Effect of Gamification With and Without Financial Incentives to Increase Physical Activity Among Veterans Classified as Having Obesity or Overweight
Authors: Anish K. Agarwal, Kimberly J. Waddell, Dylan S. Small, Chalanda Evans, Tory O. Harrington, Rachel Djaraher, Ai Leen Oon, Mitesh S. Patel
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Gamification is increasingly being used for health promotion but has not been well tested with financial incentives or among veterans. <h3>Objective</h3> To test the effectiveness of gamification with social support, with and without a loss-framed financial incentive, to increase physical activity among veterans classified as having overweight and obesity. <h3>Design, Setting, and Participants</h3> This 3-group randomized clinical trial had a 12-week intervention period and an 8-week follow-up period. Participants included veterans with a body mass index greater than or equal to 25 who were receiving care from a single site in Philadelphia, Pennsylvania. Participants underwent a remotely monitored intervention from March 19, 2019, to August 9, 2020. Data analyses were conducted between October 1, 2020, and November 14, 2020. <h3>Interventions</h3> All participants received a wearable device to track step counts and selected a step goal. The control group received feedback from their devices only. Participants in the 2 gamification groups were entered into a 12-week game with points and levels designed using behavioral economic principles and selected a support partner to receive weekly updates. Participants in the loss-framed financial incentive group had $120 allocated to a virtual account and lost $10 if weekly goals were not achieved. <h3>Main Outcomes and Measures</h3> The primary outcome was the change in mean daily steps from baseline during the intervention. Secondary outcomes include proportion of days goals were achieved and changes during follow-up. <h3>Results</h3> A total of 180 participants were randomized, 60 to the gamification with social support group, 60 to the gamification with social support and loss-framed financial incentives group, and 60 to the control group. The participants had a mean (SD) age of 56.5 (12.9) years and a mean (SD) body mass index of 33.0 (5.6); 71 participants (39.4%) were women, 90 (50.0%) were White, and 67 (37.2%) were Black. During the intervention period, compared with control group participants, participants in the gamification with financial incentives group had a significant increase in mean daily steps from baseline (adjusted difference, 1224 steps; 95% CI, 451 to 1996 steps;<i>P</i> = .005), but participants in the gamification without financial incentives group did not (adjusted difference, 433 steps; 95% CI, −337 to 1203 steps;<i>P</i> = .81). The increase for the gamification with financial incentives group was not sustained during the follow-up period, and the step count was not significantly different than that of the control group (adjusted difference, 564 steps; 95% CI, −261 to 1389 steps;<i>P</i> = .37). Compared with the control group, participants in the intervention groups had a significantly higher adjusted proportion of days meeting their step goal during the main intervention and follow-up period (gamification with social support group, adjusted difference from control, 0.21 participant-day; 95% CI, 0.18-0.24 participant-day;<i>P</i> &lt; .001; gamification with social support and loss-framed financial incentive group, adjusted difference from control, 0.34 participant-day; 95% CI, 0.31-0.37 participant-day;<i>P</i> &lt; .001). <h3>Conclusions and Relevance</h3> Among veterans classified as having overweight and obesity, gamification with social support combined with loss-framed financial incentives was associated with a modest increase in physical activity during the intervention period, but the increase was not sustained during follow-up. Gamification without incentives did not significantly change physical activity. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03563027