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Gamification Design Framework for Mobile Health: Designing a Home-Based Self-Management Programme for Patients with Chronic Heart Failure


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Gamification is the design nexus between psychology and technology; thus, the ensemble of game design concepts and mobile health is promising for a far-reaching impact in public health. This paper presents a gamification design framework for mobile health as a unified, structured representation of activity systems aiming towards better health-related outcomes. It provides a valuable guideline for researchers and designers to model and gamify complex interventions into mobile health design with four steps: (i) defining activity systems, (ii) modelling, (iii) transforming, and (iv) designing. The framework is demonstrated for gamification of a home-based self-management programme for patients with chronic heart failure.
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© Springer-Verlag Berlin Heidelberg 2011
Gamification Design Framework for Mobile Health:
Designing a Home-Based Self-Management Programme
for Patients with Chronic Heart Failure
Hoang D. Nguyen1*, Ying Jiang2, Øystein Eiring3,
Danny Chiang Choon Poo1, Wenru Wang2
1Department of Information Systems and Analytics, School of Computing, National University
of Singapore, Singapore, Singapore
hoangnguyen, dpoo
2Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University
of Singapore, Singapore, Singapore
nurjiy, nurww
3Norwegian Institute for Public Health, Oslo, Norway
Abstract. Gamification is the design nexus between psychology and technology;
thus, the ensemble of game design concepts and mobile health is promising for a
far-reaching impact in public health. This paper presents a gamification design
framework for mobile health as a unified, structured representation of activity
systems aiming towards better health-related outcomes. It provides a valuable
guideline for researchers and designers to model and gamify complex interven-
tions into mobile health design with four steps: (i) defining activity systems, (ii)
modelling, (iii) transforming, and (iv) designing. The framework is demonstrated
for gamification of a home-based self-management programme for patients with
chronic heart failure.
Keywords: Gamification Design Framework Mobile Health • Activity The-
ory Self-Management Chronic Disease Heart Failure
1 Introduction
Gamification has increasingly become a hot topic over the past few years. The adapta-
tion of game design concepts in non-gaming contexts is a new, promising paradigm for
reshaping user engagement [1, 2]. Gamification design has been studied as useful in
many areas such as e-commerce [3], education [4, 5], and health [6], especially. It is
the combination of psychology and technology point towards business objectives [7];
however, the role of technology has been significantly evolved in gamification. With
unique technological capabilities, mobile health is the next suitable wave of technolo-
gies for revolutionizing patient engagement and activities, thereby changing gamifica-
tion design in health care. Hence, the focal research question of this paper is: “how to
gamify mobile health to address public health problems?”
Chronic Heart Failure (CHF) has become a major problem of public health with its
high and increasing prevalence worldwide [8]. The risk of CHF increases sharply along
with patients’ age and gender [9]. It is estimated that over 30% of individuals who are
aged 55 and above will likely develop heart failure during the remaining course of their
life [10]. CHF occurs as a clinical endpoint of many cardiovascular disorders, especially
those that impair cardiac function or strain the cardiac workload [11]. It has become a
heavy burden of healthcare systems; hence, self-management has been long recom-
mended as an integral component of treatment for patients with CHF [12]. Neverthe-
less, many older patients who would potentially benefit from self-management inter-
ventions do not participate them [13]; moreover, a past study has shown that feelings
of hopeless and powerlessness are common in them [14]. Therefore, it is imperative to
explore the ensemble of gamification and mobile health for a simple, convenient means
of self-management with a right amount of motivational affordances. It has capabilities
to empower patients with continuous psychological and social support from care givers,
family members, and friends.
This study investigates gamification design as a holistic structure of activity systems.
We propose a gamification design framework for mobile health with four steps: (i) de-
fining activity systems, (ii) modelling, (iii) transforming, and (iv) designing.
This paper contributes to the cumulative theoretical development of gamification
design and mobile health in several folds. The proposed design framework provides a
structured procedure for researchers and designers to model and to gamify complex
interventions into mobile health design. We also present a gamification of home-based
self-management programme for patients with CHF.
The structure of the paper is as follows. Firstly, we discuss the background of our
research in the next section. Secondly, we describe a gamification design framework
for mobile health in great details in the section 3. And then, the paper demonstrates the
use of the design framework for a home-based heart failure self-management pro-
gramme. Lastly, we concluded our paper with findings and contributions of the research
in the final section.
2 Background
2.1 Gamification Design
Gamification refers to the use of game design elements in non-gaming [1]. Such design
elements are motivational affordance contexts for engagement purposes aim towards
specific goals [16]. Recent studies have shown positive, psychological effects of gam-
ification in many areas such as e-commerce [3], education [4, 5], and health care [6],
especially. Table 1 summarizes the typical game design elements, which are adapted
from Hamari et al. (2014) [17].
Table 1. Typical Game Design Elements (Adapted from Hamari et al. 2014)
Game Design Element
An obtainable object in recognition of participation, ef-
forts, or performance such as monetary incentive, status,
or self-development benefit.
Users earn points by joining the activity.
Clear goal
The object of users’ efforts to achieve in the activity.
A visual board for displaying and comparing user’s per-
formance with others.
Achievement / Badge
Users can be awarded with virtual badges or recognitions,
or merits for participation and performance.
Level / Progress / Feed-
An indicator that provides reflections to users on where
they are in the activity.
Story / Theme
A mechanic that draws the users’ interest into the activity.
They provide guidance for users to move forward.
A pre-defined task that motivates users to action.
An engagement mechanic that integrates positive rein-
forcement into repeated activities to keep users engaged.
The design process of gamification is about how to incorporate various gamification
elements into different contexts [18]. Several gamification design framework have been
developed as guidelines for researchers and designers in general and business-specific
domains [16]. Werbach and Hunter (2012) proposed the most popular design frame-
work in Six Steps to Gamification (6D) [19]. The 6D framework consists of six steps:
(1) define business objectives, (2) delineate target behaviors, (3) describe your players,
(4) devise activity cycles, (5) don’t forget the fun!, and (6) deploy the appropriate tools.
In a similar vein, the GAME framework developed by Marczewski (2012) suggests
breaking the design process into two phases: planning and designing, to derive a solu-
tion in the gamification context [20]. In additions, a number of business-specific frame-
works for designing gamification has been introduced to activate game elements and
techniques in complex business processes [21, 22]. Nonetheless, there is a dearth of a
structured framework for gamification design that is capable of modelling and translat-
ing activities in different contexts into practical design. Furthermore, new technologies
are constantly reshaping human engagement; thus, gamification is not without consid-
ering the enabling role of technologies.
2.2 Mobile Health
The growth spur of mobile technologies has paved the path for new health interven-
tions, “mobile health” or “mHealth” [23]. It is broadly defined as the use of mobile
computing and communication technologies in health care and public health[24]
which is capable of delivering health services to a huge number of people. Mobile
health technologies have transformed a variety of health-related activities such as dis-
ease management and prevention [2529], care surveillance [3032] and instructional
interventions [27, 33].
With the significant advantages of usability and mobility, mobile health apps are the
next suitable wave of interventions for revolutionizing healthcare [34, 35]. They offer
a wide range of capabilities from displaying and reporting to real-time sensing and so-
cial media sharing. Table 2 shows a list of common mobile health capabilities, which
are typically used in combination.
Table 2. Common Mobile Health Capabilities
Interactive Touch
A smartphone is typically equipped with a touch
screen which allows users to control through simple
or multi-touch gestures.
Connectivity and Social
Mobile and internet connectivity allow smartphone
users to maintain constant connections with social
support actors or care givers.
Displaying/ Reporting / Vis-
Rich displaying and reporting contents such as web-
sites, images, and videos provide multiple means for
health intervention delivery.
Wireless Health Sensing
and Monitoring
Wireless technologies such as Bluetooth, Near-Field
Communication (NFC), and Wi-Fi allow users to
connect medical devices for continuous sensing and
Push Notification / Re-
A mechanism to bring information to smartphone
users for their attention.
Mobile health interventions in their current form, however, are limited in psychological
capabilities, which possibly render their effects temporary on health-related behaviors
[36]. Hence, gamification of mobile health is a promising paradigm towards transform-
ing patients’ engagement for better outcomes.
3 Gamification Design Framework for Mobile Health
Gamification is defined by the Oxford dictionary as “the application of typical elements
of game playing (e.g. point scoring, competition with others, rules of play) to other
areas of activity” [37]. The core of gamification leverages on the principles of game
design theory [16]; however, the design process of gamification is conceptually distin-
guished from game design, which is typically for entertainment purposes. The main
purpose of gamification design is to enhance activities in different contexts towards
specific, shared outcomes. Hence, the design process does not only entail the use of
game design elements or techniques, but also revolves around human activities with the
use of technology. In this paper, gamification design is viewed as the investigation of
activity systems based on multiple factors such as tools, controls, contexts and commu-
nications. Exploring activities as dynamic phenomena is the key to obtaining extensive
understanding of the design process, and supporting expressive human interactions in
The engagement between people and technology develops and shares meanings and
objectives in activity systems. Mobile health, in which smartphones are interactive
agents, has continuingly transformed human-technology interactions in an unprece-
dented way. It is necessary for the design process to capture the operationalization of
the dialectal relationship between people and mobile technology. Therefore, a design
framework for gamification of mobile health is proposed as a unified structure of ac-
tivity systems, which encompasses various aspects of human-technology interactions,
game design elements, and mobile health capabilities. It consists multiple steps for re-
searchers and designers to extend the framework structure into practical design arte-
facts. Four steps in the gamification design framework are: (1) defining activity sys-
tems, (2) modelling, (3) transforming, and (4) designing.
Step 1: Defining activity systems
The first step of the gamification process is to define the activity systems in mobile
health. It involves decomposition of the activity systems into several components for
analysis and design from both psychological and technological perspectives. Grounded
in the activity theory [38], we propose a holistic structure of activity systems for
gamification of mobile health based on our previous thereotical framework [28]. It
consists of seven components: (1) outcome, (2) subject, (3) object, (4) tool, (5) context,
(6) control, and (7) communication, as shown in Fig. 1,
Fig. 1. Activity Systems for Gamification of Mobile Health
1) Outcome. A well-developed understanding of the outcome in activities is vital
for the gamification design process. In mobile health, improvements in
knowledge and skills, as well as health-related behaviors are commonly defined
as the collective outcome.
2) Subject. The “subject” component depicts both individual and social nature of
the activity. The stakeholders of health interventions are patients and
psychological/social support actors.
3) Object. The “object” or “objective” component reflects the purposes of activities
that allow the manipulation of subjects’ actions. In mobile health, the object is
typically a collection of health-related behaviours and outcomes.
4) Tool. The “tool” component shows the mediation aspects where in-teractions
between subjects are not direct, but mediated through the use of technological
capabilities and instructional materials. Mobile health apps have excellent
capabilities as discussed in section 2.2 to facilitate health interventions.
5) Control. The “control” component refers to how activities are conducted and
managed based on technological and psychological elements. Game design
elements such as stories, clear goals, or challenges are some examples of
gamification controls.
6) Context. The “context” component highlights the situation and environment, in
which the subjects perform activities. For instance, locational, temporal, and
social constraints have been removed in mobile health; thus, it enables subjects
to participate in activities anywhere anytime. Social media is also a
technological context that motivates subjects to action.
7) Communication. The “communication” component refers to how subjects
engage and what are their role structure in the activity systems. The use of
mobile technologies empowers the subjects with different forms of
communication such as one-to-one or group communication.
In this step, it is important to have well-defined activity systems and a comprehen-
sive list of activities as inputs of the gamification design process.
Step 2. Modelling
The modelling step consists of two structured tasks: (i) modelling each and every
activity listed in the previous step, and (ii) identifying gamification design components.
They are described as the following.
i) Developing activity models. This objective of this task is to describe the dynamic
aspects of activity systems. In this paper, we propose the use of Unified
Modelling Language (UML) [39] to depict the flow from one action to another.
Activity diagrams are graphical representations of such flow for researchers and
designers to investigate the activity systems.
ii) Identifying gamification design components. The second task of this step is to
explore the mediating role of different components in our design framework
including tool, control, context, and communication. We suggest the use of
Mwanza’s techniques [40] to generate possibile gamification opportunities. In
Fig. 1, the arrows run from the subject through a mediating component towards
the object, in which gamification opportunities can be recognized in the activity
systems. There are four questions to identify gamification elements: what tool
can help the subject to achieve the objective? what control can affect the subject
to transform the object? what context can influence the subject to reach the
object? or what communication can change the way the subject reach the object?
This step develops activity descriptions with a list of gamification design components.
Step 3. Transforming
Psychological/social support actors, including doctors, nurses, care givers, family
members, or friends, play a critical role to intrigue patients to participate in health
interventions. Based on activity diagrams in the step 2, the activities can be transformed
by supplementing or substituting such actor with technological subject in this step. In
the former scenario, smartphones can be explored as an ancillary resource for
enhancing patient engagement; while, the latter scenario portrays mobile devices as the
primary actor, as known as mobile support actor. Hence, the activity diagrams and the
list of gamification design components can be revised with the new role of mobile
support actors. There are additional questions to describe gamification and design
mechanics: how does tool help the subject to achieve the objective? how does control
affect the subject to transform the object? how does context influence the subject to
reach the object? or how does communication change the way the subject reach the
For example, how do wireless monitoring devices help patients to improve weight
management? Or how does reward points motivate patients to participate in a health
exercises? Or how do displaying and visualization capabilities enable patients to
recognize symptoms?
In additions, the inter-connections among tool, control, context, and communication
can also be investigated to enhance the gamification models.
Step 4. Designing
The objective of the designing step is to translate gamification models in to a prac-
tical design product. In mobile health, mobile apps are commonly referred as the end
product of the design and development process. Hence, this step involves the creative
design of user interfaces of mobile apps for touch-sensitive display on smartphones.
We suggest the use of UML-based use case diagrams and use case descriptions to de-
scribe design concepts. These concepts service as the basis for user interface/experience
(UI/UX) designers to create mobile user interfaces.
This gamification design framework presents a unified, structured guideline for game
designers, UX/UI designers, researchers, and theorists to gamify mobile health inter-
ventions. The use of the framework in a health-specific application is illustrated in the
next section.
4 Designing Home-Based Heart Failure Self-Management
This paper discusses a home-based self-management programme for patients with
chronic heart failure (CHF). The primary aims of the programme are to increase self-
care behaviors, self-efficacy, and social support, as well as, improving health-related
quality of life. It is imperative to equip CHF patients and family members / care givers
with knowledge to improving heart failure self-management skills. In a long run, the
programme is promising for a far-reaching impact, extending beyond the individual’s
physical and financial costs and affecting society at large. With integration of mobile
health technologies, a larger proportion of the patients with CHF would be able to re-
ceive the rehabilitation in a more acceptable, easily accessible and fun way, especially
for older patients. Hence, gamification design of the programme has been deliberated
at the very beginning at the study.
The design process has spanned over six months by a group with more than ten
members from many disciplines including clinicians, researchers, designers, and soft-
ware developers. We employed the proposed gamification design framework as an ef-
fective means for brainstorming and communicating among team members to reach the
final, practical design for the mobile-based self-management intervention. The process
of gamification design is clearly documented in great details in subsequent sections.
4.1 Identifying Activity Systems
Self-care management is an integral component of heart failure treatment [12]; thus, it
is critical to motivate patients, family members, and care givers to mandate tailored
interventions on self-care maintenance and management with suitable practical guide-
lines and activities. Therefore, the home-based heart failure self-management pro-
gramme is developed with several objectives in accordance to international practical
recommendations for patients with CHF [41]. Fig. 2 summarizes the objects of the ac-
tivity systems under the programs towards achieving the primary aims.
Fig. 2. The Home-Based Heart Failure Self-Management Programme
Heart Failure Management Programme
Knowledge About Heart Failure
Dietary Matters
Weight/Vital Logs
Fluid Intake
Symptom Recognition
1) Knowledge About Heart Failure. The set of education activities for improving
patients’ knowledge and skills for several areas: (i) understanding heart failure,
(ii), managing heart failure, and (iii) living with heart failure.
2) Dietary Matters. Enhancing patients’ self-care behaviors in selecting healthy
food, and taking low salt diet. It is advisable for patients to have 2000 mg sodium
nutrition plan per day.
3) Weight/Vital Logs. Monitoring of lean weight, blood pressures, and heart rates
on regular basis. It is critical for patients to respond to a sudden unexpected
weight gain of more than 2 kg in 3 days.
4) Medication. Understanding of medications and their uses/side-effects. The
patients are instructed to take medications timely in accordance to doctors’
5) Fluid Intake. Focusing on optimal fluid management for patients with heart
failure which is recommended at 1500mL of fluid intake over 24h. Participants
can join interactive activities to keep track of their fluid consumption per day.
6) Symptom Recognition. The patients are advocated to detect and recognize
warning symptoms quickly to take appropriate action.
The activity systems of the home-based heart failure self-management programme,
hence, are described in Table 3.
Table 3. Activity Systems of the Programme for CHF Patients
Self-care behaviors, self-efficacy, social support, and
health-related quality of life
Patients, Psychological/social support actors (e.g., family
members, friends, caregivers, or clinicians)
Knowledge about heart failure, dietary matters, weight/vital
logs, medication, fluid intake, symptom recognition
Instructional materials
Mobile health capabilities: interactive touch, connectivity
and social media, displaying / reporting / visualization,
wireless health sensing and monitoring, push notification /
Guidelines, protocols and recommendations
Gamification controls: reward, point, clear goal, leader-
board, achievement / badge, level / progress / feedback,
story / theme, challenge, loop
Virtual communities: social media or health communities
Face-to-face, one-to-one, group discussion, role structures
The activity systems consist of several high-level activities as below: (1) transferring
knowledge and skills, (2) nutrition planning, (3) weight and vital signs monitoring, (4)
medication management, (5) fluid management, and (6) symptom recognition.
4.2 Modelling
For each high-level activity, we use UML activity diagrams to model the activity
with the structured flow of actions. This step enables us to identify the opportunities for
gamification design. For brevity, we use the “nutrition planning” activity as the exam-
ple of the modelling step; because it has been identified as one of complex activities in
the programme. The nutrition planning activity requires patients’ knowledge and pa-
tience to learn and manage their daily diets to avoid excessive salt intake. Fig. 3 depicts
the UML activity diagram of the nutrition planning.
Fig. 3. The UML Activity Diagram of Nutrition Planning
There are eight (8) sub-activities in the nutrition planning activity. For each sub-
activity, the questioning technique is employed to develop the activity descriptions as
shown in Table 4.
Table 4. Gamification Design Elements in Nutrition Planning
1. Invite
Tool: push notifications / reminders
Control: challenge
Context: time-based
2. Join
Control: point
3. Provide List of Foods
Tool: displaying & visualization, instructional
4. Choose Food(s)
Tool: interactive touch
Control: clear goal
5. Provide Information on
Tool: displaying & visualization
Control: achievement
6. Plan Meal
Tool: interactive touch, and reporting
Control: achievement, reward
Context: time-based
7. Calculate Total Sodium
Tool: displaying & visualization
Control: challenge, loop, progress
8. Provide Suggestions
Tool: displaying & visualization, connectivity
and social media
Control: reward, level / progress, point, feedback
Context: social media
4.3 Transforming
In this step, the activity systems are transformed into mobile health by introducing the
mobile support actor. Each component of the activity systems is investigated through a
structured information gathering technique to determine how it can mediate the subject
to achieve the objective. The interactions between people and technology are docu-
mented in use case descriptions, which are not included in this paper for brevity.
Fig. 4. Design Concepts for Nutrition Planning
In Fig. 4, the design concepts for nutrition planning are illustrated in the left panel.
There are several elements designed based mobile health capabilities and game design
elements: (i) information box for providing list of foods, selecting food, and providing
information; (ii) time-based boxes for planning different meals of the day, (iii) infor-
mation box for a total sodium of the day, and (iv) information box for providing sug-
gestion and feedback.
The deliverables of the transforming step are the revised activity diagrams, the up-
dated use case descriptions, and the design concepts in words or graphical representa-
4.4 Designing
The last step of the gamification design framework is to translate the design concepts
into practical user interfaces. This step heavily involves creative work from UI / UX
designers to follow the information architecture and flow concepts for each activity.
Mobile and design constraints are also considered to produce the final design of mobile
health apps.
In the home-based heart failure self-management programme, several prototypes are
developed iteratively and are improved over time with the updates of design concepts.
The final design prototype is reviewed by a group of clinical experts and patients. It
encompasses a number of gamification design elements and mobile health capabilities.
The following highlights the key features of our mobile apps for patients with CHF.
Fig. 5. Rewards and Nutrition Planning
Rewards. The source of motivational affordances is embedded in the gist of the
mobile app as shown in Fig. 5. It provides the gamification backbone for every activity
participated by the users in the activity systems. An intelligent point system is intro-
duced with different numbers of points awarded for participation and performance in
different activities. For instance, users earn more points for adherence to medication
management than following educational activities. In this study, the rewards feature is
linked with monetary incentives for weekly self-care behaviors.
Nutrition Planning. A mini-game is designed for patients to memorize healthy
foods with sodium information as illustrated in Fig. 5. CHF patients are encouraged to
play this game repeatedly to receive more reward points. It has over 40 common local
foods, which potentially modify the dietary behaviors of the patients.
Fig. 6. My schedule and weight monitoring
My Schedule. The mobile app offers clear goals and the day journey of self-care
management to guide patients to perform activities as shown in Fig. 6. This feature is
tightly integrated with push notification and reminder capabilities to constantly prompt
for patients’ actions. In additions, it also provides a one-stop screen for events related
to patients’ self-management activities such as play and learn, as well as, home visits
by care givers.
Weight Monitoring. CHF patients are advised to monitor their weights in a regular
basis. If there is a weight change of more than 2 kg in 3 days, an alert will be sent to
care givers for timely interventions. Furthermore, Bluetooth-enabled weighting scales
are supported by the mobile app to streamline to burden of manual inputs for patients.
Fig. 7. Vital Sign Monitoring and Fluid Intake Management
Vital Sign Monitoring. The mobile app allows patients to monitor their blood pres-
sures, and pulse rates several times per day as shown in Fig. 7. The design of this fea-
tures follows conventional blood pressure monitoring devices; thus, it is friendly for
older patients to avoid confusions for entering vital sign measurements.
Fig. 8. Symptom Reporting, Education and Social Connectivity
Fluid Intake Management. The overloaded volume of fluid intake can worsen the
symptoms of heart failure; and the patients are recommended to keep track of fluid
intake daily as shown in Fig. 7. The optimal fluid management is 1500 mL over 24h;
the mobile app allows patients to enter estimated fluid intake with instant feedback for
Symptom Reporting. Symptoms have negative impacts on physical and psycholog-
ical aspects of patients’ daily life. The app allows patients to view the images of symp-
toms and to report warning symptoms quickly when they are worsening as shown Fig.
8. An alert will be sent to necessary psychological / social support actors to take
appropriate action.
Social Connectivity. The app allows the ability to connect with friends and family
members as well as care givers via major social networking sites such as Facebook and
Twitter. Once connected with appropriate permissions, the platform ensures the inter-
actions and information exchange amongst the users in real-time. With the social sup-
port, the engagement between users and the mobile app would strengthen the frequent
usage leading to a healthier lifestyle. In additions, in-app messaging between patients
and psychological/social support actors is incorporated for timely recommendations
and responses as illustrated in Fig. 8.
As illustrated in the methodological steps, the design process for gamification of mobile
health entails the comprehensive understandings of activity systems towards achieving
health-related outcomes. By exploring activities supported by technological capabilities
and game design elements, the design framework is capable of translating complex
health interventions into practical design artefacts.
5 Conclusion
This paper redefines gamification beyond the use of game design elements and tech-
niques in non-gaming contexts. It is the nexus between psychology and technology;
where activities can be transformed by motivational affordances, as well as, technolog-
ical capabilities. We propose a gamification design framework for mobile health for
translating activity systems into practical design. The framework provides a structured
procedure of steps: (i) identifying activity systems, (ii) modelling, (iii) transforming,
and (iv) designing; which are clearly demonstrated through a mobile health self-man-
agement programme for patients with chronic heart failure.
This study contributes to the cumulative theoretical development of gamification and
mobile health in three folds. First, the dialectal engagement between people and tech-
nology is highlighted in gamification to make clear the requirements for a theoretical
discourse. Second, the proposed design framework is capable of transforming health
interventions supported by mobile technologies towards better outcomes. Last but not
least, the study provides a holistic guideline how to incorporate psychological and tech-
nological elements in domain-specific gamification.
There are multiple implications for designers and developers of mobile health. The
paper introduces a unified representation of gamification design for developing game-
ful mobile health applications. Furthermore, its findings on design concepts of mobile-
based self-management interventions are well-informed and practical for creating new
programmes for other chronic diseases.
This study is funded by a grant from the Singapore National Medical Research Council
(grant number: HSRGWS16Jul007).
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