Vector gamification concept - digital device with touchscreen and game interface on it with award and achievement icons on background

"You have to really take game design as seriously as the health care content." (Getty Images)

Sitting all day is not a great way to stay heathy, as Debi Bisnette had long known. But in spite of all the articles she'd read about the health benefits of taking a walk at lunchtime, somehow the accounts payable clerk from Orlando, Florida, always ended up sitting in the break room with her colleagues.

Then, in January, Bisnette signed up for a special clip-on gadget – a "Trio Tracker" she wears on her waistband – customized for her by UnitedHealthcare, her company's insurer. It buzzes if she sits for more than an hour, and little trophies pop up on its face for each of three goals she seeks to meet daily: six sessions of 300 steps within five minutes, separated by an hour; 3,000 steps in 30 minutes; and 10,000 steps total for the day. Now Bisnette does get moving at lunchtime.

"It's fun to see the trophies appear," says Bisnette, 59, who has lost 12 pounds. It also doesn't hurt that meeting the challenges earns her up to $4 per day in health care reimbursement, which can add up to $1,460 per year toward her deductible.

Bisnette is among the millions of Americans experiencing the gamifying of health care, the application of game principles like competition or cooperation that play to such motivations as desire for mastery, all in the service of inspiring people to make better decisions. It's a trend that's only taken off recently, with the widespread use of smartphones, wearable devices and wireless technology.

Game theory has been applied to everything from getting the best price on a car to political machinations to suggestions by some German academics for how to break through the impasses on climate talks. "Games activate certain very deep and core aspects of our psychology, which is why every civilization has had them," says Kevin Werbach, an associate professor of legal studies and business ethics at the University of Pennsylvania's Wharton School and a leader in the emerging field of gamification. Werbach's class on the topic, which teaches the mechanisms and how to use them effectively, is one of Coursera's most popular massive open online courses, or MOOCs.

[See: 15 Best Weight-Loss Diets at a Glance.]

In health, designers are creating apps that nudge people along in all sorts of ways. They use the intrinsic sense of accomplishment and the extrinsic unlocking of achievements (and gifts) to encourage pregnant women on Medicaid to keep their doctors' appointments, for example. Or to get young cystic fibrosis patients to do their breathing exercises by puffing into a tube controller to speed an on-screen pirate ship. Insurance companies, of course, have embraced games because they can promote better lifestyle habits, such as walking or eating more vegetables. Minnesota-based UnitedHealthcare, for example, even has a full-time games producer.

You don't have to be a video game fan to see the appeal; anyone who's ever played tag or hide-and-seek can get the idea. Arrianne Hoyland, that UnitedHealthcare games producer, notes that "If I asked my dad, 'Are you a gamer?' he'd say no way. But he plays solitaire. Solitaire is, like, his sport."

One quick and easy way to turn an activity into a game is to award points, badges or financial incentives. But the best attempts to gamify go beyond that, says Frank Lee, associate professor of digital media and director of Drexel University's Entrepreneurial Game Studio. He recently organized an international workshop called "Serious Games for Health."

"Nice graphics or a little achievement system misses the entire point," Lee says. "You have to really take game design as seriously as the health care content." The most absorbing games, for example, provide immediate feedback. People want to know if they're closer or farther from their goal, Lee says. That's abundantly clear in, for example, the ultrapopular game Angry Birds, which involves birds attacking egg-stealing pigs with slingshots. (You can immediately tell if you've hit one.) A 2012 Gartner report on the fledgling phenomenon predicted that 80 percent of gamified apps would quickly disappoint because of poor design.

Financial incentives or disincentives don't always work as well as you might think. In a famous 2000 study of day care operations, researchers found that fining parents for late pickups nearly doubled the number of offenses, because parents started to see the fine as simply a fee for a service as opposed to a penalty for inconveniencing teachers. "Sometimes you internalize that this is a tax," Werbach says. "It's not really that I should quit smoking; it will extend my life. It becomes, 'Is the pleasure of smoking worth $200 to me?'"

On the other hand, a 2015 study in the New England Journal of Medicine found that when it comes to quitting smoking, a financial incentive ($650 for six months without cigarettes) paired with a penalty (a deposit of $150, surrendered for failing to reach that mark) was best. Nearly twice as many people succeeded compared to those offered the $650 carrot alone. Typically financial disincentives are administered by charging the credit card number you've given at sign-up.

[See: How to Break 7 Unhealthy Habits.]

Pact is an app that grew out of a behavioral economics class its co-founders took as undergraduates at Harvard. It debuted in 2012 as GymPact, asking users to commit to a certain number of gym visits per week and using GPS to track their check-ins at sports facilities. Users were charged penalties for not reaching their goals, but also received cash if they did.

The app has since evolved to include goals like eating more vegetables (users upload pictures of what they're eating; technology verifies that the pictures actually have been taken with the user's phone, as opposed to being "borrowed" from somewhere on the Internet). Anyone can use the app, though the company also works with some businesses to allow employees to collect cash rewards and offset health care expenses, like deductibles.

A game available to everyone that takes aim at mental as well as physical health, called SuperBetter, was designed by Jane McGonigal, the director of games research and development at the nonprofit Institute for the Future in Palo Alto, out of personal need. McGonigal had sustained a head injury in 2009 that had left her feeling depressed, hopeless and lethargic – until she decided to turn her recovery into a game. The result, a free app, was released in 2012.

The game encourages people to be their own superheroes, renaming long-term goals (such as quitting smoking, exercising more, lowering stress and combating anxiety) "epic wins." These are broken down into daily "quests" such as, in the case of exercise, walking around the block or dancing to a favorite song. Along the way, players also work on four kinds of resilience (physical, emotional, social and mental) by completing "Power Ups," activities that help them in day-to-day life such as making contact with a friend. Players strive to defeat the "bad guys" standing in their way – procrastination, say, or short car trips that could just as easily be walked. Research at the University of Pennsylvania found that playing SuperBetter for 30 days reduced symptoms of anxiety and depression and increased a player's belief in his or her own ability to succeed and achieve goals.

Like SuperBetter, Rally Health offers help making small daily changes, though the online and mobile platforms call them "missions" instead of quests. Rally, so far available to some 23 million Americans through their health insurers or employer groups, suggests missions based on a survey users fill out. Users can also choose their own from four different categories: eat, move, feel and care.

Missions can range from turning off the computer and TV early (in the "feel" category, relating to stress) to swapping a sugary drink for water. Completing missions earns you virtual coins that can be used in sweepstakes and auctions that are dangling goods like an Apple TV or an Apple watch.

The platform's core customer is a fortysomething female – these women tend to be "the stewards of health care for the family," says Rhett Woods, Rally's chief creative officer. Rally subscribes to the positive affirmation model. There's no loss aversion (as in penalties) here. "We want people always to feel like they're earning or moving forward," Woods says. More than 40 percent of users are actively involved in earning rewards, according to company figures.

[See: 6 Ways to Train Your Brain for Healthy Eating.]

As any good game does, Rally is evolving based on people's experience using it. An early iteration offered multiple types of currency, with different colored coins that could be earned in various categories. "We learned that things need to be as simple as humanly possible," Woods says. "And when we simplified to a single currency, we found engagement went up significantly." That counts as a win.

Tags: games, video games, health, weight loss, exercise and fitness, smoking and tobacco

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