Experience with a team-based gamification health app for behavior change adapted to people with diabetes: A pilot study

2.1 Study design

This study employed a mixed-methods approach. Data were collected using a written questionnaire, which included both numerical responses and open-ended questions allowing participants to describe their experience using the application. The quantitative findings from the numerical responses were further enriched by integrating insights from the qualitative analysis of the participants’ free-text descriptions.

2.2 Design and features of the app used in this study

The Minchalle app, developed by A10 Lab Inc. and launched in 2015, promotes the development of “desirable habits” and is available for both Android and iOS users. With a user base of 1.5 million, the app is widely used. Rooted in social cognitive theory, it motivates specific behaviors through group interactions, enhancing social support and fostering social comparison.

Available on a free plan, users can opt for a monthly fee of approximately 500 yen (approximately US$3) for additional services, such as ad-free usage and participation in more teams. The app offers a variety of teams targeting various areas, such as physical activity, eating habits, and academic performance. Users anonymously join goal-specific groups of up to five members, sharing daily progress photos in the team chat. Several teams have focused on improving self-management strategies for people with diabetes.

The team chat allows members to report challenges, provide feedback, and earn coins and badges for meeting set conditions. Noncontributing members are automatically removed, emphasizing active participation. Challenge records are stored in My Data, allowing users to track their achievements. Coins earned through challenges can be donated to local government and non-governmental organization social contribution activities. The app also features a chatbot that engages in team chats, offering encouragement and support based on members’ progress. Figure 1 provides a sample image (For detailed descriptions of the app, refer to Supplementary Figures 1–5 in Supplementary File 1).

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Figure 1.

Sample images of the app. (a) The user chooses a team to post the challenge. (b) The user posts a photo, step count, and comment to the team thread (posting the challenge). (c) The challenge is displayed in the team thread. (d) Reply to the team member's post or approve the member's challenge by tapping OK. (e) The record of the challenge is saved in My Data, and the user can check his/her achievement.

Participants were recruited by posting recruitment posters on bulletin boards at 11 clinics from January to December 2022. Each clinic displayed the posters for approximately three months. Eligible participants were individuals with diabetes (types 1 and 2), smartphone users who could cover communication expenses, and those able to download the app independently. The exclusion criteria included prior app usage; however, no participants were excluded based on this criterion.

Interested individuals contacted a principal investigator previously unknown to them and received a 15-min briefing via phone or video call explaining the purpose of the study and how to participate, with the promise of a 3000 yen reward for using the app for seven days and 1000 yen per completed questionnaire.

After receiving a 23-page instruction manual, they independently downloaded the app. Using the app like regular users, the participants underwent an initial tutorial on app usage, challenge posting, and team selection. Although not directed toward diabetes management teams, participants chose the teams based on personal preferences, such as exercise-oriented teams.

2.4 Data collection

All study data were obtained through self-administered questionnaires. The participants were given a questionnaire after a six-week trial period. They were asked to complete the questionnaire whether they had used the application for the full seven days or not.

The questionnaire assessed system satisfaction, ease of use, enjoyment, usefulness for diabetes self-care, and burden, using a five-point scale (from strongly agree to strongly disagree). Free-text descriptions were also included. The survey also asked which app features they found useful.

2.5 Data analysis

2.6 Ethics and conflict of interest

This study was conducted in accordance with the guidelines stipulated in the Declaration of Helsinki. It was approved by the Ethical Committee of Kobe City College of Nursing (2021-1-0401). Consent was obtained for the publication of this report during the informed consent process. The authors have no conflicts of interest to declare regarding the development, operation, or evaluation of the application.

3.1 Description of participants

Thirty-two people with diabetes consented to participate. The participants’ demographic data are presented in Table 1. Although two participants discontinued the app during the 7-day implementation period, all 32 participants completed the questionnaire. Table 2 presents responses to five questions assessing participants’ insights from using the app. The summarized participant statements are available in Supplementary File 2, with a representative description included below.

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Table 2.

Insights on using the app (n = 32).

		Strongly agree	Agree	Neutral	Disagree	Strongly disagree
1.	I am satisfied with the use of Minchalle.	16%	59%	13%	9%	3%
2.	The use of Minchalle was enjoyable.	9%	50%	22%	16%	3%
3.	Minchalle was easy to operate and use.	6%	44%	28%	16%	3%
4.	The use of Minchalle was useful for diabetes self-management.	19%	63%	6%	13%	0%
5.	The use of Minchalle was a burden for me.	0%	3%	28%	34%	34%
						(%)

3.3 Ease of use

3.4 Functionality

3.5 Relevance of app use and self-care

The majority of respondents (81.3%) agreed or strongly agreed that using Minchalle was useful for diabetes self-management. The most significant contribution to lifestyle, as perceived by participants, was related to regular physical activity, as shown in Table 3. Moreover, the features that were beneficial to these self-care efforts are shown in Table 4. The feature that was perceived as the most supportive was the team system, followed by the display of challenge-tracking features and the encouragement provided by the AI. In their open-ended responses, participants explained that the experience had affected their lifestyle and feelings, such as their willingness to engage in self-care.

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Table 4.

App functions that respondents found useful (n = 32).

	Features/functions	%
1	Team system	59.4%
2	Challenge-tracking (the number of days challenged)	46.9%
3	Cat encouragement (AI-based encouragement)	37.5%
4	Notification: posting prompts	25.0%
5	Coins usable (donation or exchange)	21.9%
6	My page: reflecting on an individual challenge	18.8%
7	Encouragement messages delivered in the morning	18.8%
8	Badge system	6.3%

4.1 Benefits of the key features of the app

The Minchalle app integrates social support and comparison mechanisms, which are grounded in social cognitive theory,^34,35 to enhance app retention and foster new habits. Over 70% of the participants found the app beneficial for developing exercise habits, confirming the utility of smartphones in promoting physical activity. ³⁶ The reasons for this may lie in exercise itself, which requires less effort and provides immediate feedback compared with other lifestyle habits.^36,37 Similar to traditional healthcare apps, this team-based gamification health app can also encourage physical activity.

Approximately 60% of the participants enjoyed using the app, with peer collaboration and emotional support cited as contributing factors. Such support may enhance engagement, satisfaction, and retention rates. ¹⁵ Peer support, established through reciprocal relationships, ³⁸ fosters emotional support, ³⁹ a key benefit of peer-support apps compared with solo health apps.

The design of health apps often integrates goal-setting and evaluation mechanisms, which are standard features.^40,41 Additionally, the inclusion of goal-sharing among team members has been shown to enhance user engagement and motivation. ⁴² In this study, the app exemplifies this approach by facilitating team-based interactions that leverage these principles. This collective approach to goal achievement likely strengthens users’ motivation and commitment, as suggested previously.^43–45 Beyond promoting goal achievement, this team-based structure may also alleviate some of the psychological burdens associated with self-management, such as maintaining motivation and reducing feelings of isolation and burnout.

Furthermore, half of the participants endorsed challenge-tracking features, such as the number of successful challenge days. This feature creates a clear sense of accomplishment, which may boost self-efficacy and sustain motivation over time. ⁴⁶ Although other gamification elements, such as badge and coin systems,^47,48 were available, most participants did not intentionally utilize them. The results suggest that while gamification elements are increasingly integrated into healthcare apps, their effectiveness may vary depending on the context. In this study, users appeared to favor social connections and immediate feedback over system-oriented gamification mechanics. Therefore, while these features are helpful for some users, the app's core strength may lie in its emphasis on fostering social connections and providing immediate feedback, both of which were valued by the participants.

4.2 Role of social support in user engagement

Emotional support also emerged as a key benefit of the app, as participants mentioned feeling understood and encouraged by their peers. For example, one participant stated, “I received encouraging messages when my blood test results were not so good, and when I was feeling alone and depressed, those messages helped me stay positive and try harder the next time.”. Emotional support not only helps individuals feel understood and motivated but also contributes to the formation of a shared social identity. By receiving encouragement and recognition from peers, participants are more likely to perceive themselves as valued members of a group, fostering a sense of belonging that is consistent with social identity theory. ⁴⁹ Furthermore, it could be argued that Japan's cultural tendencies toward collectivism, which may subtly favor mutual support over overt individual competition, may enhance certain aspects of group-based health interventions. This perspective is consistent with observations that interdependent self-construal may contribute to social cohesion and adherence in such settings. ⁵⁰ Our findings align with those of previous research, which indicated the critical role of peer support in maintaining motivation during health behavior change.^39,51 According to social identity theory, group membership fosters a sense of belonging and guides behaviors through social norms. ⁴⁹ Participants reported feeling less alone in their efforts to establish healthy new habits, underscoring the value of visualizing others’ contributions during team interactions, ⁵² as exemplified by statements such as, “It makes me feel better that I am not alone when I know that the other members are also making such an effort.” Similar results to those of previous studies were observed, in which social identity and group norms influenced eating ⁵³ and exercise habits.^54,55 By collaborating as a team in achieving goals and visualizing their collective efforts, participants can experience a sense of meaningful and socially significant contribution, which aligns with the concept of role satisfaction. ⁵⁶ As a participant noted, “there is a sense of camaraderie and that each of us is making an effort,” emphasizing the importance of teamwork. The design of this app enables users to organically contribute through simple posts and is thus both rational and effective in fostering a sense of belonging, as reflected in comments like, “It encourages me to carry out my daily activities, and I don't feel bad when I receive compliments. It creates a virtuous cycle.” Compared with traditional individual-focused diabetes management strategies, a team-based approach promotes collaborative goal-setting and accountability, which can enhance engagement and adherence.^43,57,58 Participants noted that the shared team goals provided an additional layer of motivation, creating a sense of responsibility not only to themselves but also to their peers.

This observation can also be understood through the lens of social comparison theory, which posits that peer support facilitates positive upward social comparisons, validating individuals’ thoughts and feelings while cultivating hope and motivation during the behavior change process.^49,59 For instance, one participant described feeling compelled to add squats to their routine to compensate for a lack of stride after seeing others’ posts, illustrating how observing peers’ activities can inspire additional effort. However, dissatisfaction with team collaboration emerged, particularly due to the difficulty in finding like-minded peers, which undermined engagement. Building on the concept of role satisfaction, participants appreciated opportunities for sharing practices and receiving support, although some struggled to find like-minded peers, revealing a limitation in the development of cohesive team dynamics. Dissatisfaction with team collaboration highlights the need for strategies to enhance alignment and mutual understanding among members. Being part of a well-matched team is crucial for effective app use and habit development.^60,61 Because peer support often relies on strong social bonds, ²¹ the absence of like-minded peers can hinder engagement. ⁶² Online-based peer support is particularly valuable in areas with limited social resources.^63,64 The app's ability to allow users to compare and change teams could enhance its effectiveness when utilized appropriately.

Overall, although the app demonstrates significant potential in nurturing social connections and deepening user engagement through team-based mechanisms, challenges remain in addressing mismatched expectations and managing user burdens, such as team dynamics.

4.3 Barriers to engagement and operational challenges

It is commendable that even the elderly participants were able to use the app independently. However, it is worth noting that two participants dropped out immediately, without joining a team. Early dropout is common in intervention studies,^65,66 and can be caused by a mismatch of expectations, a lack of enjoyment, or a lack of functionality.^11,12 A recent systematic review reported that there are few effective ways to prevent early dropout, except for external rewards. ⁶⁷ In this study, elderly users may have immediately judged that they could not use the app effectively. This suggests that a certain level of technological adaptability is required.

Although a certain level of technological adaptability is required, digital health interventions have shown potential in overcoming such barriers, ⁶⁸ with emerging research indicating successful engagement even among older populations. ²³ However, in this study, participants – whose average age was 61 – gave mixed reviews, with around 30% not denying the burden of the input work, and 50% disagreeing with the ease of use of the app. Specifically, the notification function, which participants found inconvenient, was effectively used by only a few and led to multiple complaints. Although notifications can serve as helpful prompts, ⁶⁹ they can also induce stress, ⁷⁰ particularly when users feel rushed.^71,72 Furthermore, some participants found the notification sounds at night to be unpleasant, which could detract from the user experience. Intuitive notification customization is likely important.

The app's group dynamics created a complex motivational environment. As one participant noted, “By creating a sense of solidarity, there is a bit of a sense of obligation, which is either that or motivation as a result.” This reflects the balance between leveraging group support and avoiding overwhelming external pressure. The app's ability to foster a supportive community is key to encouraging participation and providing social reinforcement. However, it needs to balance encouragement with user independence to prevent it from becoming a burden and to sustain participation.

About 30% of participants reported feeling pressured to communicate and post regularly, reflecting controlled motivation. ²⁴ Some felt compelled to exercise or post to avoid leaving a team, indicating a tension between motivation and the perceived burden of meeting the team's demands. In particular, this progression reflects the nuanced psychological dynamics of behavior change outlined in self-determination theory. While external pressure can initiate habit formation, the ultimate goal is to cultivate intrinsic motivation to sustain long-term engagement. Over time, external pressure is expected to be gradually replaced by autonomous motivation. ⁷³ The gradual transition from controlled to autonomous motivation is a critical mechanism in sustained health behavior change. Autonomous motivation for diabetes self-care takes time to develop,^74,75 and a 6-week program is insufficient for this transition. Although controlled motivation can help establish discipline, strategies are needed to support the transition to autonomous motivation for sustained engagement.

Participants also noted the added burden of photo submissions, which required extra effort compared to solo health apps like Fitbit. For continued use, it is important that participants perceive the benefits of emotional support and efficacy as outweighing the input burden.

As previously discussed, frequent notifications and pressure to contribute may have compromised the user experience. These concerns are linked to the app's notification system and team selection process. Though notification customization is available, some participants were unaware of it. To improve user experience, future apps should make these settings more intuitive and accessible. Additionally, participants may not have fully understood team characteristics before joining, which could lead to mismatches. Clarifying team features and providing more detailed descriptions could help users make more informed decisions, reducing disengagement.

4.4 Limitations of the study and implications for future research

The study has several limitations. First, this pilot study had a relatively small sample size (N = 32), which reduced the statistical power and generalizability of the findings to the broader population of people with diabetes in Japan. The demographic distribution of our sample showed an overrepresentation of people with Type 2 diabetes, and the age distribution was skewed toward older participants, and thus may not fully reflect the experiences of younger Japanese patients with diabetes. Moreover, selection bias may exist as participants were enrolled through message board recruitment, indicating a potentially high baseline interest in digital health management and technological literacy. The study design is also limited by the absence of a control group, which prevents comparative assessments. The 6-week follow-up period, while sufficient for initial usability assessment, may have been too short to sufficiently observe sustained behavioral changes in diabetes self-management, capturing seasonal variations in diet and physical activity patterns typical of the Japanese lifestyle, or identifying long-term adherence patterns and potential app fatigue. Furthermore, this timeframe may be insufficient to detect meaningful changes in clinical outcomes, such as HbA1c levels, which typically require 2–3 months to reflect significant lifestyle modifications. The reliance on self-reported data also introduces potential recall bias. The comprehensive usability study, while providing rich qualitative insights, employed unique open-ended questions that may limit comparability with other studies. Despite these limitations, this pilot study provides valuable initial insights into user experiences with the novel health app in the context of limited traditional peer support options. Furthermore, the findings lay the groundwork for conducting future studies involving larger participant pools to explore associations between application usage, self-care motivation, self-care behaviors, and HbA1c levels.