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      Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game

      , MBBS (Hons), MRes, MRCGP, MRCP (UK), DFSRH , 1 , 2 , , MSc 3 , , MEng, MSc 4 , 5 , , BSc, MSc, PhD 1 , 6 , , BSc, MSc, PhD 1 , 2 , , BEng, MSc 3 , , BSc, MSc, PhD 1 , 2 , , BSc, MSc, PhD 1 , 2 , , MSc 7 , , MBBS, MRCP (UK) 1 , 2 , , BSc, PhD 8 , , BSc, PhD 3 , , BA, MBBS, DPhil, FRCP (UK), FRCGP (UK) 1 , 2 , , BSc, MBBS, MD, FRCP (UK), FRCGP (UK) 1 , 2

      (Reviewer), (Reviewer)

      JMIR Serious Games

      JMIR Publications

      smoking cessation, health behaviors, behavioral medicine, games for health, mHealth, eHealth

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps.

          Objective

          This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app.

          Methods

          A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers.

          Results

          Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend.

          Conclusions

          A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.

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          Most cited references 138

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          Developing and evaluating complex interventions: the new Medical Research Council guidance

          Evaluating complex interventions is complicated. The Medical Research Council's evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance
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            The behaviour change wheel: A new method for characterising and designing behaviour change interventions

            Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
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              The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions.

              CONSORT guidelines call for precise reporting of behavior change interventions: we need rigorous methods of characterizing active content of interventions with precision and specificity. The objective of this study is to develop an extensive, consensually agreed hierarchically structured taxonomy of techniques [behavior change techniques (BCTs)] used in behavior change interventions. In a Delphi-type exercise, 14 experts rated labels and definitions of 124 BCTs from six published classification systems. Another 18 experts grouped BCTs according to similarity of active ingredients in an open-sort task. Inter-rater agreement amongst six researchers coding 85 intervention descriptions by BCTs was assessed. This resulted in 93 BCTs clustered into 16 groups. Of the 26 BCTs occurring at least five times, 23 had adjusted kappas of 0.60 or above. "BCT taxonomy v1," an extensive taxonomy of 93 consensually agreed, distinct BCTs, offers a step change as a method for specifying interventions, but we anticipate further development and evaluation based on international, interdisciplinary consensus.
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                Author and article information

                Contributors
                Journal
                JMIR Serious Games
                JMIR Serious Games
                JSG
                JMIR Serious Games
                JMIR Publications (Toronto, Canada )
                2291-9279
                Oct-Dec 2018
                29 November 2018
                : 6
                : 4
                Affiliations
                [1 ] Centre for Primary Care and Public Health Blizard Institute, Bart’s and The London School of Medicine and Dentistry Queen Mary University of London London United Kingdom
                [2 ] Asthma UK Centre for Applied Research Bart’s and The London School of Medicine and Dentistry Queen Mary University of London London United Kingdom
                [3 ] Faculty of Science Engineering Computing Kingston University London United Kingdom
                [4 ] MRC Integrative Epidemiology Unit University of Bristol Bristol United Kingdom
                [5 ] School of Psychological Science University of Bristol Bristol United Kingdom
                [6 ] Social Science Research Unit University College London London United Kingdom
                [7 ] Centre for Complexity Science University of Warwick Coventry United Kingdom
                [8 ] Department of Statistics University of Warwick Coventry United Kingdom
                Author notes
                Corresponding Author: Elizabeth A Edwards dr.elizabeth.ann.edwards@ 123456gmail.com
                Article
                v6i4e10252
                10.2196/10252
                6293248
                30497994
                ©Elizabeth A Edwards, Hope Caton, Jim Lumsden, Carol Rivas, Liz Steed, Yutthana Pirunsarn, Sandra Jumbe, Chris Newby, Aditi Shenvi, Samaresh Mazumdar, Jim Q Smith, Darrel Greenhill, Chris J Griffiths, Robert T Walton. Originally published in JMIR Serious Games (http://games.jmir.org), 29.11.2018.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org.as well as this copyright and license information must be included.

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