This study used a cross-sectional qualitative interview study design grounded in a pragmatic and interpretive orientation, using semistructured interviews to generate user-centered insights. This approach was chosen to generate practical design implications for gamified exercise apps while facilitating an interpretive understanding of participants’ exercise-related experiences. To ensure adherence to qualitative research reporting standards, we followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist (Checklist 1) and the American Psychological Association Journal Article Reporting Standards for Qualitative Research (JARS-Qual) [17,18].

The study was conducted from June to July 2025 through online poster recruitment in mainland China. To ensure the richness and relevance of the findings, purposive sampling was used to select individuals with prehypertension [19]. We aimed to achieve gender balance and include individuals from diverse socioeconomic backgrounds and occupations in our recruitment. The sample size was determined in accordance with the principle of data saturation. Interviews were discontinued after a minimum of 10 sessions, when no new codes or themes emerged after 3 consecutive interviews [20].

Inclusion criteria included the following: (1) aged between 18 and 60 years old; (2) met the 2024 Chinese diagnostic criteria for prehypertension, defined as systolic BP between 120 and 139 mm Hg and/or diastolic BP between 80 and 89 mm Hg [21]; (3) able to communicate verbally in Mandarin and willing to participate voluntarily; (4) expressed an interest in the association between exercise and BP; and (5) had prior experience using smartphone apps. Exclusion criteria were as follows: (1) individuals with any known cognitive impairments or mental illnesses that could affect their ability to participate in an interview and (2) individuals with physical conditions that may impact their PA behavior.

The interview guidelines were systematically developed through integration of SDT and the Octalysis Gamification Framework, encompassing questions regarding 3 aspects: exercise behavior, needs, and preferences for exercise apps, and gamified incentive mechanisms (Multimedia Appendix 1) [14,16]. According to SDT, human motivation undergoes a continuous transition from amotivation to extrinsic motivation and then to intrinsic motivation. When the external environment provides appropriate support and satisfies an individual’s basic psychological needs (autonomy, competency, and relatedness), it can stimulate intrinsic motivation or facilitate the transformation of extrinsic motivation [16,22]. The Octalysis Gamification Framework, developed by Chou in 2019, has been widely adopted across diverse fields and is recognized for emphasizing human motivation rather than mere functionality to improve the impact of gamification [14,23]. It categorizes game elements into 8 fundamental psychological drives (ie, epic meaning, accomplishment, empowerment, ownership, social influence, scarcity, unpredictability, and avoidance) that shape human behavior and decision-making. These core drives serve to motivate, empower, and influence behavioral patterns, ultimately prompting individuals to take action.

The relationship between the Octalysis Framework and SDT is illustrated in Figure 1. The figure conceptually depicts how selected white hat Octalysis motivational drives may be interpreted through an SDT-informed lens in relation to basic psychological needs of autonomy (empowerment), competence (accomplishment and ownership), and relatedness (social influence), as well as a sense of purpose (epic meaning). Ownership is depicted as having a weaker association with competence, as it often relies on responsibility rather than intrinsic mastery. The horizontal axis distinguishes between predominantly psychological need support (white hat) and more externally driven (black hat) motivation. Black hat drives (scarcity, avoidance, and unpredictability) are shown as operating outside psychological need satisfaction and are therefore not theoretically aligned with SDT.

This dual-theory approach enabled us to systematically explore both the functional features of gamification (Octalysis) and its psychological aspects (SDT) in health behavior change.

Prior to data collection, the interview guide was rigorously reviewed by 3 qualitative methodology experts, pilot-tested with 2 prehypertensive individuals, and iteratively finalized. Data were gathered through one-on-one semistructured interviews, which were conducted by a trained qualitative researcher (SJL), a female master’s student with 2 years of experience in health behavior research and a research interest in gamified exercise apps, to ensure consistency. The researcher’s prior understanding of behavior change theories and gamification informed the development of the interview guide. Interviews were conducted either through online Tencent Meetings (Tencent) or face-to-face in a quiet meeting room with no other person present, depending on the specific circumstances and participant preferences. Before the interviews, the researcher provided participants with an explanation of the topic, reasons, and purposes for doing the research, and privacy protections to foster trust with the participants. Participants were also invited to complete demographic questionnaires prior to the interview. Those participating in face-to-face interviews completed paper-based questionnaires, whereas those interviewed through Tencent Meetings completed questionnaires through Wenjuanxing (Changsha Ranxing Information Technology Co, Ltd), a widely used online survey platform in China.

During the interview, before discussing gamification, the interviewer introduced the concept to the participants using examples from well-known apps such as Starbucks (Starbucks Corporation) and Duolingo (Duolingo, Inc). Interviews took place in private, comfortable environments, with each session lasting approximately 30 to 60 minutes. After the interviews, the interviewer took notes on key information. With the participant’s consent, all sessions were audio-recorded and transcribed verbatim within 24 hours. The researchers then returned the transcriptions to the participants to verify the accuracy of the content.

The interviewer (SJL) transcribed the interview recordings verbatim using the transcription software iFlytek Hearing. Subsequently, the transcriptions were reviewed and verified for accuracy by listening to the audio recordings again in Microsoft Word, with any necessary corrections made based on the recordings. The finalized transcriptions were then uploaded to NVivo 20 (QSR International) for systematic qualitative data analysis, where coding and thematic analysis were conducted. Thematic analysis is a flexible method that can be applied to both inductive and deductive approaches to data analysis [24]. According to our research aim, we used an inductive or deductive hybrid thematic analysis, a methodologically rigorous approach that combines both theory-driven and data-driven approaches to identify key themes [25]. Specifically, inductive thematic analysis was used to explore the needs and preferences of prehypertensive individuals regarding exercise apps, while the deductive analysis was applied using predetermined codes derived from SDT and the Octalysis Gamification Framework. For example, SDT-informed deductive codes included autonomy (eg, sense of volition and preferences), while Octalysis-informed codes included motivational drives such as accomplishment (eg, points and progress bars).

Two researchers (SJL and HMM) with expertise in qualitative methods and health gamification independently coded the first 6 transcripts, then compared and discussed their results to establish preliminary themes and insights. In cases of disagreement, a third researcher (MHP) with extensive experience in behavioral health research was consulted to reach a consensus. The interviewer then proceeded to code the remaining transcripts, collaborating with the second researcher to incorporate any newly emerging themes. Finally, the entire research team reviewed and finalized the themes through iterative discussion until consensus was achieved.

Rigor was determined using Lincoln and Guba (1985) 4 criteria of credibility, dependability, confirmability, and transferability [26]. Credibility was established through the use of probing questions during interviews, such as “Can you elaborate?” These questions encouraged participants to provide more detailed responses, allowing researchers to gain a more comprehensive understanding of their experiences. Member checking, where participants were asked to review and confirm the accuracy of the interview data, was also used to ensure that the research findings reflected their true perspectives. An audit trail, which included a detailed record of how data were collected, kept, analyzed, and interpreted, was used to ensure dependability by providing a transparent research process and confirmability by ensuring that the qualitative findings were not influenced by researchers’ biases. Additionally, a detailed description of the research aim, participants, and context was provided to facilitate transferability to similar populations and settings.

Fidelity was ensured through consistent alignment among the research objectives, the guiding theoretical frameworks (SDT and the Octalysis Gamification Framework), the semistructured interview design, and the hybrid inductive-deductive thematic analysis. Utility was demonstrated by addressing a meaningful research problem and generating context-specific design implications to inform the future development of gamified exercise apps for individuals with prehypertension. These findings offer actionable insights for researchers and software designers working in digital behavior change contexts.

The study was approved by the Ethics Committee of Peking Union Medical College School of Nursing (approval number: PUMCSON-2024‐36) before data collection began and was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants after providing comprehensive information about study objectives, procedures, and data protection measures. All data were anonymized prior to analysis, and no information could be used to identify individual participants. Each interviewee received a compensation of 200 RMB (approximately US $28) as appreciation for their time. No identifiable images of participants were included in the manuscript or supplementary materials.

The following results are based on interviews with 14 adults with prehypertension recruited online in mainland China.

In this qualitative study, we interviewed 14 prehypertensive individuals, providing valuable insights into their needs and preferences for exercise apps, gamified design considerations based on the Octalysis Gamification Framework, and basic psychological needs satisfaction and motivation according to SDT.

To the best of our knowledge, this study is among the first to systematically integrate these 2 theoretical frameworks to understand user requirements for digital health interventions in prehypertension management. Our research advances both theoretical understanding and practical application by revealing how the Octalysis Gamification Framework and SDT can synergistically inform exercise behavior change interventions, while providing evidence-based guidance for app design. The design implications discussed below should be interpreted according to the study context, which involved a small qualitative sample of individuals with prehypertension recruited online in mainland China. Notably, these findings are most applicable to prehypertension populations in similar Chinese digital health contexts. They are not directly generalizable to offline-recruited prehypertension groups, individuals from other cultural backgrounds, or nonexercise-focused gamified apps.

The qualitative study has several strengths. In the digital age and the era of technological explosion, integrating user-centered design principles into technology development is crucial. The study used a hybrid inductive or deductive thematic analysis to explore prehypertensive individuals’ needs and preferences for gamified exercise apps through semistructured interviews. Based on SDT and the Octalysis Gamification Framework, the study enriches the theoretical basis for behavior change experts and provides practical design insights for software developers. It is timely and aligns well with global trends.

The study also has limitations. We recruited participants through an online poster, and individuals who responded were more likely to pay attention to their physical health compared with the general populations. Therefore, the insights derived from the included participants may not be generalizable to the broader population. Intervention designs based on these insights may not always be effective. Future quantitative studies, including participants from diverse cultural backgrounds and regions, should be conducted to validate our findings.

Moreover, since motivation and psychological need satisfaction are likely to change over time, longitudinal studies could provide a better understanding of exercise behavior according to SDT. Additionally, ethical considerations warrant reflection when designing gamified exercise apps, as some participants expressed concerns about pressure, competition, and the possibility that excessive entertainment-oriented gamification may weaken the app’s exercise-focused purpose. Future researchers remain attentive to the potential psychological burden of such apps and ensure that participation is voluntary and supportive. A further limitation is that interrater reliability (eg, Cohen κ) was not formally calculated. Although discrepancies in coding were resolved through consensus among researchers, future studies can incorporate statistical measures of interrater reliability to strengthen methodological rigor.

This theory-informed qualitative study is among the first to explore the needs and preferences of individuals with prehypertension for gamified exercise apps by integrating the Octalysis Gamification Framework with SDT. The findings suggest that successful gamified exercise apps for prehypertensive individuals may benefit from going beyond traditional game mechanics to address deeper psychological needs. Participants emphasized the importance of personalized exercise programming, robust health monitoring capabilities, and human-centered gamification designs that support autonomy, competence, and relatedness. Satisfaction of these basic psychological needs is critical for transforming extrinsic motivations, such as weight management and health values, into intrinsic enjoyment of exercise. By integrating a theoretical basis with user-centered perspectives, this study provides context-specific design implications for future development of gamified exercise apps tailored to prehypertensive individuals in similar digital health contexts.