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The United States is currently in an age of obesity and inactivity despite increasing public awareness and scientific knowledge of detrimental long-term health effects of this lifestyle. Behavior-tracking diaries offer an effective strategy for physical activity adherence and weight management. Furthermore, Web-based physical activity diaries can engage meaningful partners in people’s social networks through fun online gaming interactions and generate motivational mechanisms for effective behavioral change and positive health outcomes.
Wellness Partners (WP) is a Web-based intervention in the form of a physical activity diary with social networking and game features. Two versions were designed and developed for the purpose of this study—“Diary” only and “Diary+Game”. The objectives of this study included pilot testing the research process of this intervention design, implementation, evaluation, and exploring the effectiveness of social gaming features on adult participants’ physical activity and anthropometric measures.
We conducted a field experiment with randomized crossover design. Assessments occurred at baseline, first follow-up (FU, 5-8 weeks after using one version of WP), and second FU (5-8 weeks of using the other version of WP). In the control condition, participants started with the “Diary” version of WP while in the experimental condition, participants started with the “Diary+Game” version of WP. A total of 54 adults (egos) ages 44-88, and their family and friends (alters) ages 17-69 participated in the study in ego-network groups. Both egos and their alters completed online surveys about their exercise habits. In addition, egos completed anthropometric measurements of BMI, fat percentage, and fat mass by bioimpedance.
From October 2009 to May 2010, flyers, emails, and Web advertisements yielded 335 volunteers who were screened. Rolling recruitment resulted in enrollment of 142 qualified participants in 54 ego-network groups, which were randomly assigned to a study condition. The final analytic sample included 87 individuals from 41 groups. Data were collected from December 2009 to August 2010, and data analysis was completed in 2011. Overall, the participants were given access to the intervention for 10-13 weeks. Statistical analysis suggested an increase in self-reported exercise frequency (mean days per week) from baseline (2.57, SD 1.92) to first FU (3.21, SD 1.74) in both conditions. Stronger effects were seen in the condition where Diary+Game was played first, especially in network groups with larger age variation between the alters and egos. Overall, the decrease in egos’ BMI was statistically significant from baseline to first FU, with greater decrease for those in the Diary+Game first condition (-0.26 vs -0.16 in the Diary first condition).
The Wellness Partners program increased physical activity among participants and resulted in health benefits among the egos. Web-based diary interventions designed with social gaming features hold potential to promote active lifestyles for middle-age adults and people in their social networks.
The United States is currently in an age of obesity and inactivity despite increasing public awareness and scientific knowledge of detrimental long-term health effects of this lifestyle [
Self-monitoring is a long-standing and effective strategy for weight maintenance and weight loss [
Early and middle adulthood are particularly challenging periods in life, with major life transitions in education, career, and family responsibilities that lead to changes in PA [
This study had 3 objectives. First, we aimed to develop an intervention that combines social networking and digital game features in the form of a Web-based PA diary. Second, we aimed to pilot test the research process of this intervention design, its implementation, and its evaluation. We conducted a pre-study estimate of sample size and employed a rigorous procedure of recruitment, randomization, treatment, and follow-up (FU) assessments. Third, we aimed to explore the potential effectiveness of the intervention with social gaming features on participants’ PA, body mass index (BMI), fat percentage, and fat mass. We hypothesized that participants would report an increase in PA using either version of the socially networked PA diary (one with and one without game features), with a greater increase expected for those who used the version with game features in addition to social networking. Given the brief duration of the study, changes in BMI, fat percentage, and fat mass were not expected but examined.
Wellness Partners (WP) is a Web-based intervention in the form of a PA diary with social gaming features. It was designed by the first author in consultation with the other members of the research team and with contributions from an interdisciplinary group of students and alumni. We used iterative playtesting [
To facilitate the user experience, a question mark was placed next to each key feature on the WP website with descriptions in a pop-up window. Contact points for technical support were provided on the WP study website frequently asked questions page with an email and a phone number, a hyperlink to the bug report was included in the daily email reminders, and an open-ended question was offered for comments and suggestions at the end of each online survey. The qualitative feedback was obtained through participant interviews.
This study used a randomized crossover design with two arms. Assessments occurred at baseline, at first FU (5-8 weeks) and at second FU (10-13 weeks) (
In coordination with the Center for Work and Family Life at USC, a mass email announcement and 12,000 paper advertisements were sent to all university staff directing volunteers to an email, voicemail, and website. Before they were contacted for screening, volunteers had to fill out an online consent for contact form. Volunteers were screened over the phone for the following inclusion/exclusion criteria: (1) age between 25 and 44, (2) English fluency (rating of at least 7 on a 10-point scale), (3) employment status (required to be university staff, employed full-time, or part-time), (4) daily Internet access, (5) cell phone ownership, (6) no current participation in any other formal studies of weight loss or healthy lifestyle, (7) no prior participation in WP, and (8) report of having a social support network containing at least 4 people.
Qualified volunteers became egos in the study and were instructed to fill out the online referral form, nominating members of their social network to join their ego-network group and enroll in the study as their alters. Volunteers who were referred by egos were asked to fill out the online consent for contact Form. Potential alters were screened over the phone for the following inclusion/exclusion criteria: (1) age between 12 and 85, (2) English fluency (rating of at least 7 on a 10-point scale), (3) daily Internet access, and (4) no prior participation in WP.
Employment by USC was not a criterion used for alters because we wanted to encourage participants to enroll any member of their friends or family, regardless of employment and where they lived. Egos had to be willing to come to campus for anthropometric measurement, but since alters did not have to be seen in person by our staff they could be located anywhere.
When an ego and at least one alter mutually confirmed their participation in the study, they were each asked to review the online informed consent form and complete a baseline survey. Parental consent was obtained for minors. Then, the ego was scheduled for an in-person baseline anthropometric assessment before the entire ego-network group was assigned a group ID and randomized (as a group) in blocks of 10 to begin one of the two study conditions. A random number generator was set up with a minimum value of 1 and a maximum value of 10 where odd numbers were assigned to Diary+Game and even numbers were assigned to Diary until one of the two conditions reached 5 ego-network groups and the rest were assigned to the other condition. These steps were repeated as the group sample exceeded 10, 20, 30, etc.
Upon completion of baseline assessment milestones, participants were emailed a user name and password with user instructions and encouraged to log on to the WP website everyday (
Incentives were provided after completion of each data collection milestone—$10 for assessment at baseline, $10 for first FU, and $25 for second FU. All egos and up to their first 5 alters were mailed checks and minors were mailed gift certificates. This study procedure (
The main outcome variables for this study included self-reported exercise frequency of all participants and anthropometric measures of all egos. PA was measured using one item that asked, “on average, how often do you exercise (minutes per day, days per week)” as used in previous studies [
Means were reported first by survey wave and condition (Diary vs Diary+Game) to establish data trends.
Using a general power equation with standard assumptions and reaching a medium effect size [
CONSORT 2010 flow diagram. Of these 54 ego-networks, 12 groups (28 people) failed to complete all survey measurements and were dropped from the analyses (n=142, 22.3% attrition). In addition, 27 participants dropped out from the study, leaving a final analytic sample of 87 individuals from 41 groups (n=142, 38.7% attrition).
Pre-enrollment and post-enrollment study procedures.
The initial sample included 54 egos and 88 alters that added up to a total of 142 individual participants in 54 ego-network groups at baseline (
Sociodemographic characteristics of study participants by condition.
|
Total | Lost to |
Analytic |
Diary |
Diary+Game |
|
Number of participants | 142 | 55 | 87 | 49 | 38 | |
Male, n (%) | 46 (32.4) | 17 (30.9) | 29 (33.3) | 14 (28.6) | 15 (39.5) | |
College graduate, n (%) | 103 (72.5) | 35 (63.2) | 73 (83.9) | 39 (79.6) | 34 (89.5) | |
Asian ethnicity, n (%) | 25 (17.6) | 5 (9.1) | 20 (23.0) | 9 (18.4) | 11 (29.0) | |
Hispanic ethnicity, n (%) | 40 (28.2) | 20.2 (36.4) | 20 (23.0) | 10 (20.4) | 10 (26.3) | |
Mean age (SD) years | 35.56 (9.51) | 35.24 (10.05) | 35.80 (9.21) | 38.69 (9.21) | 32.00 (7.82) | |
Alters, n (%) | 89 (62.7) | 42 (76.4) | 47 (54.0) | 25 (51.0) | 22 (57.9) | |
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|
Group size | 3.11 | 3.07 | 3.14 | 3.14 | 3.13 |
|
Mean group age in years (SD) | 35.56 (5.72) | 34.8 (6.04) | 36.1 (5.5) | 38.9 (6.6) | 32.4 (4.2) |
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|
Mean days of PA per week (SD) |
|
2.35 (1.86) | 2.57 (1.89) | 2.59 (1.83) | 2.55 (1.98) |
|
Estimated baseline BMI | 26.97 (6.00) | 29.06 (7.82) | 26.30 (5.17) | 26.52 (4.97) | 26.02 (5.47) |
The WP server kept track of user activities. Overall, participants were given access to the intervention for 10-13 weeks. Our server data suggested that among participants in the analytical sample, in general, they accessed the WP website every other day, with the number of total logins ranging from 1-102 (mean 38.00, SD 22.31), the number of days they logged in ranged from 1-81 days (mean 32.75, SD 18.32), and the most popular times of the day they logged in were 9 am to 12 noon (mean 8.68 times), 6 pm to 9 pm (mean 7.32 times), and 9 pm to 12 midnight (mean 7.11 times).
Over time, mean number of self-reported days of exercise per week at baseline, first FU, and second FU were: 2.57, 3.21, and 3.23, respectively.
These overall trends, however, mask differences by condition (Diary vs Diary+Game first), and by participant status (ego vs alter).
Self-reported days per week exercised by study condition and participant status.
|
Baseline |
1st FU |
2nd FU |
|
Total | 2.57 (1.92) | 3.21 (1.74) | 3.23 (1.68) | |
|
||||
|
Total | 2.59 (1.83) | 3.03 (1.64) | 3.07 (1.55) |
|
Egos | 2.64 (1.96) | 3.04 (1.52) | 3.04 (1.57) |
|
Alters | 2.54 (1.73) | 3.02 (1.78) | 3.10 (1.55) |
|
|
|
|
|
|
Total | 2.55 (1.98) | 3.43 (1.87) | 3.43 (1.89) |
|
Egos | 2.81 (2.14) | 2.75 (1.84) | 3.06 (2.17) |
|
Alters | 2.36 (1.89) | 3.93 (1.76) | 3.70 (1.65) |
A random effects regression model was calculated using the ego-network group (the ego and their alters) as the random effects and sociodemographic variables (sex, education, ethnicity, age, estimated BMI, mean group age, and SD group age) were entered as controls, which may also mask intervention effects. The results in
As expected, baseline exercise frequency was strongly and significantly associated with exercise frequency at both first and second FU. The only significant predictor of increased self-reported PA at first FU was group age variation, indicating that groups composed of people of varying ages were more likely to increase their PA than those with less variation.
Random effects regression coefficients on number of days per week exercised at FU.
|
Number of days exercised |
Number of days exercised |
|||
|
Main effects only | Interaction included | Main effects only | Interaction included | |
1st FU | NA | NA | 0.52 (<.001) | 0.49 (<.001) | |
Baseline | 0.61 (<.001) | 0.64 (<.001) | 0.35 (<.001) | 0.38 (<.001) | |
Diary+Game first | 0.55 (.08) | -0.30 (.40) | 0.23 (<.35) | 0.01 (.89) | |
Male | 0.45 (.11) | 0.37 (.14) | -0.19 (.45) | -0.19 (.16) | |
Education | 0.59 (.09) | 0.52 (.07) | 0.24 (.25) | 0.24 (.61) | |
Asian ethnicity | -0.40 (.12) | -0.35 (.15) | 0.20 (.27) | 0.20 (.36) | |
Hispanic ethnicity | 0.42 (.31) | 0.37 (.37) | 0.79 (.004) | 0.78 (.004) | |
Age | 0.03 (.34) | 0.05 (.09) | 0.04 (.017) | 0.04 (.011) | |
Alter (vs ego) | 0.68 (.035) | -0.15 (.65) | 0.18 (.47) | -0.03 (.93) | |
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|
|
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Group size | -0.03 (.76) | -0.03 (.72) | -0.04 (.25) | -0.05 (.25) |
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Mean group age | -0.01 (.70) | -0.02 (.57) | -0.02 (.33) | -0.03 (.30) |
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Group age SD | 0.07 (.012) | 0.06 (.023) | 0.01 (.53) | 0.01 (.54) |
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|
|
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Estimated baseline BMI | -0.04 (.26) | -0.04 (.18) | 0.01 (.79) | 0.0 (.88) |
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Diary+Game alter interaction | not applicable | 1.74 (.009) | not applicable | 0.48 (.26) |
|
Adjusted R2 | 57% | 63% | 79% | 79% |
To test the combined effects of study condition and participant status, an interaction term of condition (Diary+Game first) and being an alter (rather than an ego) was constructed. Model estimates showed that the covariates remained mostly unchanged and the interaction term was statistically significant indicating that alters in the networks that started with the Diary+Game condition increased their self-reported PA significantly compared to egos and those in the Diary first condition.
Whether the changes in self-reported behavior translated into changes in anthropometric measures (ie, BMI, fat percentage, fat mass) for the egos was also examined. Anthropometric measures were only available for egos, and of the 40 egos, 34 had measurements at all 3 waves paired
Anthropometric measures by study condition.a
|
Baseline | 1st FU | Difference |
|
Baseline | 2nd FU | Difference from 1st FU |
|
|
N | 38 | 38 |
|
|
33 | 33 |
|
|
|
|
|||||||||
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Total | 28.02 | 27.83 | -0.19 | .02 | 28.09 | 27.99 | -0.10 | .23 |
|
Diary → Diary+Game | 28.02 | 27.86 | -0.16 | .10 | 28.05 | 27.94 | -0.10 | .28 |
|
Diary+Game → Diary | 28.03 | 27.77 | -0.26 | .07 | 28.16 | 28.05 | -0.10 | .32 |
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|||||||||
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Total | 30.95 | 30.84 | -0.12 | .40 | 30.63 | 30.51 | -0.12 | .39 |
|
Diary → Diary+Game | 30.70 | 30.94 | 0.25 | .64 | 30.27 | 30.54 | 0.27 | .66 |
|
Diary+Game → Diary | 31.34 | 30.67 | -0.67 | .11 | 31.13 | 30.49 | -0.64 | .12 |
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|||||||||
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Total | 54.00 | 53.51 | -0.49 | .27 | 53.58 | 52.97 | -0.61 | .25 |
|
Diary → Diary+Game | 54.17 | 54.21 | 0.05 | .52 | 53.53 | 53.48 | -0.05 | .48 |
|
Diary+Game → Diary | 53.74 | 52.43 | -1.31 | .09 | 53.66 | 52.29 | -1.37 | .16 |
a N=38, Diary → Diary+Game, n=23; Diary+Game → Diary, n=15; N=33, Diary → Diary+Game, n=19; Diary+Game → Diary, n=14.
We also compared egos’ and alters’ self-reported health status by examining responses to one question at baseline, “in general, would you say your health is…” (1 = excellent and 5 = poor). Alters tended to report significantly better health status than egos (2.48 vs 2.81;
Exercise days per week at baseline, first, and second FU overall (total) and by Diary first versus Diary+Game first. The exercise frequency increase was greater in the Diary+Game first condition.
Exercise days per week at baseline, first, and second FU overall (total), by study condition (Diary first vs Diary+Game first), and by participant status (ego vs alter). The exercise frequency increase was greatest for alters in the Diary+Game first condition (1.57 days per week).
To our knowledge, this is the first study to design, develop, and evaluate a Web-based PA diary intervention for adults that focused on the effects of social gaming. The concept of using game mechanics for motivating real world behaviors is now known as “gamification” [
The greater effectiveness of the social gaming features among alters is an intriguing finding. Alters were not different from each other on demographic characteristics. Their increased PA may have been prompted by a desire to have their egos look good in the study. Alternatively, they may have genuinely been more motivated to increase their PA because their family or friends recruited them. A third possibility is that the egos selected the alters purposely as someone who either would, or needed to, change their own behavior. However, the finding that alters reported significantly better perceived overall health than egos suggests that although individuals recruited others who were similar on sociodemographic characteristics, they may have reached out to “healthier” friends and family who could “help” them rather than try to positively influence others themselves. This pattern may have implications for recruitment of PA studies that have a social networking component.
The effectiveness did not vary by sociodemographic characteristics, indicating that the intervention was just as effective among younger and older participants, those of different ethnicities, with different educational levels, and different genders. This indicates that the social gaming features had broad appeal among this selected but varied population. This is encouraging considering the rudimentary nature of the game mechanics and interface. Interactive entertainment applications can be costly to develop and this study demonstrated that even basic features could provide behavior modification potential for increasing PA.
Any new technology-based innovative interventions will have to face technical challenges. Engagement and retention of participants in this study may have been influenced by software problems and limitations they encountered. A number of projected features including a Twitter-enabled reporting function were not deemed stable enough for the main study after beta testing. Some software problems were known from beta testing, such as slow loading. Some participant activities did not get logged on the WP website due to a persistent random software bug that could not be corrected while the study was in progress. During one particular week, no email reminders were sent out to the participants. Upon quality assurance review of data, we discovered that the conditions of a few ego-network groups were not switched after first FU, and were excluded from the analytical sample (
An additional limitation of the study related to accumulation of points earned from exercise in the Game+Diary version of the software. Participants could report an infinite number of PA or setbacks per day, but they were awarded points only for the first report within a 24-hour period. Several participants voiced frustration about this as a usability problem within the first few weeks of the study. We had not anticipated that participants would login more than once per day to report. We revised the reward schedule to 12 hours while the study was ongoing. This means that some of the participants earlier in the study received fewer points and may have not enjoyed the experienced as much as later participants. No other revisions were made to the point system as seen in (
Wellness Partners Game+Diary point reward system.
|
Number of participants | >15 mins | <15 mins | <30 mins | <45 mins | <60 mins | <75 mins | <90 mins | |
|
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Light | 1 | 1 | 3 | 5 | 7 | 8 | 9 | 9 |
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Medium | 1 | 1 | 8 | 10 | 12 | 15 | 17 | 17 |
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Heavy | 1 | 1 | 12 | 15 | 18 | 21 | 24 | 24 |
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|
Light | 2 | 1 | 1 | 3 | 2 | 2 | 2 | 2 |
3 | 2 | 2 | 4 | 3 | 3 | 3 | 3 | ||
≥4 | 3 | 3 | 5 | 4 | 4 | 4 | 4 | ||
|
Medium | 2 | 1 | 1 | 2 | 2 | 2 | 1 | 1 |
3 | 2 | 2 | 3 | 3 | 3 | 1 | 1 | ||
≥4 | 3 | 3 | 4 | 4 | 4 | 1 | 1 | ||
|
Heavy | 2 | 1 | 1 | 3 | 3 | 2 | 1 | 1 |
3 | 2 | 2 | 4 | 4 | 3 | 2 | 2 | ||
≥4 | 3 | 3 | 5 | 5 | 4 | 3 | 3 | ||
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|
First activity ever | 5 | |||||||
|
Second activity of the day | 2 | |||||||
|
First setback of the day | 1 (0 points thereafter) |
We did collect feasibility data in this study, which includes FU survey questions on usability and evaluation of various features in each version of the intervention, user technology literacy (eg, prior gaming experience and participation on social networking websites), daily software bug reports, and 20 semi-structured, in-depth interviews [
Another limitation of this study is the use of a single self-report item measure of PA, which did not include accelerometry. Given limited resources at the time of study design, we determined that self-reported PA combined with objective measures of outcome, such as BMI, fat percentage, and fat mass would be adequate for this interventional pilot study.
A future version of this study would include a number of revisions in both versions of the intervention and study procedures. The first proposed revision relates to mobile access. Due to the exploratory nature of the intervention and the wide variety of socioeconomic characteristics of the intended audience, it was determined that the lowest common denominator technology would be a computer with a Web browser that participants could access at least once per day at home or at work. The Diary version of the intervention was compatible with mobile phones that had full Web browser support and the Diary+Game version was only compatible with Flash-enabled mobile phones. Given current smartphone ownership and social networking website diffusion, a revision of the software would be developed as a mobile app as well as a website to provide participants easy access.
The second revision would be the study design. This study used a crossover design without a washout period. Ego-network groups switched conditions within 24 hours of egos completing their first anthropometry FU. Although a washout period is common for pharmaceutical studies, this study did not have a washout period for several reasons. One secondary objective for this study was to determine whether a simple game could help jumpstart PA self-reporting and/or make it less tedious. Observing the immediate effects of ending the game was therefore important. In future analyses, researchers might also compare participants’ satisfaction with the website versions and see whether greater affinity for either version (with or without game features) resulted in changes in usage behavior and/or changes in PA or other measures. For example, participants may report dislike of a version, yet they may benefit from adherence to it and not realize it is working for them until the program is swapped for something else. In addition, this study focused on the evaluation of the effectiveness of social gaming features as opposed to social networking only. Future studies may consider adding a control group with no intervention, or a wait list control group.
The third revision relates to the research procedure. A fully powered study based on the criteria described under the section Power Analysis would have to address both adequate enrollment and strategies for minimizing attrition. Given budgetary constraints, a manual rolling recruitment and data collection process was designed and adopted in this study. It was complicated to manage and required too many steps, which was a burden for study coordinators and potential participants. For example, egos whose alters delayed contacting us may have experienced higher frustration, which contributed to dropout rates. Future attempts of a similar approach could benefit from an automated content management system for participant recruitment, screening, and frequent reminders to egos about inviting unlimited alters.
The fourth proposed revision is on the objective measurement. Scheduling in-person anthropometric measurements was another challenge to participant retention. Since switching of the condition followed the egos’ schedule of data collection, if an ego delayed completion of anthropometry or the online survey, the group would stay longer in their initially assigned condition. Future studies should take advantage of the more widely available free accelerometer mobile apps and obtain anthropometric measures from both egos and alters rather than relying on self-reports.
Finally, the fifth revision is regarding sampling. Implementing the study in a community setting, rather than a workplace setting, could be more convenient for some participants. Conducting the study with a population sample, rather than an organizational one, would provide even greater generalizability.
WP was designed as a Web-based PA promotion diary with social gaming features for adults. The intervention design requires an iterative process to ensure the quality of basic features. Rigorous research design and study procedure are needed to implement and evaluation the intervention. The game features included in the Diary+Game version of WP did not have a great variety or superb sophistication, greater depth and length of play would be required to produce stronger effects and sustain long-term changes. However, our empirical findings suggest that the Diary+Game version had stronger effects on BMI and body fat, with a trend for increased PA. Results were modest, yet surprising, given the short study duration and the absence of a nutritional intervention. This suggests that interventions with social gaming features hold promise in the battle against obesity.
Video documentation of Wellness Partners website (Game Version).
Art asset documentation of Wellness Partners (Game Version).
Documentation of instructions emailed to Wellness Partners study participants with their username and password. Version of instructions and version of website participants received access to was determined by random assignment of ego-network groups.
body mass index
follow-up
physical activity
University of Southern California
Wellness Partners
This research was funded by the Robert Wood Johnson Foundation, Pioneer Portfolio Health Games Research (U-64448). The sponsor did not hold an active role in any research activities or in publication of this manuscript. We would like to thank the Center for Work and Family Life at University of Southern California for recruitment and data collection location support, and the faculty, staff, and students who contributed to the design, development, data collection, and data analysis as credited at
Gotsis and Jordan-Marsh have received workshop travel support from Humana unrelated to this project. Gotsis and Spruijt-Metz have received travel support from Apple unrelated to this project.