Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

Background There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators. Objective This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions. Methods We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3. Results The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers’ justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention’s intended effects. Conclusions Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

Being awarded permanent visual recognition, for example via badges, certificates and achievements, by the system in response to accomplishing meaningful goals inside the system. Customization Being able to customize avatars and other types of representation (of the self or of the player character), or other aspects of the user experience, either freely or through spending in-game currency or real currency. Exploratory or openworld approach User is free to explore the system at their leisure and access to system components or modules is not restricted. Includes mini-game A smaller game is included in the app or technology but it remains a subcomponent (i.e. app or technology is not a serious game).

Levels or progress feedback
User is given an indication of their progress in a task and in the overall content of the system, and how far they have to go to succeed in or finish the task and reach the next milestone. Narrative or theme The system adopts a certain theme or premise and presents itself faithfully according to that premise (e.g. a CBT program may be presented on a game board; results may be presented on a spinning wheel), and may or may not include an underlying storyline.

Personalization
The system learns about you either by asking you directly or by analyzing your behavior in the system, and adapts what and how it presents to you to suit you (e.g. adaptive difficulty, using real-time location data). As opposed to 'Customization', this is driven by the system. Points or scoring The user gains points for completing tasks, which can be either static or scale based on their performance.

Quests or challenges
Users are invited to complete specific tasks in exchange for rewards.

Randomness
Having the result of a certain aspect of the system (quests, tasks, etc.) be determined by chance, either partially or entirely. Includes scripted events (i.e. the appearance of chance).

Rewards or prizes
Receiving rewards or prizes by completing specific tasks or goals, or by reaching certain milestones. Social comparison The system allows users to see other users' actions, and to show off their own achievements, progress and/or status to other users.

Social competition
Users are placed in implied (via leaderboard) or direct competition with each other.

Social cooperation
Working together with other users, for example as part of a team, to achieve a goal. "It was anticipated that providing feedback in the context of a game, which was not explicitly focused on alcohol, might improve efficacy among heavier drinkers by reducing defensive reactions to the intervention content." [1] Reduce participants' distress "In the context of [virtual reality exposure therapy], which can be highly distressing for patients, gamification may reduce the negative experiences of treatment." [2] Encourage usage Be fun, interesting, or enjoyable "The rehabilitation games were designed to combine a variety of rehabilitation exercises with gaming elements, thus making the otherwise monotonous practice more competitive, motivating, interesting and enjoyable." [3] Create a sense of mastery "Digital coins and badges give the users a sense of accomplishment […]" [4] Encourage retention and repeated engagement "The design of this mindfulness project exercises several common game mechanics to maintain user interest over time, without attempting to distract them during mindfulness meditation." [5] Increase engagement with intervention "The Wellbeing Game uses gamification to encourage engaging in the Five Ways to Wellbeing through." [6] Increase motivation to use "Similar to the ARET system, the VRET system will also follow a gamification approach to motivate the patient during her/his therapy by feeding back the actual achievements but also the progress that is already accomplished." [7] Enhance an intervention's intended effects Behavior change Encourage and motivate intended behaviors "In this paper we explore how a gamified digital behaviour change intervention can be adapted to encourage people of different personality types to engage in simple acts of kindness." [8] Sustain behavior change over time "Gamification also can be useful for clients with initiation impairments due to frontal lobe deficits by acting as an adaptive aid to prompt behavior and develop habits and routines." [9] Intervention efficacy Complement delivery of intervention ingredients "Because the ultimate goal of PNF interventions is to induce behavior change by helping participants learn facts about the true prevalence of various behaviors among their peers, CampusGANDR was designed to reward participants for accurate perceptions of peers' behaviors using a system of points." [10] Encourage attitude change "[…] the present study explored the effects of gamification on […] creating positive attitudes towards sleeping and waking up at optimal times." [11] Enhance learning "To enhance learning and motivation, the program calibrated the difficulty level between each round, depending on the participant's performance." [12] Cheng VWS, Davenport T, Johnson D, Vella K, Hickie IB. (2019). Gamification in Apps and Technologies for Improving Mental Health and Well-Being: A Systematic Review. JMIR Mental Health Improve wellbeing "Through gamification, many benefits, such as the commitment of users to participate in various activities and sharing of experiences that have potential well-being effects on the users may be reached." [13] Intervention efficiency Increase costeffectiveness "Delivering a brief alcohol intervention within the context of a gamified app allows the intervention to be disguised as something fun and interesting, which may reduce or even eliminate the need to provide compensation in order to attract and retain participants." [10]