Date of Award

May 2024

Degree Type

Dissertation

Degree Name

Doctor of Philosophy

Department

Biomedical and Health Informatics

First Advisor

Jake Luo

Committee Members

Jennifer Fink, Min Wu, Xiangming Mu

Keywords

Gamification, Hypertension, Medication Adherence, mHealth, Motivational theories, User-centered Design

Abstract

Medication non-adherence poses a significant challenge across healthcare, leading to adverse health outcomes, increased hospitalizations, and substantial costs. This dissertation explores the potential of a theory-driven, gamified smartphone-based medication reminder system to address this prevalent issue. Drawing on insights from a systematic review of the literature and extensive user-centered design methods, the research aims to develop a solution that effectively addresses the complex barriers individuals face in medication management. By integrating established behavioral theories and gamification elements into the design, the system seeks to enhance patient motivation, engagement, and adherence behaviors. The ultimate goal is to create a tailored, gamified tool that empowers individuals to confidently manage their medications and improve their health outcomes.Study one: Gamification in Medication Adherence: A Systematic Review of Theoretical Frameworks, Game Elements, and Populations The rising burden of chronic diseases necessitates innovative approaches to improve medication adherence for sustained health management. Gamification has surfaced as a promising technique to motivate patients and encourage adherence. This systematic review examines the potential of gamification to enhance medication adherence while exploring how theoretical frameworks, patient involvement, and game elements influence efficacy. The purpose is to provide insights into the effectiveness of gamified interventions and identify future research priorities to optimize these strategies. Methodical search and analysis of pertinent studies was conducted, concentrating on adherence outcomes and interactions between games, patient input, and theories. Results largely support gamification’s effectiveness in enhancing engagement, motivation, self-efficacy, and knowledge. However, inconsistencies existed in applying theoretical frameworks, underscoring the importance of patient participation in design for better outcomes. The efficacy of individual game elements and optimal combinations remains inconclusive, warranting additional research to determine ideal configurations across diseases and groups. In summary, gamification harbors potential to improve medication adherence for chronic diseases. Nonetheless, future efforts should prioritize rigorously constructed studies with standardized measures, considering patient characteristics and disease factors. Incorporating frameworks, patient input, and tailored designs can produce gamified solutions to effectively target adherence obstacles among diverse chronic disease populations. Further exploration is needed to crystallize understanding of mechanisms underlying effective gamification while accounting for individual variability. Through comprehensive evaluative approaches additionally inclusive of well-established theoretical frameworks and high levels of patient population engagement, tailored gamification solutions may be designed for optimal addressing of medication adherence impediments manifesting across diverse chronic disease groups. Study Two: Perspectives Study on Medication Reminder Apps: Identifying Key Features and Opportunities for Improvement Mobile health applications providing medication reminders show promise for addressing the widespread public health issue of medication non-adherence. However, real-world evidence on patient experiences and which features drive sustained engagement remains limited. This study extensively analyzed over 40,000 user reviews spanning five years across top medication reminder apps. Employing LDA-based topic modeling and qualitative techniques, we elucidate critical drivers of user satisfaction and continued usage. The analysis employed qualitative techniques on user reviews to deeply investigate user experiences and views on the strengths and weaknesses of current apps. Findings on 20 top medication reminder apps and 41,566 user reviews emphasized ease of use, reliability, prompt delivery, and high customizability of medication schedules/reminders as pivotal for perceived value and effectiveness. 45.43% of reviews contained positive feedback on efficiency and reliability, while 54.34% highlighted improvement areas, like notification issues (2.40%) and data privacy concerns (6.66%). 14.33% noted a lack of support for managing multiple medications as an unmet need. The study highlights the necessity of moving beyond fundamental alerts to sophisticated, personalized platforms tailored to individuals’ lifestyles and requirements. Thoughtfully incorporating gamification and motivational principles could further boost engagement by making regimen management more rewarding. The analysis provides a useful roadmap for the design of next-generation medication reminder apps. By focusing on the satisfaction drivers identified and targeting the present barriers, future interventions can shift from mere reminders to customizable health companions that actively engage patients in their care. Study Three: Integrating Theoretical Models and Gamification into Medication Adherence Strategies: A Holistic Framework Non-adherence to medication is a prevalent concern for patients with chronic illnesses, and it can significantly affect their health outcomes. To address this issue, we propose a comprehensive theoretical framework incorporating various theoretical models, such as the Health Belief Model, Self-Determination Theory, Social Cognitive Theory, Transtheoretical Model, and gamification techniques. This approach enables healthcare professionals and mHealth designers to develop individualized interventions that promote patient motivation, self-efficacy, and behavior modification, resulting in better medication adherence and overall patient outcomes. The framework addresses the multidimensional factors influencing adherence, including patients’ beliefs, motivations, self-efficacy, readiness to change, and engagement. It advocates crafting tailored, patient-centered interventions informed by these theories that educate on treatment benefits, enhance perceived competence in self-management, utilize social influence, and incorporate customized game elements to motivate adherence behaviors intrinsically. The integrative approach allows interventions to be adapted to individual contexts and evolving needs. The conceptual model has significant potential to advance clinical practice and research by providing a blueprint for developing holistic, evidence-based adherence promotion strategies. However, empirical testing across diverse populations and validation of the most effective components are critical next steps. Overall, the unified framework signifies an interdisciplinary advancement toward understanding and intervening upon the complex determinants of medication non-adherence. Study Four : Designing 'Heartbeat+': A Theory-Grounded and Patient-Centered Gamified Mobile App for Hypertension Medication Management Hypertension medication non-adherence significantly impacts health outcomes and healthcare costs. This study presents the design of 'Heartbeat+,' a prototype gamified mobile app for hypertension management grounded in a multi-theoretical approach. Drawing on the Health Belief Model, Transtheoretical Model, Social Cognitive Theory, and Self-Determination Theory, 'Heartbeat+' aims to enhance medication adherence, promote positive health behaviors, and improve patient engagement. The app's design integrates gamification elements such as points, badges, and challenges to increase motivation and provide rewards for medication adherence. It also incorporates features like medication reminders, educational content, progress tracking, and a community forum to address users' needs across different stages of behavior change. These features foster self-efficacy, perceived benefits, social support, and autonomy, all critical for sustained adherence. The effectiveness of the app's design will be evaluated through user feedback, allowing for the refinement of features to better align with patient needs. Notably, the multi-theoretical approach underpinning 'Heartbeat+' aims to create a comprehensive and adaptable solution tailored to the complex motivations and barriers influencing medication adherence in hypertension management. This study highlights the potential of utilizing theory-driven design and gamification to create engaging and effective mHealth interventions for chronic disease management. Study five : Evaluating the Efficacy of 'HeartBeat+': A Gamified Hypertension App Prototype Based on Integrated Behavioral Theories This study investigates the impact of "HeartBeat+," a gamified mobile application designed to promote hypertension medication adherence. Grounded in a multi-theoretical framework incorporating the Health Belief Model, Self-Determination Theory, Social Cognitive Theory, and the Transtheoretical Model, the app aims to enhance user motivation, engagement, and adherence. A comparative study with 100 participants evaluated the gamified app against a non-gamified control. Results revealed that "HeartBeat+" users reported significantly greater perceived usefulness, engagement, and motivation from gamification elements. This included significantly higher ratings for the app's effectiveness in managing hypertension (p=0.015) and overall visual appeal (p = 0.003). User preference data indicated that rewards-driven features, challenges, and leaderboards were particularly effective in driving motivation. These findings demonstrate the benefits of integrating gamification and a multi-theoretical design approach when tackling the challenge of medication non-adherence. The study offers valuable insights for developing effective mHealth interventions and strategies to improve chronic disease management.

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