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Motivation: Motivation is crucial for treatment adherence, particularly for chronic disease management. Insufficient motivation can result in non-adherence, negatively affecting self-management activities and treatment outcomes [1]. Gamification – the use of game design elements in non-game contexts – is a promising approach for enhancing patient motivation and adherence. It can stimulate intrinsic and extrinsic motivation by satisfying basic psychological needs such as competence, autonomy, involvement, and safety [2]. However, the specific effects of individual game design elements remain poorly understood.

Methods: A structured categorisation of game design elements was achieved by analysing and synthesising Werbach and Hunter's hierarchy of game elements, and Deterding and Dixon's levels of abstraction [3], [4]. Unstructured lists of game elements identified through exploratory internet searches were also structured and incorporated into the hierarchy of game elements. To determine their motivational potential, all identified game components were analysed using established theories of motivation, primarily Self-Determination Theory, Maslow’s Hierarchy of Needs and ERG Theory. The analysis focused on how the design of individual game components and mechanics can trigger different game dynamics and thus address different psychological motives and needs.

Results: Twenty-three game components, eighteen game mechanics and eight game dynamics were identified. The impact on motivation depends not only on the chosen elements and how they are designed and implemented, but also on how they interact with each other and adapt to users' needs and personalities. Furthermore, it is important to note that psychological needs can only be satisfied if users voluntarily use the gamified application and its associated services. Game components such as awards, badges, and collecting virtual goods can increase performance, membership, and satisfaction. Teams, quests, economic systems and messages can fulfil motives for meaning and social interaction. Meanwhile, rankings, boss fights and virtual goods can encourage success, self-esteem and social competition. Cascading information and stories can satisfy the motives for cognitive stimulation, curiosity, meaning, individualisation and a sense of safety.

Discussion: This analysis outlines the relationship between game elements and various motivational factors. However, more empirical evidence is needed on the effect of these elements on patient motivation. Furthermore, the dual nature of gamification, which has the potential to have both positive and negative effects on motivation, should be considered in more detail. Inappropriate or poorly tailored game elements, such as overly complex tasks or competition features that do not match users' abilities, may frustrate or demotivate them rather than motivate them. While this analysis primarily focused on SDT and Maslow's hierarchy, other theories (e.g. McClelland's and Vroom's) remain to be fully explored in this context.

Conclusion: This work presents a structured framework that maps game design elements to motivational needs and motives, supported by psychological theory. The findings indicate that the impact of game design elements on patients' needs and motives depends on various factors, including the combination and specific implementation of game components, the game design itself, and the personality profile of a patient. Nevertheless, the framework provides practical guidance for purposefully designing gamified interventions to support long-term patient engagement and adherence.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.

References

[1] World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003.
[2] Blohm I, Leimeister JM. Gamification. Wirtschaftsinf. 2013;55(4):275-8.
[3] Werbach K, Hunter D, Dixon W. For the win: How game thinking can revolutionize your business. Philadelphia: Wharton Digital Press; 2012.
[4] Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: defining "gamification". In: Lugmayr A, Franssila H, et al, editors. Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments. 2011. p. 9-15.