Accepted Manuscript

Developing and implementing a gamification method to improve user engage-

ment: A case study with an m-Health application for hypertension monitoring

Nathália Pinto Cechetti, Ericles Andrei Bellei, Daiana Biduski, João Pedro
Mazuco Rodriguez, Mateus Klein Roman, Ana Carolina Bertoletti De Marchi

PII: S0736-5853(18)31265-6
DOI: https://doi.org/10.1016/j.tele.2019.04.007
Reference: TELE 1226

To appear in: Telematics and Informatics

Please cite this article as: Cechetti, N.P., Bellei, E.A., Biduski, D., Mazuco Rodriguez, J.P., Roman, M.K., De
Marchi, A.C.B., Developing and implementing a gamification method to improve user engagement: A case study
with an m-Health application for hypertension monitoring, Telematics and Informatics (2019), doi: https://doi.org/
10.1016/j.tele.2019.04.007

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 Developing and implementing a gamification method to
improve user engagement: A case study with an m-Health
application for hypertension monitoring

Nathália Pinto Cechetti 1, BSc, MSc

Ericles Andrei Bellei 1 *, BInfTech, MSc

Daiana Biduski 1, BSc, MSc

João Pedro Mazuco Rodriguez 2, BSc,

Mateus Klein Roman 2, BSc,

1,2,3
Ana Carolina Bertoletti De Marchi , BSc, MSc, PhD

1
Graduate Program in Applied Computing, Institute of Exact Sciences and
Geosciences, University of Passo Fundo, Passo Fundo, RS, Brazil.

2
Undergraduate Program in Computer Science, Institute of Exact Sciences and
Geosciences, University of Passo Fundo, Passo Fundo, RS, Brazil.
3
Graduate Program in Human Aging, College of Physical Education and
Physiotherapy, University of Passo Fundo, Passo Fundo, RS, Brazil.

* Corresponding author.
E-mail: [email protected] (Ericles Andrei Bellei)
Postal address: Graduate Program in Applied Computing, Institute of Exact Sciences
and Geosciences, University of Passo Fundo, BR 285, São José, CEP 99052-900,
Passo Fundo, RS, Brazil.
Telephone: +55 54 33168354.

Keywords: Gamification; Engagement; m-Health; Development method; Digital

intervention; Hypertension.

Word count: 4800.

Figures count: 7 (Color figure available online only).

Tables count: 2.
Developing and implementing a gamification method to
improve user engagement: A case study with an
m-Health application for hypertension monitoring

Abstract

The lack of engagement throughout a patient’s treatment is a regular con-

cern among health professionals, who have been adopting technology as a mo-
tivational factor. This study presents a gamification proposition that aims to
promote engagement in the user’s treatment with the use of health-related sys-
tems. Seven stages compose the method: inspection of system requirements and
its functionalities; mapping of the target audience characteristics; identification
of interaction flows; gamification analysis applied in similar systems; selection
of gamification elements; development; and evaluation. To validate the method,
we developed two versions of an m-Health application, one with the game el-
ements and one without these elements. In the evaluation stage, 14 patients
with hypertension were divided into four groups to verify if the inclusion of
game elements would promote greater engagement in health care. Data collec-
tion included engagement questionnaire, technology acceptance questionnaire,
system logs, and participants’ feedback. Results showed gamification favored
the engagement, stimulating intrinsic motivation in the participants. Groups
assisted by health professionals spent more time with the app and were moti-
vated in maintaining control of their health. In conclusion, gamification proved
to be effective for this context, since it did not add complexity to the application
and promoted the desired engagement results.
Keywords: Gamification, Engagement, m-Health, Development method,
Digital intervention, Hypertension

Preprint submitted to Telematics & Informatics, Elsevier TEX template. April 17, 2019
1. Introduction

One of the significant challenges in the mobile app market is to keep the
user engaged in the long-term or in an ongoing regular basis during app’s usage,
avoiding loss of interest. Engagement is a consequence of the depth of par-
ticipation a user can reach while interacting with the features available in an
application (Hamari et al., 2016).
In healthcare, the lack of commitment to the treatment is a constant con-
cern among professionals, who have been adopting technology as a motivational
factor for patients (Veiga et al., 2017). In this environment, cardiovascular
conditions have been addressed continuously in apps aimed at healthcare, en-
compassed by the concept of m-Health (Fiordelli et al., 2013). Although m-
Health applications bring benefits and provide information that can aid in the
patient’s treatment, Ribeiro et al. (2016) argues that most users do not follow
the recommendations proposed by doctors.
The use of techniques that can provide user engagement is a suitable strategy
to motivate behavior changes and instigate users to complete tasks and achieve
goals more adequately. Among these techniques, there is gamification (Werbach
and Hunter, 2012), described as the use of game design elements in non-game
contexts (Deterding et al., 2011a). The key purpose of gamification is to help
with problem-solving, promote learning, and explore user’s motivation (Bowman
et al., 2004; Dias et al., 2018).
Gamification establishes intrinsic reasons, using heuristic design patterns
and dynamic game elements to enrich user satisfaction (Zichermann and Lin-
der, 2010). The use of game elements in conventional applications is becom-
ing a widely accepted trend, indicating gamification’s effectiveness, specially
in health-related services (Johnson et al., 2016; Klaassen et al., 2018; Cotton
and Patel, 2018). Compelling and addictive gamification generates excitement,
which only adds to the user’s experience (Deterding et al., 2011b). However,
the success in adding game elements to a system depends mostly on the planning
and on the in-depth analysis of the proposed goal for implementing gamification

2
(Fabrı́cio et al., 2015). Some researchers also state that when studying gamifi-
cation, it is necessary to consider users characteristics, since different types of
users are affected in different ways by gamification, influenced by their person-
ality and individual peculiarities (Codish and Ravid, 2014; Jia et al., 2016).
The literature about gamification implementation is comprehensive in sev-
eral aspects. However, questions about user characteristics and app context are
not properly addressed in the existing methods, which show the lack of verified
techniques (Jia et al., 2016). Given this context, this study presents a proposal
of gamification to favor the engagement of users in treatment for hypertension.
We present a case study comparing the usage of two versions of the same mobile
app, one of which contains game elements, incorporated from the gamification
method. Both versions of the app were developed in this research. We per-
formed tests with users to check the different levels of engagement provided
by each version of the app. The application is called e-LifeStyle and aims to
remotely integrate and monitor patients with hypertension.

2. Related Work

Information systems designers have increasingly used engagement techniques

as a way to enhance user experience. There is a growing number of profession-
als and researchers working to apply gamification in various domains, such as
education, health, corporate systems, data collection, sustainable consumption,
among others (Jia et al., 2016).
Aparicio et al. (2012) present a method of analysis and implementation of
gamification in an application to motivate the accomplishment of activities and
tasks proposed to the users. The method follows a sequence of interactive ac-
tivities, composed of four stages: (I) Identification of the primary objective;
(II) Identification of the transversal objective relevant to users; (III) Selection
of game mechanism, whose purpose is autonomy, competence and connection;
(IV) Analysis of the effectiveness through the assessment of gamification, based
on fun, quality indicators, satisfaction, and service quality.

3
 The study of Richards et al. (2014) describes only the target audience anal-
ysis, showing that, in addition to the traditional engagement techniques, de-
signers should consider the broad context of system deployment, limits of user
performance, and limitations that may arise from the post-implementation en-
vironment. The authors considered the post-implementation development to
discover features that required greater attention.
The study of Klock et al. (2016) presents a framework to guide stages like
gamification design, development, and evaluation. This tool has seven dimen-
sions: “Who?”, “What?”, “Why?”, “When?”, “How?”, “Where?” and “How
much?”. In the first dimension, the purpose is to identify the target audience
and user characteristics. The second one identifies the behaviors of the target
audience when interacting with the system. The third dimension distinguishes
persuasive motivation in the target audience. The fourth dimension refers to the
most appropriate ways to encourage the audience. In the fifth one, the inten-
tion is to define methods of using persuasion. The sixth dimension is where the
system deployment process begins, including the creation of a prototype, and
the design evaluation. In the last step, the stages are evaluated and validated,
resulting in the measurement of implanted gamification.
In this context, the analysis for gamification deployment still is a relatively
new process (Werbach and Hunter, 2012), which involves design techniques
(Deterding et al., 2011a), the context of the intended software (Deterding et al.,
2011b), and people who will use the system (Bowman et al., 2004). The studies
analyzed did not show any integration between the three factors mentioned
above. Furthermore, few studies are presenting validated results of the methods
used for gamification deployment.

3. Material and methods

We considered three main factors while composing a method to implement

game elements: design techniques, system context, and end user. These factors
are established in the literature and should always be considered in user-centered

4
studies (Garrett, 2010). Based on methods proposed by Aparicio et al. (2012),
Klock et al. (2016), and in traditional approaches of software development re-
lated to the waterfall model (Boehm, 1988), we defined a sequential process
composed of seven stages, depicted in Figure 1.

STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5 STAGE 6 STAGE 7

Survey and Mapping Identification of Analysis of Selection of Development of Evaluation of

analysis of system characteristics of interaction flows gamification in game elements the software acceptance and
requirements and target audience similar systems engagement
functionalities

Figure 1: Stages of the proposed method.

The three initial stages help the designers to understand the system’s whole
context, with its functionalities, users, and how this interaction works. The first
stage consists of classical system modeling, to be developed according to Soft-
ware Engineering methods, building the structure to the development project.
In the next stage, it is necessary to understand and map the system’s target
audience characteristics. The third stage identifies interaction and data flow in
the system by the user’s usage. The fourth stage compares intended solutions
with existing software, available in commercial repositories or in the literature,
to verify how the gamification elements were included and the implications of
their use. After gathering all the necessary information, with notions of the
intended system and ideas from systems for similar purposes, the fifth stage
lists the appropriate gamification elements where the interaction flow can be
performed. The final stage shows the results of the analysis process for imple-
menting game elements.

3.1. Stage 1. Survey and analysis of system requirements and functionalities

Stage one consists of analyzing and modeling requirements to list system

functionalities. The first step to gamify a system is to know its purposes and
characteristics. In this study, we had to identify the purpose of our case study
application (e-LifeStyle App), which factors the patient would have to monitor,
and what kind of support the system would have to provide for the treatment
of patients with hypertension.

5
 We created an Ishikawa Diagram (Wong, 2011) to organize the reasoning
of our discussions on a priority issue (Figure 2). In addition, we used use case
diagrams, activity diagrams, and sequence diagrams to illustrate the behavior
of system functionalities’, according to the Unified Modeling Language (Pahl
et al., 2015).

FACTORS USER

Heartbeat Blood pressure Perceive benefits Get back to the app

Sleeping Exercises Feel challenged Improve health outcomes

Body weight Mood Log measurements data Accomplish reminders

Waist circumference Body fat Use app everyday

IMPROVEMENT IN
HYPERTENSION
SELF-MANAGEMENT
Be useful Easy to use

Don’t be inconvenient Fun to use

Engage the user Keep the user active

SYSTEM

Figure 2: Ishikawa Diagram for the analysis of hypertension m-Health application.

3.2. Stage 2. Mapping characteristics of target audience

Richards et al. (2014) mention that it is necessary to understand and deal

with the target audience’s limitations. A population identified as the target
audience for a specific system may have characteristics that significantly affect
its ability to respond to the gamification interaction. For this, it is necessary
to draw the profile of who will use the system, with characteristics such as
age, profession, sociodemographic profile, limitations, among others. These are
essential factors for the requirements elicitation and for the software design, as
they can directly influence the choice of which gamification elements should be
used, due to the context and purpose of the user that will interact with the
system.
Klock et al. (2015) identified which user characteristics interfere with the
gamification process, focusing on virtual learning environments. The identified

6
points are demographic characteristics such as age and gender, along with type
of player and users’ motivation. Klock et al. (2015) point out the difficulty and
importance of identifying differences among target audiences, while analyzing
how they can be related to each gamification element.
For the e-LifeStyle App, the target audience is composed of people with Ar-
terial Hypertension (HA), a major risk factor for the overall increase of cardio-
vascular disease rates worldwide (Lim et al., 2013). According to data provided
by the 7th Brazilian Hypertension Guidelines (Malachias et al., 2016), the target
audience for this specific scenario will consist of hypertensive, mostly elderly,
black women, overweight or obese individuals with low education levels. With
this information, we idealized a persona, considering details such as personality
traits and preferences (Anvari et al., 2017; Kim and Kim, 2018), to imagine how
a user with these characteristics would deal with a hypertension m-Health app.

3.3. Stage 3. Identification of interaction flows

This stage consists of mapping all tasks related to user’s data feed and
interaction. After this, the most important aspects of interaction are listed to
identify where and how the gamification can be implemented. In our case study,
the user is responsible for the insertion and management of their measurements,
and scheduling reminders related to activities, the key factors to be gamified.
Using a Use-Case Diagram from Stage 1, we mapped the key points to be
gamified in the app. These were the most recurrent tasks related to data feeding
in the system: insertion of measurements, its visualization and maintenance, as
well as the scheduling of goals and related activities.

3.4. Stage 4. Analysis of gamification in similar systems

This step analyzes implemented gamification in similar systems to investigate

which elements are being used, along with its respective meaning and influence.
For this process, we searched for similar m-Health apps in mobile repositories
and app stores. We found and analyzed the gamification elements on Samsung

7
Health1 , iCare Health Monitor2 , and 30-Day Fitness Challenge3 applications.
Regarding the literature, we considered the results presented by Cechetti et al.
(2017) in a systematic literature review of gamification elements implemented
in mobile apps.

3.5. Stage 5. Selection of game elements

This stage specifies gamification elements according to the needs listed be-
fore. It is important to highlight that not all elements can adjust to every
context, i.e., game elements present in the enterprise or commercial apps may
not be appropriate for health systems.
Main game mechanics used to gamify a system, as reported by Liu et al.
(2011), must include score system, rewards, leaderboards, progress levels, among
other elements. Every time the user achieves goals, some reward must be given
accordingly, usually supported by a scoring system (e.g., virtual coins, expe-
rience score). Based on score system and achievements history, badges and a
scoreboard (global or partial) are provided to players to motivate challenge and
competition, resulting in a virtual change of the player’s status on a leaderboard.
The following elements were chosen to be a part of e-LifeStyle App:

• Score System: Points are assigned every time the user adds new values for
blood pressure, heartbeat, mood, sleeping, weight, waist circumference,
body fat, and physical activity. All these values are in accordance with
the recommended levels for each user’s profile. Points are also scored
when the user includes a reminder and complete it on schedule. The user
may gain a bonus score when achieving better or more stable levels of
hypertension.

• Progress Bar and Levels: User actions and score points are used as a
parameter to calculate progress in treatment, shown in a progress bar.

1 https://play.google.com/store/apps/details?id=com.sec.android.app.shealth
2 https://play.google.com/store/apps/details?id=comm.cchong.HealthMonitorLite
3 https://play.google.com/store/apps/details?id=com.popularapp.thirtydayfitnesschallenge

8
 Thereby, the user can monitor his or her performance.

• Leaderboard: Composed of user’s score records, shows the names and

current scores of the leading users. The more points a user gets, the greater
will be his or her position in the leaderboard, resulting in a patient’s
ranking. Leaderboards can provide an incentive for patients to improve,
as they give a sense of superiority or accomplishment (Chen and Pu, 2014).

• Feedback: Occurs when an environment reacts to an action or behav-

ior, e.g., when a user requires the system’s assistance, provided through
reminders, alerts on the logs and tips or suggestions on how to use the
system.

Figure 3 represents the gamification context for e-LifeStyle app.

Figure 3: Gamification loop for the hypertension m-Health app.

9
3.6. Stage 6. Development of the software

The mobile application was developed with Ionic Framework, version 1.7.10.
This framework provides an HTML5 software development package that sim-
ulates a native application in multiple mobile operating systems, allowing the
application to run in different devices, reaching a larger group of users. All the
data is centralized in a cloud computing based server. Data can be logged offline,
but an Internet connection is required for synchronization with the server.

3.7. Stage 7. Evaluation of acceptance and engagement

The effects of gamification on engagement and user acceptance were evalu-

ated based on the interaction of a group of patients with hypertension using the
app. For this study, 14 adults with hypertension were invited, of whom 6 were
patients undergoing treatment for arterial hypertension monitored by cardiolo-
gists, and 8 individuals were not monitored by a health professional during the
test period. All participants were selected by simple random sampling, agreeing
with the research specifications and signing an informed consent form.
The inclusion criteria were: ability to go to pharmacies, hospitals or ba-
sic health units to have blood pressure measured; owning a smartphone with
Android operating system; familiarity with the use of mobile apps (social net-
works or others); internet connection at home (Wi-fi or Mobile Data); achieving
minimum score in the Mini-Mental State Examination (MMSE) (Cockrell and
Folstein, 2002).
The criteria for the MMSE results were based on Brucki et al. (2003), which
consider the education level of the individual: 20 points for illiterates; 25 points
for people with education from 1 to 4 years; 26.5 for 5 to 8 years; 28 for those
with 9 to 11 years and 29 for more than 11 years of education. All participants
reached the minimum score required in the MMSE. Afterwards, participants
answered a Sample Characterization Questionnaire, including questions such as
age, education, habits, and body measurements.
Participants were randomly divided into four groups:

10
 • NGWA: (no gamification, with assistance) three participants who used
the app version without gamification and were assisted by a cardiologist
doctor;

• NGNA: (no gamification, no assistance) four participants who used the

version without gamification and had no assistance from doctors;

• WGWA: (with gamification, with assistance) three participants who used

the version with gamification and were assisted by a cardiologist doctor;

• WGNA: (with gamification, no assistance) four participants who used the

version with gamification and without the assistance of a cardiologist;

The local research ethics committee approved the study. Participants were
registered in the e-LifeStyle platform and instructed to use the app for 21 days.
According to Maltz (2002), this is the minimum period required for a person to
acquire any habit. At the end of the 21st day, counting from app installation
and registration, we performed evaluations with each participant, applying the
following instruments:

• Acceptance Questionnaire (based on Technology Acceptance Model - TAM

(Davis et al., 1989)): used by researchers to describe the acceptance of
information technologies after its use. The evaluation process encompasses
five categories: perceived utility, ease of use, external factors, attitude
towards and demonstrated results. This questionnaire has 15 questions,
and the answers are measured with a five-point Likert scale (Figure 6).

• Engagement questionnaire (adapted from O’Brien and Toms (2010)): eval-

uates six features that are a part of the engagement, being: focus and
attention, usability perception, aesthetics aspects, supportability, origi-
nality, and involvement. This questionnaire has 25 questions and also
classifies answers using the five-point Likert scale (Figure 7)

A Likert Scale is a psychometric rating scale used to measure the level of

agreement or disagreement on a symmetric agree-disagree scale for a series of

11
statements (Likert, 1932). In a 5-point Likert scale, the respondent chooses
between (1) Strongly agree, (2) Agree, (3) Neutral, (4) Disagree, (5) Strongly
disagree. For results from TAM and Engagement Questionnaires, mean and
standard deviation were applied to calculate individuals dispersion and vari-
ability. In addition to the instruments, information such as usage logs and gam-
ification ranking were analyzed. Usage logs contain access counting records,
amount of entered data for each measurement type, accomplishment to alerts
and reminders, and withdrawal or non-use registers. To examine the gamifica-
tion ranking, we calculated the score that each user of the non-gamified version
could have achieved with the records made. Then, we concatenated the results
with the users scores from the gamified version, recalculating the gamification
ranking as a single list. Since the score reflects the app’s usage by each partici-
pant, it facilitates the understanding of engagement in general.

4. Results

4.1. The mobile app

Two versions of the application were used to evaluate user engagement and
acceptance of e-LifeStyle App: one with gamification elements and other one
with no game features.
In the non-gamified version, the user’s next reminders, profile and last in-
serted measurements are visible on the home screen for blood pressure, heart-
beat, mood, sleeping, weight, waist circumference, body fat, and body mass
index. In the gamified version, in addition to this information, gamification
indicators are presented through a progress bar with the level completion per-
centage and the amount of points the user has earned. Both versions of the
home screen interface are shown in Figure 4a and Figure 4b. The screens “How
to earn points?” (Figure 4c) and “My performance” (Figure 4d) show all the
factors that generated the user’s current score and instructions on how to earn
points.

12
 There are screens for visualization, inclusion, editing, and deleting records
of blood pressure, heartbeat, mood, sleeping, weight, waist circumference, body
fat, and physical activity (Figure 5ab) where the user can earn points and
bonus due to improvement in their treatment history, calculated according to
the Brazilian Guidelines on Hypertension.
In the gamified version, users have access to specific recommendations ac-
cording to their health profile. The user can also check the number of points he
or she can get by complying with recommendations (Figure 5c). Ranking screen
(Figure 5d) displays a leaderboard with the general position of patients ordered
by score, allowing to filter the view by patients related to a particular doctor
and by each monitoring factor. Each app user is a patient, while doctors are
particular users who can remotely assist their patients. In both app versions,
users can talk to their doctor using the chat feature (Figure 5e).
Both versions allow the user to set reminders of treatment tasks (Figure 5f),
which are notified by email. Alerts allow the user to indicate whether the activity
was performed. Figure 5 illustrate how the app give orientations and display
feedback to users, showing their performance and helping them to achieve goals
while interacting with the system’s functionalities.

(a) Home screen of the (b) Home screen of (c) Instructions of

non-gamified version. the gamified version. how to earn points. (d) My performance details.

Figure 4: Main app’s screens related to the gamification.

13
(a) List of blood pressure (b) A message rewarding a (c) Recommendations of (d) Ranking of points from
measurements. good registered measurement. good measurements. blood pressure measurements.

(e) Chat between patient and (f) A message regretting a poor (g) A message for a progressing (h) Reminders of measurements.
health professional. registered measurement. performance.

Figure 5: e-Lifestyle app’s screens.

4.2. Evaluations and Assessments

Due to the limited and heterogeneous sample, it was not possible to apply
an explanatory statistical test. Only values with a standard deviation greater
than 2 were analyzed, as well as questions whose average variations among
the different groups were greater than 1, since these results suggest possible
significant changes.
Thirteen participants completed all the evaluations. One participant of the
NGWA group abandoned the study. Participant’s age ranged from 22 to 63
years, with a mean of 47.5 ± 10.5, median of 48. Women represented 78.6%
(n=11) of participants while men were 21.4% (n=3). Except for one, all other

14
participants were classified as overweight, considering the body mass index be-
tween 25 and 29.9 (Nuttall, 2015). Most participants performed exercises only
occasionally; four participants affirmed they performed exercises regularly, and
four said they did not practiced physical activities. Regarding the socioeconomic
aspect, all participants had a complete elementary education degree.
Figure 6 presents the answers to the questionnaire on technology acceptance.
Figure 7 presents results to the Engagement Questionnaire

0
PU1 PU2 PU3 PU4 * PU5 * PU6 * EU1 EU2 * EU3 EU4 * EV1 * EV2 BI1 * RD1 * RD2 *

WGWA Group WGNA Group NGWA Group NGNA Group * Questions whose variations
With Gamification With Gamification No Gamification No Gamification among groups were greater
With medical assistance No medical assistance With medical assistance No medical assistance than 1.0

Topic Code Question

Perceived usefulness PU1 I think e-Lifestyle App is important to my health care.
PU2 I think e-Lifestyle App is useful for managing my health.
PU3 Using e-Lifestyle App makes taking care of my health a more interesting task.
PU4 The e-Lifestyle App helps me to keep track of my health condition and history.
PU5 The e-Lifestyle App increases the care with my health.
PU6 The e-Lifestyle App motivates my involvement in controlling my health.
Perceived ease of use EU1 I think my interaction with e-Lifestyle App is clear and understandable.
EU2 I think my interaction with e-Lifestyle App does not require a lot of mental effort.
EU3 The e-Lifestyle App is easy to use.
EU4 It's easy to learn how to use the e-Lifestyle App.
External variables EV1 I was instructed on how to use e-Lifestyle app.
EV2 The researcher has a good level of knowledge about the e-Lifestyle App and helped me to understand it.
Behavioral intention BI1 It would be better to use e-Lifestyle App instead of my current monitoring method.
Result demonstrability RD1 The results of using e-Lifestyle App are unquestionable.
RD2 I will continue to use e-Lifestyle App to take care of my health.

Figure 6: Questionnaire Answers from the Technology Acceptance Model - TAM. Results in
a 5-point Likert scale.

15
 5

0
FA1 * FA2 * FA3 FA4 * FA5 * FA6 PU1 PU2 PU3 PU4 PU5 PU6 * PU7 *

0
AE1 * AE2 AE3 SP1 * SP2 * SP3 * SP4 * OR1 * OR2 * IN1 * IN2 * IN3 *

WGWA Group WGNA Group NGWA Group NGNA Group * Questions whose variations
With Gamification With Gamification No Gamification No Gamification among groups were greater
With medical assistance No medical assistance With medical assistance No medical assistance than 1.0

Topic Code Question

Focus and Attention FA1 I forgot about the immediate environment around me when using e-Lifestyle App.
FA2 I was so involved while using e-Lifestyle App that I ignored everything around me.
FA3 I was so involved while using e-Lifestyle App that I lost track of time.
FA4 I blocked out things around me when I was using e-Lifestyle App.
FA5 While using e-Lifestyle App, I lost track of things happening around me.
FA6 I wasted my time using e-Lifestyle App.
Perception of Usability PU1 I felt frustrated when e-Lifestyle App.
PU2 I found the e-Lifestyle App confusing to use.
PU3 I felt annoyed while using e-Lifestyle App.
PU4 I felt discouraged e-Lifestyle App.
PU5 Using the e-Lifestyle App was mentally demanding.
PU6 I felt in control while interacting with eLifestyle App.
PU7 I couldn’t perform some tasks in the e-Lifestyle App.
Aesthetics AE1 I find the e-Lifestyle App attractive.
AE2 I liked the design, elements and images used in the e-Lifestyle App.
AE3 The e-Lifestyle App screens are visually pleasing.
Supportability SP1 My experience with e-Lifestyle App was rewarding.
SP2 I consider my experience of using the e-Lifestyle App a success.
SP3 My experience of using the e-Lifestyle App was rewarding.
SP4 I would recommend e-Lifestyle App to my friends and family.
Originality OR1 I continued to use e-Lifestyle App out of curiosity.
OR2 The contents of e-Lifestyle App incited my curiosity.
Involvement IN1 I was instigated to use e-Lifestyle App
IN2 I felt involved while using e-Lifestyle App.
IN3 The experience of using e-Lifestyle App was fun.

Figure 7: Answers to the Engagement Questionnaire. Results in a 5-point Likert scale.

4.3. Usage Logs

Table 1 shows the interaction logs of patients with the application during
the 21-day period. We created a ranking with the points that each participant
achieved during the trial period (Table 2), including scores of participants who
did not use the gamified app’s version.

16
 Table 1: Usage logs.

Group ID L HB BP R M W S WC PA BF Chat
HC01G 23 6 6 15 6 2 4 1 0 0 0
WGWA HC02G 21 20 20 9 25 3 20 1 1 0 1
T05G 52 4 17 2 1 1 1 0 3 0 0
T02G 5 0 0 1 1 1 1 0 0 0 1
T03G 5 1 6 1 1 2 3 0 1 0 0
WGNA
VL05G 6 2 3 2 1 2 1 0 0 0 0
PF01G 13 7 8 1 3 1 7 1 0 0 0
HC02 20 13 16 2 12 1 10 0 0 0 1
NGWA HC03 17 11 11 2 3 4 2 1 9 0 7
HC04∗ 0 0 0 0 0 0 0 0 0 0 0
VL01 0 0 0 0 2 0 2 0 1 0 0
VL02 15 12 12 2 9 9 6 2 0 0 0
NGNA
T01 5 0 10 0 0 1 0 0 0 0 0
T02 4 1 2 0 2 1 1 1 1 0 0

∗Abandoned the study. The abbreviated columns refer to the number of interactions or mea-
surements added to the e-LifeStyle App by each user, namely:
L = Login; HB = Heartbeat; BP = Blood Pressure; R = Reminders; M = Mood; W = Weight;
S = Sleeping; WC = Waist Circumference; PA = Physical Activity; BF = Body Fat.

Table 2: Leaderboard of the app’s usage.

Position Points ID From Group
1o 4304 HC02G WGWA
2o 1628 VL02 NGNA
3o 730 HC01G WGWA
4o 709 PF01G WGNA
5o 578 HC02 NGWA
6o 435 T05G WGWA
7o 205 HC03 NGWA
8o 200 T03G WGNA
9o 140 VL05G WGNA
10o 105 VL01 NGNA
11o 60 T02G WGNA
12o 30 T01 NGNA
13o 0 T02 NGNA
14o 0 (Abandoned) HC04 NGWA

17
5. Discussion

5.1. Acceptance Questionnaire

Overall, for users from groups with the non-gamified app (NGWA and NGNA),
the app’s usage was neutral in improving health care, since most of the partici-
pants’ answers had a more negative feeling. The app without gamification did
not sufficiently motivate participants to change their habits regarding treat-
ment. Thus, the results suggest the gamification was a factor that led to more
acceptance and motivation by the users. For the other groups, motivation and
commitment to health control were positive, as asserted in the studies by Fitz-
Walter et al. (2013); Peham et al. (2014); Munemori et al. (2013); Setiawan and
Putra (2015); Su and Cheng (2015); Melero et al. (2015); Vicent et al. (2015).
Overall, gamification resulted in user motivation (question PU5). Nevertheless,
according to the results of question PU6, in addition to gamification, the super-
vision and monitoring of a health professional is also a motivational factor for
user engagement.
According to the WHO – World Health Organization (2013), implementing
lifestyle changes corresponds proportionately to the recommendations specified
along with the health professional that assists the patient. Furthermore, litera-
ture studies show that the motivation for treatment engagement is multifaceted,
requiring support for education, self-management, and interaction between pa-
tients, caregivers, and health professionals (Fioravanti et al., 2015; Alanzi et al.,
2016; Colineau et al., 2009).
About the ease of use, specifically in question EU2, for all participants of the
groups NGNA, WGNA, and WGWA, mean answers were equal or greater than 4.
In the NGWA group, a participant affirmed that the app required high mental
effort. The low score obtained by this participant may have been influenced
by his lack of experience with technology and lower educational attainment.
Other participants did not report difficulty in using the app, which suggests the
selected game elements did not add complexity to the system.
Considering the use of app-based monitoring tools instead of conventional

18
methods (question BI1), the groups without medical assistance agreed that us-
ing the app would be a better alternative. Data presented in Taylor’s study
(Taylor, 2007) indicate that 50% to 60% of patients tend not to follow medical
recommendations when these are related to changes in their health habits. Con-
sequently, the health professional becomes an educator who uses psychological
techniques to encourage the patient to acquire healthier habits (Marinho-Araujo,
2006). For the WGWA and NGWA groups, the achievement of higher levels of
engagement to incorporate the app as a part of the treatment also relied on the
encouragement from the health professionals. This emphasizes the perception
that the clinician’s involvement in the use of an m-Health app can improve en-
gagement for the patient, resulting in a positive experience (Andersen et al.,
2017; Bellei et al., 2019; Parmanto et al., 2013).
Also, for the SGCA group, the question RD1 concerning benefits in using
the app obtained a neutral result. This perception is directly linked to the RD2
question (“I will continue to use e-Lifestyle App to take care of my health”),
where the resulting scale of mean and standard deviation were similar. The
questions regarding External Variables, EV1 and EV2, evidence that partici-
pants felt oriented in this study.

5.2. Engagement Questionnaire

Considering the results from the Engagement Questionnaire, there was dis-
similarity between groups and low variability among individuals (Figure 7).
Besides presenting variability between groups, the affirmative FA1 showed
disagreement between participants. Perhaps this was influenced by the lack
of understanding in the expression “I forgot about the immediate environment
around me when using e-Lifestyle App ”, since we were asked about the mean-
ing of this expression several times. The same condition occurred concerning
the question FA2 because affirmation “...that I ignored everything around me”
gave a pessimistic feeling; and in question IN1, because participants did not
understand the meaning of “instigate” in the sentence “I was instigated to use
e-LifeStyle App”. These questions belong to the original O’Brien and Toms

19
questionnaire (O’Brien and Toms, 2010), elaborated for the English language
and adapted for this study. Still, there is no validated version of this question-
naire for the Brazilian Portuguese context in the literature.
Regarding the feeling of control during the app’s usage, participants from
NGNA group reported they were able to perform all the desired actions dur-
ing the usage period. The NGNA classified as neutral the feeling of being
rewarded by the app (SP1 question), while other groups that used the gam-
ified version or that were supported by a doctor affirmed they felt rewarded.
This factor provides eminent positive feelings and beneficial effects when using
e-LifeStyle App. The same behavior was repeated in questions SP2 and SP3.
The curiosity factor addressed in question OR “I continued to use e-LifeStyle
App out of curiosity” and in question OR2 “The contents of e-Lifestyle App
incited my curiosity” did not have a significant impact in groups with the non-
gamified version. On the other hand, groups that used the gamified version
had positive results in these questions. The effects generated by gamification
instigated the participants to continue using e-LifeStyle, corroborating with lit-
erature findings on gamification indicating that interaction with ludic elements
instigates activities motivated by curiosity and exploration (Gaver et al., 2004;
Falcão and Tenório, 2015; Morrison et al., 2007).
In the questions on involvement (IN1, IN2, and IN3), the groups that used
the app without gamification did not achieve the same level of excitement and
connection as the groups that interacted with games elements. This factor is
revealed in the evaluation results shown in Figure 7, where NGWA and NGNA
group had means ≤ 4, and WGWA and WGNA had a mean ≥ 4. This reveals
that gamification excelled in making the experience more fun, similarly to the
study of Browne and Anand (2013).

5.3. Analysis of Usage Logs

Through the logs (Table 1), we can observe the WGWA group performed
the greater amount of interactions and, therefore, showed greater motivation as
evidenced by the engagement questionnaire. A similar condition was observed

20
in a study with diabetics patients (Steinbeck et al., 2012), which resulted in
a 49.6% increase in the daily mean frequency of blood glucose measurements.
The authors concluded that the use of gamification promoted the monitoring of
blood glucose, letting the participants acquire this habit. The study of Vicente
et al. (2014) implemented gamification for physical activities, in which 70% of
the individuals started exercising regularly.
The groups that were assisted by doctors were more committed to registering
data in the app. Such results are similar to those found by Fioravanti et al.
(2015); Alanzi et al. (2016); Colineau et al. (2009), who report that it is essential
to instruct the doctor to encourage the app’s usage.
In this case, gamification improved user engagement, even though health-
care did not have extreme changes. Studies that have evaluated applications
in the context of health and behavior change argue that, after interacting with
game elements, users who were once not motivated can work towards improving
engagement to modify their health conditions. AlMarshedi et al. (2015) gami-
fied an app for diabetes monitoring through user observation, concluding that
gamification was the key factor for behavior change among diabetics patients
who interacted with the app.
Of the seven participants ranked as the top seven, four used the gamified
version, and five had medical assistance. These indicators corroborate the re-
sults obtained with the applied questionnaires, which asserts that gamification
combined with medical supervision promotes noticeable changes in healthcare.
The significant interval between the participant placed in the first position,
belonging to the WGWA group, stands out from the others.
For the user in the second place (Table 2), who did not use gamification and
was not under medical supervision, the technology factor only was enough to
engage him in using the application. According to the user, the app was an
incentive for monitoring his health. Despite having included measurements on
the app, a user finished the test without scoring, i.e., in the last place, indicating
that his measurements did not meet the recommended levels for his profile.

21
6. Limitations

A limitation of this study is the reduced sample size, since it was difficult to
find a more significant number of participants that could meet the inclusion cri-
teria. Another limitation is the lack of literature about validated questionnaires
on engagement or gamification for the Brazilian Portuguese context, since we
could not validate the instrument. This is the first study with our gamification
method. It still needs to go through more applications to achieve a strongest
effectiveness evidence.

7. Conclusion

This study proposed the implementation of a gamification method to im-

prove user engagement in treatment with the use of m-Health systems. The
results suggest that gamification increased the engagement of participants who
interacted with game elements, also motivating those who did not have adher-
ence to their treatment before the study.
From these observations, we noticed that applying gamification to a system
can eventually boost engagement, providing key factors such as involvement,
curiosity, and enjoyment to users. This allows them to follow and comply with
their treatment, which can make it more effective. Gamification offers the op-
portunity for users to engage with the app’s content in many ways, promoting
intrinsic motivation and helping users to achieve more successful outcomes. In
addition, the evaluated groups assisted by professionals were the ones who inter-
acted most with the app and demonstrated more motivation to maintain health
control. Thus, the supervision and support of a health professional seems to
be a fundamental part when considering the user’s commitment to observe the
treatment factors.
Finally, the method used for implementing gamification demonstrated to be
valid for this context, since it did not add complexity to the application and
appeared to promote the desired engagement results. For future studies, we
intend to perform new tests with a more significant number of participants to

22
verify the stability of the results, also employing the method to other m-Health
applications.

Acknowledgments

The authors would like to acknowledge the patients and professionals who
participated in the assessments. Acknowledgements to J. E. V. and M. T. R. for
their assistance. For research funding, the authors acknowledge to the National
Council of Scientific and Technologic Development – CNPq, and to the Ministry
of Health of Brazil – MoH.

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Highlights

 A proposition of a gamification method to improve user engagement.

 The development of two versions of a hypertension m-Health app.

 One version was gamified using the method, and the other one was not.

 Both versions were used and assessed to compare user engagement and acceptance.

 The gamified version had a better rating, evidencing the method's effectiveness.