Accepted Manuscript

Title: Understanding Persuasion Contexts in Health

Gamification: A Systematic Analysis of Gamified Health
Behavior Change Support Systems Literature
Author: Tuomas Alahaivala Harri Oinas-Kukkonen
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DOI:
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S1386-5056(16)30026-0
http://dx.doi.org/doi:10.1016/j.ijmedinf.2016.02.006
IJB 3306

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International Journal of Medical Informatics

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17-2-2015
20-1-2016
15-2-2016

Please cite this article as: Tuomas Alahaivala, Harri Oinas-Kukkonen, Understanding
Persuasion Contexts in Health Gamification: A Systematic Analysis of Gamified
Health Behavior Change Support Systems Literature, International Journal of Medical
Informatics http://dx.doi.org/10.1016/j.ijmedinf.2016.02.006
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Understanding Persuasion Contexts in Health

Gamification: A Systematic Analysis of Gamified
Health Behavior Change Support Systems Literature
Authors: Tuomas Alahivl & Harri Oinas-Kukkonen
Affiliation: University of Oulu
Contact details for corresponding author:
Tuomas Alahivl
Department of Information Processing Science
PL 3000, 90014
University of Oulu
Finland
Phone: +358 40 820 87 15
E-mail: tuomas.alahaivala@oulu.fi

Highlights

Gamified Health BCSSs are implemented under different facets of lifestyle change and treatments
compliance and use a multitude of technologies and methods.
Understanding contextual factors is critical for successful gamification, but this has yet been
overlooked in the research on gamified health interventions.
Future research on gamified HBCSS should systematically compare the different combinations of
contextual factors, related theories, chosen gamification strategies, and the study outcomes.

ABSTRACT
Background
Gamification is increasingly used as a design strategy when developing behavior change support systems
in the healthcare domain. It is commonly agreed that understanding the contextual factors is critical for
successful gamification, but systematic analyses of the persuasive contexts have been lacking so far
within gamified health intervention studies.
Objectives and methods
Through a persuasion context analysis of the gamified health behavior change support systems (hBCSSs)
literature, we inspect how the contextual factors have been addressed in the prior gamified health BCSS
studies. The implications of this study are to provide the practitioners and researchers examples of how to
conduct a systematic analysis to help guide the design and research on gamified health BCSSs. The ideas
derived from the analysis of the included studies will help identify potential pitfalls and shortcomings in
both the research and implementations of gamified health behavior change support systems.
Results
We systematically analyzed the persuasion contexts of 15 gamified health intervention studies. According
to our results, gamified hBCSSs are implemented under different facets of lifestyle change and treatments
compliance, and use a multitude of technologies and methods. We present a set of ideas and concepts to
help improve endeavors in studying gamified health intervention through comprehensive understanding
of the persuasive contextual factors.
Conclusions
Future research on gamified hBCSSs should systematically compare the different combinations of
contextual factors, related theories, chosen gamification strategies, and the study of outcomes to help
understand how to achieve the most efficient use of gamification on the different aspects of healthcare.
Analyzing the persuasion context is essential to achieve this. With the attained knowledge, those planning
health interventions can choose the tried-and-tested approaches for each particular situation, rather
than develop solutions in an ad-hoc manner.

Keywords: gamification, health, behavior change support systems, persuasive technology, serious games,
e-health

1 Introduction
Healthcare providers are looking constantly for effective ways to help people improve their health
behaviors. Promoting healthy lifestyles to prevent diseases, supporting self-management of treatments,
and raising public awareness are being carried out increasingly through information technology. It is
important that these systems are designed in a manner that is engaging and motivating for the users, so as
to achieve and maintain a sustainable behavior change.
One such approach has been to adapt design strategies from video games, which have commonly been
associated primarily with entertainment. Gamification, defined as the use of game design elements in
non-game contexts [1], or a process of enhancing a service with affordances for gameful experiences in
order to support users overall value creation [2], provides promising possibilities for supporting
behavior change in healthcare.
Health behavior change support systems (hBCSSs) [3] seem to be highly potential areas for the
application of gamification. However, gamification designers have been criticized for often using certain
pre-existing patterns of design elements with presumed motivational effects, regardless of the different
implementation situations [4, 5]. Identifying the contextual factors is critical for designing gamification in
systems that support actual user needs [6]. Gamified systems have been described as complex
interventions, which require thorough analysis of the content, structure, and delivery of the intervention
and its components, as well as a linking of these to the desirable outcomes [7]. However, gamification
studies commonly fail to provide a systematic analysis of the contextual factors.
Analyzing the persuasion context containing the contextual factors of system use and users has been
stated as a fundamental phase in the hBCSS development [3, 8]. The persuasion context analysis of the
Persuasive Systems Design (PSD) model has been used to inspect and analyze existing systems [9], as
well as to guide the design of hBCSS software implementation [10]. However, there has not been in the
literature a systematic analysis of persuasion contexts in the area gamified hBCSSs.
We adopt the persuasion context analysis [8] here as a framework for identifying the different aspects of
persuasion in the current health gamification literature. We inspect how the contextual factors have been
addressed in gamified health BCSS studies, identifying issues yet to be discovered due to the prior lack of
systematic analysis. This study will provide practitioners and researchers an exemplar of thorough
conceptual analysis, which may help to guide the design and research on gamified health BCSSs and
reveal the current issues and present problems. This will help advance the research on gamified health
BCSSs.
1.1 Behavior Change Support Systems
Modern communication technologies such as the Web and mobile phones enable many possibilities for
persuasion, as their users can be reached easily, and they can combine means of interpersonal and mass
communication. Persuasive systems may use either computer-human persuasion or computer-mediated
persuasion [11]. Differing persuasion strategies that exploit social-psychological theories and techniques
can be used in the system design to reach persuasion goals [8, 12].

A behavior change support system (BCSS) is, by definition, an information system that has been designed
to form, alter, or reinforce attitudes, behaviors, or an act of complying, but does not use deception,
coercion, or inducements to reach these goals [3]. The interests in BCSS research include the approaches,
methodologies, processes, and tools for developing such systems, as well as studying their possible
impacts [3].
Welfare, commerce, education, safety, environmental preservation, and occupational effectiveness,
among others, are all viable application areas for persuasive technology [12]. Health behavior change is
one of the most prominent areas of persuasive systems, and physical activity intervention systems
specifically have proven to be a viable application domain [1315]. hBCSSs have been utilized
successfully in domains such as smoking cessation, hazardous drinking, diabetes, asthma, tinnitus, stress,
anxiety and depression, complicated grief, and insomnia [16]. Information systems that promote
improved health and healthier lifestyles have been stated as one of the most prominent areas for future
healthcare improvement [17].
The prior research on persuasion has provided multiple approaches and techniques for studying
persuasive systems [8, 3]. Different theories can be used as background for designing persuasive systems,
such as the theories listed by Oinas-Kukkonen and Harjumaa [8]: information processing theory [18],
cognitive consistency theory [19], elaboration likelihood model [20], Cialdinis influence techniques
approach [21], and coactive approach [22]. Information processing theory indicates that the persuasive
impact of messages derives from six steps a person goes through [18]. The cognitive consistency theory
states that people work to keep their mental structures organized and consistent [19]. The elaboration
likelihood model [20] concludes that people are prone to persuasion, either through an argumentative
central route or a cue-induced peripheral route. Cialdinis [21] influence techniques approach suggests
that people may answer to behavioral triggers in either an automatic or a controlled way. The coactive
approach to persuasion indicates ways to move the persuader psychologically closer to the subject [22]. In
addition, theories such as the Technology Acceptance Model [23] and the Unified Theory of Use and
Acceptance of Technology [24] have been constructed to understand the factors affecting peoples
intention to use information systems.
1.2 Gamification of Health BCSSs
Gamification can be seen as one form of persuasive or motivational design [25, 26]. Many of the gamified
applications are designed to support individuals in adopting good health behaviors via positive reinforcing
experiences [27, 28, 29]. Pereira et al. [28] performed an analysis on a selection of such applications,
identifying the specific application domains, such as physical activity, diet and weight loss, hygiene,
healthy working habits, and medical treatment. A similar study by Lister, West, Cannon, Sax, &
Brodegard [29] identified physical activity and dietary monitoring as the most common context of use.
These applications commonly track some data from users, either through manual input or sensory values,
and provide game-like feedback based on it.
The purpose of gamification in these cases either has been to have people use the application more, or
facilitate more completions of certain behaviors. Lister et al. [29] argue that, while the applications focus

mostly on increasing motivation of their users, other components of health behavior, such as capability or
behavioral triggers, are not addressed enough in general. Pereira et al. [28] also point out that managers
and healthcare professionals may not be familiar with the gamification technologies and approaches, and
may deem them not credible. Careful attention must be paid to concerns such as ethics, confidentiality,
and personal privacy when designing gamification in healthcare situations [27, 28]. Often, implementing
gamification successfully also requires additional awareness campaigns and investments, which may hold
back some developments [28]. Still, gamification poses interesting opportunities for adding more positive
experiences to the different facets of healthcare.

2 Materials and Methods

2.1 Identification of Studies
To acquire the material for the analysis, literature searches were made of six scientific databases: Elsevier
Scopus, ISI Web of Science, PubMed, EBSCOHost, ACM Digital Library, and IEEE Explore. These six
databases cover the main outlets of academic health BCSS studies in information systems, humancomputer interaction, health informatics, and other related research fields. Most of the citations were
obtained through Scopus, to which the searching for the rest were added. We limited our study to
academic studies only, although we acknowledge that a lot of work into gamification design has also been
conducted in industry-driven projects. However, industry-driven research reports usually do not provide a
full account of persuasive intentions behind the designs, nor do they give attention to the theoretical
background for design. Studies have already been conducted on the qualities of commercial health
gamification applications (e.g., [28, 29, 30]).
The search terms used to identify relevant studies were gamif* and health*. We acknowledge that parallel
terms, such as serious games, exergames, game-based learning, and playful design, have been
used to discuss the use of game-inspired design in serious contexts. Still, there are small subtleties that
differ among these from the emerged gamification phenomenon, and hence we only adapt here the term
gamification for our use [1]. We presume that using the term gamification, when describing the study,
reveals that the authors have made a conscious effort to make a service or a system more game-like in a
way that fits our understanding and definition of the phenomenon. However, there also may have been
similar studies conducted under different intersecting terms that were made prior to the time when use of
the term became widespread.
Papers were included in this study if they 1) explicitly stated that gamification was utilized as a design
strategy, 2) gamification was implemented in the health domain, 3) targeted a behavioral or attitudinal
change, 4) involved data from real users, either from a randomized controlled trial, or an experimental or
quasi-experimental study, and 5) were published as peer-reviewed, full research articles. The searches
resulted in a total of 390 references, from which duplicates were removed. The resulting papers were then
screened, based on their abstract and publication information. This resulted in 60 potential studies, of
which 32 were excluded for not being primarily concerned with the topic of health intervention. Finally,
28 full articles were obtained, the contents of which were then carefully evaluated according to our
inclusion criteria. The study identification process is presented visually in Figure 1.

Because the term gamification has only recently entered academic discussions, the studies in the search
results were relatively recent, only dating from the years 2011 to 2015. The oldest paper that met all
inclusion criteria was from 2012. The most common reason for excluding studies was that they did not
include any data from users: many of the papers only presented conceptual or technical designs of the
systems. Studies that only had user data from superficial user evaluations or surveys, or where the
researchers did not themselves set up the system with the purpose of an intervention or an experiment,
were excluded.
Finally, 15 papers were found to meet our criteria [3145]. Six of the included studies [31, 33, 38, 40, 42,
45] were published as journal articles, while the rest of the nine were published in conference
proceedings. The Zuckerman & Gal-Oz study [45] covered two studies, from which we focused on the
second study, which addressed gamification effects. Due to the novelty of the topic, longitudinal studies
with large sample sizes have yet to arrive. The length of the studies varied from short-form field studies to
interventions lasting for several months. The largest sample sizes were 251, in Jones et al. [38], and 157,
in Allam et al. [31], while the smallest were nine, in Elias et al. [36], and five, in Giannakis et al. [37].
While some of the studies had small sample sizes, their methodology and size of the collected data were
considered sufficient for them to be included. However, considering that the main purpose of this study
was to gain as much knowledge as possible for understanding the context, such shortcomings were
considered bearable. To further the analysis, each selected article was thoroughly examined and coded
using a predefined form.
2.2 Persuasion Context Analysis
Our method of analysis was adopted from the Persuasive Systems Design (PSD) model [8]. This states
that the development of persuasive systems requires three steps: understanding the key issues behind
persuasive systems, analyzing the persuasion context, and designing the system qualities. We adopted a
Persuasion Context construct as our main instrument of analysis. The PSD model [8] reveals that such
analysis can take place through recognizing the intent of persuasion, understanding the persuasion event,
and defining and/or recognizing the strategies in use.
Acknowledging the persuasive intent includes determining who the actual persuader is. Because
computers dont have intentions of their own, the source of persuasion is always those who create,
distribute, or adopt the technology [12]. Analyzing the intent also covers defining the change type,
intended for either an attitude or behavior change, or both, and different means of persuasion should be
used according to which kind of change is pursued. The types of behavioral change for which persuasive
systems can aim can be divided into three categories: C-, B-, and A-Changes [3]. C-Change means
change in the act of complying with the goals provided by the system. This can be achieved by providing
triggers for the users to take action on and comply with given requests, although they might not be
properly motivated necessarily to do so. Achieving a long-term behavior change is more challenging,
although a successful C-Change may eventually lead to a B-Change, which ensues and provides a more
enduring behavioral change. However, for a sustainable B-Change to occur, an A-Change is needed,
meaning the influence altogether on the users attitudes. For example, to successfully overcome
addictions, the users need support for both the A-and B-Changes. From each type of behavioral change
there are three potentially successful outcomes: formation (F-Outcome), altering (A-Outcome), and

reinforcement (R-outcome). F-Outcome equals the formulation of a novel behavioral pattern for a
situation. A-Outcome means a change in an individuals response to an issue. R-outcome stands for the
reinforcement of existing attitudes or behaviors. From the intended outcomes and the change categories, a
design matrix can be built to help decide if the BCSS in question should aim for the goal of forming,
altering, or reinforcing an act of complying, a behavior, or an attitude.
As for understanding the persuasion event, the contexts of use, the user, and the technology should be
recognized [8]. The Use Context covers the characteristics of the problem domain in question, the User
Context includes the differences between the individuals, and the Technology Context contains the
technical specifications of a system.
Finally, identifying the persuasion strategies includes analyzing the persuasive message that the persuader
is attempting to convey and the route, whether direct or indirect (or central/peripheral) that is used to
reach the persuaded [8]. Direct routes influence through argumentative claims, while indirect routes are
used to influence through persuasive clues [8, 20].

3 Results
3.1 The Intent
3.1.1 Persuader
The included articles all explicitly stated the purpose of the study, hence making the research team as the
principal persuader apparent. The studies that were conducted from a more medical background [31, 33,
40] used health-care providers and physicists for recruitment, which also made the staff stakeholders and
persuaders in the intervention. Similarly, studies that were conducted in elementary school settings [38,
43] also positioned the school authorities as persuaders.
Many of the studies used commercial products as a part of the study. Chen et al. [35] and Reynolds et al.
[39] took advantage of commercial console game products, which may have included branding and other
implicit messages from the original manufacturers. Similarly, Spillers & Asimakopoulos [41] used
commercial fitness apps in their study; some of these may also have adhered to the original developers
undisclosed intentions.
3.1.2 Change Type
Only one of the included studies targeted C-Change: Whittinghill & Brown [44] studied how complying
to therapeutic postures in home settings could be made more motivational through an exertion-based
action game. While the ultimate goal would most likely be more enduring changes in adhering to the
therapy program, in this study only the compliance aspect to what was happening in the game was
reckoned.
A clear majority of the studies [3337, 4143, 45] focused on the combination of R-Outcome and BChange. In most of these studies, the intended purpose of the intervention or experiment was to increase

the behaviors that lead to a healthy lifestyle. The exceptions were Cafazzo et al. [33] and Elias et al. [36],
where the purpose was to reinforce the behaviors necessary to manage a medical condition. No studies
were specifically designed to form new habits or alter existing ones.
Five studies targeted some sort of an A-Change. Reynolds et al. [39] studied what kind of attitudes the
beginner and non-beginner fitness practitioners would form towards a gamified persuasive system.
Brauner et al. [32] studied which factors affected the attitudes that different groups would form toward
exergames, i.e. games that are also a form of exercise. In Allam et al. [31] and Riva et al. [40], the
intention was to empower and reinforce an awareness to a clinical condition, where as in Jones et al. [38],
the study facilitated improvement of attitudes towards healthy eating behaviors. See Table 1 for a
summary.
3.2 The Event
3.2.1 Use Context
Generally, the included studies all focused on the problem domains of either accomplishing healthy
lifestyles or managing self-care compliance (see Table 2). The Use Context was sufficiently described in
all of the studies. A majority of the studies took place in the fitness domain, and sought to increase
physical activity in different Use Contexts: the daily lives of the elderly [32], exergame playing [35, 39],
casual exercise [34, 37, 41, 45], exercise during a school day [43] or a distinct intervention period [42].
One study took place in the context of school lunches in order to increase the vegetable consumption of
participants [38].
The rest of the studies dealt with the situations of managing different medical conditions. In these cases,
the context was mainly outside clinical care; the technological intervention was designed to assist selfmanagement and compliance. The conditions targeted included rheumatoid arthritis [31], asthma [36],
chronic back pain [40], and diabetes type 1 [33].
3.2.2 User Context
User Context was clearly stated in all of the studies (see Table 2); however, due to convenience sampling
being used in many cases, the users involved in the experiments did not necessarily correspond totally to
the intended target audience. Undergraduates were used as participants in multiple studies [34, 35, 43,
44]. In medical self-care interventions, participants were recruited through their healthcare providers [31,
40]. Other forms of recruitment included posting advertisements in newspapers. Overall, the potential
individual user characteristics were not extensively covered in the studies. Different user groups may
respond to gamified interventions in different ways according to variables such as age, lifestyles, and
prior experiences [30]. This was considered only in some of the studies: Reynolds et al. [39] studied the
differences of beginner and non-beginner fitness practitioners positions towards exergaming, while in
Brauner et al. [32], the participants were distributed according to three different age groups; attention was
paid as well to prior gaming experiences and gamer type. Some of the other studies also used the
participants prior experiences with technology use or regular exercising as recruitment criteria.

3.2.3 Technology Context

The Technology Context in the studies varied greatly (see Table 2). Most studies utilized either Webbased solutions, mobile apps with sensors, or exertion-based gaming technologies to deliver the
intervention. In Jones et al. [38], only an ambient display was used as a medium, so there was no
immediate interaction between the system and its users. The most common technologies used were
mobile apps in either iPhone or Android environments [33, 34, 36, 37, 41, and 45]. Spillers &
Asimakopoulos [41] used commercial fitness-tracking mobile apps, while the rest of these studies used
custom-built software. The studies generally described the technical details of the systems rather vaguely.
Chen et al. [35] used a game for the Xbox gaming console system, and Reynolds et al. [39] studied
gaming with the Nintendo Wii, while Brauner et al. [32], Watson et al. [43], and Whittinghill & Brown
[44] made use of custom-made PC software. The exertion-based controllers that were used included a
Kinect [32, 35, 43, 44], a Wii Fit [43, 39], and a stationary bicycle [43].
Web-based intervention platforms were also a common strategy. Allam et al. [31], Riva et al. [40], and
Thorsteinsen et al. [42] used static websites or portals, and Allam et al. [31] additionally used a social
networking site. Allam et al. [31] and Thorsteinsen et al. [42] also used text messages for reminder
purposes.
3.3 The Strategy
3.3.1 Route
All of the studies tended to use indirect routes for persuasion: game-based interactions are mainly based
on evoking feelings, such as fun and curiosity, rather than providing solid, rational arguments. In some
cases the informational content for the direct-route persuasion was provided elsewhere, upon which the
indirect gamification persuasion added. Only five studies stated explicitly that they used underlying
psychological concepts or theories. These included the self-determination theory [45], the theory of
planned behavior [35], extrinsic and intrinsic motivation [36], the Antecedent-Behavior-Consequence
model [44], and the VARK (visual, aural, read/write, kinesthetic) model of learning [43].
3.3.2 Message
It was possible to interpret the intended message from all of the studies. The messages included
facilitations to increase physical exercise [34, 37, 40, 41, 42, 45], to comply with self-management
behaviors [31, 33, 36, 40, 44], to eat more healthy foods [38], and to comply with exergame playing [32,
39]. Six of the studies gamified the intended activity into a full game for delivering their messages, [32,
35, 36, 39, 43, 44] while six presented them in the form of gamified mobile app features [33, 34, 36, 37,
41, 45]. The short message service (SMS) was used as a message channel in two studies [31, 42], while
three studies used websites [31, 40, 42] for presentation. See Table 3 for a summary of identified routes
and messages.

3.4. The Relationship between the Persuasion Context and the Outcomes of the Studies
We also reviewed the outcomes of the inspected studies (see Table 2 for summary). Using gamification,
especially in the self-care Use Context, seems to have provided positive results, as seen in studies by
Cafazzo et al. [33] and Allam et al. [31]. However, due to the methodological plurality and the
heterogeneity of sample sizes and data, it would be implausible to draw strong conclusions about which
persuasion contexts provided the most positive effects. While a clear majority of the studies used mainly
quantitative methods to assess their data, qualitative methods [36, 39, 41] and a mixed-method approach
[35] were also used. Hence, it was not deemed viable to conduct systematic meta-analysis of the effects at
this time. However, it can be stated that gamification of hBCSSs seems to provide mostly neutral or
positive effects on the inspected outcomes and the perceived user experiences. This supports the
discussion on gamification in general, having provided mostly positive results in different application
areas [5].
The outcomes of the studies also state that gamification is clearly not a silver bullet for health behavior
change. In Chen et al. [35], the version of the exergame that did not feature any explicit game elements
but rather framed the activity as an exercise performed better than the game-like version. This was the
only study where gamification could be interpreted arguably as providing negative results. However, the
exercise version still used a game technology as its platform, which itself could be accounted as
gamification. In some cases the gamification features simply did not have an effect on the activities as
compared to non-gamified versions. The technologies used did not appear to make a difference in the
potential effects. The studies that gave particular attention to the User Context provided some interesting
results. The results in Reynolds et al. [39] showed that beginner and non-beginner users experienced the
gamification elements very differently. Brauner et al. [32] revealed that the age of the player influenced
the perceived fun from the game, as did the task performance and whether the game was liked or not.

4 Discussion and Conclusions

This study has provided a systematic analysis of the persuasion contexts in health gamification systems,
which to a great extent has remained unexplored in prior literature. Understanding the situations
thoroughly is essential for successful gamification, and we emphasize that a comprehensive contextual
analysis may benefit both the practitioners implementing gamification strategies and researchers planning
their studies.
Considering the persuasion intent, it is important for the designers of the gamification interventions to
acknowledge all persuasive parties involved: many studies used commercial gaming technologies to
deliver the interventions, which exposes the users to potential commercial messages from the vendors. All
proprietary software platforms, such as mobile phone and game console operating systems, can
potentially expose their participants to possible third-party influencers. These intents should be
thoroughly analyzed when planning the interventions that use such technologies. Stakeholders such as
healthcare staff may also be in a position of authority, which may influence the outcome of the
intervention. Researchers should note that in most cases the persuasive system alone is neither responsible

nor solely to be thanked for the potential behavior change; rather, these contextual matters all have their
own role in the persuasion event.
The main change-type identified was reinforcing behaviors through positive feedback, which seems to be
the most common type of gamification strategy. However, for a sustainable behavioral change, an attitude
change is ultimately needed [3], so it is arguable that the designers of gamification interventions should
target the attitudes of the users more often. However, pushing attitudinal messages that are too strong may
be experienced negatively by users. It is also presumable that people adopt gamified services more easily
when they already have a proper mindset for the change, and rather use these systems for additional
motivation to reinforce the desired habits. It would also be worth inspecting how gamification would
function in altering ones behavior, such as smoking cessation. As of yet, this aspect seem to remain
largely unexplored. Similarly, compliance to medical treatments could benefit from gamification in
situations requiring less critical behavior change, such as short-term medication periods. More systematic
research is needed to figure out what gamification strategies adapt best to different change types.
Health gamification takes place within a multitude of Use Contexts. The studies that concerned a lifestyle
change most commonly targeted increasing physical activity and fitness, which seems to be one of the
main uses of current health gamification. Gamification may function as an additional motivation for
giving beginners a kick-start to exercise, but for those that already are engaged in a physically active
lifestyle, gamification may just be a redundant and irritating addition. Another prominent area is selfmanagement of diseases and management of medication. In this case, it is important to adopt the
gamification to the actual self-medication behaviors, such as using a spirometer, rather than to generic
solutions, like point systems. While the use of gamification strategies in these contexts is likely to
increase, it should be regarded that when these strategies are adopted into healthcare situations, there
should be a possibility to opt out. Research should also look out for more potential application areas of
gamification in the health domain, both in preventive care and medical treatments.
The gamification approach may not be suitable for everyone, and furthermore, peoples individual
characteristics affect the outcomes of different gamification types [30]. Most of the studies did not pay
attention to the differences between the possible user groups, and instead implemented the same features
for all. Future health gamification should pay more attention to the User Context and provide tailored
services for different needs. For example, some people might dislike the idea of competition, while others
see it as motivating. For future research, it is essential to pay attention to the participant demographics:
age, gender, experiences with technology and games, attitudes, and lifestyles all may potentially have an
impact on the outcomes.
The Technology Context also needs to be carefully considered: the smartphones and gaming consoles that
often are used as vehicles for health gamification might not be available to all potential users, and
peoples different personal backgrounds regarding these technologies may greatly impact how they
perceive them. While the elderly can probably adopt modern technologies such as mobile applications for
health [46], many gaming concepts may appear unfamiliar to them. The decisions as to which
technologies to use should be made so that the technologies are accessible to people from a multitude of
backgrounds, not just a limited group of enthusiasts or groups of a certain age. Cross-medial design,
where the functionality of the system has been distributed to multiple modes of delivery, has been deemed

a potential way to address different needs [47]. In the future, implementing gamification features as their
own functional segments of a larger health intervention could prove beneficial. For example, a medicinal
self-care program could include a gamified mobile application for its younger users, to make the
interaction with the system more fun and captivating. It would also be useful to reflect on the allotment of
indirect and direct persuasion: Would gamification be usable only with indirect persuasion, or could it be
used to directly provide information and arguments in an engaging manner? The powerful simulation
qualities of game technologies could be a potential way to provide direct arguments for the purpose of
health behavior change. The studies, especially those that use tailored software artifacts developed for
research purposes, should describe the technical details of the hardware and software comprehensively for
study reproducibility, and for the audience to be able to get a clear understanding of the used solutions.
The detailed analysis of the individual persuasive features and/or gamification strategies falls outside the
scope of this paper. Many gamification strategies depicted in the studies correspond to general persuasive
features [8]. For example, persuasive social support features, such as social comparison, social
facilitation, or recognition, are often present in gamified health BCSSs, as well as rewards and other
forms of dialogue support. However, game-based systems entail highly complex interactions between a
system and its users [7, 48], and regarding them as simply individual software or interface features might
not reveal the whole truth. Furthermore, inspecting the studies that utilize full-fledged game worlds would
require more intricate analytical tools to understand their procedural argumentation [49] or system-level
interactions of mechanics, dynamics, and aesthetics [50]. Currently, there is a lack of heuristics or
frameworks to analyze specifically game-induced behavior change support systems, although there have
been recent developments on the matter [51].
In the general discussion, gamification is often dismissed as adding systemic game elements, such as
points or badges, to the user interfaces of existing systems. However, gamification strategies may also be
carried out through novel or existing full-fledged games or virtual worlds. Furthermore, studies indicate
that solely framing an activity as a game may be as effective as implementing actual game mechanics
[52]. Future studies on the topic should inspect further the impacts of game elements and the game frame,
as well as the differences between using full games and game-inspired interaction design elements.
Many of the inspected studies implemented multiple gamification strategies at once, without examining
their individual effects. Most of the studies we inspected also lacked sufficient theoretical background to
explain the possible outcomes, which is a sharp contrast to the remarks made in [4], [5], and [8]. Carrying
out research on the health behavior change field should always be based on the theoretical groundwork,
not just the recent trends of the software industry. Hence, it is critically important to employ the theories
to fully understand the studied phenomenon. Special attention should also be paid to how to measure the
study outcomes. In our inspected studies, the metrics for behavior change varied from intricate statistical
analyses to brief post hoc interviews. Future studies should be conducted with instruments upon which
there is common agreement, to give a more precise picture of the outcomes, and to enable meta-analyses.
The overall quality of the studies in regards to sample size and rigorous research design should be
emphasized. These notions adhere to the recent critical discussion on gamification research. (e.g., [45])
The primary contribution of this paper has been to introduce an application of the Persuasion Context
construct into the area of gamified hBCSSs. The hope is that this will advance the development of
theoretical endeavors for analyzing and developing gamified health interventions in the future. Building

on the discussion in prior literature [3-7] and our discoveries, we summarize that understanding the
persuasion context can help guide future research on gamified hBCSSs, as the designers of the
intervention sequentially acquire the capability to:
1) identify the potential outside persuaders,
2) decide and/or recognize what change is targeted and which gamification strategy use is based on
it,
3) understand the application area, and find the right actions on which to apply gamification,
4) mind the potential effects of the user demographics,
5) decide what technologies to use, based on the other contextual factors,
6) use either or both direct and indirect persuasion routes when appropriate,
7) use theories of health-behavior change for guidance,
8) choose the gamification strategies based upon the aforementioned matters, and
9) analyze and present the results rigorously, with appropriate instruments.
Following these steps will result hopefully in a more comprehensive view on the internal aspects and
outcomes of hBCSSs in the future. The next steps in advancing these notions, theory-wise, would be to
compare the different combinations of contextual factors, related theories, chosen gamification strategies,
and study outcomes systematically, to help understand how to use gamification most efficiently on the
different aspects of healthcare. With this knowledge, people planning the health interventions could
choose the tried and tested approaches for each particular situation, rather than develop solutions in an
ad-hoc manner.
The limitations of this study were that, as we had to rely only on textual descriptions of the systems and
their use situations, there might have been context-specific matters that were not covered
comprehensively in the papers.
The notion of which gamification strategies to use with which context would be an important research
question in the future, towards which the contextual analysis present in this paper may contribute. We
hope that this systematic literature review will function as a reminder to pay more attention to analyzing
the persuasion context in health gamification research, and to provide an example for carrying out such an
analysis. The notions derived from the included studies may help identify the potential pitfalls and
shortcomings for future research on, and implementations of, gamified hBCSSs.

CONFLICT OF INTEREST
No conflicts of interesting appeared when preparing this paper.

AUTHOR CONTRIBUTION
Tuomas Alahivl did literature searchess and performed coding of the data and its analysis.
Harri Oinas-Kukkonen provided comments on the manuscript and facilitated choosing the topic and
methods used.

Summary Table
What was already known

Gamification is increasingly used as a

design strategy for user engagement when
developing health behavior change support
systems.

Understanding contextual factors is critical

for successful gamification, but this has
been overlooked so far in the research on
gamified health interventions.

What this study added to our knowledge

Gamified Health BCSSs are implemented

under different facets of lifestyle change
and treatment compliance, and use a
multitude of technologies and methods.
There isnt yet a clear, generally accepted
vision of the relationships among the
contextual factors, gamification strategies,
and study outcomes.

We show that, in order to advance the

knowledge on gamified hBCSSs, the
designers of the interventions should,
sequentially, 1) identify the potential
outside persuaders, 2) decide what change
is targeted and which gamification strategy
use should be based on it, 3) understand
the application area, and find the right
actions on which to apply gamification, 4)
mind the potential effects of the user
demographics, 5) decide what technologies
to use, based on the other contextual
factors, 6) use either or both direct and
indirect persuasion routes when
appropriate, 7) use theories of health
behavior change for guidance, 8) choose
the gamification strategies based upon the
aforementioned matters, and 9) analyze
and present the results rigorously, with
appropriate instruments.

Future research on gamified hBCSS

should compare the different combinations
of contextual factors, related theories,
chosen gamification strategies, and study
outcomes systematically, to help
understand how to use gamification most
efficiently on the different aspects of
healthcare.

Acknowledgements
This research is part of OASIS research group of Martti Ahtisaari Institute, University of Oulu.

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Figure 1.

Table 1. Studies Sorted by Outcome/Change

C-Change

B-Change

F-Outcome

N/A

N/A

A-Outcome

N/A

N/A

R-Outcome

Whittinghill & Brown

[44]

Cafazzo et al. [33]

Chen & Pu [34]
Chen et al. [35]
Elias et al. [36],
Giannakis et al. [37]
Spillers &
Asimakopoulos [41]
Thorsteinsen et al. [42]
Watson et al. [43]
Zuckerman & Gal-Oz
[45]

A-Change
Reynolds et al. [39]
Brauner et al. [32]
N/A

Allam et al. [31]

Jones et al. [38]
Riva et al. [40]

Table 2. Persuasion Contexts and Outcomes of the Studies

Study

Allam et al.
(2015) [31]

Brauner et al.
(2013) [32]

Cafazzo et al.
(2012) [33]

Chen & Pu
(2014) [34]

Chen et al.
(2014) [35]

Use
Context

User Context
(and sample size)

Technology
Context

Rheumatoid
arthritis selfcare

Rheumatoid arthritis
patients recruited
through healthcare
providers (N=157)

Website or
portal, Social
Networking
site, SMS

Gamification alone or with

social support increased
physical activity and
empowerment and decreased
healthcare utilization.

Exertion-based
controller, PC
software

Majority of the users reported

increased motivation toward
exercise. All age groups
showed an increase in
performance. A positive effect
on perceived pain was found.

Mobile
application,
Sensor device

The daily average frequency of

blood glucose measurement
increased 50%. Use satisfaction
was high, with 88% stating that
they would continue to use the
system.

Mobile
application,
Sensor device

Users significantly enhanced

physical activities compared
with exercising alone by up to
15%. Cooperation (21%
increase) and hybrid (18%
increase) outperformed
competition (8% increase)
modes.

Exertion-based
controller,
Gaming
console

Providing health feedback

resulted in more positive affect
compared to the game-only
feedback. Those primed to
exercise condition also
performed longer than those in
the game condition.

Increasing
physical
activity

Diabetes type
1 self-care

Increasing
physical
activity

Increasing
physical
activity

Volunteers aged 20
86 distributed to 3
age groups (N=71)

1216 year old

Diabetes patients
(N=20)

Students and
professionals with
varying experience
of mobile fitness
tracker use (N=36)

University students
and staff (N=44)

Outcomes

Elias et al.
(2013) [36]

Asthma selfcare

Children aged 714

with asthma (N=9)

Mobile
application,
Sensor device

All children surveyed said they

would play similar games if
they involved breathing into a
spirometer. Two-thirds would
prefer the game over the
spirometer alone and one third
would prefer having both. No
children preferred the
spirometer over the game.

Giannakis et al.
(2013) [37]

Increasing
physical
activity

Irregularly
exercising young
adults (N=5)

Mobile
application,
Sensor device

Gamification through
performance feedback had an
impact on the average speed of

the runners.

Jones et al.
(2014) [38]

Enhancing
eating habits

Ambient
display

Fruit and vegetable

consumption increased during
the intervention by 39% and
33%. According to survey data,
the students enjoyed the game
and teachers recommended its
use in other schools.

Exertion-based
controller,
Gaming
console

All participants were initially

attracted to the game-like
elements. Beginning users
found the gamification
motivating, but non-beginners
perceived game and fitness
elements to be conflicting.

Website or
portal

The availability of gamified

interactive sections
significantly increased patient
empowerment and reduced
medication misuse.

Mobile
application

Gamification and social-user

experience features in general
did not have significant effect
on the fitness usage activities.

Website or
portal, SMS

The intervention group

reported more minutes of
physical activity at higher
intensity levels, but there was
no significant effect found at
the end of the study period.

Exertion-based
controller, PC
software

Gamification increased positive

affect, autonomy, and
immersion. Adding either
exercise or game to a
classroom activity resulted in
improvements, but there was
no compounding improvement
of adding both.

Non-random
undergraduates,
aged 634 (N=21)

Exertion-based
controller, PC
software

The players found the game

enjoyable on all three observed
dimensions of graphics, input,
and overall enjoyment. This is
seen to confirm the games
therapeutic benefit through
positive reinforcement.

Owners of Android
mobiles aged 2354

Mobile
application

The quantified version of the

application facilitated reflection

Elementary school
students (N=251)

Increasing
physical
activity

Beginners and nonbeginners regarding

regular exercise
(N=15)

Riva et al.
(2014) [40]

Chronic back
pain self-care

Chronic back pain

sufferers recruited
through their
healthcare providers
(N=51)

Spillers &
Asimakopoulos
(2014) [41]

Increasing
physical
activity

Reynolds et al.
(2013) [39]

Thorsteinsen et
al. (2014) [42]

Watson et al.
(2013) [43]

Whittinghill &
Brown (2014)
[44]
Zuckerman &
Gal-Oz (2014)

Increasing
physical
activity

Increasing
physical
activity

Treatment of
Pediatric
Cerebral Palsy
Increasing
physical

Experienced iPhone
app users (N=15)

Healthy adults
(N=21)

Elementary school
students (N=68)

[45]

activity

(N=40)

on activity and significantly

increased walking time over
baseline level. The gamified
versions offering virtual
rewards and social comparison
were similarly, but not more,
effective.

Table 3. Persuasive Routes and Messages in the Studies

Study
Route
Message
Adopt health information and
A website with informational,
feel empowered, complying to
social, and gamified features,
good medication and health
Allam et al. (2015) [31]
SMS.
behaviors.
Brauner et al. (2013) [32]
Exertion-based mini-games.
Adopt use of exergames.
Mobile app with self-monitoring, Increase self-monitoring of
Cafazzo et al. (2012) [33]
social, and rewarding features.
glucose levels.
Chen & Pu (2014) [34]
Mobile app with social features.
Increase daily physical activity.
An exergame with/without
Play the exergame longer and
Chen et al. (2014) [35]
gaming feedback.
more actively.
Elias et al. (2013) [36]
Spirometer-controlled game.
Increase spirometer use.
A mobile app with feedback on
Giannakis et al. (2013) [37]
performance.
Increase casual exercising.
A collaborative game on a public
Jones et al. (2014) [38]
display.
Increase vegetable consumption.
Reynolds et al. (2013) [39]
An exertion-based console game. Adopt use of exergames.
A website with either static only
or static and interactive content:
Empowerment, use medication
virtual gym, action plan, quiz
properly, and increase physical
Riva et al. (2014) [40]
game, testimonials.
exercise.
Spillers & Asimakopoulos
Mobile fitness apps with social
Increase and/or maintain fitness
(2014) [41]
and gamification features.
behaviors.
Activity planner website and
Thorsteinsen et al. (2014) [42]
SMS reminders/feedback.
Increase physical activities.
A game world with different
mini-games for learning and
Increase physical activity during
Watson et al. (2013) [43]
exercise.
the school day.
Whittinghill & Brown (2014)
[44]
Exertion-controlled game world. Perform therapeutical poses.
Zuckerman & Gal-Oz (2014)
Different versions of a self[45]
tracking mobile app.
Promote routine walking.