Enhancing the Collaborative Experience of a Collaborative Game to Achieve Lifestyle Change | Lifestyle Behaviors | JAMA Network Open | JAMA Network
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Invited Commentary
Diabetes and Endocrinology
May 24, 2021

Enhancing the Collaborative Experience of a Collaborative Game to Achieve Lifestyle Change

Author Affiliations
  • 1VA Puget Sound Healthcare System, Department of Health Services, University of Washington School of Public Health, Seattle
  • 2Seattle-Denver Center of Innovation, US Dept of Veterans Affairs, Washington, DC
JAMA Netw Open. 2021;4(5):e2110308. doi:10.1001/jamanetworkopen.2021.10308

A prominent framework in game design is the mechanics-dynamics-aesthetics (MDA) framework.1 Mechanics are the rules of the game. In baseball, the mechanics say that a baserunner advances to second base if the runner can get there before being tagged. The dynamics are how players interact with the mechanics and each other. For example, a baserunner realizes they can shorten the distance to second by taking a lead off first base and thereby increase the likelihood of making it to second before the tag. The pitcher realizes they don’t want that to happen. The aesthetics of the game are the emotional experiences created by these dynamics. The aesthetics are the drama created by the pitcher trying to keep the runner close to first and the baserunner trying to get further away. Game designers suggest that games should be designed with the aesthetic experience as the goal and work backward to the mechanics.2 If you want drama in baseball, then use game mechanics that allow a runner to take a lead.

The results of the iDiabetes trial by Patel et al3 represent the latest in a series of pathbreaking studies of the effects of incorporating game mechanics into interventions to help people improve health behaviors. Researchers at the Penn Medicine Nudge Unit4 have devised elegant and exceptional simple game mechanics that are rooted in behavioral economic principles and are effective. In the iDiabetes trial, participants randomized to the supportive and competitive gamification study arms experienced sustained effects on physical activity compared with participants in the control group during a 1-year intervention period. No sustained increase in physical activity compared with the control group was found for patients randomized to the collaborative arm. This study adds substantially to the Nudge Unit body of work by showing that gamified interventions can help people maintain higher levels of physical activity for a longer period of time in a population more economically and demographically diverse than has been shown in previous studies.

The lack of effectiveness of the collaborative arm in iDiabetes suggests that a closer examination is warranted, in part because of the positive effect of similar game mechanics in the BE FIT trial,5 which was also conducted by the Penn Medicine Nudge Unit. In BE FIT, patients in the collaborative arm increased physical activity more than usual care and sustained it 12 weeks after the cessation of the intervention. The collaborative arms in BE FIT and iDiabetes are similar but not identical. In both trials, participants randomized to the collaborative arm formed teams of either 2 or 3 members. Each day of the intervention, a random team member was chosen. If that person did not meet a goal on the previous day the entire team lost points. Several aspects of the mechanics of these games merit discussion.

First, does the collaborative arm in either BE FIT or iDiabetes truly offer a collaborative game experience for study participants? On its face, the MDA description of the game mechanics does not conform to a common use of the term collaboration. These mechanics bear little resemblance to health care clinicians collaborating on the care of a patient, or researchers collaborating on a manuscript. Even in the realm of games such as the popular board game Pandemic, the collaboration among players mimics the actual collaboration between government, research, and industry to defeat a pandemic. The collaborative arm in iDiabetes and BE FIT involves a collective loss because of an individual failure. This feature is standard in collaborative endeavors but hardly the only or most compelling one.

Moreover, the game mechanics that distinguish the collaborative arm in iDiabetes and BE FIT likely prevents the dynamic that would stimulate a more collaborative game experience for study participants. In both BE FIT and iDiabetes, a team was assessed a penalty if a chosen teammate had not met a specified goal on the prior day. Coming to the aid of a teammate is a dynamic of collaborative games that creates the aesthetic experience of fellowship, but you can’t come to the aid of a teammate yesterday if you discover their need today.

Second, the collaborative arm in BE FIT and iDiabetes differed in both substantial and subtle ways that may have lowered its effectiveness in iDiabetes. A notable difference between BE FIT and iDiabetes was that BE FIT team members were generally family members and iDiabetes team members were randomly assigned. Patel et al3 suggest that this factor was a primary reason for the success of the collaborative arm in BE FIT but not iDiabetes. This suggestion is reasonable, especially given the findings of the LOSE IT6 study, which found better outcomes among collaborative teams that were residents of the same household than those who were not. However, more subtle differences might have played a role as well. BE FIT generally enrolled teams of 2 whereas iDiabetes used teams of 3, which decreases the likelihood of being randomly chosen on a given day in iDiabetes. Thus, the expected utility loss of disappointing your teammates tomorrow by failing to meet a target behavior today was likely higher in BE FIT than iDiabetes. In iDiabetes, teams were penalized if a teammate did not weigh themselves the prior day, whereas in BE FIT the penalty was for missing their physical activity target—that is, BE FIT targeted the primary outcome while iDiabetes targeted a tangential process. The collaborative arm in iDiabetes had the highest rate of daily weighing of any arm, which suggests the game mechanism was working as designed but perhaps not as intended, given that participants in this arm performed no better than usual care on primary outcomes. In BE FIT, each teammate was given 5 lifelines to opt out of being chosen and thereby assuring that they did not cause their team to lose points that day. This mechanism was dropped in subsequent trial because it was infrequently used; however, knowing that your teammate has your back is an aesthetic of a collaborative game even if your teammate never needs to demonstrate it. In addition, BE FIT had a brilliant reward for teams that hit their goal at the end of the intervention period: a coffee cup. For family members who have breakfast together this could be a daily reminder of their success and could have helped sustain the effects of the intervention in the post intervention period.

In the iDiabetes trial, the competitive arm could be described as generating a challenging experience, and the supportive arm as a generating a supported experience, but it’s not easy to see how the mechanics of the collaborative arm generated the experience of fellowship that we typically associate with engaging team-based collaborative games. The primary experience seems to be avoiding regret from failing to perform a task that is only tangentially related to the outcome of interest. If you want a fellowship aesthetic in a gamified intervention, then use game mechanics that encourage fellowship. Mechanics that promote fellowship may not need to be elaborate or rely on personal acquaintances between team members. Changing the penalty from retroactive to prospective and reintroducing the lifelines might help. Future research may explore whether simple changes to game mechanics could engender a more collaborative aesthetics, which in turn might make the collaborative arm more engaging and effective.

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Article Information

Published: May 24, 2021. doi:10.1001/jamanetworkopen.2021.10308

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hebert PL. JAMA Network Open.

Corresponding Author: Paul L. Hebert, PhD, VA Puget Sound Healthcare System, Health Services Research and Development, 1660 S Columbian Way, Bldg 101, Rm 4W65, Seattle, WA 98112 (paul.hebert2@va.gov).

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Hunicke  R, LeBlanc  M, Zubek  R. MDA: A formal approach to game design and game research. Published 2004. Accessed April 29, 2021. https://users.cs.northwestern.edu/~hunicke/MDA.pdf
Fullerton  T.  Game Design Workshop: A Playcentric Approach to Creating Innovative Games. 3rd ed. AK Peters/CRC Press; 2014. doi:10.1201/b16671
Patel  MS, Small  DS, Harrison  JD,  et al.  Effect of behaviorally designed gamification with social incentives on lifestyle modification among adults with uncontrolled diabetes: a randomized clinical trial.   JAMA Netw Open. 2021;4(5):e2110255. doi:10.1001/jamanetworkopen.2021.10255Google Scholar
Penn Medicine Center for Health Care Innovation. The Nudge Unit. Accessed April 29, 2021. https://nudgeunit.upenn.edu/
Patel  MS, Benjamin  EJ, Volpp  KG,  et al.  Effect of a game-based intervention designed to enhance social incentives to increase physical activity among families: The BE FIT randomized clinical trial.   JAMA Intern Med. 2017;177(11):1586-1593. doi:10.1001/jamainternmed.2017.3458 PubMedGoogle ScholarCrossref
Kurtzman  GW, Day  SC, Small  DS,  et al.  Social incentives and gamification to promote weight loss: the LOSE IT randomized, controlled trial.   J Gen Intern Med. 2018;33(10):1669-1675. doi:10.1007/s11606-018-4552-1 PubMedGoogle ScholarCrossref
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