Gamified physical activation of young men – a Multidisciplinary Population-Based Randomized Controlled Trial (MOPO study)

Particularly in industrialised wealthy societies physical inactivity causes 1.9 million deaths per year [1] because of its several adverse health effects [2]. Physical activity provides important health benefits already in adolescence, including reduced symptoms of depression and anxiety, improved physical fitness, as well as reduced body fatness and favourable cardiovascular and metabolic disease risk profiles [3]. Positive health effects of a physically active lifestyle among youth are tracked to adulthood, such as lesser amount of adult obesity [4, 5]. Sedentary behaviour and physical activity have also been shown to persist and track from youth into adulthood [5, 6]. Despite the known benefits of physical activity on health and future life opportunities, recent evidence consistently demonstrates that a majority of adolescents do not meet current physical activity and public health recommendations of at least 60 minutes per day of moderate or vigorous intensity activity on at least five days per week [3, 7, 8]. In fact, even less than 10% of the 16–19 years old meet these recommendations [9]. Obesity has become more common while physical fitness has deteriorated markedly. The change in weight has been rapid where the average weight of male adolescents has increased by more than six kilos over a period of 13 years [10]. At the same time, physical performance has declined dramatically [11, 12].

Recent evidence underlines the importance of focusing on the balance of light-intensity activities and sedentary behaviours due to the deleterious effects of sitting on health and wellbeing [13]. A meta-analysis showed a dose–response relation between increased sedentary behaviour and unfavourable health outcomes in children and youth [14]. Furthermore, a reduction in any type of sedentary time is associated with lower health risk in youth. Daily TV viewing in excess of 2 hours is associated with diminished physical and psychosocial health, and a lowered sedentary time reduces body mass index [14]. Physical inactivity has also been associated with an increased likelihood of having several emotional and behavioural problems among boys [15‐17]. Hence, an early intervention promoting physical activity and decreasing sedentary behaviour at young age may prevent any future adverse health outcomes.

At present it is not known what the most appropriate method for promoting physical activity among young men is. This would require knowledge and understanding of factors related to deciding to engage in or abstain from physical activity. Interventions to promote physical activity have typically involved teaching individuals the skills to change their activity behaviour, providing knowledge about the goals or opportunities of physical activity, or creating a more physically active environment. In adolescents, multicomponent interventions including school, family and communal elements seem to be most beneficial, yet studies outside the school setting are called for [18, 19]. Tailored health communication has proved to be an effective method in promoting healthy behaviours [20, 21], but has not been utilized in activation interventions among youth. Innovative approaches taking into account the context of changing youth cultures and trajectories are needed.

In research of behaviour and behaviour change understanding and analysing the phenomena in its socio-cultural setting is essential [22]. Qualitative research methods allow observing the phenomena multifaceted and in the actual context [23]. Thus the socially constructing cultural meanings such as values, attitudes and motives, which direct the actual health behaviour, can be incorporated to the study of the physical activity and activation of young men. Both cultural studies of health and technology are recognised fields of research [24, 25], but the combination of these in studies which aims at activation of certain populations through intervention are just emerging.

There is indicative evidence that information and communication technologies (ICTs) such as the Internet and mobile phones can be more effective than other methods for carrying out physical activity interventions among young people [26]. The technology allows a possibility to distribute tailored feedback to a wide range of people and settings in a low cost manner [18, 27]. One effective way to convey health information and affect health behaviour could be through games [28, 29]. Recent RCT trials show successful interventions [30] and improved health-related behaviour [31, 32] through the use of games. Recently, a study showed that using a 3D fantasy game for the treatment of depressive symptoms among adolescents was as effective as conventional counselling and significantly reduced depression, anxiety and hopelessness, and improved quality of life [33]. It seems that the inherent orientation towards playing together transfers from other areas of life into computer games. Social skills are needed, or must be developed, in order to succeed in most of the multi-player games. The social bonding can be so strong that it becomes one of the most important motivating factors for playing the games [34]. This might also apply in the context of physical activation when utilizing a game technology. In this study gamification means the process of increasing user engagement and participation by integrating game mechanics into other youth oriented services, such as communal services, networking and distribution of health information [35].

The results of this study will provide evidence on the effectiveness of the online gamified activation service for increasing the activity and reducing inactivity in young men. This is the first study to combine a gamified service with objective continuous measurement of physical activity in daily life; i.e. also when the subject is not using the service. The study also provides novel information on the health status, physical fitness, motivational factors and profiles of physically active and inactive young men. This information can be utilized in future development of tailored gamified services. Promotion of physical activity at young age provides an early intervention for preventing any future adverse health effects. Hence, the produced physical activation method has broad public health significance.

The developed new model of gamification used for promoting physical activity will provide a new approach for reaching young people. Tailored health messages are delivered based on applying the transtheoretical model that is augmented with the concept of information behaviour to identify the participants’ stages of exercise behaviour change. This study will explore new possibilities to direct the health behaviour of young men without many times ineffective and provoking top-down coercive health instructing, which may have opposite effects that was intended among adolescents [59]. For finding new, affecting, and at same time entertaining and socially acceptable means for adolescents, their active participation to the development process is essential. The produced gamified platform may exert other positive social effects which may directly or indirectly improve health and wellbeing.

There are challenges in this trial. Firstly, the young men form a challenging target group that has not been widely studied. Furthermore, the most inactive young men may not be willing to participate to the study resulting in selection bias. Based on our previous pilot study, this will not likely affect the main results since the main characteristics of the participants and non-participants did not differ. Secondly, in previous studies compliance to wear physical activity monitors has been low. Although the Internet is a promising medium to deliver behaviour change programs, previous research have shown low exposure rates to web-based interventions [60]. The increased use of smartphones may change this due improved access to internet from almost anywhere. As a strength of our study, the target group is actively involved in the design of the gamified activation service and its social elements to provide appealing contents. Online social features have reduced attrition from health behaviour change interventions, especially in populations with low social support [61]. Tailored health messages will be delivered based on an application of the transtheoretical model. The degree of message tailoring may influence engagement to the intervention program, which is associated with positive health behaviour change [62].

In conclusion, the planned multidisciplinary co-operation aims to produce information of health and factors affecting health behavior in young men. This information will be utilized for the development of new methods for physical activation of young people. The development work is conducted in co-operation with the participants and utilizing important elements of youth culture. If successful, this unique intervention to activate young men can provide a translational model for community use. Also, if proven effective, the produced physical activation method can be utilized as such or tailored to other selected populations or age groups.