Effect of gain- and loss-framed gamification with or without social support on daily step counts in patients with cardiovascular disease: the FOOTSTEPS randomized controlled trial

Background Physical activity is crucial for the prevention of cardiovascular disease (CVD), yet most patients with CVD fail to achieve recommended activity levels. Gamification strategies by behavioral economics show promise for increasing physical activity, but their effectiveness in older populations with CVD remains unknown. The authors aimed to evaluate the efficacy of gamification, with different framing approaches (gain vs. loss) and social support, on physical activity among patients with CVD. Methods In this five-arm randomized controlled trial, adults with heart failure or coronary artery disease were assigned to control (Arm 1: n=70), loss-framed gamification (Arm 2: n=69), gain-framed gamification (Arm 3: n=64), loss-framed gamification with social support (Arm 4: n=67), or gain-framed gamification with social support (Arm 5: n=66). The smartphone-based intervention incorporated gamification elements (points, rankings, and daily feedback) for 6 weeks, followed by a 6-week follow-up. The primary outcome was the change in mean daily steps during the intervention; secondary outcomes included changes during follow-up and the proportion of goal-achieving days. Linear mixed models and generalized estimating equations were used to estimate treatment effects on step changes and goal achievement, respectively. Results A total of 336 patients (mean age 65 years; 22% female) were enrolled. During the intervention period, the largest increase in daily steps was observed in the loss-framed gamification with social support group (adjusted difference, +572.5 steps [95% CI, 97.2 to 1047.8]; p = 0.0182), although no arms met the conservative Bonferroni-corrected significance level (Figure, Table). During the follow-up period, loss-framed gamification with social support increased both daily steps (adjusted difference, +693.0 steps [209.6 to 1176.4]; p = 0.0050). Regarding goal achievement, goal-achieving days increased during the intervention in both loss-framed (adjusted risk difference, 0.109 [95% CI, 0.031 to 0.187]; p = 0.0059) and gain-framed (0.119 [0.040 to 0.199]; p = 0.0033) groups with social support. This effect was sustained during follow-up in the loss-framed with social support group (0.152 [0.067 to 0.237]; p = 0.0005). Conclusions Loss-framed gamification with social support increased physical activity among patients with CVD during the follow-up period, indicating sustained behavioral change. These findings suggest that smartphone-based gamification programs incorporating loss framing and social support represent a promising and scalable strategy for promoting sustained physical activity in this population.FigureTable