Norman Swan: One of the hardest things to do when it comes to looking after your own health and well-being is to change ingrained behaviours. Two techniques for behaviour change that recently came together to get people to exercise more were turning behaviour change into a game and adding what's called behavioural economics, using the quirks of the way our brains work when they make decisions to nudge us in the right direction, in this case using apps to increase people's daily step counts. Mitesh Patel is director of the Penn Nudge Unit at the University of Pennsylvania in Philadelphia, and he spoke to James Bullen.
Mitesh Patel: Traditional economics assumes that humans behave rationally, that if you give them a bunch of choices they are going to make the right choice, they're going to think about their long-term health. But we know that's not how people behave, people are more motivated by immediate gratification, they don't want to lose something that they have and they are really influenced by the peers and that the family members and friends around them. And so in order to incorporate that within the gamification design, we did a couple of things. We had participants sign a pre-commitment contract to strive to achieve your goal every day, and any time they logged back into the platform they were reminded that they committed to sticking to that goal. We gave them points up front, 70 points, 10 for each day of the week. Your typical game actually you have to do something first, you have to reach your step goal and then you get points. Here we flip that, we gave you the points up front and you could lose them.
We had a multiple levels ranging from blue, bronze, silver, gold and platinum, and usually you start at the lowest level and work your way up, but actually we start people at the middle. That made the highest level seem more achievable and then if people didn't get engaged in the beginning they would actually drop down from silver to bronze and feel that loss of social status, and that can be energising and motivating to get people over that initial hump of engaging in the program.
We added something called the fresh start effect, this idea that people are more motivated around temporal landmarks, New Year's resolutions, the beginning of the year is the best example, but in our case we use the beginning of the week. So if you had a bad week you get a fresh start with seven new points the following week. And then if you got to gold or platinum by the end, then you would get either a trophy or medals. So there was some sort of prize, although it wasn't a monetary prize in any sense.
James Bullen: And just to tease out one of those points, I think where you lost points from your balance, that was about something called loss aversion, so people trying to avoid losses rather than being motivated by gains?
Mitesh Patel: That's right. We know that actually losing something is twice as motivating as gaining an equivalent amount, it's a 2 to 1 ratio. And so we've seen in a lot of different contexts that people will do much more to avoid losing something that they have. It makes them feel like they have some skin in the game and they actually have some ownership in those points that are theirs and so they don't want to give them up.
James Bullen: There was a further test that you were doing about whether players were battling each other or working together really.
Mitesh Patel: That's right. So we had four arms to this study and we had 602 people from 40 US states enrolled in this, they were all overweight or obese, and you either got put in the control arm, which you used a wearable device just by itself, or one of the three gamified arms. But we slightly changed the game to enhance a different type of social incentive. In one arm we gave people a leaderboard at the end of each week to show them how they were doing in their points for the week and cumulatively, and that was meant to enhance competition.
In another arm we tried to focus on collaboration. We'd randomly pick someone from a group of three every day and they would represent the team, and the idea was you didn't know if you were going to be the one selected or not, and so you wanted to work together with your teammates to make sure no matter who was selected everybody met their goal.
And the third focused on support. We asked each person to pick a family member or friend who could get a weekly notification on how they were doing, and they were meant to either praise them when they were doing well or really help support them when they weren't.
James Bullen: How did the different groups do?
Mitesh Patel: We got a baseline step count, we asked them to pick a goal about 33% to 50% higher, and what we found was that all three of the intervention groups, the gamification groups, did better than the control arm in the six-month period. But the competition did the best. So, competition increased their step counts by about 920 steps per day more than the control arm, while collaboration and support increased their step counts by a little over 600 steps per day.
James Bullen: Did that surprise you, that competition did the best?
Mitesh Patel: No one has ever compared these different things, and I think a lot of people get concerned that competition could turn people off if you're not doing well. And so the fact that it was so much more motivating and had such a larger increase than the others was a bit surprising. I would say the most surprising thing was actually what happened in the follow-up period. We turned the game off and said let's just continue to follow everyone for three months, basically everyone did what the control arm was doing. And what we found was that support and collaboration, which increased daily step counts by about 600 steps per day while they were playing the game, had no difference compared to the control arm after you turned it off. They basically went back to doing what they were doing before.
But the competition arm actually had a 570 step increase that was significantly different from the control, meaning that competition was so motivating, not only did they do the best during the six-month game, but it built new habits that maintained even in the three months after the game stopped. And on average, the average person in the competition arm walked about 100 miles more than the average person in the control arm during the nine-month study. Every couple of 100 steps that you increase up until about 7,500 is linked to lower chances of dying early. Even changing your step counts by 500 to 900 steps per day can really add up over time.
James Bullen: And another interesting finding you made was that the people who had the lowest step counts to begin with improved the most. Why do you think that was?
Mitesh Patel: That's right. We had some questions around the study, people actually wondered whether the ones who were already active were the ones who were increasing their step counts, and it actually ended up being the reverse. The ones that were already active, they probably didn't need the game. They were already motivated and the game wasn't the thing that was going to push them further. But the people who were sedentary at baseline, the people who were struggling to get their exercise up, they benefited the most. Those are the ones that there is the greatest opportunity to really change their behaviour.
James Bullen: Do we know how this intervention compares to other means of improving step count, maybe things like coaching or web based interventions or even financial incentives?
Mitesh Patel: So we don't know that yet. We actually have a large trial going on right now to compare gamification, financial incentives or both together over twice the period. So this study was nine months, the current study that we have in the field is a year and a half to figure out what leads to the biggest impact over a 12-month intervention, and then if we follow people an additional six months, which one leads to more sticky behaviour change.
James Bullen: And these findings might have implications for workplace wellness programs, other health interventions, where gamification is becoming more common.
Mitesh Patel: Yes, I think gamification is used widely. Some insurance companies offer gamified programs to 5 million, 10 million members. The challenge is that they haven't incorporated a lot of these behavioural insights because there haven't been many studies doing it, ours is really the largest clinical trial of gamification to date, but also because this is something that is an emerging science, and now that we have some insights there is a real opportunity to be able to do this. And what we are finding is that a little friendly competition can really go a long way. So you not only want to think about the design of the game, but you want to think about how social networks can really enhance the benefit from these types of programs.
James Bullen: Mitesh Patel is director of the Penn Nudge Unit at the University of Pennsylvania, Philadelphia, and he spoke to James Bullen.