Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials

by | Jan 1, 2022 | Research Publications

Author(s):

  • Alexandre Mazeas
  • Martine Duclos
  • Bruno Pereira
  • Aïna Chalabaev

Abstract:

Background: Gamification refers to the use of game elements in nongame contexts. The use of gamification to change behaviors and promote physical activity (PA) is a promising avenue for tackling the global physical inactivity pandemic and the current prevalence of chronic diseases. However, there is no evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature.

Objective: The aim of this systematic review and meta-analysis is to evaluate the effectiveness of gamified interventions and their health care potential by testing the generalizability and sustainability of their influence on PA and sedentary behavior.

Methods: A total of 5 electronic databases (PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials published in English from 2010 to 2020. Eligibility criteria were based on the components of the participants, interventions, comparators, and outcomes framework. Studies were included when they used gamified interventions in daily life with an active or inactive control group and when they assessed a PA or sedentary behavior outcome. We conducted meta-analyses using a random-effects model approach. Sensitivity analyses, influence analyses, and publication bias analyses were performed to examine the robustness of our results.

Results: The main meta-analysis performed on 16 studies and 2407 participants revealed a small to medium summary effect of gamified interventions on PA behavior (Hedges g=0.42, 95% CI 0.14-0.69). No statistical difference among different subgroups (adults vs adolescents and healthy participants vs adults with chronic diseases) and no interaction effects with moderators such as age, gender, or BMI were found, suggesting good generalizability of gamified interventions to different user populations. The effect was statistically significant when gamified interventions were compared with inactive control groups, such as waiting lists (Hedges g=0.58, 95% CI 0.08-1.07), and active control groups that included a nongamified PA intervention (Hedges g=0.23, 95% CI 0.05-0.41). This suggests that gamified interventions are not only efficient in changing behavior but also more effective compared with other behavioral interventions. The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) was weaker, with a very small to small effect (Hedges g=0.15, 95% CI 0.07-0.23).

Conclusions: This meta-analysis confirms that gamified interventions are promising for promoting PA in various populations. Additional analyses revealed that this effect persists after the follow-up period, suggesting that it is not just a novelty effect caused by the playful nature of gamification, and that gamified products appear effective compared with equivalent nongamified PA interventions. Future rigorous trials are required to confirm these findings.

Documentation:

https://doi.org/10.2196/26779

References:
  1. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 2012 Jul 21;380(9838):247-257. [CrossRef] [Medline]
  2. Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012 Jul 21;380(9838):219-229 [FREE Full text] [CrossRef] [Medline]
  3. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002 Sep 05;347(10):716-725. [CrossRef] [Medline]
  4. Wolin KY, Yan Y, Colditz GA, Lee I. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer 2009 Feb 24;100(4):611-616 [FREE Full text] [CrossRef] [Medline]
  5. Duclos M, Oppert J, Verges B, Coliche V, Gautier J, Guezennec Y, SFD Diabetes and Physical Activity Working Group. Physical activity and type 2 diabetes. Recommandations of the SFD (Francophone Diabetes Society) diabetes and physical activity working group. Diabetes Metab 2013 May;39(3):205-216. [CrossRef] [Medline]
  6. Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015 Dec;25 Suppl 3:1-72. [CrossRef] [Medline]
  7. Ekelund U, Tarp J, Steene-Johannessen J, Hansen BH, Jefferis B, Fagerland MW, et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis. Br Med J 2019 Aug 21;366:l4570 [FREE Full text] [CrossRef] [Medline]
  8. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, et al. Daily sitting time and all-cause mortality: a meta-analysis. PLoS One 2013 Nov 13;8(11):e80000 [FREE Full text] [CrossRef] [Medline]
  9. Ekelund U, Tarp J, Fagerland M, Johannessen J, Hansen B, Jefferis B, et al. Joint associations of accelero-meter measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middle-aged and older individuals. Br J Sports Med 2020 Dec;54(24):1499-1506 [FREE Full text] [CrossRef] [Medline]
  10. 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. 2011 Presented at: MindTrek ’11: Academic MindTrek 2011; September 28 – 30, 2011; Tampere Finland p. 9-15. [CrossRef]
  11. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games 2013 Dec;1(1):e3 [FREE Full text] [CrossRef] [Medline]
  12. Hamari J, Koivisto J, Sarsa H. Does Gamification Work? — A Literature Review of Empirical Studies on Gamification. In: Proceedings of the 47th Hawaii International Conference on System Sciences. 2014 Presented at: 47th Hawaii International Conference on System Sciences; January 6-9, 2014; Waikoloa, HI, USA. [CrossRef]
  13. Johnson D, Deterding S, Kuhn K, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: a systematic review of the literature. Internet Interv 2016 Nov;6:89-106 [FREE Full text] [CrossRef] [Medline]
  14. Munson S, Poole E, Perry DB, Peyton T. Gamification and health. In: Walz SP, Deterding S, editors. The Gameful World: Approaches, Issues, Applications. Cambridge, London: MIT Press; 2015:597-624.
  15. Koivisto J, Hamari J. Gamification of physical activity: a systematic literature review of comparison studies. In: Proceedings of the 3rd International GamiFIN Conference. 2019 Presented at: 3rd International GamiFIN Conference, GamiFIN 2019; April 8-10, 2019; Levi, Finland p. 106-117   URL: https:/​/researchportal.​tuni.fi/​en/​publications/​gamification-of-physical-activity-a-systematic-literature-review-
  16. Seaborn K, Fels DI. Gamification in theory and action: a survey. Int J Hum-Comput Stud 2015 Feb;74:14-31. [CrossRef]
  17. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med 2009;3(3):123-130 [FREE Full text] [Medline]
  18. Quintana DS. From pre-registration to publication: a non-technical primer for conducting a meta-analysis to synthesize correlational data. Front Psychol 2015 Oct 08;6:1549 [FREE Full text] [CrossRef] [Medline]
  19. Mazéas A, Duclos M, Pereira B, Chalabaev A. Does gamification improve physical activity? A systematic review and meta-analysis. Center for Open Science (OSF) 2020. [CrossRef]
  20. Moreau D, Gamble B. Conducting a meta-analysis in the age of open science: tools, tips, and practical recommendations. Psychol Methods 2020 Sep 10. [CrossRef] [Medline]
  21. Corepal R, Best P, O’Neill R, Kee F, Badham J, Dunne L, et al. A feasibility study of ‘The StepSmart Challenge’ to promote physical activity in adolescents. Pilot Feasibility Stud 2019 Nov;5:132 [FREE Full text] [CrossRef] [Medline]
  22. Dadaczynski K, Schiemann S, Backhaus O. Promoting physical activity in worksite settings: results of a German pilot study of the online intervention Healingo fit. BMC Public Health 2017 Sep 08;17(1):696 [FREE Full text] [CrossRef] [Medline]
  23. Leinonen A, Pyky R, Ahola R, Kangas M, Siirtola P, Luoto T, et al. Feasibility of gamified mobile service aimed at physical activation in young men: population-based randomized controlled study (MOPO). JMIR Mhealth Uhealth 2017 Oct 10;5(10):e146 [FREE Full text] [CrossRef] [Medline]
  24. Maher C, Ferguson M, Vandelanotte C, Plotnikoff R, De BI, Thomas S, et al. A web-based, social networking physical activity intervention for insufficiently active adults delivered via facebook app: randomized controlled trial. J Med Internet Res 2015;17(7):e174 [FREE Full text] [CrossRef] [Medline]
  25. Nishiwaki M, Kuriyama A, Ikegami Y, Nakashima N, Matsumoto N. A pilot crossover study: effects of an intervention using an activity monitor with computerized game functions on physical activity and body composition. J Physiol Anthropol 2014 Dec 02;33:35 [FREE Full text] [CrossRef] [Medline]
  26. Patel MS, Benjamin EJ, Volpp KG, Fox CS, Small DS, Massaro JM, et al. Effect of a game-based intervention designed to enhance social incentives to increase physical activity among families: the BE FIT randomized clinical trial. JAMA Intern Med 2017 Nov 01;177(11):1586-1593 [FREE Full text] [CrossRef] [Medline]
  27. Patel MS, Small DS, Harrison JD, Fortunato MP, Oon AL, Rareshide CA, et al. Effectiveness of behaviorally designed gamification interventions with social incentives for increasing physical activity among overweight and obese adults across the united states: the STEP UP randomized clinical trial. JAMA Intern Med 2019 Sep 09:1-9 [FREE Full text] [CrossRef] [Medline]
  28. Paul L, Wyke S, Brewster S, Sattar N, Gill JMR, Alexander G, et al. Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study. Top Stroke Rehabil 2016 Jun;23(3):170-177. [CrossRef] [Medline]
  29. Thorsteinsen K, Vittersø J, Svendsen GB. Increasing physical activity efficiently: an experimental pilot study of a website and mobile phone intervention. Int J Telemed Appl 2014;2014:746232 [FREE Full text] [CrossRef] [Medline]
  30. Zuckerman O, Gal-Oz A. Deconstructing gamification: evaluating the effectiveness of continuous measurement, virtual rewards, and social comparison for promoting physical activity. Pers Ubiquit Comput 2014 Jul 5;18(7):1705-1719. [CrossRef]
  31. Direito A, Jiang Y, Whittaker R, Maddison R. Apps for IMproving FITness and increasing physical activity among young people: the AIMFIT pragmatic randomized controlled trial. J Med Internet Res 2015;17(8):e210 [FREE Full text] [CrossRef] [Medline]
  32. Edney SM, Olds TS, Ryan JC, Vandelanotte C, Plotnikoff RC, Curtis RG, et al. A social networking and gamified app to increase physical activity: cluster RCT. Am J Prev Med 2020 Feb;58(2):51-62. [CrossRef] [Medline]
  33. Garde A, Umedaly A, Abulnaga SM, Junker A, Chanoine JP, Johnson M, et al. Evaluation of a novel mobile exergame in a school-based environment. Cyberpsychol Behav Soc Netw 2016 Mar;19(3):186-192. [CrossRef] [Medline]
  34. Gremaud AL, Carr LJ, Simmering JE, Evans NJ, Cremer JF, Segre AM, et al. Gamifying accelerometer use increases physical activity levels of sedentary office workers. J Am Heart Assoc 2018 Jul 02;7(13) [FREE Full text] [CrossRef] [Medline]
  35. Höchsmann C, Müller O, Ambühl M, Klenk C, Königstein K, Infanger D, et al. Novel smartphone game improves physical activity behavior in type 2 diabetes. Am J Prev Med 2019 Jul;57(1):41-50 [FREE Full text] [CrossRef] [Medline]
  36. Kurtzman GW, Day SC, Small DS, Lynch M, Zhu J, Wang W, et al. Social incentives and gamification to promote weight loss: the LOSE IT randomized, controlled trial. J Gen Intern Med 2018 Oct;33(10):1669-1675. [CrossRef] [Medline]
  37. Helmerhorst HJ, Brage S, Warren J, Besson H, Ekelund U. A systematic review of reliability and objective criterion-related validity of physical activity questionnaires. Int J Behav Nutr Phys Act 2012;9:103 [FREE Full text] [CrossRef] [Medline]
  38. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions, Second Edition. Hoboken, New Jersey, United States: John Wiley & Sons; 2019.
  39. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005 Apr 20;5:13 [FREE Full text] [CrossRef] [Medline]
  40. DerSimonian R, Laird N. Meta-analysis in clinical trials revisited. Contemp Clin Trials 2015 Nov;45(Pt A):139-145 [FREE Full text] [CrossRef] [Medline]
  41. IntHout J, Ioannidis JP, Borm GF. The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis is straightforward and considerably outperforms the standard DerSimonian-Laird method. BMC Med Res Methodol 2014 Feb 18;14:25 [FREE Full text] [CrossRef] [Medline]
  42. Hedges LV. Distribution theory for glass’s estimator of effect size and related estimators. J Edu Stat 2016 Nov 23;6(2):107-128. [CrossRef]
  43. Cohen J. Statistical Power for the Behavioral Sciences (2nd Edition). Hillsdale, NJ: Laurence Erlbaum Associates; 1988.
  44. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Br Med J 2003 Sep 06;327(7414):557-560 [FREE Full text] [CrossRef] [Medline]
  45. Baujat B, Mahé C, Pignon J, Hill C. A graphical method for exploring heterogeneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med 2002 Sep 30;21(18):2641-2652. [CrossRef] [Medline]
  46. Egger M, Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Br Med J 1997 Sep 13;315(7109):629-634 [FREE Full text] [CrossRef] [Medline]
  47. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000 Jun;56(2):455-463. [CrossRef] [Medline]
  48. Kossmeier M, Tran US, Voracek M. Power-enhanced funnel plots for meta-analysis. Zeitschrift für Psychologie 2020 Mar;228(1):43-49. [CrossRef]
  49. Harrer M, Cuijpers P, Furukawa TA, Ebert DD. Doing Meta-Analysis with R : A Hands-On Guide. Boca Raton, Florida, United States: Chapman and Hall/CRC; 2021.
  50. McGuinness LA, Higgins JP. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods 2021 Jan 06;12(1):55-61. [CrossRef] [Medline]
  51. Garde A, Umedaly A, Abulnaga SM, Robertson L, Junker A, Chanoine JP, et al. Assessment of a mobile game (“MobileKids Monster Manor”) to promote physical activity among children. Games Health J 2015 Apr;4(2):149-158. [CrossRef] [Medline]
  52. Garde A, Chowdhury M, Rollinson AU, Johnson M, Prescod P, Chanoine JP, et al. A multi-week assessment of a mobile exergame intervention in an elementary school. Games Health J 2018 Feb;7(1):1-8. [CrossRef] [Medline]
  53. Orwin R, Vevea J. Evaluating coding decisions. In: The Handbook of Research Synthesis and Meta-Analysis, 2nd Ed. New York: Russell Sage Foundation; 2009.
  54. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000 Jan;55(1):68-78. [CrossRef] [Medline]
  55. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research & Practice 1982;19(3):276-288. [CrossRef]
  56. Bandura A. Health promotion from the perspective of social cognitive theory. Psychol Health 1998 Jul;13(4):623-649. [CrossRef]
  57. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991 Dec;50(2):179-211. [CrossRef]
  58. Schwarzer R. Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol 2008 Jan;57(1):1-29. [CrossRef]
  59. Gomersall S, Maher C, English C, Rowlands A, Olds T. Time regained: when people stop a physical activity program, how does their time use change? A randomised controlled trial. PLoS One 2015 May;10(5):e0126665 [FREE Full text] [CrossRef] [Medline]
  60. Lee I, Shiroma EJ, Kamada M, Bassett DR, Matthews CE, Buring JE. Association of step volume and intensity with all-cause mortality in older women. JAMA Intern Med 2019 May 29:1105-1112 [FREE Full text] [CrossRef] [Medline]
  61. Yates T, Zaccardi F, Dhalwani NN, Davies MJ, Bakrania K, Celis-Morales CA, et al. Association of walking pace and handgrip strength with all-cause, cardiovascular, and cancer mortality: a UK Biobank observational study. Eur Heart J 2017 Nov 14;38(43):3232-3240 [FREE Full text] [CrossRef] [Medline]
  62. Oja P, Kelly P, Murtagh EM, Murphy MH, Foster C, Titze S. Effects of frequency, intensity, duration and volume of walking interventions on CVD risk factors: a systematic review and meta-regression analysis of randomised controlled trials among inactive healthy adults. Br J Sports Med 2018 Jun;52(12):769-775. [CrossRef] [Medline]
  63. Murtagh EM, Nichols L, Mohammed MA, Holder R, Nevill AM, Murphy MH. The effect of walking on risk factors for cardiovascular disease: an updated systematic review and meta-analysis of randomised control trials. Prev Med 2015 Mar;72:34-43. [CrossRef] [Medline]
  64. Gao H, Gao H, Sun FM, Zhang L. Effects of walking on body composition in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Menopause 2016 Aug;23(8):928-934. [CrossRef] [Medline]
  65. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The physical activity guidelines for Americans. J Am Med Assoc 2018 Nov 20;320(19):2020-2028. [CrossRef] [Medline]
  66. Finkelstein EA, Haaland BA, Bilger M, Sahasranaman A, Sloan RA, Nang EE, et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol 2016 Dec;4(12):983-995. [CrossRef] [Medline]
  67. Romeo A, Edney S, Plotnikoff R, Curtis R, Ryan J, Sanders I, et al. Can smartphone apps increase physical activity? Systematic review and meta-analysis. J Med Internet Res 2019 Mar 19;21(3):e12053 [FREE Full text] [CrossRef] [Medline]
  68. Chen XS, Changolkar S, Navathe AS, Linn KA, Reh G, Szwartz G, et al. Association between behavioral phenotypes and response to a physical activity intervention using gamification and social incentives: Secondary analysis of the STEP UP randomized clinical trial. PLoS One 2020;15(10):e0239288 [FREE Full text] [CrossRef] [Medline]
  69. Rhodes RE, Janssen I, Bredin SS, Warburton DE, Bauman A. Physical activity: health impact, prevalence, correlates and interventions. Psychol Health 2017 Aug;32(8):942-975. [CrossRef] [Medline]
  70. Faggiano F, Allara E, Giannotta F, Molinar R, Sumnall H, Wiers R, et al. Europe needs a central, transparent, and evidence-based approval process for behavioural prevention interventions. PLoS Med 2014 Oct;11(10):e1001740 [FREE Full text] [CrossRef] [Medline]
  71. 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 Feb 13;7(1):e11444 [FREE Full text] [CrossRef] [Medline]
  72. Haque MS, Kangas M, Jämsä T. A persuasive mhealth behavioral change intervention for promoting physical activity in the workplace: feasibility randomized controlled tria. JMIR Form Res 2020 May 04;4(5):e15083 [FREE Full text] [CrossRef] [Medline]

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