Almost daily a new smartphone app is released to help you lose weight, sleep better and send you on that one track road to perfection. However, there is a nervousness in the scientific community about the evidence that these apps are founded on and how effective they really are.

There are over 100,000 smartphone applications that aim (or claim) to improve health-related behaviours (Lister et al., 2014). Despite this huge number, very few health apps are designed alongside public health experts, or have even been assessed in a rigorous manner (Aitken et al., 2013). Likewise, there is no need for apps to demonstrate effectiveness in their ability to change behavioural or emotional outcomes.

Increasingly gaming components or ‘gamification’ is being used in health apps to try and introduce a competitive and addictive element.

The present systematic review aimed to examine the behaviour change techniques used by ‘gamification’ apps claiming to improve health outcomes (Edwards et al, 2016).

Methods

This study was a systematic review of smartphone applications, conducted by the lead researchers.

• Apps from Apple, Android and NHS app stores were systematically screened

• Inclusion criteria were apps that:
  • were available in English
  • contained gamification methods
  • aimed to bring about a change in physical behaviour
  • had to be found in the health, fitness or medical subcategories of the app stores

• Both free and paid apps were included in the search

• Apps were not included if they did not have any customer ratings (see limitations).

Of the 1680 apps screened, 64 apps fulfilled the inclusion criteria and were included in the review.

The ‘behaviour change technique taxonomy’ (Michie et al., 2013) was used as a tool to measure how many techniques were used in each app.

Results

The median average number of behaviour change techniques in each app was 14 (range 5 – 22).

42 techniques from the ‘behaviour change taxonomy’ were not found in any of the apps. These included techniques such as reflecting on pros and cons, situation specific rewards and a review outcome goals.

Self-monitoring and goal setting were the most commonly used behaviour change techniques.

Many of the techniques used by the apps have been previously shown to be effective in improving the likelihood of a behaviour change (Michie et al., 2009).

Quality and price was unrelated to the number of techniques in the apps.

Summary of findings

Despite a wide variation in the type of behaviour change techniques used by smartphone apps, at least 5 techniques are included in all gamification related behaviour change health apps. 

Only three included apps were found on the NHS Health Apps Library, which suggests that reviewing and accreditation of these apps is a lengthy and limited process.

As the authors note:

We suggest that strengthening collaboration between app developers, behavioural scientists and public health practitioners is necessary to realise the full health benefits of this new technology.

Future studies may examine whether certain behaviour change techniques correlate with user ratings or the price of the apps, as well as their effectiveness at producing the desired change.

The big question that remains is how effective are apps in producing behaviour changes, and does the number of techniques and use of gamification impact the likelihood of their success. Ultimately, questions need to be asked about the regulation of these apps and how developers can follow evidence-based guidelines more in the future.

Strengths and limitations

The use of two reviewers during the rating stages makes this study a reliable and useful review of the field.

As noted by the researchers, only rated apps were included in this review. It would be interesting to find out about what the difference in behaviour techniques are in apps that have low ratings, and why unpopular apps that have not received any ratings differ in their behaviour change techniques.

The search was conducted in 2015. Due to the nature of the smartphone app market, the number of similar apps would have increased massively and each may employ very different behaviour change strategies.

The initial search of apps was conducted by only one researcher. This increases the chances that apps are not correctly categorised or assessed properly.

Only apps with a given rating were included in the study. This could be a problem, as apps targeting less common health issues may not have received enough popularity to receive votes. Likewise, apps with a ‘1 star’ rating would still be included in the review.

Summary

This study is the first to review behaviour change techniques in gaming applications aimed at improving health outcomes.

The main conclusions are that apps aiming to improve health related behaviours are not using gamification techniques as much as they could, and possibly should. However, many apps reviewed in this study do use a combination of behaviour change techniques which is encouraging to see, as many of techniques are effective in producing a behaviour change (Michie et al., 2009).

The researchers found no link between the number of behaviour change techniques and user rating of the app. They tentatively infer that this may be that the number of techniques does not impact the effectiveness of the app.

Interestingly, they found that there were more behaviour change techniques in the smartphone gaming apps (median: 14) compared to previous reviews of non-smartphone interventions (healthy eating: 6; physical activity: 6) (Abraham et al., 2008).

Links

Primary paper

Edwards EA, Lumsden J, Rivas C, Steed L, Edwards LA, Thiyagarajan A, Sohanpal R, Caton H, Griffiths J, Munafo MR, Taylor S, Walton RT. (2016) Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps. BMJ Open, 6: e012447

Other references

Abraham C, Michie S. (2008) A taxonomy of behavior change techniques used in interventions. Health Psychol, 27:379–87

Aitken M, Gauntlett C. (2013) Patient apps for improved healthcare, from novelty to mainstream, in reports. IMS Institute for Healthcare Informatics. http://www.imshealth.com

Lister C, West J H, Cannon B, et al. (2014) Just a fad? Gamification in health and fitness apps. JMIR Serious Games, 2:e9.

Michie S, Abraham C, Whittington C, et al. (2009) Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol, 28:690–701.

Michie S, Richardson M, Johnston M, et al. (2013) The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med, 46:81–95.

Photo credits

• Blake Patterson CC BY 2.0
• Michelle Milla CC BY 2.0
• Brian Pennington CC BY 2.0
• Bill Daly CC BY 2.0