GAME ELEMENTS FROM LITERATURE REVIEW OF GAMIFICATION IN HEALTHCARE CONTEXT

Gamification is a conceptual framework to apply game elements and techniques to improve the interesting process in non-game context. Gamification offers the motivation approach to motivate the player to handle the challenge tasks with game mechanics, game dynamics, and components. Nowadays, To discover the set of game elements and techniques from evaluating the existing related research is more opportunity for success in the exciting process. The core objective of this paper is to review the literature by using descriptive statistics of game elements with the review methodology. The reviewed literature was first coded author-centrally. After each paper was scrutinized for the analysis, the perspective was pivoted, and further analyses were conducted concept-centrally. A systematic review has been conducted that proves the wide variety of game elements, being retrieved a total of fifteen terms of game elements from twentytwo selected papers that were screened from a total of eighty-two documents. Only a few terms are used: points, feedback, levels, leaderboards, challenges, badges, avatars, competition, and cooperation. However, only some can be considered actual elements mechanics and that have not a similar abstraction level. Additionally, the authors examined the relationship between game elements and Self-Determination Theory (SDT): Competence, Autonomy, and Relatedness. The results indicated that a few terms of game elements were used: points, feedback, levels, leaderboards, challenges, badges, avatars, competition, and cooperation to explaine the relationship to SDT: Competence, Autonomy, and Relatedness. The results from this study will be used to design a gamified system in a healthcare context to promote physical activity.


Introduction
Gamification is a conceptual framework to apply game elements and techniques to improve the interesting process in non-game context.Gamification offers the motivation approach to motivate the player to handle the challenge tasks with game mechanics, game dynamics, and components.Gamification can be applied in almost every area of knowledge.The most common areas of using gamification are followed: (a) Education, not only with applications or serious games but The form can also gamify teaching to increase academic performance.(b) Entertainment, gamification is used to improve user experience and ensure loyalty.(c) Health, there are many examples of gamified applications of telemedicine, and self-learning about diseases and to support the treatment and diagnosis.(d) Business environments, trying to improve the productivity and satisfaction of workers.Furthermore, (e) Marketing, where gamification can enhance the visualization of the product and becomes it nearer to the final consumer.There is still a gap in the definition and classification of game elements for some successful cases of gamified context; in this paper, The authors aim to identify the most common game elements and propose a term of game elements which related Self-Determination Theory that can be applied in the healthcare context.This paper is organized as follows: Section 2 is dedicated to exploring the related works related to gamification.Section 3 describes the performed systematic review of gamification for Healthcare.Section 4 presents the results of a Systematic Review of Gamification Research in Healthcare Context.Finally, Section 5 concludes the paper.

Gamification
The most commonly define "Gamification" as the following statements: Deterding, Dixon, Khaled and Nacke (2011) described gamification as the use of game elements in non-game contexts.Bunchball.com (2010) defines gamification as the use of game mechanics in non-game activities to influence people's behavior.Zichermann and Cunningham (2011) describe gamification as the process of using game thinking and game mechanics to engage audiences and solve problems.If we want to simplify the definition of gamification, then we might think of it as the application of the essential elements that make games fun and engaging to things that typically are not considered a game.The main elements of gamification are followed: (a) Game elements: points, badges, leaderboards.(b) Game techniques: thinking as a computer game designer.and (c) Non-game contexts in other business domain such as education, entertainment, health, business, marketing.Johnson, Deterding, Kuhn, Staneva, Stoyanov and Hides (2016) indicated that gamification could have a positive impact on health and wellbeing, Especially for health behaviors from the empirical evidence of the effects of gamification on health and well-being.Furthermore, The findings were evident for healthrelated behaviors but mixed for cognitive outcomes.While, Lumsden, Edwards, Lawrence, Coyle and Munafò (2016) concluded that working memory and general executive functions were most objective for both gamified assessment and training Additionally, Heterogeneous study designs and typically small sample sizes should be evaluated more.Furthermore, Dicheva, Dichev, Agre and Angelova (2015) indicated the research should be more on the empirical study to understand more how gamification can influence both extrinsic and intrinsic motivation to players.On the other hand, Clark, Tanner-Smith and Killingsworth (2016) indicated that digital games mainly enhanced player learning relative to non-game conditions, and value-added comparisons mainly indicated learning benefits associated with additional game designs.The results of using a random-effects meta-regression model with media comparisons explained the affordances of games for learning as well as the crucial role of design beyond the medium.

Self-Determination Theory: SDT
Self-Determination Theory (SDT) by Edward L. Deci and Richard M. Ryan (2000) states that the basic psychological needs that comprise Self-Determination as autonomy, competence, and Relatedness.(1) To meet the needs for self-determination.(2) To meet the needs of the ability.And (3) to meet the need for social interaction.Forde, Mekler and Opwis (2015) studied the fundamental psychological mechanisms by comparing autonomy, competence, and intrinsic motivation between an informational and a controlling condition on gamification work and (2016) indicated that informational game elements such as points in form of scoreboards were ignored.Hiniker, Lee, Sobel and Choe (2017) indicated that the self-regulation in a non-digital setting can be applied effectively to children's use of technology by creating tools for preschoolers and parents to plan their device-based play-time.Huang (2017) applied the Self-Determination Theory in Human-Robot Interaction by using robotics tournaments as a test bed to seek evidence of people's need for autonomy, competence, relatedness to other humans, and intrinsic motivation and emotions toward interactions with robots.Noll, Razzak and Beecham (2017) studied the effect of global software development on motivation by finding the impact of misalignment between needed and actual autonomy.

Research Questions
This research question was elaborated to meet the purpose of the study.

RQ: Which game elements are being implemented in the research of gamification?
Thus, the authors conducted a systematic review to answer the formulated RQ.The flow to perform the systematic the review was the following: First, to determine the electronic database(s) were exploring to the objectives of this study.Second, To identify the target keywords and define the searching string.Third, to determine inclusion/exclusion criteria, i.e., the mandatory eligibility factors to include documents in the current study.Forth, to screen those documents that previously accomplished the eligibility factors using the title and abstract.Fifth, Based on the content of the papers, to select those documents that provide information about game elements; Sixth, to determine the metrics to characterize them and deliver the results of this systematic review.

Data Collection
The searched electronic databases were follow: ACM (Association for Computing Machinery), IEEE (Institute of Electrical and Electronics Engineers), and Science Direct.The authors used the following criteria: (1) use the search terms that related term of gamification, gamified, and gamifying: ("gamif*").( 2) use the inclusion criteria: name fulfill one of the search strings; journal, conference; Publication during 2013-2017; and Paper was written in English, and exclusion criteria: Papers that do not relate to gamification; Papers which are available only abstract; Workshop's paper; Gamification which was implemented in non-health context; Duplicated study.Furthermore, the authors had extracted data from the title, abstract, and keywords in the first step, and from introduction, methods, and conclusions in the last step.

Coding of papers
Coding of game elements: game dynamics, game mechanics, and components.
Coding of methods: study design, sampling, data collection, data analysis, and results and conclusions.
Coding of the basic psychological need of SDT: autonomy, competence, and relatedness.

Results
Table 2 shows the summary of the extract data from the selected papers: the published year, authors, the problem points, proposal, type of studies design, and performance evaluation.The results revealed both negative and positive outcomes of the gamification approach Pokémon Go adopted.
Table 2. Summary of the extract data from the selected papers

Game Elements Used in Papers
Table 3 shows that game elements were used in the papers: seven for points, four for levels and leaderboards, three for badges, two for avatars, and one for quests, social graph, and virtual goods, while the rest components were not used.In Table 1.The authors can prepare a dataset as follows.

Conclusion
In this study, the authors have evidenced the broad interpretation of game elements, including a different terminology to define the way in which gamification is developed.Using Werbach and Hunter (2012) as the reference, the authors propose the use of game elements as aseptic but concrete terminology or technique when the authors need to remark the proved effectiveness of game elements.A systematic review has been conducted that proves the wide variety of game elements, being retrieved a total of fifteen terms of game elements from twenty-two selected papers that were screened from a total of eighty-two documents.Only a few terms are used: points, feedback, levels, leaderboards, challenges, badges, avatars, competition, and cooperation.However, only some can be considered actual elements mechanics and that have not a similar abstraction level.

Figure 1 .
Figure 1.Flow diagram of the systematic review process Figure 2. Frequency of game elements (Components)