Physicians often struggle to help patients change their health behaviors. Patients may know that they need to quit smoking, lose weight, or exercise more, but summoning the will to change is hard. It’s particularly difficult for the highest-risk patients who may have life circumstances challenges such as unemployment or homelessness that make it harder for them to focus on the long-term. But combining behavioral economics and “gamification” putting game elements such as points and achievement levels into non-game contexts holds promise for driving behavior change when a doctor’s advice, and patient’s good intentions, are not enough.
Other industries have long used game elements that leverage behavioral science to drive desired customer behavior (think airline loyalty programs that award points and status for miles traveled). And indeed gamification in healthcare is increasingly being incorporated into health insurance design and wellness programs. However, despite its growing use, there’s only limited evidence of its effectiveness in health care, and in particular whether existing gamification makes the best use of behavioral economic principles. Members of our group recently evaluated 50 of the most popular smartphone applications for health and fitness and found that while nearly two-thirds of the apps used game elements in their design, none incorporated several key insights from behavioral economics that could effectively influence desired actions and address predictable barriers to behavior change.
A central challenge for all gamification in healthcare programs is engaging participation, particularly among high-risk patients. Several design elements commonly found within gamified health and wellness programs could be made more engaging by incorporating behavioral insights. For example, most programs invite patients to join, framing their choice as an opt-in decision. But we have found that opt-out framing significantly improves participation. In a randomized trial, our group tested how to engage adults with uncontrolled diabetes in a remote-monitoring program. In the traditional, opt-in approach, only 13% signed up. But when the introductory letter framed the program as standard care, but allowed patients to opt out if they wished, enrollment rates nearly tripled to 38%. We’ve found similar results when testing ways to engage patients in a medication adherence program after a heart attack.
Another common feature of gamification in healthcare programs is goal-setting. The traditional approach is to assign everyone the same goal (for example, taking 10,000 steps per day) and ask to them to strive for it immediately. However, this is probably overly ambitious for many and not sufficiently ambitious for others. We have found that it is more effective for programs to establish a baseline for each individual and then engage him or her in personalized goal-setting, with goals that gradually become more demanding and that adapt to ongoing performance. For example, in a randomized trial of patients with heart disease, we combined financial incentives of $2 per day for each day step goals were met with personalized goal-setting in a program that used wearable devices to measure activity.
Half the patients were assigned to use the device’s preset 10,000 step per day goal that began immediately. The other half established a personal baseline step count which increased for the first two months and then remained steady for four months. During the 6-month trial, the patients who had been assigned the preset goal had no overall change in activity. But those with personalized step goals increased their activity significantly, walking about 100 miles more than the patients in the control group. They even remained more active than the control group for two months after the incentives stopped.
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