Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers

Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers This editorial provides a behavioral science view on gamification and health behavior change, describes its principles and mechanisms, and reviews some of the evidence for its efficacy. Furthermore, this editorial explores the relation between gamification and behavior change frameworks used in the health sciences and shows how gamification principles are closely related to principles that have been proven to work in health behavior change technology. Finally, this editorial provides criteria that can be used to assess when gamification provides a potentially promising framework for digital health interventions. (JMIR Serious Games 2013;1(1):e3) doi: 10.2196/games.3139 KEYWORDS behavioral medicine; behaviour and behavior mechanisms; behavioral research; behavioral sciences; persuasive communication; health psychology; psychology; experimental game; interactive games; computer games In this editorial, I describe and evaluate gamification, address Introduction misconceptions, show linkages to health behavior change theory, and advocate when gamification is a good or bad approach for Although health behavior change research suggests that it is digital health behavior change interventions. easy to influence how people think and behave, practitioners who have worked in the health behavior change field, with Hype Around Gamification populations or individuals, will often complain that that behavior change is difficult to achieve, expensive, and impacts are often At present, there is no shortage of gamification advocates who short-lived. claim badges, points, and competition will get everyone so The average public health campaign is able to impact the hooked on digital technologies, that developers should gamify behavior of roughly 5% of a population [1], while a their interventions immediately, or get left behind. However, meta-analysis that I co-investigated a few years ago showed jumping on this gamification bandwagon is a risky undertaking. that online behavior change technologies could impact the Not because gamification does not work, but rather, because it behavior of roughly 10% of their users [2](this figure was is easy to get it wrong if developers do not understand what it derived by comparing a Pearson's coefficient effect size to a is, know its limits, and make informed decisions on its percentage, as used by Snyder (2007); however, this method is application. Gamification is just one of many persuasive subject to significant statistical bias [3] and should therefore architectures. However, like all other persuasive design patterns, only be taken as a ballpark figure at best). Given the modest gamification has merit when used in the right way, under the impacts from evidence-based interventions, why are we now right circumstances. witnessing widespread claims that gamification makes it easy to shape how people think and behave, simply by rewarding The Active Ingredients of Gamification users with points and badges? Is gamification really a magic Gamification is defined as the use of game design elements in solution to shaping behavior, or simply, unrealistic hype? non-game contexts [4]. The idea is that if we can isolate the http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman active ingredients that make games addictive, then intervention exception of fun and playfulness, which has perhaps, not developers can put those ingredients into their digital received much attention in the health behavior change literature. technologies and make them addictive too. For instance, we can These 7 ingredients of gamification are listed in Textbox 1. make a routine non-game activity, such as taking medication, My goal was to identify the persuasive architecture of into a game that is fun and engaging by adding game elements, gamification, the essential strategies that combine to produce such as earning points for taking medications. an effect greater than the sum of its parts. Put another way, the To apply gamification, developers first need a list of game persuasive architecture of gamification is the combination of design elements, and then second, they need to integrate these ingredients that make a product fun and engaging. Take away elements into their intervention. However, the problem is that some of these core ingredients, and the product becomes dull. gamification researchers do not always agree on what these Add them back in, and the magic happens. A persuasive ingredients are, and some researchers take the position that these architecture is the optimal blend of persuasive strategies for a ingredients cannot even be named. particular application [2]. Within this debate, I take the view that technology is only Whereas the strategies in Textbox 1 are the broad principles persuasive when it employs specific behavior change that make gamification addictive, the gamification mechanics ingredients, as one of the key principles of evidence based (or tactics) are the on-screen features that users interact with. behavioral medicine [5-7]. These persuasive ingredients are the For instance, the strategy of motivating a user by comparing factors that exert persuasive force on people, encouraging them their progress with others can be implemented with the to shift their beliefs, attitudes, and actions. If these ingredients gamification tactic of showing the game leaders. Textbox 2 are removed, the technology is no longer persuasive. In the shows 10 of the most popular gamification tactics [13]. sciences, these ingredients have different names, but I will refer One of the chief misconceptions about gamification is that any to them as "behavior change strategies", "persuasive strategies", technology that employs game tactics will be more engaging. or simply, "strategies". The problem with this thinking is that it mistakes superficial To identify these gamification strategies, I reviewed a number game tactics for deeper psychological strategies. For instance, of popular gamification taxonomies from academic and it is risky to believe that badges will motivate users, without non-academic sources by Charles Coonradt [8], Reeves and considering the persuasive strategies that the game tactics must Read [9], Gabe Zichermann [10], and Marc Prensky [11]. I satisfy, where a badge’s value comes from a community that identified the common strategies listed by these authors, and places value on that badge, and where the badge’s value is compared them to a taxonomy of interactive behavior change further dependent on whether it transfers anything of value to and persuasive design strategies within my Persuasive the person. Offering game tactics that do not satisfy persuasive Communication Model [12]. strategies is like cooking dinner for someone with ingredients (game tactics) they do not like (strategies). After, I identified 7 core ingredients of gamification that have clear linkages to proven behavior change strategies, with the Textbox 1. The persuasive architecture of gamification and its 7 persuasive strategies. 1. Goal setting: Committing to achieve a goal 2. Capacity to overcome challenges: Growth, learning, and development 3. Providing feedback on performance: Receiving constant feedback through the experience 4. Reinforcement: Gaining rewards, avoiding punishments 5. Compare progress: Monitoring progress with self and others 6. Social connectivity: Interacting with other people 7. Fun and playfulness: Paying out an alternative reality http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Textbox 2. Popular gamification tactics. 1. Providing clear goals 2. Offering a challenge 3. Using levels (incremental challenges) 4. Allocating points 5. Showing progress 6. Providing feedback 7. Giving rewards 8. Providing badges for achievements 9. Showing the game leaders 10. Giving a story or theme with some users complaining that gamification was annoying. The Efficacy of Gamification Additionally, there were far more studies in particular contexts, such as online learning, intra-organizational systems, and work Overview environments, with the lack of studies from other domains In order for gamification to be considered effective, gamified possibly signaling that gamification may only work in contexts technology must outperform other design patterns, in terms of that already share a common persuasive architecture. Finally, its ability to influence people's beliefs, attitudes, or behaviors. the researchers raised one red flag, as they could not tell if the Moreover, to be considered effective, gamification must sustain reported outcomes represented sustainable long-term impacts, these impacts over the long-term, and offer more than a or just short-term novelty effects. short-term novelty effect. Ingredients That Have Been Proven to Work However, the question that is rarely asked is whether there is From the point of view of evidence-based behavioral medicine, evidence that shows gamification can influence how people the only thing that would matter in gamification is whether it think or behave? To answer this question, there are perhaps four employs principles and tactics that have been scientifically stream of evidence that we can draw from. They include (1) proven to influence health outcomes. anecdotal evidence, (2) research on the efficacy of gamification, (3) ingredients that have been proven to work, and (4) persuasive To quickly assess the link between gamification and health architecture that is related to proven theories. behavior change, I conducted an exploratory comparison of the 7 ingredients of gamification to behavioral science principles Anecdotal Evidence that have been proven to work in digital health behavior change Much of the hype around gamification seems to come from ad interventions, drawing on validated principles from my prior hoc anecdotal evidence, in the form of case studies and industry meta-analysis on the factors that make health behavior change claims. Although highly unreliable, this body of ad hoc success technologies work [2]. stories has served to raise awareness of gamification concepts, I mapped 27 techniques and principles to the 7 gamification and prompted researchers to take a closer look at gamification. strategies. Table 1 shows the top two most effective and Research on the Efficacy of Gamification statistically significant behavior change principle and techniques. As research on gamification started to appear just before 2010, This exploratory mapping demonstrates that there are some we recently reached the point where there were enough quality promising links between gamification principles and digital academic studies, that a team of researchers conducted a health behavior change science, with one gap that stood out, systematic review of the scientific literature [13]. In their being no strong link to fun and playfulness in health behavior publication, "Does Gamification Work?", the research team change approaches. Although gamification shows some clear found evidence across numerous studies, that gamification can links to health behavior change strategies and tactics, the influence psychological and physical outcomes, meaning technical mechanics used in health behavior change gamification can make a digital product more fun and engaging. interventions can be radically different than those used in However, not all studies showed positive effects, and the impact gamified technologies, even though they may appeal to similar seemed to vary according to the community, users, and product, psychological faculties. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Table 1. Gamification strategies and validated behavior change ingredients. Gamification strategies Validated behavior change ingredients [2] 1. Goal setting Agree behavioral contract Goal setting (behavior) 2. Capacity to overcome challenges Time management Action planning 3. Providing feedback on performance Prompt self-monitoring of behavioral outcome Prompt self-monitoring of behavior 4. Reinforcement Provide rewards contingent on successful behavior 5. Compare progress Prompt self-monitoring of behavioral outcome Provide normative information about others’ behavior 6. Social connectivity Social influences (norms) Plan social support/social change 7. Fun and playfulness N/A Persuasive Architecture That is Related to Proven Selecting the Right Persuasive Theories Architecture for an Interventions Beyond the direct empirical evidence, there is also theoretical Although there is evidence that suggests gamification works, support for gamification, as a framework that shares many there are some major risks associated with the current strategies in common with other theories that have been proven gamification hype. The chief risk is becoming overconfident in to work in the health field. the ability of gamification to exert massive influence across all The persuasive architecture of gamification shares elements in contexts, which can cause developers to form tunnel vision and common with coaching, which relies on a coach's ability to fixate on just one of many persuasive architectures. foster team member motivation, employ strategies to help their Locking into one framework might cause developers to miss team overcome opposition, provide support in building member's opportunities to identify the best architecture for the job. Every techniques, and help members build their character [14]. The persuasive architecture has its own unique mix of ingredients, architecture of gamification is also extremely close to the and suitability to particular users and contexts. For instance, a cybernetic variations of self-regulation theory, based on sign-up landing page, health screener, donation page, or social feedback loops, which cover all strategies except perhaps, social networking site all draw on different combinations of persuasive connectivity, and fun and playfulness [15]. Although ingredients. Moreover, my recent research is showing that the gamification shares the same strategies, there are big differences world's most successful websites are hyper optimized, often in the tactical way that these strategies are implemented. offering more persuasive strategies per square inch than many However, the similarity does mean that it is easier to gamify of the less popular sites. digital interventions modeled on coaching or self-regulation theory, because they are already quite similar. What matters in behavior change design is knowing which persuasive architecture is right for a particular application, and One of the theories that is infrequently used in the health field, identifying when gamification, in whole or part, is suitable to but popular among video game designers, is flow, the study of a particular application. how people become absorbed and engaged in an activity when they are doing something where their skill level is perfectly Assessing the Suitability of Gamification matched to the challenge level [16]. According to the principle of flow, if a game is too difficult, people will become stressed Intervention developers should only use gamification when it and stop playing. If a game is too easy, people will become is suitable to a given audience-product mix. However, it is not bored and stop playing. But if the challenge keeps increasing easy to know in advance whether or not gamification makes as the person’s skill increases, they will have a flow experience, sense for a particular project and its unique become absorbed in the task at hand, and experience a audience-intervention mix. meditative-like absorption in what they are doing. Bringing people to this state of mind is a key goal in game design. To evaluate if gamification is suitable to a particular intervention, Textbox 3 presents criteria that developers can use to evaluate when gamification offers a promising framework. However, users are the ultimate judges of intervention efficacy, so any gamified interventions will require user testing, to determine if they can work or not. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Textbox 3. Criteria to consider when evaluating if gamification is suitable to a particular intervention. 1. The intervention users 2. The users’ social context 3. The psychological and behavioral outcomes that are being pursued 4. How closely the intervention's logic model or theory of change fits with the persuasive architecture of gamification 5. The interactive product or platform that is being planned 6. The compatibility of the interactive product, users, and community with the 7 gamification strategies 7. The compatibility of the interactive product, users, and community with gamification tactics finding innovative ways to make digital health interventions Final Thoughts fun and engaging. There is promising evidence that suggests gamification works, JMIR Serious Games is a new important journal devoted to and on the surface, gamification appears to share elements in research and opinion around games and gamification for common with proven health behavior change approaches. Given behavior change and other applications, and as one of the this, it is easy to see how existing digital interventions can editorial board members I look forward to help building the borrow gamification principles, by considering flow, meaningful evidence base in this emerging area. rewards, making them more social, and most importantly, Conflicts of Interest None declared. References 1. Snyder LB. Health communication campaigns and their impact on behavior. J Nutr Educ Behav 2007;39(2 Suppl):S32-S40. [doi: 10.1016/j.jneb.2006.09.004] [Medline: 17336803] 2. Cugelman B, Thelwall M, Dawes P. Online interventions for social marketing health behavior change campaigns: a meta-analysis of psychological architectures and adherence factors. J Med Internet Res 2011;13(1):e17 [FREE Full text] [doi: 10.2196/jmir.1367] [Medline: 21320854] 3. Lipsey M, Wilson D. Practical meta-analysis. Thousand Oaks, Calif: Sage; 2001. 4. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: Defining gamification. In: Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments.: Envisioning Future Media Environments; 2011 Presented at: MindTrek 11; 28-30 September 2011; Tampere, Finland. 5. Embry DD, Biglan A. Evidence-based kernels: fundamental units of behavioral influence. Clin Child Fam Psychol Rev 2008 Sep;11(3):75-113 [FREE Full text] [doi: 10.1007/s10567-008-0036-x] [Medline: 18712600] 6. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care 2005 Feb;14(1):26-33 [FREE Full text] [doi: 10.1136/qshc.2004.011155] [Medline: 15692000] 7. Davidson KW, Goldstein M, Kaplan RM, Kaufmann PG, Knatterud GL, Orleans CT, et al. Evidence-based behavioral medicine: what is it and how do we achieve it? Ann Behav Med 2003 Dec;26(3):161-171. [doi: 10.1136/qshc.2004.011155] [Medline: 14644692] 8. Coonradt CA. The Game of Work. Layton, Utah: Gibbs Smith; 2007. 9. Reeves B, Read J L. 2010. Ten ingredients of great games URL: http://www.cedma-europe.org/newsletter%20articles/misc/ Ten%20Ingredients%20of%20Great%20Games%20(Apr%2010).pdf [accessed 2013-11-26] [WebCite Cache ID 6LQaqKH16] 10. Zichermann G. 2011. The six rules of gamification cited 2013 5 Nov 2013; URL: http://www.gamification.co/2011/11/29/ the-six-rules-of-gamification/ [accessed 2013-11-26] [WebCite Cache ID 6LQb7JCpU] 11. Prensky M. Fun, play and games: What makes games engaging. In: Digital game-based learning. New York: McGraw-Hill; 12. Cugelman B. Persuasive design toolkit. Toronto, Canada: AlterSpark Corp; 2013. 13. Hamari J, Koivisto J, Sarsa H. Does gamification work? - a literature review of empirical studies on gamification (forthcoming). 2014 Presented at: 47th Hawaii International Conference on System Sciences; January 6-9, 2014; Hawaii, USA. 14. Kavussanu M, Boardley ID, Jutkiewicz N, Vincent S, Ring C. Coaching efficacy and coaching effectiveness: Examining their predictors and comparing coaches' and athletes' reports. The Sport Psychologist 2008;22(4):383-404. 15. Carver C, Scheier M. On the structure of behavioral self-regulation. In: Boekaerts M, Pintrich PR, Zeidner M, editors. Handbook of self-regulation. San Diego, Calif: Elsevier Academic Press; 2005:41-84. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman 16. Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York, USA: Harper Perennial Modern Classics; Edited by G Eysenbach; this is a non–peer-reviewed article. Submitted 26.11.13; accepted 28.11.13; published 12.12.13. Please cite as: Cugelman B JMIR Serious Games 2013;1(1):e3 URL: http://games.jmir.org/2013/1/e3/ doi: 10.2196/games.3139 PMID: 25658754 ©Brian Cugelman. Originally published in JMIR Serious Games (http://games.jmir.org), 12.12.2013. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 6 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers

Cugelman, Brian
JMIR Serious Games , Volume 1 (1) – Dec 12, 2013
Download PDF
6 pages

Loading next page...
 
/lp/jmir-publications/gamification-what-it-is-and-why-it-matters-to-digital-health-behavior-TC8A8brYFE
Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/games.3139
Publisher site
See Article on Publisher Site

Abstract

This editorial provides a behavioral science view on gamification and health behavior change, describes its principles and mechanisms, and reviews some of the evidence for its efficacy. Furthermore, this editorial explores the relation between gamification and behavior change frameworks used in the health sciences and shows how gamification principles are closely related to principles that have been proven to work in health behavior change technology. Finally, this editorial provides criteria that can be used to assess when gamification provides a potentially promising framework for digital health interventions. (JMIR Serious Games 2013;1(1):e3) doi: 10.2196/games.3139 KEYWORDS behavioral medicine; behaviour and behavior mechanisms; behavioral research; behavioral sciences; persuasive communication; health psychology; psychology; experimental game; interactive games; computer games In this editorial, I describe and evaluate gamification, address Introduction misconceptions, show linkages to health behavior change theory, and advocate when gamification is a good or bad approach for Although health behavior change research suggests that it is digital health behavior change interventions. easy to influence how people think and behave, practitioners who have worked in the health behavior change field, with Hype Around Gamification populations or individuals, will often complain that that behavior change is difficult to achieve, expensive, and impacts are often At present, there is no shortage of gamification advocates who short-lived. claim badges, points, and competition will get everyone so The average public health campaign is able to impact the hooked on digital technologies, that developers should gamify behavior of roughly 5% of a population [1], while a their interventions immediately, or get left behind. However, meta-analysis that I co-investigated a few years ago showed jumping on this gamification bandwagon is a risky undertaking. that online behavior change technologies could impact the Not because gamification does not work, but rather, because it behavior of roughly 10% of their users [2](this figure was is easy to get it wrong if developers do not understand what it derived by comparing a Pearson's coefficient effect size to a is, know its limits, and make informed decisions on its percentage, as used by Snyder (2007); however, this method is application. Gamification is just one of many persuasive subject to significant statistical bias [3] and should therefore architectures. However, like all other persuasive design patterns, only be taken as a ballpark figure at best). Given the modest gamification has merit when used in the right way, under the impacts from evidence-based interventions, why are we now right circumstances. witnessing widespread claims that gamification makes it easy to shape how people think and behave, simply by rewarding The Active Ingredients of Gamification users with points and badges? Is gamification really a magic Gamification is defined as the use of game design elements in solution to shaping behavior, or simply, unrealistic hype? non-game contexts [4]. The idea is that if we can isolate the http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman active ingredients that make games addictive, then intervention exception of fun and playfulness, which has perhaps, not developers can put those ingredients into their digital received much attention in the health behavior change literature. technologies and make them addictive too. For instance, we can These 7 ingredients of gamification are listed in Textbox 1. make a routine non-game activity, such as taking medication, My goal was to identify the persuasive architecture of into a game that is fun and engaging by adding game elements, gamification, the essential strategies that combine to produce such as earning points for taking medications. an effect greater than the sum of its parts. Put another way, the To apply gamification, developers first need a list of game persuasive architecture of gamification is the combination of design elements, and then second, they need to integrate these ingredients that make a product fun and engaging. Take away elements into their intervention. However, the problem is that some of these core ingredients, and the product becomes dull. gamification researchers do not always agree on what these Add them back in, and the magic happens. A persuasive ingredients are, and some researchers take the position that these architecture is the optimal blend of persuasive strategies for a ingredients cannot even be named. particular application [2]. Within this debate, I take the view that technology is only Whereas the strategies in Textbox 1 are the broad principles persuasive when it employs specific behavior change that make gamification addictive, the gamification mechanics ingredients, as one of the key principles of evidence based (or tactics) are the on-screen features that users interact with. behavioral medicine [5-7]. These persuasive ingredients are the For instance, the strategy of motivating a user by comparing factors that exert persuasive force on people, encouraging them their progress with others can be implemented with the to shift their beliefs, attitudes, and actions. If these ingredients gamification tactic of showing the game leaders. Textbox 2 are removed, the technology is no longer persuasive. In the shows 10 of the most popular gamification tactics [13]. sciences, these ingredients have different names, but I will refer One of the chief misconceptions about gamification is that any to them as "behavior change strategies", "persuasive strategies", technology that employs game tactics will be more engaging. or simply, "strategies". The problem with this thinking is that it mistakes superficial To identify these gamification strategies, I reviewed a number game tactics for deeper psychological strategies. For instance, of popular gamification taxonomies from academic and it is risky to believe that badges will motivate users, without non-academic sources by Charles Coonradt [8], Reeves and considering the persuasive strategies that the game tactics must Read [9], Gabe Zichermann [10], and Marc Prensky [11]. I satisfy, where a badge’s value comes from a community that identified the common strategies listed by these authors, and places value on that badge, and where the badge’s value is compared them to a taxonomy of interactive behavior change further dependent on whether it transfers anything of value to and persuasive design strategies within my Persuasive the person. Offering game tactics that do not satisfy persuasive Communication Model [12]. strategies is like cooking dinner for someone with ingredients (game tactics) they do not like (strategies). After, I identified 7 core ingredients of gamification that have clear linkages to proven behavior change strategies, with the Textbox 1. The persuasive architecture of gamification and its 7 persuasive strategies. 1. Goal setting: Committing to achieve a goal 2. Capacity to overcome challenges: Growth, learning, and development 3. Providing feedback on performance: Receiving constant feedback through the experience 4. Reinforcement: Gaining rewards, avoiding punishments 5. Compare progress: Monitoring progress with self and others 6. Social connectivity: Interacting with other people 7. Fun and playfulness: Paying out an alternative reality http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Textbox 2. Popular gamification tactics. 1. Providing clear goals 2. Offering a challenge 3. Using levels (incremental challenges) 4. Allocating points 5. Showing progress 6. Providing feedback 7. Giving rewards 8. Providing badges for achievements 9. Showing the game leaders 10. Giving a story or theme with some users complaining that gamification was annoying. The Efficacy of Gamification Additionally, there were far more studies in particular contexts, such as online learning, intra-organizational systems, and work Overview environments, with the lack of studies from other domains In order for gamification to be considered effective, gamified possibly signaling that gamification may only work in contexts technology must outperform other design patterns, in terms of that already share a common persuasive architecture. Finally, its ability to influence people's beliefs, attitudes, or behaviors. the researchers raised one red flag, as they could not tell if the Moreover, to be considered effective, gamification must sustain reported outcomes represented sustainable long-term impacts, these impacts over the long-term, and offer more than a or just short-term novelty effects. short-term novelty effect. Ingredients That Have Been Proven to Work However, the question that is rarely asked is whether there is From the point of view of evidence-based behavioral medicine, evidence that shows gamification can influence how people the only thing that would matter in gamification is whether it think or behave? To answer this question, there are perhaps four employs principles and tactics that have been scientifically stream of evidence that we can draw from. They include (1) proven to influence health outcomes. anecdotal evidence, (2) research on the efficacy of gamification, (3) ingredients that have been proven to work, and (4) persuasive To quickly assess the link between gamification and health architecture that is related to proven theories. behavior change, I conducted an exploratory comparison of the 7 ingredients of gamification to behavioral science principles Anecdotal Evidence that have been proven to work in digital health behavior change Much of the hype around gamification seems to come from ad interventions, drawing on validated principles from my prior hoc anecdotal evidence, in the form of case studies and industry meta-analysis on the factors that make health behavior change claims. Although highly unreliable, this body of ad hoc success technologies work [2]. stories has served to raise awareness of gamification concepts, I mapped 27 techniques and principles to the 7 gamification and prompted researchers to take a closer look at gamification. strategies. Table 1 shows the top two most effective and Research on the Efficacy of Gamification statistically significant behavior change principle and techniques. As research on gamification started to appear just before 2010, This exploratory mapping demonstrates that there are some we recently reached the point where there were enough quality promising links between gamification principles and digital academic studies, that a team of researchers conducted a health behavior change science, with one gap that stood out, systematic review of the scientific literature [13]. In their being no strong link to fun and playfulness in health behavior publication, "Does Gamification Work?", the research team change approaches. Although gamification shows some clear found evidence across numerous studies, that gamification can links to health behavior change strategies and tactics, the influence psychological and physical outcomes, meaning technical mechanics used in health behavior change gamification can make a digital product more fun and engaging. interventions can be radically different than those used in However, not all studies showed positive effects, and the impact gamified technologies, even though they may appeal to similar seemed to vary according to the community, users, and product, psychological faculties. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Table 1. Gamification strategies and validated behavior change ingredients. Gamification strategies Validated behavior change ingredients [2] 1. Goal setting Agree behavioral contract Goal setting (behavior) 2. Capacity to overcome challenges Time management Action planning 3. Providing feedback on performance Prompt self-monitoring of behavioral outcome Prompt self-monitoring of behavior 4. Reinforcement Provide rewards contingent on successful behavior 5. Compare progress Prompt self-monitoring of behavioral outcome Provide normative information about others’ behavior 6. Social connectivity Social influences (norms) Plan social support/social change 7. Fun and playfulness N/A Persuasive Architecture That is Related to Proven Selecting the Right Persuasive Theories Architecture for an Interventions Beyond the direct empirical evidence, there is also theoretical Although there is evidence that suggests gamification works, support for gamification, as a framework that shares many there are some major risks associated with the current strategies in common with other theories that have been proven gamification hype. The chief risk is becoming overconfident in to work in the health field. the ability of gamification to exert massive influence across all The persuasive architecture of gamification shares elements in contexts, which can cause developers to form tunnel vision and common with coaching, which relies on a coach's ability to fixate on just one of many persuasive architectures. foster team member motivation, employ strategies to help their Locking into one framework might cause developers to miss team overcome opposition, provide support in building member's opportunities to identify the best architecture for the job. Every techniques, and help members build their character [14]. The persuasive architecture has its own unique mix of ingredients, architecture of gamification is also extremely close to the and suitability to particular users and contexts. For instance, a cybernetic variations of self-regulation theory, based on sign-up landing page, health screener, donation page, or social feedback loops, which cover all strategies except perhaps, social networking site all draw on different combinations of persuasive connectivity, and fun and playfulness [15]. Although ingredients. Moreover, my recent research is showing that the gamification shares the same strategies, there are big differences world's most successful websites are hyper optimized, often in the tactical way that these strategies are implemented. offering more persuasive strategies per square inch than many However, the similarity does mean that it is easier to gamify of the less popular sites. digital interventions modeled on coaching or self-regulation theory, because they are already quite similar. What matters in behavior change design is knowing which persuasive architecture is right for a particular application, and One of the theories that is infrequently used in the health field, identifying when gamification, in whole or part, is suitable to but popular among video game designers, is flow, the study of a particular application. how people become absorbed and engaged in an activity when they are doing something where their skill level is perfectly Assessing the Suitability of Gamification matched to the challenge level [16]. According to the principle of flow, if a game is too difficult, people will become stressed Intervention developers should only use gamification when it and stop playing. If a game is too easy, people will become is suitable to a given audience-product mix. However, it is not bored and stop playing. But if the challenge keeps increasing easy to know in advance whether or not gamification makes as the person’s skill increases, they will have a flow experience, sense for a particular project and its unique become absorbed in the task at hand, and experience a audience-intervention mix. meditative-like absorption in what they are doing. Bringing people to this state of mind is a key goal in game design. To evaluate if gamification is suitable to a particular intervention, Textbox 3 presents criteria that developers can use to evaluate when gamification offers a promising framework. However, users are the ultimate judges of intervention efficacy, so any gamified interventions will require user testing, to determine if they can work or not. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman Textbox 3. Criteria to consider when evaluating if gamification is suitable to a particular intervention. 1. The intervention users 2. The users’ social context 3. The psychological and behavioral outcomes that are being pursued 4. How closely the intervention's logic model or theory of change fits with the persuasive architecture of gamification 5. The interactive product or platform that is being planned 6. The compatibility of the interactive product, users, and community with the 7 gamification strategies 7. The compatibility of the interactive product, users, and community with gamification tactics finding innovative ways to make digital health interventions Final Thoughts fun and engaging. There is promising evidence that suggests gamification works, JMIR Serious Games is a new important journal devoted to and on the surface, gamification appears to share elements in research and opinion around games and gamification for common with proven health behavior change approaches. Given behavior change and other applications, and as one of the this, it is easy to see how existing digital interventions can editorial board members I look forward to help building the borrow gamification principles, by considering flow, meaningful evidence base in this emerging area. rewards, making them more social, and most importantly, Conflicts of Interest None declared. References 1. Snyder LB. Health communication campaigns and their impact on behavior. J Nutr Educ Behav 2007;39(2 Suppl):S32-S40. [doi: 10.1016/j.jneb.2006.09.004] [Medline: 17336803] 2. Cugelman B, Thelwall M, Dawes P. Online interventions for social marketing health behavior change campaigns: a meta-analysis of psychological architectures and adherence factors. J Med Internet Res 2011;13(1):e17 [FREE Full text] [doi: 10.2196/jmir.1367] [Medline: 21320854] 3. Lipsey M, Wilson D. Practical meta-analysis. Thousand Oaks, Calif: Sage; 2001. 4. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: Defining gamification. In: Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments.: Envisioning Future Media Environments; 2011 Presented at: MindTrek 11; 28-30 September 2011; Tampere, Finland. 5. Embry DD, Biglan A. Evidence-based kernels: fundamental units of behavioral influence. Clin Child Fam Psychol Rev 2008 Sep;11(3):75-113 [FREE Full text] [doi: 10.1007/s10567-008-0036-x] [Medline: 18712600] 6. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care 2005 Feb;14(1):26-33 [FREE Full text] [doi: 10.1136/qshc.2004.011155] [Medline: 15692000] 7. Davidson KW, Goldstein M, Kaplan RM, Kaufmann PG, Knatterud GL, Orleans CT, et al. Evidence-based behavioral medicine: what is it and how do we achieve it? Ann Behav Med 2003 Dec;26(3):161-171. [doi: 10.1136/qshc.2004.011155] [Medline: 14644692] 8. Coonradt CA. The Game of Work. Layton, Utah: Gibbs Smith; 2007. 9. Reeves B, Read J L. 2010. Ten ingredients of great games URL: http://www.cedma-europe.org/newsletter%20articles/misc/ Ten%20Ingredients%20of%20Great%20Games%20(Apr%2010).pdf [accessed 2013-11-26] [WebCite Cache ID 6LQaqKH16] 10. Zichermann G. 2011. The six rules of gamification cited 2013 5 Nov 2013; URL: http://www.gamification.co/2011/11/29/ the-six-rules-of-gamification/ [accessed 2013-11-26] [WebCite Cache ID 6LQb7JCpU] 11. Prensky M. Fun, play and games: What makes games engaging. In: Digital game-based learning. New York: McGraw-Hill; 12. Cugelman B. Persuasive design toolkit. Toronto, Canada: AlterSpark Corp; 2013. 13. Hamari J, Koivisto J, Sarsa H. Does gamification work? - a literature review of empirical studies on gamification (forthcoming). 2014 Presented at: 47th Hawaii International Conference on System Sciences; January 6-9, 2014; Hawaii, USA. 14. Kavussanu M, Boardley ID, Jutkiewicz N, Vincent S, Ring C. Coaching efficacy and coaching effectiveness: Examining their predictors and comparing coaches' and athletes' reports. The Sport Psychologist 2008;22(4):383-404. 15. Carver C, Scheier M. On the structure of behavioral self-regulation. In: Boekaerts M, Pintrich PR, Zeidner M, editors. Handbook of self-regulation. San Diego, Calif: Elsevier Academic Press; 2005:41-84. http://games.jmir.org/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Cugelman 16. Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York, USA: Harper Perennial Modern Classics; Edited by G Eysenbach; this is a non–peer-reviewed article. Submitted 26.11.13; accepted 28.11.13; published 12.12.13. Please cite as: Cugelman B JMIR Serious Games 2013;1(1):e3 URL: http://games.jmir.org/2013/1/e3/ doi: 10.2196/games.3139 PMID: 25658754 ©Brian Cugelman. Originally published in JMIR Serious Games (http://games.jmir.org), 12.12.2013. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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/2013/1/e3/ JMIR Serious Games 2013 | vol. 1 | iss. 1 | e3 | p. 6 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: Dec 12, 2013

Keywords: behavioral medicine; behaviour and behavior mechanisms; behavioral research; behavioral sciences; persuasive communication; health psychology; psychology; experimental game; interactive games; computer games

There are no references for this article.