Gamification makes employee wellness fun, which can increase interest in these programs, but groundbreaking research into this trend suggests that a more holistic approach is needed to sustain healthy behaviors over the long run. There could even be legal concerns if employers aren’t careful about what they’re promoting.

A Brigham Young University analysis of more than 2,000 health and fitness apps, most of which feature game-styled aspects and design – part of an industry that’s projected to pocket $2.8 billion by 2016 – offers a revealing glimpse at the wellness gamification phenomenon.

The researchers downloaded and tested 132 of those apps, many of which focused on friendly competition between peers and coworkers to maintain an exercise routine, or provide weight-loss rewards. Their conclusion: There’s no evidence that these popular apps will provide wellness program participants with positive long-term results.

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“We’ve found is that these gaming apps rely heavily on motivation, and they ignore other components of behavior like ability, skills, training, triggers, cues to action – really important components of helping people maintain their habits,” says Cameron Lister. Lister is lead author of the revealing study from BYU’s Department of Health Science, published in the Journal of Medical Internet Research. The school describes its research as “the first comprehensive review of gamification use in health and fitness apps, and the potential to impact health behavior.”

Lister says he criticizes gamified apps in wellness programs for focusing too much on short-term (and often unrealistic) behaviors or objectives, as well as failing to adopt a more holistic approach that includes mental aptitudes with physical capabilities.

Beyond physicality

Another key ingredient to success is relevance. The TwinStar Credit Union in Olympia, Wash., designed a program that appealed to each participant’s interest within the context of friendly competition, transcending the purely physical aspect of wellness.

“It can be that they eat better, do things with their family, put down their cell phones or play games,” says Nicole Colgan, the company’s director of HR and employee development. TwinStar developed its program in collaboration with its wellness vendor, Portland, Ore.-based hubbub health.

She says many of the credit union’s 350 employees appreciated gamification being incorporated into employee wellness and fitness training programs, rather than old-fashioned wellness lectures or quizzes. But the jury is still out: TwinStar’s management wants to know how the significant investment in employee wellness is affecting health claims experience, morale and other areas.

The wellness field is riddled with flavor-of-the month approaches (will the Apple iWatch device become the latest example, many wonder?) without much data to support those particular programs, observes Don Powell, Ph.D., president and CEO of the American Institute for Preventive Medicine.

He believes apps are generally downloaded more than they’re actually used. “In fact,” Powell explains, “I saw one study that said that people have about 45 apps on their phone, but only use six of them on any regular basis.” Another study by the Pew Research Center conducted last year found that nearly half of the respondents make a mental note of their progress on health issues, while 34% track the data on paper and only 21% use some form of technology.

Harmful apps

Powell says one problem with gamification apps is that competition between employees may come at the expense of a co-worker – an issue that can spark legal trouble if the game features (or the larger wellness program itself) prove harmful or discriminatory in any way or involve the collection of information that violates medical privacy.

Ed Leeds, an attorney with Ballard Spahr LLP in Philadelphia, reports that “there has been some litigation in this area on the nondiscrimination side,” albeit very limited. “It really depends on how an employer uses the gadgetry and how it fits into an overall employer program. Employers have to exercise the same kind of caution that they would with any other wellness program. It probably means that they need to know about the gadgetry and what it’s doing when they make the offer to employees.”

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Due diligence, of course, must include compliance with the Health Insurance Portability and Accountability Act. “If there’s some connection between the apps and an employer-sponsored health plan, then an employer has to meet the HIPAA requirements,” Leeds says. “Those requirements depend on what kind of a wellness program the employer is maintaining, which in some ways the apps may play into.” Wellness plan sponsors must be mindful of limitations on how much of a reward is being offered in outcomes-based programs.

Beyond legal matters, another issue to consider is the ineffectiveness of extrinsic rewards or recognition in terms of sustaining healthy behaviors over the long term.

“Unless you keep on giving the reward over and over and also make that reward higher and higher, people tend to revert back to their previous behavior,” Powell cautions. Also, if wellness program gamers view the apps as work rather than fun, then he says they run the risk of becoming unhealthy again when the game ends or loses its appeal.

The key to sustainable behavior change is through intrinsic motivation and rewards, which he says gamification does not accomplish “in any appreciable way.” One example is a proprietary model he developed called BEMEM, which stands for “Behavioral/Educational/Motivational/Enjoyable/Maintainable.”

“Behavior modification is king of the hill when it comes to behavior change,” he explains, noting the importance of combining each of these key elements.

More than ‘buttons and badges’

Brian Berchtold, VP of sales and marketing of hubbub health, agrees that while gamification apps may drive interest in wellness programs, they lack the tools for sustainable change. All the bells and whistles used to turbocharge a fitness program ultimately cannot compete with what needs to be a multi-faceted approach.

“It’s not all about buttons and badges,” he says. “It’s about creating a program predicated on behavior design, centered those things that motivate individuals the most.” That may include what he describes as “proper use of social networking.”

Hubbub has found nationwide that employees are twice as engaged in their own wellness program if gamification strategies feature the right mix of nudging employees and providing incentives. Get the right mix and the results can still be impressive, Berchtold notes: Engaged employee populations on average are losing 3.1 pounds over a 12-month period at a time when the Centers for Disease Control and Prevention reports that the average American adult is gaining two pounds per year.

Although gamification creates fun and excitement, employers still need to offer a supportive programming based on the results of a health-risk appraisal, employee-interest surveys, culture audit and stages of change, just to name a few approaches. So says Kathy Nellor, a wellness business consultant for Blue Cross & Blue Shield of Nebraska.

In her employer’s case, she’s most pleased that more than 80% of the workforce is actively participating in a program with Seattle-based wellness vendor EveryMove 18 months after implementation. There’s also continued monitoring of changes in aggregate personal health assessment data and fitness evaluation data to determine larger outcomes within the employee population.  

The most promising message associated with BYU’s findings is that “real, honest-to-goodness game elements seem highly correlated with increased user motivation and app popularity,” according to Isaac Barry, lead game designer at EveryMove. But he says the notion of gamifying a wellness app with a basic, gimmicky premise – or an overly simple modification – simply doesn’t work.

“Most game designers would agree that you can’t just stick points on a pig to get a game,” he says. While gamification can spur interest in wellness, it’s the “real” games that keep wellness programs moving, he notes.

Bruce Shutan is a Los Angeles-based freelance writer.

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