To Increase Physical Activity, Put Patients In Charge and Make It a Game

A strategy that combines wearable monitors and “gamification” of physical activity, along with encouraging participants to pursue their own goals, may help motivate people at risk for CVD to get and stay more physically active, new research suggests.

According to researchers who reported their results in JAMA Cardiology, a key component of the Evaluation of the Novel Use of Gamification With Alternative Goal-setting Experiences (ENGAGE) randomized clinical, conducted in an economically disadvantaged, high-risk group, was involving individuals in choosing and meeting their own activity targets.

“The main takeaways from this study for a cardiologist who is recommending physical activity to their patients is to work with them to let the patient identify a goal they think is best for them, as opposed to what I think the common approach right now, [which is] to tell patients ‘This is how much you should walk’ or ‘This is how much you should exercise,” said lead author Mitesh Patel, MD, MBA (Ascension Health, St Louis, MO). “Really what might work better is to say: ‘Here's the guidelines. Let's get a sense of where you are. We want to work toward that, but why don't you pick the goal that works best for you to start?’ And that's going to get people more likely to stick with it.”

Gamification, based on the idea that creating a game out of tasks or services makes them more engaging, has been shown in the past to increase physical activity—Pokemon Go being a memorable example. But the specifics of motivating patients to move more by making the intervention more game- and goal- focused remain undefined and likely vary from person to person.

“What this study reveals is that with really simple and subtle changes that really cost nothing around goal setting can have a big impact on how likely we are to achieve those goals,” Patel said, adding that this method can be used to increase patient physical activity, but also potentially to encourage smoking cessation and other healthy habits. “Here, by letting someone decide what the goal is, basically they get a choice as opposed to telling them what the goal is; they're more intrinsically motivated to follow through on that because they feel like it's their goal.”

Immediate, Self-Chosen Goals Win Out

For the study, Patel and colleagues paid 500 individuals from low-income neighborhoods who were at high-risk of major adverse cardiovascular events to participate in the study. In all, 66.2% were Black, 69.6% were women, mean age was 58.5 years, mean body mass index was 33.2, and 43.0% had an atherosclerotic cardiovascular disease condition. Mean baseline step count was 5,777.

Between January 2019 and June 2020, participants all received wearable step trackers (Fitbit Alta or Fitbit Inspire) and were randomized to a control group or one of four gamification intervention arms that gave them either a choice of or assigned step goals as well as a gradual buildup or immediate goal implementation. Follow-up included an 8-week introductory intervention period, 8 weeks of maintenance intervention, and a further 8 weeks of follow-up.

Participants kept in touch via “Way to Health, a research technology platform at the University of Pennsylvania used previously for remote monitoring and physical activity interventions,” the paper explains. “Participants used the study website to create an account, provide informed consent online, and complete baseline and validated survey assessments. Each participant received regular study communications by email and text message.”

Over the course of the study, steady increases in step count were observed among controls and in three of the four gamification groups. Notably, those with self-chosen and immediately implemented step goals had the most significant increases in daily steps during the maintenance period of weeks 9-16 (1,384 vs controls) that were also sustained during follow-up of weeks 17-24 (1,391; P < 0.001 for both). This group also reported significant increases in daily minutes of moderate-to-vigorous physical activity during the maintenance intervention (4.1 vs controls; P < 0.001) that were sustained over follow-up (3.5; P = 0.004). Similar significant increases in step counts were not seen in any of the other three gamification arms.

Sensitivity analyses confirmed these results, even for the participants enrolled during the COVID-19 pandemic. Only one adverse event was reported during the study in a patient with arthritic knee pain related to walking.

Participants seemed highly satisfied with their study experience, the researchers report, and 93.3% of them said they planned to continue using the wearable device.

The ‘Extra Boost’

Patel said he was surprised at how well the group with self-chosen goals, when applied immediately, adhered to their plan even after the ‘game’ ended. “There was about a 1,400 step per day increase compared to the control arm when this behaviorally designed game was running,” he said. “But then when we turned it off, a lot of times that behavior would drop down, but in this setting it was completely sustained in the 8-week follow-up period.”

Most of the available evidence on goal setting is in populations of people “who are generally more motivated or healthy,” Patel said, explaining why his team included a population at higher risk. Additionally, “in most cases, you can expect that if a population is either less motivated or has less resources [and] something works, you can apply it to a more-general population.”

Because of this, he said, “the core principles here could be applied much broader and also beyond just physical activity,” although they should be tested in other populations, as well.

As for the reasoning as to why letting people pick their physical activity goals works better than assigning them, Patel said “it builds up intrinsic motivation.”

Notably, the participants in this study were motivated by personal health reasons, so that could be a baseline characteristic for an intervention like this to work. “If you have a heart attack, it's a life-changing event and you really want to get on your feet and prevent the next heart attack,” Patel said. “A lot of people in the study were motivated for that. But despite that, people struggle. They struggle to quit smoking and they struggle to lose weight. They struggle to be physically active. I think that motivation was there, but this was the extra boost to help that group succeed.”