Objective Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques.
Methods Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price.
Data sources We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using ‘gamification’ (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals.
Results 64 of 1680 (4%) health apps included gamification and met inclusion criteria; only 3 of these were in the NHS Library. Behaviour change categories used were: feedback and monitoring (n=60, 94% of apps), reward and threat (n=52, 81%), and goals and planning (n=52, 81%). Individual techniques were: self-monitoring of behaviour (n=55, 86%), non-specific reward (n=49, 82%), social support unspecified (n=48, 75%), non-specific incentive (n=49, 82%) and focus on past success (n=47, 73%). Median number of techniques per app was 14 (range: 5–22). Common combinations were: goal setting, self-monitoring, non-specific reward and non-specific incentive (n=35, 55%); goal setting, self-monitoring and focus on past success (n=33, 52%). There was no correlation between number of techniques and user ratings (p=0.07; rs=0.23) or price (p=0.45; rs=0.10).
Conclusions Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes.
Trial registration number CRD42015029841.
- PUBLIC HEALTH
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Contributors EAE, JL, CR, LS, ST and RTW were involved in conception and design of the review. EAE searched app databases and EAE and JL extracted data and coded behaviour change techniques. EAE, JL, CR, LAE, AT and RS analysed data. EAE, JL, CR, LS, RS, ST, RTW and HC were involved in interpretation of the results. EAE and RTW drafted the manuscript, and CR, LS, ST, CJG, MRM and HC revised it critically for intellectual content. All authors approved the final version of the article. All authors had access to all study data and take responsibility for data integrity and accuracy of the analysis. RTW is the guarantor.
Funding RTW is principal investigator on NIHR Programme grant RP-PG-0609-10181. EAE and AT are NIHR-funded Academic Clinical Fellows. JL is conducting a PhD funded by the Economic and Social Research Council and Cambridge Cognition Limited. MRM is a member of the UK centre for Tobacco and Alcohol Studies, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical, Research Council and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.
Competing interests HC is a smartphone game developer and director of Healthy Games.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Additional data for this article have been provided as supplementary. There is no additional unpublished data.
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