Most chronic diseases have obvious behavioral risk factors including smoking, physical inactivity, and unhealthy diet [1]. Therefore, the treatment and management of these diseases increasingly involve cooperation with patients, relying on self-management. Barlow et al [2] defined self-management as the ability to manage symptoms, treatment, physical and psychosocial changes as well as lifestyle changes that patients develop in coping with chronic diseases. However, poor self-management compliance of patients with chronic diseases, such as nonprescribed medication, lack of regular physical activity, and unhealthy eating habits, is a common clinical problem worldwide [3,4]. People with chronic diseases not only cannot see the benefits of self-management in the short term but also endure repeated and monotonous training or changes in past health habits, which is a struggle between low impulses and high cognitive control [5]. With the rapid development of technology, mobile health (mHealth) and telemedicine based on the internet and mobile electronic devices can provide internet-based health services for acute and chronic care, intervention, counseling, and social support for patients with chronic diseases [6]. The process of motivating individuals to find joy in monotonous, repetitive, or uninteresting tasks in a planned, selective way and guiding individuals to make positive changes is called “gamification.”

Gamification refers to the application of game design elements to nongame contexts [7]. The specific practice is to integrate game design elements such as points, badges, leaderboards, and avatars into nongame contexts such as marketing [8] and classroom teaching [9] to realize “meaningful play,” that is, to achieve serious purposes other than entertainment in an interesting process [10]. When gamification emerges in the field of health care, its serious purposes include, but are not limited to, helping patients with chronic diseases adhere to self-management [11], promoting their basic needs of autonomy, and balancing the unidirectional and paternalistic relationships between doctors and patients [12]. The core of gamification design lies in human-computer interaction and instant feedback, which conforms to the abovementioned difficulties and pain points in the self-management of patients with chronic diseases and is an important measure to break the failure of patients with chronic diseases to adhere to long-term self-management.

Since 2011, there has been an intense discussion about gamification, and the literature on gamification in the health care field has grown rapidly. In the field of rehabilitation and behavioral sciences, gamification attracts patients with cardiovascular disease [13-15], diabetes [16,17], and stroke [18-20] to participate more actively in the management of their long-term health problems with the application of mHealth, virtual reality (VR) technology, and robots.

Gamification in the field of chronic disease self-management is at an emerging stage. However, in some studies on gamification design in the field of health care, there is a lack of understanding of gamification as a design strategy, narrowly limiting its application to the use of video games [21] or blindly adding game design elements solely to encourage certain behaviors (such as physical activity) [22]. At present, the theoretical framework design of gamification is a hot topic [23]. Therefore, based on the evidence-based methodologies and from the perspective of gamification design, we integrated the forms, functions, and effect evaluation of gamification in the self-management of patients with chronic diseases to explore the mechanics, dynamics, and experience of gamification design of users with chronic diseases.

Considering the heterogeneity of scientific research design and measurement methods of different studies, we believe that a scoping review is a method of knowledge synthesis that is suitable for discussing large-scale, diverse, and complex heterogeneity themes. For these reasons, a scoping review could be a better choice than a systematic review to quickly describe the research progress of a certain field, showing the scope, depth, breadth, and deficiency and providing more information for the future [24]. Therefore, this scoping review aimed to classify, compare, and synthesize gamification in chronic disease self-management.

This study was designed according to the framework developed by Arksey and O’Malley [25]. The five main stages are as follows: (1) identify the research question (RQ), (2) identify relevant studies, (3) search strategy and study selection, (4) chart the data, and (5) summarize and report the results. This scoping review is reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist.

This scoping review aimed to describe how gamification design has been implemented in self-management promotion for patients with chronic diseases and how to evaluate the effect of gamification in the self-management of patients with chronic diseases. We articulated the study objectives using the following RQs:

The research team used brainstorming to establish the eligibility criteria for relevant studies. According to the definition of chronic disease by the Centers for Disease Control and Prevention, we retrieved synonyms for chronic disease and specific disease names for cardiovascular diseases, chronic pulmonary diseases, metabolic syndrome, and cancer. On the basis of the widely accepted definition of gamification [7], relevant studies should apply games or game design elements to promote self-management needs with joyful experiences of patients with chronic diseases. We retrieved cognates and synonyms of gamification, game based, game design elements, game component, game design, and game principle. Given the inseparable connection between the application of gamification and electronic devices, we also retrieved synonyms of video games, computer games, exergames, and VR.

PubMed, Web of Science, CINAHL, APA PsycINFO, Embase, Cochrane Library, China National Knowledge Network, Wanfang (Wanfang Data), and VIP (CQVIP) were used as the data sources. In the past decade, there has been an increase in health-oriented gamified clinical research and applications [11]. Considering the speed of electronic technology changes, the technology before 2012 does not have a reference value, and we searched for the literature on gamification of chronic disease self-management from January 2012 to December 2022.

The retrieval strategy was based on the combination of subject terms and keywords, and the retrieval scope was the titles and abstracts. The search strategy did not limit any inclusion based on the affiliation of the authors, but the publication language was limited to English and Chinese to ensure an accurate understanding of the research. All databases were run on March 18, 2022, and updated on January 7, 2023. Refer to Multimedia Appendix 1 for the detailed search strategy.

Under the guidance of an academic librarian, along with a brainstorming session, the research team set the following inclusion and exclusion criteria.

Inclusion criteria were as follows: (1) the research participants or targets were patients diagnosed with chronic diseases aged >18 years; (2) the gamification design in this study must include game design elements; and (3) the study was published in Chinese or English.

Exclusion criteria were as follows: (1) patients with diseases that require long-term rehabilitation owing to trauma (eg, patients with fractures or brain injuries); (2) special research participants such as high-risk groups of people with chronic diseases; groups people with genetic diseases; groups of people with occupational diseases; and special groups such as those who are disabled, sexual minorities, and pregnant women; (3) conference abstracts, patents for an invention, and so on, which only have descriptions but no experimental data; (4) studies for which the full texts are not available.

In total, 2 reviewers (XH and XX) independently screened abstracts and full-text articles with EndNote (version X9; Thomson Corporation) software. In case of conflicting opinions, a third reviewer was consulted (YL) to reach a consensus. The following information was extracted from the articles included in the review: first author, country, publication year, types of study design, objective population (chronic disease type), (if any) sample size and gender distribution, gamification realization forms, theoretical frameworks, game design elements, roles of gamification in chronic disease self-management, and gamification design evaluation tools. All data are presented with data charts suggested by Arksey and O’Malley [25].

To describe the sample and study characteristics, the first author coded papers for the following information using Excel (version 2019; Microsoft Corporation) software: publication year and country of publication (extracted from the paper metadata); types of study designs (extracted from the Methods section); number of patients with chronic diseases and their disease types (extracted from the Results section); and sample characteristics (extracted directly from the Results section or calculated mean value of all sample data).

To describe the application of gamification in chronic disease self-management, the first author coded the paper for following factors: gamification realization (extracted the description of the research tool from the Methods section); gamification evaluation (extracted related outcome measurements from the Methods section); gamification function (extracted verbatim from the “aim” or “objective” statements of each paper).

After data extraction, the fourth author calculated the frequencies of the quantitative data and charted the data. The first author coded the extracted material for qualitative content analysis. After 2 coding cycles, subthemes of “gamification forms” emerged, including “technical support” and “theoretical support,” and subthemes of “gamification function” emerged, including “symptom management,” “medication management,” “physical activity and rehabilitation,” “cognitive function rehabilitation,” and “psychological support.”

The initial search yielded 16,221 results, of which 7966 (49.11%) were duplicates and 8100 (49.94%) were excluded by reading the titles and abstracts. Of the remaining 155 articles, 70 (45.2%) met the inclusion criteria. The PRISMA-ScR flowchart (Figure 1) shows more detailed information [26].

A total of 70 articles included in this review were mainly from 22 countries. Most studies (56/70, 80%) were concentrated in developed countries. The United States was the country with the most research (18/70, 26%), followed by the United Kingdom (6/70, 9%). There were 5 relevant studies in Canada and Australia and 3 relevant studies in China, Norway, Germany, Spain, Brazil, and Switzerland. The remaining 18 studies were conducted in 12 countries (South Korea, Greece, Iran, France, Malaysia, Portugal, Pakistan, Denmark, Japan, Singapore, Israel, and Indonesia).

Among the included studies, studies within the last 3 years accounted for half of the included studies (35/70, 50%). There were no restrictions on the study designs or chronic diseases in this review. The study design included experimental studies (27/70, 39%), literature studies (18/70, 26%), observational studies (13/70, 19%), and other types of studies (12/70, 17%). Survivors of stroke accounted for the largest number of studies (29/70, 41%), followed by patients with unclassified or multiple chronic diseases (11/70, 16%; Table 1). Except for some studies that only reported the development of gamification designs without data on research participants (26/70, 37%), the review extracted data from 2193 participants, most of whom were female (n=1423, 64.89%). The age distribution of the patients ranged from 33 to 85 years, with the mean age of 55.56 (SD 8.69) years (26/70, 37%). Details are provided in Multimedia Appendix 2 [13-20,27-87].

Gamification in the self-management of patients with chronic diseases helped to manage symptoms, improve medication compliance, maintain physical activity and rehabilitation motivation, and provide psychological support (Figure 2).

This review did not find a unified evaluation criteria for the gamification design of chronic disease self-management. The evaluation indicators of gamification design mentioned in the literature have been compiled into Table 2.

Of the 70 articles, 39 (56%) reported the evaluation indicators of the chronic disease self-management gamification system. Of the 39 articles, 9 (23%) used existing scales, including the System Usability Scale [32,37,85], Ease of Use Scale [32], Acceptance Questionnaire [14], User Experience Questionnaire [58], User Interface Features Questionnaire [58], User Satisfaction Evaluation Questionnaire [80], and Game Experience Questionnaire [53]. Of the 39 articles, 12 (31%) used self-designed scales to evaluate users’ satisfaction [52,64,65], experience [32,44,49,63,76,80], engagement [14], and preference [41,79,80]. Of the 39 articles, 10 (26%) with gamification design through AVGs used system log files to record symptom management strategies [14,63] and their duration [16,20,59,71], activity and rehabilitation training intensity, and related data of users [19,44,47,83].

In total, 17 studies showed user experience and preferences through interviews.

Most users mentioned experiencing pleasure and effectiveness when using gamified systems [29,58,59,66,68,71,80,82]. They could receive timely feedback for error correction or affirmation with human-computer interaction [58,82], stimulate self-efficacy of self-management with the competition mechanism [49,57], and realize personal progress visualization and internal motivation promotion with game design elements such as points and the progress bar [40]. On the basis of mobile devices, users’ physical activities and rehabilitation training could be free from the limitations of time, location, weather, or other medical activities, achieving self-management liberalization and confidentiality [16,30,37,66,71]. Using the internet, users could obtain support and supervision from health care professionals and patients more conveniently [27,31,37]. However, some users were older adults, and obstacles in technology and health status were inevitable [75]. They stated that they were unfamiliar with electronic technology and required accompaniment or technical support from their family members or health care professionals [13,27,31,66,71,75]. Owing to the severity of the disease, individual differences in participation and challenge difficulty among different users made it difficult for the gamification design to achieve absolute fairness [27,57]. Therefore, the gamification design of the system interface required comprehensive consideration of users’ cognitive and physical functions. This could be simplified by reducing the number of buttons instead of background music to prevent visual information overload [49,57]. Security preparedness was the most important issue when AVG was used for physical activity or rehabilitation training. Without it, users would not have the motivation to use the gamification system [77]. It would be helpful to present action guidance from the first perspective in AVG so that users can operate better and increase their interest, thereby entering a flow state [49]. In terms of competition mechanism and goal setting of gamification design, user engagement and actual situations showed individual differences, preferably allowing users to set their own goals to avoid physical exhaustion and disrupting the fun of exercise itself [27,29].

Overall, the evaluation focused on the experience of patients with chronic diseases, reflecting the self-management motivation, technical novelty, fun of the game experience, and the degree of personalization related to the motivation for self-management [30,82]. Only a few studies reported safety-related outcomes [35,70,75] and adverse events triggered by individual exercises with a gamification system (such as knee pain and low back pain) [70]. We suggest that to promote gamification in chronic disease self-management, health care professionals should pay attention to the safety protection and emergency plan for patients’ home use.

This scoping review identified 70 gamification studies on chronic disease self-management conducted from 2012 to 2022. Stroke was the leading disease in gamification research (29/70, 41%), and the field of physical activity and functional rehabilitation was the central research content of chronic disease self-management gamification. In all studies, gamification practice was dominated by AVGs (58/70, 83%), and its theoretical support was mainly derived from existing psychological and cross-disciplinarity concepts or theories. The main functions of gamification were promoting physical exercise and rehabilitation training in patients with chronic diseases (48/99, 48%), especially in the field of poststroke rehabilitation; AVGs have become a rehabilitation tool for survivors of stroke [48] and are used for symptom management (18/99, 18%), psychological support (14/99, 14%), cognitive exercise (12/99, 12%), and medication management (7/99, 7%). Evaluation indicators and qualitative text showed that the use of gamification in chronic disease self-management was widely recognized by patients.

Compared with traditional self-management methods, the combination of gamification design and mobile technology has broken through the traditional medical mechanism and experience of patients with chronic diseases, allowing them to have more autonomy in the choice of rehabilitation training time and rehabilitation forms. Therefore, gamification enabled patients with chronic diseases to maintain a high motivation for self-management for 6 months [38], meeting the requirements of disease self-management such as physical activity, symptom management, and disease cognition. In addition, patients with chronic diseases who coexisted with diseases for a long time often had negative emotions such as anxiety and depression, which had a negative impact on their health outcomes, disease management, and quality of life [87]. Gamification used game design elements to create enjoyable experiences, allowing patients to better immerse themselves and complete self-management in a state of flow [46,57,73]. When patients reacted as the requirements of self-management, the gamification would provide timely praise through human-computer interaction, like points accumulation. This timely positive feedback helped to improve the self-efficacy of patients with chronic diseases engaged in self-management, and they sincerely felt happy [79], thereby reducing the conflict between long-term health goals and previous unhealthy habits [50,60], fostering sustainable long-term self-management.

We suggest that health care professionals, developers, and researchers of gamification design should take ethnic characteristics, personal lifestyles, personality, interests, and hobbies into consideration when applying gamification. The most controversial game design element in this study was the competitive mechanism. Competition is bound to result in winners and losers. It is undoubtedly an incentive for patients who win and lead the leaderboard, but if the patient is far behind others, it may make the user give up [57]. This could be a disease characteristic of the susceptibility to fatigue. Patients with cancer and patients with COPD believe that game design elements should be used to build confidence, and even if they want to compete, they should constantly challenge and surpass themselves, rather than emphasizing the competition for patient performance. Patients with different disease severity levels have different perceptions of difficulty in completing the same challenge. For those with severe disease, failure to challenge, especially over a long period, may even lead to depression and a lack of self-efficacy [27,29,45]. For people with diabetes, the fun of competition lies in the fast-paced disease knowledge competition [52,89]. Therefore, the application of game design elements should be related to the frequency of interactions between users and the system or the degree of participation between users and the community to gamify the experience of chronic disease self-management. In addition, patients with chronic diseases of different ages have different preferences for game design elements. Among middle-aged and older adults, users do not want too many rewarding elements such as badges and likes, avoiding making the gamification system of chronic disease self-management like a children’s game [40]. Technical barriers should be considered when older patients with chronic diseases use electronic products, which reminds the gamification designer to simplify the game interface and game rules without affecting the user’s fun [46,49,52,58,61,77,79].

Therefore, successful gamification design cannot be separated from the following four universal gamification design rules: (1) focus on incentive mechanism, (2) do not terminate games at will, (3) not overemphasizing specific gamification mechanism, and (4) link games with health and happiness [39]. Before the gamification design of chronic disease management, 4 core questions are recommended to be based on the following: Can it provide a good motivation for chronic disease self-management? Is the set target activity meaningful and interesting? Is there a structured pattern of the expected activity behavior? Does the gamification mechanism use potentially conflict with the target behavior?

Although this review found that gamification had a positive and universal effect on chronic disease self-management, we still need to view the results dialectically. Most of the gamification intervention periods in the included studies were all within 1 year, and most interventions were within 6 months; therefore, we cannot rule out the novelty effect of technology. We also need to consider that the users included are themselves interested in the study, which inevitably leads to a selection bias. In addition, the gamification of chronic disease self-management involved multiple environments such as clinical settings [73,80] and family settings [30,44,77], which interferes with the effectiveness of gamification interventions. To better explore how gamification promotes self-management in patients with chronic diseases and promotes their expected long-term outcomes, the consistency of the research setting should be controlled, the sample size should be expanded, and the follow-up period should be extended in the future, and more methodological research is encouraged to investigate the extent to which various forms of gamification impact chronic disease self-management.

Unfortunately, this review retrieved only the literature published in Chinese or English, omitting valuable data from relevant articles published in other languages. Gray material and unpublished studies were not included in this review. Many health-related applications were privately operated, and their development and evaluation information were not disclosed. The sample sizes of some diseases in the included studies were insufficient and could not represent the entire population. Therefore, in the future, we will expand the search to focus on the literature published in other languages and further study the heterogeneity of disease populations.

This review was based on a definition of gamification, without limiting the type of research, that focused on gamification designs for chronic disease self-management; the study synthesized the differences in the gamification realization forms and functions in self-management of different disease populations, which helped the researchers to completely understand the use experience and opinions on gamification for the self-management of patients with chronic diseases. Before using gamified interventions for chronic disease self-management, researchers must conduct a comprehensive survey of the target group, clarify the shortcomings of the self-management and game preferences of patients with chronic diseases, and stimulate internal motivation through appropriate game design elements. At the same time, it is also necessary to consider the multidisciplinary expert qualifications of the research team and the cost of research interventions, developing attractive chronic disease self-management plans based on the definition of gamification to be applicable to chronic disease management in developing countries.