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Gamification has become a popular and promising tool to positively impact the usage of health behavior change support systems (HBCSSs). Fun and engaging components are purposefully integrated in the design of HBCSSs in an effort to encourage users to employ the system in a more regular manner or over a longer period of time. Although extant research has made extensive efforts to understand the psychological and behavioral outcomes of gamification, its potential unintended side effects have been mostly neglected. We approached this gap by reviewing 33 articles on gamification in HBCSSs. We identified 16 potential unintended side effects in five categories. By taking a critical view, our research contributes to a more nuanced approach to gamification, which helps to understand how it can be utilized as a valuable tool for developers that motivates and does not harm users of HBCSSs.
14th International Conference on Wirtschaftsinformatik,
February 24-27, 2019, Siegen, Germany
Gamification in Health Behavior Change Support
Systems - A Synthesis of Unintended Side Effects
Manuel Schmidt-Kraepelin1, Scott Thiebes1, Stefan Stepanovic2,
Tobias Mettler2, and Ali Sunyaev1
1 Karlsruhe Institute of Technology,
Department of Economics and Management, Karlsruhe, Germany
2 University of Lausanne, Lausanne, Switzerland
Abstract. Gamification has become a popular and promising tool to positively
impact the usage of health behavior change support systems (HBCSSs). Fun and
engaging components are purposefully integrated in the design of HBCSSs in an
effort to encourage users to employ the system in a more regular manner or over
a longer period of time. Although extant research has made extensive efforts to
understand the psychological and behavioral outcomes of gamification, its
potential unintended side effects have been mostly neglected. We approached this
gap by reviewing 33 articles on gamification in HBCSSs. We identified 16
potential unintended side effects in five categories. By taking a critical view, our
research contributes to a more nuanced approach to gamification, which helps to
understand how it can be utilized as a valuable tool for developers that motivates
and does not harm users of HBCSSs.
Keywords: Gamification, Health Behavior Change, Literature Review, Side
Effects, Negative Effects
1 Introduction
In today’s Western societies the main health challenges and most important risks for
mortality have been shifted from pre-modern health risks such as malnutrition and poor
water quality to health risks that are generated by the modern world itself, like high
blood pressure, tobacco use, high blood glucose levels, obesity, and high cholesterol
levels [1]. Thus, major public health concerns are often directly linked to people’s
individual health behavior and modern lifestyle habits such as sedentary living, chronic
stress, and intake of energy-dense foods [1]. Trying to tackle the challenge of unhealthy
modern lifestyles, health behavior change support systems (HBCSSs) are a promising
approach to positively influence people’s health behavior [2-4]. Typical examples of
such HBCSSs include systems that aim to foster healthy eating habits [5, 6], systems
that motivate their users to be more physically active [7, 8], or systems that help to
properly manage chronic diseases [9, 10]. HBCSSs come in many forms, such as
wearables, mobile apps or dedicated software. However, recent research suggests that
people often do not use HBCSS frequently and over a sustained period of time [11]. As
a consequence, the desired beneficial health behavior may not be maintained. Trying to
address this issue, developers of HBCSS frequently employ gamification. Gamification
refers to the implementation of game elements in non-game contexts [12].
In HBCSSs gamification is primarily applied to make the usage of a HBCSS more
engaging and fun, thus encouraging users to use the HBCSS more regularly or
promoting the completion of certain health-related activities [2, 4]. However, designing
meaningful and effective gamification is associated with high complexity and extensive
resource requirements [13]. In fact, researchers have repeatedly criticized practitioners
and fellow researchers for oversimplifying gamification by superficially implementing
single game elements such as points or badges [14]. Adding to that, recent research
suggests that gamification approaches that do not consider the overall application
context and gamification concept are less effective than more holistic approaches to
gamification [15]. Mindless approaches to gamification might not only lack
effectiveness in increasing users’ motivation and engagement but additionally cause
unintended side effects that could counteract the positive effects of gamified systems
or even harm their users [16, 17]. Especially in a context like HBCSSs, where systems
are intended to have a positive impact on peoples’ health behavior, unintended side
effects of gamification can have serious negative influences on users’ health outcomes
(e.g., by unintentionally incentivizing wrong exercising). Thus, developers of gamified
HBCSSs need to be aware of potential unintended side effects in order to incorporate
suitable strategies to address them into the design process. Within this research, we
hence aim to answer the following research question:
RQ: What unintended side effects may occur when implementing gamification in
Past research on gamification has focused on investigating the positive effects of
gamification on psychological and behavioral outcomes [18, 19] or proposing
theoretically grounded frameworks for designing specific gamified systems [e.g., 20].
Risks and negative aspects of gamification were only treated as side notes [e.g., 1, 21].
Some researchers have started to investigate negative aspects of gamification in general
[16] or within educational systems [17]. However, those studies are based on the
analysis of secondary literature and do not consider the special context of HBCSSs.
This is rather problematic since (1) unintended side effects of (gamified) HBCSSs yield
potential to seriously harm users’ health and thus substantially differ from side effects
in less serious contexts and (2) the investigated secondary literature did not thoroughly
elaborate on negative aspects of gamification. In consequence, research still lacks a
comprehensive overview of unintended side effects of gamification in HBCSSs.
Although existing studies make first valuable contributions to the research field, a
synthesis of literature is necessary to understand unintended side effects of gamification
in particular with regard to specifics of HBCSSs and the serious contexts of HBCSSs.
To answer our research question, we conduct a structured review of literature to
identify and analyze relevant academic publications. In particular, we review those
publications that discuss and elaborate on potential unintended side effects of applying
gamification to HBCSSs. An overview and explanation of unintended side effects of
gamification in HBCSSs helps to (1) guide developers of gamified HBCSSs in
identifying potential risks within their gamification concepts and (2) raise awareness
that gamification is not a silver bullet which creates positive outcomes all by itself and
without extensive design considerations.
This paper proceeds as follows. The next section provides an outline of gamification
in HBCSSs as well as an overview of research on unintended side effects of
gamification. Section three describes our research approach, while section four presents
our results. We discuss our results in section five and briefly conclude our paper in
section six.
2 Background
2.1 Gamification in Health Behavior Change Support Systems
Literature provides two prevailing definitions for gamification. Huotari and Hamari
[22] refer to gamification as the process of enhancing services with motivational
affordances for gameful experiences. Hamari et al. [19] advanced this conceptualization
by introducing the three essential concepts in gamification research (i.e., implemented
motivational affordances, resulting psychological outcomes, and further behavioral
outcomes). Deterding et al., define gamification as “the use of game design elements in
non-game contexts” [12]. Popular game elements used in gamification include points,
badges, leaderboards, and time constraints [12]. In general, gamification aims to utilize
peoples’ growing passion for games to positively influence their personal motivation
or perception concerning a selected action in order to make it more engaging and fun
[2, 21, 23]. However, it is important to differentiate gamification and serious games.
Gamified systems are no full-fledged games. In fact, game elements in gamified
systems are only means to foster certain behaviors and not the main object of the system
[24]. Serious games, on the other hand, are fully-developed games that serve specific
non-entertainment purposes [24].
Extant research has made extensive efforts to investigate psychological and
behavioral effects of gamification in various research fields such as education [25, 26],
crowdsourcing [27], or enterprise systems [21]. Among these research fields, HBCSSs
have emerged as one of the most relevant application areas for gamification [1, 28]. In
HBCSSs, gamification is primarily applied for motivating individuals to continue using
the systems more regularly or promoting the completion of activities or tasks that are
associated with positive health outcomes [2, 4]. According to extant literature, there are
three major groups of use contexts for gamification in HBCSSs [2]: (1) Individual
lifestyle habits (e.g., fitness, food consumption, unhealthy habits), (2) chronic disease
management (e.g., diabetes, cancer), and (3) support of health professionals (e.g., for
educational purposes or daily habits). However, as we focus our research on unintended
side effects concerning patients and users aiming to improve their health status as well
as the fact that a majority of HBCSSs in group three can also be classified as educational
systems, we concentrate our analysis on such HBCSSs belonging to group one and two.
2.2 Unintended Side Effects of Gamification
Extant research on gamification has primarily focused on investigating intended
psychological and behavioral effects on gamification. Two studies exist that focus on
shedding light on potential unintended side effects of gamification. Hyrynsalmi and
Kimppa [16] conducted a meta study and reviewed existing literature reviews on
gamification concerning negative impacts. They classify their results in two main
groups: (1) Limiting issues and (2) harmful issues. However, they also state that most
reviewed studies had only little if any discussion on the negative effects of gamification.
As a result, their data basis is scarce and lacks an in-depth discussion of side effects
and potential consequences. Second, Toda et al. [17] reviewed literature on
gamification in education and identified four negative effects (i.e., indifference, loss of
performance, undesired behavior, and declining effects). However, the results of their
study are only applicable to the context of educational systems. In addition to these two
studies, some research has dealt with risks or negative effects of gamification as a side
note. For example, Thiebes et al. [21] have discussed four risks of gamification in
information systems, and Johnson et al. [1] outline some negative aspects of
gamification found in studies in health and well-being. Furthermore, Kim and Werbach
[29] elaborate on ethical issues in applying gamifications such as potential for
manipulation and exploitation. In summary, to the best of our knowledge, no study
exists that focuses on identifying and purposefully reasoning on unintended side effects
of gamification in HBCSSs.
3 Structured Literature Review
3.1 Data Collection
For the identification of publications discussing potential unintended side effects of
gamification in a HBCSSs context, we applied a systematic online literature database
search following the guidelines by Levy and Ellis [30]. We thus searched the scientific
databases IEEE Xplore, ProQuest, AIS Electronic Library, ACM Digital Library,
EBSCO Host, and ScienceDirect using the following search string: TITLE-ABSTR-KEY
(gamif*) and TITLE-ABSTR-KEY(health* OR medic* OR life* OR fitness OR well-
being) and TITLE-ABSTR-KEY(risk* OR danger* OR peril* OR effect* OR negative*
OR disadvantage*).
Where possible, our search was limited to peer-reviewed publications published in
2010 or later, since gamification only gained widespread recognition by researchers
and practitioners in 2010. The database search yielded a total of 212 publications,
excluding duplicates. Two researchers separately assessed the relevance of each article
by utilizing predefined exclude criteria. In this process, we excluded ten articles not
written in English, seven articles that were not peer-reviewed, 140 articles that had no
focus on gamification in HBCSSs (i.e., they dealt with related concepts such as serious
games or researched gamification in a non-healthcare context), and 43 articles that did
not discuss any unintended side effect of gamification. In addition, a forward and
backward search was conducted on the twelve relevant articles which lead to the
identification of three additional relevant publications and a set of 15 relevant articles.
In a second step and in an effort to integrate scientific literature from health and medical
perspectives, we searched the scientific database PubMed using our research string.
Our PubMed search yielded a total of 145 additional unique publications. By screening
these publications against our exclusion criteria, we excluded 104 publications that had
no focus on gamification in HBCSSs and 23 publications that did not discuss any
unintended side effects of gamification. Through searching PubMed, we identified 18
additional relevant publications, which led to a final set of 33 relevant publications.
3.2 Concept-centric Data Analysis
To identify unintended side effects of gamification in health & well-being, we
conducted a manual content analysis. Two researchers independently coded the 33
articles with regard to unintended side effects using an open coding approach [31]. As
suggested by Strauss and Corbin [31], during open coding, the data was broken down
into discrete parts (i.e., text passages), closely examined, compared for similarities and
differences, and coded with regard to the phenomena as reflected in the data. The results
were iteratively reviewed and discussed with a third researcher to consolidate them. To
improve the explanatory power of our results and to find semantically coherent groups,
the identified side effects were grouped into categories if they were logically related to
the same subject.
4 Results
Our review of relevant literature yielded a total of 16 potential unintended side effects
due to the application of gamification in HBCSSs, which we grouped into five
categories of unintended side effects. Table 1 provides an overview of the categories of
unintended side effects. It also highlights for which unintended side effects we were
able to find empirical support within the reviewed literature and which side effects are
specific to the HBCSSs context. We describe each unintended side effect in detail
4.1 Adverse Motivational Outcomes
Undermining Intrinsic Motivation. Researchers often argue that gamification aims to
foster users’ intrinsic motivation in order to make using gamified systems more
engaging and fun [32]. However, gamified HBCSSs sometimes tend to focus on
extrinsic motivation and thereby even corrupt and undermine intrinsic motivation for
positive health behavior change [33, 34]. As a result, users’ health behavior may
become dependent on the presence of the gamified HBCSSs and their motivation may
immediately decrease once the extrinsic rewards are not available anymore [1, 33].
Attig and Franke [33], for example, showed in their study that motivation for physical
activity can become dependent on the presence of an activity tracker as well as the
related game elements and decreases in case the tracker is not available.
Table 1. Overview of unintended side effects.
Class of Unintended
Side Effects
Unintended Side Effect
Undermining Intrinsic
[13, 33-42]
[33-35, 38,
40, 41]
Motivation Decreasing
Over Time
[15, 35, 38, 40,
[35, 40, 43,
[36, 45, 49, 50]
[45, 49]
Distraction from
Health Purpose
[13, 15, 34, 41,
45, 51, 52]
[15, 45, 51,
Trivializing the Health
[1, 13, 15, 24,
36, 41, 53]
Reduced Usability
[13, 15, 45, 54]
Reduced Integrity
of Exercise
Cheating the Self
[37, 55]
Rewarding Incorrect
[34, 36, 56]
[13, 55, 57, 58]
Demoralization of
Cheating Others
[13, 37, 55, 59]
Overemphasized Peer
[37, 38, 41, 57,
[38, 41, 57,
[37, 40]
Feeling of
[36, 42, 49, 57]
[49, 57]
Discouragement Due
to Failure
[36, 61]
Privacy Infringements
[13, 36, 37, 40,
44, 55, 60]
[40, 60]
Fostering Behavior
that Harms Third
Motivation Decreasing Over Time. An often-discussed problem with gamification is
novelty effects. Novelty effects describe a situation in which users are often curious
and enthusiastic for gamification at first, as it is visually appealing and something they
did not experience before [15]. However, interest and enthusiasm for gamification most
likely decrease in the long run when these novelty effects wear off. With it, motivation
to perform healthy behaviors could decrease as well, ultimately dropping below the
initial level of motivation. El-Hilly et al. [40], for instance, describe this effect in their
study of a gamified HBCSS for smoking cessation where participants exhibited
monotony and decreased levels of engagement as they perceived achievements as
Unfulfilled Expectations. Gamification of HBCSSs might raise high expectations by
claiming to bring fun and engagement to health activities while maintaining therapeutic
effectiveness of the system. If these expectations are not met, users might be
disappointed, which could lead to decreasing levels of satisfaction. To this end,
Lumsden et al. [49] report that participants of their study of different web-based
cognitive testing systems were disappointed of a task that had the graphical impression
of a game but did not offer any actual gameplay.
4.2 Informational Noise
Distraction from Health Purpose. Sardi et al. [15] point out that gamification
concepts sometimes tend to not provide “a tangible health-driven meaning in terms of
the user’s competence and health skills” and that game mechanics are “sometimes
wrongly located on the application’s display”. As a result, it can be difficult for users
to identify a link between the gamification concept and their health behavior and they
do not understand the purpose of certain game mechanics. This effect can lead to a
distraction from the core health behavior elements of the system and thus reduce the
overall system’s efficacy [34]. For example, Boendermaker et al. [45] conclude in their
study that their gamified HBCSSs for attentional bias modification in the context of
alcohol consumption contained distracting game elements that negatively influenced
the systems efficacy.
Trivializing the Health Context. Developers of gamification concepts frequently aim
to design visual appearances that resemble existing games [21]. Thus, gamification
design is often colorful and eye-catching [1]. In some cases, exaggerated visual design
might lead to perceptions that important health topics, which deserve a serious and
professional tone, might be trivialized and that gamification is more of a marketing
gimmick than a serious tool that supports health behavior change [36]. As a result,
recent studies reported that some health professionals shy away from participating in
designing gamified HBCSSs as they worry about their credibility and respect among
patients [15].
Reduced Usability. Introducing gamification to a HBCSS is always associated with
adding new possibilities of system interaction for the user. As a result, established paths
of human-system interaction may change and users’ might initially be confused as the
system does not longer work the way it used to. Gamifying HBCSSs adds an additional
layer of interaction complexity and, thus, might lead to an initial decrease in usability
[15]. For example, Boendermaker et al. [45] observed that participants in a gamified
intervention differed with regard to speed and accuracy of responses in comparison to
a non-gamified intervention. They ascribe this observation to the more complex nature
of the gamified intervention.
4.3 Reduced Integrity of Exercise
Cheating the Self. Gamifying HBCSSs can open the door to cheating and exploiting.
Especially users that have higher interest in achieving game rewards than the actual
health behavior change sometimes try to achieve a target in a way in which it was not
supposed to be achieved according to the game rules [13, 37]. Users cheat by, for
example, “exploiting inherent sensor-related limitations to fabricate false detection”
[37]. Cheating is also promoted by the fact that most gamified HBCSSs are used while
being online and without supervision by professionals, which might lower the threshold
for lying [55]. Cheating the self can lead to misdirected incentives and false health
behavior and might thus negatively impact health-related outcomes [55].
Rewarding Incorrect Execution. Creating gamified HBCSSs requires a great variety
of different resources and expertise [34]. In particular, developers need to ensure that
games rewards and progresses adequately reflect peoples health behavior. If the
gamification concept is not sufficiently aligned with the desired health behavior change,
users might unintentionally be incentivized for wrong or even unhealthy behavior (e.g.,
distributing a reward although an exercise was not performed correctly) [36].
Overuse. Gamification frequently aims to motivate people to use an HBCSS in a more
regular manner. However, gamification concepts that are not sufficiently balanced but
instead reward exaggerated repetitions of certain tasks might incentivize users to use
an HBCSS too excessively and thus overreaching their personal limits [55, 58]. In an
extreme case, gamification concepts might lead to users that are “driven by obsession
rather than enjoyment […] resulting in problems relating to overtraining, overexertion
and risk taking [57]. Barrat [57], for example, reported in his study about a gamified
HBCSS for cycling that some participants driven by peer pressure and competition
ended up cycling excessively thereby negatively influencing their overall health and
social outcomes.
4.4 Demoralizing Effects
Cheating Others. As stated before, cheating can be an important problem in gamified
HBCSSs. When users cheat they often aim to gain an advantage over other users by
exploiting certain game mechanisms in a way that should not be allowed according to
the game rules [37]. Cheating can ruin the fairness of competitive game mechanisms
and might even result in other users giving up [37]. As a result, dissatisfaction among
users that do not cheat might increase [13]. Recent research suggests that users are more
likely to cheat the more they are exposed to other users cheating [62].
Overemphasized Peer Pressure. Gamification often contains competitive game
elements that, for example, enable comparing the scores of different users [37].
However, competition and social comparison is not for everyone. Recent research
suggests that introverted users are likely to be demotivated by gamification that
contains social comparison [60]. In addition, competitive game elements that publicly
compare the scores of different users can also be discouraging to those who have low
scores due to temporary setbacks or simply being new to the system [37]. Thus, studies
found that social comparison can have negative effects on users’ health behavior [38].
For example, Horse-Fraile et al. [41] report of collaborative health app studies in which
parents complained about the possibility that their children may become demotivated
if other families ranked better than theirs did.
Exaggerated Punishment. Users might also be discouraged due to the feeling of
disproportionate punishment. Even regularly active users might get sick or be otherwise
unable to perform desired health-related behavior (e.g., exercises), resulting in a sharp
drop of their (average) score [37]. Although this drop might sufficiently represent
reality, users’ might perceive it as unreasonable and unrepresentative of their health
behavior and thus get discouraged or even stop using the HBCSS [37].
Feeling of Manipulation. Gamification aims to foster users' motivation to perform
certain activities in a specific way or in a more regular manner, for example, by
applying rule-based systems. This could cause users to perceive a feeling of being
manipulated or forced into performing those actions, especially if the underlying health
activity is inherently unstructured and requires a great degree of autonomy. For
example, Barratt [57] reports that participants in a study of a cycling application
complained about negative experiences due to a restricted level of autonomy.
Discouragement Due to Failure. Gamification often relies on goal-oriented game
elements. These may discourage users if they fail to meet certain goals despite putting
in a lot of effort. According to extant literature, it is particularly important for more
serious contexts such as heart diseases [61] that developers avoid a sense of defeat while
adjusting the level of difficulty according to users’ capabilities.
4.5 Overstepping Boundaries
Privacy Infringements. Information about users’ health status and health behavior is
often sensitive and subject to specific laws which limit the disclosure of healthcare
information without explicit consent from the user [36]. Implementing gamification in
HBCSSs can add another level of complexity concerning privacy and data protection
[13]. Based on game elements additional health information about HBCSS users might
be gathered and stored. For example, users badge collections might disclose
information about health status and past health-related behaviors. This can be
particularly problematic when unknown third parties, such as employers or insurance
companies, start reviewing badge collections by individuals or user groups for specific
purposes [36]. Research also indicates that some users are more likely to participate in
HBCSSs if they are not required to disclose personal data [60].
Fostering Behavior that Harms Third Parties. Gamification of HBCSSs might also
cause unintended side effects for third parties outside of the system. This was
particularly observed in GPS-based HBCSSs that aim to foster physical activity and
use auto-generated outdoor locations for specific rewards. For example, in 2011 an
object used in a GPS-based gamified HBCSS was placed in the Downtown Disney Park
in Anaheim, CA, USA. As a result, people that not played the game were scared and
triggered a bomb alarm. This led to temporary closure of the park [58]. Another
example for behavior that harms third parties might be overcrowding of specific real-
world places that promise special rewards as observed in the beginning of Pokémon
5 Discussion
Our objective within this research was the identification and analysis of unintended side
effects of gamification in HBCSSs. Building on the results described in section four,
we were generally able to provide answers to our research question and thus contributed
to the knowledge base on gamification. We discuss some of the most interesting
findings and their implications in the following.
By intensively reviewing and discussing the 16 identified side effects, we were able
to build five logically coherent groups of unintended side effects. First, adverse
motivational outcomes describe those side effects which basically result in the main
objective of gamification (i.e., fostering user motivation and engagement) not being
achieved. Reasons for the occurrence of side effects of this group are diverse. Many
researchers emphasize that applying gamification is a demanding process that requires
excessive resources and expertise in order to be effective [13, 15]. When developers
decide not to include game design knowledge in the design process and instead go for
“cheap” gamification solutions that are based on extrinsic rewards that are easy to
implement and promise short-term behavior change, their gamification approach is
likely to fail in the long run. If adverse motivational outcomes occur, they are likely to
negatively impact users’ adoption of gamified HBCSSs. Second, informational noise
describes unintended side effects that are related to a flawed visual representation and
interaction concept of the gamified HBCSSs. They are often caused by insufficient
consideration of the unique seriousness of the health context and thus choosing
inappropriate gamification elements. If those unintended side effects occur, users’
might perceive an HBCSS as being less professional and serious. Third, reduced
integrity of exercise describes those unintended side effects that can directly lead to
health-related disadvantages for the user. Thus, it is particularly important to prevent
these side effects from occurring. They are often caused by not carefully aligning the
gamification concept of HBCSSs with their core activities and thus providing users
with wrong incentives. Fourth, demoralization of users describes unintended side
effects that might cause users to stop using the system because they feel treated unfairly.
Fifth, overstepping of boundaries describes those side effects that might lead to legal
issues for developers of gamified HBCSSs. In order to prevent legal uncertainties in
particular when considering the high sensitivity of health-related data, it is very
important for developers to prevent these side effects from occurring.
As mentioned before, some side effects are more specific to HBCSSs than others.
For example, although cheating the self might occur in any gamification context, its
potential consequences are particularly critical in HBCSSs as they threaten the correct
execution of health behavior and thus yield potential harm to users’ health. Another
side effect that is strongly linked to HBCSSs is the trivialization of the context. While
colorful and eye-catching design themes might be unproblematic for less serious
contexts, within HBCSSs users might perceive them as especially inappropriate and
unprofessional and subsequently avoid using the system for a serious context such as
Our research yields some implications for practice. First, by presenting and
discussing our results we show that developers of HBCSSs need to be aware of potential
drawbacks of gamification. In addition, developers need a set of suitable prevention
strategies to address these potential side effects when designing gamified HBCSSs.
However, it was beyond the scope of this work to derive such prevention strategies.
Thus, we leave it to future research and to developers of gamified HBCSSs to carefully
develop prevention strategies that fit the diverse application scenarios of HBCSSs.
Concerning implications for research, existing frameworks for gamification of
HBCSSs mostly have been created on the basis of potential positive effects of
gamification. With regard to our results we think that existing frameworks should be
critically reviewed and evaluated whether they adequately consider unintended side
effects of gamification.
Our research contributes to the scientific knowledge base in several aspects. By
synthesizing knowledge on unintended side effects of gamification in HBCSSs, we
contribute to the conceptual knowledge on gamification in the context of health and
well-being. In particular, although we acknowledge the various potential positive
aspects of gamification, we contribute to conceptual knowledge by taking on a more
critical view of gamification, which has so far been underrepresented in gamification
research [16, 29]. This critical view leads to a more nuanced perception of gamification
and thus contributes to a better understanding of how to apply gamification as a
valuable tool that motivates and does not harm users of HBCSSs.
The limitations of this study are as follows. First, our literature base is limited to 33
articles that discuss potential unintended side effects of gamification in HBCSSs. This
shows that the topic received only little attention among researchers so far. Although
we carefully performed our keyword-based search, we cannot rule out the possibility
that we might have missed relevant articles. Second, there are different kinds of
HBCSSs with various levels of context seriousness [2]. Thus, side effects might also
differ between these different types of HBCSSs. It would be interesting for future
research to delve deeper and compare potential side effects of different types of
HBCSSs. Lastly, interpreting literature and text passages always leave some room for
interpretation. However, we aimed to address this issue by carefully performing the
concept-centric data analysis and developing a common understanding of side effects
while synthesizing the literature. Future research might further strengthen the
knowledge base by conducting qualitative research and gathering primary data from
experts of the field. Future research could also aim to delve deeper in order to
understand the underlying reasons for the observed side effects and the circumstances
under which they occur.
6 Conclusion
Although gamification has received tremendous attention from practitioners and
researchers interested in HBCSSs, little attention has been paid to the unintended side
effects that potentially come with the implementation of gamification in HBCSSs.
Within this research, we have taken a first step towards closing this gap by reviewing
past research on gamification in HBCSSs and synthesizing 16 unintended side effects
that may occur when using gamification. Our research adds to the knowledge base on
gamification by, for the first time, providing a comprehensive overview of potential
unintended side effects. We also contribute to a more nuanced view of gamification,
which helps relieving gamification from unrealistic expectations threatening to position
it as a silver bullet rather than a valuable tool for developers of HBCSSs. Future
research should delve deeper into this topic and examine in more detail under which
circumstances such side effects can occur and how they can be avoided or counteracted.
7 Acknowledgements
This study was partially supported by the Swiss National Science Foundation (grant
no.: 172740).
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... Studies on the effectiveness of this approach relative to its goals in different contexts are also rather frequent, although to a lesser extent. On the other hand, despite the production of useful and interesting literature review studies on detecting and grasping the limitations, negative consequences, unintended side effects, challenges and risks of gamification, this topic appears to be one of the least covered areas so far and probably insufficiently understood [7][8][9]. Since the information systems do influence users' behaviour [10], it is meaningful to examine the possible harms caused by gamification, which overall remain under addressed and represent an area needing further research. ...
... In principle, the areas in green are affordances, psychological and behavioural outcomes that gamification is meant to promote [7], whereas the words in red represent those that the tool is not supposed to foster and may designate risky areas [7,9]. The words in black and underlined would be affordances, psychological and behavioural outcomes that gamification would use and aim at in moderation. ...
... In principle, the areas in green are affordances, psychological and behavioural outcomes that gamification is meant to promote [7], whereas the words in red represent those that the tool is not supposed to foster and may designate risky areas [7,9]. The words in black and underlined would be affordances, psychological and behavioural outcomes that gamification would use and aim at in moderation. ...
Full-text available
The appearance of gamification dates back about a decade and since this tool has been increasingly used not only in the entertainment sector but also in the industry, army, education, health and others. Studies suggest that this approach may provide added value outcomes, in particular in the users’ motivational and engagement areas, in a wide range of fields such as customer relations, skills learning, physical exercises, health management, etc. On the other hand, the consequences and potential risks related to its use remain insufficiently understood and have started to become the object of research in the last years. This chapter aims at exploring and deepening the understanding of the possible threats resulting from the use of software gamification at both the individual and collective levels. To do so, an integrative literature review was carried out on studies examining the negatives effects and challenges of this tool so as to identify the possible adverse impacts arising from them. Overall, results would show that an inadequate gamification design and implementation and its implications in terms of a flawed rewarding system and ethical issues may entail perils such as demotivating users, engendering mistrust, health issues and tarnishing the gamification credibility as well as that of the management in charge of it.
... Moreover, lack of desired features in the app (18.7%), the app not being fun (10%), and not being easy to use (8.6%) were also identified as reasons for discontinued use of mHealth apps. Our results are broadly in line with the literature, which found that the novelty effect significantly influences user abandonment of health-intervention apps [9,15,32]. While users may be drawn to a new app out of curiosity at first, they may lose interest in the app once the novelty effect wears off. ...
... More importantly, our data underscores the importance of the novelty effect as a critical factor influencing the lack of sustained use after adoption [32,41]. In a previous study [42], for instance, respondents reported boredom and loss of motivation as reasons for abandoning these apps. ...
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Mobile health (mHealth) apps have great potential to improve health outcomes. Given that mHealth apps have become ubiquitous, there is limited focus on their abandonment. Data concerning crucial metrics, including reasons for adoption and discontinued use, are limited. This study aims to gain broad insights into utilization of mHealth and game-like features promoting user engagement. We conducted a cross-sectional survey of 209 mHealth users worldwide. The 17-item survey assessed sociodemographics, as well as the key motivators for mHealth uptake and discontinued use. Our findings show that sports and fitness activity tracking were the most common categories of health apps, with most users engaging with them at least several times a week. Interestingly, the most downloaded mHealth apps among younger adults include MyFitnessPal, Fitbit, Nike Run Club, and Samsung Health. Critical drivers of abandonment of mHealth apps were amotivation, loss of interest, and experimenting with different apps to identify the most suitable tool. Additionally, the financial cost of mHealth apps is crucial, with most participants advocating for free or more affordable apps. The study findings suggest that while many individuals utilize mHealth, several factors drive their abandonment. Moreover, data indicate that mHealth developers need to consider gamification strategies to sustain user commitment, as well as psychological variables, such as intrinsic motivation
... Rewards are often grouped into a larger category of gamification elements, which are designed to provide extrinsic motivation to engage with the intervention. Though gamification elements can improve engagement in digital health interventions, it's worth noting there is some debate (24,25), and there are very few studies examining the precise impact of rewards by comparing the same intervention with and without rewards or other gamification elements. There are other components of gamification that can influence users' motivation beyond reward, however, such as motivation by purpose, autonomy, relatedness, or competence (26). ...
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Digital mental health interventions, or digital therapeutics, have the potential to transform the field of mental health. They provide the opportunity for increased accessibility, reduced stigma, and daily integration with patient's lives. However, as the burgeoning field continues to expand, there is a growing concern regarding the level and type of engagement users have with these technologies. Unlike many traditional technology products that have optimized their user experience to maximize the amount of time users spend within the product, such engagement within a digital therapeutic is not sufficient if users are not experiencing an improvement in clinical outcomes. In fact, a primary challenge within digital therapeutics is user engagement. Digital therapeutics are only effective if users sufficiently engage with them and, we argue, only if users meaningfully engage with the product. Therefore, we propose a 4-step framework to assess meaningful engagement within digital therapeutics: (1) Define the measure of value (2) Operationalize meaningful engagement for your digital therapeutic (3) Implement solutions to increase meaningful engagement (4) Iteratively evaluate the solution's impact on meaningful engagement and clinical outcomes. We provide recommendations to the common challenges associated with each step. We specifically emphasize a cross-functional approach to assessing meaningful engagement and use an adolescent-focused example throughout to further highlight developmental considerations one should consider depending on their target users.
... You have completed X Tai Chi lessons this week (Y% of your weekly target and Z lesson less/more than patients similar to you." A potential problem with this template is that people vary in response to social comparison [56]; some get motivated others may get discouraged [57]. ...
Full-text available
Designing theory-driven digital health interventions is a challenging task that needs support. We created a guide for the incomers in the field on how to design digital health interventions with case studies from the Cancer Better Life Experience (CAPABLE) European project. The guide explains how behaviour change theories can inform customisation and personalisation of the intervention. The proposed SATO (ideaS expAnded wiTh bciO) design workflow is based on the IDEAS (Integrate, Design, Assess, and Share) framework and is aligned with the Behaviour Change Intervention Ontology (BCIO). We provide a checklist of the activities that should be performed during intervention planning as well as app design templates which bundle together relevant behaviour change techniques. In the process of creating this guide, we found the necessity to extend the BCIO to support the scenarios of multiple clinical goals in the same application. The extension utilizes existing classes and properties where possible.
... Payne et al. [24] emphasize that effective coping apps should incorporate predisposing (providing general information or knowledge), enabling (available when needed), and reinforcing (rewarding use or progress) elements to accomplish a sustainable behavior change. Schmidt-Kraepelin et al. [43] recommend developers of behavior change support systems to use gamification to motivate individuals to use the app more regularly and enable healthy behavior changes. Christmann et al. [25] also suggest a list of techniques to realize behavior change through a stress management app, including gamification elements such as (virtual) rewards (e.g., points, levels, badges) or social comparisons (e.g., leaderboards). ...
... Furthermore, ethical issues in applying gamification, such as the potential for manipulation and exploitation (Marczewski, 2017), have begun to emerge in the literature. Only a few studies have focused on exploring the potential negative outcomes of gamification (Schmidt-Kraepelin et al., 2019;Hyrynsalmi, Smed, & Kimppa, 2017) or the potential project risks in designing and developing gamified IS (Warsinsky et al., 2021). These studies have yielded interesting initial insights. ...
... When considering a marketing perspective, gamification is applying game elements to a product to improve user interaction by making it more fun and challenging (Prabowo et al., 2019). Gamification has been used in several areas, such as education (Huang & Soman, 2013;Majuri, Koivisto, & Hamari, 2018), health care (Johnson et al., 2016;Schmidt-Kraepelin, Thiebes, Stepanovic, Mettler, & Sunyaev, 2019), and transportation (Marcucci, Gatta, & Le Pira, 2018;Murawski, 2020;Prabowo et al., 2019). In general, gamification has been shown to increase product use and individual motivation to complete a task in some fields (Murawski, 2020). ...
The main purpose of this paper is to explore the performance of white-collared gig workers using three theoretical perspectives: knowledge-based view theory, employee engagement theory, self-determination theory. The study investigates the relationship between intellectual capital, collective cognitive engagement, intrinsic motivation, and knowledge management as antecedents to the performance of gig workers. Furthermore, it investigates whether a moderation effect of intrinsic motivation using game elements can improve the performance of gig workers. This study uses primary data collected over 8 weeks from January 2020 to Feb 2020. This study collects self-administered cross-sectional primary data from an online platform that currently engages white-collar gig workers or has engaged them in two previous years (2018 and 2019) in either one or more platforms. This study also develops a conceptual model to measure the performance of white-collared gig workers using an extension of the three theoretical perspectives.
... However, it is important to understand that there are often undesirable outcomes that have begun to be identified with the use of gamification. Use of these methods can lead to outcomes such as a decrease in motivation, undesired behaviors, overuse, cheating, and trivialization of the intended outcome (Schmidt-Kraepelin et al., 2019). ...
As technological advances continue to develop, delivering macro human service through social work innovations becomes a new priority for the discipline. Digital technologies offer potential applications using tablets, smartphones, cloud computing, artificial intelligence, and wearable technology to enable whole new possibilities for human services. As a result, policymakers and community organizers alike can access the existing information much faster, and potentially connect with hard-to-reach communities to make meaningful decisions. Incorporating the latest digital trends from business and industry settings to macro social work practice are highlighted. By utilizing digital technology, human service organizations can become more proactive and citizen-centered, potentially transforming personal and economic capacity. (Encyclopedia of Social Work)
... In the T&H context, only two studies mention the limitations of gamification usefulness (Lee, 2019;Tan, 2018). This critical issue is detected also in the health context (Schmidt-Kraepelin et al., 2019;Johnson et al., 2016), in education (Toda et al., 2017) and in general services research (Thiebes et al., 2014). This has produced a significant increase in calls for research into potential gamification side effects, adverse events and mitigation practices (Koivisto and Hamari, 2019;Hyrynsalmi et al., 2017). ...
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Purpose The present study aims to synthesize and conceptualize, through a systematic literature review (SLR), the current state of gamification knowledge in the tourism and hospitality (T&H) sector, providing a roadmap for future research recommendations for service research and practice. Design/methodology/approach The research is based on a systematic literature review and adopts a systematic quantitative approach to summarize existing evidence on gamification usage in the T&H sector, focusing on relevant service literature on gamification. The authors analyze 36 papers published between 2011 and 2019. Findings The authors synthesize existing knowledge into five themes describing gamification's role in T&H (Edutainment, Sustainable behavior, Engagement factors, Service provider-generated content and User-generated reviews). Then, a cross-analysis of the five themes reveals the pivotal elements (affordances, behavioral and psychological outcomes, and benefits) generated by gamification mechanics in T&H, simultaneously highlighting potential implications and relevant insights for service literature. The review identifies critical issues affecting gamification research and provides a future research agenda, considering opportunities for T&H and service research. Originality/value The study provides the first SLR investigating gamification in T&H. The findings present potential implications and relevant insights for T&H contributing to the construction of a more holistic understanding of gamification adoption in service research.
Conference Paper
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Educators frequently face serious problems concerning students' engagement and knowledge retention. As a proposed solution, gamification represents a new tool for active learning to increase students' motivation and thus improve their learning results. The goal of this paper is to investigate the effects of gamification on short-and long-term knowledge retention in all-day workshops on sustainable transport. A longitudinal experiment with 334 logistics students was conducted comparing the results of gamified and non-gamified workshops with students as future managers. The results suggest that gamification is an effective measure to increase students' learning outcomes with respect to sustainable transport.
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Background Compared to traditional persuasive technology and health games, gamification is posited to offer several advantages for motivating behaviour change for health and well-being, and increasingly used. Yet little is known about its effectiveness. Aims We aimed to assess the amount and quality of empirical support for the advantages and effectiveness of gamification applied to health and well-being. Methods We identified seven potential advantages of gamification from existing research and conducted a systematic literature review of empirical studies on gamification for health and well-being, assessing quality of evidence, effect type, and application domain. Results We identified 19 papers that report empirical evidence on the effect of gamification on health and well-being. 59% reported positive, 41% mixed effects, with mostly moderate or lower quality of evidence provided. Results were clear for health-related behaviours, but mixed for cognitive outcomes. Conclusions The current state of evidence supports that gamification can have a positive impact in health and wellbeing, particularly for health behaviours. However several studies report mixed or neutral effect. Findings need to be interpreted with caution due to the relatively small number of studies and methodological limitations of many studies (e.g., a lack of comparison of gamified interventions to non-gamified versions of the intervention).
Conference Paper
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Gamification is a popular design approach with the purpose to increase engagement and continuous use of Health Behaviour Change Support Systems (HBCSS) with the purpose to establish health and well-being. It is widely employed for promoting healthier life choices or for supporting people with chronic diseases in their daily activities. Yet, there is a lack of evidence concerning gamification and its ability to sustain favourable effects on health behaviour change. This paper presents a scoping review about the long-term perspective in gamified HBCSS, focusing primarily on IT-reliant systems that treat individual lifestyle habits like healthy nutrition, exercise or smoking cessation. We systematically selected studies that consider gamified HBCSS for health promotion and discuss to what extent long-term engagement is explicitly included in their design. Our results underline a deficit of consideration of the long-term perspective as well as a lack of measurement related to the lasting effects of gamification. We therefore propose to intensify the use of longitudinal and prospective observational studies in the context of HBCSS, in order to increase the level of evidence of gamification interventions.
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Background: Sedentary work is hazardous. Over 80% of all US jobs are predominantly sedentary, placing full-time office workers at increased risk for cardiovascular and metabolic morbidity and mortality. Thus, there is a critical need for effective workplace physical activity interventions. MapTrek is a mobile health platform that gamifies Fitbit use for the purpose of promoting physical activity. The purpose of this study was to test the efficacy of MapTrek for increasing daily steps and moderate-intensity steps over 10 weeks in a sample of sedentary office workers. Methods and results: Participants included 146 full-time sedentary office workers aged 21 to 65 who reported sitting at least 75% of their workday. Each participant received a Fitbit Zip to wear daily throughout the intervention. Participants were randomized to either a: (1) Fitbit-only group or 2) Fitbit + MapTrek group. Physical activity outcomes and intervention compliance were measured with the Fitbit activity monitor. The Fitbit + MapTrek group significantly increased daily steps (+2092 steps per day) and active minutes (+11.2 min/day) compared to the Fitbit-only arm, but, on average, participants' steps declined during the study period. Conclusions: MapTrek is an effective approach for increasing physical activity at a clinically meaningful level in sedentary office workers, but as with accelerometer use alone, the effect decreases over time. Clinical trial registration: URL: Unique identifier: NCT03109535.
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Background: New mobile health (mHealth) software apps are emerging and are providing the foundation to radically transform the practice and reach of medical research and care. For this study we collaborated with Quit Genius, a cognitive behavioral therapy (CBT) based mHealth app that helps users quit smoking, to explore the effective design of a digital mHealth app; one that delivers important benefits to its users and helps them change their behaviors for a healthier lifestyle. Objective: The specific aims of this study were to (1) explore the key role of CBT program progress, (2) examine the gamification design app elements that deliver significant benefits (ie, empowerment, well-being, inspiration) to users, (3) explore the effectiveness of these app elements to help users quit smoking or reduce the number of cigarettes smoked, and (4) identify and describe any potential drivers and hindrances arising from the app design elements. Methods: We developed an online survey and sent an email invitation to 4144 individuals, who had previously or were at the time using the Quit Genius mHealth app, to encourage participation in the study. We matched the online survey data with objective app usage data of the study participants. Results: A dataset of 190 completed responses was used. At the time of the survey, respondents had completed an average of 60% of the CBT program in the Quit Genius mHealth app. Of the respondents, 36.3% (69/190) noted to have quit smoking successfully after using the Quit Genius app. As for those who remained smokers after using the app (N=121), the number of cigarettes smoked per day was significantly reduced by 59.6%. The ability of the app to enhance users' hedonic well-being and psychologically empower them in their daily lives was identified as being key in helping users quit smoking. Specifically, the results show that users whose well-being was enhanced through the app were 1.72 times more likely to quit smoking successfully. Moreover, a one-unit increase on a 7-point Likert scale in the app's ability to empower smokers in their daily lives led to a reduction of cigarettes smoked per day of 53%. The app's inspiration to users, however, was negatively associated with quitting success and the reduction in cigarette smoked per day. Conclusions: The findings offer important insights for the effective design of digital mHealth apps. Specifically, we find that perceived psychological empowerment and enhanced hedonic well-being from the mobile solution may be a more impactful way to support the effectiveness of mobile cognitive behavioral therapy for smoking cessation than eliciting strong inspiration.
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Personal quantification is one fundamental mechanism of gamification. Activity trackers constitute a prototypic case for studying the psychological dynamics of this mechanism. Despite their high potential to increase physical activity, health and well-being, the effects of trackers on users’ motivation to be physically active have yet rarely been explored. The present research examines the notion that quantified feedback of gamified systems can create a dependency that can harm motivation, which becomes apparent through activity reduction when the tracker is not available. To generalize findings from experimental studies to a naturalistic setting, we examined motivational effects of activity trackers in 210 actual users through a scenario- and questionnaire-based survey. Moreover, facets of user diversity (i.e., need for cognitive closure, affinity for technology interaction, achievement motivation, and the Big Five personality traits) were taken into account. Results indicated that a decrease of motivation for physical activity in situations when the tracker is not available plays a role in everyday usage. This dependency effect was stronger for participants with high extrinsic motivation for physical activity and tracker usage, high need for cognitive closure, and low hope of success. In contrast, high intrinsic motivation for physical activity was related to a less strong dependency effect.
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Background The prospect of assessing cognition longitudinally and remotely is attractive to researchers, health practitioners, and pharmaceutical companies alike. However, such repeated testing regimes place a considerable burden on participants, and with cognitive tasks typically being regarded as effortful and unengaging, these studies may experience high levels of participant attrition. One potential solution is to gamify these tasks to make them more engaging: increasing participant willingness to take part and reducing attrition. However, such an approach must balance task validity with the introduction of entertaining gamelike elements. Objective This study aims to investigate the effects of gamelike features on participant attrition using a between-subjects, longitudinal Web-based testing study. Methods We used three variants of a common cognitive task, the Stop Signal Task (SST), with a single gamelike feature in each: one variant where points were rewarded for performing optimally; another where the task was given a graphical theme; and a third variant, which was a standard SST and served as a control condition. Participants completed four compulsory test sessions over 4 consecutive days before entering a 6-day voluntary testing period where they faced a daily decision to either drop out or continue taking part. Participants were paid for each session they completed. Results A total of 482 participants signed up to take part in the study, with 265 completing the requisite four consecutive test sessions. No evidence of an effect of gamification on attrition was observed. A log-rank test showed no evidence of a difference in dropout rates between task variants (χ²2=3.0, P=.22), and a one-way analysis of variance of the mean number of sessions completed per participant in each variant also showed no evidence of a difference (F2,262=1.534, P=.21, partial η²=0.012). Conclusions Our findings raise doubts about the ability of gamification to reduce attrition from longitudinal cognitive testing studies.
Conference Paper
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Gamification is a promising approach to tackle users’ infrequent and decreasing use of health apps. For this purpose, extant research provides developers of health apps with a vast number of different game elements. By abstracting from the implementation of single game elements and choosing a more holistic approach to gamification concepts, we iteratively develop a taxonomy of gamification concepts for health apps using inductive and deductive approaches and discuss its transferability to other gamification contexts. We contribute to a profound understanding of the main characteristics of gamification concepts and enable researchers and practitioners to classify and distinguish them. Our results provide interesting insights into the essential characteristics of health apps’ gamification concepts.
Importance: Gamification, the application of game design elements such as points and levels in nongame contexts, is often used in digital health interventions, but evidence on its effectiveness is limited. Objective: To test the effectiveness of a gamification intervention designed using insights from behavioral economics to enhance social incentives within families to increase physical activity. Design, setting, and participants: The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial with a 12-week intervention period and a 12-week follow-up period. The investigation was a community-based study between December 7, 2015, and August 14, 2016. Participants in the modified intent-to-treat analysis were adults enrolled in the Framingham Heart Study, a long-standing cohort of families. Interventions: All participants tracked daily step counts using a wearable device or a smartphone, established a baseline, selected a step goal increase, and received daily individual feedback on goal performance by text message or email for 24 weeks. Families in the gamification arm could earn points and progress through levels based on physical activity goal achievement during the 12-week intervention. The game design was meant to enhance collaboration, accountability, and peer support. Main outcomes and measures: The primary outcome was the proportion of participant-days that step goals were achieved during the intervention period. Secondary outcomes included the proportion of participant-days that step goals were achieved during the follow-up period and the change in the mean daily steps during the intervention and follow-up periods. Results: Among 200 adults comprising 94 families, the mean age was 55.4 years, and 56.0% (n = 112) were female. During the intervention period, participants in the gamification arm achieved step goals on a significantly greater proportion of participant-days (0.53 vs 0.32; adjusted difference, 0.27; 95% CI, 0.20-0.33; P < .001) and had a significantly greater increase in the mean daily steps compared with baseline (1661 vs 636; adjusted difference, 953; 95% CI, 505-1401; P < .001) than the control arm. During the follow-up period, physical activity in the gamification arm declined but remained significantly greater than that in the control arm for the proportion of participant-days achieving step goals (0.44 vs 0.33; adjusted difference, 0.12; 95% CI, 0.05-0.19; P < .001) and the mean daily steps compared with baseline (1385 vs 798; adjusted difference, 494; 95% CI, 170-818; P < .01). Conclusions and relevance: Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community. Trial registration: Identifier: NCT02531763.