Can gamified behavioral change mental health mobile apps reduce students’ anxiety and improve well-being? An efficacy study

Abstract

Aim: Designed to support the mental well-being of university students, the gamified Student Stress Resilience (SSResilience) app guides users in setting and working toward goals related to studying, socializing, and exercising. The app monitors progress through a combination of data from a user’s phone (via Internet of Things sensors) and information they enter themselves. This efficacy study documented students’ goal-setting efforts (RQ1) and examined the app’s effect on students’ anxiety, resilience, and psychological well-being (RQ2).

Methods: A quasi-experimental pretest-posttest control group design was used. Experimental group students (n₁ = 25) used the app for two weeks. Control group students (n₂ = 50) used different means to set the same goals. All students were pre-tested and post-tested on anxiety, well-being, and resilience using standardized questionnaires.

Results: Nineteen out of 25 experimental group students used the app to set one or more goals (19/25), and 18 of them found it helpful (18/25). The experimental group experienced a significant (t(22) = 2.72, P = 0.013) decrease in anxiety from M_pre = 8.96 (SD = 5.30) to M_post = 5.76 (SD = 4.59), an increase in well-being from M_pre = 54.6 (SD = 25.88) to M_post = 65.12 (SD = 23.90), but no change in resilience. Control group students’ (n = 43) measurements remained unchanged.

Conclusions: Preliminary findings indicate a potential value of the SSResilience app for significantly reducing students’ anxiety and increasing their well-being. Integrating Internet of Things technology (built-in phone sensors) into gamified apps for health holds significant promise by offering valuable data to users, app developers, and researchers. Future research will use wearables to measure stress and physical activity more accurately than self-reports.

Keywords

gamification / behavioral change / mobile applications / resilience / anxiety / mental health

References

[1] Zhang M, Liu Y. Impact of fear of COVID-19 on students’ performance, moderating role of mindfulness: HSK students’ perception-based view. Front Public Health. 2022; 10:967125.

[2] Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor-davidson Resilience Scale (CD-RISC): Validation of a 10-item measure of resilience. J Trauma Stress. 2007; 20:1019-28.

[3] Osborn TL, Wasanga CM, Ndetei DM. Transforming mental health for all. BMJ. 2022; 377:o1593.

[4] Digital 2020: July Global Statshot [Internet]. Kepios; [cited2023 Apr 18]. Available from:https://datareportal.com/reports/digital-2020-july-global-statshot

[5] Lupton D. The Oxford Handbook of Digital Media Sociology. In: Rohlinger DA, Sobieraj S, editors. The Sociology of Mobile Apps. New York: Oxford University Press; 2020. pp. 197-218.

[6] Lang M, Zawati MH. The app will see you now: mobile health, diagnosis, and the practice of medicine in Quebec and Ontario. J Law Biosci. 2018; 5:142-73.

[7] Alamoodi AH, Garfan S, Zaidan BB, Zaidan AA, Shuwandy ML, Alaa M, et al. A systematic review into the assessment of medical apps: motivations, challenges, recommendations and methodological aspect. Health Technol. 2020; 10:1045-61.

[8] Ndayishimiye C, Lopes H, Middleton J. A systematic scoping review of digital health technologies during COVID-19: a new normal in primary health care delivery. Health Technol (Berl). 2023; 13:273-84.

[9] Zhao Y, Morris A, Marais BJ, Pardo A, Scott KM. Exploring how medical students learn during clinical rotations: a pilot study with a mobile application. Health Technol. 2019; 9:257-67.

[10] Lupton D. The digitally engaged patient: Self-monitoring and self-care in the digital health era. Soc Theory Health. 2013; 11:256-70.

[11] van Dijck J, Poell T, de Waal M. The Platform Society: Public Values in a Connective World. New York: Oxford University Press; 2018.

[12] Oyebode O, Ndulue C, Alhasani M, Orji R. Persuasive Mobile Apps for Health and Wellness: A Comparative Systematic Review. In: Gram-Hansen SB, Jonasen TS, Midden C, editors. Proceedings of 15th International Conference on Persuasive Technology (PERSUASIVE 2020); Aalborg, Denmark. Cham: Springer International Publishing; 2020. pp. 163-81.

[13] Miller AS, Cafazzo JA, Seto E. A game plan: Gamification design principles in mHealth applications for chronic disease management. Health Informatics J. 2016; 22:184-93.

[14] Morris JW, Murray S, editors. Appified: Culture in the Age of Apps. Michigan: University of Michigan Press; 2018.

[15] Yan M, Filieri R, Raguseo E, Gorton M. Mobile apps for healthy living: Factors influencing continuance intention for health apps. Technol Forecast Soc Change. 2021; 166:120644.

[16] Milne-Ives M, Homer SR, Andrade J, Meinert E. Potential associations between behavior change techniques and engagement with mobile health apps: a systematic review. Front Psychol. 2023; 14:1227443.

[17] Schmidt-Kraepelin M, Warsinsky S, Thiebes S, Sunyaev A. The Role of Gamification in Health Behavior Change: A Review of Theory-driven Studies. Proceedings of the 53rd Hawaii International Conference on System Sciences; 2020 Jan 7-10; Hawaii, US. Hawaii: HICSS; 2020. pp. 1256-65.

[18] Six SG, Byrne KA, Tibbett TP, Pericot-Valverde I. Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis. JMIR Ment Health. 2021; 8:e32199.

[19] Nicolaidou I. Turn Your Classroom Into a Gameshow With a Game-Based Student Response System. Proceedings of 12th European Conference on Games Based Learning; 2018 Oct 4-5; Sophia Antipolis, France. Reading, UK: Academic Conferences and Publishing International Ltd; 2018. pp. 487-94.

[20] Patel M, Asch DA, Volpp KG. Wearable devices as facilitators, not drivers, of health behavior change. JAMA. 2015; 313:459-60.

[21] Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997; 12:38-48.

[22] Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986.

[23] Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000; 55:68-78.

[24] Edwards EA, Lumsden J, Rivas C, Steed L, Edwards LA, Thiyagarajan A, et al. Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps. BMJ Open. 2016; 6:e012447.

[25] Hurmuz MZ, Jansen-Kosterink SM, Hermens HJ, van Velsen L. Game not over: Explaining older adults’ use and intention to continue using a gamified eHealth service. Health Informatics J. 2022; 28:14604582221106008.

[26] VandeWeerd C, Yalcin A, Aden-Buie G, Wang Y, Roberts M, Mahser N, et al. HomeSense: Design of an ambient home health and wellness monitoring platform for older adults. Health Technol. 2020; 10:1291-309.

[27] D’Addario M, Baretta D, Zanatta F, Greco A, Steca P. Engagement Features in Physical Activity Smartphone Apps: Focus Group Study With Sedentary People. JMIR Mhealth Uhealth. 2020; 8:e20460.

[28] Laranjo L, Ding D, Heleno B, Kocaballi B, Quiroz JC, Tong HL, et al. Do smartphone applications and activity trackers increase physical activity in adults? Systematic review, meta-analysis and metaregression. Br J Sports Med. 2021; 55:422-32.

[29] Lee D, Frey GC, Min A, Kim B, Cothran DJ, Bellini S, et al. Usability inquiry of a gamified behavior change app for increasing physical activity and reducing sedentary behavior in adults with and without autism spectrum disorder. Health Informatics J. 2020; 26:2992-3008.

[30] Cotton V, Patel MS. Gamification Use and Design in Popular Health and Fitness Mobile Applications. Am J Health Promot. 2019; 33:448-51.

[31] Khademian F, Aslani A, Bastani P. The effects of mobile apps on stress, anxiety, and depression: overview of systematic reviews. Int J Technol Assess Health Care. 2020; 37:e4.

[32] Wu J, Ma Y, Zuo Y, Zheng K, Zhou Z, Qin Y, et al. Effects of Mindfulness Exercise Guided by a Smartphone App on Negative Emotions and Stress in Non-Clinical Populations: A Systematic Review and Meta-Analysis. Front Public Health. 2022; 9:773296.

[33] D’Alfonso S, Santesteban-Echarri O, Rice S, Wadley G, Lederman R, Miles C, et al. Artificial Intelligence-Assisted Online Social Therapy for Youth Mental Health. Front Psychol. 2017; 8:796.

[34] Eisenstadt M, Liverpool S, Infanti E, Ciuvat RM, Carlsson C. Mobile Apps That Promote Emotion Regulation, Positive Mental Health, and Well-being in the General Population: Systematic Review and Meta-analysis. JMIR Ment Health. 2021; 8:e31170.

[35] Edge D, Watkins ER, Limond J, Mugadza J. The efficacy of self-guided internet and mobile-based interventions for preventing anxiety and depression-A systematic review and meta-analysis. Behav Res Ther. 2023; 164:104292.

[36] Sleven Y. Effective Strategies for Overcoming Stress and Anxiety. Junic. 2024; 1:35-40.

[37] McColl LD, Rideout PE, Parmar TN, Abba-Aji A. Peer support intervention through mobile application: An integrative literature review and future directions. Can Psychol. 2014; 55:250-7.

[38] Stawarz K, Preist C, Coyle D. Use of Smartphone Apps, Social Media, and Web-Based Resources to Support Mental Health and Well-Being: Online Survey. JMIR Ment Health. 2019; 6:e12546.

[39] Firth J, Torous J, Nicholas J, Carney R, Pratap A, Rosenbaum S, et al. The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry. 2017; 16:287-98.

[40] Zhang MWB, Ho RCM. Moodle: The cost effective solution for internet cognitive behavioral therapy (I-CBT) interventions. Technol Health Care. 2017; 25:163-5.

[41] Camacho-Sánchez R, Rillo-Albert A, Lavega-Burgués P. Gamified Digital Game-Based Learning as a Pedagogical Strategy: Student Academic Performance and Motivation. Appl Sci. 2022; 12:11214.

[42] BinDhim NF, Shaman AM, Trevena L, Basyouni MH, Pont LG, Alhawassi TM. Depression screening via a smartphone app: cross-country user characteristics and feasibility. J Am Med Inform Assoc. 2015; 22:29-34.

[43] Khan KS, Mamun MA, Griffiths MD, Ullah I. The Mental Health Impact of the COVID-19 Pandemic Across Different Cohorts. Int J Ment Health Addict. 2022; 20:380-6.

[44] Nicolaidou I, Aristeidis L, Lambrinos L. A gamified app for supporting undergraduate students’ mental health: A feasibility and usability study. Digit Health. 2022; 8:20552076221109059.

[45] Golden EA, Zweig M, Danieletto M, Landell K, Nadkarni G, Bottinger E, et al. A Resilience-Building App to Support the Mental Health of Health Care Workers in the COVID-19 Era: Design Process, Distribution, and Evaluation. JMIR Form Res. 2021; 5:e26590.

[46] Reyes AT, Muthukumar V, Bhatta TR, Bombard JN, Gangozo WJ. Promoting Resilience Among College Student Veterans Through an Acceptance-and-Commitment-Therapy App: An Intervention Refinement Study. Community Ment Health J. 2020; 56:1206-14.

[47] Litvin S, Saunders R, Maier MA, Lüttke S. Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial. PLoS One. 2020; 15:e0237220.

[48] Aryana B, Brewster L. Design for mobile mental health: Exploring the informed participation approach. Health Informatics J. 2020; 26:1208-24.

[49] Villalobos-Zúñiga G, Cherubini M. Apps that motivate: A taxonomy of app features based on self-determination theory. Int J Hum Comput Stud. 2020; 140:102449.

[50] Cheng VWS, Davenport T, Johnson D, Vella K, Hickie IB. Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review. JMIR Ment Health. 2019; 6:e13717.

[51] Nicolaidou I. The Impact of an App on Students’ Anxiety, Well-Being, and Resilience: A Pilot Efficacy Study. In: Arai K, editor. Intelligent Computing. Cham: Springer; 2023. pp. 848-55.

[52] Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008; 46:266-74.

[53] Topp CW, Østergaard SD, Søndergaard S, Bech P. The WHO-5 Well-Being Index: a systematic review of the literature. Psychother Psychosom. 2015; 84:167-76.

[54] Baumel A, Muench F, Edan S, Kane JM. Objective User Engagement With Mental Health Apps: Systematic Search and Panel-Based Usage Analysis. J Med Internet Res. 2019; 21:e14567.

[55] Wu A, Scult MA, Barnes ED, Betancourt JA, Falk A, Gunning FM. Smartphone apps for depression and anxiety: a systematic review and meta-analysis of techniques to increase engagement. NPJ Digit Med. 2021; 4:20.

[56] Roepke AM, Jaffee SR, Riffle OM, McGonigal J, Broome R, Maxwell B. Randomized Controlled Trial of SuperBetter, a Smartphone-Based/Internet-Based Self-Help Tool to Reduce Depressive Symptoms. Games Health J. 2015; 4:235-46.

[57] Avey J, Newman A, Herbert K. Fostering employees’ resilience and psychological well-being through an app-based resilience intervention. Pers Rev. 2023; 52:2229-44.

[58] MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C. Adverse Childhood Experiences and Building Resilience With the JoyPop App: Evaluation Study. JMIR Mhealth Uhealth. 2021; 9:e25087.

[59] Ang WHD, Chew HSJ, Dong J, Yi H, Mahendren R, Lau Y. Digital training for building resilience: Systematic review, meta-analysis, and meta-regression. Stress Health. 2022; 38:848-69.

[60] Antezana G, Venning A, Smith D, Bidargaddi N. Do young men and women differ in well-being apps usage? Findings from a randomised trial. Health Informatics J. 2022; 28:14604582211064825.

[61] Aryana B, Brewster L, Nocera JA. Design for mobile mental health: an exploratory review. Health Technol. 2019; 9:401-24.

[62] Nicolaidou D, Nicolaidou I. Evaluating the effectiveness of stress management applications: questionnaires or wearables? A methodological study. In: Bastiaens T, editors. Proceedings of EdMedia + Innovate Learning; 2023 Jul 10; Vienna, Austria. Vienna, Austria: Association for the Advancement of Computing in Education (AACE); 2023. pp. 181-8.