MOTIVATION FOR EXERCISE THROUGH
THE GAMIFICATION OF DIGITAL HEALTH INTERVENTIONS
University of Amsterdam
Faculty of Business and Economics
MSc Business Administration: Marketing Track
Master Thesis
Author: Kim E. Tas
ID: 11199377
Supervisor: Roger Pruppers
2016-2017
STATEMENT OF ORIGINALITY
This document is written by Kim Tas who declares to take full responsibility for the contents of this document.
I declare that the text and the work presented in this document is original and that no sources other than those mentioned in the text and its references have been used in creating it.
The Faculty of Economics and Business is responsible solely for the supervision of completion of the work, not for the contents.
PREFACE
This thesis is driven by my interest in health, health technologies and behavior change. Digital health interventions and the motivation of individuals for lasting health behaviors and habits is a vital area of research. We must work to support improved health outcomes in a world with increasing chronic disease due to poor lifestyle behaviors.
Completion of this thesis has not been easy and with several setbacks and frustrations, but I can confidently say that I have learned a lot during this time. This did not come without help and I would like to thank the following for their continued support. First, I would like to thank all the respondents of the study. Without their participation there would be no results.
Additionally, this thesis would not have been possible without the help of my thesis supervisor, Roger Pruppers. Thank you for the support, advice and patience.
Finally, I would like to thank my wonderful family, friends and boyfriend. Thank you for your unwavering support throughout the entire process. You have given me the strength and motivation to continue when my motivation to write about motivation dwindled.
Kim E. Tas July 2017
ABSTRACT
Gamification (the use of game elements in non-game contexts) is an increasingly popular technique used to drive performance outcomes, engagement and adherence in a variety of fields. However, not much research has been done on the effects of gamification and its underlying motivational mechanisms. Gamification typically makes use of extrinsic incentives, such as points and badges, in an attempt to increase enjoyment and intrinsic motivation for behaviors. Previous studies and literature is often contradicting and controversial as there is a lack of research on extrinsic and intrinsic motivational effects of the technique. Motivation and gamification are areas with a wealth of past research, but there are few studies that connect the two in the way that this study does.
Health and fitness are trending topics in the field of digital interventions and gamification, as they are areas where people have a difficult time motivating
themselves. In general, people know what they should do to be healthy but need an extra motivational push to actually do it. It is hypothesized that techniques such as gamification can close this intention-behavior gap. However, research still stands on different sides on how gamification works and whether it focuses on a user’s extrinsic (external) motivation, intrinsic (internal) motivation or both.
A 2 (pre vs. post) x 2 (personalization) x 3 (level of gamification) mixed design online randomized controlled trial experiment with 133 participants was conducted to test and assess the motivational effects of various types of gamification (or levels of gamification) in addition to personalization, using a fictional fitness application (app), Thrive. It strives to answer the main research question: What are the effects of gamification on intrinsic and extrinsic motivation?
Results showed that gamification mainly had an effect on extrinsic motivation and a significant increase in motivation was found only at level 3, social competition. The addition of personalization showed no significant effect on extrinsic motivation or intrinsic motivation. This study is an important step towards the use of new technological tools and techniques to increase a user’s motivation for healthy behaviors and long-term health.
Keywords: health, behavior change, digital health interventions, health apps,
gamification, badges, points, social competition, personalization, coaching, adherence, fitness, physical activity, motivation, intrinsic motivation, extrinsic motivation
TABLE OF CONTENTS
CHAPTER 1: INTRODUCTION ………. 1
1.1 Digital Health Interventions, Motivation and Gamification ……...…...…. 1
1.1.1 Digital Health Interventions ……….. 1
1.1.2 Motivation and Engagement Through Gamification ………. 2
1.1.3 Using Gamification Elements in Digital Health Interventions for Increased Intrinsic and Extrinsic Motivation ………. 3
1.2 Problem Definition ……….…. 4 1.2.1 Problem Statement ………. 4 1.2.2 Sub-questions ………..…………... 4 1.2.3 Delimitations of Research ……….. 5 1.3 Contributions of Research ……….. 6 1.3.1 Theoretical Contributions ……….. 6 1.3.2 Managerial Contributions ………... 6 1.4 Research Structure ……….. 7
CHAPTER 2: HEALTH BEHAVIOR CHANGE AND DIGITAL HEALTH INTERVENTIONS ……… 8
2.1 Health Behavior Change ………. 8
2.2 Digital Health Interventions ……….…….. 9
2.2.1 Digital Health Interventions for Behavior Change ………... 9
2.2.2 Study Focus: Fitness Apps ………... 10
2.2.3 Why Digital Health Interventions Fail ……… 11
2.3 User Motivation within Digital Health Interventions: Motivation for Behavior Change ..……….………..… 12
CHAPTER 3: GAMIFICATION AND PERSONALIZATION AS MOTIVATORS ……….………... 14
3.1 Gamification ……….………. 14
3.1.1 What is Gamification? ……….………. 14
3.1.2 Common Gamification Elements and Mechanisms…….………... 14
3.1.3 Levels of Gamification ……….…….…...………. 15
3.1.4 Applying Behavior Change and Motivation Theory to Gamification ... 16
3.1.5 Gamification Elements on The Motivational Spectrum: Moving Beyond Extrinsic Motivation ……….………...………... 17
3.2 Personalization ……….………... 18
3.2.1 Digital Health Intervention Personalization ……….………… 18
3.2.2 Personalized Digital Coaching ……….……… 19
CHAPTER 4: PERSONALIZATION ……….…………... 24
4.1 Digital Health Intervention Personalization ……….………. 24
4.2 Personalized Digital Coaching ……….……… 25
CHAPTER 5: CONCEPTUAL MODEL AND HYPOTHESIS ……….. 21
5.1 The Extrinsic and Intrinsic Motivational Effects of Gamification ……... 21
5.2 Hypothesis Formulation ……….…….………….……….……… 23
5.2.1 Digital Health Intervention Effects ……….……….……… 23
5.2.2 Gamified Digital Health Intervention Effects …..………….…………... 24
5.2.4 Personalized (Meaningful Gamification) …….………... 28
CHAPTER 6: METHODOLOGY ……….……… 31
6.1 Research Design ………..………..……… 31
6.2 Stimuli Selection and Development ……….………...…. 31
6.2.1 Gamification Levels ……….…………..……….. 32
6.2.2 Personalization ……….…………...……… 32
6.3 Pretests ……….……….….. 32
6.3.1 Qualitative Pretest ……….……….. 33
6.3.2 Quantitative Pretest ……….……… 33
6.3.3 Adjustments for Main Study ……….……… 34
6.4 Main Study ……….……… 35
6.4.1 Sample ……….………. 35
6.4.2 Procedure ……….……… 35
6.4.3 Development of Main Questionnaire ……….……….. 36
CHAPTER 7: RESULTS ……….……… 38
7.1 Sample Characteristics ……….……….……...…… 38
7.2 Factor Analysis ……….………. 38
7.3 Reliability Analysis: Correlations and Cronbach’s Alpha ……… 40
7.2.1 Extrinsic Motivation ………...…….……… 40 7.2.2 Intrinsic Motivation ……….……… 41 7.3 Manipulation Checks …...……….……… 41 7.3.1 Gamefulness ……….……… 42 7.3.2 Personalization ……… 43 7.4 Hypotheses Testing ……….………... 45 7.5 Additional Analyses ……….……….. 53
7.5.1 Intention for Behavior ……….………. 53
CHAPTER 8: DISCUSSION ……….………….. 55
8.1 Interpretation of the Research Results ……….……...……… 55
8.1.1 Digital Health Intervention Effects ……….……...……... 55
8.1.2 Gamification Effects ……….……….……...…..…... 55
8.1.3 Personalization Effects ……….……….…...…..…... 55
8.2 Implications ……….………... 58
8.2.1 Theoretical Implications of the Research Results ………….………58
8.2.2 Managerial Implications of the Research Results ………….………59
CHAPTER 9: CONCLUSION ……….………... 62
9.1 Summary of Findings ……….………... 62
9.2 Limitations of the Study ……….………... 62
9.3 Suggestions for Future Research ……….………….…... 63
CHAPTER 10: REFERENCES ……….………. 66
CHAPTER 11: APPENDIX ……… 73
CHAPTER 1: INTRODUCTION
1.1 Digital Health Interventions, Motivation and Gamification 1.1.1 Digital Health Interventions
“Today’s behaviors are tomorrow’s risk factors and today’s risk factors are
tomorrow’s diseases” was stated at The World Health Summit (Reddy, 2013, p. 3). Many of these diseases are caused by our modern world and are preventable by a healthy diet and balanced lifestyle decisions. In spite of this, over half of annual deaths are still due to chronic illness (The Nutrition Source: Disease Prevention, 2017) that can be directly linked to behavioral decisions such as tobacco use, insufficient physical activity, poor eating habits and excessive alcohol consumption (Koeppl and Robertson, 2015). The need for health interventions that support
successful and sustainable health behavior change is imperative. However, change is hard and human behavior is complex so the health and medical community continues to struggle with understanding health behavior change and designing effective means to promote and support behavior change for long-term health.
Luckily, rapid technological progress and the wide acceptance of the Internet, mobile apps and wearable trackers in combination with the current revolution in digital healthcare are driving a massive amount of new digital health interventions to be introduced to the market. These interventions are aimed at changing user health behaviors ranging from increasing physical activity to monitoring serious chronic illnesses and present an exciting opportunity to leverage mobile access, data collection, tracking and digital technologies. However, these digital health
interventions (DHIs) have extremely low adherence rates and often fail due to a lack of ongoing user motivation, interest and engagement. For example, Fitbit, the world’s leading health and fitness tracking app, saw a 70% churn of its purchasers from the first three quarters of 2004 before the end of the year (Markelz, 2016). Currently, there are over 165,000 mobile health applications (apps) on the market (Misra, 2015) with most of these failing within a short amount of time. However, when designed and implemented according to user-centered needs these DHIs have a huge potential to impact disease prevention and change millions of lives.
1.1.2 Motivation and Engagement Through Gamification
This paper explores the motivational effect of the application of gaming techniques to digital health interventions (gamification). Gamification is defined simply as the use of gaming methods and mechanics in non-gaming subjects to improve user experience and user engagement, loyalty and fun. Merriam-Webster (2017) states that gamification “refers to the incorporation of game elements, like point and reward systems, to tasks as incentives for people to participate.” Many prime examples of gamification exist across multiple domains and can be applied to digital as well as non-digital realms. Examples of gamification range from designing a set of stairs to look like piano keys to increase exercise by adding an element of “fun” to using the stairs to Starbucks Rewards where customers can collect points for rewards to increase buying behavior and consumer loyalty.
Health behavior change is an interesting marketing concept due to the fact that it does not concern a one-time behavior change, but encourages the continuation and repetition of healthy behaviors. This distinction amplifies the importance of
understanding motivation as a major driver of DHI use. Since health behavior is often related to long-term goals such as disease prevention and weight loss we must find ways to increase motivation and engagement to achieve these goals by tapping into intrinsic motivators. Literature in regard to motivation often acknowledges the
concept of gaming and gamification to increase the enjoyment of tasks and to enhance engagement and learning, but different types of motivation in relation to various levels of gamification has never been studied, let alone in the context of health behaviors.
The inclusion of gamification elements within DHIs has promising effects on user behavior, yet not much is known of motivational effects when applied to digital health interventions focused on health behavior change. There is ample literature on the effectiveness of gamification elements in general, but little literature on the application to digital health solutions. Within the medical field, there is research on health in the telemedicine health environment but there is a clear gap when we look into the motivational affordances of gamification techniques beyond medication adherence and the targeting of specific medical conditions.
1.1.3 Using Gamification Elements in Digital Health Interventions for Increased Intrinsic and Extrinsic Motivation
Within the digital realm, games developed for mobile phone platforms are becoming increasingly popular, yet little is known about their content or inclusion of health behavior theory (Payne, Moxley & MacDonald, 2015) while this possible integration has the potential to greatly impact the efficacy of gamification to change behavior (Lister et al., 2015). This paper will further explore the intersection of digital health interventions, gamification and motivational effects drawn from behavioral theory. It is still unclear what effect gamification elements and game mechanics such as points and badges, which are mainly extrinsic motivators, have on intrinsic motivation and how exactly they affect general motivation for behavior change, both positively and negatively (Bielik, 2012). Thus, this paper focuses on how the addition of certain gaming elements can increase intrinsic motivation by applying theories of motivation and behavior change to tap into user’s sense of autonomy, competence and
relatedness.
The use of gamification has been readily studied and applied to other offline and online realms such as education, workplace productivity, fostering creativity, customer loyalty and banking. While there is prior research on the general
effectiveness of gamification on outcome behavior, there remains a gap in research on the motivational effect of the application of various gamification mechanisms and their combinations (which we refer to as gamification levels) specifically to digital health interventions. A recent comprehensive systematic review of literature on gamification in the health and wellness domain by Johnson et al. (2016) found that prior studies have focused solely on the empirical effectiveness of multiple game elements simultaneously, but that no study has tested for the independent effects of gamification levels. This study combines certain gamification elements to explore the promise of intrinsically motivating elements (proven to be more successful in
behavior change than extrinsically motivating elements by Seiferd et al., 2012) by taking learnings from game design and motivational theory to propose gamification levels, which is currently neither explored nor tested.
This addition of fun and engagement is important in the health realm since we are often hardwired towards instant gratification and the “true” rewards of health— feeling better, living longer and reduced stress—are typically attached to a distant
future resulting in delayed gratification (Seifertet al. 2012). It is evident we need a new, innovative way to help people move toward health improvement by providing salient rewards and gratification along the way by tapping into increasingly intrinsic motivators. But why do we care to understand intrinsic and extrinsic motivators in the first place? Zichermann (2012) outlines three main reasons: closer alignment with users’ intrinsic motivations produces greater satisfaction, higher quality outcomes (particularly when we measure tasks that require a great deal of sophisticated thinking and perseverance) and knowing what rewards users will value means focusing efforts and capital in useful incentives.
1.2 Problem Definition 1.2.1. Problem Statement
This paper will focus on mobile apps (a type of digital health intervention) that are positioned as preventive healthcare tools aimed at creating general wellbeing and easy integration into everyday life through supporting lifestyle modifications such as increased physical fitness and a healthy diet. Specifically, this study will explore various gamification techniques and levels such as real-time feedback, competition and points to explore their intrinsic and extrinsic motivational effects. Additionally, we examine whether the addition of personalization via personalized coaching has differential effects on motivation.
Research Question: What are the effects of gamification on intrinsic and extrinsic motivation for changing health behaviors?
1.2.2. Sub-questions
In order to answer this research question, the exploration of sub-questions is needed. These questions will help to develop a theoretical framework and hypothesis.
First, the goal of digital health interventions is to successfully change health behaviors. Thus, health behavior change needs to be further explored to understand the underlying consumer cognitive processes that lead to sustainable change. This leads to the first sub-question: What are the key elements necessary for health behavior motivation and health behavior change?
Second, motivation as driver of [health] behavior change and within the context of digital interventions must be explored. This leads to the second
sub-question: What role does the motivational continuum play in changing health behaviors via digital health interventions?
Third, digital health interventions will be defined and explored. This study will mainly focus on one type of digital health intervention: an exercise app to help increase physical activity and overall wellbeing. This leads to the third sub-question: What are digital health interventions and how do health apps work to increase motivation for behavior change?
Fourth, gaming, gamification and serious gaming will be further explored and defined. These techniques and elements will then be explored in application to digital health interventions. We then propose the idea of gamification levels. This leads to the fourth sub-question: Which gaming elements or combinations of (levels) can most successfully be applied to digital health interventions (increasing physical activity in particular) to increase (intrinsic) motivation?
Lastly, personalization has been proven to increase motivation, yet little is known about the application of personalization techniques in combination with gamification within digital health interventions. This leads to the fifth sub-question: Does personalization, specifically personalized coaching, increase (intrinsic) motivation?
1.2.3 Delimitations of Research
This study will explore the motivational effects of gamification elements when applied to digital health interventions via a quantitative experiment. Individual
gamification mechanisms, or levels, will be explored when applied to digital health interventions: increasing physical activity via mobile apps in particular. This study will not focus on the market of medical technology and medicine adherence interventions. It will also not focus on digital health interventions that target
managing chronic or complex diseases (clinical interventions). Yet it should be noted that there is typically some overlap in techniques and both are easily transferable and scalable. Individual gamification elements and mechanisms to be tested vary in placement on the motivational continuum and include points, badges, levels, leaderboards, progress feedback, challenges and competition.
1.3 Contributions of Research 1.3.1 Theoretical Contributions
Academically, this study will present an interesting application of
gamification to increase user motivation in the digital health space. The study of gamification components to certain consumer behavior has important scientific and academic implications due to the elements of consumer motivation, adoption, adherence and sustained behavior change. This study will further explore behavior change theory in connection to intrinsic and extrinsic motivation. It will expand Fogg’s behavior change model, which states that motivation, ability, and trigger are required for true behavior change (Fogg, 2009), by focusing on increasing motivation through gamification techniques. Additionally, no intervention has previously
examined intrinsic motivation support (Johnson et al, 2016) and we will explore the effect of gamification on the increase in “good feelings” and motivation based on various elements of gamification such as competition and achievement.
1.3.2 Managerial Contributions
Further research and insights into digital health intervention adoption and sustained adherence has clear managerial implications regarding to consumer
behavior and engagement and the success of digital health interventions. The current influx of apps, trackers and other digital health interventions in addition to the current trend of gamification has led to an abundance of unsuccessful digital interventions with high attrition rates. A deeper understanding of the application of certain gamification elements to these digital interventions can help provide managers and designers to develop a framework of motivation and engagement strategies via individual gaming strategies. Policymakers and health care providers are increasingly looking for interventions that motivate positive health behavior change, particularly interventions that leverage the capabilities of computing technology. Opportunity to move beyond risk management and move into “fun” prevention programs can have a huge impact on government health programs, community wellbeing and employee wellness programs.
1.4 Research Structure
In order to answer the central research question, this paper will be organized in various sections. First, the general concepts of health behavior change, digital health interventions and gamification will be elaborated. Next, a theoretical framework will be presented based on previous research and literature. The literature review is broken down into the following three chapters: health behavior change and digital health interventions, user motivation within digital health interventions and gamification. This will lead to the design of a conceptual model. Second, the hypotheses and experiment method used for this research will be explained. Third, the findings of the analysis of the experiment will be presented. This will be followed by a discussion of the results, which will lead to the implications and limitations of this research. Finally, a concluding chapter will summarize the most important findings and insights, answer the research question and give directions for future research.
CHAPTER 2: HEALTH BEHAVIOR CHANGE AND DIGITAL INTERVENTIONS
2.1 Health Behavior Change
The ultimate goal of digital health interventions is to successfully change health behaviors, so a thorough understanding of the behavior change process is essential. Health behavior change is a unique concept due to the fact that it does not solely concern a one-time behavior change, but concerns the start and continuation of healthy lifestyle behaviors such as exercise, healthy diet, smoking cessation and medication adherence. This distinction amplifies the importance of studying ways to increase long-term motivation, the primary driver of behavior change, to increase user engagement and adherence to these interventions.
The Theory of Planned Behavior (TPB) is often mentioned in connection to health behavior change and describes three main factors that influence intention for behavior and behavioral outcomes: attitude towards the behavior, subjective norms or the perception of behavior influenced by others and perceived behavioral control or ability to master the challenge (Hansel et al., 2015). When looking at health behavior change it is evident within the TPB that feelings of self-efficacy are essential to drive positive thoughts, behaviors and feelings. Self-efficacy, also referred to as personal efficacy, is the extent to which one believes in his/her own ability to complete tasks and reach goals (IGI Global: Self-Efficacy, 2017). Self-efficacy must remain high to support behaviors in the long-term as this increases commitment and motivation to master challenges. Motivation, foremost, is the driving force by which humans achieve their goals (Seifert et al., 2012). Accordingly, the focus of this paper is the design of motivational affordances via gamification techniques for health behavior change.
Fogg’s Behavior Model (FBM) for persuasive design is also commonly used within behavior change. Similar to TPB, FMB explains the necessity of three major factors: motivation, ability and triggers, each of which has various subcomponents for behavior change. The model posits that for a person to perform a behavior he or she must be sufficiently motivated, have the ability to perform the behaviors, and be triggered to perform the behavior (Fogg, 2010). All three factors must be present at the same instant for the behavior to occur, but this paper will focus mostly on
motivation as it is argued to be the starting point of behavior change. Fogg (2010) describes three main drivers of motivation: pleasure/pain, hope/fear and social acceptance/rejection. This paper focuses on pleasure/pain and social
acceptance/rejection in connection to gamification within digital interventions, which will be further explained in the following sections wherein we explore the connection between behavior motivation and gamification.
Health behavior change remains a challenge for health practitioners, health promoters and researchers alike. The medical, health and wellness industries continue to seek new and effective ways to motivate patients and users via various techniques and interventions. The recent surge in technology and increase data tracking capacity has lead to many of these interventions becoming digital, presenting a new set of possibilities but also challenges.
2.2 Digital Health Interventions
2.2.1 Digital Health Interventions for Behavior Change
Digital health and lifestyle interventions have started to transform healthcare by making prevention, diagnosis and treatment broadly accessible while reducing costs. Digital health interventions can be used to promote effective lifestyle modification and are categorized as e-Health technology. E-Health technologies are generally defined as standalone devices, integrated web-based interventions and personal mobile devices, or a combination and integration of these various devices to monitor the online and offline activities of a user (Kulyk et al., 2010). These smart health devices and interventions range from general devices like activity trackers, body weight and sleep monitors, fitness performance devices to medical devices for measuring blood glucose or blood pressure (Hansel et al., 2015), such as the connected products from iHealth which provide (1) physical health activity
monitoring and coaching, (2) mobile e-Health and coaching and (3) serious gaming for lifestyle support (Kulyk et al., 2014).
The digitalization of health interventions is an answer to consumer interest in wanting to know more about their own health and fitness levels, contributing to the rise of the empowered patient and consumer, in addition to supporting patients (for example, fall detection for the elderly) and bringing healthcare to communities in need (for example, telehealth in developing countries). Digital health interventions
(DHIs) such as Apple’s HealthKit and Google Fit are new mobile health tracking platforms with a focus on fitness and wellbeing. They allow for the obtainment and interchange of health data (a technique coined the Quantified Self or QS) between various applications making digital interventions available to a broader population. The QS trend describes the quantification of aspects within our lives often found in DHIs which allow us to become aware of behaviors and habits and to reflect, learn and improve by collecting data and analyzing it (Hansel et al, 2015). By 2020, 551 million people are expected to make use of a digital health app at least once a month (“mHealth App Developer Economics”, 2016). Data can now be easily obtained, but it must also be made meaningful, which requires the exploration and application of various consumer behavior change techniques in this new space. As apps and wearables become increasingly capable and useful, and smartphones continue their march of dominance, mHealth (mobile health) has a promising future. Studies of technology-based markets forecast that global revenues for mHealth will reach $21.5 billion in 2018, with Europe becoming the largest mHealth market (“Things Are Looking App”, 2015). Interventions to improve user motivation and adherence should capitalize on the availability, and our reliance on, technology.
2.2.2 Study Focus: Fitness Apps
Thousands of apps exist to promote an increase in physical activity from Fitbit fitness trackers to the Philips Health Band. Generally, these apps and wearables track step count, distance, heart rate and calories burned. Many smartphones are now embedded with functionality that provides activity data such as accelerometers, gyroscopes, GPS and barometers (Misra, 2015). Fitness apps allow users to set a target, get direct biofeedback from a pedometer and the possibility to share activity levels with their social network to motivate themselves as well as others. Some apps even create financial incentives or penalties around physical activity targets (such as the app Pact Health). We argue that the use of gamified apps to increase fitness behaviors will be especially successful because once started, exercise in itself releases the feel good hormone dopamine, the neurotransmitter linked to happiness and rewards. People who exercise regularly feel good post-workout and additionally also release dopamine in response to the anticipation of pleasure as well leading to repeat behavior.
2.2.3 Why Digital Health Interventions Fail
Unfortunately, these apps, trackers and other digital health interventions have an extremely low adherence rate and are susceptible to high levels of user drop-off. Despite the number of health-related digital health intervention technologies and their ever-increasing popularity, there is little in-depth research on actual user experiences and effects on user motivation. A recent comprehensive report by Rock Health states that despite huge jumps in technology data, wearable products today fail to engage users over meaningful periods of time. Roughly 13 million Americans bought smart activity trackers in 2015 with one-third abandoning them within six months and adherence dropping below fifty percent (50%) before eighteen months (Gandhi & Wang, 2013).
Adherence remains low despite decades of research, highlighting the need for innovative approaches to tackle this problem. Interventions to improve health behavior motivation should capitalize on our dependence on technology, as digital interventions show promise that consumers can attain and maintain their health goals (Castaño et al, 2013).
Digital health interventions have an enormous potential as tools to improve health by improving efficiency, effectiveness, accessibility and personalization (Murray et al., 2016), thus increasing user motivation for behavior change. However, it is important to reflect on the features of these technologies that foster behavioral change, since it is not the technology itself that causes the actual behavioral change (De Maeyer & Jacobs, 2013), but instead the resulting underlying user motivation.
More and more individuals and organizations are designing experiences via technology channels that they hope will influence people’s behaviors. However, many fail because there is an apparent lack of understanding of the factors that lead to true behavior change (Fogg, 2010). DHIs are presently seen as utility tools, but lack a motivational entertainment factor – a vital ingredient for success – that would strike balance between useful, fun and entertainment (Miles, 2017). When motivational affordances are integrated with health behavior theory and we look beyond data this level of meaningful motivation and fun can be accomplished. As stated by Markelz (2016): “Data without engagement is dead.”
2.3 User Motivation within Digital Health Interventions: Motivation for Behavior Change
A comprehensive understanding of motivation will help us design more effective health interventions. Motivation is demonstrated by the choice to engage in an activity and the intensity of effort and persistence in that activity (Garris et al., 2002).
Motivation is a multifaceted phenomenon, as people have different amounts and different kinds of motivation at different times and in response to different activities (Ryan & Deci, 2000). The main theory concerning human motivation is the Self-Determination Theory (Deci & Ryan, 1985, 2002). The Self-Self-Determination Theory (SDT) is a macro theory of human motivation and personality that concerns people's inherent growth tendencies and innate psychological needs. It distinguishes between various types of motivation that underlie all behaviors, ranging from lack of intention to act, or amotivation, to intrinsic motivation, a motivation rising from within the individual. SDT posits that humans are motivated by the need to be competent at things, the need for autonomy (own control; locus of control) and the need to be part of a group, society or meaningful unit.
When we look further into motivational factors we must note the difference between intrinsic and extrinsic motivation, wherein the latter is further distinguished into three different aspects: introjection, identification and integration (Ryan & Deci, 2000). At one end of the spectrum, external regulation or extrinsic motivation refers to engaging in the behavior because of external rewards. Introjected regulation refers to the internalization of motivation so that one does the activity to avoid guilt and/or to maintain self-esteem. Identified regulation refers to further internalization which occurs when the person recognizes the value of the behavior and integrated regulation refers to performing the activity in order to be consistent with one’s sense of self. At the other end of the spectrum, intrinsic regulation refers to engaging in the behavior or activity for the enjoyment of satisfaction in doing so (Markland & Tobin, 2004). When a user is provided with a sense of connectedness and belongingness, or in SDT terms relatedness, this internalization of behavioral regulations increases intrinsic motivation for the behavior.
Unfortunately, most of the activities that people do, especially health behaviors, are not perceived as intrinsically motivating. However, by applying SDT we can design behavior change interventions that increase motivation in a way that drives the
user up the continuum and increases different types of motivation. A common technique to increase motivation is gamification, which will be further defined in the following chapter. This study posits that increasing levels of gamification can
increase a user’s intrinsic motivation (move them up the continuum), which will lead to increased motivation for behavior change and sustained DHI usage.
CHAPTER 3: GAMIFICATION AND PERSONALIZATION AS MOTIVATORS
3.1 Gamification
3.1.1 What is Gamification?
Recently, health and lifestyle interventions have begun to implement a variety of game features in the form of gamification in order to influence behavior by
encouraging motivation and engagement (Kim, 2015) in offline and online domains. Gamification is a relatively new concept and is defined as the use of game design principles to improve customer (user) engagement in non-game environments. Gamification includes the incorporation of game elements, such as points and
rewards, to tasks as an incentive for participation. Gamification can potentially make tedious tasks into a game by tapping into people’s natural desires for competition, fun and achievement (Merriam-Webster, 2017).
We first make the distinction between games, serious games and gamification. Games are typically an activity that engages for amusement. Serious games, on the contrary, are designed for purposes other than entertainment. For example, serious games can be useful for training and education such as in flight simulations and emergency management. Gamification is the use of game design elements and features in non-game contexts. It does not necessarily mean the creation of a full-fledged game, but is rather designed as a persuasive system that will change the behavior of consumers, patients or users. The technique is often used to track goals and achievements and to help motivate into willing participation on a regular basis. It applies the techniques of game mechanics to shape target behaviors by leveraging the power of immediate reward and social elements (RedBrick Health, 2012).
3.1.2 Common Gamification Elements and Mechanisms
Below we outline a few core elements and mechanisms of gamification typically utilized within digital interventions:
(1) Points: Points are a goal metric that provides feedback on player performance and is a requirement for all gamified systems, even if those points are never visible to the user. Points often reward the completion of tasks or behaviors. (2) Badges: Badges, achievements, trophies and other such concepts are used to
identify and visually reward individual achievements. There are primarily two kinds of badges: absolute badges and relative badges. Absolute badges can be attained by meeting non-relative goals, such as achievement benchmarks, while relative badges are limited achievements rewarded to users relative to their peers (Miller et al. 2014).
(3) Levels: Levels are commonly seen as an extrinsic incentive and goal metric that provides the user with feedback and shows progression. Levels make points more meaningful, indicate progress, communicate to the user how well he/she is doing and where they are located in the system.
(4) Social Sharing and Leaderboards: Leaderboards are used to allow users to compare themselves against others and tend to dynamically rank the
individual user. Players earn points and are ordered based on the total number of points they have accumulated. This ranking may be in regard to the number of points earned relative to the highest scorer or may be a comparison to other players within a certain area or age range (McNamara, Jackson, & Graesser, 2010).
(5) Competition: Competition, either against themselves or against others, allows users to share progress and results with their friends or other users of the service – therefore, a competitive spirit is created to elicit more or better use of the service.
(6) Feedback: Feedback is the display of deliberate and immediate information, autonomously offered by system on action taken by user. It is used to inform the user of current and accumulated progress (Deterding, 2015).
When examining these elements we can see direct connections to SDT as gamification implementation includes: ownership (points, token, badges);
achievements (points, badges, levels that are representations of accomplishment); status (computing and displaying a rank or level); collaboration (challenges that can be resolved by working together) (Vassileva, 2012). However, it is not known if and how these different gamification techniques affect motivation differently.
3.1.3 Levels of Gamification
We propose the notion of gamification levels in this research due to the fact that each “level” has an increasing amount of gamification elements, while still including the
elements from the previous level. Gamification uses various game design elements and we suggest that certain combinations of these elements result in increasing levels of gamification that could theoretically increase intrinsic motivation. The levels are designed where each increasing and cumulative level taps into additional intrinsic motivators according to behavioral theory. We postulate the following levels:
Level 1: No Gamification / Control
This level simply displays tracked data without any gamification elements, but does display a user’s progress, tapping into a user’s need for competence.
Level 2: Virtual Rewards
This level displays tracking data and additionally rewards users with points and badges for completing certain tasks and/or behaviors tapping into a user’s need for competence, mastery and autonomy.
Level 3: Social Competition
This level builds upon the previous levels by adding the element of social competition between users, friends and family, thus tapping into a user’s need for social
relatedness.
3.1.4 Applying Behavior Change and Motivation Theory to Gamification
Gamification helps us leverage our capacity for cooperation, resilience, focus, drive, competition and creativity and when tailored to individual needs and goals games can help behavior change. Jane McGonigal, the creator of the successful
gamified recovery app SuperBetter, states that gamification helps health goals become attainable by creating optimism, arousing curiosity, and providing the user with agency, personalization and choice which consequently increases their motivation and investment.
Gamified systems use game mechanisms, or elements, to create motivational affordances that invoke enjoyable and intrinsically motivating gameful experiences (Karanam et al 2014). Gaming mechanisms make personal investment in future good health gratifying in the here-and-now and taps into universal human desires for skill mastery, achievement, autonomy, status, socializing, feelings of competence and social acceptance. It reinforces small successes through rewards, point collection, leveling up and winning competitions to positively impact confidence and
self-efficacy by utilizing people’s innate desire for achievement and progress.
Digital games are unique as they have the ability to give immediate feedback and integrate personalized tracking and monitoring data. This gives the user or “player” motivation to keep learning and improving towards mastery, another key element of intrinsic motivation. The more personalized these games get, the more potential they have for helping a user gain intrinsic motivation through setting specific goals with personalized feedback and giving a sense of support rather than simply winning meaningless points.
Special attention must be paid to players’ motivation while crafting tailored challenges and goals to ensure empowerment through relevant challenges that lead to mastery over their health. Games for health that have a social element should favor mutual support and use competition to help one another (Keefe, 2016). It has been shown that people desire continuous recognition and feedback to know how well they are doing (Richter et al., 2015). Thus, gamification goes beyond monetary rewards and uses engrained human nature and need for play and achievement to encourage feelings of pride and meaning. Nonetheless, gamification often fails when common elements such as points, badges and leaderboards (PB & L in game designer lingo) are haphazardly added as a layer that will magically create user motivation and engagement.
3.1.5 Gamification Elements on the Motivational Spectrum: Moving Beyond Extrinsic Motivation
Humans are hardwired towards instant gratification (Seifert et al., 2012). Within health behavior change there tends to be an intention-behavior gap due to the fact that the true intrinsic rewards of healthy behavior change such as feeling better, reduced stress, weight loss and living longer are attached to a distant future making the
rewards elusively far away while the behavior itself may not necessarily be rewarding at the time. Consequently, we must design health interventions in a way that
motivates behavior through the provision of some salient awards along the way (Seifer et al., 2012). Frequently extrinsic incentive programs, such as points and badges, are installed to begin new health behaviors, but we must also identify and reinforce the intrinsic value of these behaviors to help people maintain these behaviors over time.
It has been argued that in the context of gamification, intrinsic motivation is the best way to make your app or platform more engaging. However, most gamified apps make use of purely extrinsic rewards such as points and badges. Extrinsic rewards are often tangible such as a certificate of accomplishment, a price, a badge or point and monetary incentive (John, 2016). By contrast, intrinsic rewards are
intangible such as recognition, satisfaction and the sense of achievement you get from doing something.
Let’s take Nike+ Fuelband as an example to show intrinsic and extrinsic rewards. The FuelBand, a wearable, has its own mobile app that displays fuel points and numerically tracks how active you are. These points can then be compared to other user’s fuel points as well as show what you and your friends have accomplished. Thus it relies on the addition of increasingly intrinsic rewards like accomplishments, self-development, social influence and social recognition. Moreover, it has been argued that the goal of gamification is to create and maintain intrinsic motivation, yet commonly gamification is the application of extrinsic motivators. It is the careful selection and implementation of these motivators that hopes to trigger internal motivation (Richter et al., 2015).
3.2 Personalization
3.2.1 Digital Health Intervention Personalization
To date, feedback technologies have been limited to providing overall statistics and visualization of tracked data or are simply tailored based on age, gender and overall calorie or activity information (Rabbi et al., 2015). As noted previously, more work is needed to create successful engagement strategies and better digital solutions for increased user motivation, leveraging personalization where possible (O’Connor et al, 2016). This study stresses that we must enhance meaning within gamification and move beyond using “easy” extrinsic rewards such as arbitrary points and badges and leverage technological advancements such as personalized coaching, data and feedback. Gamification within mobile apps (a popular type of DHI) not only has the ability to create an enjoyable experience for users, but further has the ability to provide relevant information and support through past performance, personalized suggestions, social networks and reminders (Want, 2017). It is evident that everyone has unique health conditions and goals, so one-size-fits-all interventions cannot serve everyone equally. Therefore, personalized interventions are a solution to the barrage
of irrelevant information and strategies that most DHIs currently present.
Technology is a tool to increase personalization and can maintain motivation for healthy behaviors when theory is integrated into design. Combining gamification techniques with personalized coaching and contextualization gives users the
continued support they need and increases meaning for the behavior and therefore has the potential to increase intrinsic motivation. Additionally, personalized coaching in particular increases sense of support and self-efficacy by helping users achieve their goals, complete tasks and master challenges (Sernack, 2014).
TNO: Innovation for Life outlines four major aspects of (personalized) design in order to make an application more effective, namely: the inclusion of effective sustainable behavioral change strategies; the inclusion of interaction strategies; the creation of timely and adaptive interventions and the creation of systematic and integrated solutions (Van Empelen et al., 2016). Behavioral change strategies
integrated with theoretical models in digital health intervention apps can include self-monitoring, prompts to help users identify and overcome barriers, performance feedback and explanations of techniques to prevent the user from falling back into old, unhealthy behaviors. Interaction strategies maximize user involvement and prevent dropout by creating a relationship between the user and the app through chat support, a coach and other users. Timely and adaptive interventions refer to DHIs that incorporate changes over time as users are diverse and use the app in different ways for different goals. Sensors, wearables and other trackers provide the ability to contextualize user data and the opportunity to provide timely and tailored support. Finally, systematic and design-integrated solutions denote the notion that these DHIs must be able to integrate easily into real life and must move beyond stand-alone solutions so that they can become effortlessly applied to daily challenges. By implementing these aspects and features, personalized digital health can empower users to make healthy and informed choices, manage their own health and help sustain behavior change (Van Empelen et al., 2016).
3.2.2 Personalized Digital Coaching
Some personalized interventions implement some form of a coach, which can be an automated and animated computer agent or a real person that communicates digitally. They help users to track what matters and to provide recommendations, support and encouragement to keep users engaged and motivated. Coaches have the ability to
create daily and weekly plans tailored to user’s short-term and long-term goals and adjust and contextualize them to their environment and previous behavior. They help users stay accountable by regularly checking-in with their progress and actively giving feedback and suggestions.
Sessions, an interactive coaching app to create healthy habits, currently owned by MyFitnessPal, has reputable data for high adherence and program completion proving that finding motivation to exercise can be difficult and sometimes all we need is a nudge from a friend, family member, colleague or even stranger (Schwartz, 2014). The app includes activity assessment, personal support and progress reviews to work slowly and sustainably toward a user’s goal(s). This grows upon the
aforementioned “quantified-self” proposal, which includes calorie, weight, exercise functions and a platform that integrates other connected products (such as wifi scales, exercise bikes and wearable fitness trackers). Coaches can now digitally leverage this data to help clients achieve personal goals and see what people are actually doing versus what they say they are doing. Without personalized coaching general goals and suggestions are offered, but without actionable insights on when, where and how to achieve them users often disengage.
To summarize, “new technologies are showing great promise as effective, accessible and inexpensive solutions to a number of chronic health conditions and Internet-based interventions are demonstrating reductions in weight using a
combination of self-monitoring, education and motivational messaging. We believe these results may be further enhanced with the addition of automated coaching, to promote accountability and adherence,” stated Dr. Joseph Kvedar, Founder and Director, Center for Connected Health and co-author of a prevalent study on virtual coaching and obesity (Dolan, 2012).
CHAPTER 5: CONCEPTUAL MODEL AND HYPOTHESIS
This chapter develops various hypotheses based on the theoretical framework that will help answer the central research question. First, a conceptual model is presented to illustrate the general concepts, research variables and their relationships. These different aspects of the research and their measurements will lead to insights regarding the central research question: What are the effects of gamification on
intrinsic and extrinsic motivation for changing health behaviors? Next, we will take a closer look at each concept and develop specific hypotheses.
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Figure 1. Conceptual Model.
5.1 The Extrinsic and Intrinsic Motivational Effects of Gamification
Most of the previous research on gamification and motivation has been within the education and workplace realms, but these same principles and theories can be applied to digital health interventions and health behaviors. When mapping
gamification principles to motivational and behavioral theory we can see that extrinsic virtual rewards stimulate feelings of achievement (via awards, trophies, badges), progress (via levels, scores, points), and reputation (via leaderboards, ranking, rating). Intrinsic rewards include autonomy, mastery, purpose, meaningful feedback,
reinforcement and internal needs such as friendship, commitment, feelings of competence and a sense of belonging that can be generated by gamification. Thus, extrinsic and intrinsic motivation are both stimulated by gamification, but increasing levels of gamification will facilitate more intrinsic rewards and consequently the more intrinsically motivated a person will become for the behavior. This is the primary goal as it was found that internalized extrinsic motivation and thus increased intrinsic motivation were associated with greater engagement, better performance and lower dropout (Deci & Ryan, 2000).
The main goal of this study is to explore whether certain gamification
techniques can increase intrinsic motivation for exercise and physical activity, as the results of previous studies show a consistent positive relation between more intrinsic motivation and the prediction of long-term exercise adherence (Teixeira et al., 2012). The conceptual model shows that the presence of a DHI (with or without
gamification) increases both extrinsic and intrinsic motivation. When the various levels of gamification are implemented, intrinsic and extrinsic motivation increases in varying amounts depending on the level. We break down gamification into three proposed levels where each level includes elements, or active gamification
ingredients, from the previous level: (1) No Gamification, (2) Virtual Rewards and (3) Social Competition. We hypothesize that as we move up the gamification levels, each increasing level will tap into more components that drive intrinsic motivation and user motivation will be affected accordingly in a positive correlation. Moreover, the
addition of personalization will further increase intrinsic motivation.
As described previously, according to the Self-Determination Theory (Deci & Ryan, 1985) intrinsic motivation, where exercise is motivated by an internal desire, is driven by feelings of autonomy, competence and relatedness while extrinsic
motivation is driven by a desire to gain a reward or avoid an adverse outcome. In connection to gamification, autonomy refers to the ownership of one’s behavior and feelings of choice, control and personal preference, which can lead to deeper loyalty to the behavior and app. Competence refers to meaningful growth, progress and feelings of mastery and effectiveness. Competence also contributes to feelings of self-efficacy, which is necessary for sustained motivation and engagement as it increases perceived performance ability for exercise (Bandura, 1997). Relatedness refers to the human intrinsic motivation to seek meaningful connections with others, create
communities and create relationships (in this case real or virtual).
In general, games help to increase intrinsic motivation by fostering feelings of competence and self-efficacy through the use of feedback and rewards and support feelings of relatedness through social connection, competition and cooperation (Bleumers et al., 2012; Ryan, Rigby, & Przybylski, 2006). It is important to note that although many people may consider extrinsic and intrinsic motivation and motivators to be polar opposites, they are effectively co-dependent on each other. This means that gamification can help users to become motivated to exercise intrinsically (Denny, 2014) and therefore we propose gamification levels that include elements from the previous level. Accordingly, gamification works best when intrinsic motivations and extrinsic rewards can align (Zichermann & Cunningham, 2011), as we predict will be the case for increasing levels of gamification. Gamification combines these two motivations; on one hand using extrinsic rewards such as levels, points, badges to improve engagement while striving to raise feelings of achieving mastery, autonomy, sense of belonging (Muntean, 2011). We hypothesize that certain gamification elements, and combinations of these elements, will more successfully drive the user beyond fleeting pleasure of a “game” and increase enjoyment and true meaning intrinsically for sustained health.
5.2 Hypotheses Formulation
5.2.1 Digital Health Intervention Effects
The presence of the digital health intervention leads to an increase in both extrinsic and intrinsic motivation as the simple presentation of a user’s activity and other data is likely to stimulate and engage users to a certain extent. Health behavior change typically requires a lot of self-regulation and is therefore not typically seen as an inherently enjoyable activity thus the use of DHIs work to enhance users’ motivation by positively framing individual feedback and presenting goal progress, which is argued to facilitate ongoing self-regulation of goal-directed behavior. This satisfaction increases motivation for continued goal pursuit (Morrison, 2015).
Digital health interventions and exercise apps can be viewed as intervention delivery systems consisting of features that help users overcome specific barriers, such as lack of understanding or organization, by stimulating a sense of self-efficacy (Litman et al., 2015). A recent study found that almost 75% of current app users said
they were more active and less than half of the non-users and former users said the same. These results show that motivation to exercise is gained via app as it provides a nudge in the right direction and provide a clear direction (Kleeman, 2015). They provide extrinsic motivation as an extra boost in the form of tracking, data collection and visible numbers while also providing intrinsic motivation or the inner enjoyment of belief in exercise for exercise's sake (Kleeman, 2015).
Digital health interventions use the framework of self-determination theory to engage users and drive lasting behavior change (Bucher, 2017). Mainly, they engage users through behavior monitoring, tracking, feedback and goal setting. In SDT terms this can be seen as a way to drive a users sense of competence. By using the above techniques users gain a sense of awareness and progress, growth, and ability. Previous studies showed that the use of a DHI resulted in twice as much weight loss due to food tracking (Hollis et al., 2008) and people that track their activity keep their physical activity levels at 27% above baseline levels (Bravata et al., 2007). Therefore, the following hypotheses may be formulated:
H1a Extrinsic motivation after the implementation of a digital health intervention will
be higher than before the implementation of a digital health intervention.
H1b Intrinsic motivation after the implementation of a digital health intervention will
be higher than before the implementation of a digital health intervention.
5.2.2 Gamified Digital Health Intervention Effects
Traditional fitness apps can help people develop an exercise routine and track their progress. Level of gamification 1, no gamification, presents an elementary form of feedback and helps users to visualize their progress and keep track of their activity and progress. The introduction of gamification elements adds a notion of “fun” and has a feel good effect on users when accomplishing targeted behavior and receiving rewards (Kotler, 2014). Gamification typically implies the implementation of extrinsic incentives such as points, badges and levels aimed at providing extrinsic motivation (Boulet, 2016). However, when aligning gamification elements with motivational theory and SDT, intrinsic motivators such as competence, autonomy, meaningfulness and social relatedness are supported. This leads us to hypothesize that
the addition of gamification will increase both extrinsic and intrinsic motivation change compared to the no gamification/control level.
H2a Extrinsic motivation increase due to the implementation of a digital health
intervention (H1a) will be larger when gamification elements are present than when they are not.
H2b Intrinsic motivation increase due to the implementation of a digital health
intervention (H1b) will be larger when gamification elements are present than when they are not.
5.2.3 Differential Effects of Different Levels of Gamification Level of Gamification 2: Virtual Rewards
The introduction of virtual rewards is the most basic level of gamification. Virtual rewards mainly affect the extrinsic side of the motivational spectrum since at this level motivation to perform actions or health behaviors are being induced mainly by extrinsic rewards (Vassileva, 2012). This can be explained by one of the oldest theories of motivation, B.F. Skinner’s Reinforcement Theory (Skinner, 1953). This theory states that when operant conditioning is applied, in this case through points and badges, it results in an increase in extrinsic motivation by focusing on external
incentives and rewards to motivate. Points and badges tap into users strong urge to collect things and be rewarded for actions (Miller et al., 2014) and are visual
representations of achievement, completion and progress. Furthermore, B.F. Skinner’s Reinforcement Theory explains how virtual rewards can increase extrinsic motivation by fulfilling a user’s desire for feedback and reinforcement. The theory claims that behavior is the result of reinforcements and learning and that external reinforcement can positively manipulate, shape and motivate people’s behavior. Although points may not be inherently rewarding, their use in gamification as a progression dynamic is motivating when implemented effectively.
Although users attain a sense of mastery and competence when gathering points and badges, it is proposed that there will be a greater increase in extrinsic motivation than intrinsic motivation at the virtual rewards level due to the fact that rewards provide a largely external pressure for behavior. That said, it is hypothesized
that there will also be an increase in intrinsic motivation as virtual rewards further incentivize a user to continue the healthy behavior and progress towards their goals while increasing their self-efficacy. As noted previously, self-efficacy is necessary to work towards intrinsic motivation and continued interest as a lack of motivation generally stems from not seeing the value of the behavior or lack of interest and not feeling competent or able to perform the behavior (low self-efficacy).
Additionally, we cite Daniel Pink’s Drive Theory of Motivation, which posits mastery and purpose are needed in addition to autonomy for increased intrinsic motivation (Pink, 2012). Here, mastery can be seen as similar to SDT’s notion of competence as it denotes that the user must feel as though they are actively improving, learning and developing (produced via virtual rewards and feeling of accomplishment). Purpose implies that the user must feel that they are doing something that is meaningful, purposeful and that their behavior has an effect.
Apps and other DHIs that use rewards and incentives as motivational hooks can help to maintain interest and help to stretch engagement and repeat usage. Generally, incentives are reliant on some aspect of performance (McNamara et al., 2009). Reinforcement as understood by Skinner constitutes outcomes that strengthen the probability of a response (Lillienfeld et al., 2009; Skinner, 1957). This clear connection between points, effort of behavior and outcomes can thus satisfy a person’s esteem, confidence and sense of achievement on Maslow’s Hierarchy of Needs (Richter et al., 2015). This is reflected by the following hypothesis:
H3a Extrinsic motivation increase due to the implementation of a digital health
intervention containing virtual rewards (level 2) will be larger than after the implementation of a digital health intervention containing social competition (level 3).
Level of Gamification 3: Social Competition
Additionally, new gamified apps offer social encouragement for exercise and some entertainment too and is a good way to shake things up because some people find working out incredibly boring, said Steve Portenga, chief executive of Denver-based Performance Psychology (Alsever, 2013). One way to increase intrinsic motivation is by the addition of social elements. The social aspect of games is important since
competition, social interaction and cooperation can influence user behavior (Richter et al., 2015). Festinger’s Social Comparison Theory states that we evaluate our beliefs, abilities and reactions by comparing them to others and that there is an “unidirectional drive upward” which asserts that people generally wish to improve their abilities to strive toward a comparatively better position than others (Wood, 1989). Although social competition can still be seen as a type of extrinsic motivator because extrinsic rewards are still present, we argue that it will further increase intrinsic motivation at this level since motivators become more integrated. The best systems of motivational design speak to the intrinsic motivation of the user while also providing extrinsic rewards that they value (Zichermann, 2011). It can also be reasoned that with the addition of social elements the user is competing with, and/or may feel guilty towards, others and not just themselves, which leads to increased feelings of accountability and ultimately adherence. The public aspect of social competition amplifies feelings of success as well as failure, thus there is more motivation to avoid possible failure and celebrate success.
The previously mentioned Drive Theory by Pink has been linked to Maslow’s Hierarchy of Needs Theory and describes that individuals have a hierarchy of needs that must be fulfilled sequentially if the individual is to work toward self-actualization (true intrinsic motivation). This hierarchal pyramid moves up from basic
physiological needs to belongingness and esteem needs to self-actualization, which Pink argues is driven by autonomy, mastery and purpose.
Additionally, users tend to value an arguable intrinsic motivation that can be derived in the form as a feeling of “belonging” (Seiferd, 2012) as this is a basic human need. The user gains a sense of value that is derived from being part of a program and an affiliation with others based on a common purpose or level of achievement. Additionally, status and recognition are associated with belonging and relatedness, or connection with others, and are a highly valued as a source of
motivation as the user feels as though they are part of something bigger. Furthermore, Fogg’s Behavior Model (2010) includes social acceptance and rejection as a core sub-component of motivation for behavior change. This dimension indicates that people are motivated to do the things that will win them social acceptance, gain status and avoid social rejection. The power of social motivation is likely to be hardwired into us as historically as ostracization from the group often meant certain death.
Competition and leaderboards are used to allow users to compare themselves against others and see their progress and achievements in comparison to their social peers. Beyond comparing players along quantitative measurements, competition can also be introduced as the user’s challenge to master given tasks (e.g., complete
workout or achieve daily step goal). Other forms of social sharing beyond competition include social investment in systems (where friends can see user points and badges) and crowdsourcing (e.g., voting for the best workout plan). A social network can offer encouragement, advice and accountability.
In conclusion, the positive emotions derived from social interaction reinforce the positive experience of exercise, leading to further repeated activity (Teixeira, 2012). Leaderboards, badges, levels and an interactive social community can support a user’s need for status, recognition and prestige while also strengthening competence and mastery (Richter et al., 2015). In the context of physical activity, it was found that intrinsic motives that related to enjoyment and competence were predictors of
exercise adherence (Ryan, Frederick, Lepes, Rubio, & Sheldon, 1997). Therefore, the following hypothesis is formulated:
H3b Intrinsic motivation increase due to the implementation of a digital health
intervention containing social competition (level 3) will be larger than after the implementation of a digital health intervention containing virtual rewards (level 2).
5.2.4 Personalized (Meaningful Gamification)
In addition to extrinsic rewards and social elements, a sense of mastery, meaning and purpose must be established to increase feelings of intrinsic motivation. This can be accomplished through the contextualizing of information in addition to (digitally) gathered data and has major potential to support positive behavior change by
supporting long-term engagement via tailored messaging and just in time messaging making information relevant (Hänsel et al., 2015). Furthermore, personalization and customization can contribute to a feeling of participation and ownership for “their” wellness or exercise program, reinforcing personal connection to the program (Seifert, 2012).
There is an inherent human desire for significant accomplishment, mastering of skills, and control and personalized DHIs can help users to work with purpose and
