An intervention that combined gamification, social support, and loss-framed financial incentives led to short-term increases in physical activity among veterans who were diagnosed with obesity or overweight—however, that improvement was not sustained in the long run, researchers found.
Over 80% of veterans have two or more risk factors for cardiovascular disease (CVD), and sustained physical activity has the potential to attenuate this risk. Unfortunately, motivating physical activity can be challenging at the individual level, and less than half of veterans engage in enough physical activity to reduce CVD risk. The question then is what interventional approaches can successfully encourage physical activity in this at-risk group.
In their study, published in JAMA Network Open, Anish K. Agarwal, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues landed on three potential strategies: gamification, or the application of game-design elements to motivate behavior change; social incentives, or motivating via social ties and connections; and loss-framed financial incentives, or cash/prize offers that the individual risks losing if they do not meet certain goals.
For their analysis, Agarwal and colleagues assessed the effectiveness of gamification with social support, with and without loss-framed financial incentives, against usual care to promote physical activity among veterans with overweight and obesity.
“In this randomized clinical trial of veterans classified as having overweight and obesity, we found that gamification with social support was associated with modestly increased physical activity compared with control during the intervention period when combined with loss-framed financial incentives,” they reported. “The magnitude of effect was approximately 1200 steps per day (1031 steps per day in the gamification with social support group and 1659 steps per day in the gamification with social support and financial incentives group), or 50 miles per individual over the intervention period (estimated as 2,000 steps per mile)… During the follow-up, the change in step counts compared with control decreased to 564 steps and was not significantly different. Gamification without incentives was not significantly different in either period. To our knowledge, this is one of the first trials to test these behavioral economic approaches among veterans.”
The study authors concluded that future studies should test interventions among a more representative sample of veterans, noting that such approaches may need to be combined with additional strategies—such as team-based cooperation or competition—to motivate larger and sustained changes in physical activity.
For this study, Agarwal and colleagues recruited patients ages 18 years or older receiving care at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia with a body mass index (BMI) greater than or equal to 25 who owned a smartphone or tablet. The study authors used Way to Health (WTH), a platform at the University of Pennsylvania, for remote monitoring and interventions—participants used WTH to create an account, provide consent, and complete baseline assessments, after which they were mailed a wrist-worn wearable device linked with WTH to allow for data sharing. In addition to the wearable device, all participants received $25 at enrollment and a further $50 upon completion.
After a two-week baseline period during which researchers established a baseline step count for patients, the control participants received feedback and goal-setting from their wearable device only. As for the intervention groups, after baseline patients were entered into an automated game with points and levels and were provided a daily progress notification. The design incorporated behavioral economic principles and progressed as follows:
- First, participants signed a precommitment pledge to strive for physical activity goals—this study included a four-week ramp-up period in which step goal targets increased 25% each week leading to the final goal. Patients were permitted to change their goals during the study period.
- Participants received 70 points per week (10 per day), but they lost 10 points if they did not achieve their goal.
- Participants moved up or down levels on the basis of weekly point totals (ranked from lowest to highest as blue, bronze, silver, gold, and platinum). If participants had 40 points or more at the end of each week, they would rank up.
- Participants in the interventions identified a social support sponsor; this sponsor was encouraged to support the participant, but the sponsor did not receive specific training on how to accomplish this. A weekly report detailing step goals, mean step count, points, and level was emailed to the sponsor.
In the loss-framed incentive group, participants played the same game but had $120 placed in a virtual account; if the participant missed their weekly goal, $10 was deducted.
The study’s primary outcome was change in mean daily steps from baseline during weeks 5-12 of the intervention period; secondary outcomes were change in mean daily steps from baseline during follow-up (weeks 13-20) and proportion of participant-days that step count was achieved during the intervention and follow-up.
A total of 10,046 veterans were invited to participate; of these, 677 (6.7%) were assessed for eligibility and 180 (1.8%) were randomized—60 to gamification with social support, 60 to gamification with social support and loss-framed financial incentive, and 60 to the control group. Mean age of participants was 56.5, mean weight was 217.3, 71 participants (39.4%) were women, 90 (50.0%) were White, and 67 (37.2%) were Black. Mean (SD) baseline daily step counts were 5,881 (2,038) for the control group, 6,012 (2,494) for the gamification with social support group, and 6,105 (2,320) for the gamification with social support and loss-framed financial incentive group.
“During the intervention period, compared with control group participants, participants in the gamification with financial incentives group had a significant increase in mean daily steps from baseline (adjusted difference, 1,224 steps; 95% CI, 451 to 1996 steps; P=0.005), but participants in the gamification without financial incentives group did not (adjusted difference, 433 steps; 95% CI, −337 to 1203 steps; P=0.81),” they found.
The increase for the gamification with financial incentives group was not sustained during follow-up and was not significantly different than the control group (adjusted difference, 564 steps; 95% CI, −261 to 1389 steps; P=0.37). However, compared with the control group, “participants in the intervention groups had a significantly higher adjusted proportion of days meeting their step goal during the main intervention and follow-up period (gamification with social support group, adjusted difference from control, 0.21 participant-day; 95% CI, 0.18-0.24 participant-day; P<0.001; gamification with social support and loss-framed financial incentive group, adjusted difference from control, 0.34 participant-day; 95% CI, 0.31-0.37 participant-day; P<0.001),” they added.
Agarwal and colleagues argued that, while the positive effects of the intervention were not sustained long-term, “the findings highlight the effect of combining gamification with financial incentives to increase activity by 20%. Future studies should explore how to sustain these changes, how to increase their magnitude, and the varying effect across patients.”
Study limitations included limiting the study population to patients in single VA system with smartphone or tablet access, which may limit generalizability; only a small percentage of veterans invited to participate expressed interest and were ultimately enrolled; a lack of data on other measures of activity beyond step count; longer term evaluations are needed, including investigations on metrics such as weight loss; the impact of increased step counts remains understudied; and the population was predominantly male, further limiting generalizability.
-
An intervention that combined gamification, social support, and loss-framed financial incentives led to short-term increases in physical activity among veterans who were diagnosed obese or overweight—however, that improvement was not sustained over follow-up.
-
The study authors concluded that future studies should explore how to sustain these changes in physical activity, how to increase their magnitude, and the varying effect across patients.
John McKenna, Associate Editor, BreakingMED™
Agarwal reported receiving contracts and grants from the US Food and Drug Administration, the Agency for Healthcare Research and Quality, and the Patient Centered Outcomes Research Institute (grant K12 HS026372) outside the submitted work. Coauthor Patel reported being a founder of Catalyst Health, a technology and behavior change consulting firm; serving on the medical advisory boards for Healthmine Services, Life.io, and Holistic Industries; and receiving research funding from Deloitte outside the submitted work.
Cat ID: 518
Topic ID: 86,518,730,795,518,917
