Presented by Menna Brown

Presented by Menna Brown

Gamification and Adherence to Web-based based Mental Health Interventions: A Systematic Review Theme: Protecting and Improving the Public s Health Authors Menna Brown, Noelle O Neill, Hugo van Woerden, Parisa Eslambolchilar, Matt Jones, Ann John

Overview Context Gamification Methods Results Limitations Conclusions

Context Promoting well-being while improving and managing mental health conditions is a worldwide priority (WHO) Common mental health disorders (CMD) and poor well-being have significant ifi economic, social, and individual id cost Web-based based psychological treatments to improve mental health and well- being outcomes are now well established and widely accepted. However, adherence is a critical issue.

Gamification the use of game design elements in nongame contexts Detarding et al 2011 Goal setting Challenge Levels Points Progress Rewards Badges/trophies Game leaders Story/theme Feedback

Fitbit App and wearable device that tracks your steps and dhelps you reach your goals. Compete (leader boards) with friends and other users to try and go the furthest distance Track personal achievements and progress Publish your information to your social media channels PokemonGo Get up, adventure outside and catch wild Pokémon advocating behaviour change Interactive real world map Catch as many Pokémon as you can to earn Experience Points (XP) and increase your Trainer level Earn medals for distance travelled Unlock medals

Aim and Methods Undertake a systematic review of peer reviewed randomised control trials (RCT s) s), designed to manage CMDs or wellbeing, which incorporated gamification features. PROSPERO registration (CRD42015017689) Seven electronic databases were searched: Medline, PsychINFO, CINAHL,Business source complete, Cochrane central, INSPEC,ACM digital library. Search terms combined: Web-based, intervention, CMD/wellbeing, and adherence Title/abstract followed by full text review by three independent reviewers Data extraction piloted data extraction form Risk of bias assessment carried out using Cochrane tool

Inclusion Criteria The intervention must include one or more gamification features; Designed to manage any CMD or improve well-being (including physical conditions that report CMD/well-being outcome); The intervention was delivered via the Web (Internet); The intervention was designed to be accessed on more than one occasion; RCT study design; and The study must have reported at least one measure of attrition, adherence, engagement, dropout, or other term referring to such.

Results 61 RCTs included = 82 interventions 47 different intervention programmes identified The majority managed depression using cognitive behaviour therapy (CBT) Eight of ten gamification features reviewed were in use. Levels and Game leaders were not used The majority utilised only one gamification feature (n=58) with a maximum of three features, 19 used two GFs and 5 used 3 GFs The most commonly utilised feature was story / theme

Data analysis SPSS 22 and Review Manager 5.3 Adherence to study protocol: primary outcome measure A percentage score for adherence to each intervention was calculated to allow comparison across interventions. This was the percentage of those completing post-assessment by the number of participants i t initially iti randomized d (to an intervention ti trial arm) Used because limited data were available on total completion rate of Used because limited data were available on total completion rate of interventions

Adherence Overall adherence to study protocol ranged between 3.3% and 100% (mean 71.7%, 7% SD 20.3%) Mean adherence to intervention was lower overall than mean adherence to control when control was inactive 71.7% vs 78.2%) Mean adherence to interventions excluded (no Mean adherence to interventions excluded (no gamification feature) was 75.2% (SD 19.6%) with a range of 5.3% to 100%.

Gamification and adherence 90 80 70 60 50 40 30 20 10 Mean adherence % in studies using only one gamification feature (n=58) 75.9 72.3 72 53.5 76.3 0 Goal setting (n=6) SD Progress (n=10) SD Feedback (n=3) SD Rewards (n=6) SD Story/theme (n=33) 22.8 31.2 24 13.3 SD 17%

80 78 Mean adherence in studies using one, two or three gamification features 78.2 76 74 72 70 68 71.5 70.5 66 One feature (n=58) SD 21.6 Two features (n=19) SD17.9 Three features (n=5) SD 12.3

Mean adherence rate (%) by condition 100 90 80 70 60 50 40 30 20 10 0

Examination of Additional Intervention Characteristics No significant statistical differences observed: Delivery format (sequential / free navigation) (P=.197) Automated / guided (P=.05) Intended duration (P=.14) Modules (P=.80) Ttl Total number of fit interactive ti features (P=.08) Standard multiple regression indicated that the independent variables Standard multiple regression indicated that the independent variables only explained 10.3% (P=.22) of the variance in adherence.

Limitations Use of adherence to study protocol as the outcome measure (less insightful) rather than completion data. Only included RCTs Varied reporting complicated initial identification of studies for inclusion Interventions using gamification features in conditions other than depression were small in number, which limited opportunity to explore the influence of gamification features on adherence across health conditions. Use of gamification features: Goal setting and feedback were aligned with established strategies used in therapeutic treatment of CMD and their role is well defined in terms of supporting and encouraging behavior change. Adherence also may be influenced by additional factors that could not be assessed in this review Publication bias

Conclusions Gaming features have been implemented in the design of interventions to manage CMDs and well-being No evidence that specific gamification features improved higher adherence to the intervention program as measured by adherence to protocol. No evidence to suggest interventions incorporating additional gamification features had any statistically significant influence on adherence. However, no studies explicitly examined the role of gamification on program adherence or engagement. Interventions intended to last 10 weeks or longer and those incorporating 3GFs had higher mean adherence

Further research Further research should look to examine whether application of specific gamification features influences adherence to protocol and completion rate: Compare same intervention ti altering gamification features (number, combination and type) Look across different health context s (different conditions) Alternative therapies (ACT) Navigation style Assessment of participants motivation

References Deterding S, Dixon D, Khaled R, and Nacke L. From game design elements to gamefulness: defining gamification. in Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments 2011 ACM. doi:10.1145/2181037.21810401145/2181037 2181040 Cugelman B. Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers. JMIR Serious Games 2013 PMID:25658754 Hamari K, Koivisto J, and Sarsa H. Does gamification work? A literature review of empirical studies on gamification. in 47th hawaii International ti conference on system science 2014 6-9. Hawaii, USA. doi 10.1109/HICSS.2014.377 Kelders S, Bohlmeijer E, and Gemert-Pijnen J. Participants, usage, and use patterns of a web-based intervention for the prevention of depression within a randomized controlled trial. Journal of Medical Internet research 2013 15, e172. PMID:23963284 Cochrane, Cochrane Handbook for Systematic Reviews of Interventions, ed. Higgins J and Green S. 2008 England: Wiley-Blackwell. ISBN 978-0-470-69951-5

Risk of Bias