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Games for health are a promising approach to health promotion. Their success depends on achieving both experiential (game) and instrumental (health) objectives. There is little to guide game for health (G4H) designers in integrating the science of behavior change with the art of game design.
The aim of this study is to extend the Behaviour Change Wheel program planning model to develop Challenges for Healthy Aging: Leveraging Limits for Engaging Networked Game-Based Exercise (CHALLENGE), a G4H centered on increasing physical activity in insufficiently active older women.
We present and apply the G4H Mechanics, Experiences, and Change (MECHA) process, which supplements the Behaviour Change Wheel program planning model. The additional steps are centered on identifying target G4H player experiences and corresponding game mechanics to help game designers integrate design elements and G4H objectives into behavioral interventions.
We identified a target behavior of increasing moderate-intensity walking among insufficiently active older women and key psychosocial determinants of this behavior from self-determination theory (eg, autonomy). We used MECHA to map these constructs to intervention functions (eg, persuasion) and G4H target player experiences (eg, captivation). Next, we identified behavior change techniques (eg, framing or reframing) and specific game mechanics (eg, transforming) to help realize intervention functions and elicit targeted player experiences.
MECHA can help researchers map specific linkages between distal intervention objectives and more proximal game design mechanics in games for health. This can facilitate G4H program planning, evaluation, and clearer scientific communication.
Games for health (Gs4H) are a promising venue through which to increase motivation for, and enjoyment associated with, health-related behaviors. Its success is largely dependent on eliciting a playful, enjoyable, fun experience while simultaneously delivering efficacious behavior change techniques (BCTs) [
The extent to which a game for health (G4H) brings about behavior change defines its success. G4H developers have long recognized the potential utility of using insights from the field of behavioral science to achieve health-related behavior change [
Detailed program planning methods exist for traditional health promotion programs. Systematic methods such as Intervention Mapping and the Behaviour Change Wheel (BCW) emphasize using behavior change theories and techniques to link modifiable determinants of behavior to health-related behaviors and outcomes [
Models of gamification or using game design elements to achieve nongame objectives emphasize the importance of designing game systems that are chiefly centered on the benefits to, and interests of, the user [
Most Gs4H do not seem to be grounded in models of gamification or health behavior change theory [
The development of Gs4H typically demands considerable up-front costs [
To develop the behavioral intervention core of CHALLENGE, we adapted the BCW program planning process enumerated by Michie et al [
This study was approved by the institutional review board of The University of Texas Medical Branch at Galveston (protocol number: 19-0158).
A Mechanics, Experiences, and Change Model for game-induced behavior change.
Steps of game for health Mechanics, Experiences, and Change Model.
Step | Description | Example |
Step 1: Define the problem in behavioral termsa | Identify the specific target population. Review the epidemiological evidence concerning the health-related outcomes of interest. Identify relevant behaviors linked to these outcomes and their location in that target population | We identified the target population as women aged 65-85 years who are not meeting nationally recommended physical activity guidelines |
Step 2: Select a target behaviora | Select a target behavior from the relevant behaviors identified in step 1. Consider the relative impact of each behavior, its likelihood of change, the potential for spillover into other important behaviors, and ease of measurement of the behavior | The nationally recommended physical activity guidelines for older adults include several related behaviors (eg, aerobic physical activity, muscle-strengthening physical activity, and time spent sedentary) [ |
Step 3: Specify the target behaviora | Specify the target behavior identified in step 2 in detail. To do so, use the 6 template questions proposed by Michie et al [ |
We specified details pertaining to the target behavior selected in step 2 (presented in the |
Step 4: Identify what needs to changea | Conduct a behavioral analysis as recommended by Michie et al [ |
We identified key constructs that need to change to promote the target behavior identified in step 3 (the |
Step 5: Identify intervention functionsa | Identify the primary intervention functions of the G4Hd intervention to target each of the constructs identified in step 4. The process of mapping intervention functions to psychosocial constructs can be guided by the BCWe [ |
|
Step 6. Identify target player experiences | Identify experiential objectives that would facilitate compelling gameplay and can be integrated with the intervention functions (identified in step 5). Behavior change theory can facilitate this process | We used the Playful Experiences Framework to frame the identification of target player experiences [ |
Step 7: Identify BCTsa,f | Select the BCTs to be featured in the intervention. BCTs are the “active ingredients” of a behavioral intervention, or “the observable, replicable, irreducible components of an intervention” designed to change behavior (eg, the provision of feedback). The taxonomy of 93 distinct BCTs developed by Michie et al [ |
Existing literature suggests that prompting self-monitoring of behavior, as an example, may be particularly useful for helping older adults increase physical activity [ |
Step 8: Identify game mechanics | Identify specific game mechanics designed to evoke target participant experiences [ |
As an example, participants’ physical activity performance (game mechanics) [ |
Step 9: Identify mode of deliverya | Identify modes of delivery of the intervention that would be appropriate for the target population. These decisions can be informed by formative research and the scientific literature | For example, previous research may suggest that older adults tend to prefer computer-based Gs4H to those delivered through mobile devices |
aMichie et al [
bSDT: self-determination theory.
cCOM-B: Capability-Opportunity-Motivation Behavior.
dG4H: game for health.
eBCW: Behaviour Change Wheel.
fBCT: behavior change technique.
We applied MECHA to develop CHALLENGE. In doing so, we sought to refine our understanding of the context of the behavior in the target population and mapped the hypothesized linkages between health behavior change theory constructs, intervention functions, target participant experiences, BCTs, and game mechanics.
Sustained moderate-to-vigorous intensity physical activity is beneficial for older adults [
Moderate-intensity (ie, 3.0-6.0 metabolic equivalents) brisk walking has consistently emerged as a physical activity preference of older adults and can satisfy the nationally recommended aerobic physical activity guideline of engaging in at least 150 minutes of moderate to vigorous intensity physical activity per week [
Keeping in mind the existing literature norms for older adults and findings from pilot study research [
Target behavior
Walking at least 8000 steps per day for at least 5 days per week
Who needs to perform the behavior?
Women aged 65-85 years in southeast Texas who are not meeting nationally recommended aerobic physical activity guidelines
What do they need to do differently to achieve the desired change?
Increase walking, both as a lifestyle and for exercise. Increases should occur gradually with a target of ≥1000 daily steps per week until target goals are met
When do they need to do it?
Daily
Where do they need to do it?
Outdoors if possible, indoors at large venues, or at home
How often do they need to do it?
Daily
With whom do they need to do it?
Alone or in small groups
We chose to ground the intervention in SDT [
Identify what needs to changea.
Theoretical constructs | Requirements for the target behavior to occur | Should the intervention target this construct? |
Perceived autonomy | Participant wants to engage in physical activity for autonomous reasons (ie, enjoyment, interest, identity, and values) [ |
Yes; autonomous motivations for physical activity predict long-term compliance to physical activity goals, and older women want autonomy-promoting interventions [ |
Perceived competence | Participant feels competent and able to engage in physical activity | Yes; self-efficacy is a strong predictor of physical activity, and many older women report low levels of self-efficacy for consistently meeting nationally recommended physical activity guidelines [ |
Perceived relatedness | Participant feels supported by others regarding her physical activity | Yes; social support is a strong predictor of physical activity, and older women want social physical activity interventions [ |
Intrinsic regulation | Participant perceives physical activity as fun and interesting | Yes; previous studies suggest that these factors predict physical activity, and this is an identified barrier in this population [ |
Integrated regulation | Participant perceives physical activity as being in line with her values and identity | Yes; previous studies suggest that integrated regulation predicts physical activity in this population [ |
Identified regulation | Participant perceives physical activity as associated with an outcome that is important to her | Yes; previous studies suggest that identified regulation predicts physical activity in this population [ |
Introjected regulation | Participant feels obligated to engage in physical activity | No; although in some cases this type of motivation may lead to behavior initiation, it is not conducive to long-term adherence to physical activity [ |
External regulation | Participant perceives physical activity as something that outside forces are encouraging her to do | No; although in some cases this type of motivation may lead to behavior initiation, it is not conducive to long-term adherence to physical activity [ |
aTarget behavior: walking at least 8000 steps per day for at least 5 days per week.
We identified 6 functions of our intervention to bring about change in the key psychological needs enumerated in
We selected the Playful Experiences Framework to guide our identification of target player experiences [
We identified 13 BCTs to increase moderate-intensity walking in CHALLENGE by pairing the target player experiences identified in step 6 with the taxonomy of 93 distinct BCTs described by Michie et al [
We selected the library of game mechanics developed by Järvinen [
We identified Facebook as an appropriate platform through which to deliver this intervention [
Template for Intervention Description and Replication Checklist for Challenges for Healthy Aging: Leveraging Limits for Engaging Networked Game-Based Exercise (CHALLENGE).
Item name | Item |
Brief name | CHALLENGE |
Why | Despite short-term benefits, older adults’ adherence to physical activity and tracker use decrease sharply over time. Most existing intervention systems use a corrective frame: they are oriented toward |
What (materials) | Participants are provided a wrist-worn electronic physical activity tracker (Fitbit Inspire 2 [Google LLC]) and various props (eg, scavenger hunt bingo cards and sunglasses or masks to help obscure their identities). If participants do not already have Facebook and Fitbit accounts, study staff help the participants to create them |
What (procedures) | Participants meet face-to-face with study staff for orientation procedures (eg, aiding with technology) and data collection. Participants engage in goal setting and action planning with study staff at baseline and are invited to join a private Facebook group. Through this private Facebook group, participants receive weekly challenges that are centered on encouraging walking behaviors and eliciting playful experiences (see examples in Multimedia Appendix 1). Participants are encouraged to directly respond to challenges through Facebook posts and like or comment on others’ posts. Participants also receive weekly messages providing feedback on their physical activity levels and study engagement (ie, number of times participants posted in the Facebook group) |
Who provided | Interventionists are trained by the principal investigator (EJL) on basic aspects of the Playful Experiences Framework [ |
How | Goal setting and action planning are conducted face-to-face or through videoconferencing at the start of the study. All other intervention content is delivered on the web. Challenges are posted weekly using social media to a single, private Facebook group. Participants also receive individual weekly emails presenting their device-measured physical activity levels, suggested goals, and engagement level |
Where | Face-to-face meetings and data collection sessions are held at a large medical research university in southeast Texas. The intervention content is largely delivered through the internet |
When and how much | Intervention content is sent weekly over the course of 1 year for participants, with participants being enrolled on a rolling basis until the target sample size is reached (estimated to be 2-3 years). Recruitment began in June 2021 |
Tailoring | At the beginning of the intervention, study staff meet with participants to establish physical activity goals (ie, target step count and number of days per week that participants aim to meet that target step count). In this meeting, participants also select their target weekly improvement rate (eg, participants may indicate that if they did not meet their target step count one week, then they would like their goal for the next week to be to increase their daily average step count by 1000). Weekly emails accordingly present feedback on the previous week and provide a suggested step count goal for the upcoming week |
How well (planned) | Moderators’ weekly posts are based on a set schedule and accompanying scripts. The only communication with participants that is not heavily based on scripts are responses to direct messages or SMS text messages sent regarding scheduling, reporting unacceptable content, and so on. We will extract information from the Facebook group and Fitbit app regularly to track participant engagement |
Human involvement in the G4H intervention is conducted by moderators, who facilitate all web-based proceedings. They post all weekly challenges with example responses, review the Facebook group for adverse events or inappropriate comments, provide supportive and clarifying comments to study participants as necessary, and publicly recognize consistent participation (eg, badges awarded to
To evaluate the G4H, we aim to recruit 300 participants reflective of the target population detailed in step 1. We will recruit participants on a rolling basis by using several strategies, including in-person recruitment at gerontology and primary care clinics, web-based recruitment methods, and flyers and brochures placed at locations frequented by members of the target population. Outcome measures for the developed G4H include objectively measured step count and moderate to vigorous physical activity levels [
We extended the BCW to create MECHA, a step-by-step program planning model for designing Gs4H, and applied it to the development of a behavioral intervention centered on increasing physical activity in insufficiently active older women. MECHA may help researchers map specific linkages between distal instrumental and experiential objectives to the more proximal elements of game design. This may facilitate program planning, evaluation, and clearer communication of results to expedite scientific accumulation of knowledge.
MECHA shares similarities with other models that can help researchers parse G4H game design elements. The Mechanics, Dynamics, and Aesthetics Framework emphasizes the importance of mapping game mechanics to targeted emotional responses in game design [
We used the library of primary game mechanics developed by Järvinen [
Evoking enjoyable participant experiences is likely critical to sustained adherence to Gs4H and their associated health-related behaviors but designing games that do so reliably is a challenge. Consumption of games, as opposed to consumption of books, movies, and so on, is inherently nonlinear, and this introduces some uncertainty in predicting player experience [
We identified areas of needed research while conducting this project. First, more research is needed to elucidate how game experiences may affect SDT constructs. Greater clarity regarding if and how different experiences afforded by Gs4H affect critical psychosocial constructs may help game designers to develop more efficacious Gs4H. Second, more research that explicates how different G4H game mechanics engender specific player experiences is needed. Although this is likely to remain the purview of experts because of its inherent complexity, literature that helps to frame these links may help researchers to systematize iterative game development and communicate research proposals and study findings. Third, engagement is a key issue in securing a person’s participation in, and thereby exposure to, a game. Thus, engagement is critical for G4H effectiveness. Engagement likely hinges on participants’ G4H-related experiences—both experiences stemming from the game and the health-promoting aspects of the G4H. More research is needed to characterize how specific G4H-related experiences correspond to effective engagement with the G4H [
The strengths of this study include adherence to recommended procedures for increasing transparency of scientific research (eg, the Template for Intervention Description and Replication Checklist), a systematic approach to game design, and the real-world application of the G4H development process to create a behavioral intervention. The limitations of this study include, first, that we did not conduct a formal systematic review of the literature. As G4H design exists at the confluence of several fields, this was not within the scope of this study. Although our study team has considerable expertise in G4H research, there may be additional relevant studies not covered in this paper. Furthermore, our study team did not include professional game designers or developers. We made extensive use of relevant scientific literature, but future research would benefit from the inclusion of individuals with expertise in these areas. The MECHA model is a useful starting point, but it would likely be improved by incorporating the unique insights that game designers and experts in human-computer interaction may provide. This may be especially useful as MECHA is applied to help design health-promoting video games.
G4H design combines the art of game design and the science of behavior change. In this paper, we have presented a process for systematically integrating these perspectives and illustrated its use in the design of a G4H centered on increasing physical activity in insufficiently active older adults. This systematic approach to G4H design may facilitate program planning, evaluation, and clearer communication of G4H interventions.
Mapping self-determination theory constructs, intervention functions, target participant experiences, behavior change techniques, and game mechanics.
behavior change technique
Challenges for Healthy Aging: Leveraging Limits for Engaging Networked
game for health
games for health
Mechanics, Experiences, and Change
self-determination theory
This study was supported in part by the Center for Energy Balance in Cancer Prevention and Survivorship, which is supported by the Duncan Family Institute for Cancer Prevention and Risk Assessment. This study was funded by an award from the National Institute on Aging (R01AG064092). This study was also supported by the Claude D Pepper Older Americans Independence Center (P30AG024832), The University of Texas Medical Branch at Galveston Clinical and Translational Science Award (TR001439), and the Sealy Center on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging or the National Institutes of Health. Additional salary support for EJL was provided by a Mentored Research Scholar Grant in Applied and Clinical Research (MRSG-14-165-01-CPPB) from the American Cancer Society and by a grant from the National Cancer Institute (R21CA218543).
EJL and MCR conceived the project and developed the behavioral intervention with support from MCS, TB, DT, and KMBE. MCR wrote the manuscript with support from EJL, TB, DT, KMBE, and MCS.
None declared.