Gamification for global health

Co-authored by Raluca Buzdugan, a research scientist in UC Berkeley’s School of Public Health

Have you ever used a smartphone app to track physical activity and compete with your friends? Perhaps you belong to a coffee shop or supermarket customer loyalty program? Maybe you recently participated in UC Berkeley’s Big Give and watched the campus leaderboard to see your school’s share of the fundraising dollars? If so, you have first hand experience with gamification, the use of game elements in non-game settings.

Gamification is popping up everywhere in our daily lives, with applications to management, commerce and health. Why? Because the evidence suggests that it works. Specifically, gamification creatively improves attitudes towards activities that individuals are unmotivated to undertake by embedding them in game-like environments. Gamification’s effect on motivation is supported by theories from psychology and behavioral economics as well as game design know-how.

two young men with a phoneFor example, the rewards used in gamification (e.g., points, badges, leaderboard position) may influence people by leveraging their basic needs for autonomy, cooperation and competition. Furthermore, challenging activities that require a pattern of attempt-failure-attempt-success – an experience common in games – can increase dopamine levels, which increase motivation (McGonigal, 2011). 

Support for the effectiveness of interventions using gamification is growing. For example, Goalpost, a smoking cessation app that incorporates social networking and game mechanics, helped 23 percent of 7,000 Goalpost users in New Zealand quit smoking after 12 weeks, double the quit rate among the general population (Gomura-Elkan, R, 2015). In Zambia, a project rewarded hairdressers who sold female condoms by giving them gold stars, which were publicly displayed on a plaque in beauty salons and counted towards an award from a local celebrity. Using gamification terminology, the stars were “points”, the hairdressers earned fun “rewards”, and the plaques were “leaderboards” of rankings. This low-tech approach was twice as effective as small financial incentives at motivating women to sell condoms.

In the United States, Thrive With Me was an online social support intervention for gay and bisexual men living with HIV which incorporated some gamification elements such as reminders and points for participation towards weekly raffles. After three months, antiretroviral treatment adherence significantly improved among the subset of men who used drugs (Horvath, K. J. et al , 2013).

Taken together, these studies and others suggest that incorporating game-like elements into health programs is both feasible and beneficial.

We hypothesize that gamification is a promising tool to address many global health challenges. For example, gamification interventions could facilitate the initial linkage to a health service, product, or program (e.g., bed nets, family planning services, antenatal care) and could help people establish good health habits (e.g., resisting the urge to smoke, adherence to medication, regular exercise). In addition, gamification could be used to build communities through community competitions or could improve health service delivery by motivating providers to engage in training programs and/or to improve the quality of their services. Furthermore, in many resource-constrained settings, health programs typically operate by passively “waiting” for clients to access their services. Gamification interventions have a unique advantage in this situation by offering patients something else in addition to health services, often in the form of a fun reward mechanism. In doing so, gamification interventions have the potential to create demand for health products, services, and programs beyond what has been achieved with traditional public health approaches alone (e.g., information, education, communication).

We are currently evaluating the potential of gamification applied to an HIV prevention program for young gay and bisexual men in California. In collaboration with researchers at UCLA and the AIDS Healthcare Foundation, we developed the intervention Stick To It using principles from user-centered design and game design. The goal is to determine whether gamification can boost the impact of existing and effective sexual health prevention services, including encouraging men to be regularly screened for HIV and other sexually transmitted infections. Young men in Stick To It register online and earn points for various activities including: completing periodic whimsical health-related quizzes, setting a countdown “testing timer” to keep track of quarterly clinic visits (recommended by the Centers for Disease Control), and referring their friends. Points can be redeemed in participating clinics for a chance to win prizes. We will know later this year if the approach was successful, and if so, we will identify which elements of the intervention could be used to enhance sexual and reproductive health programs here and in other parts of the world.

Certainly, games aren’t for everyone. However, behavior change is about finding the right tool to motivate different kinds of people. Gamification interventions may resonate particularly well with adolescents, who are extremely comfortable with games and technology. However, adults play games, too, and often the game elements in gamification-infused projects are not as overt as they are in traditional video games or apps like Candy Crush. For example, it’s unlikely that people in customer loyalty programs – which are rudimentary applications of gamification – would describe these programs as “games” despite the presence of game elements like points and rewards. Gamification can be subtle and therefore can work for a variety of people and contexts. And what’s even more compelling is that gamification done well may create longer-lasting behavior change than tools like financial incentives alone.

New innovations are often introduced with significant hype but do not fulfill their potential in the long term. Will this be the case with gamification in the global health context? While possible, we don’t think so. Certainly, we need more studies of interventions that include game elements in both resource-limited and resource-rich environments. This will require recognition by funding agencies that gamification is a promising avenue of research as well as the development and evaluation of truly fun and creative gamification interventions, a process that must include game design and gamification experts. It may also require a new way of working with ethical review boards to reflect the need for rapid iteration to refine and adapt these highly innovative programs. With these building blocks in place, we can better understand the full potential of gamification for the global health challenges of today.

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