Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial
Open accessAbstract
Forty percent of all general-practitioner appointments are related to mental illness, although less than 35% of individuals have access to therapy and psychological care, indicating a pressing need for accessible and affordable therapy tools. The ubiquity of smartphones offers a delivery platform for such tools. Previous research suggests that gamification-turning intervention content into a game format-could increase engagement with prevention and early-stage mobile interventions. This study aimed to explore the effects of a gamified mobile mental health intervention on improvements in resilience, in comparison with active and inactive control conditions. Differences between conditions on changes in personal growth, anxiety and psychological wellbeing, as well as differences in attrition rates, were also assessed. The eQuoo app was developed and published on all leading mobile platforms. The app educates users about psychological concepts including emotional bids, generalization, and reciprocity through psychoeducation, storytelling, and gamification. In total, 358 participants completed in a 5-week, 3-armed (eQuoo, "treatment as usual" cognitive behavioral therapy journal app, no-intervention waitlist) randomized controlled trial. Relevant scales were administered to all participants on days 1, 17, and 35. Repeated-measures ANOVA revealed statistically significant increases in resilience in the test group compared with both control groups over 5 weeks. The app also significantly increased personal growth, positive relations with others, and anxiety. With 90% adherence, eQuoo retained 21% more participants than the control or waitlist groups. Intervention delivered via eQuoo significantly raised mental well-being and decreased self-reported anxiety while enhancing adherence in comparison with the control conditions. Mobile apps using gamification can be a valuable and effective platform for well-being and mental health interventions and may enhance motivation and reduce attrition. Future research should measure eQuoo's effect on anxiety with a more sensitive tool and examine the impact of eQuoo on a clinical population.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In much of the literature, gamification and integration of social components strengthened mHealth app use and engagement, resulting in more positive outcomes and increased peer support for MMs and PSP.
“In much of the literature, gamification and the integration of social components strengthened mHealth app use and engagement, resulting in more positive outcomes and an increased sense of peer support for the MMs and PSP populations [14,36,46]”
From Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation (2022) · cites this paper as [46]
The Introduction describes gamification as a promising way to increase engagement, and the Conclusion reports better well-being outcomes and lower attrition with the gamified app. But the paper does not establish that integrating social components increased peer support, or report these effects for MMs and PSP populations. Its Discussion also cautions that the trial’s results cannot be attributed directly to gamification because the apps differed in other ways. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMechanics like daily challenges or streak counters are effective in triggering consistent behaviour and fostering psychological ownership of the service.
“In particular, mechanics like daily challenges or streak counters are effective in triggering consistent behaviour and fostering psychological ownership of the service (Litvin et al., 2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al., 2020
The Discussion (page unavailable) reports significantly lower attrition in the gamified-app group, which offers some support for improved adherence. But the paper does not establish that daily challenges or streak counters trigger consistent behaviour or foster psychological ownership; its Strengths and limitations section says app usage was not recorded, so the effect on nonusage attrition could not be evaluated. (LLM, conf=0.88)
Experimental — accuracy not yet measuredStreak mechanics convert initial interest into habitual behaviour.
“This finding extends Edney et al. ' s (2019) work on attrition reduction by demonstrating that streak mechanics specifically interrupt the honeymoondecline pattern characteristic of subscription services, converting initial interest into habitual behaviour as theorised by Litvin et al. (2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al. (2020)
The Introduction describes gamification generally as a promising way to increase engagement and reduce attrition, and the Discussion reports lower attrition in the gamified-app group. Neither passage identifies streak mechanics or theorizes that they convert initial interest into habitual behaviour; a search for streaks and habit formation found no such account. (LLM, conf=0.77)
Experimental — accuracy not yet measuredStreak mechanics specifically interrupt the honeymoon-decline pattern characteristic of subscription services.
“This finding extends Edney et al. ' s (2019) work on attrition reduction by demonstrating that streak mechanics specifically interrupt the honeymoondecline pattern characteristic of subscription services, converting initial interest into habitual behaviour as theorised by Litvin et al. (2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al. (2020)
The Introduction describes the difficulty of turning interest in mental-health apps into regular use and presents gamification as a possible way to improve engagement. The Discussion reports lower attrition in the gamified-app group but cautions that the result cannot be attributed directly to gamification. Neither section supports the more specific claim that streak mechanics interrupt a honeymoon decline in subscription services or create habitual behaviour. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFamily- and community-level factors were seldom addressed in the identified apps, despite being indicated as an important component of resilience.
“family- and community-level factors were seldom addressed in our identified apps, despite being indicated as an important component of resilience [44,46].”
There was an observed lack of social connectedness components within the apps reviewed.
“there was an observed lack of social connectedness components within the apps reviewed [14,23,36,46].”
From Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation (2022) · cites this paper as [46]
The Introduction discusses social relationships as an aspect of well-being, and the Methods describe the two apps used in a randomized trial. Neither section reports a review of apps or an observed lack of social-connectedness components. Searches for social-connectedness components and social features found no passage making that observation; page numbers were unavailable in our copy. (LLM, conf=0.75)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Development and validation of brief measures of positive and negative affect: The PANAS scales.
Watson, D., Clark, L. A., & Tellegen, A. (1988) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.54.6.1063 · Cited by 32,433 · cited 1× · see citing works
“We suggest a multimethod approach for well-being, that is, use of various validated outcome measures such as the 5-item World Health Organization Well-Being Index [90], the Positive and Negative Affect Schedule [91] and the Psychological Distress Scale [92].”
Method(1970) · Cited by 24,983 · see citing works
On Happiness and Human Potentials: A Review of Research on Hedonic and Eudaimonic Well-Being
Ryan, R. M., & Deci, E. L. (2001) · Annual Review of Psychology · doi:10.1146/annurev.psych.52.1.141 · Cited by 11,567 · see citing works
THE BIG FIVE PERSONALITY DIMENSIONS AND JOB PERFORMANCE: A META‐ANALYSIS
BARRICK, M. R., & MOUNT, M. K. (1991) · Personnel Psychology · doi:10.1111/j.1744-6570.1991.tb00688.x · Cited by 8,689 · cited 1× · see citing works
“The first type of question is the “concept question”, which tests an individual’s mastery of the skills learned in the tutorial, and the second is a personality question based on the Big Five Personality Test [62].”
From game design elements to gamefulness: defining "gamification"
Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011) · Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments · doi:10.1145/2181037.2181040 · Cited by 8,402 · see citing works
The WHO-5 well-being index: A systematic review of the literature
Topp, C. W., Østergaard, S. D., Søndergaard, S., & Bech, P. (2015) · Psychotherapy and Psychosomatics · doi:10.1159/000376585 · Cited by 4,708 · cited 1× · see citing works
“We suggest a multimethod approach for well-being, that is, use of various validated outcome measures such as the 5-item World Health Organization Well-Being Index [90], the Positive and Negative Affect Schedule [91] and the Psychological Distress Scale [92].”
MethodMental illness and/or mental health? Investigating axioms of the complete state model of health
Keyes, C. L. M. (2005) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.73.3.539 · Cited by 3,357 · cited 2× · see citing works
“Although mental health, defined as hedonic and eudaimonic well-being [37], is not the opposite of mental illness, the two are interrelated [38].”
BackgroundThe motivational pull of video games: a self-determination theory approach
Ryan, R. M., Rigby, C. S., & Przybylski, A. (2006) · Motivation and Emotion · doi:10.1007/s11031-006-9051-8 · Cited by 3,332 · see citing works
Marteau, T. M., & Bekker, H. (1992) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1992.tb00997.x · Cited by 3,238 · see citing works
Psychological Well-Being Revisited: Advances in the Science and Practice of Eudaimonia
Ryff, C. D. (2014) · Psychotherapy and Psychosomatics · doi:10.1159/000353263 · Cited by 2,976 · cited 1× · see citing works
“Cronbach’s alpha reliability = 0.88 [55].”
InfluentialEysenbach, G. (2005) · Journal of Medical Internet Research · doi:10.2196/jmir.7.1.e11 · Cited by 2,524 · cited 3× · see citing works
“This is in line with previous research according to which attrition occurs when a participant fails to complete the study protocol associated with the intervention [24, 61].”
BackgroundResultGarnefski, N., Kraaij, V., Schroevers, M. J., & Somsen, G. A. (2008) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-008-9136-5 · Cited by 2,487 · see citing works
Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019) · Journal of Abnormal Psychology · doi:10.1037/abn0000410 · Cited by 1,469 · cited 1× · see citing works
“With the increasing trends in psychological distress, suicide, and self-harm among young people [4], effective treatment and prevention are urgently needed.”
BackgroundGamification for health and wellbeing: A systematic review of the literature
Johnson, D., Deterding, S., Kuhn, K.-A., Staneva, A., Stoyanov, S., & Hides, L. (2016) · Internet Interventions · doi:10.1016/j.invent.2016.10.002 · Cited by 1,237 · see citing works
Smartphones for smarter delivery of mental health programs: A systematic review
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M.-R., & Christensen, H. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2791 · Cited by 1,136 · cited 1× · see citing works
“The paucity of such data notwithstanding, there is a growing body of randomized controlled trials (RCTs) showing the potential of mobile mental health apps to reduce symptoms of depression, anxiety, and stress [17, 18].”
BackgroundFindings from the Global Burden of Disease Study 2021
Murray, C. J. L. (2024) · The Lancet · doi:10.1016/s0140-6736(24)00769-4 · Cited by 1,071 · see citing works
A systematic review of gamification in e-Health
Sardi, L., Idri, A., & Fernández‐Alemán, J. L. (2017) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2017.05.011 · Cited by 1,041 · cited 1× · see citing works
“With respect to the aim of this study, gamification has been acknowledged as a promising strategy to increase engagement with an intervention and thereby to reduce attrition and augment the intended treatment effects [28, 30, 31].”
BackgroundObjective user engagement with mental health apps: systematic search and panel-based usage analysis
Baumel, A., Muench, F., Edan, S., & Kane, J. M. (2019) · Journal of Medical Internet Research · doi:10.2196/14567 · Cited by 965 · cited 1× · see citing works
“Examining objective app usage data, a systematic review by Baumel et al. revealed that only a small portion of individuals actually use apps targeting depression, anxiety, and emotional well-being over a long time period [22].”
MethodBarriers to mental health treatment: results from the National Comorbidity Survey Replication
Mojtabai, R., Olfson, M., Sampson, N. A., Jin, R., Druss, B., Wang, P. S., Wells, K. B., Pincus, H. A., & Kessler, R. C. (2011) · Psychological Medicine · doi:10.1017/s0033291710002291 · Cited by 951 · cited 1× · see citing works
“Indeed, recent research suggests that the most common reasons for not seeking mental health treatment are respondents’ desire to manage their problems on their own, stigma associated with seeking psychological help, and perceptions of treatment as inconvenient or ineffective [11–13].”
BackgroundThe association between social relationships and depression: A systematic review
Santini, Z. I., Koyanagi, A., Tyrovolas, S., Mason, C., & Haro, J. M. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2014.12.049 · Cited by 949 · cited 1× · see citing works
“On the other hand, a recent systematic review indicated that social support and a large, diverse social network serve a protective role against depression [43].”
BackgroundA Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies
Donkin, L., Christensen, H., Naismith, S. L., Neal, B., Hickie, I. B., & Glozier, N. (2011) · Journal of Medical Internet Research · doi:10.2196/jmir.1772 · Cited by 876 · cited 1× · see citing works
“The randomness comes from atmospheric noise, which for many purposes is better than the pseudo-random number algorithms typically used in computer programs [77].”
Torous, J., Nicholas, J., Larsen, M. E., Firth, J., & Christensen, H. (2018) · Evidence Based Mental Health · doi:10.1136/eb-2018-102891 · Cited by 790 · cited 1× · see citing works
“Moreover, smartphone-delivered interventions for mental health problems suffer from low engagement, with mean attrition rates ranging from 9.6% for interventions targeting general stress to 50.0% for apps focusing on insomnia relief [23].”
BackgroundInfluentialSocial Functioning in Depression: A Review
Hirschfeld, R. M. A., Montgomery, S. A., Keller, M. B., Kasper, S., Schatzberg, A. F., Moller, H.-J., Healy, D., Baldwin, D., Humble, M., Versiani, M., et al. (2000) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.v61n0405 · Cited by 586 · cited 1× · see citing works
“Depression has also frequently been linked to maladaptive social functioning [40, 41], and the risk of depression is significantly negatively correlated with social support and relationship quality [42].”
BackgroundLinardon, J., & Fuller-Tyszkiewicz, M. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000459 · Cited by 573 · cited 2× · see citing works
“This is in line with previous research according to which attrition occurs when a participant fails to complete the study protocol associated with the intervention [24, 61].”
BackgroundResultKazdin, A. E. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.06.004 · Cited by 554 · cited 1× · see citing works
“Despite the high demand and need for services, the majority of individuals in need of mental health services receive no treatment [5, 6].”
BackgroundTorous, J., Lipschitz, J., Ng, M., & Firth, J. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.11.167 · Cited by 546 · cited 2× · see citing works
“Considering the high rate of attrition reported in internet-based interventions [25] which is on average between 43–99%, emails were sent out to 2,500 participants with an invitation to participate in the study.”
BackgroundRathbone, A. L., & Prescott, J. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.7740 · Cited by 497 · see citing works
Strengths‐Based Cognitive–Behavioural Therapy: A Four‐Step Model to Build Resilience
Padesky, C. A., & Mooney, K. A. (2012) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.1795 · Cited by 476 · cited 1× · see citing works
“Different CBT techniques and positive psychology methods have been linked to mental well-being [72], including the constructs tested in this paper: resilience [73], interpersonal relationships skills—even in settings as dire as domestic abuse [74], personal growth and various types of anxiety [75].”
BackgroundWebsite-Delivered Physical Activity Interventions
Vandelanotte, C., Spathonis, K. M., Eakin, E. G., & Owen, N. (2007) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2007.02.041 · Cited by 475 · cited 1× · see citing works
“These tools have been shown to enhance exposure to digital therapies, which has a direct link to effectiveness [49].”
BackgroundBlaine, B. E., & Crocker, J. (1993) · Springer eBooks · doi:10.1007/978-1-4684-8956-9_4 · Cited by 458 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundPreventing the Onset of Depressive Disorders: A Meta-Analytic Review of Psychological Interventions
Cuijpers, P., van Straten, A., Smit, F., Mihalopoulos, C., & Beekman, A. (2008) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2008.07091422 · Cited by 456 · cited 1× · see citing works
“This is somewhat surprising given the fact that prevention reduces both economic costs [3] and risk of recurrence of symptoms [9].”
BackgroundRomantic relationships and the physical and mental health of college students
Braithwaite, S. R., Delevi, R., & Fincham, F. D. (2010) · Personal Relationships · doi:10.1111/j.1475-6811.2010.01248.x · Cited by 429 · cited 1× · see citing works
“The subsection “Positive Relations with Others” was selected to avoid questionnaire fatigue while still addressing the isolation and feelings of personal disconnect that have been reported to be major factors in mental unhappiness [54] in the population targeted in this trial.”
BackgroundSocial relationships and depression: ten-year follow-up from a nationally representative study
Teo, A. R., Choi, H., & Valenstein, M. (2013) · PLoS ONE · doi:10.1371/journal.pone.0062396 · Cited by 423 · cited 1× · see citing works
“Depression has also frequently been linked to maladaptive social functioning [40, 41], and the risk of depression is significantly negatively correlated with social support and relationship quality [42].”
BackgroundEbert, D. D., Mortier, P., Kaehlke, F., Bruffaerts, R., Baumeister, H., Auerbach, R. P., Alonso, J., Vilagut, G., Martínez, K. U., Lochner, C., et al. (2019) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.1782 · Cited by 407 · see citing works
Development and psychometric evaluation of the Personal Growth Initiative Scale–II.
Robitschek, C., Ashton, M. W., Spering, C. C., Geiger, N., Byers, D., Schotts, G. C., & Thoen, M. A. (2012) · Journal of Counseling Psychology · doi:10.1037/a0027310 · Cited by 388 · cited 2× · see citing works
“The Personal Growth Initiative Scale (PGIS) was designed by Robitschek in 1999 [56].”
MethodInfluentialA one-item question with a Likert or Visual Analog Scale adequately measured current anxiety
Davey, H. M., Barratt, A. L., Butow, P. N., & Deeks, J. J. (2006) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2006.07.015 · Cited by 367 · cited 1× · see citing works
“The one-item anxiety scale measures the current anxiety level by asking how anxious someone feels at the moment [58].”
BackgroundFactor structure of mental health measures.
Compton, W. C., Smith, M. L., Cornish, K. A., & Qualls, D. L. (1996) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.71.2.406 · Cited by 339 · see citing works
Mobile Sensing and Support for People With Depression: A Pilot Trial in the Wild
Wahle, F., Kowatsch, T., Fleisch, E., Rufer, M., & Weidt, S. (2016) · JMIR mHealth and uHealth · doi:10.2196/mhealth.5960 · Cited by 333 · cited 2× · see citing works
“…is important to note that, compared with the majority of other studies, the interventions in this research were personalized based on context features derived from the interactions of each participant with the smartphone, such as location (home vs. work) or level of current physical activity [87].”
BackgroundResultAmbulatory Assessment - Monitoring Behavior in Daily Life Settings
Fahrenberg, J., Myrtek, M., Pawlik, K., & Perrez, M. (2007) · European Journal of Psychological Assessment · doi:10.1027/1015-5759.23.4.206 · Cited by 317 · see citing works
Relation between catastrophizing and depression in chronic pain patients.
Sullivan, M. J. L., & D’Eon, J. L. (1990) · Journal of Abnormal Psychology · doi:10.1037//0021-843x.99.3.260 · Cited by 316 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundTheory of mind in major depressive disorder: A meta-analysis
Bora, E., & Berk, M. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2015.11.023 · Cited by 308 · see citing works
Gamification in apps and Technologies for Improving Mental Health and Well-Being: systematic review
Cheng, V. W. S., Davenport, T., Johnson, D., Vella, K., & Hickie, I. B. (2019) · JMIR Mental Health · doi:10.2196/13717 · Cited by 280 · see citing works
Maiter, S., Simich, L., Jacobson, N. A., & Wise, J. (2008) · Action Research · doi:10.1177/1476750307083720 · Cited by 279 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundEffects of actual deception and suspiciousness of deception on interpersonal perceptions.
Toris, C. C. M., & DePaulo, B. M. (1984) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.47.5.1063 · Cited by 274 · see citing works
Relation between catastrophizing and depression in chronic pain patients.
Sullivan, M. J. L., & D’Eon, J. L. (1990) · Journal of Abnormal Psychology · doi:10.1037/0021-843x.99.3.260 · Cited by 240 · see citing works
Bakker, D., & Rickard, N. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.11.016 · Cited by 231 · cited 1× · see citing works
“For instance, approximately 83% of participants did not complete the study protocol in a recent app-based mood diary study with a follow-up period of 1-month (similar to the present study) [78].”
BackgroundTorous, J., Chan, S. R., Yee-Marie Tan, S., Behrens, J., Mathew, I., Conrad, E. J., Hinton, L., Yellowlees, P., & Keshavan, M. (2014) · JMIR Mental Health · doi:10.2196/mental.4004 · Cited by 228 · cited 1× · see citing works
“For example, survey data indicate that roughly three-quarters of psychiatric patients expressed an interest in using a smartphone to monitor their mental health and willingness to do so [19, 20].”
BackgroundThe Economic Case for the Prevention of Mental Illness
McDaid, D., Park, A., & Wahlbeck, K. (2019) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-040617-013629 · Cited by 226 · cited 2× · see citing works
“Beyond individual burden, mental disorders entail considerable economic costs exceeding expenditures for other common diseases, such as cardiovascular diseases [3].”
BackgroundFarvolden, P., Denisoff, E., Selby, P., Bagby, R. M., & Rudy, L. (2005) · Journal of Medical Internet Research · doi:10.2196/jmir.7.1.e7 · Cited by 223 · see citing works
Torous, J., Wisniewski, H., Liu, G., & Keshavan, M. (2018) · JMIR Mental Health · doi:10.2196/11715 · Cited by 201 · cited 1× · see citing works
“However, translation from interest to actual use of apps to manage health-related concerns remains a challenge, as patients tend to use apps only rarely in their daily routine [21].”
BackgroundKafka, G. J., & Kozma, A. (2002) · Social Indicators Research · doi:10.1023/a:1014451725204 · Cited by 199 · cited 1× · see citing works
“Ryff’s Scales of Psychological Well-Being (PWB) was developed in 1989 [53], and is a 6 × 14-item scale of psychological well-being (84 items total) designed to measure the dimensions of autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and…”
MethodTaft, C. T., Murphy, C. M., King, D. W., Musser, P. H., & DeDeyn, J. M. (2003) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.71.4.812 · Cited by 197 · see citing works
Action Bias and Environmental Decisions
Patt, A., & Zeckhauser, R. (2000) · Journal of Risk and Uncertainty · doi:10.1023/a:1026517309871 · Cited by 182 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundSocial psychology of behavior modification: Problems of implementation in natural settings.
Reppucci, N. D., & Saunders, J. T. (1974) · American Psychologist · doi:10.1037/h0037630 · Cited by 180 · cited 1× · see citing works
“The leap from learning psychological concepts within a game to learning the skills needed to enhance the user’s well-being within a psychological intervention is not that broad [47]; thus, we hypothesized that users completing all elements would also benefit significantly from gamified interventions.”
BackgroundElements of Gameful Design Emerging from User Preferences
Tondello, G. F., Mora, A., & Nacke, L. E. (2017) · Annual Symposium on Computer-Human Interaction in Play · doi:10.1145/3116595.3116627 · Cited by 180 · cited 1× · see citing works
“In eQuoo, 8 gamification elements were implemented, as defined by Tondello and colleagues [48],: (1) Levels: one level a week where the player has to learn two skills and implement them correctly in a choose your own adventure story in order to unlock the following level; (2) progress feedback in the form of a “progre…”
MethodGamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review
Brown, M., O'Neill, N., van Woerden, H., Eslambolchilar, P., Jones, M., & John, A. (2016) · JMIR Mental Health · doi:10.2196/mental.5710 · Cited by 178 · cited 1× · see citing works
“In contrast, a systematic review by Brown et al. [34] could not find a positive effect of gamification on program adherence to web-based mental health intervention.”
BackgroundAhtinen, A., Mattila, E., Välkkynen, P., Kaipainen, K., Vanhala, T., Ermes, M., Sairanen, E., Myllymäki, T., & Lappalainen, R. (2013) · JMIR mhealth and uhealth · doi:10.2196/mhealth.2596 · Cited by 173 · cited 2× · see citing works
“As in our study, Ahtinen et al. reported positive effects of a gamified mobile app targeting working-aged people to reduce stress and enhance satisfaction with life in a 1-month field study [85].”
BackgroundResultEng, W., Coles, M. E., Heimberg, R. G., & Safren, S. A. (2005) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2004.01.007 · Cited by 168 · cited 1× · see citing works
“Different CBT techniques and positive psychology methods have been linked to mental well-being [72], including the constructs tested in this paper: resilience [73], interpersonal relationships skills—even in settings as dire as domestic abuse [74], personal growth and various types of anxiety [75].”
BackgroundChiu, T., & Eysenbach, G. (2010) · BMC Medical Informatics and Decision Making · doi:10.1186/1472-6947-10-73 · Cited by 142 · cited 1× · see citing works
“Usability is pivotal when considering whether to use a service at all, whereas positive attitudes toward technology, and experiencing a positive impact of the intervention are crucial to long-term adherence [82].”
BackgroundResilience: A psychobiological construct for psychiatric disorders
Shrivastava, A., & Desousa, A. (2016) · Indian Journal of Psychiatry · doi:10.4103/0019-5545.174365 · Cited by 127 · cited 1× · see citing works
“Resilience is an individual’s ability to adapt and recover following adverse events [44] and is another psychological construct besides well-being worth considering in the context of mental health apps.”
BackgroundInfluentialBehavioral and Neural Mechanisms of Overgeneralization in Anxiety
Laufer, O., Israeli, D., & Paz, R. (2016) · Current Biology · doi:10.1016/j.cub.2016.01.023 · Cited by 121 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundKelders, S. M., Sommers‐Spijkerman, M., & Goldberg, J. M. (2018) · Journal of Medical Internet Research · doi:10.2196/jmir.9923 · Cited by 113 · cited 6× · see citing works
“[36] found evidence for significantly higher personal involvement and flow in participants who used a gamified versus non-gamified web-based intervention designed to improve well-being in the general population.”
BackgroundInfluentialGamification and serious games in depression care: A systematic mapping study
Dias, L. P. S., Barbosa, J. L. V., & Vianna, H. D. (2018) · Telematics and Informatics · doi:10.1016/j.tele.2017.11.002 · Cited by 112 · cited 1× · see citing works
“The primary aim of gamification is to improve adherence to and motivation in the intervention [86].”
BackgroundA Social Ecological Measure of Resilience for Adults: The RRC-ARM
Liebenberg, L., & Moore, J. (2016) · Social Indicators Research · doi:10.1007/s11205-016-1523-y · Cited by 109 · cited 1× · see citing works
“Cronbach’s alpha reliability = 0.953 [52].”
InfluentialHartley, M. T. (2013) · Rehabilitation Counseling Bulletin · doi:10.1177/0034355213480527 · Cited by 107 · cited 1× · see citing works
“Resilience has been identified as one of the major factors in maintaining mental well-being and dealing with stressors in a healthy way, as well as reducing risk-taking behaviors [51].”
BackgroundBoyle, S. C., Earle, A. M., LaBrie, J. W., & Smıth, D. J. (2016) · Addictive Behaviors · doi:10.1016/j.addbeh.2016.11.024 · Cited by 103 · cited 1× · see citing works
“For instance, adding common game elements such as a reward system to a standard web-based intervention to reduce alcohol consumption significantly increased the efficacy of the treatment over a 2-week course [88].”
BackgroundBry, L. J., Chou, T., Miguel, E. M., & Comer, J. S. (2017) · Behavior Therapy · doi:10.1016/j.beth.2017.07.008 · Cited by 103 · cited 1× · see citing works
“Despite the utility of mobile health apps as a low-threshold mechanism to deliver treatment having been frequently praised [16], evidence for the efficacy of commercially available apps is scarce [10].”
BackgroundIs higher resilience predictive of lower stress and better mental health among corporate executives?
Kermott, C. A., Johnson, R. E., Sood, R., Jenkins, S. M., & Sood, A. (2019) · PLoS ONE · doi:10.1371/journal.pone.0218092 · Cited by 101 · see citing works
The association between adherence and outcome in an Internet intervention for depression
Fuhr, K., Schröder, J., Berger, T., Moritz, S., Meyer, B., Lutz, W., Hohagen, F., Hautzinger, M., & Klein, J. P. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.12.028 · Cited by 97 · cited 1× · see citing works
“Other research indicates that factors such as personal guidance in internet-delivered interventions [79], sociodemographic factors [80], confidence in the effectiveness of the online intervention [80], usability of the service [25], and perception of the intervention as personally relevant [81] play an important role…”
BackgroundHöchsmann, C., Infanger, D., Klenk, C., Königstein, K., Walz, S. P., & Schmidt‐Trucksäss, A. (2018) · JMIR Serious Games · doi:10.2196/11444 · Cited by 90 · cited 1× · see citing works
“[33] found significant increases in motivation and adherence to physical exercise in a gamified health app intervention group compared with a control group (one-time lifestyle counseling).”
BackgroundAkeman, E., Kirlic, N., Clausen, A. N., Cosgrove, K. T., McDermott, T. J., Cromer, L. D., Paulus, M. P., Yeh, H., & Aupperle, R. L. (2020) · Depression and Anxiety · doi:10.1002/da.22969 · Cited by 85 · cited 1× · see citing works
“Resilience may reduce susceptibility to depression and improve stress regulation [45].”
BackgroundMental health stigma: Impact on mental health treatment attitudes and physical health
Sickel, A. E., Seacat, J. D., & Nabors, N. A. (2019) · Journal of Health Psychology · doi:10.1177/1359105316681430 · Cited by 82 · see citing works
Ormel, J., Cuijpers, P. J., Jorm, A. F., & Schoevers, R. A. (2019) · World Psychiatry · doi:10.1002/wps.20580 · Cited by 77 · cited 1× · see citing works
“Moreover, although mental health promotion has long been advocated as a means of preventing mental disorders, prevention has been neglected [7, 8].”
BackgroundLin, Y., Tudor-Sfetea, C., Siddiqui, S., Sherwani, Y., Ahmed, M., & Eisingerich, A. B. (2018) · JMIR mhealth and uhealth · doi:10.2196/10024 · Cited by 68 · cited 1× · see citing works
“For instance, Lin et al. found a substantial reduction of smoking after use of a CBT-based mobile app employing game elements aimed to boost participants hedonic well-being, inspiration, and empowerment [83].”
MethodSmartphone, Social Media, and Mental Health App Use in an Acute Transdiagnostic Psychiatric Sample
Beard, C., Silverman, A. L., Forgeard, M., Wilmer, M. T., Torous, J., & Björgvinsson, T. (2019) · JMIR mHealth and uHealth · doi:10.2196/13364 · Cited by 58 · cited 1× · see citing works
“For example, survey data indicate that roughly three-quarters of psychiatric patients expressed an interest in using a smartphone to monitor their mental health and willingness to do so [19, 20].”
BackgroundPrice, M., Gros, D. F., McCauley, J. L., Gros, K. S., & Ruggiero, K. J. (2012) · Psychiatry: Interpersonal and Biological Processes · doi:10.1521/psyc.2012.75.3.267 · Cited by 49 · cited 1× · see citing works
“Other research indicates that factors such as personal guidance in internet-delivered interventions [79], sociodemographic factors [80], confidence in the effectiveness of the online intervention [80], usability of the service [25], and perception of the intervention as personally relevant [81] play an important role…”
BackgroundGratitude diary for the management of suicidal inpatients: A randomized controlled trial
Ducasse, D., Dassa, D., Courtet, P., Brand‐Arpon, V., Walter, A., Guillaume, S., Jaussent, I., & Olié, E. (2019) · Depression and Anxiety · doi:10.1002/da.22877 · Cited by 44 · see citing works
Russoniello, C., Fish, M. T., & O'Brien, K. F. (2019) · Games for Health Journal · doi:10.1089/g4h.2019.0032 · Cited by 38 · cited 1× · see citing works
“A recent trial showed that playing a videogame may reduce treatment-resistant depressive symptoms in patients receiving antidepressant medication [35].”
BackgroundAffective models of depression and anxiety: Extension to within-person processes in daily life
Naragon-Gainey, K. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.09.061 · Cited by 37 · cited 1× · see citing works
“For instance, trait negative affect predicted symptoms of depression, social anxiety, panic, and worry in a momentary assessment study [39].”
BackgroundLeón, F. R., Lundgren, R., Huapaya, A., Sinaï, I., & Jennings, V. H. (2007) · Evaluation Review · doi:10.1177/0193841x06289044 · Cited by 26 · see citing works
Naturally occurring expectation effects.
Hart, A. J. (1995) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.68.1.109 · Cited by 25 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundThe halo effect: Is it a unitary concept?
Fox, S., Bizman, A., & Herrmann, E. (1983) · Journal of Occupational Psychology · doi:10.1111/j.2044-8325.1983.tb00135.x · Cited by 23 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundRajaei, A., Daneshpour, M., & Robertson, J. (2019) · Journal of Couple & Relationship Therapy · doi:10.1080/15332691.2019.1567174 · Cited by 20 · cited 1× · see citing works
“The skills taught in eQuoo are as follows: emotional bids [63], generalization [64], action bias [65], confirmation bias [65], catastrophizing [66], halo effect [67], reciprocity [68], expectancy effect [69], courtesy bias [70], and self-serving bias [71].”
BackgroundLivingston, N. A., Shingleton, R. M., Heilman, M. E., & Brief, D. J. (2019) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-019-00099-6 · Cited by 20 · cited 2× · see citing works
“…mental health conditions and their lack of delivery and implementation in the healthcare system has been referred to as the “research-practice gap” [10]. mHealth (mobile health care), the delivery of mental health treatment using smartphones and wearables, presents an opportunity to narrow the…”
BackgroundGuided internet CBT versus “gold standard” depression treatments: An individual patient analysis
Forand, N. R., Feinberg, J. I., Barnett, J. G., & Strunk, D. R. (2018) · Journal of Clinical Psychology · doi:10.1002/jclp.22733 · Cited by 15 · cited 1× · see citing works
“Other research indicates that factors such as personal guidance in internet-delivered interventions [79], socio-demographic factors [80], confidence in the effectiveness of the online intervention [80], usability of the service [25], and perception of the intervention as personally relevant [81]…”
BackgroundImplementing a problem‐based learning curriculum in occupational therapy: A conceptual model
Salvatori, P. S. (2000) · Australian Occupational Therapy Journal · doi:10.1046/j.1440-1630.2000.00216.x · Cited by 14 · see citing works
Social psychology of behavior modification: Problems of implementation in natural settings.
Saunders, J. T. (1974) · American Psychologist · doi:10.1037//0003-066x.29.9.649 · Cited by 13 · see citing works
A Mobile Game for the Social and Cognitive Well-Being of Elderly People in China
Li, N., & Weiqin, C. (2017) · Studies in health technology and informatics · doi:10.3233/978-1-61499-798-6-614 · Cited by 5 · see citing works
Flagged first, then by citations
Research works printed but not linked: 5
- [7]National Academies of Sciences, Engineering, and Medicine. Fostering healthy mental, emotional, and behavioral development in children and youth: a national agenda. Washington, DC: The National Academies Press; 2019. 31869055
- [52]Liebenberg L, Moore JC. A social ecological measure of resilience for adults: The RRC-ARM. Soc Indic Res. 2018 1; 136(1): 1– 9.
- [68]Maiter S, Simich L, Jacobson N, Wise J. Reciprocity: an ethic for community-based participatory action research. Action Res. 2008; 6(3): 305– 25.
- [72]Vázquez C, Hervás G, Rahona JJ, Gómez D. Psychological well-being and health. Contributions of positive psychology. Annuary of Clinical and Health Psychology. 2009; 5(2009): 15– 27.
- [89]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(6): e13717 10.2196/13717 31244479 PMC6617915 · DOI · Paper page
Cited by
Sorted by citations
Jakob, R., Harperink, S., Rudolf, A. M., Fleisch, E., Haug, S., Mair, J. L., Salamanca-Sanabria, A., & Kowatsch, T. (2022) · Journal of Medical Internet Research · doi:10.2196/35371 · Cited by 446 · see citing works
Eisenstadt, M., Liverpool, S., Infanti, E., Ciuvat, R. M., & Carlsson, C. (2021) · JMIR Mental Health · doi:10.2196/31170 · Cited by 185 · see citing works
Six, S. G., Byrne, K. A., Tibbett, T. P., & Pericot-Valverde, I. (2021) · JMIR Mental Health · doi:10.2196/32199 · Cited by 95 · see citing works
Digital training for building resilience: systematic review, meta-analysis, and meta-regression
Ang, W. H. D., Chew, H. S. J., Dong, J., Yi, H., Mahendren, R., & Lau, Y. (2022) · Stress and Health · doi:10.1002/smi.3154 · Cited by 83 · see citing works
“18 trials adopted a two‐arm randomised controlled trial design, and four (Flett et al., 2019; Litvin et al., 2020; Roig et al., 2020; Suranata et al., 2020) used a three‐arm randomised controlled trial.”
BackgroundMethodInfluentialGoldberg, S. B., Bolt, D. M., & Davidson, R. J. (2021) · Journal of Medical Internet Research · doi:10.2196/26749 · Cited by 72 · see citing works
Recommendations for implementing gamification for mental health and wellbeing
Cheng, V. W. S. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.586379 · Cited by 74 · see citing works
The impact of Exergames on emotional experience: a systematic review
Marques, L. M., Uchida, P. M., & Barbosa, S. P. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1209520 · Cited by 70 · see citing works
“Thus, gamification has the potential to revolutionize the field of health promotion by increasing motivation, engagement, knowledge, treatment plan adherence, leading to overall well-being (17).”
BackgroundThe Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis
Abd-Alrazaq, A. A., Alajlani, M., Alhuwail, D., Schneider, J., Akhu‐Zaheya, L., Ahmed, A., & Househ, M. S. (2021) · JMIR Serious Games · doi:10.2196/29137 · Cited by 69 · see citing works
“Litvin et al [60] examined the effect of a psychoeducation game (eQuoo), conventional CBT, and no intervention on anxiety levels among healthy employees.”
BackgroundMethodInfluentialGamification: a Novel Approach to Mental Health Promotion
Cheng, C., & Ebrahimi, O. V. (2023) · Current Psychiatry Reports · doi:10.1007/s11920-023-01453-5 · Cited by 75 · see citing works
A meta-analytic review of gamified interventions in mental health enhancement
Cheng, C., & Ebrahimi, O. V. (2022) · Computers in Human Behavior · doi:10.1016/j.chb.2022.107621 · Cited by 70 · see citing works
Exploring the Impact of Gamification Elements in Brand Apps on the Purchase Intention of Consumers
Kaur, J., Lavuri, R., Parida, R., & Singh, S. V. (2023) · Journal of Global Information Management · doi:10.4018/jgim.317216 · Cited by 66 · see citing works
Chen, B., Yang, T., Xiao, L., Xu, C., & Zhu, C. (2022) · Journal of Medical Internet Research · doi:10.2196/39128 · Cited by 70 · see citing works
“The 3 outcomes had a close positive correlation with mental health [66].”
Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review
Bernstein, E. E., Weingarden, H. M., Wolfe, E. C., Hall, M. D., Snorrason, Í., & Wilhelm, S. (2022) · Journal of Medical Internet Research · doi:10.2196/33307 · Cited by 55 · see citing works
Del-Valle-Soto, C., López-Pimentel, J. C., Vázquez-Castillo, J., Nolazco-Flores, J. A., Velázquez, R., Varela-Aldás, J., & Visconti, P. (2024) · Sensors · doi:10.3390/s24082429 · Cited by 52 · see citing works
Aschentrup, L., Steimer, P. A., Dadaczynski, K., McCall, T., Fischer, F., & Wrona, K. J. (2024) · BMC Public Health · doi:10.1186/s12889-023-17517-3 · Cited by 45 · see citing works
“Personal growth ( = 1) [33], sleep problems ( n = 1) [37], emotional cognition ( n = 1) [36], frustration and irritability ( n = 1) [27], cognitive engagement ( n = 1) [32], cognitive and affective engagement ( n = 1) [32], energetic arousal ( n = 1) [24], and recovery ( n = 1) [24], were…”
BackgroundInfluentialTen Years of Gamification-Based Learning: A Bibliometric Analysis and Systematic Review
Al-Hafdi, F. S., & Alhalafawy, W. S. (2024) · International Journal of Interactive Mobile Technologies (iJIM) · doi:10.3991/ijim.v18i07.45335 · Cited by 69 · see citing works
Edge, D., Watkins, E. R., Limond, J., & Mugadza, J. (2023) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104292 · Cited by 42 · see citing works
Litvin, S., Saunders, R., Jefferies, P., Seely, H., Pössel, P., & Lüttke, S. (2023) · JMIR Mental Health · doi:10.2196/47285 · Cited by 43 · see citing works
Game elements enhance engagement and mitigate attrition in online learning tasks
Huber, S. E., Cortez, R. L. A., Kiili, K. J. M., Lindstedt, A., & Ninaus, M. (2023) · Computers in Human Behavior · doi:10.1016/j.chb.2023.107948 · Cited by 44 · see citing works
Six, S. G., Byrne, K., Aly, H., & Harris, M. W. (2022) · JMIR Mental Health · doi:10.2196/39516 · Cited by 31 · see citing works
“Although it may not provide any additional benefits in reducing depressive symptoms when coupled with therapeutic techniques such as cCBT [40], it has been shown to increase adherence in therapy trials for a variety of mental health disorders, such as depression and anxiety [41,42].”
BackgroundA meta-analysis of persuasive design, engagement, and efficacy in 92 RCTs of mental health apps
Valentine, L., Hinton, J. D. X., Bajaj, K., Boyd, L., O’Sullivan, S., Sorenson, R. P., Bell, I., Vega, M. S., Liu, P., Peters, W., et al. (2025) · npj Digital Medicine · doi:10.1038/s41746-025-01567-5 · Cited by 43 · see citing works
Nicolaidou, I. A., Aristeidis, L., & Lambrinos, L. (2022) · Digital Health · doi:10.1177/20552076221109059 · Cited by 43 · see citing works
“17,30–33 However, only a few studies were found that used gamification to improve resilience in a mobile mental health intervention.(20,23,34) These studies had positive findings demonstrating effectiveness but did not address a general population.”
BackgroundInfluentialVoth, M., Chisholm, S., Sollid, H., Jones, C., Smith-MacDonald, L., & Brémault-Phillips, S. (2022) · JMIR mHealth and uHealth · doi:10.2196/26453 · Cited by 35 · see citing works
“In much of the literature, gamification and the integration of social components strengthened mHealth app use and engagement, resulting in more positive outcomes and an increased sense of peer support for the MMs and PSP populations [14,36,46]; however, this was lacking in practice.”
Exploring gamification design elements for mental health support
Ibrahim, E. N. M., Jamali, N., & Suhaimi, A. I. H. (2021) · International Journal of Advanced Technology and Engineering Exploration · doi:10.19101/ijatee.2020.s1762123 · Cited by 37 · see citing works
“Today, gaming has become a ubiquitous therapy for serious purposes such as education [31] and health [32].”
Backgroundalsswey, A., & Malak, M. Z. (2024) · Learning and Motivation · doi:10.1016/j.lmot.2024.101993 · Cited by 33 · see citing works
Lockwood, J., Williams, L., Martin, J. L., Rathee, M., & Hill, C. (2022) · JMIR Mental Health · doi:10.2196/29008 · Cited by 32 · see citing works
Gkintoni, E., Vantaraki, F., Skoulidi, C., Anastassopoulos, P., & Vantarakis, A. (2024) · Medicina · doi:10.3390/medicina60122085 · Cited by 38 · see citing works
Exploring the features of an app-based just-in-time intervention for depression
Everitt, N., Broadbent, J., Richardson, B., Smyth, J. M., Heron, K. E., Teague, S. J., & Fuller‐Tyszkiewicz, M. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.05.021 · Cited by 33 · see citing works
Taylor, S. C., Smernoff, Z., Rajan, M., Steeman, S. L., Gehringer, B. N., Dow, H. C., Barzilay, R., Rader, D. J., Bućan, M., Almasy, L. A., et al. (2022) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2022.01.046 · Cited by 29 · see citing works
User engagement in mobile apps for people with schizophrenia: A scoping review
de Almeida, R. S., & Marques, A. J. (2023) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.1023592 · Cited by 29 · see citing works
A systematic review of digital storytelling as psychotherapy for people with mental health needs.
Ogbeiwi, O. I., Khan, W., Stott, K., Zaluczkowska, A., & Doyle, M. (2024) · Journal of Psychotherapy Integration · doi:10.1037/int0000325 · Cited by 27 · see citing works
Bulaj, G. W., Clark, J. E., Ebrahimi, M., & Bald, E. M. (2021) · Frontiers in Pharmacology · doi:10.3389/fphar.2021.612602 · Cited by 29 · see citing works
“, 2019), and can be improved by personalization and gamification (Litvin et al., 2020; Wei et al., 2020).”
BackgroundHow Avatar Customization Affects Fear in a Game-based Digital Exposure Task for Social Anxiety
Dechant, M., Birk, M. V., Shiban, Y., Schnell, K., & Mandryk, R. L. (2021) · Proceedings of the ACM on Human-Computer Interaction · doi:10.1145/3474675 · Cited by 28 · see citing works
Linking self-congruence and functional congruence to mobile health apps
Mähner, P. M., Zogaj, A., & Tscheulin, D. K. (2022) · Journal of Services Marketing · doi:10.1108/jsm-06-2021-0215 · Cited by 24 · see citing works
Lau, B. H. P., Cheung, M. K. T., Chan, L. T. H., Chan, C., & Leung, P. P. Y. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18115875 · Cited by 24 · see citing works
“Gamification, offering monetary compensation, regular reminders and online (rather than offline) enrollment may foster retention of smartphone delivered programs [44,45].”
BackgroundGamification pedagogy: A motivational approach to student-centric course design in higher education
Gironella, F. (2023) · Journal of University Teaching and Learning Practice · doi:10.53761/1.20.3.04 · Cited by 23 · see citing works
Zuo, X., Tang, Y., Chen, Y., & Zhou, Z. (2024) · JMIR Serious Games · doi:10.2196/55785 · Cited by 25 · see citing works
Egger, S. M., Frey, S., Sauerzopf, L., & Meidert, U. (2023) · Workplace Health & Safety · doi:10.1177/21650799231170872 · Cited by 26 · see citing works
“Furthermore, improved mental health outcomes were improved resilience (Champion et al., 2018; Kim et al., 2018; Litvin et al., 2020), work commitment (Möltner et al.”
Smartphone-based serious games for mental health: a scoping review
Gómez-Cambronero, Á., Mann, A.-L., Mira, A., Doherty, G. J., & Casteleyn, S. (2024) · Multimedia Tools and Applications · doi:10.1007/s11042-024-18971-w · Cited by 19 · see citing works
“Gamification and by extension Serious Games, are promising solutions to increase user engagement, and therefore improve adherence to treatment and reduce attrition rates [29, 30].”
Alzghoul, B. I. (2024) · The Open Public Health Journal · doi:10.2174/0118749445234806240206094335 · Cited by 19 · see citing works
“Similarly, Litvin et al. (2020) reported a significant increase in behaviour change that reduced anxiety and panic in raising mental health awareness.”
BackgroundPrisms of Neuroscience: Frameworks for Thinking About Educational Gamification
Serice, L. (2023) · AI Computer Science and Robotics Technology · doi:10.5772/acrt.13 · Cited by 18 · see citing works
Bas‐Sarmiento, P., Julián-López, C., Fernández‐Gutiérrez, M., Poza‐Méndez, M., & Paz, A. J. M. (2025) · Humanities and Social Sciences Communications · doi:10.1057/s41599-025-04670-w · Cited by 22 · see citing works
“…results related to new technologies involving gami fi cation, especially in different areas, such as in the treatment and promotion of mental health (Cheng et al., 2019; Litvin et al., 2020), as well as in other stages of the life cycle, such as old age (De Vette et al., 2015; Hurmuz et al., 2022).”
Spors, V., & Kaufman, I. (2021) · Proceedings of the ACM on Human-Computer Interaction · doi:10.1145/3474690 · Cited by 20 · see citing works
“time or the intensity that somebody engages with the technology at hand [16, 102].”
Background‘Let’s play?’ A systematic review of board games in biology
Teixeira, J. D. S., Angeluci, A. C. B., Júnior, P. P., & Martin, J. G. P. (2022) · Journal of Biological Education · doi:10.1080/00219266.2022.2041461 · Cited by 19 · see citing works
“Several studies have demonstrated the potential of gamification in different application contexts (Aboalshamat et al. 2020; Kurtzman et al. 2018; Litvin et al. 2020; Obaid, Farooq, and Abid 2020).”
BackgroundHurmuz, M. Z. M., Jansen-Kosterink, S. M., Hermens, H. J., & van Velsen, L. (2022) · Health Informatics Journal · doi:10.1177/14604582221106008 · Cited by 17 · see citing works
Manzano-Sánchez, D., Mármol, A. G., Jiménez-Parra, J. F., Bohórquez, I. G., & Valenzuela, A. V. (2021) · PLoS ONE · doi:10.1371/journal.pone.0256293 · Cited by 16 · see citing works
“On the other hand, the implementation of active methodologies in the classroom, based on motivation, show their effectiveness in improving resilience [24].”
BackgroundEmpower Psychotherapy with mHealth Apps: The Design of “Safer”, an Emotion Regulation Application
Diano, F., Sica, L. S., & Ponticorvo, M. (2023) · Information · doi:10.3390/info14060308 · Cited by 17 · see citing works
Palacios, V. A. F., Jaramillo-Galarza, K. A., Calle, J. V. Q., & Orozco-Cantos, L. (2023) · Salud Ciencia y Tecnología · doi:10.56294/saludcyt2023639 · Cited by 15 · see citing works
Mair, J. L., Castro, Ó., Salamanca-Sanabria, A., Frese, B. F., von Wangenheim, F., Tai, E. S., Kowatsch, T., & Müller‐Riemenschneider, F. (2023) · BMC Public Health · doi:10.1186/s12889-023-15598-8 · Cited by 14 · see citing works
Kemp, J., Chorney, J. M. L., Kassam, I., MacDonald, J., MacDonald, T., Wozney, L., & Strudwick, G. (2021) · Journal of Medical Internet Research · doi:10.2196/30491 · Cited by 14 · see citing works
“Some considerations were discussed that can address the needs of specific youth groups who may benefit from the use of personalized game-based interventions [18-21].”
Liem, A., Pakingan, K. A., Garabiles, M. R., Sit, H. F., Burchert, S., Lam, A. I. F., & Hall, B. J. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.836156 · Cited by 12 · see citing works
Naor, N., Frenkel, A., & Winsberg, M. E. (2022) · JMIR Formative Research · doi:10.2196/36018 · Cited by 12 · see citing works
“Owing to its ease of use and high validity, the WHO-5 has been extensively used in mental health– and physical health–related mobile apps [19-23].”
BackgroundEisenstadt, M., Liverpool, S., Metaxa, A.-M., Ciuvat, R. M., & Carlsson, C. (2021) · JMIR Formative Research · doi:10.2196/31064 · Cited by 12 · see citing works
Navarro-Mateos, C., Mora-González, J., & López, I. J. P. (2023) · Games for Health Journal · doi:10.1089/g4h.2023.0059 · Cited by 11 · see citing works
Mytsyk, H., Попова, А. С., & BOHDANOVA, M. (2024) · Journal of Education for Students Placed at Risk (JESPAR) · doi:10.1080/10824669.2024.2309359 · Cited by 10 · see citing works
“Gamification serves as the tool that facilitates the interconnectedness of all elements, while addressing the core challenges faced by teenagers (Álvarez-Bermejo et al., 2016; Fleming et al., 2023; Litvin, 2020).”
Gómez-Cuesta, N., Mateo‐Orcajada, A., Meroño, L., Abenza‐Cano, L., & Vaquero‐Cristóbal, R. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1380621 · Cited by 10 · see citing works
Gamification solutions for persons with disabilities: a systematic literature review
Boubakri, M., & Nafil, K. (2024) · Universal Access in the Information Society · doi:10.1007/s10209-024-01170-7 · Cited by 12 · see citing works
“‘Framework’ and ‘Trial’ categories contribute 9% [34, 35, 49, 66, 70] and 8% [59, 60, 74, 83], respectively, underlining the importance of conceptual frameworks and empirical studies in advancing gamification strategies for persons with disabilities.”
Basit, A., Ali, R., Rahman, S., & Shah, A. A. (2024) · Review of Education, Administration & Law · doi:10.47067/real.v7i4.395 · Cited by 13 · see citing works
“The results have important implications for clinical practice, where gratitude interventions-whether it is gratitude journaling or expressing appreciation in relationships-could be part of the therapeutic approach to promote psychological health and social cohesion (Litvin et al., 2020).”
The dark side of gamification: an experimental study on digital fitness apps
Bai, Z., Xu, C., Ailikamujiang, A., & Sun, Y. (2024) · Kybernetes · doi:10.1108/k-03-2024-0792 · Cited by 11 · see citing works
Juniar, D., van Ballegooijen, W., Kleygrewe, G., van Schaik, A., Passchier, J., & Riper, H. M. (2025) · Frontiers in Digital Health · doi:10.3389/fdgth.2025.1603389 · Cited by 17 · see citing works
Nasri, S. A. E. M., Kavakli, M., Hassan-Smith, Z. K., Salt, A., & Hassan‐Smith, G. (2025) · F1000Research · doi:10.12688/f1000research.172599.1 · Cited by 9 · see citing works
A preliminary investigation of gamification from the young consumer’s perspective
Hass, D., Hass, A., & Joseph, M. (2021) · Young Consumers Insight and Ideas for Responsible Marketers · doi:10.1108/yc-10-2020-1221 · Cited by 10 · see citing works
Amer, N. A., Shohieb, S. M., Eladrosy, W., El-Bakry, H. M., & Abdelrazek, S. M. (2023) · International Journal of Gaming and Computer-Mediated Simulations · doi:10.4018/ijgcms.324098 · Cited by 11 · see citing works
Doorley, J. D., Lentz, T. A., Yeh, G. Y., Wayne, P. M., Archer, K. R., & Vranceanu, A.-M. (2022) · Physical Therapy · doi:10.1093/ptj/pzac141 · Cited by 8 · see citing works
Chawla, S., & Saha, S. (2024) · BMC Public Health · doi:10.1186/s12889-024-19565-9 · Cited by 8 · see citing works
“Most research studies exist outside of the Indian context and are based on geriatric, clinical, and young adult population [23].”
BackgroundOtani, V. H. O., Novaes, R. A. C. B., Pedron, J., Nabhan, P. C., Rodrigues, T. M., Chiba, R., Guedes, J. V. C., Marques, L. M., & Vissoci, J. R. N. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1297332 · Cited by 9 · see citing works
de Miquel, C., Haro, J. M., Feltz-Cornelis, C. M. V. D., Ortiz-Tallo, A., Chen, T., Sinokki, M., Naumanen, P., Olaya, B., & Lima, R. A. (2024) · Scandinavian Journal of Work Environment & Health · doi:10.5271/sjweh.4173 · Cited by 8 · see citing works
“It may also increase motivation and decrease attrition (71).”
Chen, B., Yang, T., Lin, T., Song, Y., Liu, Y., Wang, Y., Xiao, L., Xu, C., & Chen, H. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-058686 · Cited by 8 · see citing works
“36 Improving mindfulness, well-being and resilience will help nurses efficiently handle mental health problems, such as stress, anxiety, and depression.”
BackgroundHabib, S., Noureldin, A. A., Aboueldahab, M., AbouSheashaa, A., Abaker, M., & Fakhfakh, A. (2025) · Journal of Lifestyle and SDGs Review · doi:10.47172/2965-730x.sdgsreview.v5.n03.pe05565 · Cited by 7 · see citing works
“Research suggests that gamification fosters resilience by incorporating goal-setting, feedback mechanisms, and problem-solving activities, which strengthen employees' ability to cope with workplace demands (Trunk Širca et al ., 2024; Litvin et al ., 2020).”
Amer, N. A., Shohieb, S. M., Eladrosy, W., Liu, S., Nam, Y., & Abdelrazek, S. M. (2024) · Digital Health · doi:10.1177/20552076241263317 · Cited by 8 · see citing works
Cojocaru, A., Braha, A., Anastasescu, C. M., Folescu, R., Bugi, M.-A., Puiu, M., Zamfir, C. L., Hogea, L., Levai, C. M., Bratosin, F., et al. (2024) · Behavioral Sciences · doi:10.3390/bs14100898 · Cited by 9 · see citing works
Rubio, V. J., & Zafra, A. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182412997 · Cited by 7 · see citing works
“Gamification has also shown to be a promising approach to increase user engagement with e-Health apps [3].”
BackgroundMethodA Behavioral Strategy to Nudge Young Adults to Adopt In-Person Counseling: Gamification
Piao, S., & Joo, J. (2022) · Behavioral Sciences · doi:10.3390/bs12020040 · Cited by 7 · see citing works
“who developed a game called eQuoo and tested its impact on psychological resilience, well-being, and anxiety attrition rates [23].”
BackgroundUsta, E., & İnözü, M. (2023) · Current Psychology · doi:10.1007/s12144-023-05318-1 · Cited by 6 · see citing works
Järvelä, S., Wei, L., Hassan, L., & Hamari, J. (2022) · International Conference on Entertainment and Media in the Ubiquitous Era · doi:10.1145/3569219.3569343 · Cited by 5 · see citing works
Beer, O. W. J., McInroy, L. B., Hefner, J. L., & Beer, S. (2024) · Journal of Public Child Welfare · doi:10.1080/15548732.2024.2312838 · Cited by 5 · see citing works
“Previous online-based studies indicate that attrition could be reduced using “gamification” (Krause, Mogalle, Pohl, & Williams, 2015; Litvin, Saunders, Maier, Lüttke, & Matsuoka, 2020).”
AVALIAÇÃO DE UM JOGO DE TABULEIRO PARA CONTROLE DE ANSIEDADE EM ADOLESCENTES ESCOLARES
da Silva, A. G. C., de Andrade, J. S., da Silva, F. J. C. P., & de Oliveira, L. L. (2023) · Revista Enfermagem Atual In Derme · doi:10.31011/reaid-2023-v.97-n.2-art.1864 · Cited by 5 · see citing works
James, L., Maessen, M., Genga, L., Montagne, B., Hagenaars, M. A., & Gorp, P. M. E. V. (2024) · Lecture notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering · doi:10.1007/978-3-031-59717-6_13 · Cited by 5 · see citing works
“…Theory (SDT), in the context of an mHealth tool, a tool that satisfies the need for autonomy (i.e., the desire to have control over tasks), competence (i.e., the need to acquire new skills), and relatedness (i.e., the desire to feel connected to others) can enhance intrinsic motivation [15] [20].”
MethodWenger, F., Allenhof, C., Schreynemackers, S., Hegerl, U., & Reich, H. (2023) · JMIR Formative Research · doi:10.2196/53768 · Cited by 5 · see citing works
Experiences of Users with an Online Self-Guided Mental Health Training Program Using Gamification
van der Lubbe, L. M., Gerritsen, C., Klein, M. C. A., Rodgers, R. F., & Hindriks, K. V. (2023) · Journal of Healthcare Informatics Research · doi:10.1007/s41666-022-00124-z · Cited by 5 · see citing works
Moore, M., & O’Sullivan, D. (2023) · International Journal of Mentoring and Coaching in Education · doi:10.1108/ijmce-07-2022-0050 · Cited by 5 · see citing works
Gamification and Retention in Mental Health Apps
Nagvanshi, S., Munshi, A., & Bhatnagar, S. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-8886-0.ch011 · Cited by 4 · see citing works
Griffith, F. J., Ash, G. I., Augustine, M., Latimer, L., Verne, N., Redeker, N. S., O’Malley, S. S., DeMartini, K. S., & Fucito, L. M. (2024) · npj Digital Medicine · doi:10.1038/s41746-024-01321-3 · Cited by 4 · see citing works
Alqahtani, F., & Orji, R. (2025) · Human Behavior and Emerging Technologies · doi:10.1155/hbe2/8111089 · Cited by 14 · see citing works
Jiao, M., Ding, Z., Huang, C., Xu, Y., 钟宝亮, & Chen, H. (2025) · Behavioral Sciences · doi:10.3390/bs16010040 · Cited by 3 · see citing works
“Gamified features are hypothesized to enhance intrinsic motivation, user engagement, and emotional reward, potentially amplifying training effects and mitigating attrition (de Paiva Azevedo et al., 2019; Litvin et al., 2020).”
von Boros, L., Schaubruch, L. M., Arnold, M., Rigotti, T., Helmreich, I., Lieb, K., Wessa, M., Tüscher, O., & Schäfer, S. K. (2026) · Work & Stress · doi:10.1080/02678373.2026.2618071 · Cited by 2 · see citing works
“For example, one study found a significant effect only when comparing a gamified resilience intervention to a waitlist, but not to a CBT diary intervention (Litvin et al., 2020).”
Science‐Based Mobile Apps for Reducing Anxiety: A Systematic Review and Meta‐Analysis
Doğan, T., Koçtürk, N., Akın, E., Kurnaz, M. F., Öztürk, C. D., Şen, A., & Yalçın, M. (2024) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.3058 · Cited by 4 · see citing works
Tang, S. X., Foroughi, M., Brinen, A. P., Birnbaum, M. L., Berretta, S. A., Behbehani, L. M., Kane, J. M., Yoon, E., & Cronin, W. F. (2026) · Early Intervention in Psychiatry · doi:10.1111/eip.70119 · Cited by 3 · see citing works
“…activating reward circuitry and eliciting positive experiences and emotions in people with SSD by leveraging proven design elements like points, rewards and progress tracking (Välimäki et al. 2021; Litvin et al. 2020), thereby creating a neuropsychological state that may be conducive to treatment.”
The Magic of the In-Between: Mental Resilience Through Interactive Narrative
Harmon, S., Gale, H., & Dermendzhiyska, E. (2021) · Lecture notes in computer science · doi:10.1007/978-3-030-92300-6_35 · Cited by 4 · see citing works
Manning, J. B., BLANDFORD, A. E., & Edbrooke-Childs, J. H. (2023) · JMIR Formative Research · doi:10.2196/50460 · Cited by 2 · see citing works
“Reflection is not limited to PI; it can also be facilitated through apps supporting emotional self-awareness [56,57], chatbots offering guided therapy [41,58], or timely reminders [32,41,59].”
BackgroundA Behavioural Strategy to Nudge Young People to Adopt In-Person Counselling: Gamification
Piao, S., & Joo, J. (2022) · [ ] With Design: Reinventing Design Modes · doi:10.1007/978-981-19-4472-7_88 · Cited by 3 · see citing works
Singh, P., Chen, E., Steel, B., Chicoine, N., Yakdan, S. M., Bydon, M., Steinmetz, M. P., Ghogawala, Z., Ray, W. Z., Johnson, B. P., et al. (2025) · Neurosurgery · doi:10.1227/neu.0000000000003717 · Cited by 3 · see citing works
Qiu, Y., Carter, E. A., Benda, N. C., Sirey, J. A., Kim, S., Kim, Y.-H., Yu, Z., Kiosses, D. N., Marino, P., Gunning, F. M., et al. (2025) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2025.09.004 · Cited by 2 · see citing works
Kim, E., Jeon, H., Lee, J., Oh, H., Kim, M., Shin, J., & Kim, E. (2025) · Journal of Medical Internet Research · doi:10.2196/69248 · Cited by 2 · see citing works
“However, these products did not clearly address caregivers’ concerns regarding potential side effects and overdependence on DTx. Nonetheless, gamification is an effective strategy to encourage participation and enhance the effectiveness of digital intervention [33,34].”
Alharthi, M. (2024) · International Journal for Research in Education · doi:10.36771/ijre.48.2.24-pp55-113 · Cited by 2 · see citing works
Towards an effective methodology for the integral gamification of classes
Lepe-Salazar, F., & Álvarez, T. Y. C. (2024) · Multimedia Tools and Applications · doi:10.1007/s11042-024-19846-w · Cited by 2 · see citing works
Manning, J. B., BLANDFORD, A. E., & Edbrooke-Childs, J. H. (2024) · Journal of Medical Internet Research · doi:10.2196/50457 · Cited by 2 · see citing works
“Other approaches include condition-based education [17], self-management through guided therapy [18,19], peer or social support [20,21], and gaming or entertainment [22,23].”
The Design of a Gamified App for Supporting Undergraduates' Resilience
Nicolaidou, I. A., & Aristeidis, L. (2022) · European Conference on Games Based Learning · doi:10.34190/ecgbl.16.1.708 · Cited by 2 · see citing works
“Most resilience apps target adults belonging to specific professional groups (e.g., Litvin et al., 2020) and not the general public, are not gamified (e.g., Wood et al., 2017), and do not have strong theoretical foundations.”
BackgroundA Review of Gamification Related to Mental Health Treatment
Arihta, C., Fujiono, D., Verónica, V., Moniaga, J. V., & Rianto, I. D. (2022) · doi:10.1109/iconeei55709.2022.9972282 · Cited by 2 · see citing works
Uso de jogos no controle de ansiedade em crianças e adolescentes: uma revisão integrativa
da Silva, A. G. C., de Carvalho, Y. F., & de Andrade, J. S. (2022) · Revista Científica Multidisciplinar Núcleo do Conhecimento · doi:10.32749/nucleodoconhecimento.com.br/saude/ansiedade-em-criancas · Cited by 2 · see citing works
“(LITVIN et al., 2020).”
- Authors
- Litvin, S., Saunders, R., Maier, M. A., & Lüttke, S.
- Affiliations
- Ludwig-Maximilians-Universität München (DE)
- University College London (GB)
- University of Tübingen (DE)
- Corresponding author
- Litvin, Silja
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2020-09-02
- Volume
- 15
- Issue
- 9
- Pages
- e0237220
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC7467300
- OpenAlex
- W3082570758
- Cited by
- 177
- References
- 88
- Citations by year
- 2026: 33 · 2025: 31 · 2024: 32 · 2023: 34 · 2022: 25 · 2021: 21 · 2020: 1
- FWCI
- 18.28
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UCL Discovery (University College London) (submittedVersion)
- Open access LMU (Ludwid Maxmilian's Universitat Munchen) (submittedVersion, cc-by)
- HRB National Drugs Library (Health Research Board) (submittedVersion, cc-by)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Developmental and Educational Psychology › Educational Games and Gamification
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- gamification, mobile mental health intervention, resilience, attrition, mobile application, psychoeducation, anxiety, psychological well-being, personal growth, intervention adherence, reciprocity, generalization
- MeSH terms
- Adolescent, Adult, Anxiety, Female, Humans, Male, Mental Health, Middle Aged, Surveys and Questionnaires, Treatment Outcome, Outcome Assessment, Health Care, Telemedicine, Video Games, Resilience, Psychological, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
