If walking more could earn you points in a game, or even money, would you feel incentivized to become more physically active?

Research from LDI Fellows at the Center for Health Incentives and Behavioral Economics (CHIBE) indicates that behavioral interventions can boost physical activity over 18 months.

“This is one of the largest and longest-duration randomized trials of a home-based intervention to promote physical activity,” said LDI Senior Fellow Alexander Fanaroff, Assistant Professor of Medicine at the University of Pennsylvania Perelman School of Medicine and lead author of the study. 

Improving health does not always mean going to the doctor for treatment; sometimes it requires innovative approaches that make healthy choices more appealing and achievable. Lessons from behavioral economics can help inform these approaches. 

In a promising clinical trial featured on the Today Show, LDI Senior Fellows Fanaroff, Neel Chokshi, Louise Russell, Dylan Small, Kevin Volpp, and colleagues designed interventions to determine how behaviorally-designed gamification, loss-framed financial incentives, or a combination of the two could influence physical activity. The three interventions showed a 10% increase in daily steps across the board compared with attention control, and a 40% increase from participants’ baselines,  and were sustained for one year.

Physical activity is known to lower the risk of major adverse cardiovascular events, yet many people struggle to meet recommended activity levels (e.g., 7,000 to 10,000 steps per day according to the American Heart Association). This is where behavioral economics comes in, which integrates fundamental concepts from economics and psychology to shape patterns of decision making.

Testing Behavioral Health Tools to Increase Physical Activity

The study examined effects over a 12-month period, followed by a six-month post-intervention follow-up. The study enrolled about 1,000 participants who were patients with clinical atherosclerotic cardiovascular disease (ASCVD) or who had a high risk for cardiovascular disease.

Participants were provided with a Fitbit, a wrist-worn fitness device, to track daily steps. They established baseline step counts, followed by setting personalized goals to increase their daily step count by at least 1500 from their baseline, and then were randomly assigned to 1 of 4 intervention groups:

• Control group (i.e., daily text reminders)
• Gamification group
• Financial incentives group
• Combined gamification and financial incentives group

The gamification intervention entailed playing a game administered by the research team where participants could gain points and progress through different levels by meeting the step goals. Each week participants received 70 points. If their daily step goal was achieved, they retained their points—if the step goal was not achieved, they lost 10 points. Also, at the end of each week, gamification participants moved up or down five different levels (i.e., blue, bronze, silver, gold, or platinum) according to the points they retained during the previous week. 

The financial incentives intervention entailed earning money upon goal completion. Specifically, participants in the financial incentives group received $14 per week but lost $2 per day if they did not meet their step goals.

Gamification and Financial Incentives Increased Physical Activity

The findings were promising:

• At the 12-month mark, participants in the gamification and financial incentives groups increased their daily steps by an average of almost 2,000 steps in comparison to the average increase of about 1,500 in the control group.
• Those in the combined gamification and financial incentives group showed the most significant improvement with an average increase of almost 2,300 steps in comparison to the control group. This group had the most success during the six-month follow-up period after the program ended.

With an almost 90% completion rate, all intervention groups saw an increase in their average daily steps from the study’s onset, along with more than 40 additional minutes of moderate-to-vigorous physical activity per week. 

The study did not collect the impacts on participants’ health in this trial. But such an increase would correspond to a 6% lower risk of death from any cause and a 10% lower risk of death from heart attack or stroke, “highlighting the clinical relevance of the change achieved in this trial,” Fanaroff said.

Putting Behavioral Economics Tools into Practice to Increase Physical Activity

The combined gamification and financial incentives approach yielded the most substantial and sustained improvements, suggesting that such behavioral interventions could be integrated into broader strategies aimed at reducing cardiovascular risk. The annual health care costs of cardiovascular disease in the U.S. reached $320 billion in 2016, so such interventions may be a cost effective way to improve health.

By leveraging these insights, providers, policymakers, and health care leaders can develop more effective programs to promote physical activity and improve cardiovascular health outcomes.

For example, some Medicare Advantage plans provide free fitness trackers and smartwatches, such as Fitbits, as part of their efforts to improve health and lower the costs of your care. Lessons from the study and behavioral economics suggest that efforts of this kind may benefit from being paired with games and/or money incentives.

---

The 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,” was published on April 7, 2024 in Circulation. Authors include Alexander C. Fanaroff, Mitesh S. Patel, Neel Chokshi, Samantha Coratti, David Farraday, Laurie Norton, Charles Rareshide, Jingsan Zhu, Tamar Klaiman, Julia E. Szymczak, Louise B. Russell, Dylan S. Small, and Kevin G. M. Volpp.

---

Author

---