gamification of behavior change: using game mechanics and behavior change techniques in...

Gamification of behavior change:Using game mechanics and behavior change techniques in ehealth/mhealth interventionsElizabeth J. Lyons, PhD, MPH

Maria Swartz, PhD, MPH, RD

February 19, 2015

Department of Nutrition and Metabolism

Gamification & behavior change


What gamification is (theoretically)

What gamification is (in practice)

But what should gamification be?

Game mechanic or behavior change technique?

Using theory to guide BCT implementation

What is gamification?


Using game mechanics to increase motivation

In practice, though…

• Using badges, leaderboards, and leveling up to trick people into doing something they don’t like

• Often added to something required to make it more appealing

Those sound kind of like extrinsic rewards to me…

• You’re right!

• That’s bad, isn’t it?

• You’re right!

What should gamification be?


Using game mechanics to increase motivation

What is a game?

• “Gratuitous introduction of unnecessary obstacles to the achievement of an end” (Suits)

What is required for a game to be a game?

• Lusory goals

• Pre-lusory goals

• Rules

• Pure, complete autonomy

Gamification = autonomy support


Magic circle

• The state of mind that defines play as safe, separated from the real world but still connected to it

Intrinsic motivation

• Play IS intrinsic motivation

Practice and failure

• Games require failure (arguably)

• Games reframe failure as well as success

• Games are practice

So you want to use video games…


…to increase physical activity in a program

• There are some really important things to consider

• Recall that the vast majority of studies have found null results

• You need to be super clear about how EXACTLY the desired behavior change is supposed to occur

Game mechanics have meaning


Just throwing a game mechanic on an app is unlikely to work

Context is extremely important

You are working to encourage and support feelings of

• Autonomy

• Competence

• Relatedness

Game characteristics of particular import are

• Feedback

• Rewards

• Challenge

Feedback


Social cognitive theory:

• Specific

• Clear

• Compare to past accomplishments, similar groups, goals

Self-determination theory

• Richly informational

• Empowering mastery

• Multiple levels (moment to moment, sustained, cumulative)

Rigby, 2012; Rovniak et al., 2005

Not-so-good feedback


A breakdown of good feedback


Rewards


Why are extrinsic rewards so bad?

• They seem to work short-term

• But once you have the achievement, there’s no point to continuing

• They dictate how you are supposed to play, which can be good or bad

• Large literature on extrinsic rewards reducing intrinsic motivation

• Controversial

• Likely due to the presence of many moderating variables

• In other words: implementation and context matter

Autonomy vs. control & rewards


Four types of rewards

• Verbal, intangible

• “The grateful masses” in RPGs

• Unexpected, task non-contingent

• Task-contingent

• Engaging in task

• Completing task

• Performance-contingent

Rigby, 2009

Not great rewards: an example


Beauty Idol (iOS) boyfriends

• Acquire boyfriend

• Sequester him in your home

• Tap on him to receive rewards

• Discard boyfriend

Highly reinforcing rewards


Fire Emblem: Awakening (3DS) supports

• Your mating strategy impacts both the story and your success

• Example: Gerome, or “If Batman were also Morrissey”

• Strategy 1: give him the strongest dad, mate

• Rewards: super strong kid, declarations of love, sparkles

Highly reinforcing rewards


Fire Emblem: Awakening (3DS) supports

• Your mating strategy impacts both the story and your success

• Example: Gerome, or “If Batman were also Morrissey”

• Strategy 2: mate with his mom

• Rewards: torture him with dad jokes, team up as angsty father/son duo, witness significantly less smooth romancing

Why autonomy in rewards matters

Department of Nutrition and Metabolismhttp://www.xboxachievements.com/game/your-shape-fitness-evolved/achievement/45480-Calorie-Score-10-000.html

Challenge


Repens (exploration, discovery, learning from surprise)

Repositio (replaying, returning, learning from re-trying)

Falstein, 2005 cited in Juul, 2009; Lauwaert et al 2007

Failure isn’t the end of the world


Failure is necessary for autonomy support

Games should frame failure as

• Unstable vs. stable

• Specific vs. global

• Internal vs. external

• Less pleasurable, but must take responsibility

Games induce failure, then teach us how to overcome it

• Reframing failure from trait to state

• The right kind of failure should actually support competence

Juul, 2013

What gamification should be


It’s not just “make exercise more fun”

It’s “make exercise more fun by…”

• Providing a solid rationale and choices

• Increasing feelings of competence (which involves deliberately inducing failure)

• Encouraging relationships with others (including fake others)

Behavioral Change Techniques and Wearable Activity Trackers


• <50% of U.S. adults meet the 2008 Physical activity (PA) guidelines.

• Behavioral PA interventions have shown success in increasing activity levels, but may be costly to implement on a larger scale. (Archer et al., 2012)

• Traditional health behavior change interventions are limited (Pagoto & Bennett, 2013):

o Ability to measure and intervene on behavior in real time

o Adherence varied widely (e.g. physical activity log)

Wearable Activity Trackers: Promising Medium


• 1 in 10 U.S. adults now own a fitness tracker. (NDP Connected Intelligence Report, 12/2014)

Device Category 2013 2014 2015 2016Smart Wristband 30 20 17 19Sports Watch 14 18 21 24

Other Fitness Monitor 18 20 12 15Chest Strap 11 12.1 8 7.3Smart Garment 0.01 0.1 10.1 26Total Market 73.01 70.2 68.1 91.3

Table 1 — Worldwide Wearable Electronic Fitness Devices Shipments Forecast, 2013-2016 (Millions of Units)

• Wearable activity trackers and their apps show promise as a medium to deliver a more personalized PA intervention.

Which one to choose?


• Cost vs. Function

Behavioral Change Techniques and Wearable Activity Trackers


• A mix of behavioral and cognitive strategies are needed in order to change PA behavior. (Pagoto & Bennett, 2013)

o Which one is most effective to impact change?

• Purpose of the study by Lyons et al. (2014)1. Characterize behavior change techniques used

in trackers

2. Determine the extent to which they include techniques associated with successful outcomes

3. Compare implementation of several critical techniques to theory-based and evidence-based recommendation

What is a behavior change technique?


Higher category Technique Description

Goals & planning

Goal-setting (behavior) Set or agree on a goal defined in terms of the behavior to be achieved

Action planning Prompt detailed planning of performance of the behavior

Commitment Ask the person to affirm or reaffirm statements indicating commitment to change the behavior

Feedback & monitoring

Feedback on behavior Monitor and provide informative or evaluative feedback on performance of the behavior

Self-monitoring of behavior Establish a method for the person to monitor and record their behavior(s) as part of a behavior change strategy

Michie et al., 2013 (http://www.ucl.ac.uk/health-psychology/bcttaxonomy)

Lyons et al. (2014)—Methods


• Evaluated 13 wearable activity trackers.

o Sources: CNET reviews, “Health and Fitness” section of the Apple Store, “Activity Monitor” search on Amazon, and suggestion from expert colleagues.

o Monitors: Basis B1, BodyMedia Fit, Fitbit Force, Fitbug Orb, Gruve, Ibitz Unity, Jawbone Up24, Lumo Back, Misfit Shine, Nike FuelbandSE, POLAR Loop, Striiv Play, and Withings Pulse.

• Inclusion criteria:

1. Continuous monitoring of some kind of physical activity outcome

2. Recent iteration of similar series of products by the same company

3. Provide feedback through mobile device or personal computer

Lyons et al. (2014)—Methods (Cont.)


• Coding procedure done based on the taxonomies of behavior change techniques by Michie et al (2013).

o Tentative list of 16 behavioral change techniques impactful behavior change techniques on changing PA behavior was developed.

• Meta-analyses

• Meta-regressions

• Systematic reviews

• U.S. Preventive Services Task Force

• 2 Coders wore each of the monitors and used the apps for at least 1 week between 11/2013 and 2/2014.

• Coding was based on full access to all behavioral tools (including the paid options)

List of BCT associated with PA (Part 1)


BCT # Behavior Change Techniques (BCT)

8.1 Prompt practice

2.3 Prompt self-monitoring of behavior

1.1 Goal-setting/intention formation

1.2 Barrier identification/problem solving

2.2 Provide feedback on performance

1.5 Prompt review of behavior goals

5.1 Provide information on consequences of behavior in general

Lyons et al. 2014

List of BCT associated with PA (Part 2)


BCT # Behavior Change Techniques

1.4 Action planning

10.3 Prompt rewards contingent on effort or progress towards behavior

6.2 Facilitate social comparison

4.1 Provide instruction

15.4 Self-talk

10.9 Self-rewards

3 Social support

7.1 Teach to use prompts/cues

Lyons et al. 2014

Lyons et al. (2014)—Results


• 6 behavior change techniques in >76% (10/13 to 13/13) of the wearable activity trackers’ apps.

BCT category BCT # of Monitors

Goals & Planning Goal setting (behavior) 13

Review behavior goal(s) 10

Discrepancy between current behavior and goal

13

Feedback & Monitoring Feedback on behavior 13

Self-monitoring of behavior 13

Antecedents Adding objects to the environment 13

Goal-setting (behavior) & Feedback

Institute for Translational Sciences

Self-monitoring of PA behavior

Lyons et al. (2014)—Results (Cont.)


• 6 additional behavior change techniques in >60% (8/13) of the wearable activity trackers’ apps:

BCT category BCT # of Monitors

Goals & Planning Goal setting (outcome) 8

Feedback & Monitoring Self-monitoring of outcome(s) of behavior

8

Feedback on outcome(s) of behavior 8

Social support Social support (unspecified) 8

Comparison of behavior Social comparison 8

Reward and threat Social reward 8

Lyons et al. 2014

Goal-setting (outcome) & Social Support

Institute for Translational Sciences

Lyons et al. (2014)—Results (Cont.)


• Rare/Missing behavior change techniques/alternative presentation:

o Rare: Information about consequences of the behavior, action planning, and problem solving

o Missing: Prompting practice, self-rewards, and self-talk

Lyons et al. 2014

Action planning & problem-solving


Theory-based recommendations


Top 3 monitors’ apps with the most techniques coded (Appendix 2)

Department of Nutrition and MetabolismLyons et al. 2014

Top 3 monitors’ apps with the most techniques coded (Cont.)

Department of Nutrition and MetabolismLyons et al. 2014

Conclusion


• Apps interfaced with the wearable activity trackers incorporated into this review included a variety of evidence-based behavior change techniques. Many also conform to theory-based recommendations.

• Most commonly found techniques are:

o Self-monitoring

o Feedback provision

o Adding objects to the environment

o Goal-setting

• Be aware of missing techniques such as prompting practice, self-reward, and self-talk.

Recommendations


• Conduct a mini trial prior to full-scale implementation.

o Apps are being updated constantly.

• Example: Contents within several apps were changed within 6 months of manuscript submission. Lyons et al. had to re-code and update the results.

• Familiarize yourselves with the location and the display of various options within the apps.

• Familiarize yourselves with how the apps and the monitors interact.

• Keep track of what behavior change techniques participants are using during the intervention.

Acknowledgements and thanks


Funding• ACS (MRSG-14-165-01-CPPB)• AHA (13BGIA17110021)

• NIH CTSA (UL1RR029876)

• NIH Pepper OAIC (P30AG024832)

Mentors & collaborators• Tom Baranowski (BCM)

• Karen Basen-Engquist (MDA)

• Abbey Berenson

• Jim Goodwin

• Koyya Lewis-Powell

• Eloisa Martinez

• Sara Nowakowski

• Ken Ottenbacher

• Jennifer Rowland

• Maria Swartz

• Elena Volpi

Happy Chinese New Year!

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