In a recent study published in the journal Circulation, researchers evaluated the effects of gamification and financial incentives on physical activity in individuals at risk of adverse cardiovascular events.

Higher physical activity is associated with a lower risk of adverse cardiovascular events and improved control of cardiovascular risk factors. By leveraging behavioral economic concepts, such as loss-framing, immediacy, and endowment effects, shorter-term analyses have implemented financial incentives and gamification interventions and observed increased physical activity in patients at risk of or with atherosclerotic cardiovascular disease (ASCVD). Nevertheless, the effect of these interventions over the long term remains unclear.

Study: Effect of Gamification, Financial Incentives, or Both to Increase Physical Activity Among Patients at High Risk of Cardiovascular Events: The BE ACTIVE Randomized Controlled Trial. Image Credit: Alliance Images / Shutterstock

About the study

In the present study, researchers evaluated the efficacy of financial incentives, gamification, or both to improve physical activity over the long term in individuals at risk of major cardiovascular events. This randomized controlled trial was conducted between May 2019 and January 2024. Eligible participants had ASCVD or a 10-year risk of stroke, myocardial infarction, or cardiovascular death.

Eligible subjects received a wearable device to track their step count. During the two-week run-in period, a baseline step count was established. Subsequently, participants were instructed to set a goal to increase their step count relative to baseline. Next, participants were randomized to attention control, financial incentives, gamification, or financial incentives plus gamification (combination).

The control group received text messages daily for 18 months, inquiring if they had achieved their step goal the previous day. In the gamification arm, participants signed a pre-commitment pledge to reach their step goal. They received 70 points at the beginning of each week. Points were retained if they succeeded in their daily goal; otherwise, 10 points were removed.

Their levels, viz., platinum, gold, silver, bronze, and blue, changed based on points at the end of the week. All participants began at the silver level; blue- or bronze-level participants were restarted at the silver level every eight weeks. Gold- or platinum-level participants were awarded a trophy after the intervention.

On the other hand, the financial incentives group was informed that $14 would be deposited in a virtual account each week. The balance did not change if the goal was achieved; otherwise, $2 was deducted. In the combination arm, participants completed interventions from both arms. After 12 months, interventions were discontinued; however, daily text messages recording the count continued for six additional months (follow-up).

The primary outcome was the change in daily step count from baseline to the end of the intervention. Secondary outcomes were the average changes in daily step count from baseline to follow-up, weekly moderate-to-vigorous physical activity (MVPA) minutes, and the proportion of participant weeks with at least 150 MVPA minutes.

Findings

Overall, 151, 304, 302, and 304 individuals were randomized to control, gamification, financial incentives, and combination arms, respectively. The average age of participants was 66.7 years; 60.5% were female, and 25% were Black. At baseline, the average daily step count was 5081, mean MVPA minutes were 5.8, and the average step count increase was 1867.

In total, 89.8% of participants completed the 18-month study. The control, financial incentives, gamification, and combination groups achieved a mean increase of 1418, 1915, 1954, and 2297 steps from baseline to the intervention period, respectively. The corresponding figures over the follow-up period were 1245, 1576, 1708, and 1831, respectively.

Over the 12-month intervention, compared to the control arm, participants had a greater increase in average daily step count. The combination arm was superior to financial incentives during the intervention period. Weekly MVPA increased by 39.6, 56.6, 54.7, and 65.4 minutes, on average, for control, financial incentives, gamification, and combination arms from baseline to intervention.

Over the follow-up period, weekly MVPA minutes increased by 37.3 for control, 50.7 for gamification, 50.9 for financial incentives, and 57.6 for combination groups. The proportion of participant weeks with at least 150 MVPA minutes was 0.16, 0.24, 0.23, and 0.27 for control, financial incentives, gamification, and combination arms, respectively. The combination group had greater odds of a week with at least 150 minutes of MVPA.

Conclusions

Taken together, interventions with financial incentives, gamification, or both significantly improved physical activity in adults at risk of cardiovascular events compared to attention control over the 12-month intervention. This effect was sustained over the six-month follow-up period after the end of the intervention in the combination group. The combination group also increased weekly MVPA minutes more than the control group. These interventions could be helpful components of strategies aimed at alleviating cardiovascular risks.