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In today’s society, stress is more and more often a cause of disease. This makes stress management an important target of behavior change programs. Gamification has been suggested as one way to support health behavior change. However, it remains unclear to which extend available gamification techniques are integrated in stress management apps, and if their occurrence is linked to the use of elements from behavior change theory.
The aim of this study was to investigate the use of gamification techniques in stress management apps and the cooccurrence of these techniques with evidence-based stress management methods and behavior change techniques.
A total of 62 stress management apps from the Google Play Store were reviewed on their inclusion of 17 gamification techniques, 15 stress management methods, and 26 behavior change techniques. For this purpose, an extended taxonomy of gamification techniques was constructed and applied by 2 trained, independent raters.
Interrater-reliability was high, with agreement coefficient (AC)=.97. Results show an average of 0.5 gamification techniques for the tested apps and reveal no correlations between the use of gamification techniques and behavior change techniques (
This leads to the conclusion that designers of stress management apps do not use gamification techniques to influence the user’s behaviors and reactions. Moreover, app designers do not exploit the potential of combining gamification techniques with behavior change theory.
In today’s society, many people suffer from chronic exposure to stress [
A person’s well-being, however, does not solely depend on his or her exposure to stress, but also on the way he or she copes with stress [
Stress management apps, like all behavior change programs, must be based on evidence-based content from behavior change theory, such as behavior change techniques [
Gamification, that is, the use of game elements in nongame contexts, is aimed at making interventions (including mobile apps for behavior change) more enjoyable, motivating, and engaging [
Indeed, gamification has already been suggested to positively influence user self-management [
In fact, it could already be shown that the implementation of gamification in form of rewards for diabetes patients [
Regardless of these facts, gamification in the context of health and wellness [
Interestingly, the association between gamification techniques found by Lister and colleagues was only due to the motivational behavior change aspects, namely, social support, providing incentive, goal setting, cognitive strategies, and self-efficacy. Regarding the use of theoretical content, the authors concluded that these apps were greatly lacking in all three categories (behavior change techniques, gamification techniques, and game elements). These findings are in accordance with the assertion that the development of health apps is currently lacking efficient and selective implementation of gamification [
According to the mechanics, dynamics, and aesthetics (MDA) model of Hunicke at al [
For this purpose, an extended taxonomy of gamification techniques was developed. As no universal list of game elements exists, a list of features that are found in most but not necessarily in all games [
In the last step, all 17 gamification techniques were assigned to one of four categories: economic, social, performance-oriented, or embedding-focused. Economic gamification techniques include economical aspects such as “rewards” [
In addition to the number of used gamification techniques, this study also examined the correlation between gamification and the evidence-based content as presented by Christmann and colleagues [
This study was the first to investigate the use of gamification techniques in apps aimed at stress management. Its goal was to provide important information on whether designers of stress management apps are trying to influence user behavior through the use of gamification.
This study investigated the use of gamification techniques in stress management apps available through Google Play. The selected apps were reviewed by 2 trained, independent raters on their inclusion of 17 gamification techniques (see
This review included free apps that were available through Google Play. Apps were identified by using the search terms “stress management,” “stress reduction,” and “stress relief.” For each search term, the first 250 apps were examined according to the following inclusion and exclusion criteria.
First, duplicates and apps not found in the categories “health and fitness” or “ medical” were eliminated. With 563 apps being excluded at this stage, 187 apps remained. Their descriptions were reviewed with the constraint that they had to be in English and aimed at stress management, health, or wellness for healthy adults. Thus, apps whose descriptions focused on children, adolescents, and older adults (n=5) were excluded. In addition, apps targeting anxiety, depression, diabetes, insomnia as well as other medical conditions (n=82), addiction (n=2), weight management (n=13), or beauty and cosmetics (n=2) were excluded from this study. The same was done with apps that clearly focused on content other than stress management (n=8) and apps that could only be used with a wearable device (n=2). Therefore, 73 apps were downloaded and assessed for eligibility.
Taxonomy of 17 gamification techniques.
Technique | Definition | |
Marketplace and economies |
Offering a virtual currency that establishes an economy in which the user may trade, purchase, auction, receive a salary, and so on as he or she would in real life economy. | |
Digital rewards |
Include, for example, badges (signal status, aesthetic value), game currency, points, and resources or property (experience points, health, houses); virtual goods (objects, food), powers or abilities (increase as the player progresses), add to record of achievements and validation (marks of approval from others). | |
Real world prizes |
Include, for example, deals or discounts (similar to a loyalty program), financial prizes (cash prize, voucher), goods or services (tote bag, free massage, car, parking spaces, health savings account contributions, insurance contributions), time (time saved, vacation or time off), and lottery or draw or bet for any of the above. | |
Avatar |
Ability to represent oneself through a virtual character within the media and excerpt precise control over that representation. | |
Agent |
A virtual character that does not represent oneself and provides instructions or support (eg, social support). | |
Competition |
Competition with other players or between teams to achieve new levels, ranks, reputations through winning challenges, selling digital rewards, building spaces, creating materials, and so on, that are restricted by rules, which are either provided by the program, or user-generated and apply to everyone. | |
Teams |
Program involves multiple players, who interact and form relationships that allow for collaborative achievements (eg, guilds, multiplayer modes). | |
Parallel communication systems |
Allow for interaction with other players via different channels (eg, private, public) through headsets, text, email, and so on within the application. | |
Social pressure |
Competitions within or between teams that give the user the feeling he or she has to take part in events (eg, a quest) in order to avoid social consequences. The user is pressured to perform in order to be invited to a further raid or quest or event; feels he or she is needed and, therefore, does not want to let other users down. | |
Feedback |
Text or spoken language, visual or auditory feedback that is either temporary or constant and evaluates the user’s performance in relation to a set standard or other’s performance. | |
Levels |
Levels provide information on the stage of the game. Usually a specific number of points or experience is required in order to reach the next level. New levels can be shown through, for example, differences in optical design, rise in rewards, and increase in difficulty. | |
Secondary game objectives |
Optional aspects or layers or challenges or secondary goals of play (find as many treasures vs complete as soon as possible) that reward the player upon completion or simply exist for their own sake. | |
Ranks of achievement |
Measurement of character development with regards to position and value of a player or player’s avatar in the program community. | |
Leaderboards |
The purpose of a leaderboard is to make simple comparisons by displaying players at the same or different levels, ranked by proximity and recency to oneself. They can be based on player feedback, scores, and promotion. | |
Time pressure |
Time limits set for completion of tasks or the duration of the usability of specific skills, occurrences, and objects (excluding countdowns on videos and audios). | |
Narrative context |
Back stories that guide the action and help to organize character roles, rewards, and group action. | |
3-Da environments |
Rendering 3-D graphical models of physical properties that parallel those in the real world, on a 2-dimensional screen. |
a3-D: three-dimensional.
Taxonomy of 8 additional aspects.
Item | Definition |
Connection to social network | The app itself provides a connection to a social network (eg, Facebook, Twitter) |
Advertisement | Pop-up or stationary advertisements are shown within the app |
Registration or account | Registration is required in order to use the app or some functions of the app |
Pure e-booka | The app consists only of text that may or may not be divided into different chapters |
Test version | Payment or download of a full version is necessary to receive access to some features of the app |
Internet connection necessary | The app only opens when an Internet connection is available |
External links to other websites | Websites are linked in the app, or videos or audios only play with an Internet connection |
Wearable | The app can also be used with a wearable device |
ae-book: electronic book.
Eleven additional apps had to be excluded during the review process. Since the apps were reviewed over a total of 1 month, 3 of the initially selected apps were no longer available at the time of testing. One app had to be excluded during the review process because it could only be used after entering the user’s credit card data, whereas another app turned out to be solely focused on fitness aspects without any further indication toward stress reduction. One app consisted only of an external website. Another 4 apps turned out to be only accessible via a membership or company code, whereas yet another app could only be used with a wearable device. A basic outline of the selection process can be found in
Apps that met all inclusion criteria (N=62) were downloaded, installed, and tested by 2 trained, independent raters in October 2015. For this, raters used the device emulator of the development environment Android Studio 1.3 running Android OS 4.4 Android Studio [
As is common procedure [
The reviewing process of this study only included content that was provided by the app itself. Information and features on websites that were linked within the app were not considered. Because all apps allowed the user to progress at his or her own speed, both raters could thoroughly check all features of the apps until it was apparent that no new content was going to be activated. An overall outline of the study procedure is illustrated in
Each app received a score between 0 and 17, representing the number of gamification techniques included in the app. If the raters disagreed on the use of a technique, it was noted as included. Supplementary, it was noted whether an app needed an Internet connection to run, showed advertisements, required registration, had additional features available for payment, used links to external websites, and could be used with wearables (
To make sure that the evaluation criteria were applied in a consistent manner by both raters, the interrater reliability was calculated according to Gwet’s agreement coefficient (AC) [
Mean, standard deviation, and range were calculated for the sum of gamification techniques. To determine whether a linear relationship exists between the occurrence of the content from behavior theory and gamification techniques, correlational analyses were performed. For this, the Spearman correlation coefficient r and statistical significance
Levels and criteria for inclusion of identified apps.
The 62 stress management apps included an average of 0.5 (range 0-2) gamification techniques, with a standard deviation of 0.7. The sum score of gamification techniques for each app (presented in
Regarding frequency of use, “feedback” (n=16) was implemented most often, followed by “parallel communication systems” (n=3). In contrast, the aspects “social pressure,” “real world prizes,” “teams,” “competition,” “marketplace and economies,” “ranks of achievement,” “narrative context,” “agents,” and “avatars” were never included (
Outline of the overall study procedure.
Frequencies of the 17 gamification techniques included in the apps. Techniques were scored according to the previously introduced taxonomy of gamification techniques (see Methods subsection Evaluation).
Beside the use of gamification techniques, this study also considered several additional aspects regarding the selected apps. In this context, it has to be emphasized that a considerable number of apps included external links to other websites (n=40), thus utilizing additional sources for features and information. The display of advertisements was found in as many as 26 apps. Thirteen of all reviewed apps required Internet connection. Furthermore, 6 apps only included text content and were, therefore, rated as pure electronic book (e-book). The frequencies of all additional aspects investigated in this review are displayed in
Since the gamification data was positively skewed (
Frequencies of 8 additional aspects included in apps. Additional aspects were scored according to the previously introduced taxonomy for additional aspects (see Methods subsection Evaluation) and are ranked by the most frequently ones included.
The goal of this study was to investigate the use of gamification techniques in apps that are aimed at stress management for healthy adults, available for free through Google Play. By conducting an expert review to investigate the use of gamification techniques in a quantitative manner, this study focused on the first level of the MDA framework [
Results showed an average as low as 0.5 gamification techniques for the 62 tested apps. Although at least one technique was included in 32% (20/62) of the apps, no app included more than 2 techniques. In fact, as much as 68% (42/62) of the sample did not use any gamification technique at all. Thus, even though some app developers tried making use of gamification to some extent, these findings indicate little to no use of gamification techniques in the context of free stress management apps for Android. Therefore, it can be concluded that app designers have not been trying to impact user behavior through the implementation of gamification techniques.
These results contradict those presented by Payne et al [
Regarding frequency of use, “feedback” was the most often implemented technique. This is a positive result, as “feedback” is not only a gamification technique but also a common technique for promoting behavior change [
These findings differ significantly from those of Lister and colleagues [
Whereas some apps reviewed in this study made use of “digital rewards,” “levels,” and “secondary game objectives,” this was only the case to a very small degree. These aspects were only found in 2 apps. Nonetheless, app designers should make more intensive use of these techniques. As rewards are a common feature in other gamified interventions, designers could provide points [
The gamification techniques “3-D environments,” “leaderboards,” and “time pressure” were included only once. On the one hand, game designers should consider to make stronger use of “3-D environments,” as such environments may elicit an enhanced recovery from stress [
Other techniques that were never used included “marketplace and economies,” “real world prizes,” “narrative,” “avatar,” “agent,” “teams,” and “ranks of achievement,” App designers should consider a more extensive use of these techniques. As such, the implementation of a “marketplace and economy” (eg, through a currency) can help to quantify the value of rewards and objects [
The techniques reported to be used least often in this study differ from those by Lister et al [
Considering that neither the use of evidence-based content, nor gamification techniques alone is sufficient to ensure both behavior change and app usage [
The lack of correlation found in this study does not match the results of Lister and colleagues [
Because the implementation of gamification techniques is directly influenced by app designers and can largely affect user behavior and reactions, designers should carefully consider the effects specific gamification techniques might have on the user. Correspondingly, designers should chose techniques with strong regard to the context of the app they are constructing. Hence, future studies should pay close attention to the levels of dynamics and aesthetics [
The need for improvement suggested by the gamification results also extends to the additional aspects that were investigated in this study. As such, a large portion of the apps included features that require an Internet connection. This approach reduces the time that is needed for installation as well as download and provides the opportunity for larger content. Nevertheless, this aspect might require optimization, since its use makes apps dependent on Internet connections, which may not be available at all times and in all places. This point is even more important for the 10 apps that ran only when an Internet connection was available. Another aspect that needs to be addressed in this context is the fact that as many as 6 out of 62 apps consisted of text only. Therefore, it is hard to see the advantage of such apps over self-support e-books and websites—consumers expect modern technology to be interactive. The user’s perception of the media’s interactivity has great influence on user loyalty [
In view of the MDA framework by Hunicke and colleagues [
Whereas this study investigated an important aspect with its focus on the quantitative analysis of gamification usage in the sample, it needs to be kept in mind that the integration of game elements alone is no guarantee for successful gamification [
Regarding the implications of this study, one must keep in mind that the results of the correlational analysis are hard to interpret due to the low mean and the standard deviation of the number of gamification techniques in the sample. A possible reason for the low mean of gamification techniques in the current sample could be that this review only focused on free apps. This may have resulted in the exclusion of paid apps with a more extensive use of gamification. Nonetheless, according to AppBrain [
The results of this study clearly reveal that the use of gamification techniques in stress management apps is not very common. This is the case for the implementation of gamification techniques as well as the association of those techniques with evidence-based content (use of behavior change techniques and stress management methods [
This study was the first to investigate the use of gamification techniques as well as the cooccurrence of gamification techniques and evidence-based content in stress management apps. Moreover, it provides an extended framework for the investigation of gamification usage in mHealth apps.
Gamification score for each reviewed stress management app from the Google Play Store.
three-dimensional
agreement coefficient
electronic book
We thank Sarah-Jane Böttger (SJB) for supporting the data collection.
The junior research group wearHEALTH is funded by the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF, reference number: 16SV7115).
AH, CAC, and GB contributed to the manuscript in its conception and writing. AH and CAC developed the app screening and evaluation methods. AH and SJB each evaluated the downloaded stress management apps. Data analysis was done by AH and CAC. AH wrote the initial draft of the manuscript. All authors had full access to all of the data, and read and approved this initial draft and the revisions. No financial disclosures were reported by the authors of this paper.
None declared.