Effectiveness of gamified team competition in the context of mHealth intervention for medical interns: a micro-randomized trial

BackgroundTwin revolutions in wearable technologies and smartphone-delivered digital health interventions have significantly expanded the accessibility and uptake of personalized interventions in multiple domains of health sciences. Gamification, the application of gaming elements to increase enjoyment and engagement, has the potential to improve the effectiveness of digital health interventions. However, the effectiveness of competition gamification components remains poorly understood, challenging informed decisions on the potential adoption of these components in future studies and trial designs. We aimed to evaluate the effect of smartphone-based gamified team competition intervention on daily step count and sleep duration via a micro-randomized trial. MethodsWe recruited first-year medical residents (interns) in the US, who downloaded the study app, provided consent, wore a wearable device, and completed a baseline survey. Teams were formed based on participating residents institutions and specialties, and subsequently randomized weekly to the competition or non-competition arms. In the competition arm, opponent teams and competition type (step count or sleep duration) were also randomly selected. Competition participants had access to the current competition scoreboard and competition history via the study app; they also received scheduled competition-related push notifications in a competition week. We estimated the main and moderated causal effects of competition on proximal daily step count and sleep duration. This trial is registered with ClinicalTrials.gov (NCT05106439). FindingsBetween April and June 2020, we enrolled 2,286 medical interns from 263 institutions, of whom 1,936 were formed into 191 teams that met the criteria for participation in competitions between July 6 and September 27, 2020. 1,797 participants who had pre-internship baseline information were included in the analysis. Relative to the no competition arm, competition intervention significantly increased the mean daily step count by 111{middle dot}5 steps (SE 40{middle dot}4, p=0{middle dot}01), while competition did not significantly affect the mean daily sleep minutes (p=0{middle dot}69). Secondary moderator analyses indicated that, for each additional week-in-study, the causal effects of competition on daily step count and sleep minutes decreased by 9{middle dot}1 (11{middle dot}6) steps (p=0{middle dot}43) and 1{middle dot}9 (0{middle dot}6) minutes (p=0{middle dot}003), respectively. Intra-institutional competition negatively moderated the causal effect of competition upon daily step count by -114.9 (93{middle dot}7) steps (p=0{middle dot}22). InterpretationGamified competition delivered via mobile app significantly increased daily physical activity which suggests that team competition can function as a mobile health intervention tool to increase short-term physical activity level. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for studies of mobile health intervention with gamified components: ("mobile health intervention", "mHealth intervention", "mobile health gamification"). We evaluated studies published before November 30, 2021. The search was not limited by language. Previous work affirmed that in mobile health interventions, gamification is effective for improving users physical activity and mental health. Most of previous work used feedback, reward, and progress bar as game mechanics, while none have rigorously examined the effectiveness of gamified team competition. Added value of this studyThis study provides evidence that the gamified team competition has a positive effect on physical activity. The data that was intensively collected as part of this study can be used for further investigation. Implications of all the available evidenceThe results of this study indicate that gamified team competition has the potential to improve the effectiveness of and engagement with mobile health interventions.