a significant adjusted difference of 2.72 points (95% PA per week during the 24-week intervention period. A linear CI 0.28-5.16; P=.03) in favor of the intervention group despite regression model was used to assess the relationship between nonsignificant changes in either group. The score for the total in-game training (minutes) and change in IMI total score. “perceived choice” subscale increased significantly by 1.22 (SD Assumptions of the analysis of covariance were checked visually 2.44) points in the intervention group, but with a nonsignificant using residual plots. All statistical methods used to compare the adjusted difference of 0.67 points (95% CI –1.27 to 2.61; P=.91) groups for intrinsic PA motivation in the present report were between the two groups. prespecified and registered. R 3.4.0 (R Foundation for Statistical Computing) was used for statistical analyses and graphics with the significance level set to .05 (two-sided). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 1. Flow diagram of study participants. Table 1. Baseline characteristics of study participants. Characteristic Intervention (n=18) Control (n=18) n Mean (SD) n Mean (SD) Sex Female 8 9 — Male 10 — 9 — Age (years) 18 56 (5) 18 58 (6) Height (m) 18 171 (7) 18 172 (8) Weight (kg) 18 93 (12) 18 100 (16) 18 32 (4) 18 34 (5) Body mass index (kg/m ) Fat mass (%) 18 38 (7) 18 38 (7) Moderate-to-vigorous physical activity 18 39 (34) 18 37 (31) (min/week) Diabetes duration (years) 18 4 (4) 18 5 (4) Not applicable. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 2. Illustration of the group-dependent change in total Intrinsic Motivation Inventory score and for the subscales "interest/enjoyment", "perceived competence", "perceived choice", and "value/usefulness". Pre: value at baseline; Post: value after the 24-week intervention period; n.s., not significant. *P<.05, **P<.001. of 1893 (SD 723) daily steps. Participants performed an average Physical Activity Adherence of 4.9 (SD 1.3) in-game walking trainings per week (average Figure 3 illustrates the usage data regarding daily PA as well duration of 26.8 [SD 8.2] minutes per training), leading to a as patterns and total duration of in-game training as median, total average duration of 131.1 (SD 48.7) minutes of in-game IQR, and range. On an average, the participants’ phones walking per week. The analysis of the stride cadence revealed recorded 6559 (SD 1182) steps per day during the 24-week that on an average, 83.7% (SD 3.5%) of all in-game walking intervention period. The weekly steps during in-game walking, was done at a cadence of ≥100 steps/minute, indicating an averaged per day, are also shown in Figure 3, with an average http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al average weekly amount of 109.8 (SD 43.4) minutes of of strength workouts and 96.5% of walking workouts were moderate-to-vigorous-intensity in-game walking. One participant completed, and 82.6% of all in-game workout reminders led to stopped playing the game after the third week and consequently a completed work out on the same day. did not produce any usage data beyond that time. We did not The linear regression model (Figure 4) showed a significant exclude this participant from the analyses because we consider positive association between total in-game training (minutes) nonuse as important of an outcome as regular use. Participants and change in IMI total score (beta=0.0028; 95% CI engaged in an average of 6.8 (SD 6.4) strength workouts per 0.0007-0.0049; P=.01; R =0.34). This indicates that for every week with a total average duration of 15.3 (SD 24.6) minutes additional 30 minutes of in-game training per week during the per week. In total, participants used the game for an average of 24-week intervention period, the total IMI score increased by 143.1 (SD 59.1) minutes of training per week. Overall 70.4% 2.03 points (95% CI 0.54-3.51). Figure 3. Illustration of phone-recorded physical activity data during the intervention period. A: weekly average of total steps per day, B: weekly average of steps per day during in-game training, C: average duration (minutes) of in-game strength training per week, D: total duration (minutes) of in-game training per week. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Figure 4. Linear regression model illustrating the relationship between total in-game training (minutes) and change in the Intrinsic Motivation Inventory total score. IMI: Intrinsic Motivation Inventory. PA. However, a cross-sectional study [36] showed that Discussion enjoyment and perceived competence of performing a television exercise program (ie, higher intrinsic motivation) are the most Principal Findings predictive factors of more frequent participation in the program. The results of this randomized controlled trial show that a novel The recorded in-game training data in our study support this smartphone game, whose storyline is based on established finding. By illustrating the direct impact of the game-induced motivational elements and behavior change techniques, can increase in intrinsic PA motivation on the weekly PA behavior, significantly improve intrinsic PA motivation and lead to stable the usage data provide a more tangible meaning to the shown increases in PA in inactive patients with type 2 diabetes over a increase in the relatively abstract IMI scores, extending beyond 24-week period. Participants in the intervention group showed the primarily predictive value of the IMI. significant increases in the IMI total score and the subscales Analysis of the recorded usage data further shows that “interest/enjoyment,”“perceived competence,” and “perceived participants walked an average of 1893 steps per day during choice,” indicating improvements in true PA-related intrinsic in-game training. This is distinctly higher than the amount motivation and factors that predict intrinsic motivation. There reported for other PA-promoting smartphone games such as was no significant change in the “value/usefulness” subscale in Pokémon GO, even when assuming that the reported maximal the intervention group; however, it is noteworthy that the increase of 955 steps per day was entirely attributable to baseline value of this intrinsic motivation-predicting subscale Pokémon GO-related walking [13]. Further, in contrast to was relatively high (18.7 points) and thus did not leave a lot of Pokémon GO, which showed a gradual decline in daily steps room for improvement in a scale with a maximum score of 21 back to baseline values after only 6 weeks of the points. The average recorded time of 143 minutes of total abovementioned initial increase in daily PA, the amount of both in-game training per week during the intervention phase in-game steps and overall recorded daily steps in our study was underlines the game’s strong potential in motivating formerly considerably more consistent. Average daily in-game steps inactive patients with type 2 diabetes (39 minutes of between 1619 and 2206 throughout the intervention period moderate-to-vigorous PA per week at baseline) to meet and indicate a substantially better PA adherence that is especially sustainably adhere to established PA recommendations [4]; this meaningful when considering the distinctly longer timeframe level also confirmed our hypothesis that the game-induced of 24 weeks. The stable, objectively measured increases in increases in intrinsic PA motivation would lead to an improved weekly PA during the intervention period, along with the PA adherence. positive association between total in-game training (minutes) Interpretation of Results and change in IMI score, further confirm the previously indicated [25,36] importance of pursuing improvements in Intrinsic PA motivation increased significantly in the intrinsic motivation through increased PA enjoyment especially intervention group during the 24-week intervention period. A in behavioral interventions targeting inactive and unmotivated comparison of the magnitude of these improvements with other individuals. As this smartphone game is a motivating and studies is difficult, since no studies used IMI to assess changes enjoyable experience, the subjectively perceived cost of PA is in intrinsic motivation in game-based interventions that promote http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al reduced and people are encouraged to engage in regular PA Limitations and Implications for Future Research based on their personal intrinsic motivation [14,43]. Thus, our A limitation of this study is that we have no objectively game’s narrative and gameplay may be more elaborate and the measured record of any additional PA beyond the motivational elements incorporated into our storyline may be phone-recorded PA. Although participants used the game more successful in motivating players for long-term use as extensively as a training tool and accrued close to the compared to Pokémon GO. It is further possible that our guideline-recommended amount of 150 minutes of approach of tailoring the in-game PA recommendations and moderate-intensity PA per week during in-game training alone, exercises to the fitness level of each player prevented feelings it would have been interesting to see if participants engaged in of incapability and failure that result from overwhelming PA any additional structured, moderate-intensity PA outside of the volumes and intensities and instead enabled players to game. Further, although the phones recorded daily steps with experience PA-related competence by allowing them to complete a likely high accuracy when they were placed on the body [18], suitable workouts and meet appropriate and realistic PA goals. we have no record of the number of steps that were taken when The effectiveness of our game is highlighted by the fact that the phones were not placed on the body. Although participants 83.7% of all in-game walking (110 minutes/week) was of were encouraged to carry their phones with them as much as moderate-to-vigorous intensity (≥100 steps/minute) and possible (ie, reminder function of the game), and based on the therefore most likely suitable to improve aerobic fitness [44] average daily step counts, it is likely that they did most of the and prevent morbidity and premature mortality [45]. This weekly time, it is quite conceivable that especially when participants amount of moderate-to-vigorous-intensity walking is equal to were at home or work, they did not always carry their phones an average duration of 15.6 minutes per day, which has been on them. These periods without phone wear likely led to an shown to be associated with a 14% reduction in all-cause underestimation of unknown magnitude of the true number of mortality and has therefore been proposed as the minimum daily steps. Therefore, future smartphone-based studies should amount of PA required to extend life expectancy [46]. consider measuring daily steps additionally with an accurate accelerometer that has the high potential for good wear-time The average amount of time spent in in-game strength exercises compliance such as an activity wristband [18]. A further was distinctly lower than that spent in in-game walking limitation is that we are not certain of which conceptual ideas throughout the intervention period. Although the completion and motivational elements incorporated into the game have rate of strength workouts was considerably lower than that of indeed caused the increased intrinsic PA motivation and led to walking workouts (70.4% vs 96.5%), the shorter average the improved PA behavior. Although it is justifiable to argue engagement in strength workouts was a factor of how these that the ensemble of all behavior change mechanics was crucial workouts were designed. In contrast to walking workouts, which for the success of the game, a more detailed analysis would were designed to be of sufficient intensity and duration to have provided important knowledge for future game designs. improve aerobic fitness [4,44] while avoiding a demotivating Finally, a follow-up assessment after an appropriate interim physical overload, strength workouts were designed as brief period should be considered to evaluate the effectiveness of the bouts of activity to interrupt prolonged times of sedentary game regarding the sustainability of the improvements in PA behavior that could be easily integrated into the daily routine adherence beyond the 24-week intervention period. and performed anywhere without extensive equipment. This design choice is supported by recent findings, showing that Conclusions interrupting prolonged sitting by brief bouts (2-5 minutes) of In summary, our randomized controlled trial shows that a novel PA every 20-30 minutes can yield improvements in glycemic smartphone exergame that incorporates established motivational control in inactive individuals with an impaired glucose elements and personalized PA recommendations in the storyline regulation for up to 22 hours [47,48]. On an average, participants can generate significant increases in intrinsic PA motivation in made use of this design feature approximately seven times per inactive individuals with type 2 diabetes. The clinical relevance week, with an average duration of approximately 2.5 minutes of the game-induced increases in intrinsic PA motivation is per workout, and thereby made clinically relevant changes to highlighted by the associated de facto and stable improvements their sedentary daily routine. in PA adherence during the 24-week intervention period that Overall, the game encouraged an average of 143 minutes of demonstrate the game’s suitability for successfully encouraging in-game activity per week and supported patients with type 2 persistently sedentary individuals to meet and adhere to diabetes who were physically inactive for many years, in established PA guidelines. The combination of playful elements adopting and adhering to a physically active lifestyle that and an individualized PA promotion has high potential for corresponds to established PA guidelines [4]. success in other inactive, unmotivated target groups with and without chronic diseases. Acknowledgments We thank Promotion Software GmbH for providing technical support in programming the game application “Mission: Schweinehund” and during the intervention period. We are grateful to Novartis Pharma GmbH for the financial support during the development of the game application and RMIT University for providing support. We also thank all the participants for their time and effort, which was critical to the successful completion of this research. This research was funded by the Swiss National Science Foundation (SNSF grant no. 166214). http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al Authors' Contributions CH, AST, and SPW specified the research plan for the development and evaluation of the game concept. CH and AST initiated, planned, and conceptualized the present study and applied for the research grant. CH, CK, and KK were involved in the recruitment of participants and data collection and contributed to the discussion. CH and DI performed statistical analyses and created the tables and figures. CH, AST, and SPW wrote the manuscript. All authors reviewed and edited the manuscript and approved the final version to be submitted for publication. Conflicts of Interest None declared. Multimedia Appendix 1 CONSORT‐EHEALTH checklist (V 1.6.1). [PDF File (Adobe PDF File), 149KB-Multimedia Appendix 1] References 1. World Health Organization. 2017. Diabetes URL: https://www.who.int/news-room/fact-sheets/detail/diabetes [accessed 2018-12-19] [WebCite Cache ID 74mgXAAxk] 2. Centers for Disease Control and Prevention. 2017. National Diabetes Statistics Report Internet URL: https://www.cdc.gov/ diabetes/data/statistics/statistics-report.html [accessed 2018-12-19] [WebCite Cache ID 74mgbJUTK] 3. Li R, Bilik D, Brown MB, Zhang P, Ettner SL, Ackermann RT, et al. 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[doi: 10.1016/j.psychsport.2006.06.007] http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Höchsmann et al 38. McAuley E, Duncan T, Tammen VV. Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: a confirmatory factor analysis. Res Q Exerc Sport 1989 Mar;60(1):48-58. [doi: 10.1080/02701367.1989.10607413] [Medline: 2489825] 39. Deci EL, Eghrari H, Patrick BC, Leone DR. Facilitating internalization: the self-determination theory perspective. J Pers 1994 Mar;62(1):119-142. [Medline: 8169757] 40. Markland D, Hardy L. On the factorial and construct validity of the Intrinsic Motivation Inventory: conceptual and operational concerns. Res Q Exerc Sport 1997 Mar;68(1):20-32. [doi: 10.1080/02701367.1997.10608863] [Medline: 9094760] 41. Silva MN, Vieira PN, Coutinho SR, Minderico CS, Matos MG, Sardinha LB, et al. 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Physical activity and risk of all-cause and cardiovascular disease mortality in diabetic adults from Great Britain: pooled analysis of 10 population-based cohorts. Diabetes Care 2014 Apr;37(4):1016-1023. [doi: 10.2337/dc13-1816] [Medline: 24652727] 46. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. The Lancet 2011 Oct 1;378(9798):1244-1253. [doi: 10.1016/S0140-6736(11)60749-6] [Medline: 21846575] 47. Henson J, Davies MJ, Bodicoat DH, Edwardson CL, Gill JMR, Stensel DJ, et al. Breaking Up Prolonged Sitting With Standing or Walking Attenuates the Postprandial Metabolic Response in Postmenopausal Women: A Randomized Acute Study. Diabetes Care 2016 Jan;39(1):130-138. [doi: 10.2337/dc15-1240] [Medline: 26628415] 48. Dempsey PC, Blankenship JM, Larsen RN, Sacre JW, Sethi P, Straznicky NE, et al. Interrupting prolonged sitting in type 2 diabetes: nocturnal persistence of improved glycaemic control. Diabetologia 2017 Dec;60(3):499-507. [doi: 10.1007/s00125-016-4169-z] [Medline: 27942799] Abbreviations IMI: Intrinsic Motivation Inventory IQR: interquartile range PA: physical activity Edited by G Eysenbach; submitted 10.07.18; peer-reviewed by A Staiano, M Kelley; comments to author 07.10.18; revised version received 19.11.18; accepted 09.12.18; published 13.02.19 Please cite as: Höchsmann C, Infanger D, Klenk C, Königstein K, Walz SP, Schmidt-Trucksäss A Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial JMIR Serious Games 2019;7(1):e11444 URL: http://games.jmir.org/2019/1/e11444/ doi: 10.2196/11444 PMID: 30758293 ©Christoph Höchsmann, Denis Infanger, Christopher Klenk, Karsten Königstein, Steffen P Walz, Arno Schmidt-Trucksäss. Originally published in JMIR Serious Games (http://games.jmir.org), 13.02.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2019/1/e11444/ JMIR Serious Games 2019 | vol. 7 | iss. 1 | e11444 | p. 12 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Feb 13, 2019

Keywords: behavior change; exercise adherence; gamification; intrinsic motivation; mhealth; mobile phone game; physical activity; type 2 diabetes

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